Association of Non-Heavy Alcohol Use With Liver Fibrosis and Nonalcoholic Steatohepatitis

The diagnostic criteria for nonalcoholic fatty liver disease, now renamed metabolic dysfunction–associated liver disease (MASLD), include individuals who drink moderate amounts of alcohol, defined by fewer than 7 and 14 drinks per week for women and men, respectively, per AASLD guidelines.¹ Although these alcohol intake thresholds are not viewed as excessive or “heavy,” the published literature to date had been mixed on its influence on liver disease progression.

Recently, Rice et al examined the association of non-heavy alcohol use and risk of liver fibrosis and at-risk nonalcoholic steatohepatitis (NASH), in the Framingham Heart Study community-based cohort. Rice and colleagues ascertain that multiple alcohol use measures, most notably the number of alcohol drinks consumed per week, are positively associated with clinically significant liver fibrosis and at-risk NASH, defined by the FibroScan-AST (FAST) score, which uses liver stiffness on FibroScan, the controlled attenuation parameter, and AST. Importantly, the authors evaluated alcohol as a continuous measure, rather than comparing non-drinkers with drinkers, which can introduce selection bias based on established differences between those populations. The findings from Rice et al add to a growing body of literature highlighting the potential harm of alcohol use, even at modest levels, particularly in patients with obesity and diabetes who are at increased risk for fibrosis from MASLD. However, the effect of non-heavy drinking remains modest, and not statistically significant in many of the evaluated models and alcohol use patterns. Together, this study further supports recent guidance recommending that patients with MASLD with significant fibrosis should avoid alcohol. Modest alcohol use among patients without significant fibrosis but with MASLD or metabolic syndrome risk factors should involve a discussion with the patient about the dose-dependent effect on the liver. Despite older observational studies to the contrary, intuition proved correct, and the current body of evidence demonstrates that even non-heavy drinking may carry some risk for patients with MASLD. However, the effect of non-heavy alcohol use is small compared with the effect obesity and diabetes, which remain the focal point of lifestyle intervention in MASLD.

Reference

1. Chalasani N, Younossi Z, Lavine JE, et al. The diagnosis and management of nonalcoholic fatty liver disease: Practice guidance from the American Association for the Study of Liver Diseases. Hepatology. 2018;67(1):328-357. https://journals.lww.com/hep/fulltext/2018/01000/the_diagnosis_and_management_of_nonalcoholic_fatty.31.aspx