Reply
Authors: James M. Paik, Linda Henry, Zobair M. Younossi
Journal: Hepatology (2022)

We are grateful for Dr. Testino's thoughtful comments about our study.[1] We agree the under‐reporting of alcohol is an important issue when identifying and managing NAFLD. As Dr. Testino mentioned, the presence of alcohol, in even moderate amounts for those with NAFLD, can be detrimental and hasten the disease process. The USA, like Italy, is facing a rapid increase in alcohol‐associated liver disease among the younger population. Simultaneously, the rate of NAFLD among the young is also increasing because of rising rates of obesity and type 2 diabetes mellitus.[1,2] These two top causes of chronic liver disease can be responsible for an unprecedented number of younger adults developing liver disease in the near future. In this context, assessment for predisposing risk for NAFLD and development of an easy‐to‐administer, validated tool to accurately assess significant alcohol consumption are of utmost importance. However, recognizing that alcohol consumption is under‐reported, the Global Burden of Disease (GBD) accounts for this in their methodology. The GBD uses systematic literature reviews with the Global Health Data Exchange and PubMed to obtain population survey data related to the current drinking prevalence and alcohol consumed in grams per day within a specific location, year, age group, and sex. To estimate population consumption in liters per capita, the GBD obtains sales data from FAOSTAT and the World Health Organization Global Information System on Alcohol and Health database, the number of tourists, their duration of stay, and estimates of unrecorded alcohol stock from the published articles and then uses a spatiotemporal Gaussian process regression with adjustments to account for tourist consumption and unrecorded consumptions (http://ghdx.healthdata.org/gbd‐2019/data‐input‐sources).[3] Then, for a given location and year, the GBD rescales age‐ and sex‐specific estimates of individual‐level consumption so that they aggregate to estimates of population‐level consumption. A full explanation of this approach is available.[4] Despite these lengthy steps, the GBD investigators acknowledge that alcohol consumption assessment is suboptimal and under‐reported. Again, we appreciate Dr. Testino's comments, which bring attention and awareness to this very important topic, especially in the context of NAFLD. CONFLICT OF INTEREST Dr. Younossi consults for Bristol Myers Squibb, Norvartis, Gilead, Viking, Madrigal and Intercept. AUTHOR CONTRIBUTIONS Zobair M. Younossi: made substantial contributions to the conception and design of the study, was vital in the acquisition of the data as well as data interpretation, drafting and critically editing the manuscript for important intellectual content and provided his final approval of the manuscript to be published. James M. Paik: made substantial contributions to the conception and design of the study, was vital in the acquisition of the data, in the data analysis as well as data interpretation, drafting and critically editing the manuscript for important intellectual content and provided his final approval of the manuscript to be published. Linda Henry: drafted and critically edited the manuscript for important intellectual content and provided her final approval for the manuscript to be published.