Published Apr 03, 2026 | 12:32 AM ⚊ Updated Apr 03, 2026 | 12:32 AM
The findings positioned advanced liver disease alongside retinopathy, nephropathy, and neuropathy as a defining complication of diabetes. (iStock)
Synopsis: Southern centres recorded fibrosis prevalence of 30%, compared with 28% in eastern India, 27% in northern India, 24% in western India, and 21% in central India. The authors suggested that differences in dietary patterns, physical activity, healthcare access, and the timing of diabetes diagnosis may contribute to the north-south gradient.
A large multicentre study conducted across India has found that one in four people with type 2 diabetes carries undiagnosed liver fibrosis.
The study found southern India recorded the highest rates of undiagnosed liver fibrosis, raising concerns about a complication that standard diabetes care continues to overlook.
The DiaFib-Liver Study, published in The Lancet Regional Health – Southeast Asia, analysed data from 9,202 adults with type 2 diabetes drawn from routine diabetes clinics across India.
It found that 26% had clinically significant liver fibrosis, 14% had advanced fibrosis, and 5% had reached thresholds consistent with probable cirrhosis, all without symptoms pointing to liver disease.
The findings positioned advanced liver disease alongside retinopathy, nephropathy, and neuropathy as a defining complication of diabetes. The authors argued that liver health has remained outside standard diabetes management despite the scale of the problem now documented.
“This also emphasises that all physicians should actively screen for and appropriately investigate MASLD (Metabolic dysfunction-associated steatotic liver disease) in every person with type 2 diabetes and consider treatment allocation accordingly,” the authors wrote.
Southern centres recorded fibrosis prevalence of 30%, compared with 28% in eastern India, 27% in northern India, 24% in western India, and 21% in central India. The authors suggested that differences in dietary patterns, physical activity, healthcare access, and the timing of diabetes diagnosis may contribute to the north-south gradient.
Diabetologists and endocrinologists across India entered data for consecutive patients into an anonymised digital form between January and July 2024. The primary measurement tool was vibration-controlled transient elastography, a non-invasive scan that measures liver stiffness.
Patients with known liver disease, significant alcohol intake, or viral hepatitis were excluded, so the study focused exclusively on metabolic liver changes in routine diabetes care.
Of 10,739 records submitted, 9,202 passed quality checks and formed the final cohort. Records from gastroenterology centres were excluded to avoid skewing the sample toward patients already identified as high risk.
“By systematically excluding hepatology referrals and outlier centres and mandating consecutive patient entry from routine diabetes clinics, our design minimises selection bias and enhances external validity, making the results directly translatable into day-to-day diabetes care pathways,” the authors wrote.
Multivariable analysis identified four independent predictors of clinically significant fibrosis.
Obesity carried the strongest association, with people carrying a BMI of 25 or above nearly twice as likely to develop fibrosis. Dyslipidaemia, reduced kidney function, and diabetes lasting ten or more years each showed independent associations.
One finding challenged a widely held clinical assumption. Among participants without detectable liver fat, 13% still carried clinically significant fibrosis, including 4% who had reached cirrhosis-range thresholds. Fat accumulation, the study concluded, does not reliably indicate whether fibrosis has taken hold.
“Steatosis may diminish with progressive fibrosis, while fibrogenesis continues, particularly in older individuals and those with longstanding metabolic disease,” the authors noted, referring to the phenomenon as burnt-out steatohepatitis.
The study also found fibrosis in non-obese patients, with age emerging as the sole independent predictor in that subgroup, pointing to cumulative metabolic injury over time rather than fat-driven damage alone.
The authors argued that diabetes care has historically treated the liver as a secondary concern, with clinical attention concentrating on microvascular and cardiovascular complications. The new data suggested that the approach leaves a substantial burden undetected until the disease reaches an advanced stage.
“One in twenty patients with type 2 diabetes already met cirrhosis-range liver stiffness thresholds in community settings, most often undiagnosed until decompensation. This positions advanced liver disease as a fourth major complication of diabetes, demanding parity of attention in guidelines and practice,” the authors wrote.
They recommended that transient elastography or validated blood-based markers be incorporated into routine diabetes care on a par with annual retinal examinations or urine albumin testing.
From a public health standpoint, the authors called for integrating liver fibrosis screening into India’s National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke, which currently does not include it. They argued that embedding fibrosis assessment into that programme would open a window for lifestyle intervention and emerging therapies before patients progress to cirrhosis or liver cancer.
“At a global level, the study highlights that low- and middle-income countries, which shoulder the greatest diabetes burden, are simultaneously facing a silent epidemic of advanced liver disease — a dual challenge that threatens to overwhelm health systems unless addressed proactively,” the authors wrote.
The cross-sectional design does not allow tracking of outcomes such as disease progression or mortality. Because elastography was ordered by clinicians rather than applied population-wide, the cohort may over-represent patients perceived to carry a higher metabolic risk. Alcohol intake was based on clinical history, and under-reporting across regions cannot be ruled out.
The authors noted that despite these constraints, the scale, real-world nature, and quality controls applied to the dataset make the findings clinically actionable.
With India carrying more than 100 million people with diabetes, the study concluded that relying on fatty liver detection alone is insufficient and that systematic fibrosis assessment needs to become a routine part of diabetes care across the country.
(Edited by Majnu Babu).
