Global burden and projections of cardiometabolic diseases attributable to high alcohol use: a comparative risk assessment based on the GBD 2021 study

Background and aims Cardiometabolic diseases (CMDs), including cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM), remain major global health challenges. High alcohol use (HAU) is a modifiable risk factor. This study quantified the global, regional, and temporal trends in the burdens of CMDs attributable to HAU from 1990 to 2021 and projected trends to 2040. Methods and results Global Burden of Disease 2021 (GBD 2021) estimates for 204 countries and territories were analyzed to quantify HAU-attributable deaths, disability-adjusted life years (DALYs), and age-standardized mortality and DALY rates (ASMRs, ASDRs). HAU-attributable burdens were interpreted as model-based scenario estimates under the GBD 2021 comparative risk assessment framework, and not as individual-level causal effects. Associations with the Sociodemographic Index (SDI) were assessed. Trends in rates were summarized using estimated annual percentage change (EAPC) as a descriptive metric derived from log-linear regression on GBD age-standardized rate estimates, and projections were generated with a Bayesian age–period–cohort model. Although global HAU exposure declined, HAU-attributable deaths and DALYs from CVD and T2DM increased, with higher burdens among males and middle-aged adults. From 1990 to 2021, EAPCs based on age-standardized rates suggested modest declines in HAU-attributable CVD-related ASMR and ASDR (−1.53 and −1.31), whereas HAU-attributable T2DM ASMR and ASDR showed an overall increasing tendency (0.48 and 1.83), particularly in low- and middle-SDI regions. Eastern and Central Europe had the highest HAU-attributable CVD burden; Oceania and Central Latin America had the highest T2DM burden. By 2040, under a business-as-usual continuation of recent trends, scenario-based projections suggest that deaths attributable to HAU could rise substantially (on the order of 70% for CVD and nearly three-fold for T2DM), with widening sex disparities and greater quantitative uncertainty for CVD than for T2DM. Conclusion Despite declining alcohol exposure, the burden of CMDs attributable to HAU is escalating–especially for T2DM, males, and populations in low and middle SDI regions. Region-specific interventions and stronger alcohol-control policies are urgently needed.