People with both diabetes and non-alcoholic fatty liver disease face double the risk of developing severe liver scarring that can progress to cirrhosis or liver failure, a nationwide study spanning 30 hospitals across India has found.

The findings highlight the need to screen patients diagnosed with either condition for the other and to design treatment strategies that address both risks early, according to members of a research consortium that conducted the study.

The results underscore a significant public health risk in India, where both conditions are common and often remain undiagnosed. Pooled estimates from earlier studies suggest that fatty liver disease affects roughly one in three adults, while diabetes affects one in 10, representing a large, growing population at risk of severe liver disease.

Doctors have long known that diabetes and metabolic dysfunction-associated steatotic liver disease (MASLD) — the new name for non-alcoholic fatty liver disease — stem from disruptions in the way the body processes energy, including sugar and fat. Each condition increases the risk of the other. But the extent to which their co-existence influences progression to severe liver scarring, known as advanced fibrosis, had remained unclear.

“All fatty liver disease isn’t the same — some people may have a relatively benign form without inflammation or progression for years,” said Ajay Duseja, professor and head of hepatology at the Postgraduate Institute of Medical Education and Research, Chandigarh, who led the study.

Duseja added: “But our findings show that diabetes significantly raises the risk of advanced fibrosis.”

Duseja is the principal investigator of the Indian Consortium on MASLD, a research effort tracking several thousands of patients with the disease in Calcutta, Chennai, Delhi, Hyderabad, Jodhpur, Ludhiana, Mumbai, and other cities for nearly five years.

For the new analysis, the consortium examined 400 patients with MASLD confirmed through liver biopsy, among whom 93 also had diabetes. Advanced fibrosis was detected in 32 of the 93 patients with both conditions, or 34 per cent, compared with 50 of the 307 patients with MASLD alone, or 16.6 per cent, a two-fold higher risk when diabetes was present.

The study’s findings appear this month in the Journal of Clinical and Experimental Hepatology.

“This is yet another reason to prevent diabetes or maintain good sugar control,” said Shalimar, a hepatologist and consortium member at the All India Institute of Medical Sciences, New Delhi. “We’re increasingly seeing that diabetes, beyond its well-known effects on the heart and kidneys, also directly harms the liver,” Shalimar, who uses a single name, told The Telegraph.

An independent study led by Shalimar at AIIMS last year found that patients with diabetes and MASLD had higher rates of liver-related complications, including esophageal bleeding, fluid accumulation in the abdomen and hepatic encephalopathy, a liver-related brain disorder.

That study, which followed about 1,000 patients, also reported higher rates of premature death among those with diabetes.

The Indian findings mirror evidence from a much larger US study that tracked more than 21,000 patients over two decades and found that pre-diabetes or diabetes increased the risk of death in people with MASLD by about 25 per cent. The study, published in Clinical Gastroenterology and Hepatology in September 2025, had also identified high blood pressure and low levels of “good” HDL cholesterol as additional contributors to premature mortality.

“MASLD is a complex disease, and not all patients face the same risks,” Norah Terrault, professor of medicine and chief of gastroenterology at the University of Southern California, who led the US study, said in a media release then. “Understanding which factors drive poorer outcomes allows clinicians to intervene earlier and offer patients better care.”