United NationsDepartment 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)


    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.


    The main objective of this practice is to support a comprehensive contribution to the NAFLD awareness globally as well as with an educational medium toward effective disease prevention and health promotion programs. Comics have shown to be effective, educational, engaging, and shaping attitudes, medium; besides, comics appeal a broader audiences. The innovative feature of our action on SDGs is the involvement of patients, health providers, and researchers, from life sciences, biomedicine, psychology and sociology, and, together, bringing reliable information for self-management of CLD patients, also for promoting healthy lifestyles among at-risk people and general public. To expand the practice, the comic is available in 9 languages; also one version has no text for adaptation among demographic groups.

    Contribution to SDG Implementation

    NAFLD is estimated to have an incidence of 3.62 million cases/year, NCD are responsible for 70% of all deaths worldwide. We believe our action grounded on a participatory approach and a co-creation process represents a strategy toward effective disease prevention and health education programs. Thus, this practice brings reliable health information and promotion directly tackling the target 3.4 to ‘reduce by one-third the premature mortality from NCDs’ in 2030; and the target 4.6 to ‘ensure that all youth and a substantial proportion of adults, both men and women, achieve literacy’ in 2030.

    Implementation methodologies

    This action is part of the FOIE GRAS European Training Network (ETN), a Marie Skłodowska-Curie action (https://cordis.europa.eu/project/id/722619), 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 (https://doi.org/10.1186/s12889-020-09249-5). 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 (https://www.fattylivercomics.com/), 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 (https://www.eug2018.com/educational/science-at-eug2018); 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.

    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.

    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 (https://www.fattylivercomics.com/). 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.

    Contact Name
    Anabela Marisa
    Center for Neuroscience and Cell Biology (CNC), University of Coimbra
    Geographical coverage

    This practice is part of the FOIE GAS European Training Network (ETN), funded by the Horizon 2020; it was firstly implemented in Portugal, but the comic book is now available in 9 languages and maybe explored and adapted globally.

    01 January 2017 (start date)
    30 June 2021 (date of completion)
    More information
    Contact Information

    Anabela Marisa, Principal Investigator, PhD