Thursday November 27 2014
Both obesity and alcohol abuse can cause liver disease
"Doctors call for tougher laws on alcohol abuse to tackle liver disease crisis," The Guardian reports. But this is just one of 10 recommendations for tackling the burden of liver disease published in a special report in The Lancet.
The report paints a grim picture of an emerging crisis in liver disease in the UK, saying it is one of the few countries in Europe where liver disease and deaths have actually increased rapidly over the last 30 years. It concludes with 10 recommendations to tackle the burden of liver disease.
The media has approached the recommendations from many different angles, with many sources only reporting on one, not all, of the recommendations.
For example, BBC News and The Daily Telegraph focused on the call for improved diagnosis in primary care: "GPs should offer liver scans to those who drink too much," reported The Telegraph.
The Guardian focused on calls for tougher regulation of the alcohol industry, such as minimum pricing for alcohol and a restriction on advertising and sponsorship by alcohol manufacturers, while the Mail's reporting focused on their core audience: "The middle class are fuelling an increase in death from liver disease".
What is liver disease?
There are more than 100 types of liver disease, which together affect at least 2 million people in the UK.
In the UK, the three most common types are:
All three are preventable:
Who wrote this report?
The report was compiled by a group of UK doctors and academics, and was published in the peer-reviewed medical journal, The Lancet.
The work was organised by The Lancet to "provide the strongest evidence base through the involvement of experts from a wide cross-section of disciplines, making firm recommendations to reduce the unacceptable premature mortality [death] and disease burden from avoidable causes, and to improve the standard of care for patients with liver disease in hospital".
The report stated that no people involved in the report were compensated for their time and no competing interests were declared.
The report involved many of the major medical and liver research councils in the UK, including the British Liver Trust, the Royal College of General Practitioners, the Children's Liver Disease Foundation, the Royal College of Physicians, the British Society of Gastroenterology, the Foundation for Liver Research, and the British Association for the Study of the Liver.
The views expressed in the report were described as those of the authors and do not necessarily represent the views of any of the organisations involved in this report.
What were the issues identified in the report?
The report outlined how liver disease in the UK "stands out as the one glaring exception" to the vast improvements in health and life expectancy made over the past 30 years for many diseases, such as stroke, heart disease and many cancers.
The rise in liver disease-related deaths was described as being linked to similar rises in known risk factors for liver disease, namely alcohol consumption, obesity and an increasing number of cases of viral hepatitis (especially hepatitis C).
Deficiencies in hospital and primary care of liver disease were also highlighted alongside the financial impact to the NHS.
Some of the key facts used to describe the current "crisis" in liver disease include:
- Death rates from liver disease have increased 400% since 1970 overall, and almost 500% in those under 65.
- Liver disease is the third most common cause of premature death in the UK, and the rate of increase in liver disease is substantially higher in the UK than other countries in Western Europe.
- More than 1 million admissions to hospital per year are the result of alcohol-related disorders, and both the number of admissions and the increase in deaths closely parallel the rise in alcohol consumption in the UK over the past 30 years.
- Of the 25% of the population now categorised as obese, most will have non-alcoholic fatty liver disease, and many (up to 1 in 20) will have ongoing inflammation and scarring that finally leads to cirrhosis. Of those patients with cirrhosis, 5-10% will get liver cancer.
- This increasing burden of liver disease is added to by chronic viral hepatitis – annual deaths from hepatitis C have almost quadrupled since 1996, and about 75% of people infected are estimated to be still unrecognised. The same applies to chronic hepatitis B infection, which can progress to cirrhosis and liver cancer.
- The cost to the UK's National Health Service is equally staggering, with estimates of £3.5 billion per year for alcohol-related health problems and £5.5 billion per year for the consequences of obesity.
- There is an unacceptable variation in the health outcomes of people attending different specialist liver disease services across the country. This means some specialist centres are performing much worse than others.
- Based on survey data, the care of patients acutely sick with liver disease dying in hospital was judged to be good in less than half of cases. Other unacceptable findings were the inadequate facilities and lack of expertise of those caring for patients.
- Deficiencies exist in primary care, which has crucial opportunities for the early diagnosis and prevention of progressive disease.
- Those affected most by the burden of liver disease and death are the poorest and most vulnerable in our society.
What were the suggested solutions?
The report states the recommendations made were selected on the basis that they will have the greatest effect, and that these need to be implemented urgently.
"Although the recommendations are based mostly on data from England, they have wider application to the UK as a whole, and are in accord with the present strategy for healthcare policy by the Scottish Health Boards, the Health Department of Wales, and the Department of Health and Social Services in Northern Ireland."
The report's 10 most high-impact and urgently needed recommendations are:
1. Strengthen the detection of early liver disease and its treatment by improving the level of expertise and facilities in primary care.
2. Improve support services in the community setting for screening of high-risk patients.
3. Establish liver units in district general hospitals to be linked with 30 specialist centres distributed regionally to make highly specialised investigations and treatment available.
4. A national review of liver transplantation services to ensure better access for patients in specific areas of the country, and provide sufficient capacity for the anticipated increase in the availability of donor organs.
5. Strengthen the continuity of care in transition arrangements for the increasing number of children with liver disease surviving into adult life.
6. Implement a minimum price per unit, health warnings on alcohol packaging, and the restriction of alcohol advertising and alcohol sales.
7. The promotion of healthy lifestyles to reduce obesity in the country and its results on health, governmental regulations to reduce sugar content in food and drink, and the use of new diagnostic pathways to identify people with non-alcoholic fatty liver disease.
8. Eradicate infections from chronic hepatitis C virus in the UK by 2030 using antiviral drugs, reduce the burden of hepatitis B virus, target high-risk groups for these viruses, including immigrant communities, and use a universal six-in-one hepatitis B vaccination for infants.
9. Increase provision of medical and nursing training in hepatology, and wider educational opportunities for healthcare professionals to increase the number of doctors and nurses in hospitals and primary care.
10. Increase awareness of liver disease in the general population with a national campaign led by NHS England – clinical commissioning groups (CCGs) should increase awareness in area health teams.
Is the report reliable?
The report was an evidence-based piece combining established trend data and research evidence with expertise from various academics and doctors involved in liver disease and research.
It stresses the need for the recommendations to be evidence-based and scientifically focused. This gives us some confidence it is broadly reliable and represents the views of clinical opinion leaders and academics in liver disease research and treatment.
But, as far as we can tell, there was no systematic attempt to search and review the literature and data to ensure all relevant material was considered, as would be the case with a systematic review.
This means it is not clear to what extent evidence was used to support an existing stance, or whether certain relevant evidence or viewpoints have been intentionally or unintentionally excluded.
This leaves open the possibility that the report may present an overly critical or sensationalist view of the current state of affairs to stimulate a sense of urgency and instigate the action the authors perceive to be necessary.
But as the report used relatively objective data sources and stressed being scientifically focused, the impact of any bias is likely to be minimal.
What happens next?
It is difficult to predict. Some of the recommendations, such as providing resources to make the early diagnosis of liver disease more likely, are purely clinical.
Whether or not the recommendation is taken up will probably be based on whether the resources are available and this can be justified.
But other recommendations – such as introducing minimal alcohol pricing, restricting alcohol sales to certain times of the day, and bringing in new rules regarding the advertising of alcohol – are politically controversial, and are likely to meet with fierce opposition from the alcohol industry.
It would be surprising if any party publically supported the recommendations this side of the upcoming general election.
Governments do have the power to change behaviour, which, as with the smoking ban, can prove very successful in achieving large-scale change.
But ultimately the responsibility of preventing liver disease is yours. If you moderate your alcohol consumption, try to maintain a healthy weight, and never share needles (if you are an injecting drug user), you should have a good chance of avoiding liver disease.
Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.