Gender- and age-specific trends in alcohol-associated liver disease in South Korea: a nationwide study before and after COVID-19

Alcohol-associated liver disease (ALD) represents an important public health burden; however, population-level evidence on long-term trends and demographic inequalities remains limited. This study examined nationwide age- and sex-specific trends in ALD prevalence in South Korea and assessed temporal changes associated with the COVID-19 pandemic. Using nationwide health insurance claims data from the Korean Health Insurance Review and Assessment Service (HIRA), we analyzed physician-diagnosed alcohol-associated fatty liver (AFL) and alcohol-associated steatohepatitis (ASH) between 2010 and 2022, covering the entire Korean population. Annual prevalence rates were age-standardized using the national census population as the standard population. Temporal trends were evaluated using regression models, including segmented regression, to assess changes associated with the COVID-19 pandemic. Over the 13-year study period, the average annual prevalence of AFL and ASH was 2.5 and 1.8 per 1,000 persons, respectively. Prevalence was consistently higher among males, with AFL and ASH rates 3.6-fold and 4.2-fold greater than those among females, and peaked among individuals aged 60–69 years in both sexes. Long-term trends diverged by sex, with declining prevalence among males (AFL, -0.08; ASH, -0.06 per 1,000 persons annually) and increasing prevalence among females (AFL, + 0.01; ASH, + 0.03 per 1,000 persons annually). These sex-related disparities were further amplified during the COVID-19 pandemic, with an overall acceleration of decline in male AFL prevalence and statistically significant changes in female ASH prevalence, most notably among individuals aged ≥ 60 years. These findings highlight substantial and evolving sex- and age-related inequalities in the population burden of ALD. Strengthened public health surveillance and targeted prevention strategies are needed, with particular attention to vulnerable subgroups such as older women, while accounting for behavioral and healthcare access changes during and after the COVID-19 pandemic.