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Alcohol-Associated Liver Disease (ALD) is becoming an increasingly significant global health challenge, now accounting for approximately 5% of all disease and injury worldwide. Recent trends in the United States reveal a concerning rise in ALD cases, particularly since 2014, with the trajectory accelerating during the COVID-19 pandemic. This trend is marked by changes in the demographics of those affected, including a rise in cases among women, certain ethnic and racial minorities, and young adults.
The Expanding Burden of ALD
ALD encompasses a spectrum of liver conditions, including steatosis, fibrosis, cirrhosis, and hepatocellular carcinoma, along with related complications. While early stages of ALD may present without symptoms, patients often present to healthcare providers with advanced stages of the disease, such as decompensated cirrhosis. This pattern is more pronounced in ALD than in other chronic liver diseases, such as metabolic dysfunction-associated steatotic liver disease or hepatitis C.
“Unfortunately, patients with ALD more often present in late stages of disease (decompensated cirrhosis) as compared with other chronic liver diseases,” noted Dr. Doug A. Simonetto, associate professor of medicine and director of the Gastroenterology and Hepatology Fellowship Program at the Mayo Clinic, Rochester, Minnesota.
Women and ALD: Narrowing the Gender Gap
Historically, men have had higher rates of alcohol use and associated liver diseases than women. However, recent data suggest that this gender gap is closing. A 2016 meta-analysis showed that men born in the early 1900s were 2.2 times more likely to drink alcohol and 3.6 times more likely to experience alcohol-related harms than women. By the late 1990s, women’s drinking habits had nearly caught up, with men leading by only 1.1 and 1.3 times, respectively.
This increased alcohol consumption among women has been linked to a rise in ALD cases. The Global Burden of Disease Study 2019 reported a significant increase in ALD prevalence among young women (ages 15-49), with the most substantial rises observed in the 20-24 age group.
Dr. George F. Koob, director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), highlighted alarming statistics: “The age-adjusted death rate from alcohol-associated liver cirrhosis increased by 47% between 2000 and 2019, with larger increases for females than for males (83.5% compared to 33%).”
Ethnic and Racial Disparities in ALD
In the United States, certain ethnic and racial minorities, particularly Hispanic and Native American populations, experience disproportionately higher rates of ALD and its complications. A 2021 analysis found that Hispanic ethnicity was associated with a 17% increased risk for acute-on-chronic liver failure in patients with ALD-related admissions. Additionally, ALD-related mortality rates are higher among Native American populations compared to other racial and ethnic groups.
These disparities may stem from a combination of genetic predispositions, such as the PNPLA3 G/G polymorphism, and socioeconomic factors, including income discrepancies and access to care. Evidence also suggests that alcohol screening interventions are not applied equally across various racial and ethnic groups.
ALD in Young Adults: A Double-Edged Sword
The incidence of ALD has also increased among adolescents and young adults globally. In the United States, ALD-related hospitalizations among those aged 35 and younger have surged, primarily due to a rise in alcoholic hepatitis and acute-on-chronic liver failure. ALD is now the most common indication for liver transplant in individuals under 40, with the rate of cirrhosis-related mortality among people aged 25-34 increasing by 10.5% annually from 2009 to 2016.
However, there is a nuanced trend within the younger adult population. While ALD rates are rising among those aged 26 and older, younger individuals under 25 are increasingly abstaining from alcohol. A survey of over 180,000 young adults revealed a growing trend of alcohol abstinence, with many citing reasons such as health concerns and the desire to avoid interfering with work or school.
Dr. Koob expressed cautious optimism about this trend: “We have seen historic increases in alcohol consumption in the last few years — the largest increases in more than 50 years. But we are hopeful that, as the younger cohorts age, we will see lower levels of drinking by adults in mid-life and beyond.”
Conclusion
The shifting demographics of Alcohol-Associated Liver Disease highlight the need for targeted interventions and improved screening practices. Understanding the factors driving these changes, particularly among women, ethnic and racial minorities, and young adults, is crucial for addressing the growing burden of ALD and preventing its most severe outcomes. As societal attitudes towards alcohol evolve, there may be hope for reversing these concerning trends in the future.
