Jennifer Flemming, MD, FRCPC: Why Are More Women Developing Alcohol-Associated Liver Disease?

The rate of new alcohol-associated liver disease cases in the US has become the equivalent of a public health crisis of late.

An analysis earlier this year showed alcohol-associated hepatitis cases increased exponentially among younger adults, persons in lower socioeconomic status, and most particularly, women since 2015. A myriad of societal, biologic and policy-related factors have come to influence this concerning that which clinicians are now observing on the front line.

In an interview with HCPLive during The Liver Meeting 2023 from the American Association for the Study of Liver Diseases (AASLD) in Boston this weekend, Jennifer Flemming, MD, FRCPC, associate professor of Medicine and Public Health Sciences at Queen's University, discussed the evolving epidemiology liver disease. Whereas the common liver disease patient 10 - 15 years ago was presenting with hepatitis C, advances to treatment such as the direct acting antiviral (DAA) class has contributed toward a greater rate of disease management or cured status.

“And there’s been a lot of changes in culture, alcohol policy so now alcohol-associated liver disease is starting to become the most common reason why patients are developing cirrhosis and complications from that,” Flemming said. “And what’s also been noted is that it’s disproportionately affecting younger age groups.”

Regarding the particularly significant upward trend of alcohol-associated liver disease cases in women, Flemming explained the issue is multifactorial.

“From a biologic standpoint, women are more susceptible to damage from alcohol than are men due to differences in the production of alcohol dehydrogenase in the body, as well as women’s body composition being different in that they have less body water,” Flemming explained. “So, if you ingest alcohol, the concentration of alcohol in the blood gets higher for women than it does for men.”

Additionally, because the liver is a sex hormone-responsive organ, males and females process alcohol differently and therefore suffer liver disease differently as well. What’s more, sociocultural shifts have results in a narrowed gap between men and women as to who consumes alcohol more frequently.

“And we know that women are at risk at baseline, from a biologic perspective, so it’s now just accelerating and we’ve been seeing it clinically for the last decade,” Flemming said. “There’s gender differences in how we use alcohol, biases to what we traditionally think of as an individual who has alcohol use disorder.”

Flemming explained there may even be issues at the screening and referral level; if the common stereotype of an alcohol use disorder patient is a middle-aged, Caucasian male, women will always be disproportionately under-screened by primary care or other health care providers.

“There’s also other gender considerations with women—especially young women,” Flemming added. “If they’re in their childbearing years, if they’re mothers, they may hide this. They may fear there’s implications if they disclose their drinking to a healthcare professional.”

References

1. ^{Kunzmann K. Relentless: The Concurrent Alcohol Abuse, Liver Disease Epidemics in the US. HCPLive. Published October 3, 2023. https://www.hcplive.com/view/concurrent-alcohol-abuse-liver-disease-epidemics-us.}
2. ^{Kunzmann K. Alcohol-Associated Hepatitis Rapidly Increasing in the US. HCPLive. Published July 18, 2023. https://www.hcplive.com/view/alcohol-associated-hepatitis-rapidly-increasing-us}