Epidemiology of alcohol and burden of disease related to non-communicable diseases in the Americas
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Epidemiology of alcohol and burden of disease related to non-communicable diseases in the Americas
Jürgen RehmCentre for Addiction and Mental Health, Toronto, CanadaDalla Lana School of Public Health, University of Toronto, CanadaTechnische Universität Dresden, Clinical Psychology and Psychotherapy
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Overview: alcohol is the most important risk factor for burden of disease in the AmericasThis includes all disease and injury categories
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Global leading causes of attributable global mortality and burden of disease, 2004
%
1. High blood pressure 12.82. Tobacco use 8.73. High blood glucose 5.84. Physical inactivity 5.55. Overweight and obesity 4.86. High cholesterol 4.57. Unsafe sex 4.08. Alcohol use 3.89. Childhood underweight 3.810. Indoor smoke from solid
fuels 3.3
59 million total global deaths in 2004
%
1. Childhood underweight 5.92. Unsafe sex 4.63. Alcohol use 4.54. Unsafe water, sanitation,
hygiene 4.25. High blood pressure 3.76. Tobacco use 3.77. Suboptimal breastfeeding 2.98. High blood glucose 2.79. Indoor smoke from solid
fuels 2.710. Overweight and obesity 2.3
1.5 billion total global DALYs in 2004
Attributable Mortality
Attributable DALYs
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Leading causes of attributable global mortality and burden of disease, 2004, in the Americas
%
1. Tobacco use 14.0 2. High blood pressure 13.4 3. Overweight and obesity 9.54. High blood glucose 8.1 5. Physical inactivity 7.36. Alcohol use 5.6 7. High cholesterol 5.58. Low fruit and
vegetable intake 3.0 9. Urban outdoor air pollution
2.310. Unsafe sex 1.7
6.16 million total deaths in 2004
%
1. Alcohol use 9.12. Tobacco use 6.23. Overweight and obesity 5.54. High blood glucose 4.35. High blood pressure 3.86. Physical inactivity 3.07. High cholesterol 2.58. Unsafe sex 2.29. Illicit drug use 2.210. Suboptimal breastfeeding 1.7
143.2 million total global DALYs in 2004
Attributable Mortality
Attributable DALYs
But what is the impact of NCD?
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Necessary elements to do these calculations Exposure to alcohol Establishment of causality Risk relations
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Alcohol consumption in the Americas 2005Characteristics and differences
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Global consumption
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And in the Americas
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1: Least hazardous; Regular drinking, often with meals and without heavy drinking bouts
4: Most hazardous: Infrequent but heavy drinking
Patterns of consumption
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Prevalence of abstention in W orld 2005
0.00 - 0 .20
0.20 - 0 .40
0.40 - 0 .60
0.60 - 0 .80
0.80 - 1 .00
Prevalence of abstention
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Summary for exposure
Compared to global high per capita consumption
Drinkers are the majority: Americas A: 34% Americas B: 47% Americas D: 51%
Overall, high consumption per drinker and high level of binge drinking!
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Risk relations to NCD-CVD categories-Cancers-Digestive Diseases
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The relationship between alcohol consumption, NCD, and other harm
Detrimental impact of amount of alcohol consumed on various cancers (head and neck cancers, liver cancer, colorectal cancer, female breast cancer), haemorrhagic stroke, hypertensive disease, conduct disorders, liver cirrhosis and pancreatitis (monotone dose-response relationships)
Impact of drinking on ischaemic heart disease, stroke and diabetes (complex relationship)
In addition, impact of harmful use of alcohol on other diseases (TB, HIV/AIDS, pneumonia), alcohol use disorders, injuries and alcohol-related social harm (family, violence, worklife, etc.)
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For many NCDs: the more alcohol consumed the higher the risk
See the next few slides based on the meta-analyses described in Rehm et al., 2010
Rehm, J., Baliunas, D., Borges, G.L.G., Graham, K., Irving, H.M., Kehoe, T., Parry, C.D., Patra, J., Popova, S., Poznyak,V., Roerecke, M., Room, R., Samokhvalov, A.V., & Taylor, B. (2010). The relation between different dimensions of alcohol consumption and burden of disease - an overview. Addiction, 105(5). 817-843.
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Risk function and confidence interval for oesophagus cancer
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Risk function and confidence Interval for colon cancer
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Risk relation and confidence interval for liver cancer
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Risk relation and confidence interval for female breast cancer
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Risk relations and confidence interval for hypertension
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Risk relations and confidence interval for liver cirrhosis mortality
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Risk relations and confidence interval for pancreatitis
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But what about the protective effect on ischaemic disease and diabetes? There is a protective effect and a J-
shaped curve for Ischaemic heart disease Ischaemic stroke Diabetes
See ischemic stroke as example
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Alcohol consumption and stroke
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The impact of heavy drinking (RR of irregular heavy drinking at least once monthly vs. not) controlled for volume on ischaemic heart disease
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Roerecke & Rehm, 2010, meta-analysisContrary to a cardioprotective effect of moderate regular alcohol consumption,
accumulating evidence points to a detrimental effect of irregular heavy drinking occasions (> 60 grams pure alcohol or 5+ drinks per occasion at least monthly) on ischemic heart disease (IHD) risk, even among drinkers whose average consumption is moderate. The authors systematically searched electronic databases from 1980 – 2009 for case-control or cohort studies examining the association of irregular heavy drinking occasions on IHD risk. Studies were included if they reported either a relative risk (RR) estimate for intoxication or frequency of 5+ drinks stratified by or adjusted for total average alcohol consumption. The search identified 14 studies (including 31 risk estimates), containing 4,718 IHD events (morbidity and mortality). Using a standardized protocol, RR estimates and their variance in addition to study characteristics were extracted. In a random-effects model, the pooled RR of irregular heavy drinking occasions compared to regular moderate drinking was 1.45 (95% confidence interval: 1.24 – 1.70) with significant between-study heterogeneity (I2 = 53.9%). Results were robust in several sensitivity analyses. The authors conclude that the cardioprotective effect of moderate alcohol consumption disappears when on average light to moderate drinking is mixed with irregular heavy drinking occasions.
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Conclusion
The protective effects for ischaemic heart disease disappear if there are irregular heavy drinking occasions
As the biological mechanism is the same for ischaemic stroke, the same effects should apply
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And the effect of alcohol on worsening the disease course In addition to causing certain
categories of NCD, alcohol worsens the disease course by Disrupting medication regimes Weakening the immune system (both
innate and acquired)
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Consequences for burden of disease
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Disease Category AMR A AMR B AMR D Total M W M W M W M W M W
Maternal and perinatal conditions (low birth weight) 2 1 10 8 1 1 12 10 0.1% 0.4%
Cancer 188 137 164 128 12 12 364 277 3.2% 11.0%
Diabetes Mellitus 0 0 0 10 0 0 0 11 0.0% 0.4%
Neuropsychiatric disorders 1,605 593 2,378 537 474 104
4,457
1,233 39.1% 49.2%
Cardiovascular Diseases 127 33 595 133 45 13
767 178 6.7% 7.1%
Cirrhosis of the liver 245 114 654 139 117 24
1,017 278 8.9% 11.1%
Unintentional injuries 524 142 1,722 169 220 32
2,465 343 21.6% 13.7%
Intentional injuries 221 51 2,002 120 98 8
2,321 179 20.4% 7.1%
Total 'detrimental effects' attributable to alcohol 2,912 1,071 7,524 1,242 967 194 11,403 2,508 100.0% 100.0%
Diabetes mellitus -91 -33 0 0 0 0 -91 -33 26.8% 13.8%
Cardiovascular diseases -250 -208 0 0 0 0 -250 -208 73.5% 86.6%
Total 'beneficial effects' attributable to alcohol -342 -241 0 0 0 0 -342 -241 100.3% 100.4%All alcohol-attributable net DALYs 2,570 830 7,524 1,242 967 194 11,062 2,267 100.0% 100.0%
All DALYs 24,163
22,712
45,132
36,078
8,719
7,912
78,015
66,702
Percentage of all net DALYs attributable to alcohol 10.6% 3.7% 16.7% 3.4% 11.1% 2.5% 14.2% 3.4%
Population 131,482,619
138,370,521
157,158,245
165,715,199 23,799,749 24,609,538
312,440,613 328,695,258
Alcohol-attributable DALYs per population (100,000) 18.4 16.4 28.7 21.8 36.6 32.1 25.0 20.3
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Summary
Alcohol has a causal impact on NCDs which is overall negative
Alcohol policy could contribute to prevent NCDs
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A framework for NCDs (Lancet NCD group)
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Priority actions for the NCD crisis
The Lancet NCD Action Group and The NCD Alliance
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Poverty, NCD and development goals
Source: Beaglehole R, Bonita R, Horton R, et al for The Lancet NCD Action Group and the NCD Alliance. Priority actions for the NCD crisis. Lancet 2011; 377:1438-47
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Best buys, especially for low and middle income countries
Harmful use of alcohol
(> 50m DALYs;4.5% global
burden)
Restrict access to retailed alcohol * Combine
d effect: 5-10 m DALYs
averted(10-20% alcohol burden)
Enforce bans on alcohol advertising *
Raise taxes on alcohol *
• very cost-effective ($ per DALY prevented < GDP per person)• very low cost in implementation and in principle feasible