A primer on the Liver Habits Score™

What it does, how we made it, and how drinkers can use it.

In an article titled “Why we’re launching the Liver Habits Score™” we discussed the motivation behind the Liver Habits Score. In this article we are discussing what exactly it is, how it works, and how you can put it to use.

The format of the Score.

We built the Liver Habits Score™ using a format similar to the Myers-Briggs Type Indicator (MTBI), which is arguably the most used, famous, and studied personality test in the world.

Most MTBI models involve taking a guided test that uses your answers to give you your Personality Type. Upon giving you your Personality Type, it then includes all kinds of information about you, your strengths, weaknesses, opportunities, and threats. If you get others to take the MTBI personality tests, you can then use that info to understand more about how they think, feel, and overall interact with the world. Which then in turn helps you understand how to best interact with them in a way that is fitting for how they think and behave.

The MTBI model is not perfect, and many physiologists through the years have revealed faults with it. However, MTBI does accomplish one very important thing: it helps people understand that others around them might not think, feel, or interact with the world in the same way as them—and that alone is a huge accomplishment. It gets people out of their own head and into the shoes of someone else to understand things about them that they may have never considered before. All in all, MTBI does a great job of helping to establish a bonafide level of empathy between differing individuals.

In a similar way to many MBTI personality tests, the Liver Habits Score™ uses a series of questions to understand someone habits related to their liver health. For example, questions include:

• Sex (to get weekly alcohol thresholds)
• Height & Weight (to get BMI)
• How much of various foods someone eats (to estimate sugar, diet, and other info)
• How much of what type of exercise someone does (to calculate total & total vigorous exercise)

Using these questions, we then automatically populate in the backend the above chart. The above chart was my Liver Health Score before I started studying about how various habits affect liver health.

While we give this chart to test takers, we have worked hard to also make a more user friendly result page that many people may find easier to interpret and make lifestyle changes based upon. That results page based upon the above chart looks something like this:

The results page is broken down into three sections:

1. Alcohol Consumption Habits
2. BMI (which can be influenced outside of alcohol, diet, & exercise habits)
3. Diet & Exercise Habits

The reason we have broken the results page down into three sections is because it’s helpful to see the major buckets that someone is doing well or failing at. For example, as you can see with my starting Liver Habits Score™, I had been doing a great job at BMI and Diet & Exercise… but was absolutely failing in terms of my alcohol consumption habits. While I didn’t really need to change any of my non-alcohol-related habits, my alcohol habits needed some major work.

I was drinking 21+ drinks a week, consumed alcohol almost everyday, and rarely took long stretches off from alcohol per year. Based on this information, I saw very clearly areas that I could improve.

I’m not one to count drinks. It’s not really my style. I drink until I don’t want to anymore. Sometimes that’s one drink (such as showering before bed), and other times, while spending a Saturday golfing with friends, that could easily end up being 6+ for the day (4 while playing, 2–3 more at the clubhouse afterwards). 6 drinks in 5 hours isn’t going to cause any problems with my BAC levels, but it is a lot of alcohol. So what could I do if I was unwilling to count drinks? I just decided I’d try not drinking Sunday-Thursday, which left myself 4 drink-free days per week. Ironically enough, I found that this then significantly lowered my total drinks per week count… 14 drinks over 3 days is plenty. While I don’t do this to perfection every week, and usually I end up in the 14–21 drinks range, overall this has been a very easy lifestyle switch to drink significantly less alcohol, while also getting the buzz when I want it.

The whole point of the way we format the quiz and results of the Liver Habits Score™ is to give you actionable things that you can work on to reduce your risk factors for liver disease.

How the Score is calculated.

Just like the MTBI personality models, there must be a method by which fitting and tailored questions are used to calculate helpful information.

Liver health categories and their weighting:

For the Liver Habits Score, there are currently 10 categories of habits that affect liver health. Not each category has the same level of affect on liver health and so are weighted according to their likely impact on the liver. These categories can be found on the top of the graph and consist of the following:

1. # of drinks per week (weight = 8 points)
2. # of days of drinking days per week (weight = 6 points)
3. # of years of drinking at above recommended levels (weight = 6 points)
4. current BMI (weight = 5 points)
5. BMI timeline (weight = 1 points)
6. daily sugar intake (weight = 3 points)
7. weekly exercise (weight = 6 points)
8. weekly diet (weight = 6 points)
9. alcohol holiday stretches per year (weight = 4 points)
10. dietary additions related to alcohol-related liver health (weight = 5)

In total, there are 50 weighted points at stake. These weighted points are to be multiplied by a rating depending on whether they are beneficial or detrimental to liver health.

Liver health habits beneficial/detrimental rating:

The 10 categories of habits are the top series of habits that we determined at the present time to affect liver health. Each habit can either be beneficial or detrimental to liver health. Unfortunately, as far as health is concerned, there’s no cap to how unhealthy you can be, but there is a cap on how healthy you can be. And thus, we decided to rate detrimental habits as more powerful than beneficial habits. These ratings are -4, -2, 0, +1, and +2. (We thought about extending negative habits even further, such as -6, -8, and so on, but ultimately felt that was too extreme out of the scope of what would be helpful.)

For example… the max beneficial thing you can do is drink less than 7 drinks a week (or if you wanted, 0 drinks a week). However, there’s no real cap to how much alcohol you could consume. The only cap are how much you want, can stomach, and can afford. Some of the heaviest drinkers often have as much as 20 drinks a day for extended periods of time. Obviously, our Score fails to capture some extremes such as that, but the idea is that we had to rate negative things as more detrimental than positive things could be beneficial. Otherwise, a very extreme drinker, such as someone having 21+ drinks per week, drinking every day, never taking time off, and having done it for years could get a false sense of security as long as they did everything else right—BMI, diet, exercise, etc. While beneficial things can help offset some detrimental things, it’s impossible to override them completely.

If you did every habit as poorly as possible, the lowest possible score is -200. If you did every habit as well as possible, the highest possible score is 100.

If you did every non-alcohol related habit perfectly (BMI, sugar, exercise, dietary additions, etc.), but had the worst alcohol-related habits, the best score you could achieve is a -44.

And conversely, if you did every alcohol-related habit perfectly (such as not drinking at all), but had the worst non-alcohol related habits, the best score you could achieve is a -56.

The fact that non-drinker can get a worse score than a otherwise perfectly healthy extreme drinker is not to say that the drinker has less risks per se than the non-drinker, because as we mentioned before, we couldn’t design for the max extremes such as 20 drinks a day, or 500 grams of sugar a day, without adding significantly more ratings and overcomplicating things. Anything above the max red section is a major risk factor for liver disease and should be stopped immediately.

What the Score means:

Detrimental scores (under 0)

The way we designed this was for -25 to be a serious wakeup call—it’s color coordinated as dark red and should be viewed as such. Anything -5 or worse should be a wakeup call—it’s color is coordinated as light red. And anything between -5 and 0 should be viewed as an eye opener that one should be aware that there is still some work to be done to move towards a liver-healthy life. Its color will show as yellow, so as to not be an alarmist, and rather to serve as a warning that someone should slow down and be careful with what they’re doing.

Beneficial scores (over 0)

Working up from 0, the 0–5 range will be colored yellow. The reason that this color is yellow is to let people know that while they are on the beneficial side of the spectrum, they are still close to the edge and so should have some level of caution. Anything from 5–25 is colored light green and is designed to explain that you are likely doing your liver more good than harm. And finally, anything 25+ is colored dark green to signify that your habits are either maintaining liver health above that of the non-drinker with normal body weight, or are likely healing your liver over time for as long as you maintain these habits.

We designed the score to tell you whether your risk factors for liver disease are likely better or worse than the average non-drinker with normal bodyweight.

How we came up with the Liver Habits Score, its benefits/limitations, and where it’s headed.

A number of members of the Cheers management team are graduates of Princeton University and are not strangers to large projects. Princeton, and many of the other Ivy Leagues, are famous for the requirement of their students to write a “senior thesis” prior to graduating. The senior thesis is the capstone to one’s education and ability to do the highest level of scholarly work. They typically involve the production of an 80–300 page academic book on the topic of the senior’s choosing (so long as it’s fitting within their department). In many ways, the Liver Habits Score has been a project of this scope.

When looking at the literature revolving liver health, most studies are related to isolated activities and how they affect liver health. For example (not actual titles, but rather common subject matters):

• Alcohol consumption frequency and likelihood for liver cirrhosis.
• Total weekly alcohol consumption and likelihood for liver cirrhosis.
• Exercise and likelihood for liver cirrhosis.
• BMI and likelihood for liver cirrhosis.
• etc.

As you can see in the above, one can get a sense of how their BMI can affect their likelihood for liver cirrhosis, but what about if you add exercise? As it turns out, there are however a few studies out there looking at the combination of various activities.

For example, a number of studies show that exercise (either cardio or weight training) can benefit fatty liver disease independent of changes in BMI. Other studies show that BMI negatively affects liver health, and so does alcohol consumption, but the combination of having both an overweight BMI and being a heavy drinker creates not only an “additive” negative effect in liver health, but a “multiplicative” one due to negative “interaction”. I.e., it’s really bad to be an overweight drinker—you should really pick one or the other in order to significantly reduce your risk factors. (Obviously, being neither is better… but people ultimately have a free choice in what activities are worth the risk for them. The bigger problem is people not knowing the risks they’re engaging in. Knowledge is power when it comes to living a long, healthy, and happy life.)

This then begs the question… if liver disease isn’t as simple as individualized activities and their affect on liver health, how do we give people (especially drinkers) a sense of how the collective of their activities affect their liver health? That’s one of the core purposes of the Liver Habits Score.

To do this “perfectly”, one would have to do a 100 year study that closely monitored as many variables in activities related to liver health as possible. This creates its own problem… ought we really wait to help people understand how their activities likely affect their liver health because we don’t know the exact interaction between every single category, including the categories we haven’t yet thought of?

We know that i) an overweight BMI + heavy drinking creates a negative interaction. We know that ii) exercise helps fatty liver disease independent of BMI reduction. And we also know that iii) in animal studies, the consumption of fructose and alcohol together is worse than either one or the other. We don’t however know how the interaction of i), ii), and iii) all interact. However, one could make a fair assumption that i) alcohol + overweight BMI, ii) lack of exercise, and iii) chronic intake of alcohol and fructose would all together be very bad for liver health, regardless of the interaction that they may have. And the Liver Health Score works to show the public this in its results.

While we don’t contend that our Liver Habits Score is “perfect” in terms of calculation of the correlation of these habits to liver health… it is very much our thesis that the Liver Habits Score will be shown over time to have strong predictive power.

You’d be hard pressed to find a scientist, public health official, or doctor argue that if someone scored a severely negative Liver Habits Score that they wouldn’t be at significant risk for liver disease, and vice versa, someone that scored exceptionally well wouldn’t likely have significantly less risk for liver disease.

Therefore, it is our belief that the Liver Habits Score, while not perfect (an impossible standard), is a great tool in teaching people how their habits likely affect their liver health, and what they can do to reduce their overall risks of liver disease.

And finally, it should be worth noting that the Liver Habits Score is like a beaver dam: never finished. As the academic literature around liver health progresses, so will our Liver Habits Score. Furthermore, as as our research of the literature increases, so will the way our Liver Habits Score is performed and presented. One clear example of this is how we only currently have 10 categories… but one of which that is not yet included is smoking, which has significant evidence for also being a risk factor for liver disease. It’s intended that categories and their weighting (and corresponding rating) will be altered over time as knowledge about liver health increase.

Using the Liver Habits Score for your liver health.

When we were making the Liver Habits Score and casting a vision internally for its future we were inspired heavily by tools such as Weight Watchers (WW) and Noom. Both WW and Noom are systems designed to get people on track for eating healthier and losing weight.

Sure, neither are “perfect”. You don’t have to do a lot of googling to find some nutritionists out there talking about the “dangers” or limitations of using weight loss systems such as WW and Noom. However, there’s very compelling evidence that these types of tools work wonders for people looking to lose weight using a long-term sustainable system.

A 2016 study published in Scientific Reports examined nearly 36,000 Noom users, and found that the app drove sustained weight loss in 78% of people across a nine-month period. A 2011 study published in the Lancet medical journal found that overweight patients told by their doctors to do WW lost around twice as much weight as people receiving standard weight loss care over 12 months. (footnote)

The above are results that you can’t argue with. Some people like to throw out the baby with the bath water… and in the process, throw themselves out with the baby—they can’t help themselves.

In the same way, our Liver Habits Score is not perfect, but it can give you a picture into how your habits and activities are affecting your liver health.

The idea is quite simple: take a test, see how your habits are likely affecting your liver health, and notice areas that you can improve upon over time. Because each category comes with corresponding literature (tagged by category) within Cheers’ blog, you can continually learn more about activities you can partake in to boost your liver health (such as having a choline rich diet) as well as activities you can work to avoid to reduce harm on your liver (such as living a completely sedentary lifestyle).

Better yet, repeat this process monthly to get a sense of how your habits are progressing towards a healthier liver and your ability to “enjoy alcohol throughout a long, healthy, and happy life”—if you so choose. If you want to alcohol to be part of your life, you need to be thoughtful and proactive about your health. In other words… “you have to earn the right to drink.” Our Liver Habits Score helps you do just that. We hope you use it and share it with your friends and family!

References:

1. .
2. .
3. .
4. .
5. .
6. .
7. .
8. .
9. .
10. .
11. .

https://www.cnet.com/health/weight-watchers-vs-noom-which-is-better-for-weight-loss/