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Integrating Alcohol Use Into MASLD Care: A Practical Guide for Diabetes and Obesity Care Teams
Anastasia-Stefania Alexopoulos1,2, Kenneth Cusi3
1Division of Endocrinology, Metabolism and Nutrition, Department of Medicine, Duke University Medical Center, Durham, NC.
Diabetes Care
|April 20, 2026
Summary
Metabolic dysfunction-associated steatotic liver disease (MASLD) is common in diabetes and obesity. New guidelines recognize MetALD (metabolic dysfunction- and alcohol-associated liver disease), highlighting alcohol
Area of Science:
- Hepatology and metabolic disease research.
- Clinical investigation of liver disease progression and management.
Background:
- Metabolic dysfunction-associated steatotic liver disease (MASLD) impacts individuals with diabetes and obesity, frequently leading to liver transplantation.
- Emerging evidence highlights the combined negative effects of alcohol and metabolic disease on liver and overall health.
- The 2023 nomenclature revision introduced MetALD (metabolic dysfunction- and alcohol-associated liver disease) to account for alcohol's role alongside metabolic factors.
Purpose of the Study:
- To review the role of alcohol in liver injury, including direct hepatotoxicity and indirect contributions to metabolic derangements.
- To discuss how even light-to-moderate alcohol intake can accelerate MASLD progression and exacerbate cardiovascular risks.
- To provide guidance on integrating alcohol assessment and management into MASLD care pathways.
Main Methods:
- Review of current scientific literature on MASLD, alcohol-associated liver disease, and their intersection.
- Discussion of diagnostic tools for alcohol use, such as the AUDIT questionnaire and phosphatidylethanol testing.
- Analysis of current MASLD management strategies and their potential application to MetALD.
Main Results:
- Alcohol acts as a direct hepatotoxin and indirectly worsens insulin resistance, dyslipidemia, and obesity.
- MetALD is associated with higher mortality (all-cause, cancer-related, liver-related) compared to MASLD.
- Alcohol assessment is crucial for managing diabetes and obesity; diagnostic tools and their clinical use are discussed.
Conclusions:
- Accurate alcohol assessment is vital for managing patients with MASLD, especially those with diabetes and obesity.
- MetALD represents a distinct clinical entity with worse outcomes than MASLD, necessitating tailored management.
- Integrating alcohol use evaluation into MASLD care pathways is essential for comprehensive patient management.
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