At the 58th Annual Meeting of the European Association for the Study of the Liver (EASL 2023) and the EASL Congress 2023, Doctor Tom Hemming Karlsen, former Secretary-General of EASL (2010-2017) and Director of Research in Surgery, Inflammation Medicine, and Transplantation at Oslo University Hospital, was invited to introduce the EASL-The Lancet Liver Commission’s initiative to improve liver health in Europe. Hepatology Digest had the privilege of inviting Doctor Karlsen to provide an overview of the initiative’s inception and the latest developments, with the hope of offering a broader perspective on liver health management in our country.

Hepatology Digest: The EASL- The Lancet European Liver Disease Commission published a report in December 2021, outlining how liver disease has become a major health threat across Europe and proposing ten actionable recommendations. Could you please discuss the current state of liver disease in Europe and the background behind these ten recommendations?

• Dr. Tom Hemming Karlsen: Liver disease is a global issue, but Europe faces a unique situation driven by two factors. Firstly, Europe has the highest alcohol consumption in the world, which is a significant characteristic. Secondly, Europe, like other regions, has a high prevalence of obesity. We know that high obesity rates are associated with fatty liver disease and an increased risk of progressive liver disease, including complications related to type 2 diabetes.

Europe is challenged by these two issues, leading to rising trends in liver disease, progression, and complications (including liver cancer). The future outlook is rather pessimistic unless interventions are implemented. This is the primary focus of the commission’s work, while also addressing other aspects of liver disease.

Liver disease is a global problem, but Europe faces a unique situation driven by two factors. Firstly, Europe has the highest alcohol consumption in the world, which is a significant characteristic. Secondly, Europe, like other regions, has a high prevalence of obesity. We know that high obesity rates are associated with fatty liver disease and an increased risk of progressive liver disease, including complications related to type 2 diabetes.

Europe is challenged by these two issues, leading to rising trends in liver disease, progression, and complications (including liver cancer). The future outlook is rather pessimistic unless interventions are implemented. This is the primary focus of the commission’s work, while also addressing other aspects of liver disease.

Hepatology Digest: Half of the ten recommendations from the EASL-Lancet European Liver Disease Commission are directed toward healthcare providers. Could you introduce the recommendations for healthcare providers?

• Dr. Tom Hemming Karlsen: We didn’t limit our focus to liver disease related to alcohol and obesity. First, we developed a plan related to viral hepatitis elimination. Currently, regulations vary greatly among European countries in this regard, so we believe it’s necessary to promote easier access to hepatitis C testing and related medications, as well as to harmonize vaccination programs, especially for hepatitis B.

We are also working to include liver disease in the World Health Organization’s agenda for non-communicable diseases. This means approaching chronic diseases from a multidisciplinary perspective. Liver disease should not only concern hepatologists but also other healthcare providers who encounter individuals at risk of liver disease, such as endocrinologists and primary care physicians.

We are trying to provide guidance to colleagues in other specialties on how to conduct liver disease risk screening and testing. Additionally, we have proposed simplifying testing and shifting the focus from traditional liver enzyme tests to emphasizing the decisive factor in liver-related mortality—progressive fibrosis. So, in guiding colleagues outside the field of hepatology, we have much work to do. This is also the basis for our collaboration with The Lancet, which has a wide reach. Therefore, it’s necessary to convey our knowledge and concepts regarding liver disease testing to those working in other professional fields.

Furthermore, our commission is concerned with the impact of social discrimination. We are attempting to highlight this through changes in terminology because, even within the WHO system, there is some discriminatory or biased language associated with liver disease, such as “alcoholic.” We are striving to encourage the use of more neutral language when describing individuals with liver disease to avoid deterring potential candidates for liver disease screening, testing, proper care, and ongoing disease monitoring.

Hepatology Digest: What impact has the implementation of these recommendations had on liver disease health in Europe?

Dr. Tom Hemming Karlsen: Regarding recommendations for healthcare providers, we have made significant progress. We have successfully developed a plan to address social discrimination. We are working on more effective strategies for liver fibrosis screening. We are collaborating with primary healthcare and endocrinologists to transfer our specialized knowledge to other colleagues, enabling them to apply it in their daily practice. Currently, we have initiated several projects and are evaluating the effectiveness of liver fibrosis screening.

In other areas, the situation is more complex, and we are still working on it. At the policy level, for instance, in alcohol-related and food-related policies, our work has become more challenging, and progress has been slow. We have established collaborations with sister associations of the World Health Organization and are trying to make some headway.

In summary, we have made some progress in working with our colleagues, but there is still much work to be done in terms of policy.

Hepatology Digest: Will there be revisions in the future? Could you discuss further plans or suggestions?

• Dr. Tom Hemming Karlsen: We have already initiated a second commission, the second phase of the EASL-Lancet European Liver Disease Commission. The second commission will include some members or commissioners from the first commission, as well as new members. The commission’s goal is to drive the implementation of recommendations and assess and develop measures to measure the effectiveness of this implementation, as we discussed earlier.

In the second commission, we will also attempt to address some issues that were not fully resolved in the first commission. These issues involve the aging European population, migration, global sustainability, and the new economic situation. All of these issues are closely related to the core message of the first commission, emphasizing the importance of early detection of liver disease, early intervention, and preventive measures, which are more cost-effective than managing end-stage liver disease and its complications. We will continue our follow-up work to achieve more results.