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Coffee and tea breaks for liver health

  • Salvatore Petta
    Correspondence
    Corresponding author. Address: Section of Gastroenterology and Hepatology, Di.Bi.M.I.S., University of Palermo, Italy, Piazza delle Cliniche, 2, 90127 Palermo, Italy. Tel.: +39 091 655 2170; fax +39 091 655 2156.
    Affiliations
    Section of Gastroenterology and Hepatology, Di.Bi.M.I.S., University of Palermo, Italy
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  • Giulio Marchesini
    Affiliations
    Department of Medical and Surgical Sciences (DIMEC), “Alma Mater” University, Bologna, Italy
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      Let food be your medicine (Hippocrates, ≈400 B. C.)
      The quality of diet, calorie intake and physical activity/sedentariness are pivotal drivers in the interplay between health and non-communicable diseases, and the battle against the risks associated with Western-type behaviour is the top priority of medical societies and health institutions. Unfortunately, any attempt at adopting a healthy lifestyle is counteracted by unhealthy environmental pressure, which favours the diseases of affluence, including liver diseases. The typical Mediterranean diet, characterized by the consumption of complex carbohydrates, fibre- and antioxidant-rich vegetables, and polyunsaturated fatty acids, is considered the prototype of a healthy diet associated with favourable hepatic outcomes. Unfortunately, this diet is no longer the standard food choice even in the Mediterranean area, where it has largely been replaced by a Western-type diet, rich in saturated fatty acids and sugars, which are associated with a higher risk of metabolic liver disease.
      In parallel with unhealthy behaviours, there is a larger and larger use of nutraceuticals everywhere. Nutraceuticals are products derived from food sources, supposed to provide medical or health benefits in addition to their nutritional value; they include herbal and plant extracts, vitamins, minerals, amino acids. Their beneficial effects focus on prevention more than cure, with an expanding market with a lot of implications for producers, regulatory agencies, distributors and consumers.
      Coffee and tea are the most frequently used beverages prepared from plants worldwide; they are consumed primarily for their taste and flavour, but are also considered to be healthy for several organs and tissues, including the liver. Coffee is prepared from the seeds of a plant originally grown in the Arab area in the 15th century and is the second most traded commodity in the world, with lots of varieties and preparations. The consumption of coffee is increasing everywhere, headed by Finnish people with a per capita use of nearly 10 kg seeds/year and over 2.5 cups/day. Tea comes from Southwest China and hundreds of varieties are available as well; it was initially prepared as green tea, with the leaves of Camellia Sinensis dipped in hot water, before any oxidation process takes place by fermentation. Contrary to expectations and the long-dated British tradition, Turkey is the country with the largest tea use with 7.5 kg/year per person. Other herbal teas are consumed throughout the world in different amounts, in selected settings and according to specific cultures.
      Overall, there is some evidence that the consumption of these beverages may confer health benefits. However, it is difficult to support biological plausibility, to provide guidance as to the dose, and some possible warnings about safety should be taken into account.

      What is known about coffee, tea and the liver?

      Several cohort studies assessed the association between coffee intake and the presence/development of non-alcoholic fatty liver disease (NAFLD), or severity of liver damage in patients with chronic liver diseases. The largest study comes from the US and was performed on a cohort of 18,550 individuals.
      • Birerdinc A.
      • Stepanova M.
      • Pawloski L.
      • Younossi Z.M.
      Caffeine is protective in patients with non-alcoholic fatty liver disease.
      After adjusting for clinico-metabolic confounders and other dietary components, the study found a protective effect of caffeine intake on the presence of NAFLD, identified by an unexpected rise of liver enzymes.
      • Birerdinc A.
      • Stepanova M.
      • Pawloski L.
      • Younossi Z.M.
      Caffeine is protective in patients with non-alcoholic fatty liver disease.
      The results have been confirmed in a recent large multi-ethnic study,
      • Setiawan V.W.
      • Porcel J.
      • Wei P.
      • Stram D.O.
      • Noureddin N.
      • Lu S.C.
      • et al.
      Coffee drinking and alcoholic and nonalcoholic fatty liver diseases and viral hepatitis in the multiethnic cohort.
      while other studies did not support any association between coffee and both the presence and occurrence of NAFLD.
      • Gutierrez-Grobe Y.
      • Chavez-Tapia N.
      • Sanchez-Valle V.
      • Gavilanes-Espinar J.G.
      • Ponciano-Rodriguez G.
      • Uribe M.
      • et al.
      High coffee intake is associated with lower grade nonalcoholic fatty liver disease: the role of peripheral antioxidant activity.
      • Zelber-Sagi S.
      • Salomone F.
      • Webb M.
      • Lotan R.
      • Yeshua H.
      • Halpern Z.
      • et al.
      Coffee consumption and nonalcoholic fatty liver onset: a prospective study in the general population.
      • Catalano D.
      • Martines G.F.
      • Tonzuso A.
      • Pirri C.
      • Trovato F.M.
      • Trovato G.M.
      Protective role of coffee in non-alcoholic fatty liver disease (NAFLD).
      Conflicting data were also reported on the association between coffee intake and the severity of liver damage in NAFLD patients. Two cross-sectional studies showed that a large amount of coffee was protective towards histologically diagnosed liver fibrosis,
      • Anty R.
      • Marjoux S.
      • Iannelli A.
      • Patouraux S.
      • Schneck A.S.
      • Bonnafous S.
      • et al.
      Regular coffee but not espresso drinking is protective against fibrosis in a cohort mainly composed of morbidly obese European women with NAFLD undergoing bariatric surgery.
      • Molloy J.W.
      • Calcagno C.J.
      • Williams C.D.
      • Jones F.J.
      • Torres D.M.
      • Harrison S.A.
      Association of coffee and caffeine consumption with fatty liver disease, nonalcoholic steatohepatitis, and degree of hepatic fibrosis.
      whereas the largest study in this field, in 782 biopsy-proven NAFLD patients, limited the protective effect to patients without insulin resistance, not to the entire cohort.
      • Bambha K.
      • Wilson L.A.
      • Unalp A.
      • Loomba R.
      • Neuschwander-Tetri B.A.
      • Brunt E.M.
      • et al.
      Coffee consumption in NAFLD patients with lower insulin resistance is associated with lower risk of severe fibrosis.
      In patients with chronic liver disease due to hepatitis C
      • Khalaf N.
      • White D.
      • Kanwal F.
      • Ramsey D.
      • Mittal S.
      • Tavakoli-Tabasi S.
      • et al.
      Coffee and caffeine are associated with decreased risk of advanced hepatic fibrosis among patients with hepatitis C.
      • Freedman N.D.
      • Everhart J.E.
      • Lindsay K.L.
      • Ghany M.G.
      • Curto T.M.
      • Shiffman M.L.
      • et al.
      Coffee intake is associated with lower rates of liver disease progression in chronic hepatitis C.
      • Costentin C.E.
      • Roudot-Thoraval F.
      • Zafrani E.S.
      • Medkour F.
      • Pawlotsky J.M.
      • Mallat A.
      • et al.
      Association of caffeine intake and histological features of chronic hepatitis C.
      or hepatitis B
      • Setiawan V.W.
      • Porcel J.
      • Wei P.
      • Stram D.O.
      • Noureddin N.
      • Lu S.C.
      • et al.
      Coffee drinking and alcoholic and nonalcoholic fatty liver diseases and viral hepatitis in the multiethnic cohort.
      • Hodge A.
      • Lim S.
      • Goh E.
      • Wong O.
      • Marsh P.
      • Knight V.
      • et al.
      Coffee intake is associated with a lower liver stiffness in patients with non-alcoholic fatty liver disease, hepatitis C, and hepatitis B.
      • Ong A.
      • Wong V.W.
      • Wong G.L.
      • Chan H.L.
      The effect of caffeine and alcohol consumption on liver fibrosis – a study of 1045 Asian hepatitis B patients using transient elastography.
      viruses or alcohol abuse,
      • Liu F.
      • Wang X.
      • Wu G.
      • Chen L.
      • Hu P.
      • Ren H.
      • et al.
      Coffee consumption decreases risks for hepatic fibrosis and cirrhosis: a meta-analysis.
      most studies support a protective effect of coffee drinking on liver damage.
      • Khalaf N.
      • White D.
      • Kanwal F.
      • Ramsey D.
      • Mittal S.
      • Tavakoli-Tabasi S.
      • et al.
      Coffee and caffeine are associated with decreased risk of advanced hepatic fibrosis among patients with hepatitis C.
      • Freedman N.D.
      • Everhart J.E.
      • Lindsay K.L.
      • Ghany M.G.
      • Curto T.M.
      • Shiffman M.L.
      • et al.
      Coffee intake is associated with lower rates of liver disease progression in chronic hepatitis C.
      • Hodge A.
      • Lim S.
      • Goh E.
      • Wong O.
      • Marsh P.
      • Knight V.
      • et al.
      Coffee intake is associated with a lower liver stiffness in patients with non-alcoholic fatty liver disease, hepatitis C, and hepatitis B.
      • Liu F.
      • Wang X.
      • Wu G.
      • Chen L.
      • Hu P.
      • Ren H.
      • et al.
      Coffee consumption decreases risks for hepatic fibrosis and cirrhosis: a meta-analysis.
      Finally, solid data are in favour of a beneficial role of coffee use on the risk of hepatocellular carcinoma (HCC), as summarized in a recently updated meta-analysis,
      • Yu C.
      • Cao Q.
      • Chen P.
      • Yang S.
      • Deng M.
      • Wang Y.
      • et al.
      An updated dose-response meta-analysis of coffee consumption and liver cancer risk.
      and of a reduced liver-related mortality in cohort studies.
      • Goh G.B.
      • Chow W.C.
      • Wang R.
      • Yuan J.M.
      • Koh W.P.
      Coffee, alcohol and other beverages in relation to cirrhosis mortality: the Singapore Chinese Health Study.
      • Setiawan V.W.
      • Wilkens L.R.
      • Lu S.C.
      • Hernandez B.Y.
      • Le Marchand L.
      • Henderson B.E.
      Association of coffee intake with reduced incidence of liver cancer and death from chronic liver disease in the US multiethnic cohort.
      In summary, there is some evidence for a beneficial effect of coffee on the liver, with differences possibly due to the baseline characteristics of the populations and to the methods used for estimating coffee drinking and the severity of liver damage.
      On the contrary, only limited and not univocal evidence is available on the interplay between liver and tea consumption. As part of the NHANES I Epidemiologic Follow-up Study, a 20-year follow-up study including nearly 10,000 participants, drinking coffee and tea together decreased the cumulative incidence of chronic liver disease, particularly in subjects at higher risk of liver disease, but no separate analysis on tea consumption was provided.
      • Ruhl C.E.
      • Everhart J.E.
      Coffee and tea consumption are associated with a lower incidence of chronic liver disease in the United States.
      In patients with HCV infection, tea consumption did not show any significant effect on liver outcomes,
      • Freedman N.D.
      • Everhart J.E.
      • Lindsay K.L.
      • Ghany M.G.
      • Curto T.M.
      • Shiffman M.L.
      • et al.
      Coffee intake is associated with lower rates of liver disease progression in chronic hepatitis C.
      while caffeinated tea drinking in non-coffee consumers was associated with a reduced risk of advanced fibrosis.
      • Khalaf N.
      • White D.
      • Kanwal F.
      • Ramsey D.
      • Mittal S.
      • Tavakoli-Tabasi S.
      • et al.
      Coffee and caffeine are associated with decreased risk of advanced hepatic fibrosis among patients with hepatitis C.
      Two Western studies reported contrasting results about the impact of tea drinking and HCC occurrence,
      • Setiawan V.W.
      • Wilkens L.R.
      • Lu S.C.
      • Hernandez B.Y.
      • Le Marchand L.
      • Henderson B.E.
      Association of coffee intake with reduced incidence of liver cancer and death from chronic liver disease in the US multiethnic cohort.
      • Bamia C.
      • Lagiou P.
      • Jenab M.
      • Trichopoulou A.
      • Fedirko V.
      • Aleksandrova K.
      • et al.
      Coffee, tea and decaffeinated coffee in relation to hepatocellular carcinoma in a European population: multicentre, prospective cohort study.
      while a recent meta-analysis largely involving Asian populations reported a protective effect of green tea against HCC occurrence.
      • Huang Y.Q.
      • Lu X.
      • Min H.
      • Wu Q.Q.
      • Shi X.T.
      • Bian K.Q.
      • et al.
      Green tea and liver cancer risk: A meta-analysis of prospective cohort studies in Asian populations.
      Finally, cohort studies did not show any positive effect of both black and green tea on liver-related death.
      • Setiawan V.W.
      • Wilkens L.R.
      • Lu S.C.
      • Hernandez B.Y.
      • Le Marchand L.
      • Henderson B.E.
      Association of coffee intake with reduced incidence of liver cancer and death from chronic liver disease in the US multiethnic cohort.
      • Ruhl C.E.
      • Everhart J.E.
      Coffee and tea consumption are associated with a lower incidence of chronic liver disease in the United States.

      What is new?

      In the present issue of the Journal, Alfering et al.
      • Alferink L.J.M.
      • Fittipaldi J.
      • Kiefte-de Jong J.C.
      • Taimr P.
      • Hansen B.E.
      • Metselaar H.J.
      • et al.
      Coffee and herbal tea consumption is associated with lower liver stiffness in the general population: the Rotterdam study.
      report on the association of both coffee and tea drinking with the presence of steatosis and fibrosis in a cohort of 2,424 individuals from the Rotterdam study – an ongoing population-based cohort study. Ultrasonography-assessed steatosis was present in about 30% of the individuals; clinically relevant hepatic fibrosis, estimated by FibroScan, was present in 5%. Notably, drinking 3 or more cups of coffee per day, compared with no coffee, was protective against clinically relevant fibrosis, and both coffee and herbal tea consumption were independently associated with log-transformed liver stiffness. Finally, no association was found between either coffee or tea drinking and the presence of steatosis. These results are in keeping with those reported in a much smaller study, where fibrosis was tested by a patented test (FibroTest).
      • Zelber-Sagi S.
      • Salomone F.
      • Webb M.
      • Lotan R.
      • Yeshua H.
      • Halpern Z.
      • et al.
      Coffee consumption and nonalcoholic fatty liver onset: a prospective study in the general population.
      The study by Alfering et al. qualifies as the largest study ever reported on the relationship between coffee, tea and liver health in a general population, the only one also reporting on tea intake, and measuring the severity of fibrosis by a reliable, widely available method, i.e. liver stiffness by FibroScan. In addition, all results were confirmed after adjusting for different demographic, clinical and metabolic risk factors as well as for calorie intake and other nutrients. The beneficial effect of coffee on liver fibrosis increased after adjusting for confounders, suggesting that big coffee consumers also have unhealthy lifestyles, it was more pronounced in the subgroup of patients with fatty liver, and was also confirmed in patients with normal ALT and in subgroups where the food frequency questionnaire was either administrated at the time of liver evaluation or 5.8 years before. Finally, in the analysis of tea intake, the study not only considered overall tea intake, but also took into account the potentially different effect of black, green and herbal tea on liver outcomes. These are the main strengths of the study, but the results should be interpreted with caution as: 1) the study is limited to an elderly Caucasian population (mean age, 66 years); 2) the prevalence of coffee consumers is very high (93%), so big coffee consumers – the cohort protected from severe liver fibrosis – are compared to a very small group of individuals; 3) the prevalence of tea consumers is also high (85%), but the amount of tea intake is low, thus underestimating a potential protective effect of tea and especially of green tea, as reported in Asian populations; and 4) the lack of any effect of both tea and coffee on hepatic steatosis, already reported in the literature, might depend on the scarce sensitivity of ultrasonography. As a common concluding remark, the authors suggest that further studies using more objective non-invasive tools, like controlled attenuation parameter, are needed to define this issue. In our opinion a more pressing question remains before the results may be turned into recommendations, as detailed below.

      How can we explain the biological effects of coffee and tea on the liver?

      More than 100 components are present in coffee and tea, including polyphenols and caffeine, which are contained in both beverages in very different and variable amounts. Notably, caffeine content may be very high in a few green tea brands, totally absent in a few herbal teas (as an example, Chamomile tea) and both caffeine and polyphenols are also present in several edulcorated drinks associated with the obesity epidemics and NAFLD (Fig. 1). Experimental data, reviewed by Salamone et al.
      • Salomone F.
      • Galvano F.
      • Li Volti G.
      Molecular bases underlying the hepatoprotective effects of coffee.
      showed that caffeine inhibits hepatic stellate cell proliferation, thus exerting an anti-fibrogenic effect via adenosine receptor blockade. In addition, caffeine was reported to have haemodynamic effects in a rat model of portal hypertension, decreasing portal pressure, porto-systemic shunting and hepatic angiogenesis. Polyphenols, namely chlorogenic acid, have a potent antioxidant, anti-inflammatory and hepatoprotective effect independent of caffeine,
      • Salomone F.
      • Galvano F.
      • Li Volti G.
      Molecular bases underlying the hepatoprotective effects of coffee.
      and synergistically act with caffeine on fibrosis development. However, the amount and quality of polyphenols and related antioxidant components is dependent on coffee, tea and herbal tea varieties and by the method of preparation, and might be the basis to explain the variable positive effects on hepatic fibrosis.
      • Salomone F.
      • Galvano F.
      • Li Volti G.
      Molecular bases underlying the hepatoprotective effects of coffee.
      Figure thumbnail gr1
      Fig. 1Sources of caffeine and amount per serving in coffee, tea and other beverages. Data are expressed as minimum, maximum and average (in red), according to different preparations and brands. Redrawn and modified from data of the Institute for Scientific Information on Coffee (www.coffeeandhealth.org). Note that the amount of caffeine in decaffeinated coffee and hot chocolate is negligible (<10 mg/serving).
      While the protective effects of both coffee and tea on liver fibrosis are supported by both epidemiological and experimental evidence, conflicting results are available on the association with fatty liver. A recent meta-analysis reported a protective effect of both coffee and tea on the risk of the metabolic syndrome;
      • Marventano S.
      • Salomone F.
      • Godos J.
      • Pluchinotta F.
      • Del Rio D.
      • Mistretta A.
      • et al.
      Coffee and tea consumption in relation with non-alcoholic fatty liver and metabolic syndrome: A systematic review and meta-analysis of observational studies.
      experimental studies suggested a modest antisteatogenic effect of both beverages,
      • Salomone F.
      • Galvano F.
      • Li Volti G.
      Molecular bases underlying the hepatoprotective effects of coffee.
      but clinical studies were negative.
      • Setiawan V.W.
      • Porcel J.
      • Wei P.
      • Stram D.O.
      • Noureddin N.
      • Lu S.C.
      • et al.
      Coffee drinking and alcoholic and nonalcoholic fatty liver diseases and viral hepatitis in the multiethnic cohort.
      • Gutierrez-Grobe Y.
      • Chavez-Tapia N.
      • Sanchez-Valle V.
      • Gavilanes-Espinar J.G.
      • Ponciano-Rodriguez G.
      • Uribe M.
      • et al.
      High coffee intake is associated with lower grade nonalcoholic fatty liver disease: the role of peripheral antioxidant activity.
      • Zelber-Sagi S.
      • Salomone F.
      • Webb M.
      • Lotan R.
      • Yeshua H.
      • Halpern Z.
      • et al.
      Coffee consumption and nonalcoholic fatty liver onset: a prospective study in the general population.
      • Catalano D.
      • Martines G.F.
      • Tonzuso A.
      • Pirri C.
      • Trovato F.M.
      • Trovato G.M.
      Protective role of coffee in non-alcoholic fatty liver disease (NAFLD).
      Thus, in the complex human model, coffee and tea might in part prevent fatty liver, but are more likely to act as moderators of the detrimental effect of second hits, leading to inflammation and fibrosis.

      Conclusions

      There is an increased interest in diet and nutrition in liver diseases. A balanced diet, mostly resembling the Mediterranean diet, remains the cornerstone to reduce obesity and the risk of metabolic liver disease, and in patients with chronic liver diseases, to reduce the risk of complications, irrespective of aetiology. Should we add regular coffee and tea breaks to our daily life? Before this policy can be recommended, prospective studies are needed to identify the optimum amounts and the type(s) of coffee and tea leading to more favourable liver outcomes. Nutraceuticals are largely used with several indications without any convincing evidence; the risk of rare but severe liver toxicity associated with green tea use, as well as the cardiovascular effects of caffeine, should not be forgotten before supporting a diffuse implementation of these beverages.

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      • Coffee and herbal tea consumption is associated with lower liver stiffness in the general population: The Rotterdam study
        Journal of HepatologyVol. 67Issue 2
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          Chronic liver diseases constitute a major public health problem. Liver cirrhosis was the 12th cause of death worldwide and the sixth cause of life-years lost in the adult population in developed countries in 2010.1,2 Chronic liver diseases are often silent for over 20 years until cirrhosis develops. Indeed, several studies have suggested that liver fibrosis may be present within unselected individuals. Using transient elastography (TE) as a diagnostic tool for liver fibrosis, a prevalence of 6–7% was found in the general population3,4 and even up to 17% in those high-risk populations with metabolic syndrome and type 2 diabetes.
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      • Corrigendum to “Coffee and tea breaks for liver health” [J Hepatol 67 (2017) 221–223]
        Journal of HepatologyVol. 67Issue 5
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          It has come to our attention that the authors name of the original article “Coffee and Herbal Tea Consumption is associated with lower Liver Stiffness in the General Population: The Rotterdam Study” in which this editorial refers to was misspelt in the Editorial. The correct spelling of the author is Alferink. We apologise for this error and the inconvenience caused.
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