A silent burden affecting millions of people
Beyond hepatology: a broader public health response
Missed opportunities for prevention and early detection
Europe is facing a growing threat from chronic liver disease, according to a new series published today in The Lancet Regional Health – Europe, involving more than 75 co-authors from 30 countries. Led by the Barcelona Institute for Global Health (ISGlobal), a centre supported by the ”la Caixa” Foundation, the series entitled Ending the chronic liver disease public health threat in Europe warns that liver disease must be moved beyond the exclusive domain of hepatology and better integrated into European healthcare systems.
A silent burden affecting millions of people
Chronic liver disease represents a significant burden of disease and premature mortality in Europe, with a disproportionate impact on men and socially disadvantaged populations. It is currently the second leading cause of years of working life lost in Europe, second only to ischaemic heart disease.
The series also warns that metabolic liver disease is rapidly transforming the burden of liver disease in Europe. It is estimated that one in three people in the European Union and the United Kingdom lives with metabolic and fatty liver disease (MASLD), currently one of the main drivers of liver cancer in Europe.
Europe has the highest rates of alcohol consumption per person, the highest prevalence of episodes of heavy drinking and the lowest rates of alcohol abstinence worldwide. The combination of alcohol with obesity and other risk factors associated with liver disease is contributing to high rates of end-stage liver disease and liver cancer. It is estimated that alcohol is responsible for 40% of the 287,000 premature deaths related to liver disease that occur each year in Europe, although the actual figure could be even higher.
Across Europe, liver disease is already affecting the health of the working-age population. Deaths from alcohol-related liver disease and from undiagnosed or untreated viral hepatitis often occur decades earlier than those associated with many other chronic diseases. Hepatitis B and C account for more than 85% of the approximately 57,000 annual deaths related to HIV, tuberculosis and viral hepatitis in the EU and the European Economic Area.
Imagen de archivo de material de laboratorio – PHOTO/Fundación ”la Caixa”
Beyond hepatology: a broader public health response
“Europe does not need a new warning that liver disease is getting worse. It needs a different way of responding,” says Jeffrey V. Lazarus, head of the public health and liver diseases group at ISGlobal, professor at the CUNY Graduate School of Public Health and Health Policy, and coordinator of the The Lancet series.
“When we talk about ultra-processed foods, alcoholic drinks or unhealthy diets, we are essentially talking about the risk of liver disease. And when we talk about diabetes, obesity or a sedentary lifestyle, we are also talking about that same risk. We need stronger public health policies and interventions to tackle this burden of disease,” says Lazarus.
“And primary care must also change. It makes no sense to assess blood pressure, cholesterol or body weight without assessing liver fibrosis,” he adds.
The series analyses chronic liver disease from four complementary perspectives:
Screening and care pathways
Policy development on MASLD
Alcohol-related liver disease and MetALD (metabolic and alcohol-related fatty liver disease)
Progress towards the elimination of viral hepatitis
It also addresses the metabolic, viral and alcohol-related causes of liver disease together. “By analysing these causes in an integrated manner, these papers demonstrate why Europe needs coordinated strategies for prevention, earlier detection, care pathways and a stigma-free approach that links liver health with diabetes, obesity, cardiovascular diseases, alcohol policies, cancer prevention and the needs of the most underserved communities,” explains Elisa Pose, co-coordinator of the series.
In one of the commentaries accompanying the series, patient advocates Jeff McIntyre, Gina Bartes and Raquel Peck warn that people with liver disease often face prejudice and judgement that portray the disease as an exclusive consequence of individual choices. “The stigma arising from this lack of context directly influences the seeking of healthcare, adherence to treatment and health outcomes, as well as shaping policy priorities and contributing to the under-recognition of liver disease,” they note.
Paul Brennan, also a co-coordinator of the series, adds: “For too long we have accepted the normalisation of an approach promoted by both society at large and industry lobbyists, which places the blame on individuals rather than on the collective shortcomings and responsibilities of governments and institutions. Liver disease, particularly NAFLD, viral hepatitis and alcohol-related liver disease, disproportionately affects the most vulnerable members of society. In this series, we demonstrate how to incorporate evidence-based interventions regarding diagnosis, system readiness, care pathways and policy development to better protect future generations in Europe.”
Missed opportunities for prevention and early detection
The authors also warn that millions of people with chronic liver disease remain undiagnosed. Earlier identification in primary and community care, including screening strategies and automated, non-invasive assessments of liver fibrosis, could prevent progression to advanced fibrosis, cirrhosis, liver cancer and premature death.
Key recommendations include:
Integrating liver health into strategies for the prevention of non-communicable diseases and cancer.
Aligning responses to liver disease with policies on diabetes, obesity, alcohol, cardiovascular disease, physical activity and nutrition.
Strengthening surveillance and early detection systems.
Improving access to treatment and harm reduction services.
Implementing stronger policies on alcohol and reducing the commercial drivers of associated harm.
Addressing stigma and the barriers affecting the most underserved communities.
“Ending chronic liver disease as a public health threat in Europe is possible, but only if Europe acts before advanced disease becomes the usual point of diagnosis,” concludes Lazarus.
The publication of the series coincides with the main event organised today in Barcelona by the Global Think-tank on Steatotic Liver Disease, an initiative of ISGlobal’s public health and liver diseases group, held ahead of this year’s European Association for the Study of the Liver (EASL) Congress.
About the series
The series comprises four articles and four associated commentaries. The articles focus on:
Diagnostic innovation and care models for chronic liver disease.
Policy development on MASLD in Europe.
Alcohol-related liver disease and MetALD.
Control and elimination of viral hepatitis.
The commentaries accompanying the series address key issues such as the advocacy for patients’ rights, cultural and linguistic barriers to accessing healthcare, laboratory medicine, and the needs of people with autoimmune and rare liver diseases.