Preventive Hepatology and the Healthy Life, Healthy Liver Initiative: A Roadmap to Liver Wellness

The liver silently performs a multitude of vital functions that underpin human health. It filters toxins from the blood, produces bile essential for digestion, stores energy reserves and synthesises crucial proteins.[1] However, our modern lifestyle, often characterised by unhealthy diets, sedentary habits, high-risk behaviour and exposure to environmental pollutants, is increasingly jeopardising liver health.[2] The ‘Healthy Life, Healthy Liver’ initiative by international organisations and Preventive Hepatology, pioneered by the All India Institute of Medical Sciences (AIIMS), Rishikesh, since December 2021, emerges as crucial public health strategies, emphasising the importance of prevention and empowering individuals to make informed choices for a healthier lifestyle with a healthy liver.[3,4] This initiative seeks to raise awareness about the silent burden of liver diseases and encourage individuals to adopt proactive measures to safeguard their liver health. It emphasises that even small changes can make a significant difference in maintaining a healthy liver and preventing the progression of liver diseases.[3,4] THE ESCALATING GLOBAL BURDEN OF LIVER DISEASE Liver diseases, encompassing a wide spectrum of conditions ranging from viral hepatitis A-E, alcohol-related liver diseases (ALD) to non-alcoholic fatty liver disease (NAFLD), represent a significant global health challenge with far-reaching consequences.[5] Liver diseases are a major global health concern, responsible for over two million deaths each year. This represents approximately 4% of all deaths worldwide – that is 1 in every 25 deaths. Women are disproportionately affected, accounting for 1 in 3 liver-related deaths. Of those deaths, liver cancer is a significant contributor, causing between 600,000 and 900,000 fatalities annually.[6] NAFLD, in particular, has emerged as a leading cause of chronic liver disease (CLD) globally, with a prevalence estimated to be around 25%. The alarming rise of NAFLD is closely linked to the increasing prevalence of obesity, type 2 diabetes and metabolic syndrome.[7] This rise in NAFLD is mirrored in the growing prevalence of metabolic dysfunction associated with steatotic liver disease, a recently proposed terminology that emphasises the close interplay between metabolic dysfunction and liver disease.[8] PREVENTIVE HEPATOLOGY: A PARADIGM SHIFT IN LIVER CARE Definition of Preventive Hepatology: “Preventive hepatology, a growing subspecialty of preventive medicine, is the practice of primordial, primary, secondary, and tertiary prevention of all liver diseases.” It is a transdisciplinary approach involving both public health and clinical departments. The term ‘preventive hepatology’, first coined in December 2021 by Bhadoria et al.,[9] at AIIMS, Rishikesh, signifies a paradigm shift in liver care. It emphasises a proactive approach that focuses on preventing liver diseases before they occur, rather than solely focusing on treatment after the disease has manifested. The preventive hepatology initiative since December 2021, championed by AIIMS, Rishikesh, India, is deeply rooted in this philosophy, encompassing a range of strategies comprehensively covering all levels of prevention from primordial, primary and secondary to tertiary care.[3] It includes highlighting the role of multi-disciplinary approach involving public health specialists to work hand in hand with clinicians advocating and supporting lifestyle modifications, vaccination to regular screening and early diagnosis targeting ‘Healthy Life, Healthy Liver’ initiative. This proactive approach is critical in combating the growing burden of liver disease and improving overall public health, as highlighted in the global action agenda to address fatty liver disease.[2] KEY PILLARS OF THE ‘PREVENTIVE HEPATOLOGY’ INITIATIVE TO ACHIEVE HEALTHY LIFE AND HEALTHY LIVER The ‘Preventive Hepatology’ initiative emphasises a multi-faceted approach to liver health, focusing on health education and health promotion activities about the key lifestyle factors that can significantly impact liver function and disease risk. Healthy diet: A balanced diet rich in fruits, vegetables, whole grains and lean protein is crucial for maintaining a healthy liver. Limiting processed foods, sugary drinks and saturated fats can help prevent the development of fatty liver disease and other metabolic disorders.[7] Dietary interventions, such as the Mediterranean diet, have shown promise in improving liver health and reducing the risk of NAFLD progression[10] Regular exercise: Physical activity plays a vital role in maintaining a healthy weight and reducing the risk of NAFLD. Engaging in regular exercise can also improve insulin sensitivity, reduce inflammation and enhance overall metabolic health.[11] Current guidelines recommend at least 150 min of moderate-intensity or 75 min of vigorous-intensity aerobic activity per week, spread throughout the week, for optimal health benefits[11] Alcohol and liver health: Excessive alcohol consumption is a major risk factor for a spectrum of liver diseases, including alcoholic fatty liver disease, alcoholic hepatitis and cirrhosis.[12] These conditions can lead to liver failure, liver cancer and, ultimately, death. The ‘Healthy Life, Healthy Liver’ initiative recognises the significant impact of alcohol on liver health and emphasises the importance of no alcohol policy as the key preventive strategy Understanding the risks: The initiative aims to educate the public about the link between alcohol consumption and liver damage. It emphasises that even moderate alcohol intake can contribute to liver disease over time, especially in individuals with other risk factors such as obesity or viral hepatitis Promoting responsible drinking: For those who choose to drink alcohol, the initiative encourages responsible drinking habits. This includes limiting the amount of alcohol consumed, avoiding binge drinking and being mindful of the alcohol content in different beverages Supporting abstinence: The initiative also provides support and resources for individuals who choose to abstain from alcohol altogether. This includes promoting awareness of the benefits of abstinence and providing access to counselling and support groups. Vaccination: Vaccination against hepatitis B is a crucial preventive measure, especially in regions with high prevalence rates. Hepatitis B vaccination can prevent chronic infection and its associated complications, including liver cirrhosis and liver cancer[13,14] Regular checkups: Regular liver health checkups, including viral markers, liver function tests and imaging studies, are essential for early detection and management of liver diseases. Individuals with a personal or family history of metabolic traits such as obesity, diabetes, hypertension, dyslipidaemia, gallbladder stones and coronary artery diseases should be particularly more vigilant about regular screenings and should follow no alcohol policy as even consumption of lesser amount for lesser duration can cause more liver damage.[15-17] To achieve the WHO viral hepatitis elimination targets, increasing testing for hepatitis B and C and linkage to care is the key strategy with the availability of effective treatment for hepatitis B and cure for hepatitis C. THE IMPACT OF THE ‘PREVENTIVE HEPATOLOGY’ INITIATIVE By promoting these healthy habits amongst individuals and delivering comprehensive health care, the ‘Preventive Hepatology’ initiative can significantly reduce the burden of liver disease and improve overall public health and wellness. It empowers individuals to take control of their liver health, leading to better clinical outcomes and improved quality of life.[3] As a systematic review demonstrate, proactive management and patient engagement are crucial in improving clinical and patient-reported outcomes for individuals with NAFLD.[18] A CALL TO ACTION: INVESTING IN LIVER HEALTH The ‘Preventive Hepatology’ or ‘Healthy Life, Healthy Liver’ initiatives represent a critical investment in public health. By prioritising liver health, we can prevent both the development and the progression of liver diseases, reduce healthcare costs and improve the overall well-being of individuals and communities. There is an urgent need for policy action and inclusion of NAFLD, ALD and related CLD and liver cancer in the WHO non-communicable disease action plan.[2,19-21] Let us all join hands to support this vital initiative. By adopting a healthy lifestyle, we can protect our livers and live longer, healthier lives. Remember, a healthy liver is crucial for a healthy life!