Up to one in 10 people may have a newly recognised liver condition called MetALD, a form of damage caused by the combination of moderate alcohol consumption and being overweight or having other metabolic problems.
The condition was officially named only three years ago by liver specialists from medical societies around the world, and public awareness remains low – even among some doctors. MetALD stands for metabolic dysfunction and alcohol-related liver disease. It is usually seen in people who are overweight and who drink more than 17.5 units of alcohol per week for women, or 26 units per week for men. For context, NHS guidelines advise that men and women should not regularly exceed 14 units a week – roughly six pints of beer or ten small glasses of lower-strength wine – ideally spread over three or more days with drink-free days.
Dr Naina Shah, a liver specialist at King’s College London, said: “Even a moderate amount of alcohol can lead to liver scarring if combined with being overweight or other metabolic problems. Most people don’t realise how easy it is to damage your liver.”
The double hit: how weight and alcohol combine to damage the liver
Fat is central to the way alcohol harms the liver. When the liver breaks down alcohol, its normal function is disrupted and it begins to produce and store fat. A fatty liver is one of the earliest signs of trouble. If drinking continues, the liver develops mild scarring known as fibrosis, and eventually cirrhosis – permanent scarring that can lead to liver failure and liver cancer.
Critically, people can also develop a fatty liver and progress to cirrhosis without drinking heavily – if they are overweight or have other metabolic risk factors such as high blood pressure, high cholesterol or type 2 diabetes. Professor Neil Guha, a hepatologist at Nottingham University Hospitals, explained that MetALD represents a “double hit”: fat build-up from diet combines with fat build-up from alcohol to accelerate the progression of cirrhosis. “If you do a liver biopsy, you can’t tell the difference between someone who’s got purely alcohol-related liver disease and purely metabolic-related liver disease,” he said.
Dr Shah described MetALD as “liver damage caused by a double hit”. She recently diagnosed the condition in a man who had developed jaundice – a yellowing of the skin often linked to liver problems. He had been investigated for a different illness because his alcohol intake did not appear typical of someone with a drinking problem: two to three glasses of wine after work, five days a week, totalling about 27 units. However, he was just into the obese category on the BMI scale. “That was a shock to him,” Dr Shah said. “He professed that he had never drunk heavily in his life. But his weight was a bit of an issue. We know that these two risk factors stack up together.”
It is not yet fully understood why high blood pressure or type 2 diabetes independently increase the risk, but both conditions are now seen as part of a broader syndrome of poor metabolic health that often accompanies obesity. The age profile of people with liver damage is also changing. Dr Shah said she sees patients as young as their early twenties, who must have started drinking in their teens to develop chronic liver disease that young.
Alcohol consumption in the UK has been slowly declining over the past two decades, but obesity is on the rise. That may explain why liver disease numbers are still climbing. “The risk factors make each other worse,” Professor Guha said. Doctors from medical bodies across Europe recently published a strategy for liver disease prevention and treatment in The Lancet, identifying both alcohol and unhealthy diets as twin drivers of liver deaths, and calling for stricter regulation of the alcohol and food industries. Separately, non-alcoholic steatohepatitis (NASH) – a severe liver condition linked to obesity, diabetes and high cholesterol – is a growing cause of cirrhosis in the UK and is expected to surpass alcohol and hepatitis C as the leading cause. Cirrhosis can lead to jaundice, fluid build-up in the abdomen (ascites), confusion and memory problems (hepatic encephalopathy), liver failure, and liver cancer.
How to reverse the damage
In most cases, the scarring associated with MetALD can be reversed. “A proportion of people can get rid of scarring following complete abstinence,” Dr Shah said. Stopping alcohol consumption and achieving weight loss are the key steps. Weight-loss injections such as Mounjaro and Wegovy may also help people reduce their alcohol intake. For those worried they may have MetALD, a blood test from their GP is the first step. If results are concerning, a liver scan at hospital can follow.
Dr Shah stressed that public understanding of the condition is still poor. “I do not think public awareness of MetALD is high in the UK. It is a relatively new medical term, and many people still do not realise that liver disease can be caused by a combination of alcohol and poor metabolic health, not just by very heavy drinking alone.”