Living in the Non-alcoholic Fatty Liver Disease Silent Epidemic

A Qualitative Systematic Review of Patients' Perspectives

Cheng Han Ng; Wen Hui Lim; Yip Han Chin; Jie Ning Yong; Rebecca Wenling Zeng; Kai En Chan; Darren Jun Hao Tan; Clarissa Elysia Fu; Ansel Shao Pin Tang; Lay Hoon Goh; Kamala Devi; Nicholas W. S. Chew; Lung-Yi Loey Mak; Nobuharu Tamaki; Daniel Q. Huang; Mazen Noureddin; Mohammad Shadab Siddiqui; Rohit Loomba; Arun J. Sanyal; Mark Muthiah


Aliment Pharmacol Ther. 2022;56(4) 

In This Article

Abstract and Introduction


Background: Non-alcoholic fatty liver disease (NAFLD) affects one-fourth of the global population. Yet, the care of these patients is limited and awareness of NAFLD remains low in the general public. Investigations into the lives of these patients are often forgotten and traditional quantitative studies only paint part of the picture.

Aim: To assess the first-hand accounts of these individuals and their perspective on living with NAFLD.

Methods: A systematic search was conducted on Medline, Embase, CINAHL, PsycINFO and Web of Science database for qualitative literature regarding patients' perspectives on NAFLD. An inductive thematic analysis was conducted to generate themes and supportive subthemes.

Results: We incuded eight articles in the review. There were three major themes including the impact on the quality of life, knowledge and information, and attitudes and perceptions on care. The impact of the quality of life details the emotional and physical distress of NAFLD. Knowledge and information include the lack of sufficient communication between healthcare providers and patients with a distinct knowledge gap. Attitudes and perceptions on care extrapolate the current active participation of patients and needs of the patients and the future care that they desire.

Conclusion: This review synthesises first-hand accounts of individuals with NAFLD. With the growing burden of NAFLD, future public interventions must consider individual views for success to be found. The identified themes serve as a forefront for consideration for public policies. Ultimately, NAFLD is a multisystem disease, which must be managed by a multidisciplinary team.


Non-communicable diseases (NCDs) are estimated to account for 71% of global deaths annually.[1] Commonly, NCDs are commonly associated with chronic diseases including diabetes, cardiovascular disease and respiratory diseases by the general population. Despite results from the global burden of disease showing a rising trend of non-alcoholic fatty liver disease (NAFLD),[2,3] NAFLD remains relatively unknown at the global stage. Current global estimates suggest that 25%–33% of the global population is affected by NAFLD and will only continue to increase in parallel with the obesity epidermic.[4–7] NAFLD represents an excessive accumulation of fat in the liver resulting in hepatic steatosis[8] in the absence of substantial alcohol use and can often go unnoticed as compensatory mechanisms of the liver allows an asymptomatic progression of disease until later stages when decompensation occurs.[9,10]

Compared to other NCDs, there is a severe lack of awareness of NAFLD by the general population and healthcare providers.[3,11] A recent analysis by Lazarus et al. on the global preparedness of NAFLD, a third of countries scored 0 on the preparedness index and no countries had a comprehensive public health response for NAFLD.[12] In the population, analysis of the national health and nutritional survey (NHANES) found that only 4.49% were aware of their NAFLD diagnosis of the 4680 individuals identified to have NAFLD.[13] Additionally, while healthcare providers are well aware of the myriad of associations including cardiovascular disease,[14,15] chronic kidney disease, malignancies[16] and mortality that are tied to NAFLD, there is currently a lack of interest on the implications of individual patients personal and social life beyond their medical needs. This is in stark contrast to the care of other NCDs where greater emphasis is placed on patients' wellbeing and quality of life, which are integral aspects of quality care.[17,18] The use of qualitative studies adds another dimension in the identification of limitations in current healthcare that identification through traditional methods can prove difficult.[19] However, compared with the traditional quantitative studies, a qualitative synthesis in turn provides an excellent advantage that allows for a systematic synthesis of first-hand direct accounts on the impact, gaps and needs of patients.[19,20] Hence, with the rising burden of NAFLD, we sought to synthesise the collective views of patients living with NAFLD that would serve as fundamental groundwork for the development of future healthcare policies.