Women Face Higher Risk of Advanced Fibrosis Due to Binge Drinking Than Men

New research is shedding light on sex-based differences in the association between the frequency of binge drinking and advanced fibrosis, highlighting a heightened risk of liver injury among women even at low binge frequencies.1

Study findings were presented at the American Association for the Study of Liver Diseases (AASLD) The Liver Meeting 2025 by Winston Dunn, MD, a professor in the division of gastroenterology at the University of Kansas Medical Center, and pose important implications for the accuracy of current metabolic dysfunction-associated alcohol-related liver disease (MetALD) and alcohol-associated liver disease (ALD) definitions.1

“The 2023 steatotic liver disease (SLD) nomenclature has defined MetALD and ALD based on average daily alcohol intake. However, binge drinking patterns have not yet been incorporated into these definitions,” Dunn and colleagues wrote.1

The 2023 change in nomenclature saw nonalcoholic fatty liver disease (NAFLD) become metabolic dysfunction-associated steatotic liver disease (MASLD) and nonalcoholic steatohepatitis (NASH) become metabolic dysfunction-associated steatohepatitis (MASH). However, the update also introduced an entirely new disease category, MetALD, for patients with MASLD who consume increased amounts of alcohol. Since the introduction of MetALD, several questions have been raised about how it should be defined, including alcohol thresholds.2

To assess the associations between the frequency of binge drinking and advanced fibrosis, investigators assessed data from the NHANES 1999–2020 cohort for adults ≥ 18 years of age who did not have viral hepatitis. Alcohol intake was assessed through standardized questionnaires, capturing both average daily drinking and the frequency of binge drinking in the past year, defined as ≥4 drinks for women and ≥5 drinks for men on a single occasion. Advanced fibrosis was defined as FIB-4 ≥2.67.1

Investigators first quantified the association between MetALD and ALD-level average daily drinking and advanced fibrosis, adjusting for demographic and metabolic risk factors. They then scanned the full range of binge drinking frequency to identify cutpoints that produced comparable adjusted odds ratios for advanced fibrosis.1

Among 43447 eligible participants, 770 (2.4%) men and 559 (1.8%) women had advanced fibrosis. Investigators used the adjusted odds ratio (aOR) of MetALD-level daily drinking (2.50; 95% CI, 1.76–3.50) and ALD-level daily drinking for advanced fibrosis (5.82; 95% CI, 3.27–10.3) as reference.1

A total of 8486 men (45.4%, representing 50.3 million US adults) and 4471 women (22.0%, representing 26.8 million) reported some level of binge drinking. Investigators noted women binge drinking as infrequently as twice per year conferred a risk equivalent to MetALD-level daily drinking, while monthly bingeing matched the risk of ALD-level daily drinking. Beyond monthly frequency, they observed an exponentially increased risk.1

Further analysis revealed men exhibited a higher threshold for harm: monthly bingeing approximated the risk of MetALD-level daily drinking, while daily bingeing approached the risk seen with ALD-level daily drinking.1

“Women face elevated risk even at low binge frequencies—comparable to the risk from MetALD-level daily drinking—whereas men require more frequent binge patterns to reach comparable risk,” investigators concluded.1 “These findings support a sex-specific approach to MetALD and ALD definitions and highlight the need to incorporate binge drinking frequency into clinical risk stratification and public health messaging.”

References

1. Dunn W, Arab JP, Diaz LA, et al. Sex-Specific Risk Thresholds of Binge Drinking Frequency for Advanced Fibrosis in the United States. Presented at the American Association for the Study of Liver Diseases (AASLD) The Liver Meeting 2025. Washington, DC. November 7-11, 2025.

2. Brooks A. From NAFLD to MASLD: 2023 Brings New Liver Disease Nomenclature. HCPLive. December 13, 2025. Accessed November 7, 2025. https://www.hcplive.com/view/from-nafld-to-masld-2023-new-liver-disease-nomenclature