Michelle Clayton examines the current and future impact of liver disease and its causes, and highlights the role of nurses in educating and supporting patients to prevent the disease developing.

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Read this article to learn more about:

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    the causes and prevalence of liver disease
  • the lifestyle-related factors than can cause or exacerbate liver disease
  • the impact of the obesity epidemic on the prevalence of liver disease
  • predicted rates of liver disease in the future
  • how nurses can support and educate patients to make healthy choices to prevent liver disease developing.

L iver disease is the fifth biggest killer in the UK1 and the third most common cause of premature death.2,3 These startling statistics have shocked many healthcare professionals, who are more familiar with other high-profile causes of death such as cancer and cardiovascular disease. Lifestyle-related factors have contributed to the rise in prevalence of liver disease. As a nation, we are becoming more obese owing to overindulgence, a propensity to consume 'ready meals', and lack of exercise. In addition, many people are living in areas with health inequalities that impinge on their ability or willingness to eat healthily.4 Alcohol intake is also a factor in the rise in prevalence of liver disease; many people drink more than the recommended daily limit. This excess intake can be caused by stress, as individuals drink alcoholic beverages after work every day to unwind. There is a culture of social drinking in our country and many people are unaware of exactly how much alcohol constitutes one unit. In the light of evidence that lifestyle-related factors have an adverse effect on liver health, a Lancet commission on liver disease is looking at ways to improve overall liver health.3

The liver is a unique organ that undertakes a large number of functions (in excess of 500) every moment of every day. It is an uncomplaining organ that continues to function while damage is occurring. Some liver diseases appear after months, or even years, for example, hepatitis C, in which an individual could have contracted the virus 20–30 years before the disease appears.5 However, at some point the balance tilts, and individuals may present with a complication of cirrhosis, such as an oesophageal bleed, ascites, or jaundice, which may come as a surprise, as there may have been no previous indication or suspicion of underlying liver disease.

Lifestyle choices and liver health

Over the last 20–30 years, lifestyle choices have had a great impact on liver health. As a society, we drink more alcohol than ever, in social settings or at home. In the light of this, new guidelines issued by the Chief Medical Officers have reduced the recommended alcohol consumption to 14 units per week for both men and women. The guidelines also recommend that individuals should include 2–3 alcohol-free days per week.6

Hepatitis B and C

There is an increasing number of people infected by either hepatitis B or C. With increases in migration from high-risk areas such as China, Sub-Saharan Africa, and Eastern Europe, rates of hepatitis B are on the increase. Many people contract the hepatitis B virus via vertical transmission at birth and carry the active virus throughout their lives. Hepatitis C is also found in migrant populations, such as those originating from South Asia, where transmission of hepatitis C tends to be caused by poor vaccination practices. There is also a further category of people who inject drugs who may have hepatitis C (the disease is transmitted mainly intravenously, although the virus has also been found on drug paraphernalia). It is vital that, even if an individual has injected drugs intravenously only once, many years ago, they are tested for hepatitis B and C. Identification of individuals at risk who should be tested can be found in NICE Public Health Guideline 43 on Hepatitis B and C testing: people at risk of infection,7 also see the related Guidelines for Nurses summary.

Obesity and liver disease

Obesity is responsible for wide-ranging effects on both adults and children, and there is a growing body of evidence that obesity is a major contributing factor to the burden of liver disease owing to the development of non-alcoholic fatty liver disease (NAFLD) in obese individuals.3 There are pockets of the country where obesity rates reach almost 30%.8 It is estimated that, by 2050, 60% of men, 50% of women, and 25% of children will be obese,8 fuelling a massive epidemic of liver disease. There is a strong association between NAFLD and diabetes and/or metabolic syndrome. Health inequalities have played a part in fuelling obesity. However, obesity does not exclusively affect the lower classes.

Future directions

Promoting liver health should be an integral part of the role of healthcare professionals. Nurses are particularly well placed to make each contact with patients count, owing to the therapeutic relationship that they have with patients. There is huge potential within the nursing workforce to empower and encourage people by providing information, treatment, and support to help people live healthier lives.9 With regard to liver health, nurses could be a powerful force in identifying those at risk of liver disease and sign-posting them to support services, as well giving general advice.

Good practice includes encouraging and educating people on healthy eating, weight management, increasing exercise to prevent or reduce obesity-related liver disease, and supporting small sustainable changes that improve long-term health and wellbeing. It also includes being aware of who is at risk of hepatitis B and C and encouraging those individuals to get tested, as very successful treatments can be offered that eradicate these viruses. Finally, it is important to understand what one unit of alcohol looks like—one unit equates to:10

  • 76ml of 13% wine (a medium-sized glass of wine is 175 ml)
  • 218ml of 4.5% cider
  • 250ml of 4% beer
  • 25ml of 40% spirit, such as whisky, vodka, or gin.

It is important to ask people about their alcohol consumption. When, where, and how much alcohol they drink? By improving our knowledge and understanding of alcohol, as well as how and when people use it, we can tailor support and advice for patients to reduce their alcohol intake.

In conclusion, harnessing the potential of nurses working in a community setting is key to reducing the burden of liver disease for this generation and preventing lifestyle-related liver disease for the next.

 

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References

  1. British Association for the Study of the Liver, British Society of Gastroenterology. A time to act: improving liver health and outcomes in liver disease. London: BSG, 2009. Available at: www.bsg.org.uk/sections/liver-articles/the-national-plan-for-liver-services-uk-2009.html (accessed 9 May 2016)
  2. Public Health England. Improving liver health in the East Midlands: a call to action. London: PHE, 2015. Available at: www.gov.uk/government/publications/improving-liver-health-in-the-east-midlands-a-call-to-action (accessed 9 May 2016)
  3. Williams R, Aspinall R, Bellis M et al. Addressing liver disease in the UK: a blueprint for attaining excellence in health care and reducing premature mortality from lifestyle issues of excess consumption of alcohol, obesity, and viral hepatitis. Lancet 2014; 384 (9958): 1953–1997.
  4. Public Health England. Knowledge and attitudes towards healthy eating and physical activity. London: PHE, 2011. Available at: www.noo.org.uk/NOO_pub/briefing_papers (accessed 17 May 2016)
  5. Westbrook R, Dusheiko G. Natural history of hepatitis C. Journal of Hepatology 2014; 61: S58–S68.
  6. Department of Health. Alcohol guidelines review—report from the guidelines development group to the UK Chief Medical Officers. London: DH, 2016. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/489797/CMO_Alcohol_Report.pdf (accessed 14 March 2016)
  7. NICE. Hepatitis B and C testing: people at risk of infection. Public Health Guideline 43. NICE, 2012. Available at: www.nice.org.uk/guidance/ph43 (accessed 14 March 2016)
  8. NHS Right Care. Liver disease: the NHS atlas of variation in healthcare for people with liver disease. NHS Right Care, 2013. Available at: www.rightcare.nhs.uk/index.php/atlas/liver-disease-nhs-atlas-of-variation-in-healthcare-for-people-with-liver-disease (accessed 14 March 2016)
  9. Royal College of Nursing. Going upstream: nursing's contribution to public health—prevent, promote, and protect. London: RCN, 2012. Available at: www.rcn.org.uk/professional-development/publications/pub-004203 (accessed 14 March 2016)
  10. Drink aware. What is an alcohol unit?www.drinkaware.co.uk/check-the-facts/what-is-alcohol/what-is-an-alcohol-unit#whatisaunit (accessed 14 March 2016) G