On 28 July 2023 the medical world is drawing the world’s attention to an issue linked to a well-known disease that no longer inspires much fear, but which nevertheless continues to wreak havoc on a global scale.
According to the World Health Organisation (WHO), hepatitis, and more specifically the different forms of viral hepatitis that we will detail below, causes the death of more than one million people worldwide every year. The WHO website states: “An estimated 354 million people worldwide are still living with this potentially fatal infection, and at least one person dies of viral hepatitis every 30 seconds. That’s more than a million deaths a year – more than HIV and malaria combined (1)”. The WHO has set itself the goal of completely eradicating viral hepatitis by 2030 (2).
Is hepatitis a single disease?
It is in fact the general term for any inflammation of liver tissue. There are several types and forms of these disease, including viral, toxic and drug-induced. However, when we talk about hepatitis, we are mainly referring to hepatitis of infectious origin, and more specifically of viral origin, which is the most common form of liver disease in the world. In Europe, for example, it is estimated that around 15 million people are carriers of the hepatitis B virus and 14 million are infected with the hepatitis C virus (3). These figures underline the scale of the impact of these diseases on public health”.
There are five main forms of viral hepatitis, commonly known as hepatitis A, B, C, D and E. Each of these viruses is associated with mild or severe, acute or chronic forms of infection (4).
- Hepatitis A is best known as an acute form of liver tissue damage linked to food contamination or contaminated water. Other at-risk groups include people who inject drugs, men who have sex with men and certain isolated communities. It does not cause chronic disease like hepatitis B or C, but it can lead to a very serious fulminant form of the disease, which in rare cases can result in death. This acute form of hepatitis can be prevented by effective vaccination.
- Hepatitis B is a form of hepatitis that can be acute or chronic. It is transmitted mainly through blood, unprotected sex and from mother to child during childbirth. It can lead to serious complications such as cirrhosis and liver cancer. There is a safe and effective vaccine to prevent infection with the hepatitis B virus. This vaccine is administered in several doses and is strongly recommended, or even compulsory, in certain countries and for certain high-risk professions (doctors, nurses, etc.). There are also drugs called antivirals that can significantly slow the progression of the disease towards cirrhosis and reduce the risk of developing liver cancer.
- Hepatitis C, which is mainly transmitted by blood, is often asymptomatic, but can develop into a chronic form, leading to serious complications such as cirrhosis and liver cancer. Unlike hepatitis B, there is currently no vaccine against this viral form of hepatitis. However, in recent years, innovative treatments have come onto the market that can cure the disease in over 95% of cases. The most important thing is to act quickly, before the first signs of liver fibrosis and cirrhosis appear.
- Hepatitis D is an infection that can only develop in the presence of the hepatitis B virus. It can accelerate the progression to cirrhosis in co-infected individuals. It is a serious infection that is transmitted through blood or other bodily fluids in infected people. It can lead to acute or chronic illness. Only people already infected with the hepatitis B virus can become infected with the hepatitis D virus. There is no vaccine against this form of the virus.
- Hepatitis E, on the other hand, is generally acute and is transmitted mainly by drinking contaminated water or eating contaminated food. Although generally benign, it can be severe in pregnant women and immunocompromised individuals. In many cases, it is an acute illness that does not last long and resolves itself. The best way to prevent hepatitis E is to improve sanitary conditions, particularly drinking water.
There are several other forms of these disease, including:
- Alcoholic hepatitis: This is an inflammation of the liver caused by excessive alcohol consumption. It can lead to cirrhosis and liver failure. Alcoholic hepatitis is a major cause of liver disease worldwide, particularly in countries where alcohol consumption is high.
- Toxic hepatitis: This is caused by exposure to certain toxic substances or medicines. Toxins can include alcohol, some prescription drugs, some herbal supplements and some illegal drugs. In some cases, toxic hepatitis can be acute and severe, requiring hospitalisation
- Autoimmune hepatitis: This is a disease in which the immune system attacks the liver, causing inflammation and, in severe cases, cirrhosis and liver failure. Autoimmune hepatitis is relatively rare, but can be severe.
- Drug-induced hepatitis: This is an inflammation of the liver caused by a reaction to a drug. Many drugs can cause drug-induced hepatitis, including some antibiotics, non-steroidal anti-inflammatory drugs (NSAIDs) and anticonvulsant drugs.
- Ischaemic hepatitis: This is caused by a lack of oxygen to the liver, usually as a result of heart failure or shock.
- Steatohepatitis: This is generally associated with obesity, diabetes, hyperlipidaemia or alcoholism. It is characterised by an accumulation of fat in the liver, which can lead to inflammation and fibrosis.
These non-viral forms are important because they can all lead to chronic liver disease, cirrhosis and liver failure. Prevention of these forms of hepatitis generally involves limiting alcohol consumption, taking medication as prescribed, maintaining a healthy weight and managing underlying diseases such as diabetes.
Whether viral, alcoholic, drug-induced or autoimmune in origin, hepatitis represents a major public health challenge worldwide. It is therefore crucial to raise public awareness of this disease. Simple preventive measures can be taken to prevent the onset of hepatitis, and both preventive and curative treatments are available to slow down or delay the progression of the disease to chronic and more serious forms.
Lifestyle effect on hepatitis and fatty liver disease
Viral hepatitis may lead to chronic liver infection with inflammation, which in turn can lead to liver fibrosis and cirrhosis.
NAFLD, Non-Alcoholic Fatty Liver Disease, on the other hand is the most frequent non infectious liver disease worldwide, having a high disease burden. It is a condition in which too much fat is accumulated in the liver cells. This typically results from a combination of eating more calories than the body needs and leading a rather sedentary lifestyle. People with diabetes, especially diabetes type 2, and pre-diabetes – a stage were difficulties in glucose handling by the body start to develop – are at increased risk. These are called metabolic contributing factors.
The other most known form of fatty liver disease or steatosis is Alcoholic Fatty Liver Disease caused by excessive alcohol consumption.
It needs to be stressed that lifestyle has a huge impact in both the prevention and the management of NAFLD. Because the liver is the “detoxifying organ” of the body, it is faced with the complicated task of eliminating toxic substances and by-products. A healthy diet and continuous physical activity will significantly support the liver in performing these tasks thereby maintaining optimal liver health.
Because hepatic steatosis (fatty liver) and fibrosis (scarring tissue and inflammation) progression are often caused and worsened by bad dietary habits such as high fat diets consisting of highly processed foods, one of the main objectives of helping to improve liver health is nutrition management.
Keeping a food journal can greatly help getting an overview of where the normal diet fails to contribute to a healthy liver: food journaling accuracy is important for this purpose, and sometimes the help of a nutritionist or dietician may be required.
For optimal liver health, a daily total fat intake of maximum 20% of total energy intake should be set, with up to 20% of total calories from proteins and around 60% of total calories from carbohydrates in the form of fiber-rich whole grains, fruits and vegetables.
Nutrient rich food choices including a wide and varied choice of whole grains, fruits and vegetables and restriction of fat intake, specifically avoiding consumption of trans-fats and minimizing intake of saturated fat should be prioritized.
The Mediterranean diet is one of the diet styles which has been the most studied in recent years and has proven to be beneficial in the improvement of NAFLD.
A healthy lifestyle also includes regular physical activity in the form of moderate intensity, such as brisk walking, light jogging or cycling and this at least 3 to 7 days a week for 30 minutes. It is important to decrease overall sedentary time and breaking up sedentary time regularly throughout the course of the day. Just as nutritional improvements are essential, increasing physical activity is also important for the necessary lifestyle changes to maintain optimal liver health.
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It has been shown that lifestyle changes and adaptations towards a low-fat diet and increased physical activity can greatly improve the glucose, lipid and liver profiles of the body and improve the prevalence as well as severity of hepatic steatosis.
Francque et al. (2021) wrote a full and very detailed scientific report on all aspects of non-alcoholic fatty liver disease and patient guideline, an excellence source of validated scientific information.
2) Rebecca Dunn, Aaron Wetten et al. Viral hepatitis in 2021: The challenges remaining and how we should tackle them. World J Gastroenterol. 2022 Jan 7;28(1):76-95.
3) M Maticic, M.U. Mondelli. Elimination of viral hepatitis: where do we stand in the year 2020? Clinical Microbiology and Infection. Volume 26, ISSUE 7, P816-817, July 2020.
4) Matthew A. Odenwald, Sonali Paul. Viral hepatitis: Past, present, and future. World J Gastroenterol. 2022 Apr 14; 28(14): 1405–1429.
Francque SM, Marchesini G, Kautz A, et al. Non-alcoholic fatty liver disease: A patient guideline. JHEP Rep. 2021;3(5):100322. Published 2021 Sep 17. doi:10.1016/j.jhepr.2021.100322