Alcohol-Related Liver Disease May Be More Common Than We Think

After adjusting for underreporting of alcohol consumption, the prevalence of alcohol-related liver diseases in the U.S. was found to be higher than has been previously reported, with binge drinking being the strongest risk factor for premature mortality, according to a cross-sectional study.

From 1988 to 2023, the adjusted prevalence of metabolic dysfunction-associated alcohol-related liver disease (MetALD) increased from 1.62% to 4.10%, while the adjusted prevalence of alcohol-related liver disease (ALD) increased from 2.28% to 4.59% (P<0.0001 for both), reported Zobair M. Younossi, MD, of the Global NASH/MASH Council in Washington, D.C., and colleagues.

Without alcohol adjustment, the prevalence of MetALD was 2.14% and the prevalence of ALD was 1.65% in 2021-2023, indicating a substantial underreporting of alcohol use, they wrote in Lancet Gastroenterology & Hepatology.

Age-standardized mortality rates with MetALD and ALD were 8.74 and 14.91 per 1,000 person-years, respectively, compared with 4.76 per 1,000 person-years in abstainers with non-steatotic liver disease. Binge drinking was the main driver of premature death in those with MetALD (20.98%) and ALD (92.85%).

The authors suggested that alcohol underreporting — mainly due to recall bias or concerns about social stigma during clinical assessments — leads to misclassification of patients with significant alcohol exposure as having metabolic dysfunction-associated steatotic liver disease (MASLD) rather than MetALD or ALD, and hides the true burden of alcohol-related liver disease.

“This issue is increasingly important, as emerging evidence … suggests a shift towards younger age at onset for ALD, reflecting changing social norms, increased binge drinking, and greater alcohol availability that have attenuated traditional age-related risk gradients,” they wrote. “These evolving drinking behaviors, together with increasing rates of obesity and type 2 diabetes, have reshaped the epidemiology of steatotic liver disease.”

Younossi and colleagues also found that the adjusted prevalence of MASLD increased from 12.69% to 28.16% over the study period, with an age-standardized mortality rate of 7.86 per 1,000 person-years. Type 2 diabetes was the strongest metabolic predictor of premature mortality in those with MASLD, with a population-attributable fraction between 13.25% and 44.8%.

Of note, individuals with binge drinking co-existing with type 2 diabetes or hypertension had the greatest risk of premature mortality.

In an accompanying commentary, Helena Cortez-Pinto, MD, PhD, of the University of Lisbon in Portugal, said the study’s finding that binge drinking was associated with higher mortality was important, although “curious.”

That result needs to be “taken with caution, since binge drinking is usually associated with a lifestyle that increases mortality risks alongside those related to liver disease,” she wrote.

Regarding the impact of the study’s results on clinical practice, Cortez-Pinto noted that patterns of alcohol consumption — present or past — need to be considered for every patient with steatotic liver disease, “taking care to avoid imparting stigma that might discourage accurate recall of the pattern and magnitude of alcohol consumption.”

The development of drugs to treat MetALD and ALD is urgently needed, she added.

The authors concluded that the findings “emphasize the need for precise assessment of alcohol consumption to correctly classify steatotic liver disease subtypes and highlight the importance of aggressively managing cardiometabolic risk factors, especially type 2 diabetes, alongside implementing strong alcohol harm-reduction strategies.”

Younossi and colleagues used National Health and Nutrition Examination Survey data from 1988 to 2023 for adults at least 20 years old for their cross-sectional and longitudinal analysis. After exclusions, they identified 41,100 participants for the prevalence analysis, and 24,707 for the mortality analysis.

Age-standardized prevalence estimates for MASLD, MetALD, and ALD were calculated using the 2000 U.S. Census population as the reference and pooled across survey cycles with appropriate weights.

To correct for systematic alcohol use underreporting, the authors applied correction factors from a study that compared quantity-frequency estimates with 24-hour recall data, which found that sex and drinking frequency were the strongest predictors of bias. Infrequent drinkers and men tended to underreport intake. The adjusted self-reported consumption patterns were scaled to align with national per-capita consumption.

Younossi and colleagues defined binge drinking as consuming five or more drinks (four or more for women) over 2 hours at least once in the past year.