Burden and trends of alcohol- and NAFLD/NASH-related liver disease in 5 East Asian countries: A GBD 2021 analysis

This study quantified and compared the 2006 to 2021 burden (incidence, mortality, and disability-adjusted life years [DALYs]) of alcohol- and nonalcoholic fatty liver disease (NAFLD)/nonalcoholic steatohepatitis (NASH)-related cirrhosis and hepatocellular carcinoma (HCC) across China, Japan, South Korea, North Korea (Democratic People's Republic of Korea [DPRK]), and Mongolia to inform targeted prevention and policy priorities. Utilizing Global Burden of Disease (GBD) 2021 data, we analyzed the epidemiology of alcohol-related liver disease and NAFLD/NASH leading to cirrhosis and HCC. Using data from the GBD 2021 study, we calculated age-standardized incidence rates, age-standardized mortality rates, and age-standardized DALY rates, and assessed temporal trends using estimated annual percentage changes and segmented regression analysis. In 2021, China recorded the highest absolute all-age incidence, mortality, and DALYs for alcoholic cirrhosis, NASH-related HCC, and NAFLD-related cirrhosis. However, in terms of age-standardized incidence rates, age-standardized mortality rates, and age-standardized DALY rates, Mongolia bears the heaviest overall disease burden. Conversely, the lowest age-standardized burdens varied: alcohol-related HCC was lowest in DPRK, alcoholic cirrhosis in China, NASH-related HCC in Japan, and NAFLD in South Korea and Japan. From 2006 to 2021, alcohol-related HCC metrics declined in Japan, South Korea, and DPRK but rose modestly in China and Mongolia. Alcoholic cirrhosis declined in all 5 countries, most notably in Japan, South Korea, and Mongolia. NASH-related HCC generally decreased in Japan, South Korea, and DPRK, while increasing slowly in China and remaining stable in Mongolia. Notably, while NAFLD prevalence and incidence rose across all 5 nations, associated DALYs declined, suggesting improved clinical management despite intensifying upstream metabolic risks. East Asian countries exhibit a heterogeneous yet convergent transition where alcohol- and metabolism-related liver diseases are displacing viral etiologies. While alcoholic cirrhosis incidence is declining regionally, the rising burden of alcohol-related HCC in China and Mongolia, alongside increasing NAFLD/NASH incidence, necessitates a policy shift. Priorities should include comprehensive alcohol control, metabolic risk reduction, and targeted fibrosis/HCC screening in high-risk populations. Although GBD data are subject to inherent biases, they provide actionable guidance for regional health strategies.