Drinking in Moderation With Fatty Liver: How Risky Is It?

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Should you drink alcohol if you’re at risk for non-alcoholic fatty liver disease? What about if you’ve already been diagnosed? Alcohol is clearly contraindicated for alcoholic liver disease—but how are the conditions related?

If you’re not careful with the current and emerging data, you might be fooled into a false sense of security about the impact of drinking on liver health. Read on for an explanation of what we know about drinking in moderation with fatty liver—and the questions that remain.

Types of Fatty Liver Disease

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Photo by Anshu A on Unsplash

Non-alcoholic fatty liver disease (NAFLD) and alcoholic liver disease (ALD) are two very similar but distinct liver diseases. As their names imply, one is directly related to heavy alcohol consumption, while the other has not shown this same relationship.

NAFLD can affect anyone, regardless of how much they drink. NAFLD is very common, now affecting 20 to 30 percent of adults worldwide, and five to 10 percent of children. It’s also keeping pace with the rise of obesity. In fact, while heavy drinking causes ALD, overnutrition is the primary driving force behind NAFLD.

NAFLD on its own doesn’t typically cause symptoms or complications. But for a minority, NAFLD can progress to NASH, or non-alcoholic steatohepatitis. This means the liver has also become inflamed. While NASH isn’t always progressive, for a percentage of people NASH can lead to liver fibrosis and eventually cirrhosis, which can often require a liver transplant.

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What Do NAFLD, NASH, and ALD Have In Common?

NAFLD/NASH and ALD are very similar. Both feature a fatty liver, and both can lead to inflammation and liver damage, including fibrosis and cirrhosis. They have similar pathologies, histologies (what they look like under the microscope), and share a number of common risk factors and comorbidities, such as:

  • Metabolic syndrome
  • Type 2 diabetes
  • Insulin resistance
  • Cardiovascular disease
  • Certain types of cancer

The two are so similar, we really only know that they’re separate conditions after studying many, many cases of each. They overlap considerably, and it’s almost impossible to tell whether any particular case is ALD or NAFLD in the doctor’s office.

In fact, self-reported drinking status is the primary differentiator between NAFLD or NASH vs. ALD. As noted by one study, there needs to be “convincing evidence of minimal or no alcohol consumption” to diagnose NAFLD or NASH.

Can You Drink Moderately With Fatty Liver?

Considering heavy drinking clearly can lead to ALD, which looks strikingly similar to NAFLD, can we be sure that moderate drinking doesn’t have negative impacts on NAFLD/NASH? Are there risks to drinking in moderation with fatty liver?

Moderate Drinking and Your Health

When it comes to overall health, some of the research on alcohol can be a bit confusing. Multitudes of studies have proclaimed the cardiovascular and other health benefits of light to moderate drinking.

For some conditions, alcohol shows a “J-shaped” curve association: light/moderate drinkers show the lowest risk for disease, and the risk increases linearly with heavy drinking. But the left side of the J shows that those who don’t drink at all have elevated risks compared with moderate drinkers.

Research on Alcohol and NAFLD/NASH Is Conflicting

Some studies have shown the same protective effect of modest alcohol consumption when it comes to NAFLD or NASH. However, as the authors of one such study commented, speculation on the role of moderate drinking in the prevention or treatment of NASH is “tempting but premature.”

For example, one analysis initially showed lower rates of both NAFLD and NASH for moderate drinkers compared to non-drinkers. It even suggested that moderate alcohol use offered a 31 percent protective effect against NAFLD. However, the same data later turned up different conclusions when adjusted for body mass index and other factors.

Another large study of over 57,000 Korean adults found that moderate drinking had the opposite effect—increasing the risk of disease progression in NAFLD by a small but significant amount. But once again, a cross-sectional study of the same cohort saw results that conflicted with the first study.

At this point the available data on alcohol and non-alcoholic liver disease is confusing at best. Only one thing is clear about drinking in moderation with fatty liver—we need a lot more data!

Why Our Understanding of the Available Data Is Limited

group of friends raising glasses over a meal
Photo by Fábio Alves on Unsplash

Much of the confusion about how alcohol affects liver health relates to the way we study things in science. No one study can tell us everything—different study designs tell us different things about the questions we’re interested in.

Much of the data on the supposed health benefits of moderate drinking, for example, come from large observational studies with tens of thousands if not millions of data points. That’s good, but it still only gives us a big-picture, generalized view.

Such studies also necessarily obscure the details—a general trend may tell you almost nothing about your own individual risk.

Not only do many of these studies show the blurred, 10,000-foot view, but they are also mostly cross-sectional—a snapshot in time. These types of studies can show a general relationship, but cannot prove causation. For that, we need longitudinal data that tracks actual results over time, which we don’t have enough of.

The Relationship Between Moderate Drinking and Health Is Complex

Data on the benefits of moderate drinking may not be as generalizable as once thought; there are many gaps in our knowledge that cast doubt on the rosy glow around moderate alcohol use.

For one thing, research does not stick to one standard definition of what “moderate” alcohol consumption is. Quantities used in such studies range from half a drink per day to three drinks per day. Many studies also rely primarily on self-reported drinking quantities. Many people are likely to over or under report how much they consume.

Even if we knew precisely how alcohol affected NAFLD/NASH, there is never just one risk factor to consider when it comes to health decisions. A substance might have benefits for some aspects of our health, while hurting us in other ways.

For example, even if alcohol did offer modest benefits in some situations, it has well-known harmful effects on other conditions—including breast cancer and stroke.

Drinking in Moderation With Fatty Liver: The Takeaway

So, in conclusion, can you drink with fatty liver?

Right now, we still have a blurry view of how alcohol affects non-alcoholic liver disease. It’s possible that, for some people, light to moderate alcohol use really does have a protective effect. But depending on age, gender, ethnicity, and alcohol’s effect on other health conditions, the pros and cons of drinking can vary dramatically.

The reality is that drinking in moderation with fatty liver can have different impacts from person to person. Only you and your doctor can evaluate and calculate your own individual risk and decide what’s right for you.

Otherwise, until we have more data, experts recommend caution when it comes to alcohol use, even with non-alcoholic liver disease.

If you’ve been diagnosed with NAFLD or NASH, it’s likely you’ve spoken with your doctor about alcohol, and they’ve concluded that drinking isn’t the cause of your illness. But if you still drink regularly, and aren’t having an easy time cutting back, there is non-judgemental, online help out there. You don’t need to be an alcoholic or have alcoholic liver disease to seek some support.

Whether you want to control binge drinking on the weekends, or just reset your habits, learn more about Ria Health’s flexible approach to drinking less, 100 percent online.

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Written By:
Stacey Neglia
Stacey Neglia is a writer and blogger specializing in mental health and the science of the brain.
Reviewed By:
Evan O'Donnell
Evan O’Donnell is an NYC-based content strategist with four years’ experience writing and editing in the recovery space. He has conducted research in sound, cognition, and community building, has a background in independent music marketing, and continues to work as a composer. Evan is a deep believer in fact-based, empathic communication—within business, arts, academia, or any space where words drive action or change lives.
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