Nonalcoholic Steatohepatitis and Hepatocellular Carcinoma: Crying Wolf or Promoting Healthy Living?

Abstract

The title “Nonalcoholic Steatohepatitis (NASH) Is the Fastest Growing Cause of Hepatocellular Carcinoma (HCC) in Liver Transplant Candidates (in the US)” differs with wise warnings in the discussion section, for example, “we were unable to study temporal trends extensively in populations of patients with more than 1 cause of chronic liver disease and, most importantly, with NASH being superimposed on another etiology.” This deserved deeper insights. First, nutritional and hepatic histologic findings in a series 50 nonselected subjects with morbid obesity showed that severe liver damage (16%) was constantly associated with alcohol intake. There is no evidence yet that fatty liver, a most frequent symptom in rich countries, can be responsible per se for severe lesions despite decades of research. In addition, overweight and diabetes are associated with 11 types of cancer, the case of hepatocellular carcinoma is not specific. Second, why bypass the search for causes of a disease? Alcohol is a most potent toxin, but 58% of US patients are labeled by hepatologists as nonalcoholic fatty liver disease despite self-report of “moderate” alcohol use. How is it possible to overlook that self-report has poor reliability and most frequently underestimates use? Could use be moderate when the substance is a drug and also a human carcinogen at a dose as low as 1 glass of wine a day? In France and in the United Kingdom, the drinking at low risk level for those who choose to drink is less than 100 g/wk vs 300 g/wk in the United States. Tobacco smoking causes a dose-related increase in hepatocellular carcinoma, and is the main cause in rich countries. In Europe, the population-attributable factor (the proportional reduction in population disease that would occur if exposure to a risk factor were reduced to an alternative ideal exposure) for tobacco use in hepatocellular carcinoma is 48%, more than twice the second most attributed risk factor of hepatitis C. Nevertheless, this cause is almost always overlooked. Air pollution has deleterious effects on the liver and evidence of this is accumulating. Although these risks may be low (eg, 1.5 for tobacco), the burden is a major one because prevalence is high and combination effects (cocktail effect) have a greater effect than individual substances added together. Third, how to overlook the present “public health crisis”? In the United States, alcohol use, high-risk drinking, and alcohol use disorders are increasing. Marketing on social media has a free ride and, worse, some public policies promote use of alcohol, as in Washington state. In 2008, Washington State axed funding for the Basic Liquor Law Enforcement Academy (Washington State Criminal Justice Training Center), ending the program. In 2011, it ended the state monopoly on liquor sales despite warnings it will increase alcohol use. In 2017, it decreased liquor taxes and fees from $35 to $31 per gallon.