Abstract
This report presents further evidence on the escalating alcohol consumption in the UK and the burden of liver disease associated with this major risk factor, as well as the effects on hospital and primary care. We reiterate the need for fiscal regulation by the UK Government if overall alcohol consumption is to be reduced sufficiently to improve health outcomes. We also draw attention to the effects of drastic cuts in public services for alcohol treatment, the repeated failures of voluntary agreements with the drinks industry, and the influence of the industry through its lobbying activities. We continue to press for reintroduction of the alcohol duty escalator, which was highly effective during the 5 years it was in place, and the introduction of minimum unit pricing in England, targeted at the heaviest drinkers. Results from the introduction of minimum unit pricing in Scotland, with results from Wales to follow, are likely to seriously expose the weakness of England's position. The increasing prevalence of obesity-related liver disease, the rising number of people diagnosed with type 2 diabetes and its complications, and increasing number of cases of end-stage liver disease and primary liver cancers from non-alcoholic fatty liver disease make apparent the need for an obesity strategy for adults. We also discuss the important effects of obesity and alcohol on disease progression, and the increased risk of the ten most common cancers (including breast and colon cancers). A new in-depth analysis of the UK National Health Service (NHS) and total societal costs shows the extraordinarily large expenditures that could be saved or redeployed elsewhere in the NHS. Excellent results have been reported for new antiviral drugs for hepatitis C virus infection, making elimination of chronic infection a real possibility ahead of the WHO 2030 target. However, the extent of unidentified cases remains a problem, and will also apply when new curative drugs for hepatitis B virus become available. We also describe efforts to improve standards of hospital care for liver disease with better understanding of current service deficiencies and a new accreditation process for hospitals providing liver services. New commissioning arrangements for primary and community care represent progress, in terms of effective screening of high-risk subjects and the early detection of liver disease.
| Original language | English |
|---|---|
| Pages (from-to) | 2398-2412 |
| Number of pages | 15 |
| Journal | The Lancet |
| Volume | 392 |
| Issue number | 10162 |
| Early online date | 22 Nov 2018 |
| DOIs |
|
| Publication status | Published - 1 Dec 2018 |
Funding
This fifth annual report by the Commission is a substantial addition to European and global health data on the extent of the disease burden resulting from the lifestyle hazards of excess alcohol consumption, obesity, and viral hepatitis. Despite the effectiveness of new antiviral drugs for HCV hepatitis, the large number of unidentified cases of chronic infection in the country will add to the difficulties of complete elimination, and remaining pockets of difficult-to-treat cases in addiction clinics is a further problem. The possibility of new antiviral drugs for HBV infection becoming available over the next 5 years will face the same limitations. A 2018 report 114 on student drinking suggested the need for development of an alternative culture to the so-called strong-man syndrome if harmful levels of alcohol consumption are to be avoided. Alcohol-related and obesity-related liver disease, along with the complications of cirrhosis (including primary hepatocellular carcinoma), circulatory and metabolic disorders (particularly diabetes and chronic kidney disease), and increased risk of the ten most common cancers, together comprise a substantial burden of preventable disease. This burden is not being sufficiently recognised, nor are the costs involved, as detailed in the analysis by the Commission, 102 adding to the need for regulatory control by the UK Government. Furthermore, lifestyle factors are a major cause of the stall in life expectancy and the high number of sick years of living for older people. With alcohol consumption in the country and prevalence of obesity still increasing, the need for effective fiscal measures is paramount ( ). Halfway measures, such as the obesity strategy for children, but not for adults, and public health campaigns carried out in collaboration with the alcohol industry-funded charity Drinkaware represent poor policy choices. The measures prioritised for reducing obesity have proven efficacious, with strict dietary control able to reverse diabetes. With the current extent of harm both to public health and loss of revenue to the Exchequer, it is difficult to understand how the UK Government can continue to resist taking the necessary legislative action. The success of government measures in reducing smoking prevalence should be a sufficient encouragement for the adoption of similar regulatory approaches for other lifestyle issues. How much longer must we wait and continue with the present approach? panel 2 Contributors RW was responsible for planning and providing content for the Summary, Introduction, and Conclusion, and the writing, editing, and overall direction of the paper. ND coordinated content and editing. GA and AB contributed to the section on hepatocellular carcinoma. NBh, NBo, DT, JVe, and JW contributed with literature searches, data analysis, interpretation, and editing. KB, IG, CH, KM, CD, NS, and AY contributed to the section on alcohol services. NS contributed figure 1 . NS and KB contributed the section on alcohol policy. AD, DK, and JMa contributed to the section on paediatric liver services. GRF and MEC contributed to the section on viral hepatitis. JG contributed to the section on financial impacts. RA, JDi, HJ, JMo, and NS contributed to the section on primary care. NS, RBu, and MM contributed to the section on public awareness and industry lobbying activities. RBa, PN, and HR contributed to the section on obesity. MEC, JDy, JF, MH, JO'G, LR, and NS contributed to the section on hospital services and liver transplantation. JVe, CD, JDi, NM, PR, and AY contributed to the section on progress in the devolved nations. JVo contributed to the section on attributable cancers. Declaration of interests PR reports personal fees from WHO Europe and Scottish Health Action on Alcohol Problems outside of the submitted work. GRF reports grants and personal fees from AbbVie, Gilead, Merck, GlaxoSmithKline, and Roche during the conduct of the study; and grants and personal fees from AbbVie, Gilead, Merck, GlaxoSmithKline, and Roche outside of the submitted work. GRF is also NHS England Clinical Lead for Hepatitis C. MEC reports grants, personal fees, and non-financial support from AbbVie, Gilead, and Merck outside of the submitted work. AD reports personal fees from Gilead, Audentus Biotech, Promethius, and Bristol-Myers Squibb outside of the submitted work. JMo is funded by a 4-year Medical Research Council Clinician Scientist Fellowship to study liver disease. NS reports personal fees from Gilead outside of the submitted work. RBa reports grants from National Institute for Health Research and the Sir Jules Thorn Trust, other support from Novo Nordisk, Ethicon, Fractyl, International Medical Press, and Abbott outside of the submitted work. JDi reports grants and personal fees from Merck/MSD, Gilead, Bristol-Myers Squibb, Janssen, and Roche; and grants from Genedrive during the conduct of the study. AB reports funding from the British Liver Trust. RA reports personal fees from Norgine UK and Falk Pharma outside of the submitted work. KB reports funding from Alliance House Foundation (to the Institute of Alcohol Studies). JG reports funding from the Foundation for Liver Research (via Norgine), both during the conduct of the study and outside of the submitted work. All other authors declare no competing interests. Acknowledgments We thank all those who attended meetings of the working groups of the Commission, including Jemma Day (King's College Hospital); Richard Gardner (British Society of Gastroenterology); Maddy Farnworth and Thomas Stephens (Incisive Health); Lynda Greenslade (Royal Free Hospital); Petra Meier (Sheffield Alcohol Research Group, University of Sheffield); Zulfiquar Mirza (Chelsea and Westminster Hospital NHS Foundation Trust); Alastair O'Brien (University College London Hospital); Dr Foster; Judi Rhys (British Liver Trust); Stephen Ryder (Nottingham University Hospitals NHS Trust); Jeremy Shearman (Royal College of Physicians); Alison Taylor (Children's Liver Disease Foundation); Jeremy Thompson (Fulcrum Practice, Middlesbrough); Indra van Mourik (Birmingham Women's and Children's Hospital); Laura Webber (UK Health Forum and the London School of Hygiene & Tropical Medicine). We thank Rob Anderson-Weaver (Portsmouth City Council) and Dianna Smith (University of Southampton) for providing the data for figure 6 . We thank Norgine for their unrestricted grant to the Foundation for Liver Research, which has enabled the Commission to work with Incisive Health in bringing the work of the Commission to the attention of UK Parliament and in producing the report on Understanding the Importance of Living Well for Longer. The authors of this report were not funded for their participation. We also thank Obesity Action Scotland for their assistance with data. In addition, this report involves data derived from patient-level information collected by the NHS, as part of the care and support of cancer patients. The data is collated, maintained, and quality-assured by the National Cancer Registration and Analysis Service (part of Public Health England). The work on hepatocellular carcinoma incidence and survival was carried out by AB, who is funded through the Hepatocellular Carcinoma UK, British Association for the Study of the Liver, and National Cancer Registration and Analysis Service Partnership. CD is part funded by National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care South London at King's College Hospital NHS Foundation Trust, the NIHR South London and Maudsley NHS Foundation Trust Biomedical Research Centre, and is in receipt of a NIHR Senior Investigator Award. The views expressed are those of the authors and not necessarily those of the NHS, NIHR, or the Department of Health.
ASJC Scopus subject areas
- General Medicine
