Stevan Gonzalez, MD, MS, is the Director of Liver Transplantation at Baylor Scott and White All Saints Medical Center in Fort Worth, Texas. 

Stevan Gonzalez, MD, MS

US drinking is falling for the first time since the COVID-19 pandemic, but heavy drinking is still rising among adults aged 50 to 64.¹ Hepatologists say 

 may be slow to follow the decline, particularly for that age group, women, and other populations already at higher risk.

"The patient in front of you is more likely to be a woman or someone in their 50s than a decade ago, more likely to have metabolic comorbidity, and more likely to present with cirrhosis rather than steatosis as the first diagnosis," Brian P. Lee, MD, MAS, a hepatologist and liver transplant specialist with Keck Medicine of USC, told HCPLive.

, and hit women, young adults, and American Indian and Alaska Native people hardest. Even with the recent dip, both drinking and alcohol-related cirrhosis deaths remain above 2018 levels.¹˒²

For Liver Awareness Month, HCPLive asked 4 liver disease experts where ALD is headed and what clinicians can do now, from asking every patient about alcohol to catching liver disease before cirrhosis and treating 

Will Alcohol-Associated Liver Disease Continue to Rise?

"I'd expect it to keep climbing," Brian Lee said when asked whether the burden of ALD will peak within the next 5 years. "Three things point that way. The lag between drinking and cirrhosis means the pandemic-era increase hasn't finished working through the population. The group still drinking more is the group in the window for disease. And metabolic risk is rising in the same patients, which raises the harm per drink even where drinking is flat."

Frances Lee, MD, assistant professor of medicine (liver diseases) at the Icahn School of Medicine at Mount Sinai and director of the Alcohol-Associated Liver Disease Program, described the combination of metabolic factors and alcohol as acting "like adding fuel to the fire."

Modeling supports the lag. A 2022 study projected that a single year of increased drinking during the pandemic would lead to 8,000 additional ALD-related deaths from 2020 to 2040, with only about 100 of them expected by 2023.³

Brian Lee said he is particularly concerned about adults aged 50 to 64, whose 

heavy drinking rose >36% from 2018 to 2024

"This is the group in which the combination of exposure and timing is most concerning," he said. "Fibrosis accumulates over decades, so a 55-year-old who increased their drinking in 2020 is often adding to damage that's already there rather than starting from a healthy liver. This is also the decade when cirrhosis and hepatocellular carcinoma most often declare themselves, and there's less physiologic reserve to absorb an insult."

"Cirrhosis and liver cancer in adults over 50 I'd expect to rise through the end of the decade," Brian Lee said. He was more cautious about younger adults.

"If younger adults' drinking stays below 2018 levels, I'd expect those acute presentations to ease sooner than the cirrhosis burden in older patients," he said. "That's a hypothesis rather than something this study can show, and doesn't account for co-factors of alcohol-associated liver disease that are changing in prevalence independent of alcohol consumption."

"Whether the overall burden peaks in five years or ten depends mostly on whether the 50 to 64 trend reverses, and there is no indication of that yet in the data," he said.

Some of the observed rise may also reflect better detection. Asked whether the increase among younger adults and women reflects more disease or better recognition, Frances Lee said it is likely both.

"I believe that both can be true. The rise in ALD is likely multifactorial: increased alcohol use in our society, metabolic features/syndrome in younger and more patients, and increased detection of ALD," she told HCPLive. "More evidence is needed to inform providers in their counseling to patients."

Why Alcohol-Associated Liver Disease Is Often Diagnosed Late

Part of the challenge is that liver damage rarely announces itself.

"The liver is actually a very resilient organ that will continue doing that work every single day, without any complaints, without any symptoms," Stevan Gonzalez, MD, MS, director of liver transplantation at Baylor Scott & White All Saints Medical Center in Fort Worth, Texas, said in an 

A 2024 study at one US academic primary care network found that more than half of patients with cirrhosis or hepatocellular carcinoma had a missed or delayed chronic liver disease diagnosis, and ALD was the most common cause among them.⁴

Gonzalez said catching these patients will take more than specialists.

"What we're recognizing is that chronic liver disease in the U.S. is vastly underestimated, and it's beyond what... just a specialist can do in terms of the general population, and that's where our primary care providers and our community-based health organizations are going to play a very important role in increasing awareness, education, and screening," he said.

He added that finding liver disease earlier matters because the damage is not always permanent.

"Even if a person does have evidence of advancing or progressive liver disease, it's reversible," Gonzalez said. "So you can actually avoid cirrhosis, and the liver can actually return to an improved function."

How Clinicians Can Screen for Alcohol Use and Liver Fibrosis

"What clinicians can do is to stop relying on patients to bring alcohol use up in conversation," Brian Lee said. "Alcohol use should be asked about at every visit, like smoking, with a validated screen like the AUDIT-C, and for patients where the history is uncertain there's now a biomarker, phosphatidylethanol, that gives an objective measure of intake over the prior 4 weeks."

The 2024 American College of Gastroenterology guideline on ALD recommends brief screening tools such as the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), and identifies the Fibrosis-4 score and transient elastography as the best noninvasive tests for fibrosis.⁵

 is a common blind spot. In CDC data, most adults reported being asked about alcohol at a checkup, but only about 38% were asked about binge-level drinking.⁶

"Current definitions of metALD and ALD account for chronic consistent alcohol intake, but binge alcohol intake has also been known to be associated with worsened liver outcomes," said Frances Lee, whose research presented at Digestive Disease Week 2026 linked binge drinking frequency to advanced fibrosis. "Binge alcohol intake may increase the risk of fibrosis progression in 

"The thresholds for heavy drinking are lower than most patients and a fair number of physicians assume, so being knowledgeable about those thresholds (≥15 drinks per week or ≥5 drinks on any given day for men and ≥8 drinks per week or ≥4 drinks on any given day for women) is important," Brian Lee said. "For women, it means using the sex-specific thresholds explicitly, since a patient told '14 or fewer drinks a week' is being given the wrong number."

Frances Lee noted that much about ALD in women remains unknown. "There is still so much to learn, though, as far as other features of sex differences, such as hormone levels, menopausal status, on the progression of ALD," she said.

Federal guidance no longer offers a number. The 

2025–2030 Dietary Guidelines for Americans

 replaced the previous daily limits with advice to "consume less alcohol for better overall health."⁷

Brian Lee said physician messaging also matters.

"Many patients, and some physicians, still believe a glass of wine a day is good for the heart," he said. "That idea came from observational studies that compared drinkers with abstainers who had often quit because they were already sick, and when that bias is accounted for, the protective effect largely disappears. The current evidence is that cancer and liver risk can begin even at low alcohol levels and rise with dose, and the message coming from physicians should reflect that. A patient who hears 'moderate drinking is fine' from their doctor has no reason to cut back."

The evidence on low-level drinking remains debated. A 2023 meta-analysis found no mortality benefit for low-volume drinkers,⁸ while a 2024 National Academies review concluded that moderate drinking was associated with lower all-cause mortality but higher breast cancer risk.⁹

"Most prevention messaging is built for young people, and the data suggest young people are already responding," Brian Lee said. "The group that needs it is 50 to 64, and they're largely invisible to it. Tailored prevention for this group looks like alcohol screening built into the visits they're already having, which are for blood pressure, diabetes, and cancer screening, with a fibrosis assessment attached when drinking is at or near threshold."

Integrating Alcohol Treatment Into Hepatology Care

Screening is only the first step. A randomized trial published in 

 in June 2026 tested a telehealth stepped alcohol treatment model in 157 patients with chronic liver disease and unhealthy alcohol use at safety-net and Veterans Affairs hepatology clinics. Patients received motivational interviewing by telehealth, and those still drinking at 3 months were referred to addiction medicine.¹⁰ The trial missed its primary endpoint, but stepped care led to significantly greater reductions in drinks per week.

"One of the most important findings was that the participants receiving the step care treatment had a significantly higher reduction in the amount of average alcohol intake," Mandana Khalili, MD, professor of medicine at the University of California, San Francisco, and chief of clinical hepatology at Zuckerberg San Francisco General Hospital, said in an 

. "Even reducing alcohol consumption short of complete abstinence is meaningful clinically in this population with chronic liver disease and is also consistent with a model of harm reduction."

"Rather than thinking of alcohol treatment as something that happens only in specialty addiction services, hepatology clinics themselves can play an active role in engaging patients in this type of evidence-based care," she said.

With follow-up near 90% in a population facing medical, socioeconomic, and access barriers, Khalili said patients were willing to engage. "This lets us know that chronic liver disease patients are receptive to discussing alcohol use and engaging in treatment if it's offered in patient-centered and accessible ways," she said.

She said motivational interviewing works best when clinicians tie cutting back to what patients care about, such as sleep, mood, family, or finances. "I think helping patients connect alcohol reduction with the goals that are personally meaningful to them increases their motivation, and it's much more effective in sustaining behavioral change," she said.

AUD Medications Remain Underused in Alcohol-Associated Liver Disease

When patients do meet criteria for AUD, "we have effective medications that are prescribed far less often than they should be," Brian Lee said.

In 2024, only 2.4% of US adults with past-year AUD received medication for it.¹¹ Patients with liver disease fared worse: in one claims study, AUD medication was prescribed to 14.5% of patients without ALD but only 2.3% of those with ALD cirrhosis.¹² In a survey of liver disease providers, 71% said they had never prescribed AUD pharmacotherapy, most often citing low comfort.¹³

That gap matters. In a cohort of 9635 patients with AUD, medication for AUD was associated with lower odds of developing ALD and, among those with cirrhosis, lower odds of decompensation.¹⁴

Turning Alcohol Screening Into Earlier ALD Intervention

For now, the tools clinicians already have may matter most. A prepandemic model projected that a strong intervention to reduce high-risk drinking could prevent about 299,100 ALD deaths from 2019 to 2040.¹⁸

"It means treating a heavy drinking history the way we treat a family history of colon cancer, as an indication for evaluation rather than counseling alone," Brian Lee said.

Khalili added that a clinician's role does not end with identifying the problem. Motivation, she said, "really is something that clinicians can actively help strengthen."

Editor's note: Frances Lee does not report any relevant disclosures. Gonzalez reports relevant disclosures with Mallinckrodt Pharmaceuticals, Salix, AbbVie, Gilead, and others. Brian Lee reports consulting for Gilead Sciences, Novo Nordisk, GlaxoSmithKline, Altimmune, Bausch Health, and others. 

Khalili reports relevant disclosures with Gilead, GSK, Resolution, and Intercept.

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. 2022;75(6):1480-1490. doi:10.1002/hep.32272

Patel KM, Zhang J, Marsden J, Bays C, Mauldin PD, Schreiner AD. Missed and delayed diagnoses of chronic liver disease in primary care patients with cirrhosis. 

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Jophlin LL, Singal AK, Bataller R, et al. ACG clinical guideline: alcohol-associated liver disease. 

. 2024;119(1):30-54. doi:10.14309/ajg.0000000000002572

McKnight-Eily LR, Okoro CA, Mejia R, et al. Screening for alcohol use and brief counseling of adults—13 states and the District of Columbia, 2017. 

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US Department of Health and Human Services; US Department of Agriculture. 

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Satre DD, Taj L, Wong RJ, et al. A randomized controlled trial of stepped treatment to reduce unhealthy alcohol use in patients with chronic liver disease. 

. Published online June 24, 2026. doi:10.1097/HEP.0000000000001796

National Institute on Alcohol Abuse and Alcoholism. Alcohol treatment in the United States. Updated March 2026. Accessed October 2, 2026.

Lieber SR, Jones AR, Jiang Y, et al. Pharmacotherapy for alcohol use disorder is underutilized among commercially insured adults with alcohol-associated liver disease. 

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Im GY, Mellinger JL, Winters A, et al. Provider attitudes and practices for alcohol screening, treatment, and education in patients with liver disease: a survey from the American Association for the Study of Liver Diseases Alcohol-Associated Liver Disease Special Interest Group. 

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Vannier AGL, Shay JES, Fomin V, et al. Incidence and progression of alcohol-associated liver disease after medical therapy for alcohol use disorder. 

. 2022;5(5):e2213014. doi:10.1001/jamanetworkopen.2022.13014

Klausen MK, et al. Once-weekly semaglutide versus placebo in patients with alcohol use disorder and comorbid obesity: a randomised, double-blind, placebo-controlled trial. 

. 2026;407(10540):1687-1698. doi:10.1016/S0140-6736(26)00305-3

Schacht JP, Sakai JT, Raymond K, Shelton R. Oral semaglutide for alcohol use disorder: a randomized clinical trial. 

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Eli Lilly and Company. A study of brenipatide in participants with moderate-to-severe alcohol use disorder (RENEW-ALC-1). ClinicalTrials.gov identifier: NCT07219966.

Julien J, Ayer T, Bethea ED, Tapper EB, Chhatwal J. Projected prevalence and mortality associated with alcohol-related liver disease in the USA, 2019-40: a modelling study. 

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Articles

US alcohol consumption has begun declining post-pandemic, yet heavy drinking continues rising in adults aged 50–64, positioning ALD burden to keep increasing due to exposure–disease lag and worsening metabolic comorbidity. Clinicians are encountering more women, more metabolic risk, and later-stage presentations (cirrhosis rather than steatosis). Missed or delayed diagnosis remains common in primary care, underscoring the need for routine alcohol screening and early fibrosis assessment. Integrating AUD treatment—including harm-reduction approaches, telehealth stepped care, and pharmacotherapy—remains a major unmet opportunity.

Drinking fell for the first time since COVID-19, but not for adults 50 to 64. Hepatologists explain what clinicians can do to close the gap.

The Liver Keeps the Score: Americans Are Drinking Less, but Alcohol-Associated Liver Disease May Lag

 has trended upward, with a sharp increase during the COVID-19 pandemic and disproportionate mortality increases among women, young adults, and American Indian and Alaska Native people.¹

Recent data point to the first decline in US alcohol use since the pandemic

, although drinking remains above 2018 levels and heavy drinking continues to rise among adults aged 50 to 64.² Against that changing backdrop, hepatologists point to important differences in ALD burden by age, sex, race and ethnicity, and coexisting metabolic risk.

 spoke with 3 hepatologists about the changing US burden of alcohol-associated liver disease:


Director of liver transplantation at Baylor Scott & White All Saints Medical Center in Fort Worth, Texas


Assistant professor of medicine of liver diseases at the Icahn School of Medicine at Mount Sinai and director of the Alcohol-Associated Liver Disease Program


Hepatologist and liver transplant specialist with Keck Medicine of USC

From 1999 to 2022, the ALD death rate nearly doubled, rising from 6.71 to 12.53 per 100,000, according to a study published in 

.¹ In total, 436,814 ALD deaths were recorded over that period.¹ An important distinction is that during this time, ALD deaths increased faster in women than in men, an average of 4.29% vs 2.50% per year.¹

"There are groups of populations in the US who are disproportionately affected by alcohol-associated liver disease, and that includes women, younger people, and Native Americans," said Stevan Gonzalez, in an 

. "There are groups that we have to be careful about because they have had a significant increase in alcohol-associated liver disease that's more than in the past."

From 2000 to 2023, the age-adjusted death rate from alcohol-related cirrhosis rose 72.2% overall, from 4.3 to 7.4 per 100,000, according to the National Institute on Alcohol Abuse and Alcoholism (NIAAA).³ In 2024, alcohol-associated cirrhosis was the most common primary diagnosis among adult liver transplant recipients in the US.⁴

"Alcohol-associated liver disease was actually increasing at a gradual pace in the United States, and then in 2020 we just saw this upward shift where a significant increase occurred, and it coincided directly with the COVID-19 pandemic," Gonzalez told 

. "What's concerning is that was in 2020, but that has persisted."

For about a decade before 2020, ALD was already rising:

The age-adjusted alcohol-related cirrhosis death rate rose from 4.3 per 100,000 in 2000 to 6.1 in 2018.³

Among adults aged 25 to 34, the rate more than doubled, from 0.7 to 1.8 per 100,000.³

Liver transplant waitlisting for ALD among adults <40 rose 4-fold from 2003 to 2018.⁵

The increase in ALD predated the pandemic, but the pace accelerated around the pandemic period:

The alcohol-related cirrhosis death rate rose from 6.4 per 100,000 in 2019 to 7.8 in 2020, the largest single-year increase since 2000, and reached 8.7 in 2021.³

The ALD death rate rose 8.94% per year from 2018 to 2022.¹

Among adults aged 25 to 44, ALD mortality increased an average of 4.23% per year from 1999 to 2022.¹

Alcohol-associated hepatitis was also already increasing among younger adults before COVID-19.

"Alcohol-associated hepatitis in young adults was rising well before 2020, and the pandemic accelerated a trend rather than creating one," Brian Lee told HCPLive.

US Alcohol Use Fell for the First Time Since the Pandemic, but Remains Above 2018 Levels

New data from a study led by Brian Lee point to a decline in drinking after 2022, and separate mortality data show alcohol-related cirrhosis deaths have eased since 2021. However, neither measure has returned to its 2018 level.

The study analyzed National Health Interview Survey data from 114,352 US adults from 2018 to 2024:²

From 2022 to 2024, any alcohol use fell nearly 2% and heavy drinking fell >8%, the first confirmed decline since the pandemic.²

Gen Z adults had the largest drop in any alcohol use (>5%), and millennials had the largest drop in heavy drinking (17%).²

Both measures remain above 2018 levels.²

The study defined heavy drinking using NIAAA criteria: ≥15 drinks per week or ≥5 drinks on any day for men, and ≥8 drinks per week or ≥4 drinks on any day for women.²

"The decline occurred largely independent of clear clinical intervention as far as we know," Brian Lee said.

While it’s unclear what’s leading the decline, the drop in drinking isn't the only sign of easing. Mortality data show a similar pattern: after peaking in 2021, alcohol-related cirrhosis death rates fell in both 2022 and 2023:

The age-adjusted alcohol-related cirrhosis death rate fell from 8.7 per 100,000 in 2021 to 7.4 in 2023.³

From 2022 to 2023 alone, the crude alcohol-related cirrhosis death rate fell 7.8%, and total cirrhosis deaths fell by 2,409.³

In 2024, the age-adjusted death rate from chronic liver disease and cirrhosis of all causes fell 2.3%, from 13.0 to 12.7 per 100,000.⁶

"It looks like there's hopefully a decline, looking at the most recent statistics of mortality associated with alcohol-associated liver disease, but that was definitely a trigger," Gonzalez said.

Still, the 2023 alcohol-related cirrhosis death rate remains above its 2018 level of 6.1 per 100,000, and drinking remains above 2018 levels.²˒³

The recent population-level decline also does not mean the burden is changing equally across groups. Sex-specific, metabolic, genetic, and social factors may help explain why ALD risk and outcomes differ across populations.

Women cut heavy drinking more than men from 2022 to 2024 (9% vs 7.7%), but experts say their ALD reflects decades of rising intake and greater biological vulnerability.²

According to Brian Lee, heavy drinking among women remains about 13% above 2018 and is now slightly more prevalent among women than men in the survey, because the heavy drinking thresholds are lower for women.

"The reduction from 2022 to 2024 is real but it's a recent step down from a large step up," he said. "Women develop fibrosis at lower cumulative exposure, they progress faster once it's established, and the increase in women's drinking predated the pandemic by at least a decade. So the liver disease we're seeing in women now reflects fifteen or twenty years of rising intake."

Women's physiology may partly explain these disproportionate impacts.

"We know that women are generally smaller and have decreased total body water and higher body fat percentage, which causes higher concentrations of alcohol in the blood stream compared to men who ingest the same amount of alcohol," Frances Lee told 

Taken together, these differences mean similar levels of alcohol intake may not translate to the same biological exposure or liver risk in women and men, an important consideration when clinicians assess alcohol history and cumulative exposure.

Frances Lee added that the effects of hormone levels and menopausal status on ALD progression remain understudied, a point she discussed in a 

Alcohol-related cirrhosis deaths in women tell a similar story:

From 2000 to 2023, the alcohol-related cirrhosis death rate rose 125% in women vs 51.2% in men.³

Beginning in 2011, nearly a decade before the pandemic, the ALD death rate among women rose 8.32% per year through 2022.¹

The alcohol-related cirrhosis death rate in women peaked at 5.5 per 100,000 in 2021 and fell to 4.8 in 2023, still above 3.7 in 2018.³

Men's alcohol-related cirrhosis death rates remain greater overall: 10.2 vs 4.8 per 100,000 in 2023.³

"Two years of modest decline won't change that trajectory quickly," Brian Lee said.

Alcohol-Associated Hepatitis Hospitalizations in Young Adults Surpassed Older Adults by 2020

ALD-related hospitalizations increased particularly rapidly among young adults from 2016 to 2022, and while younger generations are now drinking less, alcohol-related cirrhosis deaths in this group remain above 2018 levels.

Hospital data from 2016 to 2022 show the shift:

ALD hospitalizations among adults aged 20 to 49 rose from 106.5 to 144.7 per 100,000, or 4.48% per year, vs 1.78% per year among older adults.⁷

By 2020, alcohol-associated hepatitis hospitalization rates were greater in younger adults than in older adults (65.6 vs 61.3 per 100,000).⁷

Older adults still had greater ALD hospitalization rates overall in 2022 (295.0 vs 144.7 per 100,000).⁷

The alcohol-related cirrhosis death rate nearly doubled, from 1.8 per 100,000 in 2018 to 3.4 in 2021, then eased to 3.0 in 2023.³

In 2023, 80.3% of cirrhosis deaths in this age group were alcohol related, the highest share of any age group.³

Among women aged 25 to 34, the rate rose from 2.3 in 2022 to 2.5 in 2023, an exception to the overall decline.³

Frances Lee pointed to metabolic and genetic factors that may help explain the trend. She noted that "with the increasing incidence of diabetes, obesity, and other features of metabolic syndrome, especially in younger patients, the more likely we are to see clinical disease."

Genetics may also play a role. "We are also increasingly aware of the genetic changes that may increase one's risk of developing liver disease, whether that be from 

 polymorphisms or otherwise," Frances Lee said. "Genetic polymorphisms may elucidate why younger patients are developing liver disease, especially with the progression of metabolic disease and alcohol intake."

In a UK Biobank cohort study, participants with obesity and excessive alcohol intake who were homozygous carriers of the 

 I148M variant had a 17.52-fold greater risk of cirrhosis than participants without obesity or excessive drinking who did not carry the variant (adjusted hazard ratio [aHR], 17.52; 95% CI, 12.84-23.90).⁸

Together, the findings illustrate why younger age alone may not capture liver disease risk. Alcohol exposure may occur alongside metabolic and genetic risk factors, making the broader risk profile relevant even in younger patients.

Still, there may be reason for cautious optimism. Younger adults drove the recent decline in drinking: from 2022 to 2024, any alcohol use among Gen Z adults fell >5%, and heavy drinking among millennials fell 17%.²

"Acute alcohol-associated hepatitis in young adults is hopefully near its peak if their drinking stays down," Brian Lee said.

American Indian and Alaska Native People Face the Highest ALD Death Rates

American Indian and Alaska Native people had the highest ALD mortality rate among the racial and ethnic groups examined in the 

 analysis, increasing from 25.21 to 46.75 deaths per 100,000 from 1999 to 2022.¹

Earlier research found that in 2020, the mean age-adjusted ALD mortality rate among American Indian and Alaska Native people in states with available data was nearly 6 times that of White people (68.5 vs 11.7 per 100,000).⁹ A 2024 review of studies on racial and ethnic disparities in ALD found this group had the highest pooled mortality rate of any racial or ethnic group, but noted that the population remains "understudied with regard to ALD epidemiology and the mechanisms behind the disproportionate mortality."¹⁰

The authors pointed to possible contributors, including genetics, drinking patterns, social determinants of health such as income and access to care, and provider bias and diagnostic delays.¹⁰

These disparities mean alcohol exposure alone cannot explain differences in ALD outcomes. Access to care, timely diagnosis, and other social and clinical factors may also shape which patients develop advanced disease or experience ALD-related mortality.¹⁰

The numbers may undercount ALD, and experts say metabolic disease may be raising the harm associated with alcohol use.

Part of that undercount may come from binge drinking going unrecognized. 

Research Frances Lee presented at Digestive Disease Week (DDW) 2026

, which analyzed National Health and Nutrition Examination Survey (NHANES) data from 2017 to 2023 for 5093 participants with steatotic liver disease, found that metabolic dysfunction and alcohol-associated liver disease (MetALD) and ALD carried 2.58-fold and 4.55-fold greater odds of advanced fibrosis, respectively, than metabolic dysfunction-associated steatotic liver disease (MASLD).¹¹

"Our study shows that many patients categorized as MASLD or metALD were participating in binge alcohol intake between twice a week to twice a month," Frances Lee said. "Physicians may also not be asking about binge alcohol intake, further reducing awareness of the harms of binge drinking."

For clinicians, the findings underscore that metabolic liver disease and clinically relevant alcohol exposure can coexist. Asking about drinking patterns, including episodes of binge drinking rather than average consumption alone, may provide information that is missed when alcohol history is treated as a simple yes-or-no distinction.

Additionally, stigma may make it difficult for patients to open up about their drinking, and it can affect how alcohol-related deaths are counted. NIAAA notes that alcohol may be omitted from some cirrhosis death certificates, including when certifiers seek to protect families, potentially contributing to undercounting of alcohol-related deaths.³ From 2000 to 2023, 43.6% to 54.3% of cirrhosis deaths were coded as alcohol related, depending on the year.³

"We know that the word 'alcoholic' comes with stigma, and in using 'alcohol-associated liver disease' or 'alcohol use disorder,' patients may feel that they are seen for more than just their addiction and open to creating a therapeutic relationship with their healthcare provider," Frances Lee said.

Metabolic factors may also modify alcohol-related liver disease risk. Brian Lee's earlier research examined how alcohol and cardiometabolic risk factors together relate to liver disease.¹²

"The finding in that work was that the per-drink harm to the liver has been rising, and the best explanation is that heavy drinkers now carry obesity, diabetes, and hypertension at rates they didn't twenty years ago," Brian Lee said. "Alcohol and metabolic dysfunction aren't additive in the liver, they're multiplicative."

Heavy Drinking Rises Among Adults 50 to 64

While drinking fell overall, one group moved in the other direction. Heavy drinking among adults aged 50 to 64 rose >36% from 2018 to 2024, and any drinking in that group rose nearly 4%.²

"Heavy drinking among ages 50-64 is up by more than a third since 2018, a concerning trend because this age group faces some of the greatest risks of harm from alcohol, including cirrhosis and alcohol-related cancers," Brian Lee said in a statement.

Will Alcohol-Associated Liver Disease Keep Falling? Questions That Remain

Because liver damage builds over years, it may take time before recent changes in drinking show up in liver disease data. Whether the post-2021 decline in alcohol-related cirrhosis mortality continues, and which patients clinicians are most likely to see next, remain open questions.

Part 2 of this series will look at where ALD is headed and what clinicians can do now.

Editor's note: Frances Lee does not report any relevant disclosures. Gonzalez reports relevant disclosures with Mallinckrodt Pharmaceuticals, Salix, AbbVie, Gilead, and others. Brian Lee reports consulting for Gilead Sciences, Novo Nordisk, GlaxoSmithKline, Altimmune, Bausch Health, and others.

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Pan CW, Danpanichkul P, Guifarro D, Wang Y, Chitnis AS, Zhang W, et al. Alarming rise in alcohol-associated liver disease hospitalization in young adults. 

Alcohol-associated liver disease mortality has nearly doubled since 1999, with a marked inflection during the COVID-19 pandemic and disproportionate increases among women, younger adults, and American Indian/Alaska Native populations. While national surveys show the first post-pandemic decline in alcohol use and heavy drinking after 2022, consumption and alcohol-related cirrhosis mortality remain above 2018 baselines. Trends vary by subgroup, reflecting sex-specific biology, shifting age patterns, and synergistic effects of metabolic dysfunction and genetic susceptibility. Under-recognition of binge drinking and stigma likely contribute to underestimation.

As drinking declines, Stevan Gonzalez, MD, Frances Lee, MD, and Brian Lee, MD, on the lingering burden of alcohol-associated liver disease.