A new study analyzing populations in Spain and the United States shows that even moderate alcohol consumption heightens the risk of liver fibrosis when paired with metabolic conditions in people with metabolic dysfunction-associated steatotic liver disease (MASLD). In fact, no level of alcohol intake is safe for individuals with MASLD, researchers report in the Journal of Hepatology.

MASLD, the new name for non-alcoholic fatty liver disease (NAFLD), and its more severe form, metabolic dysfunction-associated steatohepatitis (MASH, formerly known as non-alcoholic steatohepatitis, or NASH), are responsible for a growing proportion of advanced liver disease worldwide. Over time, fat buildup in the liver can trigger inflammation and lead to fibrosis, cirrhosis and liver cancer.

The new terminology emphasizes the link between fatty liver disease and obesity, type 2 diabetes and other metabolic abnormalities. If increased alcohol use also contributes to liver fat buildup (steatosis), the condition may be classified as metabolic dysfunction and alcohol-related liver disease, or MetALD.

María Teresa Arias-Loste, MD, PhD, of the Valdecilla Biomedical Research Institute in Spain, and colleagues explored how low or moderate alcohol consumption along with MASLD contributes to liver disease progression.

Participants in two cohorts in Spain and the United States underwent transient elastography, a noninvasive method for estimating liver fat and fibrosis. An average of 5 to 9 drinks per week was considered low consumption, while 10 to 13 drinks per week for women or 10 to 20 drinks for men was classified as moderate consumption. Women who consumed 14 to 35 drinks per week and men who imbibed 21 to 42 drinks made the cutoff for MetALD.

The Spanish cohort included 2,227 people with MASLD, with 9% and 14% having low and moderate alcohol consumption, respectively. Within this group, there were 76 cases of MetALD. Significant fibrosis was present in 8%, and 15% were considered to be at risk for developing MASH.

The U.S. cohort included 1,732 people with MASLD, with 17% having significant fibrosis and 13% being at risk for MASH. This population confirmed a significant link between moderate alcohol consumption and a higher likelihood of experiencing MASLD progression. Individuals with moderate alcohol intake had a 69% greater likelihood of MASLD progression compared to those with lower intake.

The researchers noted a dose-dependent relationship between the number of cardiometabolic risk factors and drinks per week and the development of advanced fibrosis and risk for MASH. Even moderate levels of alcohol consumption exacerbated MASLD progression, in a manner similar to the high consumption of people classified as having MetALD.

“We show that moderate alcohol consumption has a supra-additive effect with metabolic risk factors, exponentially increasing the risk of liver fibrosis,” wrote the researchers. “These results suggest that there are no safe limits of daily alcohol intake in patients with unhealthy metabolic status and MASLD.”

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