7 to 9.5 fewer years of life linked to heart disease, fatty liver, diabetes and obesity together

A 50-year-old in Britain with none of four common conditions, heart disease, fatty liver, type 2 diabetes and obesity, could expect to live about another 37 years. With all four, the figure was 30. In the United States the gap was wider still, from about 34 more years to fewer than 25.

Those estimates come from a study published on October 11 in BMC Medicine. It followed 429,722 people in UK Biobank and 38,759 in the US National Health and Nutrition Examination Survey, known as NHANES. The more of the four conditions a person had at the start, the higher their death rate over the following decade or so, with the sharpest rise in deaths from heart disease and stroke.

The team, with Jiaxiang Wang as first author and Min Zhao as senior author, calls the combination a cardiovascular-liver-metabolic syndemic, using a word for conditions that occur together and make one another worse. Its contribution is to add the liver to a cluster usually discussed as heart disease and diabetes, and to put a number on the life lost when all four meet. For death and life expectancy, the authors write, the consequences of their co-occurrence remain insufficiently quantified.

Why fatty liver belongs with heart disease and diabetes

Fatty liver is the least familiar of the four. Until 2023 it was called non-alcoholic fatty liver disease. That year a consensus process involving 236 panelists from 56 countries replaced the name with metabolic dysfunction-associated steatotic liver disease, or MASLD. One reason was that many panelists felt the words “nonalcoholic” and “fatty” were stigmatizing. Under the new definition, MASLD means fat in the liver plus at least 1 of 5 cardiometabolic risk factors, such as excess weight or high blood sugar. Heavy drinkers are classed separately.

It is common. A 2023 review of 92 studies covering more than nine million people concluded that global prevalence is 30% and increasing. Because the condition is defined by the same metabolic problems that drive type 2 diabetes and heart disease, it rarely turns up alone.

Fat in the liver can, over years, progress to liver fibrosis, cirrhosis and liver cancer, which is the danger most people associate with it. Yet the same review found that people with the condition died of heart disease more often than of liver disease. Among those diagnosed without a liver biopsy, the pooled death rate from heart causes was about 4.2 per 1,000 people each year, against about 0.9 per 1,000 from liver causes. That imbalance helps explain why fatty liver is now discussed alongside heart and metabolic disease, and not only as a liver problem.

The authors of the new study describe the four conditions as ones that frequently coexist and share overlapping mechanisms in the body. The American Heart Association made a similar argument in 2023 for heart disease, kidney disease and metabolic risk. It described the interplay among metabolic risk factors, kidney disease and the heart and blood vessels as a single syndrome, one with a high rate of heart attacks and strokes.

How the study counted heart, liver and metabolic conditions

UK Biobank and NHANES are both prospective population-based cohorts, meaning they follow large groups of ordinary adults over time. UK Biobank recruited adults in Britain between 2006 and 2010, while NHANES is a long-running survey of the US population. Running the same analysis in both is a check: a pattern that holds in two countries, with different health systems and different people, is less likely to be an artifact of one dataset.

For each participant, the researchers counted the number of coexisting conditions among the four at the start, from none to all four. They then compared death rates across those groups, taking account of other differences between people, and estimated how long a person at each level could expect to live from age 50.

During median follow-ups of 13.7 years in UK Biobank and 9.5 years in NHANES, the team tracked who died and of what. The design is observational, so it shows how strongly the conditions were linked to earlier death, not that removing any one of them would add the missing years. Each person’s conditions were recorded once, at the start, and some will have developed new ones later.

How life expectancy and death rates changed with each added condition

The pattern was a staircase: in both cohorts, mortality increased stepwise with each added condition. In UK Biobank, people with one of the four conditions had a death rate about 55% higher than people with none, after adjustment for other factors. With three, the rate was more than double, about 2.26 times as high. In NHANES the steps were smaller but climbed the same way, from about 27% higher with one condition to 90% higher with three.

People with all four conditions had the highest risk of all. Their death rate was about three and a half times that of people with none in UK Biobank, and about three times in NHANES. The British estimates are more precise than the American ones, which rest on fewer people.

Among causes of death, the four conditions together had the strongest association for cardiovascular disease, meaning heart attacks, strokes and related causes. In UK Biobank, people with all four conditions died of cardiovascular causes at more than eight times the rate of people with none. In NHANES the figure was close to four times.

Translated into time, a 50-year-old with none of the conditions could expect another 36.9 years in the UK Biobank group, against 30.0 with all four. In NHANES the figures were 34.3 and 24.8. The authors put the gap at 6.9 and 9.5 fewer years of life expectancy, respectively, for people with all four conditions compared with none.

How the liver and metabolic results fit earlier work

The finding extends a well-known one. In 2015 the Emerging Risk Factors Collaboration pooled data on 689,300 people from 91 cohorts. Diabetes, stroke and heart attack each went with roughly double the death rate, a risk the researchers found similar for each condition, and when people had more than one the risks multiplied. To give a sense of scale, the death rate, adjusted to the age of 60 years, was 6.8 per 1,000 people a year with none of the three conditions and 59.5 per 1,000 with all three. At that age, a history of any two of the three went with 12 years of reduced life expectancy, and all three with 15 years. Those losses are larger than the new study’s, but the two are not directly comparable: the earlier figures were measured from age 60 rather than 50, and the conditions differ, since obesity and fatty liver were not part of the earlier count.

Studies of fatty liver itself point the same way. A 2025 analysis of 178,336 UK Biobank participants with steatotic liver disease found that having two or more other long-term conditions doubled the death rate. Clusters involving heart disease and stroke carried the highest risk, and heart disease and stroke were the leading causes of death within them. That fits the new study’s finding that the strongest link was with cardiovascular death.

A separate team using the same two cohorts reached a related conclusion for the American Heart Association’s cardiovascular-kidney-metabolic stages, known as CKM stages. In that 2025 study, advanced CKM stages were associated with higher mortality and shorter life expectancy, and an unhealthy lifestyle and social disadvantage widened the gap. Among NHANES participants, life expectancy at 50 ranged from 33.9 years for people at the earliest stage with a healthy lifestyle to 13.2 years for those at the most advanced stage with an unhealthy one. In UK Biobank the corresponding figures were 34.2 and 21.7 years, again a wider spread in the American data than in the British.

What the cardiovascular-liver-metabolic study leaves open

Because each person’s conditions were counted only at the start, the study cannot show how risk changes when a condition develops later or is brought under control. People who lost weight, or whose diabetes was well treated, are grouped by where they began.

The fully adjusted models took account of other factors. But some influences on survival, such as income, diet and how well each condition was treated, are hard to measure completely, and any that were missed could account for part of the gap.

Counting conditions also treats them as equal, which they are not. A person with heart disease and diabetes is in the same “two conditions” group as a person with obesity and fatty liver, though their risks probably differ. And both cohorts were drawn from high-income countries; the figures may not carry over to populations with different patterns of disease and care.

What the shorter life expectancy means for patients and doctors

The authors conclude that the four conditions together were consistently associated with the highest mortality risk, particularly from cardiovascular death, and argue for integrated prevention and care that deals with heart, liver and metabolic health together.

Guidance is moving in that direction. The 2024 European guideline on MASLD, written jointly by the liver, diabetes and obesity associations, advises looking for scarring of the liver in people with cardiometabolic risk factors, particularly those with type 2 diabetes or obesity, using non-invasive tests such as blood-based scores and scans rather than biopsies. It advises lifestyle modification, including weight loss, diet changes, exercise and avoiding alcohol. It also advises treating related conditions such as type 2 diabetes and obesity, with drugs such as semaglutide and tirzepatide where indicated. The study did not test any of these, and it cannot say how many of the missing years treatment would recover. Do not stop or change a prescribed medicine without talking to your doctor.

How the four conditions are managed in any one person is assessed by their doctor.

In two countries, people who had all four conditions at once lived years less than people who had none.