Healthy eating and physical activity significantly lower sex-specific alcohol-attributable liver mortality in the United States

Abstract

Background & aims: The impact of diet quality (DQ) and physical activity (PA) on alcohol-related liver mortality is under-researched. This study investigates how DQ and PA influence alcohol-attributable liver mortality in the US.

Method: Data from 60,334 adults in the National Health and Nutrition Examination Surveys (1984-2018) were analyzed and linked to the National Death Index through December 31, 2019. Self-reported alcohol use, DQ (healthy eating index [HEI]), and PA levels were obtained. Participants were classified as light, moderate, or heavy drinkers based on NIAAA guidelines. Physically active participants reported at least 150 min of moderate-intensity PA, 75 min of vigorous-intensity PA, or a combination per week. A healthier diet was defined as being in the top quartile of HEI. The outcome was liver-related mortality.

Results: During a 12.2-year follow-up, 252 liver-specific deaths were recorded. The average daily alcohol intake increased liver-specific mortality risk (adjusted subdistribution hazard ratio [aSHR]-men: 1.04, 95% CI 1.01-1.06; women: 1.08, 95% CI 1.04-1.12) compared to abstainers. Binge drinking also raised liver mortality risk (aSHR-men: 1.52, 95% CI 1.04-2.29; women: 2.52, 95% CI 1.44-4.41) compared to non-binge drinking. Healthier dietary intake (top quartile of HEI) reduced liver mortality risk among non-heavy (aSHR: 0.35, 95% CI 0.13-0.90), heavy (aSHR: 0.14, 95% CI 0.04-0.82), and binge (aSHR: 0.16, 95% CI 0.06-0.46) drinkers compared to unhealthier diets (lower quartile of HEI). Physically active participants had lower liver mortality risk among non-heavy (aSHR: 0.52, 95% CI 0.28-0.94), heavy (aSHR: 0.64, 95% CI 0.35-0.99), and binge (aSHR: 0.31, 95% CI 0.10-0.88) drinkers. Diets high in vegetables, fruits, whole grains, seafood, plant-based proteins, and unsaturated fats - and low in solid fats, alcohol, and added sugars - were protective. The survival benefits of DQ and PA were substantially greater in women than in men.

Conclusion: Healthy eating and increased levels of PA significantly lower the risk of alcohol-attributable liver-related mortality in the US population.

Impact and implications: This study found that any amount of alcohol intake and binge drinking were associated with an increased risk of liver-related mortality. Adherence to healthy dietary patterns and increased physical activity lower the risk of liver mortality across all drinking patterns, including heavy and binge drinking. Liver survival benefits from both physical activity and diet quality are greater in women than men. A diet rich in vegetables, fruits, grains, seafood, plant-based proteins, and unsaturated fatty acids, combined with a reduced intake of empty calories from solid fats, alcohol, and added sugars, is associated with a lower risk of liver-related mortality. Economically disadvantaged populations are exposed to high-risk alcohol use, unhealthy diet, and physical inactivity, and therefore increased liver mortality.

Keywords: Alcohol consumption; Binge drinking; Dietary patterns; Liver mortality; Physical activity.