New and alarming trends in alcohol-related liver disease

Alcohol-associated hepatitis (AH), a severe and potentially life-threatening liver disease, is rising sharply among adolescents and young adults. Once primarily linked to older men with long histories of heavy drinking, AH is now disproportionately affecting young women, raising critical questions about its causes and public health implications.

This troubling trend is the focus of new research published in The Journal of the American Medical Association (JAMA) by Queen’s University researchers Dr. Jennifer Flemming (Medicine), Dr. Oyedeji Ayonrinde (Psychiatry), medical student Orli Chapman, and collaborators from , and the University of Southern California.

“When I started training in hepatology over 15 years ago, the type of individual we cared for with alcohol-associated hepatitis was very different from those we see today,” says Dr. Flemming. “We’re seeing more and more younger people, especially women, affected by alcohol-related liver diseases.”

These first-hand observations of shifting patient demographics led the research team to investigate how trends in AH have evolved over the past two decades.

A growing public health crisis

Globally, alcohol is responsible for 13.5 per cent of deaths among people aged 20 to 39. Unlike viral hepatitis, which is caused by infections like hepatitis B or C, AH occurs when the liver becomes inflamed due to prolonged excessive alcohol consumption. While both viral and alcohol-related hepatitis can lead to cirrhosis (scarring) or liver failure, their causes, prevention, and treatments require different approaches.

Using health records from ICES, the team conducted a population-based cohort study analyzing over 3,000 adolescents and young adults aged 13 to 39 diagnosed with AH between 2001 and 2022 through hospital admissions and emergency care in Ontario.

Their findings show a rise in AH cases over time, with rates increasing by eight per cent annually in men and an even steeper 11 per cent per year in women.

Six months after diagnosis, 71 per cent of patients were alive and free of cirrhosis. However, over the next four years, 22 per cent experienced disease progression, including cirrhosis or worsening liver function. Women were found to be disproportionately affected, with 37 per cent of female survivors developing severe complications compared to 29 per cent of men.

Over a 10-year period, the disparity in liver-related deaths was also significant, with 11 per cent of women dying from liver-related causes compared to just under 7 per cent of men. Women’s higher mortality rates are linked to their approximately 50 per cent increased risk of developing cirrhosis compared to men, a factor that drives the greater severity of alcohol-related liver disease in females.

"What we found is that while AH is rising in both sexes, the speed of the increase and the severity of outcomes are far worse in women."

– Dr. Jennifer Flemming

Associate Professor of Medicine and Public Health Sciences

Understanding the rise in alcohol-associated hepatitis

Several factors may help explain the rapid rise in AH cases, including the effects of the COVID-19 pandemic and social patterns. Dr. Flemming suggests that the stress, isolation, and disruptions to daily life likely accelerated the increase in alcohol consumption, worsening a trend that had already begun.

In addition to social factors, biological differences between men and women may also be playing a role in the disparity of outcomes. It is well established that there are differences in how alcohol is metabolized between the sexes with women at greater risk of alcohol-associated harm than men for the same amount of alcohol consumed. Historically, the percentage of women using alcohol was much less compared to men, however, data has shown that men and women now have equal rates of alcohol consumption which may help to explain the observed trends.

Another contributing factor is the rising popularity of alcoholic beverages with high-sugar content, such as ciders, which can be harmful to the liver. The Canadian population also already has more risk factors for liver disease, such as diabetes and obesity, that may contribute to liver damage.

In Ontario, new regulations have loosened restrictions on alcohol sales, including home delivery, making it more accessible in various settings. This increased accessibility may contribute to a further uptick in alcohol consumption, particularly among younger people. While this shift is not reflected in the current study’s data, it could amplify the already concerning trends observed in recent years.

Reversing trends

To combat this growing public health crisis, Dr. Flemming advocates for a multi-pronged approach that focuses on education, prevention and the development of clinical trials and observational studies that apply a sex or gender-based methodologies.

Primary prevention methods focus on educating the public about the risks of alcohol on the liver and implementing policies that address behaviours that lead to AH before it develops. This could include actions such as clearly labelling alcohol products in a similar fashion to nutritional information on food. Doing so could help consumers make more informed decisions about what they are consuming and avoid high-sugar alcoholic beverages.

Secondary prevention methods such as early identification and intervention are also key to preventing further damage. Dr. Flemming stresses the importance of screening for alcohol use disorder in primary care settings, which could help identify individuals at risk before liver damage becomes severe.

For those who have already developed AH, the focus becomes tertiary prevention strategies aimed at managing and minimizing the impact of a disease or condition once it has already caused liver damage. She emphasizes that early intervention can reduce the risk of further liver damage and dramatically improve patient outcomes.

“Alcohol is deeply woven into the social fabric of many cultures but what’s really encouraging is that with the right education and public health strategies, we can change behaviors for the better.”

Read the full study in .