Binge drinking, metabolic dysfunction, and the spectrum of steatotic liver disease in the U.S.
A sweeping U.S. study suggests binge drinking and type 2 diabetes together drive a large, growing share of serious liver disease, and that the problem is bigger than current estimates because many people understate how much they drink.
Investigators analyzed health data on 41,100 adults who participated in the National Health and Nutrition Examination Survey from 1988 through 2023. They adjusted self-reported alcohol use to match national per-capita consumption, used liver imaging or validated scores to detect fatty liver, and defined binge drinking as five or more drinks on one occasion at least once in the past year.
After recalibrating alcohol intake, the researchers found that alcohol-related disease and mixed alcohol-plus-metabolic disease were far more common than previously reported.
“Underreported alcohol use hides a lot of disease and death tied to alcohol,” said study co-author Juan Pablo Arab, M.D., director of alcohol sciences at the Institute. “Correcting people’s reported drinking moves many from a metabolic‑only label into alcohol‑related or mixed disease groups, changing how we count and prioritize prevention.”
The findings have practical implications for public health: When people say they drink less than they do, doctors may miss alcohol’s true role in liver disease. That hides the real problem and can stop people from getting the right help.
The study, led by Zobair Younossi of The Global NASH/MASH Council, appeared in The Lancet Gastroenterology & Hepatology.
In an editorial accompanying the paper, Helena Cortez-Pinto, M.D., Ph.D., of the University of Lisbon, wrote the results should have an immediate impact on clinical practice. “(T)here should be careful consideration of the pattern of alcohol consumption, present or past, 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 authors recommend routine screening that captures binge drinking, combined assessment of cardiometabolic risks such as diabetes and high blood pressure, and public education stressing that heavy episodic drinking plus metabolic disease multiplies liver risk.
The team divided steatotic liver disease into three groups: metabolic dysfunction–associated steatotic liver disease, metabolic dysfunction plus alcohol-related disease, and alcohol-related liver disease. In looking at the adjusted prevalence, the researchers saw that between 1988–90 and 2021–23, adjusted prevalence rose from about 12.7% to 28.2% for MASLD, from 1.6% to 4.1% for MetALD, and from 2.3% to 4.6% for ALD.
In the most recent cycle, relying on raw self-report would have missed much of the alcohol burden: ALD would appear to be only about 1.65% and MetALD about 2.14%.
To assess mortality, the authors linked earlier NHANES cycles to the National Death Index, yielding 410,293 person‑years of follow‑up and focusing on premature deaths, those before age 75 for men and 80 for women. Alcohol-related liver disease carried the highest premature mortality: roughly 14.9 deaths per 1,000 person‑years and a greater than twofold higher risk of early death compared with abstainers without fatty liver. MetALD registered about 8.7 deaths per 1,000 person‑years and MASLD about 7.9, versus roughly 4.8 among non‑drinking, non‑fatty‑liver participants.
The authors measured how much specific conditions contributed to premature death. Type 2 diabetes emerged as the leading metabolic driver of deaths in MASLD, accounting for an estimated 13% to 45% of excess mortality depending on the model, while binge drinking was the dominant driver in MetALD (about 21%) and overwhelmingly so in ALD (about 93%). The greatest risk surfaced when binge drinking coexisted with type 2 diabetes or hypertension.
What patients should do
Patients who binge drink or have diabetes or high blood pressure should talk to a health care provider about checking their liver. Cutting back on binge drinking and treating diabetes and blood pressure can lower the chance of severe liver disease and early death.
Funding for the project came from the Center for Outcomes Research in Liver Disease.