Changing landscape of steatotic liver diseases and liver fibrosis in the United States during the COVID-19 pandemic

Background: Steatotic liver diseases (SLDs) and their subcategories - metabolic dysfunction-associated steatotic liver disease (MASLD), metabolic dysfunction and alcohol-associated liver disease (MetALD), and alcohol-associated liver disease (ALD) - significantly contribute to liver-related and extrahepatic morbidity and mortality. This project aimed to assess the landscape of SLDs and clinically significant fibrosis (CSF) before (2017-2020) and during (2021-2023) the COVID-19 pandemic. Methods: Using National Health and Nutrition Examination Survey (NHANES) data, we analyzed 8965 prepandemic and 6337 pandemic participants aged ≥18 years. The main evaluated outcomes were changes in age-adjusted mean CSF, mean controlled attenuation parameter score, and age-adjusted prevalence of MASLD, MetALD, and ALD before and during the pandemic. Results: The age-adjusted prevalence of SLDs changed significantly (p=0.003) between the prepandemic and pandemic periods. ALD prevalence rose from 0.94% to 2.27%, MetALD from 2.60% to 4.42%, while MASLD declined from 30.13% to 25.46%. Vigorous and moderate physical activity decreased significantly (p<0.001), whereas moderate/excessive alcohol intake increased (p<0.001). The prevalence of CSF increased from 8.3% to 10.5% (p=0.028). Multivariable analyses showed the COVID-19 pandemic (adjusted OR: 1.47, 95% CI: 1.00-2.17) and moderate/excessive alcohol intake (adjusted OR: 2.13, 95% CI: 1.15-3.95) were associated with CSF. In addition, older age, higher body mass index, larger waist circumference, prediabetes/diabetes, and lower income were each independently associated with CSF. Conclusions: Our study highlights a shift in SLDs in the United States during the COVID-19 pandemic, showing a decrease in MASLD and increases in MetALD and ALD, with an alarming increase in the prevalence of CSF, likely reflecting lifestyle changes, including physical inactivity and alcohol consumption.