A few days ago, a senior patient walked into my clinic. As part of routine assessment, I asked about appetite and any abdominal discomfort. He replied calmly, “It doesn’t hurt, it doesn’t disturb my routine… bas thodi si thakaan hai, halki si pait mein bechaini, aur bhook bhi kam ho gayi hai. Ab umar ho rahi hai, yeh sab to hota hai.”

There was nothing alarming in his tone—only acceptance. Yet, given his 15-year history of diabetes, I advised further evaluation. The investigations told a different story: silently progressing liver damage, far beyond simple fatty liver. That encounter stayed with me—and it is precisely why this needs to be spoken about.

A recent large study has brought to light a deeply concerning reality: one in four people living with diabetes may already have hidden liver damage—without knowing it. For a country like India, with a rapidly growing elderly population and an enormous burden of diabetes, this is not just a medical finding. It is a public health warning. For seniors, this issue demands urgent attention.

Beyond sugar: Missing piece in diabetes care

For years, diabetes care has revolved around controlling blood sugar and preventing complications related to the eyes, kidneys, and heart. These are undoubtedly important. However, what has remained relatively under-recognised is the silent impact of diabetes on the liver.

The liver plays a central role in metabolism. In diabetes, especially when long-standing, the liver is constantly under metabolic stress. This leads to fat accumulation in the liver (fatty liver), which can silently progress to fibrosis (scarring) and eventually cirrhosis, an advanced and often irreversible stage.

What makes this particularly dangerous is that fatty liver alone is not a reliable warning sign. A person may have significant liver damage even without obvious fat deposition or symptoms.

Seniors are more vulnerable

Ageing changes the body’s resilience. In seniors, diabetes rarely exists in isolation. It is often accompanied by:

Dyslipidaemia (high bad cholesterol and triglycerides)

 Reduced physical activity

 Multiple medications

These factors together accelerate metabolic strain on the liver.

Moreover, the duration of diabetes itself matters. Many elderly individuals have lived with diabetes for years, even decades. This prolonged exposure increases the likelihood of silent organ damage, including the liver. Alarmingly, the risk is not limited to overweight individuals. The study highlights that even “thin diabetics” may develop liver fibrosis, challenging the common perception that only obesity drives liver disease.

Liver disease in diabetes is often asymptomatic in early stages. There is no pain, no dramatic sign, no immediate disruption. At most, there may be vague symptoms:

ï Mild abdominal discomfort

These are easily dismissed or attributed to ageing itself.

By the time clearer signs appear—such as swelling, jaundice, or weight loss—the disease is often advanced. This silence is not benign. It is dangerous.

Screening becomes essential

The current approach to diabetes care needs recalibration.

For seniors, liver assessment should not be incidental—it should be routine.

A practical screening approach should include:  Periodic liver function tests (LFTs)  Ultrasound abdomen as a baseline  Where indicated, fibrosis assessment tools such as FibroScan

Importantly, reliance on ultrasound alone is insufficient. As emerging evidence suggests, liver fat does not always correlate with the severity of damage.

What is required is a shift from detection of fat to detection of fibrosis—the stage where intervention can still alter outcomes.

Lifestyle as the First Line of Therapy

There is a tendency, especially among seniors, to depend heavily on medications. While pharmacological management is important, it is not sufficient.

Liver health in diabetes responds significantly to lifestyle measures:

ï Regular physical activity, even simple walking

ï Reduction in refined sugars and processed foods

ï Balanced, home-cooked meals

ï Modest weight reduction where applicable

Even a 5–7% reduction in body weight has been shown to improve liver parameters.

This is not about drastic changes. It is about consistent, sustainable habits.

Shared responsibility

Addressing this issue requires alignment across multiple levels.

Clinicians must expand their focus beyond glycaemic control and actively screen for liver involvement.

Families must support elderly members in maintaining regular follow-ups and lifestyle changes.

Patients themselves must move from passive recipients of care to informed participants—asking not just about sugar levels, but about overall metabolic health.

India’s healthcare system has made significant strides in managing NCDs, especially diabetes. Yet, this emerging evidence highlights a gap—the under-recognition of liver disease as a major complication of diabetes. If ignored, this gap will translate into a future burden of advanced liver disease, with profound implications for both individuals and the healthcare system.

The message is clear: Early detection is not optional. It is essential.

For seniors living with diabetes, the absence of symptoms should not be mistaken for the absence of disease. The liver does not show symptoms early. It adapts, compensates, and quietly deteriorates—until it can no longer do so. In clinical practice, one realisation stands out: The most dangerous complications of diabetes are not the ones we see, but the ones we fail to look for. It is time we start looking.

© Greater Kashmir