NEW RESEARCH shows that underreported alcohol consumption can misclassify cases of steatotic liver disease, underestimating the true burden of alcohol-related conditions. When alcohol intake is adjusted, the prevalence of alcohol-related liver disease (ALD) and metabolic dysfunction-associated alcohol-related liver disease (MetALD) rises significantly, with implications for public health and clinical interventions.
Steatotic liver disease is defined by fat accumulation in the liver and can result from metabolic dysfunction, alcohol consumption, or both. In this study, metabolic dysfunction-associated steatotic liver disease (MASLD), MetALD, and ALD were all evaluated, highlighting differences in alcohol contribution and metabolic risk.
Long-Term US Data Highlights Underreporting
Researchers conducted cross-sectional and longitudinal analyses using US National Health and Nutrition Examination Survey data from 1988 to 2023. Alcohol intake was corrected for sex-specific and frequency-specific underreporting and calibrated to national per-capita ethanol consumption. Binge drinking was defined as consuming five or more drinks on a single occasion at least once in the past year. Steatotic liver disease was assessed using ultrasound, the US Fatty Liver Index, or vibration-controlled transient elastography, depending on the survey cycle.
Underreported Alcohol Masks the Real Numbers
Among 41,100 adults, the adjusted prevalence of steatotic liver disease increased between 1988–90 and 2021–23 for all disease types. MASLD rose from 12.69% to 28.16%, MetALD from 1.62% to 4.10%, and ALD from 2.28% to 4.59%. By contrast, the uncorrected prevalence in 2021–23 based solely on self-reported alcohol intake was substantially lower, at 2.14% for MetALD and 1.65% for ALD. These findings indicate that many individuals with alcohol-related liver disease were misclassified as having MASLD due to underreported alcohol consumption. Correcting for this underreporting nearly doubles the apparent prevalence of alcohol-related forms, revealing a considerably larger population at risk.
Mortality Risk Is Highest with Alcohol Involvement
During 410,293 person-years of follow-up, premature mortality was highest in ALD (14.91 per 1000 person-years; HR 2.21), followed by MetALD (8.74; HR 1.45) and MASLD (7.86; HR 1.39), compared with 4.76 per 1000 in abstainers without steatotic liver disease. Type 2 diabetes was the strongest metabolic predictor for MASLD mortality, while binge drinking was the dominant driver for MetALD and ALD. Mortality risk was highest in those with both binge drinking and type 2 diabetes or hypertension.
Clinical and Public Health Implications
These findings emphasise the need for systematic screening of alcohol consumption, particularly binge drinking, alongside comprehensive assessment of cardiometabolic risk factors. Public health initiatives should educate patients on the combined impact of alcohol and type 2 diabetes on liver disease progression. Because underreporting of alcohol intake is unlikely to disappear, methods for correcting self-reported consumption are critical to accurately estimate disease prevalence and mortality risk. Implementing such correction strategies provides a clearer picture of the true burden of liver disease and supports more effective clinical and public health interventions.
Reference
Younossi ZM et al. Binge drinking, metabolic dysfunction, and the spectrum of steatotic liver disease in the USA: a cross-sectional and longitudinal analysis. Lancet Gastroenterol Hepatol. 2026;DOI:10.1016/S2468-1253(25)00376-0.
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