Dear Editor,
I sincerely appreciate the insightful response by Dr. Danpanichkul and colleagues to my editorial on the rising burden of alcohol-associated liver disease (ALD) and alcohol-attributable cancers [
1,
2]. Their correspondence astutely expands upon the multifactorial drivers of ALD, particularly during the COVID-19 pandemic, and reinforces the importance of a coordinated response across clinical, community, and policy levels [
3].
The COVID-19 pandemic led to the redirection of healthcare resources and public attention toward the immediate crisis, inadvertently deprioritizing chronic disease management. As noted by the authors, this disruption likely contributed to the observed spike in ALD-related mortality during the pandemic. In addition, restrictions on outdoor and social activities, coupled with prolonged confinement, may have fostered behavioral and metabolic changes—including reduced physical activity and unhealthy dietary habits—that are known to aggravate risk factors such as obesity, insulin resistance, and dyslipidemia. These changes likely accelerated liver disease progression, particularly among individuals with underlying steatosis or metabolic dysfunction.
In parallel, survey data from the United States indicated a 29% increase in average daily alcohol consumption following the implementation of stay-at-home orders in early 2020, along with a 21% rise in binge drinking and a 20% increase in the proportion of individuals exceeding recommended drinking limits [
4]. These behavioral shifts were further compounded by heightened psychosocial distress, social isolation, and economic instability—conditions known to exacerbate alcohol use disorder (AUD) and psychiatric comorbidities [
4,
5]. Stress-induced alcohol misuse and relapse have also been mechanistically linked to neurobiological alterations, underscoring the need for proactive strategies to protect at-risk individuals [
5].
Unlike smoking or illicit drug use, alcohol often benefits from greater cultural and social permissiveness across societies. This differential perception likely undermines the urgency of policy responses. As the correspondence highlights, policy effectiveness varies widely across countries depending on cultural norms, regulatory environments, and political will. Therefore, global and national strategies should not only emphasize alcohol’s carcinogenic and hepatotoxic risks but also actively challenge permissive societal attitudes.
I also support the authors’ call for sex- and age-specific strategies. The rising ALD burden among younger women is particularly alarming, given the biological vulnerability of females to alcohol-induced hepatotoxicity and their lower likelihood of accessing treatment for AUD [
6,
7]. Simultaneously, younger populations may exhibit distinct drinking patterns and risk profiles compared to older adults, further underscoring the need for targeted interventions.
Additionally, the evolving spectrum of metabolic dysfunction– associated steatotic liver disease necessitates a nuanced understanding of ALD pathophysiology. The emerging phenotype of metabolic-alcoholic liver disease straddles both metabolic and alcohol-related etiologies and may differ in clinical course, societal determinants, and treatment responses [
8]. Given that alcohol’s impact is modified by preexisting conditions such as hepatic steatosis, chronic hepatitis B or C infection, and fibrosis stage, it is essential that clinicians and policymakers adopt a precision approach— one that accounts for both the metabolic and viral backgrounds of affected individuals [
9].
In light of these challenges, public education is ultimately vital to correcting the underappreciation of alcohol’s harms. A nationwide effort to raise awareness that alcohol is a modifiable carcinogen—with risks contingent on sex, age, and underlying liver health—can foster broader support for policy change and screening programs. I strongly agree with Danpanichkul et al. that an integrated strategy involving healthcare professionals, patient navigators, community advocates, and public health agencies is essential to combat the growing burden of ALD and alcohol-attributable cancers. This strategic emphasis on systemic, cross-sectoral coordination aligns with recent global consensus recommendations, which advocate for a multidisciplinary and harmonized approach to fatty liver disease prevention, diagnosis, and management across clinical, societal, and policy levels [
10]. Future efforts should aim to institutionalize these multidimensional responses and incorporate risk stratification based on sex, age, and comorbidities.
FOOTNOTES
-
Conflicts of Interest
The author has no conflicts to disclose.
Abbreviations
alcohol-associated liver disease
REFERENCES
- 1. Kim SE. Rising burden of alcohol-associated liver disease and cancers: Insights into sex disparities and policy implications: Editorial on “Sex disparities in alcohol-associated liver disease and subtype differences in alcohol-attributable cancers in the United States”. Clin Mol Hepatol 2026;32:439-442.
- 2. Danpanichkul P, Pang Y, Mahendru T, Tothanarungroj P, Díaz LA, Arab JP, et al. Sex disparities in alcohol-associated liver disease and subtype differences in alcohol-attributable cancers in the United States. Clin Mol Hepatol 2025;31:1058-1070.
- 3. Danpanichkul P, Kim D, Wijarnpreecha K, Singal AG, Yang JD. Advancing policy and practice in alcohol-associated liver disease and alcohol-attributable cancer: Correspondence to the editorial on “Sex disparities in alcohol-associated liver disease and subtype differences in alcohol-attributable cancers in the United States”. Clin Mol Hepatol 2026;32:e96-e98.
- 4. Barbosa C, Cowell AJ, Dowd WN. Alcohol consumption in response to the COVID-19 pandemic in the United States. J Addict Med 2021;15:341-344.
- 5. Clay JM, Parker MO. Alcohol use and misuse during the COVID-19 pandemic: a potential public health crisis? Lancet Public Health 2020;5:e259.
- 6. White AM. Gender differences in the epidemiology of alcohol use and related harms in the United States. Alcohol Res 2020;40:01.
- 7. Mellinger JL, Fernandez A, Shedden K, Winder GS, Fontana RJ, Volk ML, et al. Gender disparities in alcohol use disorder treatment among privately insured patients with alcohol-associated cirrhosis. Alcohol Clin Exp Res 2019;43:334-341.
- 8. Kalligeros M, Vassilopoulos A, Vassilopoulos S, Victor DW, Mylonakis E, Noureddin M. Prevalence of steatotic liver disease (MASLD, MetALD, and ALD) in the United States: NHANES 2017-2020. Clin Gastroenterol Hepatol 2024;22:1330-1332.e4.
- 9. Xu HQ, Wang CG, Zhou Q, Gao YH. Effects of alcohol consumption on viral hepatitis B and C. World J Clin Cases 2021;9:10052-10063.
- 10. Lazarus JV, Mark HE, Allen AM, Arab JP, Carrieri P, Noureddin M, et al. A global action agenda for turning the tide on fatty liver disease. Hepatology 2024;79:502-523.
Citations
Citations to this article as recorded by
