European Journal of Cardiovascular Medicine

Non-Alcoholic Fatty Liver Disease (NAFLD) is a leading cause of chronic liver disease globally and nationally, including cirrhosis and hepatocellular carcinoma1. It is defined by fat accumulation exceeding 10% in hepatic cells from non-alcoholic causes2. In developed countries, NAFLD affects over 30% of the population, with higher prevalence in males and older adults3. Over 80% of obese individuals, particularly those with diabetes and hyperlipidaemia, are affected4. In India, prevalence ranges from 9% to 53%, most commonly in individuals aged 40–50. Metabolic syndrome components, such as obesity, diabetes, and hypertension, significantly increase NAFLD risk5,.

Individuals with components of metabolic syndrome, such as diabetes, hypertension, heart disease, and hyperlipidemia, are more prone to developing hepatic steatosis due to increased fatty acid release from adipose tissue to the liver 6. Abdominal obesity is often associated with insulin resistance, which some studies have identified as a cause of NAFLD 7. In obese adolescents, each one-centimeter increase in visceral obesity is linked to a twofold increase in the risk of NAFLD, which is strongly associated with metabolic syndrome 8. Recent trends indicate a shift in the affected age group from middle-aged adults to adolescents and young adults 5,9. Around 18% of adolescents and young adults globally have NAFLD9, which can be attributed to a sedentary lifestyle, lack of physical activity, and poor dietary habits. Public awareness remains limited; studies show significant knowledge gaps in countries like the U.S.10 and India, where 58% of urban populations are unaware of NAFLD.

The Indian government has integrated NAFLD into its National Program for control and prevention of cancer, Diabetes, Cardiovascular diseases and stroke to raise awareness11. However, lifestyle interventions have had limited success, particularly among youth12. Research on NAFLD awareness, especially among adolescents is scarce, and no Indian studies have utilized focus group discussions to assess NAFLD knowledge. This study aimed to evaluate awareness of NAFLD, its risk factors, and prevention among Degree college first year students, using a novel focus group discussion method with pre- and post-test evaluations.

A quasi-experimental pre- and post-test study was conducted from September 2022 to March 2023 among 111 first-year degree college students in Ongole, Andhra Pradesh. Focus group discussions (FGDs) were used for awareness on Non-Alcoholic Fatty Liver Disease (NAFLD) with pre- and post-tests administered to this group. Twelve trained mentors facilitated FGDs using presentations, videos, flip charts, and posters covering NAFLD's epidemiology, risk factors, clinical features, complications, investigations, and management. Content was developed and verified by faculty and experts13. Mentors underwent two days of training on conducting and moderating focus group discussions, facilitated by expert faculty members from the Department of Community Medicine and rehearsed sessions before engaging students.

Each mentor conducted FGDs with 10 students after administering pre-test questionnaires. Sessions involved interactive discussions with visual aids, including flip charts, posters, and presentations from laptops followed by post-tests using the same questionnaire, and feedback was gathered from the students.

Pre-tested, pre-structured, validated questionnaires were employed to collect information from the study participants both before and after the focus group discussions. The questionnaires covered personal and demographic details, as well as awareness regarding Non-Alcoholic Fatty Liver Disease, Foods that contribute to fatty liver, Risk factors, Clinical features, Tests for diagnosis,Complications,Safe foods, Prevention, management, and treatment options, and self-knowledge assessment.

Data Analysis

All data formats were securely stored, and statistical analyzed by using Microsoft Excel and SPSS (trial version 20). A chi-square test for paired proportions assessed knowledge differences before and after the intervention. Awareness of fatty liver was evaluated using a Likert scale.

Out of 111 first-year degree college students 42.3% were male and 57.7% were female. 57.7% of the students came from a rural background, and 59.4% belonged to nuclear families. According to the B.G. Prasad classification (2022), 41.4% of the participants belonged to the upper class and 8.1% were lower class (Table 1).

Table-1: Sociodemographic Details of Degree College Students

Only 9.0% of the students had heard of NAFLD. Participants noted that middle-aged individuals (56.8%) and the elderly (27.9%) were most frequently influenced by NAFLD. Furthermore, only 9.9% of students were aware of all four grades of NAFLD (Table 2)

Table-2: Awareness on NAFLD among Degree College Students

Before the focus group discussion, awareness of foods contributing to NAFLD was high for oily foods (68%). Post-discussion, for butter (100%) and rice (95.45%). Awareness also improved for Maida and cakes (89.18%) and chicken and meat (88.28%). (Fig-1)

Table-3: Awareness on Risk Factors for NAFLD before and After Focus Group Discussion (N=111)

Before the focus group discussion, awareness was higher for fatigability (45.9%) and lower abdominal pain (40.5%). Post-discussion, awareness improved for abdominal discomfort (99%), muscle wasting (95.4%), fatigability and lower abdominal pain (92.7%). (Table-4)

Table-4: Awareness on Clinical Features of NAFLD before and After Focus Group Discussion (N=111)

Before the FGD, awareness on investigations was highest for fasting glucose (68.4%), followed by BMI (60.3%). After FGD, highest awareness was recorded for ultrasound and fasting glucose (97.2%), followed by liver function tests, BMI, FibroScan, and lipid profile (95.4%), biopsy (93.6%) and CT scan (92.7%).(Fig-2)

Table-4: Awareness on Safe Foods for NAFLD before and After Focus Group Discussion (N=111)

Before FGD, awareness was high for statins (84.6%) and anti-diabetic drugs (73.8%). Post-discussion, statins (94.5%), treatment availability, and regular exercise (93.6%) showing the highest awareness. Significant differences were noted in areas such as anti-diabetic drugs (p=0.00061), statins (p=0.0015), treatment availability, dietary modifications, antioxidants, vitamin E, exercise, weight loss, and supplements (p=0.0001). (Table-5)

Table-5: Awareness on Management and Treatment of NAFLD Before and After Focus Group Discussion (N=111)

The mean awareness in the pretest for the focus group discussion was 5.5 out of 10 points, while the post test was increased to 8.6. The difference between the pretest and posttest scores in the focus group discussion was found to be significant, as determined by the t-test (P < 0.05) (Fig-4)

Despite the high prevalence of NAFLD, studies on awareness through focus group discussions in India remain quite limited. In our study, the majority of degree college students belonged to the upper class (41.4%) and only 9% of students had heard of NAFLD. A study conducted in Korea revealed that most of the respondents (72.8%) heard about NAFLD 14 and one study in general population revealed that 43% of the respondents had a poor knowledge and as per Saudi Arabia study 17% aware about NAFLD 15, and 18% respondents in American survey reported low awareness even in at-risk subjects 16 . A study on NASH found that, patients who had good knowledge about NAFLD expressed the source of information was internet and family members 17.

Significant increase in awareness was noted for foods related with NAFLD following the focus group discussion: butter (43.2% to 100%), rice (25.2% to 95.4%), sugar (38.7% to 94.8%), processed foods (42.3% to 94.8%), oily foods (68.5% to 92.8%). A study from Sweden found that steatosis could be managed with 10% weight loss, physical exercise and low alcohol consumption18. An observational study revealed an association between high intake of added sugars and concurrence of NAFLD in adults and children19. In our study pale stools (21.6%), muscle wasting, weight loss (23.4%), and dark urine (24.3%) were among the clinical signs of NAFLD that people were least aware of prior to FGD. A study among Asian Indians found that participants recognized abdominal pain, swelling, jaundice, and nausea as NAFLD symptoms9 and in another study it was found that most commonly presented symptoms of NAFLD as per participants were nausea and vomiting (11.7%) headache (8.8%), fatigue and  lethargy (68.5%) 20.

Before focus group discussion, percentage of people who were aware of the main metabolic syndrome components like obesity, hypertension, diabetes, and hyperlipidemia were found to be 31.5%, 33.3%, 55.8%, and 49.5% respectively, and after FGD discussion all these values were increased to above 92%. This is similar to a another study where 96% of participants viewed that NAFLD was related to Obesity, 93% to dyslipidemia, and 62% to DM 20, and another study revealed that physicians and resident doctors were well aware of the risk factors for developing NAFLD like Life Style diseases 22.It was observed in our study that before FGD there was a high awareness of NAFLD investigations among degree students' about fasting glucose (68%), body mass index (BMI) (60.3%), biopsy (58.5%), liver CT scan (48.6%), and ultrasonography (36.9%). In a similar study among medical students found that the awareness regarding the diagnostic methods were 62% for ultrasonography, 73.3% for liver biopsy and 39.6% for fibro scan and ultrasonography and MRI are sensitive modalities for diagnosing fatty liver 23.

We found that, with FGD there was a significant improvement on awareness on weight loss goal (22.5% to 54%), antioxidants (37.8% to 90.9%), vitamin E (47.7% to 90.9%), dietary modifications (59.4% to 90.9%), regular exercise (62.1% to 93.6%), supplements (63% to 91.8%), anti-diabetic drugs (73.8% to 88.2%), and statins (84.6% to 99.5%). There was a significant difference (P<0.01) in the management and treatment awareness between the pretest and posttests of the FGD group of degree college students. As per Romero-Gómez MA etal study participants agreed that diet (99.6%), exercise (99.6%) and avoidance of alcohol consumption (91.3%) were the best treatment options for NAFLD. A weight loss of more than 10% reverses the fibrosis in early stages24.

Very few studies on awareness with focus group discussion among Degree students was conducted in India and significant improvement in awareness on availability of treatment and management for NAFLD among Degree students with FGD. Health Education awareness programme on NAFLD need to be strengthened in the schools and colleges and specific Health promotion approaches need to be used for its prevention, early detection, and treatment.

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