Which population groups are at risk and why?
This section will focus on core epidemiological issues that take account of fixed risk factors (such as age, gender, ethnicity, family history) and modifiable risk factors (such as behaviour). The wider determinants of health (such as housing, transport and environment) are also considered.
Age
A study by the University of Bristol found that 1 in 5 people had signs of fatty liver by the age of 24 and 1 in 40 people had developing fibrosis (scarring) by age 24.
Liver disease is the leading cause of death among 35-49 year olds. This age group is particularly vulnerable due to cumulative lifestyle factors such as harmful drinking patterns and metabolic dysfunction6.
Gender
A study by the University of Bristol found that men were more likely to have liver disease than women6.
Men have higher overall risk for developing ARLD and MASLD, faster progression of liver fibrosis and cirrhosis in many liver conditions, and greater susceptibility to liver cancer and severe outcomes from viral hepatitis. Men are more likely to engage in high-risk drinking and have metabolic syndrome earlier.
Women have higher prevalence of autoimmune liver diseases7 and risk increases post-menopause due to hormones8.
Socioeconomic status
Using primary care data (2009-2020) a population-based study found ARLD was more prevalent and more deadly in the most deprived quintiles of IMD9.
Lower socioeconomic status not only increases exposure to risk factors but also amplifies their harmful effects, such as experiencing worse health outcomes from the same level of alcohol consumption compared to those with higher SES10.
The Lancet Commission on Liver Disease in the UK highlights that liver disease is rising fastest among those affected by poverty, unemployment and poor housing. This is due to factors such as excess alcohol consumption, poor diet leading to obesity and limited access to healthcare and early diagnosis11.
Substance Misuse
Individuals with alcohol dependence or misuse are at high risk of alcohol-related liver disease12.
Alcohol-related liver disease is one of the leading causes of liver-related deaths in the UK and alcohol misuse is the primary driver13.
Psychosocial factors are major contributors to continued alcohol misuse and poor liver outcomes. A review from University of Plymouth found many patients with ArLD continue to misuse alcohol after diagnosis and often do not engage with treatment services14.
Drug misuse is directly linked to liver damage and the overuse of over the counter medication such as painkillers and NSAIDs may also cause drug-induced hepatitis15.
Ethnicity
A University of Manchester study found that White British ethnicity was strongly associated with higher rates of “Death of Despair” which includes deaths from alcohol-related liver disease. Northern local authorities with higher proportions of White British residents had significantly elevated mortality rates from alcohol, drugs and suicide – conditions closely linked to liver disease16.
Research from Newcastle University and Health Equity North highlights ethnic minority groups in deprived Northern areas are more likely to experience multiple long-term conditions, including liver disease, earlier and more severely than their counterparts in more affluent areas17.
Sexual Orientation
LGBTQ+ individuals are at higher risk of liver disease:
- Bisexual individuals – higher rates of substance misuse, a major risk factor18.
- Gay and lesbian individuals – showed poorer health outcomes compared to heterosexual individuals particularly in terms of mental distress and illness which can correlate with alcohol misuse and delayed healthcare engagement18.
Research by NIHR ARC North East and North Cumbria found that LGBTQ+ individuals who also experienced homelessness, substance misuse, or involvement with the criminal justice system faced severe and multiple disadvantage which significantly increased risk of liver disease19.
Criminal Justice System Involvement
An alcohol-related liver disease multi-stakeholder hub (ARMS-Hub) identified people in contact with the criminal justice system are part of underserved communities with high rates of ArLD12.
University of Manchester and Health Equity North’s research found the North East of England has the highest rates of “Deaths of Despair” (encompassing alcohol, drugs and suicide) which are strongly associated with criminal justice involvement16.