Association between public health policies on alcohol and worldwide cancer, liver disease and cardiovascular disease outcomes

Noninvasive pathway for stratifying fibrosis in suspected metabolic dysfunction and alcohol-associated liver disease (MetALD)

BACKGROUND

Metabolic dysfunction and alcohol-associated liver disease (MetALD) may increase liver fibrosis progression, but data on screening are scarce. We aimed to assess the performance of noninvasive tests (NITs) for detecting significant fibrosis in individuals with suspected MetALD.

METHODS

This is a cross-sectional study of prospectively enrolled adults identified as overweight or obese. We included adults with suspected MetALD defined by ≥1 of 5 cardiometabolic criteria and self-reported alcohol use within MetALD ranges or lower self-reported alcohol use but with phosphatidylethanol (PEth) levels ≥25 ng/mL. Clinical assessment included contemporaneous magnetic resonance elastography (MRE) and vibration-controlled transient elastography (VCTE). Significant fibrosis was defined as MRE ≥3.14 kPa (or VCTE ≥7.6 kPa if MRE was missing). Analyses included AUROCs.

RESULTS

Among 617 individuals screened, we identified 97 (15.7%) with suspected MetALD. The mean age was 50.6±12.8 years, 67% were men, the mean body mass index was 31.4±6.5 kg/m2, 12.4% had diabetes, and 8% had significant fibrosis. Fibrosis-4 ≥1.3 demonstrated good performance for significant fibrosis (AUROC: 0.78, 95% CI: 0.58-0.98, sensitivity 80%, specificity 76%, positive predictive value 17%, and negative predictive value 98%). VCTE ≥8 kPa also had good performance (AUROC: 0.85, 95% CI: 0.66-1.00, sensitivity 80%, specificity 91%, positive predictive value 36%, and negative predictive value 99%). A stepwise approach using fibrosis-4 followed by VCTE yielded a low false negative rate (2% misclassified as low risk).

CONCLUSIONS

A clinical care algorithm utilizing a stepwise approach with fibrosis-4 and VCTE shows adequate performance in detecting significant fibrosis in individuals with suspected MetALD.

Metabolic Cause of Cirrhosis Is the Emerging Etiology for Primary Liver Cancer in the Asia-Oceania Region: Analysis of Global Burden of Disease (GBD) Study 2021

INTRODUCTION

Studies have shown a change in the etiological profile of liver cancer globally. We aimed to analyze the burden and changes in etiology of liver cancer in the Asia-Oceania region.

METHODS

The burden of liver cancer in Asia-Oceania was estimated using data from the 2021 Global Burden of Disease (GBD) Study. The analysis included age-standardized incidence (ASIR), prevalence (ASPR), mortality (ASMR), and disability-adjusted life years (DALY) per 100 000 population.

RESULTS

The Asia-Oceania region contributed 68.6%, 68.8%, and 67.3% of the global incidence, prevalence, and mortality of liver cancer in 2021. In 2021, Mongolia, Tonga, and South Korea had the highest ASIR, ASPR, and ASMR, whereas Australia, New Zealand, and Guam had the greatest increase in incidence and mortality rates. Viral hepatitis remained the most common etiology of liver cancer, with 47.7% and 26.1% of cases being related to hepatitis B virus (HBV) and hepatitis C virus (HCV), respectively. Around 14.5% and 7.1% of cases were related to alcohol and nonalcoholic steatohepatitis (NASH), respectively; however, the annual change in the ASIR was the highest for NASH. Alcohol, drug abuse, tobacco use, and metabolic syndrome, contributed to 15.2%, 11.7%, 11.5%, and 9.0% of liver cancer mortality in 2021; however, the change in death from 1990 to 2021 was the highest for metabolic syndrome.

CONCLUSION

Viral hepatitis remains the most common cause of liver cancer, with NASH having the highest annual rate of change in ASIR and liver cancer deaths in Asia-Oceania.

A call to action to address the steatotic liver disease public health threat in Barcelona

Despite their high prevalence worldwide, steatotic liver diseases (SLDs) are largely excluded from most non-communicable disease (NCD) guidelines and strategies. We propose policies and strategies to achieve the United Nations Sustainable Development Goal of reducing NCD premature mortality by one-third by 2030. To assess this gap-the exclusion of SLDs from NCD policies-in urban areas, we reviewed Barcelona's strategies for NCD risks (e.g., alcohol, tobacco, healthy food access). We then explored applications of geo-spatial visualisation and whole-of-society approaches (e.g., citizen science engagement) aligned with the World Health Organization (WHO) Best Buys to provide recommendations to address NCDs, generally, and SLDs specifically.

MetALD: New Perspectives on an Old Overlooked Disease

Metabolic dysfunction-associated steatotic liver disease (MASLD) and alcohol-associated liver disease (ALD) are the major contributors to the liver disease burden globally. The rise in these conditions is linked to obesity, type 2 diabetes, metabolic syndrome and increased alcohol consumption. MASLD and ALD share risk factors, pathophysiology and histological features but differ in their thresholds for alcohol use, and the ALD definition does not require the presence of metabolic dysfunction. A recent multi-society consensus overhauled the nomenclature of liver steatosis and introduced the term MetALD to describe patients with metabolic dysfunction who drink more than those with MASLD and less than those with ALD. This new terminology aims to enhance the understanding and management of liver disease but poses challenges, such as the need to accurately measure alcohol consumption in research and clinical practice settings. Recent studies show that MetALD has significant implications for patient management, as it is associated with increased mortality risks and more severe liver outcomes compared to MASLD alone. MetALD patients face increased risks of liver disease progression, cancer and cardiovascular disease. The diagnosis of MetALD involves the adequate quantification of alcohol use through standardised questionnaires and/or biomarkers as well as proper assessment of liver disease stage and progression risk using non-invasive tools including serologic markers, imaging, elastography techniques and genetic testing. Effective management requires addressing both metabolic and alcohol-related factors to improve outcomes. This review intends to provide a comprehensive overview of MetALD, covering pathogenesis, potential diagnostic approaches, management strategies and emerging therapies.

Liver cancer in 2021: Global Burden of Disease study

BACKGROUND & AIMS

The epidemiology of adult primary liver cancer continues to evolve, owing to the increasing prevalence of metabolic disease, rising alcohol consumption, advances in vaccination for HBV, and antiviral therapy for HCV. Disparities in care and the burden of liver cancer between populations persist. We assess trends in the burden of liver cancer and contributions by various etiologies across 204 countries and territories from 2010 to 2021.

METHODS

Utilizing the methodological framework of the Global Burden of Disease Study 2021, we analyzed global and regional temporal trends in incidence and mortality, and the contributions of various etiologies of liver disease.

RESULTS

In 2021, there were an estimated 529,202 incident cases and 483,875 deaths related to liver cancer. From 2010 to 2021, global liver cancer incident cases and deaths increased by 26% and 25%, respectively. Age-standardized incidence rates (ASIRs) and death rates (ASDRs) for liver cancer declined globally, but rose in the Americas and Southeast Asia. HBV remained the dominant cause of global incident liver cancer cases and deaths. MASLD (metabolic dysfunction-associated steatotic liver disease) was the only etiology of liver cancer with rising ASIRs and ASDRs. By contrast, ASIRs and ASDRs remained stable for alcohol-related liver cancer, and declined for HBV- and HCV-related liver cancer.

CONCLUSIONS

While age-adjusted incidence and deaths from liver cancer have started to decline, the absolute number of incident cases and deaths continues to increase. Population growth and aging contribute to the observed disconnect in the temporal trends of absolute cases and rates. Disparities remain, and the incidence and mortality associated with MASLD-related liver cancer continue to rise.

IMPACT AND IMPLICATIONS

Liver cancer remains a major cause of death globally, but its causes and burden in various regions are changing. This study highlights that new diagnoses and deaths related to liver cancer continue to rise. Age-adjusted death rates of liver cancer related to viral hepatitis are declining but remain high. By contrast, age-adjusted death rates of liver cancer related to MASLD (metabolic dysfunction-associated steatotic liver disease) are rising. Sustained efforts and resources are needed to eliminate viral hepatitis, reverse current trends in heavy alcohol use, and tackle the metabolic risk factors of MASLD.

Mortality of Gastrointestinal Cancers Attributable to Smoking, Alcohol, and Metabolic Risk Factors, and its Association With Socioeconomic Development Status 2000-2021

OBJECTIVE

Gastrointestinal (GI) cancers account for one-third of global cancer mortality, with nearly half being preventable. This study updates the global burden of GI cancers attributed to major risk factors.

METHODS

We utilized data from the Global Burden of Disease Study 2021 to examine trends in death and age-standardized death rates related to GI cancers caused by smoking, alcohol, high body mass index (BMI), and high fasting blood glucose (FBG) from 2000 to 2021. Trends were analyzed based on countries' developmental status using a sociodemographic index (SDI).

RESULTS

In 2021, there were 1.12 million GI cancer deaths related to smoking, alcohol, high BMI, and high FBG, which was 53.6% higher than in 2000. The largest proportion of GI cancer mortality was attributed to smoking (43.3%), followed by alcohol (20.6%), high FBG (20.5%), and high BMI (15.6%). The increases in GI cancer deaths between 2000 and 2021 were related to high BMI (+102.54%) and FBG (+107.69%), particularly in liver and pancreatic cancer. In 2021, GI cancer mortality in low, low-middle, and middle SDI countries represented 44.3% of the global GI cancer mortality attributed to smoking, 41.9% for alcohol, 34.3% for high BMI, and 31.6% for high FBG. Since 2000, these proportions have increased by +4.5% for smoking, +7.6% for alcohol, + 12.3% for high BMI, and +6.4% for high FBG.

CONCLUSION

From 2000 to 2021, GI cancer mortality increased substantially, driven primarily by obesity and alcohol. Lower SDI countries are increasingly contributing to the global GI cancer burden.

Alcohol-Attributable Cancer: Update From the Global Burden of Disease 2021 Study

BACKGROUND AND AIMS

Alcohol is a major risk factor for cancer development. Our study aimed to provide the updated global, regional and national burden of alcohol-attributable cancer.

APPROACH AND RESULTS

We analysed the Global Burden of Disease Study 2021 to determine the death and age-standardised death rate (ASDR) from alcohol-attributable cancer and the change of these measures between 2000 and 2021 (reflected as annual percent change [APC]), classified by region, nation and country's developmental status, which is based on the sociodemographic index (SDI).

RESULTS

In 2021, there were 343,370 deaths globally from alcohol-attributable cancer, which was an increase from 2000 by 51%. Alcohol-attributable cancer accounted for 3.5% of all cancer deaths. Among alcohol-attributable cancer, liver cancer (27%) accounted for the highest mortality from alcohol, followed by oesophageal (24%) and colorectal cancer (16%). From 2000 to 2021, ASDR from alcohol-attributable cancer decreased (APC: -0.66%). Regionally, from 2000 to 2021, the fastest-growing ASDR was observed in South Asia. Classified by SDI, low (APC: 0.33%) and low-to-middle SDI countries (APC: 1.58%) exhibited an uptrend in ASDR from alcohol-attributable cancer. While the ASDR from all other cancers decreased, ASDR from early-onset (15-49 years) lip and oral cavity cancer increased (APC: 0.40%).

CONCLUSIONS

From 2000 to 2021, although the ASDR from alcohol-attributable cancer declined, the total number of deaths continued to rise. This trend was accompanied by variations across sociodemographic groups and cancer types, particularly gastrointestinal cancers. Urgent efforts are needed both globally and at regional levels to address the burden of alcohol-attributable cancers.

Global epidemiology of alcohol-related liver disease, liver cancer, and alcohol use disorder, 2000-2021

BACKGROUND/AIMS

Alcohol represents a leading burden of disease worldwide, including alcohol use disorder (AUD) and alcohol-related liver disease (ALD). We aim to assess the global burden of AUD, ALD, and alcohol-attributable primary liver cancer between 2000-2021.

METHODS

We registered the global and regional trends of AUD, ALD, and alcohol-related liver cancer using data from the Global Burden of Disease 2021 Study, the largest and most up-to-date global epidemiology database. We estimated the annual percent change (APC) and its 95% confidence interval (CI) to assess changes in age-standardized rates over time.

RESULTS

In 2021, there were 111.12 million cases of AUD, 3.02 million cases of ALD, and 132,030 cases of alcohol-attributable primary liver cancer. Between 2000 and 2021, there was a 14.66% increase in AUD, a 38.68% increase in ALD, and a 94.12% increase in alcohol-attributable primary liver cancer prevalence. While the age-standardized prevalence rate for liver cancer from alcohol increased (APC 0.59%; 95% confidence interval [CI] 0.52 to 0.67%) over these years, it decreased for ALD (APC -0.71%; 95% CI -0.75 to -0.67%) and AUD (APC -0.90%; 95% CI -0.94 to -0.86%). There was significant variation by region, socioeconomic development level, and sex. During the last years (2019-2021), the prevalence, incidence, and death of ALD increased to a greater extent in females.

CONCLUSION

Given the high burden of AUD, ALD, and alcohol-attributable primary liver cancer, urgent measures are needed to prevent them at both global and national levels.

Clinical Trial to Assess the Safety and Tolerability of Anti-IL 23 Monoclonal Antibody Guselkumab in Patients With Alcohol-Associated Liver Disease

BACKGROUND

There are no FDA-approved therapies for alcohol-associated liver disease (ALD). Preclinical studies indicate that blocking IL-23/IL-17 signalling may reverse liver injury. Guselkumab, an IL-23-specific antibody approved for psoriasis, may be beneficial for ALD.

AIMS

We aimed to assess the safety and tolerability of guselkumab in patients with ALD.

METHODS

This phase-1 dose-escalation study included patients with ≥ 2 DSM-5 criteria for alcohol use disorder, significant steatosis (MRI-PDFF ≥ 8%) and MRE < 3.63 kPa (to exclude advanced disease). Guselkumab was given subcutaneously on Days 1 and 29 in 30, 70 or 100 mg dose cohorts. Primary endpoints were adverse events (AEs) and dose-limiting toxicity.

RESULTS

We enrolled 13 patients (three 30 mg, three 70 mg, and seven 100 mg). Eleven completed the study and two early discontinued in the 100 mg group. Of them, 77% were men, and the median age was 53 [IQR 49-61] years. The median MRI-PDFF and MRE were 18.4% [IQR 8.4%-34.0%] and 2.5 [2.2-2.6] kPa, respectively. The most frequent AEs were hyperuricemia (13%, mild only) and elevated lipase (11%, mild and moderate). There were no serious adverse events or significant variations in liver enzymes. There was a suppression of peripheral interleukin (IL)-17, IL-23, IL-1b and TNF-α in the 70 and 100 mg groups, and a significant decrease in alcohol consumption over time (AUDIT-C: 6 [3-7] vs. 5 [1-6], p = 0.023).

CONCLUSIONS

Guselkumab is safe in doses up to 100 mg and may reduce inflammation markers in ALD. These findings support further phase 2 studies to evaluate the efficacy of guselkumab in ALD, particularly in patients with severe phenotypes.

Harnessing NLP to investigate biomarker interactions and CVD risks in elderly chronic kidney disease patients

Chronic kidney disease (CKD) significantly increases the risk of CVD diseases, particularly among elderly patients. Understanding the interaction between several biomarkers and cardiovascular (CVD) risks is crucial for improving patient outcomes and tailoring personalized treatment strategies. There is much more to learn about the intricate relationship between biomarkers and CVD risks in elderly CKD patients. Research aims to harness natural language processing (NLP) strategies to investigate the interaction between biomarkers and CVD risks in elderly patients with CKD. This research examined how changes in baseline values of four novel and classic cardiac biomarkers relate to the danger of CVD, and all-cause death in a large cohort of patients with CKD. Initially, medical data were collected from EHR of elderly CKD patients. NLP technique, such as Named Entity Recognition (NER), is used to extract the relevant biomarkers and CVD risk factors from the data. Statistical techniques were applied to examine the associations between biomarkers and CVD risks. The predictive models, using a combination of structured and NLP-extracted features demonstrated improved accuracy in forecasting CVD outcomes compared to traditional methods. This investigation highlights the critical role of specific biomarkers like PTH and FGF-23 in predicting CVD outcomes, providing insights into the possibility of using EHR data for better patient management and enhancing predictive models for this high-risk population.

Rising Incidence of Early-Onset Liver Cancer and Intrahepatic Bile Duct Cancer: Analysis of the National Childhood Cancer Registry Database

Background/Objectives: Early-onset cancer is an emerging global health concern, including in the United States. However, data on early-onset liver and intrahepatic bile duct cancer remain limited. This study aims to fill this gap by analyzing trends in early-onset liver and intrahepatic bile duct cancer in the United States over the past two decades. Methods: This study used National Childhood Cancer Registry data to examine temporal trends in early-onset liver and intrahepatic bile duct cancer in the United States. The analysis involved estimating age-adjusted incidence rates of early-onset liver and intrahepatic bile duct cancer, stratified by histological type, ethnicity, and sex. Results: In 2021, the age-adjusted incidence rate of early-onset liver and intrahepatic bile duct cancer was estimated at 0.53 per 100,000 population (95% Confidence Interval [CI]: 0.48-0.59). From 2001 to 2021, the age-adjusted incidence rate showed a significant annual percent change (APC) of 1.35% (95% CI: 0.87-1.83%). When stratified by sex, the age-adjusted incidence rate in females increased significantly (APC: 3.07%, 95% CI: 2.26-3.87%) while remaining stable in males. Among racial and ethnic groups, non-Hispanic American Indian and Alaska Native (AIAN) individuals had the highest age-adjusted incidence rate, recorded at 2.67 per 100,000 population (95% CI: 0.95-5.85). By histological type, hepatic carcinoma had the highest age-adjusted incidence rate, significantly increasing over time (APC: 1.47%, 95% CI: 0.96-1.99%). In contrast, the incidence rates for hepatoblastoma and unspecified hepatic tumors remained stable between 2001 and 2021. Conclusions: Our study identified an increasing incidence of early-onset liver and intrahepatic bile duct cancer in the United States, primarily driven by cases in females and hepatic carcinoma.

Alcohol-Related Liver Disease, Followed by Metabolic Dysfunction-Associated Steatotic Liver Disease, Emerges as the Fastest-Growing Aetiologies for Primary Liver Cancer in the United States

OBJECTIVE

Primary liver cancer (PLC) is projected to be the third leading cause of cancer mortality in the United States in 2040. We examine the burden of PLC in the United States, stratified by sex, state and aetiological risk factors.

METHODS

Data on PLC prevalence, incidence, death and disability-adjusted life years (DALYs) were extracted from the Global Burden of Disease Study 2021. Changes in these parameters were calculated using the Joinpoint regression model.

RESULTS

There were 47,970 cases, 31,450 incident cases, 24,770 deaths and 576,920 DALYs from PLC in the United States. The highest prevalence (16,980), incidence (12,040), death (9840) and DALYs (213,410) from PLC were due to chronic hepatitis C virus infection. From 2000 to 2021, PLC incidences increased by 141%, and PLC deaths increased by 136%. Age-standardised incidence rates (ASIRs) and death rates (ASDRs) per 100,000 population for PLC increased, primarily driven by alcohol-related liver disease (ALD) (ASIR: annual percent change [APC]: +2.40%; ASDR: APC: +2.22%) and metabolic dysfunction-associated steatotic liver disease (MASLD) (ASIR: APC: +2.32%; ASDR: APC: +2.04%).

CONCLUSION

The burden of PLC in the United States has risen in the past two decades, driven mainly by ALD and followed by MASLD. These findings offer policymakers an accurate assessment of the PLC burden and emphasise the need for targeted risk factor mitigation, especially regarding alcohol related policy.

The Global Burden of Cirrhosis and Other Chronic Liver Diseases in 2021

BACKGROUND AND AIM

The burden of cirrhosis and other chronic liver diseases has changed in recent years due to shifts in the contributing aetiologies. We estimated the burden of cirrhosis and other chronic liver diseases, including etiological and regional differences, across 204 countries and territories from 2010 to 2021.

APPROACH AND RESULTS

We analysed temporal trends in the burden of cirrhosis and other chronic liver diseases utilising data from the Global Burden of Disease Study 2021. We estimated annual frequencies and age-standardised rates (ASRs) of incident cases, deaths and disability-adjusted life-years (DALYs) by sex, country, World Health Organisation region and its contributing aetiologies. In 2021, there were an estimated 58 417 006 incident cases, 1 425 142 deaths and 46 417 777 DALYs related to cirrhosis and other chronic liver diseases. From 2010 to 2021, there was a rise in age-standardised incidence rates (ASIRs) (APC: +0.35%) but age-standardised death rates (ASDRs) (APC: -1.74%) and age-standardised disability-adjusted life-years (ASDALYs) (APC: -1.85%) declined. Cirrhosis related to metabolic dysfunction-associated steatohepatitis (MASH) contributed to 48 310 981 incident cases in 2021 and was largely responsible for the overall increase in ASIRs from 2010 to 2021. Cirrhosis and other chronic liver diseases related to MASH were the only aetiology with a rise in ASIR (APC: +0.86%). Age-standardised deaths related to all aetiologies of cirrhosis and other chronic liver diseases declined during the study period. Age-standardised deaths and DALYs related to MASH increased in the Americas, unlike all other world regions where they declined or remained stable.

CONCLUSIONS

Age-adjusted deaths related to cirrhosis and other chronic liver diseases are declining. However, the age-adjusted incidence of cirrhosis and other chronic liver diseases is increasing, driven by increases in the incidence of MASH.

Increased mortality from alcohol use disorder, alcohol-associated liver disease, and liver cancer from alcohol among older adults in the United States: 2000 to 2021

BACKGROUND

To investigate the trends in alcohol-associated liver disease (ALD), liver cancer from alcohol, and alcohol use disorder (AUD) burden among older adults in the United States (US).

METHODS

We gathered the ALD, liver cancer from alcohol, and AUD prevalence, mortality, and age-standardized rates (ASRs) from the Global Burden of Disease (GBD) Study 2021 between 2010 and 2021. We estimated the annual percent change (APC) with confidence intervals (CIs) for the burden of ALD, liver cancer from alcohol, and AUD in older adults (>70 years) in the United States. The findings were contrasted with global estimates and categorized by sex and state.

RESULTS

In 2021, there were approximately 512,340 cases of AUD, 56,990 cases of ALD, and 4490 cases of primary liver cancer from alcohol among older adults in the United States. In contrast to declining ASRs of prevalence and mortality in the global burden, these parameters were increased in older adults in the United States. From 2000 to 2021, prevalence from AUD (APC: 0.54%, 95% CI 0.43% to 0.65%), ALD (APC + 0.54%, 95% CI 0.22% to 0.86%), and primary liver cancer from alcohol (APC 2.93%, 95% CI 2.76% to 3.11%) increased. Forty states in the United States exhibited a rise in the prevalence rates of ALD in older adults.

CONCLUSION

Our findings highlighted the increased prevalence and mortality of AUD, ALD, and primary liver cancer from alcohol among older adults in the United Sates, contrasting with the decline in global trends. Public health strategies on ALD, AUD, and primary liver cancer from alcohol, which targets older adults, are urgently needed.

Alcohol-related liver and extrahepatic malignancies: burden of disease and socioeconomic disparities in 2019

BACKGROUND

Alcohol is linked to various cancers. While many studies have focused on developed countries, the burden of alcohol-related cancers in developing countries remains underexplored.

METHODS

We analyzed data from the Global Burden of Disease Study (2000-2019) to assess mortality and disability-adjusted life years (DALYs) from alcohol-related cancers in low and low-to-middle sociodemographic index (SDI) countries.

RESULTS

In 2019, there were 494 730 mortality from alcohol-related cancer. Low and low-middle SDI countries contributed over 15% of global mortality of alcohol-related cancer. Among multiple types of cancer, other pharyngeal cancers in these countries accounted for over 30% of global mortality of alcohol-related cancer. Primary liver cancer exhibited the highest mortality ( n  = 16 090) in low and low-middle SDI countries. While deaths and DALYs rates from alcohol-related cancers decreased globally between 2000 and 2019, the related burden increased in low and low-middle SDI countries with a rise in all types of alcohol-related cancers, except for primary liver cancer. The most rapidly growing mortality rates in low SDI were from other pharyngeal cancers (+2.25%), whereas in low-middle SDI countries, colorectal cancer evidenced the highest increase (+2.76%).

CONCLUSION

The burden from alcohol-related cancer has risen in countries with low and low-to-middle SDI, especially other pharyngeal cancers and colorectal cancer. Policymakers should focus on improving alcohol-related policies as well as screening availability to tackle the associated burden of cancer in resource-constrained countries. However, the difficulty in isolating the impact of alcohol due to limited data on other confounders necessitates caution in interpreting these findings.

Evaluating the synergy: anxiety prevalence and alcohol consumption patterns in high-income countries using Granger causality analysis

BACKGROUND

Alcohol consumption frequently experiences episodes of severe anxiety. This study set out to explore the long-term effects of alcohol consumption on anxiety, revealing insights into how alcohol consumption uniquely impact anxiety, aiming to inform mental health and public health approaches. This research paper explores the complex relationship between the prevalence of anxiety and the consumption patterns of wine, beer, and spirits across fifty-two high-income countries with a continental analysis.

METHOD

By employing significant secondary data taken from the World Health Organization and Our World in Data online databases and covering the period from 1990 to 2019, this study seeks to explore various causality relationships over this period. Its primary objective is to fill the empirical gap in existing research by using Granger causality analysis to reveal the dynamic relationships between the consumption of alcohol and the prevalence of anxiety. This study endeavours to provide a continental analysis of the high-income countries, which allows for including a comprehensive viewpoint in the context of a single investigation.

RESULTS

The findings demonstrate a variety of patterns of causality in alcohol consumption and anxiety prevalence in a one-way causal relationship across specific continents, a bidirectional relationship in others, and no apparent causal relationship in several countries.

CONCLUSION

The inference made from the study's results goes beyond scholarly curiosity; it establishes the foundation for further investigations and the development of customised policies aimed at reducing the mutually reinforcing dangers of alcohol consumption and anxiety disorders.

Epidemiology and Outcomes of Alcohol-Associated Hepatitis in Adolescents and Young Adults

Importance

Alcohol-associated hepatitis (AH) has high mortality, and rates are increasing among adolescents and young adults (AYAs).

Objective

To define the sex-specific epidemiology of AH in AYAs and the association between female sex and liver-related outcomes after a first presentation of AH.

Design, Setting, and Participants

A retrospective, population-based cohort study of routinely collected health care data held at ICES from Ontario, Canada, was conducted. Data on AYAs (age, 13-39 years) with first presentation of AH without a history of cirrhosis and/or decompensation from January 1 to December 31, 2022, were included in the analysis.

Exposures

Study year and female sex.

Main Outcome and Measures

Overall and sex-specific yearly rates of AH were compared using Poisson regression and rate ratios (RRs). Associations between female sex and incident cirrhosis and/or decompensation were evaluated using competing risks regression, and liver-related mortality by sex was evaluated with cumulative incidence functions.

Results

A total of 3340 AYAs with AH were identified. Median age was 33 (IQR, 28-36) years, and the population included 1190 (36%) females and 2150 (64%) males. Rates of AH increased by 8% per year (RR, 1.08; 95% CI, 1.07-1.09), with yearly rates increasing faster among females (RR, 1.11; 95% CI, 1.09-1.12) than males (RR, 1.07; 95% CI, 1.06-1.07). A total of 2374 individuals (71%) were alive without cirrhosis 6 months after AH presentation. Of those, 527 (22%) developed incident cirrhosis and/or decompensation after a median follow-up of 4 (IQR, 2-9) years (37% females vs 29% males; P < .001). After adjustment, female sex was associated with a 47% higher subhazard of cirrhosis and/or decompensation compared with male sex (38%) (subhazard, 1.47; 95% CI, 1.23-1.76; P < .001). The cumulative incidence of liver-related mortality at 10 years was higher among females (11.0%; 95% CI, 8.3%-14.2%) than males (6.9%; 95% CI, 5.4%-8.6%) (P = .01).

Conclusions and Relevance

Over the past 2 decades, the rates of AH among AYAs increased significantly, with the greatest increase observed among females. The findings of this study suggest sex-specific interventions to prevent the development of AH and the progression to cirrhosis after an episode of AH are needed.

Alcohol-associated liver disease and public health policies

Alcohol-associated liver disease (ALD) rates have increased substantially in the United States and elsewhere around the globe. These increases are largely the result of increases in alcohol use. While there are many levels at which alcohol use interventions can be implemented in order to reduce alcohol use and its negative health consequences, public policy initiatives have emerged as a powerful way to intervene across a population. In this narrative review, we will review major US national as well as worldwide alcohol-associated public health policies with a particular focus on describing how such policies have influenced rates of ALD and its complications and outcomes. We will describe global alcohol public health policy frameworks, review key alcohol policy models, describe existing notable policies and their impacts, and highlight gaps in ALD policy literature where further research and policy interventions could reduce rates of mortality from ALD.

Liver diseases and hepatocellular carcinoma in the Asia-Pacific region: burden, trends, challenges and future directions

Globally, nearly half of deaths from cirrhosis and chronic liver diseases (CLD) and three-quarters of deaths from hepatocellular carcinoma (HCC) occur in the Asia-Pacific region. Chronic hepatitis B is responsible for the vast majority of liver-related deaths in the region. Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common form of CLD, affecting an estimated 30% of the adult population. Compared with people of European descent, people from the Asia-Pacific region carry more genetic variants associated with MASLD and its progression. Alcohol is a fast-growing cause of CLD and HCC in Asia as a result of the rising per-capita consumption of alcohol. Drug-induced liver injury is under-recognized and probably has a high prevalence in this region. The epidemiological and outcome data of acute-on-chronic liver failure are heterogeneous, and non-unified definitions across regions contribute to this heterogeneity. CLDs are severely underdiagnosed, and effective treatments and vaccinations are underutilized. In this Review, we highlight trends in the burden of CLD and HCC in the Asia-Pacific region and discuss the rapidly changing aetiologies of liver disease. We examine the multiple gaps in the care cascade and propose mitigating strategies and future directions.

Mortality outcomes in individuals with MASLD versus MASLD and increased alcohol intake

BACKGROUND AND AIM

Metabolic dysfunction-associated steatotic liver disease (MASLD) has become a leading cause of chronic liver disease worldwide. A new entity termed MetALD has also been described and is defined as individuals with MASLD and increased alcohol intake. However, the natural history of MetALD compared with MASLD is unknown. We aimed to compare longitudinal outcomes in patients with MASLD versus MetALD.

METHODS

This study was performed using data from the National Health and Nutrition Examination Survey from 2011 to 2018. MASLD patients (defined by the United States Fatty Liver Index > 30) who met cardiometabolic criteria including body mass index (BMI) > 25 (BMI > 23 in Asians), hypertension, diabetes mellitus, dyslipidemia, and hypertriglyceridemia were included. MetALD was defined as MASLD with increased alcohol intake (3-6 standard drinks per day in males; 2-5 standard drinks per day in females). A comparison of overall, cardiovascular, cancer-related, and other causes of mortality in patients with MASLD versus MetALD was performed.

RESULTS

A total of 2838 individuals with MASLD and 2557 individuals with MetALD were included with a median follow-up time of 56 months. MetALD patients were at increased risk of cancer-related mortality compared with patients with MASLD (hazard ratio 1.32; 95% confidence interval 1.14-1.53; P < 0.01). However, there was no significant difference in overall, cardiovascular, and other causes of mortality.

CONCLUSIONS

Patients with MetALD were at higher risk for cancer-related mortality than MASLD. Close attention to regular cancer surveillance and accurate classification of alcohol consumption in individuals with diagnosed MASLD is warranted to help improve patient care and outcome.

Disparities in steatosis prevalence in the United States by Race or Ethnicity according to the 2023 criteria

INTRODUCTION

The 2023 nomenclature defined criteria for steatotic liver disease (SLD), including metabolic dysfunction-associated SLD (MASLD), alcohol-associated liver disease (ALD), and the overlapping MASLD/ALD (MetALD). We aimed to assess racial and ethnic disparities in the SLD prevalence among United States (US) adults based on this new nomenclature.

METHODS

We undertook a cross-sectional study employing the 2017-2018 National Health and Nutrition Examination Survey (NHANES) database. We identified SLD according to a controlled attenuation parameter ≥288 dB/m, liver stiffness ≥7.2 kPa, or elevated aminotransferase levels. Alcohol use thresholds were established according to the updated SLD definition. We estimated prevalences using the complex design of the NHANES survey. Multivariable logistic regressions with complex design weights were employed.

RESULTS

A total of 5532 individuals are included. The mean age is 45.4 years, and 50.9% are women. The adjusted estimated prevalence of MASLD is 42.4% (95% CI: 41.1-43.8%), MetALD 1.7% (95% CI: 1.3-2.0%), and ALD 0.6% (95% CI: 0.3-0.8%). Hispanics exhibit a higher prevalence of SLD, but there are no significant differences in advanced fibrosis prevalence due to SLD among racial/ethnic groups. In MASLD, men, individuals aged 40-64 and ≥65 years, Hispanics, those with health insurance, higher BMI, diabetes, hypertension, hypertriglyceridemia, and low high-density lipoprotein (HDL) cholesterol or use of lipid-lowering agents are independently associated with a higher risk, while Blacks have the lowest risk. In MetALD, men and higher BMI are independently associated with a higher risk of MetALD in adjusted multivariable analysis. In ALD, the adjusted multivariable analysis shows that only health insurance is independently associated with a lower ALD risk.

CONCLUSIONS

MASLD prevalence is high in the US, especially in men, older individuals, and Hispanics. MetALD and ALD prevalence was substantial but could be underestimated.

Letter: Optimising public health policies to combat alcohol-associated liver disease in youth-Authors' reply

This article is linked to Danpanichkul et al papers. To view these articles, visit https://doi.org/10.1111/apt.18101 and https://doi.org/10.1111/apt.18239

Incidence of liver cancer in young adults according to the Global Burden of Disease database 2019

BACKGROUND AND AIMS

The worldwide burden of cancer is increasing in younger populations. However, the epidemiology of primary liver cancer remains understudied in young adults compared to other cancer forms.

APPROACH AND RESULTS

This study analyzed data from the Global Burden of Disease study between 2010 and 2019 to assess the age-standardized incidence, mortality, and disability-adjusted life years associated with primary liver cancer in the young (15-49 y), stratified by region, nation, sociodemographic index, and sex. The study found a global estimate of 78,299 primary liver cancer cases, 60,602 deaths, and 2.90 million disability-adjusted life years in the young population. The Western Pacific region exhibited the highest burden in 2019, showing the most significant increase compared to other regions between 2010 and 2019. More than half of the countries worldwide have undergone an increase in primary liver cancer incidence rates in young adults. Around 12.51% of deaths due to primary liver cancer occur in young individuals. Throughout the study period, there was a significant decline in primary liver cancer mortality due to most etiologies, except for metabolic dysfunction-associated steatotic liver disease-attributable primary liver cancer (annual percentage change + 0.87%, 95% CI: 0.70%-1.05%) and alcohol-attributable primary liver cancer (annual percentage change + 0.21%, 95% CI: 0.01%-0.42%). The limitations of the Global Burden of Disease database include reliance on the quality of primary data and possible underestimation of alcohol consumption.

CONCLUSIONS

Over the past decade, there has been a marked increase in the burden of primary liver cancer, especially that originating from steatotic liver disease. This trend calls for the development of urgent and comprehensive strategies to mitigate this rising burden globally.

Disparities in metabolic dysfunction-associated steatotic liver disease and cardiometabolic conditions in low and lower middle-income countries: a systematic analysis from the global burden of disease study 2019

OBJECTIVE

Metabolic dysfunction-associated steatotic liver disease (MASLD) and cardiometabolic conditions affect populations across economic strata. Nevertheless, there are limited epidemiological studies addressing these diseases in low (LICs) and lower-middle-income countries (lower MICs). Therefore, an analysis of the trend of MASLD and cardiometabolic conditions in these countries is necessary.

METHODS

From 2000 to 2019, jointpoint regression analysis was employed to calculate the prevalence, mortality, and disability-adjusted life years (DALYs) for cardiometabolic conditions including MASLD, type 2 diabetes mellitus (T2DM), dyslipidemia (DLP), hypertension (HTN), obesity, peripheral artery disease (PAD), atrial fibrillation and flutter (AF/AFL), ischemic heart disease (IHD), stroke, and chronic kidney disease from HTN and T2DM, in LICs and lower MICs (according to the World Bank Classification 2019) using the Global Burden of Disease 2019 data.

RESULTS

Among the eleven cardiometabolic conditions, MASLD (533.65 million), T2DM (162.96 million), and IHD (76.81 million) had the highest prevalence in LICs and Lower MICs in 2019. MASLD represented the largest proportion of global prevalence in these countries (43 %). From 2000 to 2019, mortality in LICs and lower MICs increased in all cardiometabolic conditions, with obesity-related mortality having the highest increase (+134 %). During this timeframe, there were increased age-standardized death rates (ASDR) from obesity, PAD, and AF/AFL. From all conditions, the DALYs-to-prevalence ratio was higher in LICs and lower MICs than the global average.

CONCLUSION

The burden of MASLD and cardiometabolic conditions is increasing worldwide, with LICs and lower MICs experiencing higher (DALYs) disability per prevalence. As these conditions are preventable, counteracting these trends requires not only the modification of ongoing actions but also the strategizing of immediate interventions.

Global epidemiology of early-onset upper gastrointestinal cancer: trend from the Global Burden of Disease Study 2019

BACKGROUND AND AIM

In recent years, there has been a growing incidence of gastrointestinal cancer in young individuals. Despite its significant morbidity and mortality, research on upper gastrointestinal (UGI) cancer in young populations has been relatively limited. Therefore, studies on the epidemiological changes of this cancer are needed.

METHODS

Using data from the Global Burden of Disease Study 2019, we examined the incidence, death, and disability-adjusted life years (DALYs) from UGI cancers in the young, namely, early-onset esophageal cancer (EOEC) and early-onset gastric cancer (EOGC). These results were stratified by sex, geographical region, country, and sociodemographic index.

RESULTS

There was a total of 185 140 cases, 120 289 deaths, and 5.70 million DALYs attributable to early-onset UGI cancers globally. From 2010 to 2019, the global incidence, death, and DALYs rates of early-onset UGI cancers decreased. In contrast, the incidence rates increased in both EOEC (+1.15%) and EOGC (+0.21%) in the Eastern Mediterranean region.

CONCLUSIONS

Over the past decade, the burden of UGI cancer in the young has decreased. However, it has increased in the Eastern Mediterranean region. Further research to elucidate the attributable risk factors in this population is warranted.

Changes in the epidemiological trends of primary liver cancer in the Asia-Pacific region

Primary liver cancer is the third leading cause of cancer-related mortality. The increasing prevalence of metabolic syndrome and alcohol consumption, along with the existing burden of viral hepatitis, could significantly heighten the impact of primary liver cancer. However, the specific effects of these factors in the Asia-Pacific region, which comprises more than half of the global population, remain largely unexplored. This study aims to analyze the epidemiology of primary liver cancer in the Asia-Pacific region. We evaluated regional and national data from the Global Burden of Disease study spanning 2010 to 2019 to assess the age-standardized incidence, mortality, and disability-adjusted life years associated with primary liver cancer in the Asia-Pacific region. During the study period, there were an estimated 364,700 new cases of primary liver cancer and 324,100 deaths, accounting for 68 and 67% of the global totals, respectively. Upward trends were observed in the age-standardized incidence rates of primary liver cancer due to metabolic dysfunction-associated fatty liver disease (MASLD) and alcohol-associated liver disease (ALD) in the Asia-Pacific region, as well as an increase in primary liver cancer from Hepatitis B virus infection in the Western Pacific region. Notably, approximately 17% of new cases occurred in individuals aged 15-49 years. Despite an overall decline in the burden of primary liver cancer in the Asia-Pacific region over the past decade, increases in incidence were noted for several etiologies, including MASLD and ALD. However, viral hepatitis remains the leading cause, responsible for over 60% of the total burden. These findings underscore the urgent need for comprehensive strategies to address the rising burden of primary liver cancer in the Asia-Pacific region.

Comprehensively evaluating the relationships between marital status and other family factors with cardiovascular disease and long-term overall mortality in the elderly: a study of 48 510 Chinese individuals

BACKGROUND

Marital status is associated with cardiovascular disease (CVD) incidence and overall mortality, yet limited research on this topic in elderly individuals is available. Our aim was to comprehensively assess the impact of marital status and other family factors on CVD incidence and long-term mortality among elderly people.

METHODS

Data from the Chinese Longitudinal Healthy Longevity Survey (2002/2005/2008-2018) for participants aged ≥60 years were analysed. A cross-sectional study initially examined the correlation between spouses, offspring, living arrangements, and CVD using logistic regression. Subsequently, a retrospective cohort study investigated the long-term associations of these factors with overall mortality via Kaplan-Meier and Cox regression analyses.

RESULTS

The study involved 48 510 subjects (average age: 87 years). The cross-sectional analysis revealed a correlation between living with a spouse and an increased incidence of heart disease (adjusted OR 1.27, 95% CI 1.04-1.55) and cerebrovascular disease/stroke (adjusted OR 1.26, 95% CI 1.11-1.42). According to the retrospective cohort analysis, living with a spouse significantly reduced overall mortality (adjusted HR 0.84, 95% CI 0.80-0.87), irrespective of marital relationship quality. Conversely, living with offspring (adjusted HR 1.12, 95% CI 1.08-1.16), having more children (adjusted Pnonlinearity = 0.427) or cohabitants (adjusted Pnonlinearity < 0.0001) were associated with increased overall mortality.

CONCLUSION

In the elderly population, being married and living with a spouse were not significantly associated with a decrease in CVD incidence but were associated with a reduction in long-term overall mortality. Living with offspring, having more children, or having a larger family size did not replicate the protective effect but indicated greater overall mortality.

Editorial: Sounding the alarm-The rising global burden of adolescent and young adult alcohol-related liver disease. Author's reply

This article is linked to Danpanichkul et al papers. To view these articles, visithttps://doi.org/10.1111/apt.18101andhttps://doi.org/10.1111/apt.18140

Socio-economic association of alcohol use disorder and cardiovascular and alcohol-associated liver disease from 2010 to 2019

BACKGROUNDS AND AIMS

Alcohol use leads to disabilities and deaths worldwide. It not only harms the liver but also causes alcohol use disorder (AUD) and heart disease. Additionally, alcohol consumption contributes to health disparities among different socio-economic groups.

METHODS

We estimated global and regional trends in the burden of AUD, liver disease, and cardiovascular disease from alcohol using the methodology of the Global Burden of Disease study.

RESULTS

In 2019, the highest disability-adjusted life years rate per 100,000 population was due to AUD (207.31 [95% Uncertainty interval (UI) 163.71-261.66]), followed by alcohol-associated liver disease (ALD) (133.31 [95% UI 112.68-156.17]). The prevalence rate decreased for AUD (APC [annual percentage change] -0.38%) and alcohol-induced cardiomyopathy (APC -1.85%) but increased for ALD (APC 0.44%) and liver cancer (APC 0.53%). Although the mortality rate for liver cancer from alcohol increased (APC 0.30%), mortality rates from other diseases decreased. Between 2010 and 2019, the burden of alcohol-associated complications increased in countries with low and low-middle sociodemographic index (SDI), contributing more significantly to the global burden.

CONCLUSION

The global burden of AUD, liver, and cardiovascular disease has been high and increasing over the past decade, particularly for liver complications. Lower SDI countries are contributing more to this global burden. There is a pressing need for effective strategies to address this escalating burden.

The burden of alcohol-related cardiovascular complications in young and middle-aged adults: rising burden of atrial fibrillation and hypertensive heart disease

BACKGROUND AND AIMS

The burden of alcohol-related complications is high and rising. However, there are notable deficiencies in comprehensive epidemiological study focusing on cardiovascular complications from alcohol, especially among young and middle-aged adults. We thus aimed to determine the burden of these conditions in young and middle-aged adults globally.

METHODS AND RESULTS

We used data from the Global Burden of Disease Study 2019 and analysed the mortality and disability-adjusted life years of alcohol-associated cardiovascular complications in young and middle-aged adults. The findings were classified by sex, region, country, and Sociodemographic Index (SDI). The highest age-standardized death rates (ASDR) were observed in stroke 0.84 (95% UI 0.60-1.09), followed by alcoholic cardiomyopathy 0.57 (95% UI 0.47-0.66) per 100,000 population. The overall burden of alcohol-associated cardiovascular complications decreased globally but increased in atrial fibrillation and hypertensive heart disease. Regionally, most regions underwent a decrease in ASDR, but an increase was observed in Southeast Asia (+2.82%), Western Pacific (+1.48%), low-middle (+1.81%), and middle SDI (+0.75%) countries. Nevertheless, the ASDR and ASDALYs were highest in Europe.

CONCLUSIONS

The impact of alcohol-associated atrial fibrillation and hypertensive heart disease has increased over the last decades. Regarding region, the burden in Europe and the rising burden in Asia, require immediate public health policy to lessen these cardiovascular complications from alcohol in young and middle-aged adults.

Changing landscape of alcohol-associated liver disease in younger individuals, women, and ethnic minorities

Alcohol use is the most important determinant of the development of alcohol-associated liver disease (ALD) and of predicting long-term outcomes in those with established liver disease. Worldwide, the amount, type, and pattern of use of alcohol vary. Alcohol use and consequent liver disease have been increasing in certain ethnic groups especially Hispanics and Native Americans, likely due to variations in genetics, cultural background, socio-economic status, and access to health care. Furthermore, the magnitude and burden of ALD have been increasing especially in the last few years among females and young adults who are at the prime of their productivity. It is critical to recognize the problem and care for these patients integrating cultural aspects in liver clinics. At the federal level, a societal approach is needed with the implementation of public health policies aiming to reduce alcohol consumption in the community. By addressing these challenges and promoting awareness, we can strive to reduce the burden of ALD, especially in high-risk demographic groups to improve their long-term health outcomes. Finally, we need studies and quality research examining these changing landscapes of demographics in ALD as a basis for developing therapeutic targets and interventions to reduce harmful drinking behaviours in these high-risk demographic groups.