Background

Alcohol use and metabolic disorders are common and modifiable risk factors encountered in primary care. However, how these exposures jointly influence liver fibrosis risk in the general population remains insufficiently characterized. This study aimed to evaluate the association between alcohol consumption and liver fibrosis burden and to assess the modifying effect of metabolic risk factors.

Methods

We analyzed data from 16,134 adults who underwent standardized health examinations at a national health screening center between 2020 and 2025. Individuals with viral hepatitis, cirrhosis, or hepatocellular carcinoma were excluded. Alcohol intake was assessed using validated questionnaires and categorized into non-, low-, moderate-, and high-risk groups using sex-specific thresholds. Metabolic risk factors included obesity, diabetes, hypertension, and dyslipidemia. Liver fibrosis burden was estimated using the fibrosis-4 (FIB-4) index derived from routine laboratory tests. Multivariable linear regression models were applied, and interaction analyses were performed according to the number of metabolic risk factors.

Results

Higher levels of alcohol consumption were associated with increased FIB-4 values in a dose-dependent manner. This association was particularly evident among individuals with three or more metabolic risk factors, in whom even moderate alcohol intake was linked to elevated fibrosis burden. In contrast, among metabolically healthy individuals, only high-risk alcohol consumption was associated with higher FIB-4 levels.

Conclusions

Alcohol consumption is associated with increased liver fibrosis burden, and this effect is substantially amplified by metabolic comorbidities. These findings suggest that alcohol thresholds considered acceptable for the general population may underestimate risk in metabolically vulnerable individuals. Incorporating metabolic risk profiles into alcohol counseling and liver disease prevention strategies may enhance risk stratification in primary care and public health settings.

Sae Kyung Joo has completed her PhD from Seoul National University, Republic of Korea. She is the associate professor of internal medicine department of Seoul National University, Republic of Korea. She has over 50 SCI publications. She has been serving as an editorial board member of Korean Society of Sex- and Gender-Specific Biomedical Science journal.