The Negative Bidirectional Interaction Between Climate Change and the Prevalence and Care of Liver Disease: A Joint BSG, BASL, EASL, and AASLD Commentary

Abstract

The climate crisis is one of the biggest threats to global health of the 21st century1Costello A. Abbas M. Allen A. et al.Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission.Lancet. 2009; 373: 2200Abstract Full Text Full Text PDF PubMed Scopus (1629) Google Scholar because climate change is accompanied by numerous medical consequences.2Salas R.N. Solomon C.G. The climate crisis–health and care delivery.N Engl J Med. 2019; 381: e13Crossref PubMed Scopus (29) Google Scholar We are already seeing these negative global health impacts due to excessive ambient temperatures and air pollution. One notable episode was the extreme heatwave in Europe in summer 2003, which resulted in approximately 70,000 more deaths across Europe, of which 20% in London and 70% in Paris were attributed to human-induced or anthropogenic climate change.3Mitchell D. Heaviside C. Vardoulakis S. et al.Attributing human mortality during extreme heat waves to anthropogenic climate change.Environ Res Lett. 2016; 11074006Crossref Scopus (189) Google Scholar Climate change also affects the social and environmental determinants of health, such as water and food security, mental status, and ready access to affordable health care, exercise, and other physical activity—negative changes that have deleterious effects on health globally.2Salas R.N. Solomon C.G. The climate crisis–health and care delivery.N Engl J Med. 2019; 381: e13Crossref PubMed Scopus (29) Google Scholar,4Watts N. Amann M. Ayeb-Karlsson S. et al.The Lancet countdown on health and climate change from 25 years of inaction to a global transformation for public health.Lancet. 2018; 391: 581-630Abstract Full Text Full Text PDF PubMed Scopus (585) Google Scholar, 5World Health Organization. Climate change and health.https://www.who.int/news-room/fact-sheets/detail/climate-change-and-healthGoogle Scholar, 6Watts N. Amann M. Arnell N. et al.The 2020 report of The Lancet Countdown on health and climate change: responding to converging crises.Lancet. 2021; 397: 129-170Abstract Full Text Full Text PDF PubMed Scopus (616) Google Scholar More specifically, from the hepatology perspective, liver disease causes approximately 2 million deaths per year globally, and this burden of liver disease continues to grow.7Asrani S.K. Devarbhavi H. Eaton J. et al.Burden of liver diseases in the world.J Hepatol. 2019; 70: 151-171Abstract Full Text Full Text PDF PubMed Scopus (1330) Google Scholar It is likely, albeit worthy of further investigation and proof, that the same environmental and social factors causing climate change and a deterioration in global health generally may also play a major role in the development of a number of liver diseases, the majority (perhaps all) of which are preventable. This explanation may contribute to the observation that between 1990 and 2017, nearly all countries worldwide reported an increasing prevalence of nonalcoholic fatty liver disease (NAFLD).8Ge X. Zheng L. Wang M. et al.Prevalence trends in non-alcoholic fatty liver disease at the global, regional and national levels, 1990-2017: a population-based observational study.BMJ Open. 2020; 10e036663Crossref Scopus (61) Google Scholar,9Paik JM, Kabbara K, Eberly KE, et al. Global burden of NAFLD and chronic liver disease among adolescents and young adults [published online ahead of print November 6, 2021]. Hepatology https://doi.org/10.1002/hep.32228Google Scholar Conversely, there is increasing evidence that health care itself, including the care of patients with liver disease, has adverse climactic and ecological effects.4Watts N. Amann M. Ayeb-Karlsson S. et al.The Lancet countdown on health and climate change from 25 years of inaction to a global transformation for public health.Lancet. 2018; 391: 581-630Abstract Full Text Full Text PDF PubMed Scopus (585) Google Scholar Although more research is required to understand the connection between climate change and liver disease, in this commentary we focus on the following main challenges: 1) the effect of climate change on liver disease and vice versa, and 2) how to devise sustainable hepatology solutions that might simultaneously address the challenges highlighted in 1). This current hepatology perspective (published simultaneously in Gastroenterology and the Journal of Hepatology) is co-published with 2 commentaries in Gastroenterology addressing complementary gastroenterology issues, namely, green endoscopy and a global health care systems perspective.10Baddeley R. Aabakken L. Veitch A. Hayee B. Green endoscopy: counting the carbon cost of our practice.Gastroenterology. 2022; 162: 1556-1560Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar,11Setoguchi S. Leddin D. Metz G. Omary M.B. Climate change, health and healthcare systems: a global perspective.Gastroenterology. 2022; 162: 1549-1555Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Deleterious changes in the weather (heat, wildfires, storms, flooding, and atmospheric pollution) that adversely affect physical and mental health, agriculture, economies, societies, and infrastructure worldwide, are clearly agents for deterioration in global health generally, but indirectly are also conducive to liver injury, although not necessarily causal (Figure 1). This “climate change–liver disease connection” requires further investigation. There are complex relationships between the climate crisis and ecological disruption and liver disease, as shown in Figure 1. Among the liver diseases implicated, NAFLD is pre-eminent but not exclusive. The NAFLD epidemic parallels the acceleration in the climate crisis, and this is not entirely coincidental. A global synergistic epidemic, that is, a syndemic of climate change, undernutrition, and obesity now exists,12Swinburn B.A. Kraak V.I. Allender S. et al.The global syndemic of obesity, undernutrition, and climate change: The Lancet Commission report.Lancet. 2019; 393: 791-846Abstract Full Text Full Text PDF PubMed Scopus (1057) Google Scholar and many hepatologists are concerned that the complex interaction between climate change and NAFLD is underappreciated and underaddressed. Global warming results in food insecurity (due to foundering agriculture and infrastructure) that contributes appreciably to the development of obesity13Trentinaglia M.T. Parolini M. Donzelli F. et al.Climate change and obesity: a global analysis.Global Food Security. 2021; 29: 100539Crossref Scopus (3) Google Scholar; in this context, crop yield failure across global food providers is projected to rise up to 25 times by 2050.14Caparas M. Zobel Z. Castanho A.D.A. et al.Increasing risks of crop failure and water scarcity in global breadbaskets by 2030.Environ Res Lett. 2021; 16: 104013Crossref Scopus (14) Google Scholar Even now, food insecurity is a contributor to the development of obesity by virtue of reliance on unhealthy energy intake, including refined (ie, highly processed) foodstuffs.15Farrell P. Thow A.M. Abimbola S. et al.How food insecurity could lead to obesity in LMICs: when not enough is too much: a realist view of how food insecurity could lead to obesity in low- and middle-income countries.Health Promot Int. 2018; 33: 812-826Crossref PubMed Scopus (45) Google Scholar Whereas obesity and its metabolic consequences due to unhealthy diets can lead to NAFLD, poverty and food insecurity may also lead to malnutrition. In the latter setting, there is ample historical evidence that malnutrition and wasting disorders (eg, secondary to protein-calorie malnutrition and tuberculosis) contribute to the development of fatty liver.16McLaren D.S. Bitar J.G. Nassar V.H. Protein-calorie malnutrition and the liver.Prog Liver Dis. 1972; 4: 527-536PubMed Google Scholar,17Jones J.M. Peck W.M. Incidence of fatty liver in tuberculosis with special reference to tuberculosis enteritis.Arch Intern Med (Chic). 1944; 74: 371-374Crossref Scopus (5) Google Scholar Whereas warm ambient temperatures are conducive to exercise in cold northern climates, very high temperatures are likely to encourage sedentary lifestyles because outdoor activities, including exercise, may be uncomfortable and even dangerous if they cause hyperthermia (see below). Notwithstanding, decreased physical activity may contribute to rising obesity and NAFLD. Increasing health care utilization due to obesity-related illness causes further greenhouse gas emissions. Sedentary lifestyles are associated with increased use of motorized transport, with a concomitant increase in greenhouse gas emissions. In addition, as a sedentary lifestyle is associated with increased food intake, increased greenhouse gas emissions also come from extra food production. Indeed, populations in which there is 40% prevalence of obesity require 19% more food energy for its total energy expenditure compared with populations with a normal distribution of body mass indices18Edwards P. Roberts I. Population adiposity and climate change.Int J Epidemiol. 2009; 38: 1137-1140Crossref PubMed Scopus (87) Google Scholar; a vicious circle then ensues. Furthermore, exposure to the increased air pollution that accompanies climate change may increase the risk of NAFLD in people who have central obesity and eat a high-fat diet.19Guo B. Guo Y. Nima Q. et al.Exposure to air pollution is associated with an increased risk of metabolic dysfunction-associated fatty liver disease.J Hepatol. 2022; 76: 518-525Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar Air pollution is postulated to provoke oxidative stress and stimulate inflammatory responses, and although a cause-and-effect relationship has not been proven definitively, such responses impair hepatic metabolism and increase hepatic triglycerides and cholesterol, thereby fostering NAFLD.19Guo B. Guo Y. Nima Q. et al.Exposure to air pollution is associated with an increased risk of metabolic dysfunction-associated fatty liver disease.J Hepatol. 2022; 76: 518-525Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar Perturbations in environmental biological agents injurious to the liver, as a consequence of the climate crisis, are likely to lead to an increasing incidence of many liver diseases, besides NAFLD. Aflatoxins are metabolites produced by food-borne fungi, and exposure to aflatoxins is a significant co-factor for developing hepatocellular carcinoma. Fungi that produce aflatoxin thrive in warm, damp climates and, as a consequence of increased ambient temperature and humidity, may result in an increasing incidence of liver cancer.20Bennett J.W. Klich M. Mycotoxins.Clin Microbiol Rev. 2003; 16: 497-516Crossref PubMed Scopus (2693) Google Scholar Increasing ambient temperatures are changing the geographical distribution of hepatic parasitic infections, including schistosomiasis. There have been unexpected outbreaks of schistosomiasis among swimmers in the Cavu River in Corsica, for example.21Ramalli L. Mulero S. Noel H. et al.Persistence of schistosomal transmission linked to the Cavu river in southern Corsica since 2013.Euro Surveill. 2018; 25 (18-00017)Google Scholar Climate change is reported to have contributed to increased Fasciola hepatica (liver fluke) in the United Kingdom, and it is estimated that there may be epidemics of infection in Wales by 2050.22Fox N.J. White P.C.L. McClean C.J. et al.Predicting impacts of climate change on Fasciola hepatica risk.PLoS One. 2011; 6e16126Crossref Scopus (162) Google Scholar As a result of global warming, there is increased contamination of drinking water with Cyanobacteria—colloquially known as blue-green algae. Consequently, there is an increase in ingestion of microcystins—the cyanobacterial hepatotoxic metabolites found in contaminated drinking water and swimming sites. These toxins can promote hepatic inflammation and may facilitate NAFLD progression to nonalcoholic steatohepatitis through perturbations in lipid metabolism.23He J. Li G. Chen J. et al.Prolonged exposure to low-dose microcystin induces non-alcoholic steatohepatitis in mice: a systems toxicology study.Arch Toxicol. 2017; 91: 465-480Crossref PubMed Scopus (60) Google Scholar Results of recent work suggest that increased microcystin concentrations as a result of adverse weather conditions may contribute to an increase in liver disease mortality in the United States.24Melaram R. Microcystins and daily sunlight: predictors of chronic liver disease and cirrhosis mortality.J Environ Sci Public Health. 2021; 5: 356-370Google Scholar The climate crisis is causing flooding and coastal erosion around the globe, which exacerbates waterborne infections, including epidemics of hepatitis A and E. Flooding and agricultural disruption contribute to increased human migration. The recent EASL (European Association for the Study of the Liver)–Lancet commission recognized the problem of undiagnosed and untreated liver disease in migrant populations.25Karlsen T.J. Sheron N. Zelber-Sagi S. et al.The EASL-Lancet Liver Commission: protecting the next generation of Europeans against liver disease complications and premature mortality.Lancet. 2022; 399: 61-116Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar Furthermore, hepatitis A and E can be acquired by refugees because of poor hygiene and sanitation; the ongoing outbreak of hepatitis E infection in South Sudan is a prime example.26World Health Organization. Hepatitis E virus – Republic of South Sudan.https://www.who.int/emergencies/disease-outbreak-news/item/hepatitis-e-virus-republic-of-south-sudanGoogle Scholar Another worrisome scenario is infection by Vibrio vulnificus, a gram-negative bacterium of coastal waters that can cause fatal sepsis in patients with chronic illness, particularly liver disease. Coastal water warming appears to be contributing to an increase in cases in the Carolinas and along the eastern seaboard of the United States.27Froelich B.A. Daines D.A. In hot water: effects of climate change on Vibrio-human interactions.Environ Microbiol. 2020; 22: 4101-4111Crossref PubMed Scopus (34) Google Scholar Heat events are becoming ever more common, highlighted by recent heat domes over Argentina and Australia, with elevations of up to +50°C.28NASA Earth Observatory. Southern Hemisphere Scorchers.https://earthobservatory.nasa.gov/images/149331/southern-hemisphere-scorchersGoogle Scholar These extreme weather conditions pose a risk to many organ systems, including the liver. Hyperthermia can be directly cytotoxic, and there is also reduced hepatic blood flow due to peripheral vasodilatation and other hepatic metabolic changes.29Thorne A.M. Ubbink R. Bruggenwirth I.M.A. et al.Hyperthermia-induced changes in liver physiology and metabolism: a rationale for hyperthermic machine perfusion.Am J Physiol Gastrointest Liver Physiol. 2020; 319: 43-50Crossref PubMed Scopus (15) Google Scholar Heat stroke as a result of hyperthermia can cause hepatocellular injury, leading to severe acute liver injury and acute liver failure.30Davis B.C. Tillman H. Chung R.T. et al.Heat stroke leading to acute liver injury and failure: a case series from the Acute Liver Failure Study Group.Liver Int. 2017; 37: 509-513Crossref PubMed Scopus (36) Google Scholar Climate change is known to impair mental health.31Ingle H.E. Mikulewicz M. Mental health and climate change: tackling invisible injustice.Lancet Planet Health. 2020; 4: E128-E130Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar Communities now directly affected by climate change are predominantly in low- or middle-income countries, where mental health care is a low priority in disadvantaged health care systems. Eco-anxiety, stress, self-harm, and depression resulting from disasters, economic hardship, and social insecurity (including the rising cost of living) may result in increasing alcohol and recreational substance use. Alcohol production itself is detrimental to the planet through its manufacture and transport, and to human health due to the development of liver disease and other alcohol use disorders. In Sweden, alcohol consumption is responsible for approximately 3% of dietary greenhouse gas emissions, or 11% in subpopulations with the highest reported alcohol intake.32Hallstrom E. Hakansson N. Akesson A. et al.Climate impact of alcohol consumption in Sweden.J Clean Prod. 2018; 201: 287-294Crossref Scopus (20) Google Scholar Limiting the planetary impact of alcohol demands a multifaceted approach, including sustainable production and emphasizing public health strategies to limit alcohol intake, such as the minimum unit pricing legislation introduced in Scotland and the Republic of Ireland. We see a clear need to educate ourselves, our patients, the public, and health care authorities about the relationship between climate change and the prevalence and care of liver disease. We must urgently move toward a more sustainable model of care in liver disease, emphasizing its potential benefits to patients and health care systems, including individual and institutional finances, and not least the health of the planet. As an overarching approach, it can be reasoned that the same interventions might improve both climate change and liver disease, for example, encouraging physical activity, such as walking and cycling in place of motorized transport. Although it is intuitive that there is an impact of clinical hepatology practice on the environment, and an association between liver disease and climate with some supportive evidence that we have cited, more corroborative data are needed to confirm these inter-relationships. In comparison with hepatology, the concept of a more sustainable future for endoscopy has been well promoted by the “Green Endoscopy Group,”10Baddeley R. Aabakken L. Veitch A. Hayee B. Green endoscopy: counting the carbon cost of our practice.Gastroenterology. 2022; 162: 1556-1560Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar motivated by the inconvenient observation that endoscopy is the third highest source of waste in a typical hospital.33Vaccari M. Tudor T. Perteghella A. Costs associated with the management of waste from healthcare facilities: an analysis at national and site level.Waste Manag Res. 2018; 36: 39-47Crossref PubMed Scopus (67) Google Scholar Here, we present some solutions that could reduce both climate change and liver disease simultaneously. Addressing the drivers of the global syndemic described above is vital to restoring and maintaining human liver health and a healthy environment. The same interventions might positively impact climate change and liver disease. For example, plant-based diets (as opposed to red meat and ultraprocessed foods) have lower carbon footprints than a typical Western diet, and are estimated to be associated with a reduction in greenhouse gas emissions by up to 84%34Springmann M. Wiebe K. Mason-D’Croz et al.Health and nutritional aspects of sustainable diet strategies and their association with environmental impacts: a global modelling analysis with country-level detail.Lancet Planet Health. 2018; 2: E451-E461Abstract Full Text Full Text PDF PubMed Scopus (317) Google Scholar and a lower risk of NAFLD.35Mazidi M. Kengne A.P. Higher adherence to plant-based diets are associated with lower likelihood of fatty liver.Clin Nutr. 2019; 38: 1672-1677Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar Regular exercise reduces the incidence of fatty liver,36Sung K.C. Ryu S. Lee J.Y. et al.Effect of exercise on the development of new fatty liver and the resolution of existing fatty liver.J Hepatol. 2016; 65: 791-797Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar and thus must be promoted to reduce obesity and reliance on motorized transport. Hepatology professional societies must advocate to increase physical activity. If 1 person changed 1 trip per day from driving to cycling, this would reduce that individual’s carbon footprint by approximately 0.5 tons over 1 year.37Brand C. Gotschi T. Dons E. et al.The climate change mitigation impacts of active travel: evidence from a longitudinal panel study in seven European cities.Glob Environ Change. 2021; 67: 102224Crossref Scopus (52) Google Scholar We need to reframe obesity and NAFLD as societal problems, rather than focus solely on individual responsibility; we need to campaign for public measures—promotion of active travel, reduced air pollution, and healthier diets—that will benefit our patients, the global population, and the environment. Sustainable practices apply to all medical disciplines and are not hepatology-specific but must be tailored to satisfy the circumstances of individual specialties and subspecialties. The health industry is a major source of greenhouse gases globally; in the United States, for example, the health sector accounts for approximately 8.5% of national carbon emissions.38Eckelman M.J. Huang K. Lagasse R. et al.Health care pollution and public health damage in the United States: an update: study examines health care pollution and public health damage in the United States.Health Aff (Millwood). 2020; 39: 2017-2179Crossref Scopus (89) Google Scholar The estimated cost of waste in the US health care system is roughly 25% of total health care spending.39Shrank W.H. Rogstad M.P.H. Parekh N. Waste in the US health care system.JAMA. 2019; 322: 1501-1509Crossref PubMed Scopus (377) Google Scholar Hence, the health care sector must take responsibility for its contribution to climate change and urgently provide sustainable services, including responsible attention to patients with liver disease. The 4 main domains of sustainable health care are prevention, patient empowerment and self-care, lean service delivery, and provision of low-carbon alternatives. By eliminating profligate practices, such as unnecessary testing and clinic visits, we would expect to reduce greenhouse gas emissions that result from the disposal of materials used extravagantly and from unnecessary motorized transport, thereby improving the health of the planet. Creative solutions must be devised that minimize waste-related costs and negative environmental impacts while preserving patient care and scientific advances. In this context, we must develop guidelines and criteria for determining whether patient follow-up should be in person or by some form of remote contact, and how often. Similarly, we need data regarding the value of noninvasive testing to both assess disease progression and indicate the need for invasive testing. Prevention rather than cure is a key sustainability theme outlined by the UK Centre for Sustainable Healthcare, which was also addressed recently by the EASL–Lancet Commission.25Karlsen T.J. Sheron N. Zelber-Sagi S. et al.The EASL-Lancet Liver Commission: protecting the next generation of Europeans against liver disease complications and premature mortality.Lancet. 2022; 399: 61-116Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar A link with climate change was not specifically discussed in the latter commentary, perhaps highlighting a lack of awareness in the hepatology community. The EASL–Lancet Commission that focused on protecting the next generation from complications and premature mortality due to liver disease has proposed a shift from therapy and management of complications toward prevention and early diagnosis25Karlsen T.J. Sheron N. Zelber-Sagi S. et al.The EASL-Lancet Liver Commission: protecting the next generation of Europeans against liver disease complications and premature mortality.Lancet. 2022; 399: 61-116Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar—core goals of hepatology for the near future. This conceptual shift could also reduce the negative climactic impact of the health sector. The COVID-19 pandemic has precipitated a reappraisal of medical service delivery. However, even before the COVID-19 pandemic, there were good examples of increased sustainable service delivery within hepatology. There has been a move toward reducing the use of invasive tests by using serological biomarkers and clinical and biochemical decision trees. Outpatient, unsedated, ultrathin endoscopy can be performed during a routine clinic visit, saving an additional patient journey for endoscopy and the need for accompaniment, and on disposables used for sedation.40Eqbal A. Wickremeratne T. Turner S. et al.One-stop shop for variceal surveillance: integration of unsedated ultrathin endoscopy into the routine clinic visit.Frontline Gastroenterol. 2021; 12: 545-549Crossref PubMed Scopus (4) Google Scholar Successes with telemedicine had been reported before this service became more widely adopted, for example, in delivering hepatitis C treatment to inmates incarcerated in UK prisons.41Morey S. Hamoodi A. Jones D. et al.Increased diagnosis and treatment of hepatitis C in prison by universal offer of testing and use of telemedicine.J Viral Hepatol. 2019; 26: 101-108Crossref PubMed Scopus (41) Google Scholar The COVID-19 era has forced hepatology teams worldwide to explore different ways of working; many of these novel pathways do fulfill the criteria for sustainable health care. In one UK liver transplantation unit, a virtual transplant assessment pathway has been adopted, resulting in a significant reduction in climate-unfriendly patient travel.42Pradeep A, Barker F, Ramos K, et al. Virtual liver transplant assessment: a novel pathway that is likely safe, effective and optimises access to transplantation [published online ahead of print October 7, 2021]. Frontline Gastroenterol https://doi.org/10.1136/flgastro-2021-101976.Google Scholar Telephone and video (“virtual”) consultations have been more widely adopted since the beginning of the pandemic, and can result in significant carbon savings (predominantly through the avoidance of patient travel). Outpatient hepatology data from the Royal Cornwall Hospital in the United Kingdom demonstrates that since the beginning of the pandemic, more than 120,000 patient miles have been saved through virtual consultations, with a CO2 emissions equivalent of 97 airplane trips from London to New York saved (W. Stableforth, MB BCH, FRCP, personal communication, e-mail, January 4, 2022). However, enthusiasm for telemedicine must be tempered with caution because downscaling of in-hospital liver care decreased patient satisfaction and increased liver-related mortality in one center.43Hartl L. Semmler G. Hofer B.S. et al.COVID-19 related downscaling of in-hospital liver care decreased patient satisfaction and increased liver-related mortality.Hepatol Commun. 2021; 5: 1660-1675Crossref PubMed Scopus (10) Google Scholar In another study, fewer patients with cirrhosis were satisfied with telephone consultations compared with patients with inflammatory bowel disease.44Britton E. Richardson P. Mian I. et al.Covid-19–re-initiating clinical services for chronic gastrointestinal disease. How and when?.Aliment Pharmacol Ther. 2020; 52: 1414-1415PubMed Google Scholar Virtual outpatient hepatology is attractive but may not necessarily be the panacea for a sustainable hepatology service. Yet, improvement of hepatology services with sustainable quality is mandatory now in routine clinical practice, including reduction of waste and unnecessary hospital visits across a wide spectrum of liver diseases, such as stable well-compensated patients with cirrhosis, autoimmune hepatitis, primary biliary cholangitis, and NAFLD, for whom noninvasive tests, telemedicine, and modified variceal screening may suffice. Decisive action within the hepatology community regarding the climate crisis is long overdue; we simply cannot continue with “business as usual.” Hepatology specialist societies, along with the public, patients, politicians, and researchers (representing both science and industry) need to work together now to tackle the linked threats of climate change and liver disease. Those individuals who are aware of these climate–hepatology connections must be among the vanguard in broaching this vexing concept urgently within their organizations. One goal of the current commentary is to raise awareness within the broad realms of hepatology of the link between climate change and liver disease. Practical measures need to be undertaken by individual physicians, departments, health care organizations, and professional societies. Actionable suggestions for delivering a sustainable hepatology service are provided in Table 1. Accordingly, the wider aims of hepatologists should be to:•raise awareness of the reciprocal link between climate change and liver disease, which includes instruction in medical school and specialty training;•facilitate research into the impact of climate on the liver and liver-related health care;•promote awareness of how ways of living can impact positively on the prevention of liver disease and the climate crisis, and advocate for such behavioral changes;•reduce low-value health care contacts in hepatology, for example, reduce unnecessary in-person visits and procedures;•promote sustainable hepatology services and good practice to colleagues, mostly via virtual conferences, symposia, and small group interactive meetings interspersed with occasional safe, in-person, morale-boosting, small, education and social gatherings;•develop standardized sets of sustainability metrics specific to hepatology; and•advocate for government investments, for example, policies to reduce the harmful impact of alcohol, ban marketing of junk foods, subsidize healthy foods, and make exercise free and accessible to all.Table 1Suggested Actions for Environmentally Sustainable HepatologyTarget audiencePreventionPatient empowermentLean service deliveryLow carbon alternativesIndividual doctorsPatient and colleague educationAdvise on merits of plant-based dietAdvise on benefits of physical activity and clean airEncourage risk reduction measures for viral hepatitisSocial prescribingEncourage use of apps to monitor healthAdvance care planningInvolve patients in the development of sustainable hepatology servicesSelecting suitable candidates for hepatocellular carcinoma surveillanceDe-prescribingNoninvasive testing–fibrosis scores, iLFTsAdvance care planningSocial prescribingVirtual consultationsRequest electronic journals rather than in printAttend some meetings virtuallyUse of Baveno criteria to determine need for variceal screeningTransnasal endoscopy for variceal screeningDepartmentsPatient and colleague educationAdopt patient led follow-up where ableSignpost to local support groupsAbnormal LFT pathwaysReduce low-value contacts in outpatientsSupport green endoscopyVirtual consultations where appropriate (needs infrastructure)Virtual transplant assessmentSpecialist societiesAdvocate for minimum unit pricingAdvocate for ban on marketing of unhealthy foodsAdvocate for easy access to active transport and exercise for allAdvocate for reduction in health inequalityEducate members on link between climate and healthDevelop technology, eg, apps to monitor encephalopathyInvolve patient organizations in the development of sustainable hepatology servicesPublish guidancePromote examples of good practiceEstablish an evidence base for lean service deliveryDeliver more digital educationDeliver sustainable conferencesUndertake research into low-carbon alternatives specific to hepatologyPharma and industryEducation——Reduce hardcopy material in advertisementsReduce waste in packaging of medications and devicesProvide carbon footprint information regarding manufacturing processesReduce staff travel, including in-person visits to medical centersiLFT, intelligent liver function test; LFT, liver function test. Open table in a new tab iLFT, intelligent liver function test; LFT, liver function test. The association between climate change and liver health and disease and the need for sustainable hepatology services must be recognized. As President Barack Obama stated at the UN Climate Change Summit in 2014, “We are the first generation to feel the impact of climate change and the last generation that can do something about it.”45The White House. Remarks by the President at U.N. Climate Change Summit. September 23, 2014.https://obamawhitehouse.archives.gov/the-press-office/2014/09/23/remarks-president-un-climate-change-summitGoogle Scholar As hepatologists, we must take this message on board now and work together for the health of our patients and the planet by providing environmentally sustainable hepatology.