Why Some Drinkers Suffer Devastating Liver Damage While Others Don’t

A study from Keck Medicine of USC found that heavy drinkers with diabetes, high blood pressure, or a large waistline are up to 2.4 times more likely to develop advanced liver disease. These conditions may amplify alcohol's toxic effects on the liver, leading to severe damage.

Not everyone who drinks the same amount of alcohol faces the same risk of liver disease. A new study published on February 3 in Clinical Gastroenterology and Hepatology by Keck Medicine of USC suggests that three common health conditions — diabetes, high blood pressure, and a high waist circumference — could be key factors. Researchers found that heavy drinkers with any of these conditions are up to 2.4 times more likely to develop advanced liver disease.

"The results identify a very high-risk segment of the population prone to liver disease and suggest that preexisting health issues may have a large impact on how alcohol affects the liver," said Brian P. Lee, MD, MAS, a hepatologist and liver transplant specialist with Keck Medicine and principal investigator of the study.

The Link Between Cardiometabolic Health and the Liver

Diabetes, high blood pressure, and a high waist circumference (defined as over 35 inches for women and 40 inches for men) are part of a group of five cardiometabolic risk factors. These conditions, commonly linked to obesity, also increase the risk of heart attacks and strokes.

Cardiometabolic risk factors have been linked to the buildup of fat in the liver (also known as metabolic dysfunction-associated steatotic liver disease), which can lead to fibrosis, or scarring of the liver. These risk factors affect more than one in three Americans, and cardiometabolic health has been worsening among the population, especially among those under 35, according to Lee.

Rising Alcohol Consumption and Its Consequences

Alcohol also causes fat buildup in the liver, and alcohol consumption has been on the rise since the COVID-19 pandemic, said Lee. Due to the prevalence of both cardiometabolic risk factors and drinking in the United States, Lee and his fellow researchers undertook the study to investigate which cardiometabolic risk factors predisposed the liver to damage from alcohol.

They analyzed data from the National Health and Nutrition Examination Survey, a large national survey of more than 40,000 participants, looking at the intersection of heavy drinking, individual cardiometabolic risk factors and the incidences of significant liver fibrosis. Significant liver fibrosis refers to liver scarring that can lead to liver failure.

For the study, heavy drinking was characterized as 1.5 drinks a day for women (20 grams) and two drinks a day for men (30 grams).

Who Is at the Highest Risk?

Researchers discovered that heavy drinkers with either diabetes or a high waist circumference were 2.4 times more likely to develop advanced liver disease and those with high blood pressure 1.8 times more likely. They found that the other two cardiometabolic risk factors — high triglycerides (elevated levels of a type of fat in the blood) and low HDL (high-density lipoprotein or "good" cholesterol) had less significant correlations to liver disease.

Why Are These Risk Factors So Dangerous?

While the study did not analyze why these three cardiometabolic risk factors are more dangerous for the liver, Lee speculates that these conditions share a common pathway to fat buildup in the liver that when combined with extra fat deposits in the liver from excessive alcohol, can cause significant damage.

Lee emphasizes that the study does not imply it is safe for those without these three cardiometabolic risks to consume large amounts of alcohol. "We know that alcohol is toxic to the liver and all heavy drinkers are at risk for advanced liver disease," he said.

Lee hopes that the study results will encourage people to consider their individual health and risk profile when making decisions about alcohol consumption. He would also like to see practitioners offer more personalized health screenings and interventions for those who drink with cardiometabolic risk factors so that liver damage among this high-risk group can be caught early and treated.

Reference: "Association of Alcohol and Incremental Cardiometabolic Risk Factors with Liver Disease: A National Cross-Sectional Study" by Brian P. Lee, MD, MAS, Justene Molina, MPH, Steve Kim, MPH, Jennifer L. Dodge, MPH and Norah A. Terrault, MD, MPH, 3 February 2025, Clinical Gastroenterology and Hepatology.
DOI: 10.1016/j.cgh.2025.01.003