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Effects of coffee, smoking, and alcohol on liver function tests: a comprehensive cross-sectional study
BMC Gastroenterology 2012, 12:145 doi:10.1186/1471-230X-12-145

Eun Sun Jang (jeses19@gmail.com) Sook-Hyang Jeong (jsh@snubh.org) Sung Ho Hwang (c3134@snubh.org) Hyun Young Kim (cecilup@naver.com) So Yeon Ahn (ahnsoyeon@gmail.com) Jaebong Lee (wantu4@gmail.com) Sang Hyub Lee (gidoctor@snubh.org) Young Soo Park (dkree@snubh.org) Jin Hyeok Hwang (jhhwang@snubh.org) Jin-Wook Kim (kimjw@snubh.org) Nayoung Kim (nayoungkim49@empas.com) Dong Ho Lee (dhljohn@snubh.org)

ISSN Article type Submission date Acceptance date Publication date Article URL

1471-230X Research article 31 May 2012 10 October 2012 18 October 2012 http://www.biomedcentral.com/1471-230X/12/145

Like all articles in BMC journals, this peer-reviewed article can be downloaded, printed and distributed freely for any purposes (see copyright notice below). Articles in BMC journals are listed in PubMed and archived at PubMed Central. For information about publishing your research in BMC journals or any BioMed Central journal, go to http://www.biomedcentral.com/info/authors/

© 2012 Jang et al. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Effects of coffee, smoking, and alcohol on liver function tests: a comprehensive cross-sectional study
Eun Sun Jang1 Email: jeses19@gmail.com Sook-Hyang Jeong1* * Corresponding author Email: jsh@snubh.org Sung Ho Hwang1 Email: c3134@snubh.org Hyun Young Kim2 Email: cecilup@naver.com So Yeon Ahn3 Email: ahnsoyeon@gmail.com Jaebong Lee3 Email: wantu4@gmail.com Sang Hyub Lee1 Email: gidoctor@snubh.org Young Soo Park1 Email: dkree@snubh.org Jin Hyeok Hwang1 Email: jhhwang@snubh.org Jin-Wook Kim1 Email: kimjw@snubh.org Nayoung Kim1 Email: nayoungkim49@empas.com Dong Ho Lee1,2 Email: dhljohn@snubh.org
1

Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 166 Gumi-ro, Bundang-gu, Seongnam-si 463-707, Gyeonggi-do, Republic of Korea
2

Health Promotion Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 166 Gumi-ro, Bundang-gu, Seongnamsi 463-707, Gyeonggi-do, Republic of Korea

3

Medical Research Collaborating Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 166 Gumi-ro, Bundang-gu, Seongnam-si 463-707, Gyeonggi-do, Republic of Korea

Abstract
Background
Liver function tests (LFTs) can be affected by many factors and the proposed effects of coffee on LFT require a comprehensive evaluation. The aim of this study was to elucidate whether drinking coffee, smoking, or drinking alcohol have independent effects on LFTs in Korean health-check examinees.

Methods
We used the responses of 500 health-check examinees, who had participated in a selfadministered questionnaire survey about coffee, alcohol drinking, and smoking habits.

Results
Coffee consumption was closely related to male gender, high body mass index (BMI), alcohol drinking, and smoking. On univariable and multivariable analyses, drinking coffee lowered serum levels of total protein, albumin, and aspartate aminotransferases (AST). On multivariable analyses, smoking raised serum γ-glutamyl transferase (GGT) level and decreased serum protein and albumin levels, while alcohol drinking raised GGT level after adjustment for age, gender, regular medication, BMI, coffee and alcohol drinking amounts, and smoking.

Conclusions
Coffee consumption, smoking, and alcohol drinking affect the individual components of LFT in different ways, and the above 3 habits each have an impact on LFTs. Therefore, their effects on LFTs should be carefully interpreted, and further study on the mechanism of the effects is warranted.

Keywords
Coffee, Alcohols, Smoking, Liver function tests, Gamma-glutamyltransferase

Background
Liver function tests (LFT) are useful tools in clinical practice to assess potential liver diseases, to monitor treatment responses, and to predict prognosis of the patients with liver diseases. As a battery, LFTs consists most commonly of serum total cholesterol (TC), total protein, albumin, alkaline phosphatase (ALP), total bilirubin (TB), aspartate amino transferase (AST), alanine aminotransferase (ALT), and γ-glutamyl transferase (GGT). However, the interpretation of LFTs should be comprehensive and careful because LFTs can

be influenced by many personal and environmental factors, including age, gender [1], body mass index (BMI) [2], alcohol drinking [3], cigarette smoking, malnutrition, presence of extrahepatic diseases such as cardiac, musculoskeletal, or endocrine diseases, and status of liver health in itself [4]. Although the influence of alcohol drinking on the liver function has been extensively studied, studies on the effects of coffee drinking or cigarette smoking have been relatively limited. According to the international coffee organization, people drink approximately 2.25 billion cups of coffee everyday across the globe, and Korea is the 11th highest coffee consuming country in the world, consuming 65 thousand tons of coffee a year. Considering the large amounts of consumed coffee globally and its lifetime consumption in most individuals, the effects of coffee on health merit great attention. Interestingly, coffee has been suggested to have a potential favorable impact on liver diseases. In North America and Europe, studies have shown that coffee drinking reduces the risk of liver cirrhosis and hepatocellular carcinoma (HCC) [5,6]. In addition, the protective effect of coffee drinking on the development of HCC has been reported in the Japanese [7]. Moreover, coffee consumption was inversely related with serum levels of ALT and GGT among LFT, especially in heavy alcohol drinkers [8]. Recently, it has been suggested that smoking increases GGT and boosts the alcohol-induced GGT elevations [9]. Although smoking does not damage hepatocytes directly, it may change the effect of alcohol drinking on AST, ALT and GGT activities via the actions of numerous ingredients that alter the activities of enzymes found in the liver [10]. Furthermore, smoking increased serum ALP levels [11] produced by the bone and the kidney, as well as by the liver. However, it is still not clear whether smoking is related to each component of LFTs and whether the effects are independent of alcohol drinking, since the smoking habit itself is closely related to the alcohol drinking habit [12]. Therefore, LFT changes in real clinical situations need to be interpreted carefully in the context of the interaction between various life style factors. Nevertheless, most previous studies deal with the separate effects of alcohol, coffee, or smoking on one or a few components of LFTs, and there has been a lack of data on the comprehensive effects of alcohol, smoking and coffee drinking on the commonly used all components of LFTs. Moreover, those studies have been reported primarily from Western countries and Japan, while the study of the effects of these behaviors on LFTs for persons living in Asian countries have had limited study. Thus, this study was conducted in a Korean population to evaluate the effects of coffee consumption, smoking, and alcohol drinking on the most commonly used sets of LFTs in order to consider the interactive association with major demographic factors.

Methods
Patients
In this cross-sectional study, all health-check examinees were consecutively enrolled in the health promotion center of Seoul National University Bundang Hospital from August 2007 to October 2007. Of 909 examinees during this study period, 500 (55%) subjects agreed to participate to a comprehensive self-administered questionnaire survey about smoking, alcohol consumption, and coffee drinking habits. Moreover, they were requested to answer the

questions about their current diseases undergoing medical care, their past histories of hypertension, of diabetes mellitus, of hypercholesterolemia, or of any other unspecified diseases and regular medications, in order to discern the effects of regular medication on serum LFTs. This study was approved by the Institutional Review Board of Seoul National University Bundang Hospital and all participants provided written informed consent prior to this study.

Questionnaire
Detailed information on each subject’s demographics, medical history, physical findings, and laboratory results were obtained from medical records. The information on coffee and alcohol consumption, and cigarette smoking habits was collected from the self-reported questionnaire survey (Additional file 1). Coffee consumers were classified as ‘none’, ‘past’, or ‘current drinker’. If a subject was a past or current drinker, information on total duration of coffee drinking and the daily amount of coffee consumed were requested. The types of the most consumed coffee were divided into 4 groups: instant, brewed, a combination of instant and brewed coffee, and others. The information about the duration of coffee consumption was obtained through an open question (years). The frequency and amount of coffee consumption was asked by closed-ended question with 9 options (No, < 1 cup/month, 2–3 cups/month, a cup/week, 2–3 cups/week, 4–6 cups/week, 1–2 cups/day, 3–4 cups/day, > 5 cups/day). Alcohol drinking status was classified as none, past, or current drinker and information on the detailed alcohol drinking duration and daily amount of consumed alcoholic beverages were obtained with similar way to those of coffee consumption. Since an alcoholic consumption of more than 60 g/day in men (20 g/day in women) over more than 10 years has been documented as a major risk factor for alcoholic liver disease [13], we categorized alcohol drinkers according to their mean daily drinking amounts into none, not-heavy (

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