# The impact of the COVID-19 pandemic on liver health: exploring shifts in social and psychosocial determinants of steatosis and fibrosis

## TL;DR

The study found that the pandemic changed how social and lifestyle factors affect liver disease, with significant differences between men and women.

## Contribution

This study reveals pandemic-specific shifts in risk factors for liver disease, highlighting sex-specific changes in psychosocial and behavioral associations.

## Key findings

- Advanced liver fibrosis nearly doubled during the pandemic, especially in women.
- Depressive symptoms increased ALD risk in men during the pandemic but had less impact on MetALD in women.
- Smoking and sleep patterns showed altered associations with liver disease during the pandemic.

## Abstract

The COVID-19 pandemic profoundly disrupted social structures, psychological well-being, and lifestyle behaviors, yet the collective impact on steatotic liver disease (SLD) and fibrosis remains unclear. This study aimed to examine whether the relationships of social, psychosocial, and behavioral factors with metabolic dysfunction–associated SLD (MASLD), metabolic alcohol-related liver disease (MetALD), ALD, and liver fibrosis varied across pandemic periods.

We conducted a repeated cross-sectional analysis of 6,090 adults from the National Health and Nutrition Examination Survey (NHANES) 2017–March 2020 (pre-pandemic) and 2021–2023 (pandemic), using vibration-controlled transient elastography and comprehensive social, psychosocial, and lifestyle measures. Weighted prevalence and Firth’s logistic regression assessed associations and pandemic interactions via ratios of odds ratios (RORs).

Age-standardized MASLD prevalence declined from 32.2% to 28.6%, especially among men, whereas advanced fibrosis nearly doubled from 2.6% to 4.2%, mainly in women. Pandemic-period interactions revealed substantial shifts in risk profiles. Higher income lost its pre-pandemic protective association with MetALD (ROR = 0.21), while unemployment increased MetALD risk in women. Depressive symptoms strengthened ALD risk in men during the pandemic (OR = 5.31; ROR = 6.73), but became less relevant for MetALD, particularly among women. Physical activity, which was previously protective for MASLD and ALD, lost significance post-pandemic. Current smoking markedly amplified ALD risk (OR rising from 3.49 to 17.08), whereas former smoking provided protection against MASLD in men. Dietary inflammation (DII) became inversely associated with fibrosis during the pandemic, and longer weekend sleep offered protective benefits for women.

The pandemic period was associated with substantial changes in the epidemiology and psychosocial–behavioral correlates of SLD and fibrosis, with notable sex-specific differences.