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

Overview: alcohol is the most important risk factor for burden of disease in the AmericasThis includes all disease and injury categories

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

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?

Necessary elements to do these calculations Exposure to alcohol Establishment of causality Risk relations

Alcohol consumption in the Americas 2005Characteristics and differences

Global consumption

And in the Americas

1: Least hazardous; Regular drinking, often with meals and without heavy drinking bouts

4: Most hazardous: Infrequent but heavy drinking

Patterns of consumption

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

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!

Risk relations to NCD-CVD categories-Cancers-Digestive Diseases

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.)

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.

Risk function and confidence interval for oesophagus cancer

Risk function and confidence Interval for colon cancer

Risk relation and confidence interval for liver cancer

Risk relation and confidence interval for female breast cancer

Risk relations and confidence interval for hypertension

Risk relations and confidence interval for liver cirrhosis mortality

Risk relations and confidence interval for pancreatitis

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

Alcohol consumption and stroke

The impact of heavy drinking (RR of irregular heavy drinking at least once monthly vs. not) controlled for volume on ischaemic heart disease

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.

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

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)

Consequences for burden of disease

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   

Summary

Alcohol has a causal impact on NCDs which is overall negative

Alcohol policy could contribute to prevent NCDs

A framework for NCDs (Lancet NCD group)

Priority actions for the NCD crisis

The Lancet NCD Action Group and The NCD Alliance

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

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