A paper describing a dramatic change during the 20th century in England and Wales in the association between social class and mortality from liver cirrhosis features in Alcohol and Alcoholism. While deaths from cirrhosis were more common among higher social classes in the early part of the century, the pattern changed so that deaths from cirrhosis were much more common among the lower social classes by the end of the century. Data on male cirrhosis mortality by social class were obtained from the Registrar General's Decennial Supplements for the years 1921-1991.
The authors of this paper state that more recent research suggests that alcohol drinking may not be the reason for this change over time, as surveys in the UK have shown that lower-social-class individuals do not drink more than those at higher social classes. However, the pattern of drinking may be more important than the average amount of alcohol consumed. It is suggested that drinking patterns in the upper classes may have changed during the 20th century from weekend beer and whisky drinking towards a Mediterranean-type diet that included wine with food. In addition, people in lower social classes are generally more likely to drink in binges.
One reviewer states that "The main cause of change over time in the relation of social class with mortality from cirrhosis is probably an improvement of dietary behaviour and lifestyle in the high social classes, and often still unhealthy diet and lifestyle in the lower classes' The greater rates of obesity and metabolic syndrome, results in a fatty liver, which is associated with cirrhosis. Obesity is being increasingly appreciated as an important factor in the risk of cirrhosis, especially when combined with alcohol consumption. In the Million Women Study the combination of obesity and alcohol consumption of 150 g or more each week was associated with a marked increased risk of cirrhosis (about fivefold) compared with that seen in obese women who drank less than 70 g of alcohol a week (a drink a day).
Multiple risk factors for hepatic cirrhosis: While alcohol is generally considered the most important risk factor for hepatic cirrhosis, there are a number of other factors. One International Scientific Forum on Alcohol Research member stated: "The general impression is that approximately one half of the cases of cirrhosis are related to alcohol consumption; the second important cause is "fatty liver" associated with abdominal obesity, followed by autoimmune diseases, virus hepatitis, and metabolic diseases." Another factor may be the ingestion of medications, such as paracetamol or acetaminophen, which break down to more toxic metabolites. Heavy use of acetaminophen has been shown to relate to cirrhosis.
To conclude, certain medications, coffee consumption, and many other lifestyle factors are associated with hepatic cirrhosis. The actual reasons for the changes over time reported in this paper remain unclear.
Crombie IK, Precious E. Changes in the social class gradient of cirrhosis mortality in England and Wales across the 20th century. Alcohol and Alcoholism 2011;46:80. alcalc.oxfordjournals.org/content/46/1/80.abstract