Alcohol consumption is a major contributor to global morbidity and mortality, accounting for approximately 5.3% of all deaths worldwide (1). In India, alcohol is the second most commonly abused substance after tobacco, with a significant proportion of the population affected by alcohol use disorders (2). Alcohol dependence is associated with a wide range of medical, psychological, and social complications. Chronic alcohol use leads to Alcoholic Liver Disease (ALD), which encompasses a spectrum ranging from fatty liver to cirrhosis and hepatocellular carcinoma (3). However, only a subset of individuals with heavy alcohol consumption develops advanced liver disease, indicating the role of modifying factors such as nutritional status, anthropometric characteristics, and biochemical parameters (4,5). Malnutrition is highly prevalent among individuals with alcohol dependence and has been shown to influence disease progression and outcomes (6,7). Similarly, obesity and metabolic factors may act synergistically with alcohol to accelerate liver injury (8,9). Despite these associations, Indian data examining the interplay between nutritional status, anthropometry, and liver disease remain limited. Therefore, this study was undertaken to evaluate the factors associated with liver disease in individuals with Alcohol Dependence Syndrome.

Study Design and Setting This was a cross-sectional exploratory study conducted in the Department of Psychiatry at Kempegowda Institute of Medical Sciences, Bangalore, India, over a period of one year from June 2018 to June 2019. Study Population A total of 60 patients diagnosed with Alcohol Dependence Syndrome (ADS) according to the International Classification of Diseases, 10th Revision (ICD-10) criteria were included in the study. Both inpatients and outpatients were recruited. Inclusion and Exclusion Criteria Patients who were adults and in a clear state of consciousness at the time of assessment were included. Individuals with comorbid psychiatric disorders, except for tobacco dependence syndrome, were excluded from the study. Ethical Considerations The study protocol was approved by the Institutional Ethics Committee. Written informed consent was obtained from all participants prior to enrollment. Data Collection Sociodemographic and Anthropometric Assessment Relevant sociodemographic details were recorded. Anthropometric measurements including height, weight, waist circumference, hip circumference, and mid-arm circumference (MAC) were obtained using standard techniques. Body Mass Index (BMI) and Waist-Hip Ratio (WHR) were calculated accordingly. Clinical and Laboratory Evaluation All participants underwent laboratory investigations including liver function tests (LFT) and Hepatitis B surface antigen (HBsAg) testing. Ultrasonography of the abdomen was performed for all subjects. Based on ultrasound findings, participants were categorized into four groups: ● Normal ● Fatty liver ● Chronic liver disease (CLD) ● CLD with splenomegaly Assessment of Alcohol Dependence and Dietary Intake The severity of alcohol dependence was assessed using the Severity of Alcohol Dependence Questionnaire (SADQ), and participants were classified into mild, moderate, and severe dependence categories. Dietary intake was evaluated using a 24-hour dietary recall method to estimate energy and macronutrient consumption. Statistical Analysis Data were analyzed using Statistical Package for the Social Sciences (SPSS) software version 20.0. Categorical variables were expressed as frequencies and percentages. Continuous variables were summarized using mean and standard deviation (SD) or median and range, as appropriate. For inferential analysis, associations between variables were assessed using Chi-square test and Fisher’s exact test for categorical data. Independent sample t-test and one-way analysis of variance (ANOVA) were used for comparison of continuous variables where applicable. Non-parametric tests such as Mann–Whitney U test and Kruskal–Wallis test were used for skewed data distributions. A p-value of less than 0.05 was considered statistically significant.

All participants were adult males (n = 60) with a mean age of 41.53 ± 9.44 years. The mean duration of education was 7.43 ± 3.64 years, and 10% of subjects were non-literate. Anthropometric parameters including BMI, mid-arm circumference (MAC), and waist-hip ratio (WHR) were largely within normal ranges (Table 1). A high prevalence of nutritional deficiency was observed. Energy intake was inadequate in 95% of participants, while 83.3% and 70% were deficient in protein and fat intake, respectively (Table 2). Liver function tests demonstrated considerable variability, with elevated transaminases and GGT levels indicating hepatic involvement (Table 3). Ultrasound examination revealed fatty liver as the most common finding (68.3%), followed by chronic liver disease and splenomegaly in smaller proportions. Normal findings were seen in 15% of participants (Table 4). No statistically significant association was found between nutritional intake and anthropometric indices (BMI, MAC, WHR) (p > 0.05). Similarly, severity of alcohol dependence did not show a significant association with anthropometric parameters or liver function abnormalities. Among biochemical parameters, direct bilirubin (p = 0.038) and alkaline phosphatase (p = 0.020) demonstrated a statistically significant association with ultrasound findings of liver disease, while other liver enzymes did not (Table 5).None of the participants tested positive for HBsAg. Table 1. Baseline Characteristics (n = 60) Variable Mean ± SD Median (IQR) Age (years) 41.53 ± 9.44 40 (32–48) Education (years) 7.43 ± 3.64 9 (4–10) BMI (kg/m²) 21.46 ± 4.08 21.27 (18.9–23.8) MAC (cm) 26.27 ± 3.84 26 (24–29) WHR 0.98 ± 0.06 1.00 (0.95–1.02) Table 2. Nutritional Intake Status (n = 60) Nutrient Deficient n (%) Energy 57 (95.0) Protein 50 (83.3) Fat 42 (70.0) Table 3. Liver Function Tests (n = 60) Parameter Mean ± SD Total bilirubin (mg/dL) 1.47 ± 1.62 Direct bilirubin (mg/dL) 0.78 ± 1.27 SGOT (U/L) 86.80 ± 57.97 SGPT (U/L) 52.72 ± 31.15 ALP (U/L) 138.49 ± 101.00 GGT (U/L) 306.20 ± 431.16 Table 4. Ultrasound Abdomen Findings (n = 60) Finding n (%) Fatty liver 41 (68.3) CLD 5 (8.3) CLD with splenomegaly 5 (8.3) Normal 9 (15.0)

In this cross-sectional study of patients with Alcohol Dependence Syndrome (ADS), we evaluated the relationship between nutritional status, anthropometric parameters, biochemical markers, and liver disease. The study population consisted entirely of adult males with a mean age of 41.5 years, which is consistent with previous Indian and international studies reporting that alcohol dependence predominantly affects middle-aged men (1,2). A key finding of this study was the high prevalence of nutritional deficiency, with the majority of participants showing inadequate intake of energy, protein, and fat. This observation is in agreement with previous literature demonstrating that malnutrition is highly prevalent in individuals with chronic alcohol use due to poor dietary intake, impaired absorption, and altered metabolism (3,4). Despite this, no statistically significant association was found between nutritional intake and liver disease severity in our study. Similar findings have been reported in earlier studies, suggesting that short-term dietary assessment methods such as 24-hour recall may not reliably reflect long-term nutritional status (5). Ultrasonographic evaluation revealed that fatty liver was the most common finding (68.3%), which aligns with established evidence that hepatic steatosis represents the earliest and most frequent manifestation of alcohol-related liver disease (6,7). Only a smaller proportion of participants demonstrated features of chronic liver disease, indicating that most individuals were in earlier stages of hepatic involvement. Anthropometric parameters such as BMI, mid-arm circumference (MAC), and waist-hip ratio (WHR) were not significantly associated with liver disease in the present study. While obesity and central adiposity have been shown to exacerbate liver injury in alcohol users (8,9), our findings are consistent with studies suggesting that conventional anthropometric measures may not adequately reflect metabolic risk, particularly in Asian populations where normal BMI may coexist with metabolic abnormalities (10). An important observation in our study was that direct bilirubin and alkaline phosphatase were significantly associated with ultrasound findings of liver disease, whereas other liver enzymes were not. This finding is supported by previous studies indicating that cholestatic markers such as bilirubin and ALP may better reflect advanced or structural liver damage compared to transaminases alone (11,12). These parameters may therefore serve as useful indicators for identifying clinically significant liver disease in patients with alcohol dependence. The severity of alcohol dependence, as assessed by the SADQ, was not significantly associated with liver disease severity or anthropometric parameters. Although greater alcohol consumption is generally expected to correlate with more severe liver damage, several studies have shown that the progression of alcohol-related liver disease is influenced by multiple factors including genetic predisposition, nutritional status, and duration of alcohol use rather than dependence severity alone (13,14). Overall, the findings of this study highlight that alcohol-related liver disease is multifactorial in nature. While nutritional deficiency is highly prevalent, it may not independently predict liver disease severity. Instead, biochemical markers such as direct bilirubin and alkaline phosphatase appear to have stronger associations with structural liver abnormalities.

This study demonstrates a high prevalence of nutritional deficiency among individuals with Alcohol Dependence Syndrome. Fatty liver was the most common hepatic abnormality observed. However, anthropometric parameters, dietary intake, and severity of alcohol dependence were not significantly associated with liver disease. Among biochemical markers, direct bilirubin and alkaline phosphatase showed a significant association with ultrasound findings of liver disease, suggesting their potential role as indicators of hepatic involvement. These findings highlight the multifactorial nature of alcohol-related liver disease and underscore the need for comprehensive clinical and biochemical assessment. Further large-scale longitudinal studies are required to better understand the determinants and progression of liver disease in this population. ACKNOWLEDGEMENT The authors would like to thank all the participants who consented to be a part of this study. We express our sincere gratitude to the faculty and staff of the Department of Psychiatry, Kempegowda Institute of Medical Sciences, Bangalore, for their support and guidance throughout the study. We also acknowledge the Department of Radiology and Biochemistry for their assistance in conducting the necessary investigations. Conflict of Interest The authors declare that they have no financial or non-financial conflicts of interest related to the authorship, research, or publication of this article.

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