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United Nations Department of Economic and Social Affairs Sustainable Development

A Healthy Liver Will Always Deliver! – Creating Wider Awareness on Non-Alcoholic Fatty Liver Disease (NFLD) and others Non-Communicable Diseases (NCD)

Center for Neuroscience and Cell Biology (CNC), University of Coimbra (
Academic institution

    Chronic liver disease (CLD) is a major cause of morbidity and mortality worldwide. Non-Alcoholic Fatty Liver Disease (NFLD) is a growing epidemic, associated with Type 2 Diabetes (T2DM) and obesity, being estimated that 1 in every 4 people has early stages of the disease. As others Non-Communicable Diseases (NCD), NAFLD is driven by daily-life behaviors, namely hyper-caloric diets and sedentary lifestyles. To our knowledge no participatory or co-creation approaches, counting with patients, professionals, and researchers, has been conducted to communicate the nature and progression of NAFLD, from a cellular to a societal level. This health information/promotion links with SDGs and Agenda2030.

    Implementation of the Project/Activity

    This action is part of the FOIE GRAS European Training Network (ETN), a Marie Skłodowska-Curie action (, focused on the bioenergetic remodeling in the pathophysiology and treatment of NAFLD. Alongside the basic biomedical research and development of novel therapeutic tools, the FOIE GRAS ETN has a project exclusively dedicated to raising NAFLD awareness and to promote healthy lifestyles. Therefore, this project is framed in four main activities (A): I-Selection of the biomedical information (AI); II-Participatory approach involving patients, professionals and researchers (AII); III-Co-creation of the script and visual narrative (AIII); IV-Evaluation (through a pre/post-questionnaire) and dissemination (AIV). After selecting the biomedical information, we conducted an exploratory study, semi-structured interviews at the APDP Diabetes Portugal (NCD Alliance member), to uncover the awareness of high-risk metabolic patients suffering from T2DM, estimated to be about 70% amongst the NAFLD patients. Such involvement of patients could inform us about which NAFLD-related knowledge could be useful explored in the visual narrative, such as the insulin resistance, the NAFLD progression, the nutrition knowledge, and the daily routine ( The implementation of the activities involved regular meetings for debating content and practices, analyzing the interviews, co-creating the script and narrative drawings. The AIV is ongoing, we used pre / post-questionnaire aiming to determine the effectiveness of the comic as a medium for disease prevention / health promotion programs.


    The comic book ‘A Healthy Liver Will Always Deliver!’ grounded on a participatory approach and co-creation processes is now available in 9 languages and maybe explored and adapted globally (, in patients associations, health centers, schools, science centers, municipalities, and society at large, to raise awareness on NAFLD and health promotion. Besides several awareness activities done in specific environments planned for institutional outreach programs (school visits, science fairs, open labs, European Researchers Night), in 2018, the ETN developed a science communication multimodal campaign to raise awareness on NAFLD and healthy lifestyles for the 4th edition of the European University Games, the largest university multi-sport event in Europe (; the initiative reached over 100.000 members of the local and the international community, with direct impact for the SDG3 and SDG4 and Agenda 2030 implementation.

    Enabling factors and constraints

    Some of the enabling factors include: -the active involvement of the APDP Diabetes Portugal (NCD Alliance member); -the interdisciplinarty and experience working on participatory approaches, comics science, and communication/education targeting multiple audiences; -the publication of the comic book in open access by the Coimbra University Press; -the funding, from the Horizon 2020 and the Fundação para a Ciência e a Tecnologia, the Portuguese public agency that supports science, technology and innovation. The constraint, the actual pandemic; we expected to conduct a prior qualitative evaluation of the comic with patients and health providers.

    Sustainability and replicability

    The comic ‘A Healthy Liver Will Always Deliver!’ is available in 9 languages: Portuguese (ISBN 978-989-26-2039-8 PRT; 978-989-26-2041-1 DIGI), English (978-989-26-2042-8 PRT; 978-989-26-2040-4 DIGI), Catalan (978-989-26-2117-3 PRT; 978-989-26-2118-0 DIGI), Czech (978-989-26-2129-6 PRT; 978-989-26-2130-2 DIGI), French (978-989-26-2123-4 PRT; 978-989-26-2124-1 DIGI), German (978-989-26-2119-7 PRT; 978-989-26-2120-3 DIGI), Italian (978-989-26-2121-0 PRT; 978-989-26-2122-7 DIGI), Polish, (978-989-26-2127-2 PRT; 978-989-26-2128-9 DIGI), and Spanish (978-989-26-2115-9 PRT; 978-989-26-2116-6 DIGI) (PRT=printed, DIGI= digital. Near future it will be available the study about the effectiveness of the comic (i) to communicate the biomedical concepts in the context of NAFLD, and other NCDs, as well as a medium (ii) to promote the adoption of healthy lifestyles. The pre/post-questionnaire used in this practice can also be translated and adopted in other regions in Europe and worldwide.

    Other sources of information

    Comic book ‘A Healthy Liver Will Always Deliver!’ European Training Network FOIE GRAS Insights from qualitative research on NAFLD awareness with a cohort of T2DM patients: time to go public with insulin resistance? Publicly stressing the role of mitochondria in NAFLD with(in) a sports event Awareness on NAFLD and healthy lifestyles for the European University Games Comic “Exercise, Mitochondria… & Us” Dissemination by the Coimbra University Press Dissemination by the national Portuguese media, Público…

    COVID-19 Impact

    The COVID-19 impacted on the evaluation of the comic progression. This participatory project was designed to involve actively patients and professionals in different moments of the co-creation processes. The practices involving focus groups after completing the script and visual narrative were not possible due to the COVID-19 and so the evaluation was replaced by a quantitative analysis of pre/post-questionnaire during the dissemination of the book ( Besides NAFLD, and other liver injuries, the comic book addresses high BMI, T2DM, which has being associated to severe COVID-19; we believe the information and narrative may contribute toward self-management and prevention of NCDs and a better response to a severe infection such as SARS-CoV-2.

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    This initiative does not yet fulfil the SMART criteria.
    01 January 2017 (start date)
    30 June 2021 (date of completion)
    Center for Neuroscience and Cell Biology, University of Coimbra
    Other beneficiaries

    The CNC at the University of Coimbra is the promoter of this good practise under the umbrella of the FOIE GRAS European Training Network, which involves 13 partners in academy, industry and a patient association, from 7 countries. The participants in the multiple research and outreach initiatives were the direct/initial beneficiaries of the action. The comic book published by the Coimbra University Press is now available in 9 languages.

    More information
    Contact Information

    Anabela Marisa, Principal Investigator, PhD