High burden of alcohol-related liver disease revealed across USA

medwireNews: The prevalence of alcohol-related liver disease (ALD) and metabolic dysfunction-associated alcohol-related liver disease (MetALD) has been underestimated, reveals a US national survey analysis adjusted for underreporting of alcohol consumption.

The results, published in The Lancet Gastroenterology & Hepatology, also characterize the premature mortality burden associated with binge drinking in patients with MetALD or ALD, particularly in those who also have type 2 diabetes.

The study “highlights the need for routine screening and counselling on drinking patterns, not only total intake,” say Zobair Younossi (The Global NASH/MASH and Liver Councils, Washington, USA), and colleagues.

They suggest that misclassification of MetALD or ALD as metabolic dysfunction-associated steatotic liver disease (MASLD) “due to underreported alcohol use might obscure the true contribution of alcohol to liver disease progression and liver disease burden.”

The researchers studied individuals aged 20 years and older who participated in the National Health and Nutrition Examination Survey (NHANES) cycles between 1988 and 2023 and had full data on steatotic liver disease and alcohol exposure.

The presence of steatotic liver disease was determined using hepatic ultrasonography, the US Fatty Liver index, or vibration-controlled transient elastography.

Alcohol exposure was derived from the NHANES questionnaires and adjusted for under- or overreporting using correction factors from a US-based validation study.

Binge drinking was defined as at least 5 drinks over 2 hours for men and at least 4 drinks over 2 hours for women, on at least one occasion.

Overall, 41,100 NHANES participants met the inclusion criteria for the steatotic liver disease analysis, while 24,707 aged 20–75 years were included in the mortality analysis.

The results showed that, between the periods 1988–1990 and 2021–2023, the prevalence of MASLD increased from 12.69% to 28.16%, MetALD prevalence increased from 1.62% to 4.10%, and ALD prevalence from 2.28% to 4.59%, representing a significant rise for all three conditions.

The team notes: “Without alcohol adjustment, ALD prevalence was substantially underestimated,” at just 1.65% in 2021–2023, as was that of MetALD, at 2.14% in 2021–2023.

They highlight that across the NHANES cycles participants with steatotic liver disease were older, more often men, and had higher rates of obesity, hypertension, hyperlipidemia, and type 2 diabetes than those without, with ALD specifically linked to being younger, male, and having higher rates of smoking and binge drinking.

Over a median follow-up of 17.4 years and 410,293 person–years, the premature mortality rate among individuals who abstained from alcohol and did not have steatotic liver disease was 4.76 deaths per 1000 person–years after adjustment for alcohol underreporting. Rates were substantially higher for those with MASLD (7.86 per 1000 person–years; adjusted hazard ratio (HR)=1.39), MetALD (8.74 per 1000 person–years; HR=1.45), and ALD (14.91 per 1000 person–years; HR=2.21), “showing a stepwise increase in risk with increased alcohol burden,” the authors note.

Type 2 diabetes was associated with premature mortality in participants with MASLD, at a population attributable fraction (PAF) of 13.25%. Binge drinking was the strongest contributing factor to premature mortality in both MetALD (PAF=20.98%) and ALD (PAF=92.85%).

The combination of type 2 diabetes and hypertension markedly increased premature mortality in participants with MASLD who abstained from alcohol, at an HR of 4.59 versus those without either condition. Type 2 diabetes with obesity also increased the mortality risk for patients with MASLD who did not drink alcohol, at an HR of 3.21.

In patients with MetALD or ALD, the combination of type 2 diabetes and binge drinking pushed up the early mortality risk to HRs of 7.67 and 17.50, respectively. Hypertension with binge drinking was associated with an HR of premature mortality of 14.18 in participants with ALD, while obesity with binge drinking yielded an HR of 10.42.

In an accompanying editorial, Helena Cortez-Pinto (Clínica Universitária de Gastrenterologia, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal) writes that patterns of alcohol consumption should be considered carefully, “taking care to avoid imparting stigma that might discourage accurate recall of the pattern and magnitude of alcohol consumption.”

She also calls for the wider use of biomarkers of recent alcohol consumption, and underlines that there is a “strong need to identify risk factors such as the pattern of alcohol consumption and cardiometabolic risk factors, particularly type 2 diabetes, in the general population.”

Finally, Cortez-Pinto stresses the “urgent need” for drugs to treat MetALD and ALD, especially given that food and alcohol addiction could “share common treatments.”

medwireNews is an independent medical news service provided by Springer Healthcare Ltd. © 2026 Springer Healthcare Ltd, part of Springer Nature

Lancet Gastroenterol Hepatol 2026; doi:10.1016/s2468-1253(25)00376-0
Lancet Gastroenterol Hepatol 2026; doi:10.1016/s2468-1253(26)00086-5