Internet search engines and social media are improving awareness on non-alcoholic fatty liver disease in Brazil

The authors read with great interest the recently published manuscript by Lazarus et al., highlighting that no nation is properly tackling the emerging global challenge of non-alcoholic fatty liver disease (NAFLD). To our knowledge, this is also the situation in Brazil, because no public policy for NAFLD is now under discussion and no civil society organization is currently providing advocacy for this disease. In spite of this situation, a recent population-based survey sponsored by the Brazilian Liver Institute (IBRAFIG) regarding knowledge of the general population about liver diseases led to unexpected results.

This survey was designed to be representative of the Brazilian population, comprised of 1,995 participants. Interestingly, NAFLD (better known in Brazil as fatty liver) ranked 2^nd and 3^rd as the most commonly recognized cause of liver cancer and cirrhosis, respectively, by the general population, just after alcohol abuse and smoking. In addition, more than half of the participants agreed that fatty liver could lead to diabetes, cirrhosis, myocardial infarction and/or stroke and cancer. Those findings regarding population knowledge about NAFLD were much better than those previously reported^, and demonstrated that the Brazilian population had a higher-than-average level of awareness of the burden of NAFLD. This may be due to previous campaigns conducted by IBRAFIG and other organizations to improve disease awareness or possibly the effect of social media increasing public interest about this subject. In order to assess this hypothesis, we analyzed internet search patterns over time using Google Trends for fatty liver in Brazil as well as 3 other countries, namely Spain, France, and the USA. For multiple comparisons, we have used the relative search volume, which is the query share of a particular term for a given location and time period, normalized by the highest query share of that term over time series. The resulting numbers are put on a scale in a range of 0 to 100 based on a topic’s proportion to all searches on all topics. The relative search volume of fatty liver in Brazil and other countries were then compared to those of viral hepatitis B and C. Each time fatty liver turned out to be a trending topic on social media, namely Instagram and Facebook in Brazil, its impact on relative search volume was also evaluated.

Fig. 1A depicts mean relative search volume results for fatty liver, hepatitis B, and C in Brazil, Spain, France, and the USA in the last 5 years. Greater mean relative search volume on Google Trends was observed in the Americas when compared to Europe. Interestingly, internet searches in Brazil and the USA quoting ‘fatty liver’ were much more common than searches quoting ‘hepatitis C’, which apart from alcohol-related liver disease is the main cause of cirrhosis and liver cancer in these countries. Fig. 1B discloses the Google Trends graphics of relative search volume results of fatty liver from 2004 to 2022 in Brazil. There was a continuous increase in public interest in fatty liver over time with a peak on July 10^th 2018 followed by an oscillatory plateau. There was a correlation with the post of a social media influencer, with more than 30 million (more than 10% of the Brazilian population) followers on Instagram that day announcing his diagnosis of NALFD and his fight to avoid cirrhosis and cancer with lifestyle changes. This post had 2 million likes and was followed by great mass media coverage over an entire week. No other episode of fatty liver as a trending topic on social media was recognized over time in Brazil. Those data altogether may in part explain the higher-than-average knowledge of the Brazilian population about NAFLD and suggest that social media could turn out to be a powerful tool to rapidly increase civil awareness about the global burden of NAFLD. However, it is worth mentioning that social media may increase negative feeling and stigma related to NAFLD, raising some concerns about information handling in Twitter as well as in other platdorms. Therefore, when using social media, it is of utmost importance to provide links to dedicated homepages of any relevant medical or civil societies engaged in fighting against NAFLD.

Google Trends metrics could also be very useful to measure the NAFLD awareness campaign’s effectiveness in raising public interest on the topic as more and more people worldwide are using the web to get information on health issues and are spending more time online.

In summary, we would agree with the authors that we still need to improve the preparedness index to tackle NAFLD, but we would like to suggest, in addition, that social media could play a valuable role in increasing disease awareness.