By David A. Johnson, MD

Coffee is one of the most widely consumed beverages in the world. We enjoy it, as I suspect many of our patients do too.

It's been long associated with certain adverse outcomes. I remember when I was a resident in 1981, a report was published in the NEJM suggesting that coffee was strongly associated with pancreatic cancer. So, the word was: Coffee is bad.

Since then, observational studies have suggested that coffee may have some health benefits, particularly as we look at inverse associations (more may be better) related to liver diseases. Both cross-sectional and retrospective studies have shown an association between coffee consumption and reduced risks for cirrhosis and hepatocellular carcinoma.

In 2025, the American College of Gastroenterology (ACG) published its most recent guideline on malnutrition and nutritional recommendations in liver disease, which I reviewed earlier this year. In that review, I highlighted the ACG’s recommendation of two or more cups of coffee daily to reduce the risk for fibrosis progression or development of hepatocellular carcinoma. That was a conditional recommendation based on a low level of evidence.

New Study Strengthens the Coffee-Liver Link

Most recently, a report published in Clinical Gastroenterology and Hepatology looked at approximately 350,000 participants in the UK Biobank over a median follow-up of 13 years. The investigators excluded participants diagnosed with cirrhosis or hepatocellular carcinoma at or within a year of enrollment. They also evaluated daily coffee intake, and what they found, I think, was striking.

For incident cirrhosis, they observed a 20% risk reduction associated with 1-2 cups a day, 35% with 3-4 cups, and 32% with five or more cups.

For incident hepatocellular carcinoma, the risk reductions were 24% with 1-2 cups, 35% with 3-4 cups, and 47% with five or more cups a day.

Then they looked at liver-related death. The risk reductions were 31% with 1-2 cups, 41% with 3-4 cups, and, not notably greater, 42% with five or more cups.

Now, why does this make sense?

Coffee has hundreds of compounds, and it's unclear exactly which specific ones may account for the benefit. They may include polyphenols and other antioxidants that decrease oxidative stress, hepatic cell activation, collagen deposition, and fibrogenesis.

This particular UK Biobank study looked at some very interesting things beyond the clinical outcomes. The investigators looked at imaging outcomes using MRI. They assessed proton density fat fraction as a measure of hepatic fat and iron-corrected T1 as a marker of hepatic fibroinflammation. Higher coffee intake was associated with lower hepatic fat, iron, and fibroinflammation.

Then they further backed this up with proteomic profiling. The markers they analyzed consistently changed in a favorable direction with coffee consumption. Higher coffee intake was associated with higher levels of proteins related to hepatocellular synthesis and complement proteins associated with hepatic health and regeneration, and lower levels of fibrogenic and macrophage-activation markers associated with fibrosis and progression. All of these changes were favorable.

Importantly, caffeine did not appear to be solely responsible. The favorable associations were similar with caffeinated and decaffeinated coffee.

The investigators also looked at the addition of sugar or artificial sweeteners, not something we would endorse if it can be avoided, particularly for our patients with metabolic dysfunction-associated steatotic liver disease (MASLD). Nonetheless, adding sugar or artificial sweeteners did not significantly alter the associations with incident cirrhosis, hepatocellular carcinoma, or liver-related death.

There were some differences in MRI measures, including iron-corrected T1, but not in the three clinical outcomes I just mentioned.

When I talk to my patients about this and ask them about coffee, some will say, "Well, I don't drink coffee.” So, then I will ask them about tea.

There is some evidence regarding tea, and a benefit is biologically plausible. A 2025 UK Biobank study suggested favorable associations with hepatic fat and other imaging measures, but not necessarily with clinical fibrotic liver disease.

Let’s return to the recommendations. Neither the 2025 ACG guideline nor the 2024 European Association for the Study of the Liver recommendations suggest tea as an alternative.

Coffee is really the beverage that should be at the forefront of this discussion.

How Much Should We Emphasize Coffee?

It's important to tell patients that coffee may be helpful, but it's also important for them to understand that it is not the entire treatment.

For fatty liver disease, we're talking about metabolic risk factors and weight reduction, and perhaps targeted treatment of MASLD. We now have therapies and lifestyle interventions that really go hand in hand. Coffee does not treat MASLD, nor does coffee reverse fibrosis.

These impressive clinical data are observational, and residual confounding remains possible.

But what does the data suggest? Certainly, 2-4 cups of coffee a day appear to capture much of the observed benefit. The ACG recommendation is for two or more cups, and the more recent data recommend perhaps 3-4 cups a day.

Coffee seems to have an impressive association with a reduced risk for cirrhosis and other adverse liver outcomes. So, more is less. If you like coffee, java up.

Put this in perspective however, when you talk with your patients. We need to look comprehensively at the other factors that may be influencing their liver disease and related outcomes.