1. PHP 1540: Alcohol Use and Misuse October 11, 2012
Assessing Health Impacts of Drinking:
moderate vs heavy drinking
beneficial vs. detrimental effects
global burden
relative burden

2. Heart disease (CHD, MI, cardiomyopathy) -- accounts for nearly 1 our of every 4 deaths in the US in 2008
Cancer
Stroke (ischemic stroke = blockage and cell death due to clots; hemorrhagic stroke = bleeding due to weak blood vessels and high BP)
(Mokdad et al., 2004)

3. Is moderate drinking good for you?
What are some sources of imprecision in determining the health effects of moderate drinking?
Definitions of what moderate drinking is vary (<= 1 SD/wk to <=4 SD/day)
SD varies across countries and can only be estimated via self-report measures
Averages (e.g., DPW) can obscure patterning of drinking (7 DPW as 1/day or 7 on one day)

4. Health Benefits of Moderate Drinking
Moderate drinking lowers risk of:
Hypothesized mechanism
Coronary heart disease
Incr. HDL and decr. LDL cholesterol
Ischemic stroke
Decr. blood clotting, blood pressure
Vascular dementia
Lower risk of mini-strokes
Metabolic syndrome
Incr. HDL, decr. BP, lower insulin resistance
Type 2 diabetes
Lowered insulin resistance
ALL CAUSE MORTALITY
(lowest at 1-2 drinks/day)
Small cumulative effects on the most common causes of death
Per Gmel et al. (2003); nadir and shape of J-shaped curve depends on sample demographics
(Gunzerath et al., 2004)

5. Why is the relationship of alcohol and mortality (also alcohol and CHD risk) U- or J -shaped and not shaped like a / ?
Why is it that moderate drinking confers some protection relative to abstinence?
Reasons for non-drinking vary:
Cultural values
Illness
Knowledge of family history
People in recovery
INCREASE in risk goes up at 5-6 drinks/day
Example of relationship between average alcohol consumption and CHD, as expressed by a J–shaped curve with confidence intervals.
NOTE: The middle line represents the result of the meta–analysis; the other two represent the lower and upper confidence intervals (Corrao et al. 2000).

6. Health Risks of Moderate Drinking
Moderate drinking increases risk of:
Hypothesized mechanism
Breast cancer
Incr. estrogen levels (in some women)
Hemorrhagic stroke (in young people)
Decr. blood clotting
Cognitive/behavioral problems in children whose mothers drank
Teratogenic effects of alcohol on the developing fetus; esp. with higher volume drinking episodes
Reduced lactation
Alcohol inhibits prolactin release
Injuries/accidents/violence
Occasional heavy/risky drinking in context of an overall moderate drinking pattern
Breast CA:
- For people with a family history of breast CA, daily drinking increases risk by 2.5 (Vachan et al., 2001)
- for post-menopausal women, ERT alone increases risk of breast CA, but especially in combination with drinking as little as 1.5 drinks/day – 2x risk, from 4% to 8% (Chen et al., 2002)
(Gunzerath et al., 2004)

7. What can be recommended with regard to drinking and heart disease?
People who are not currently drinking should not start drinking solely for health reasons
People who choose to drink should follow moderate drinking guidelines
Moderate drinking is not risk free
Moderate drinking is not risk free:
Moderate drinking has health risks of its own for certain people
Intoxication confers risk of accident/injury
the risk of developing alcohol abuse/dependence

8. “If alcohol were a newly discovered drug … we can be sure that no physician would develop it to prevent cardiovascular disease.
Nor would many physicians use a therapy that might reduce the rate of [heart attacks] by 25 to 50 percent, but that would result in thousands of additional deaths per year due to cancer, motor vehicle accidents and liver disease.”
(Goldberg, NEJM, 2003)

9. Health consequences of heavy drinking:
Fetal alcohol spectrum disorders Alcoholic liver disease: fatty liver, hepatitis, cirrhosis Cancers: mouth, pharynx, larynx, esophagus, colon, breast Cardiovascular diseases: HTN, stroke, CHD, cardiomyopathy Diabetes Mental health: AUDs, depression, neurocognitive disorders Unintentional injury: motor vehicle accidents, falls, drownings Intentional injury: violence, suicide
CA: risk for upper GI CA increases with ALDH2 polymorphism (inactive); repeated exposure to alcohol irritation and to acetaldehyde is carcinogenic
Inactive ALDH2 enzyme also increases risk for CNS damage and polyneuropathy

10. Assessing overall burden
Metrics
Associated health problems
Cost of medical care
Mortality
DALYs = total years of productive life lost
Social harms
“attributable to alcohol”
Alcohol is a causal factor (e.g., alcoholic liver disease)
Alcohol is a contributing factor (e.g., cancers)
net burden = detrimental – beneficial effects
Globally, associated health problems = AUDs, CA, CVD, liver cirrhosis, injury
Social harms/costs =
Law enforcement
Underemployment/productivity

11. Global burden of alcohol quiz, part I
Most of the world abstains from drinking alcohol:
TRUE or FALSE?
With regard to alcohol, men bear a larger health burden around the world than do women:
In 2004, the global burden of disease and injury attributable to alcohol was:
1.4 % % % % ✔
Abstention rate: 45% men & 66% women
Gender:
- alcohol attributable deaths, % of total: 6.3% (male) vs. 1.1% (female)
- DALYs attributable to alcohol: 7.6% (male) vs. 1.4% (female)
Global burden estimates likely to be underestimates
Lots of unrecorded/undocumented drinking
Analysis didn’t include alcohol’s effects on infections disease: TB, pneumonia, now HIV/AIDS
Effect about the same size as smoking, and equally avoidable. ✔

12. Global burden of alcohol quiz, part II
Based on the Rehm et al. regional analysis, which best represents the estimated per capita alcohol consumption, in descending order?
Eastern Mediterranean > Americas > Africa
Americas > Europe > Scandinavia
Eastern Europe + Russia > Europe > Americas ✔
On average, 6.2L of pure alcohol per adult per year around the world.
Europe/Russia 11.9L
Americas 8.7L
Middle east 0.7L

13. Global burden of alcohol quiz, part III
What 3 main factors contribute to alcohol- attributable burden in a given part of the world?
Prevalence of drinking
Disease attributable to alcohol
Other causes of death in the region
Within Europe, 1 out of every 10 deaths of men is attributable to alcohol
Relative to the volume of alcohol consumed per capita (developed>developing),
Rates of alcohol-attributed mortality were higher in developing than developed countries.