Estimating alcohol’s role in Estimating alcohol’s role in disease & disability: disease & disability:

the alcohol component in WHO’s the alcohol component in WHO’s Global Burden of Disease Global Burden of Disease

analysis for 2000analysis for 2000

David JerniganDavid JerniganCenter on Alcohol Marketing and YouthCenter on Alcohol Marketing and Youth

Georgetown UniversityGeorgetown Universitydhj@georgetown.edudhj@georgetown.edu

WHO’s Comparative Risk WHO’s Comparative Risk Assessment Collaborating GroupAssessment Collaborating Group

27 groups:27 groups:• Core, metholodology, etc. GroupCore, metholodology, etc. Group• 26 risk factor groups26 risk factor groups

Alcohol group:Alcohol group:• J Rehm, R Room, M Monteiro, G Gmel, K J Rehm, R Room, M Monteiro, G Gmel, K

Graham, N Rehn, C T Sempos, U Frick, D Graham, N Rehn, C T Sempos, U Frick, D Jernigan Jernigan

The 26 risk The 26 risk factorsfactors, roughly grouped, roughly grouped

Childhood and maternal undernutritionChildhood and maternal undernutrition: underweight, iron : underweight, iron deficiency, vitamin A deficiency, zinc deficiency; deficiency, vitamin A deficiency, zinc deficiency;

Other diet-related risks and physical inactivityOther diet-related risks and physical inactivity: blood : blood pressure, cholesterol, overweight, low fruit and vegetable pressure, cholesterol, overweight, low fruit and vegetable intake, physical inactivity;intake, physical inactivity;

Sexual and reproductive health risksSexual and reproductive health risks: unsafe sex, lack of : unsafe sex, lack of contraception;contraception;

Addictive substance useAddictive substance use: tobacco, alcohol, illicit drugs;: tobacco, alcohol, illicit drugs; Environmental risksEnvironmental risks: unsafe water, sanitation and hygiene, : unsafe water, sanitation and hygiene,

urban air pollution, indoor smoke from solid fuels, lead urban air pollution, indoor smoke from solid fuels, lead exposure, climate change;exposure, climate change;

Occupational risksOccupational risks: risk factors for injury, carcinogens, : risk factors for injury, carcinogens, airborne particulates, ergonomic stressors, noise;airborne particulates, ergonomic stressors, noise;

Other selected risks to healthOther selected risks to health: unsafe health care injections, : unsafe health care injections, childhood sexual abuse. childhood sexual abuse.

The epidemiological model

Attributable fractions

= f(prevalence, pattern weight, relative risk)

Defined as: With a given outcome exposure factor, and population, the attributable fraction is the proportion by which the incidence rate of the outcome would be reduced if the distribution of exposure would change to an alternative distribution:““When an exposure is When an exposure is believed to be a cause of believed to be a cause of a given disease, the a given disease, the attributable fraction is attributable fraction is the proportion of the the proportion of the disease in the specific disease in the specific population that would be population that would be eliminated in the absence eliminated in the absence of the exposure.”of the exposure.”

  Four drinking categories (old English et al. terminology: abstainer, moderate, hazardous, harmful) are distinguished. Prevalence for all four categories are taken from surveys

Steps to derive at pattern weight:1. Determine pattern value from survey of key informants, and/or survey data where available.2. Conduct hierarchical linear analyses on mortality using per capita consumption gross-national product, year (level 1 variables) and pattern values (level 2 variable) as determining factors (separate by age and sex).3. Construct pattern weight based on intercept and regression weight for patterns.

Relative Risk estimates for each drinking category are either taken directly from meta-analyses (chronic diseases) or indirectly from meta-analyses of attributable fractions (injuries)

  

Patterns of drinking Patterns of drinking

Countries assigned hazardous Countries assigned hazardous drinking scores, a numeric indicator drinking scores, a numeric indicator of hazard per litre of alcohol of hazard per litre of alcohol consumedconsumed

Information drawn from research Information drawn from research literature supplemented by key literature supplemented by key informant questionnaires informant questionnaires

Applied to two areas: injuries and Applied to two areas: injuries and CHD.CHD.

Dimensions of patterns of drinkingDimensions of patterns of drinking

• High usual quantity of alcohol per occasion

• Festive drinking common – at fiestas or community celebrations

• Proportion of drinking occasions when drinkers get drunk

• Low proportion of drinkers who drink daily or nearly daily

• Less common to drink with meals• Common to drink in public places

Pattern of drinking 2000(based on CRA)

Patterns of drinking

1.00 to 2.00

2.00 to 2.50

2.50 to 3.00

3.00 to 4.00

Volume of drinking

Drinking patternhazard score

(predominance ofintoxication)

Prior alcohol dependence

DepressionInjuriesCoronary

heartdisease

Physicaldiseases

(except CHD)

Alcohol-attributableconditions*

Aspects of alcohol used in estimating alcohol Aspects of alcohol used in estimating alcohol attributable fraction (AAF) for different attributable fraction (AAF) for different

conditionsconditions

*AAF = 1 by definition

Alcohol-related disordersAlcohol-related disorders Chronic disease:Chronic disease:

• Conditions arising during perinatal period*:Conditions arising during perinatal period*: low birth low birth weightweight

• Cancer*: Cancer*: lip & oropharyngeal cancer, esophageal cancer, lip & oropharyngeal cancer, esophageal cancer, liver cancer, laryngeal cancer, female breast cancerliver cancer, laryngeal cancer, female breast cancer

• Neuropsychiatric diseases: Neuropsychiatric diseases: alcohol use disorders, alcohol use disorders, unipolar major depression, epilepsyunipolar major depression, epilepsy

• Diabetes*Diabetes*• Cardiovascular diseases: Cardiovascular diseases: hypertension, coronary heart hypertension, coronary heart

disease, strokedisease, stroke• Gastrointestinal diseases*:Gastrointestinal diseases*: liver cirrhosis liver cirrhosis

Injury:Injury:• Unintentional injury: Unintentional injury: motor vehicle accidents, motor vehicle accidents,

drownings, falls, poisonings, other unintentional injuriesdrownings, falls, poisonings, other unintentional injuries• Intentional injuryIntentional injury:: self-inflicted injuries, homicide, other self-inflicted injuries, homicide, other

intentional injuriesintentional injuries* AAF based on volume of drinking only * AAF based on volume of drinking only

Estimating AAFsEstimating AAFs

1.1. Alcohol-specific categoriesAlcohol-specific categories

2.2. Chronic health conditionsChronic health conditions

3.3. CHDCHD

4.4. DepressionDepression

5.5. InjuriesInjuries

Alcohol-related global burden of disease

Alcohol-attributable mortality

0.35 to 1.00

1.00 to 4.00

4.00 to 6.00

6.00 to 8.00

8.00 to 20.00

Leading risk factors Leading risk factors ffor disease (WHR 2002) in emerging or disease (WHR 2002) in emerging and established economiesand established economies ( (% % total DALYS)total DALYS)

Developing countriesDeveloping countriesDeveloped countriesDeveloped countries

High mortalityHigh mortality Low mortalityLow mortality

UnderweightUnderweight 14.9%14.9% AlcoholAlcohol 6.2 %6.2 % TobaccoTobacco 12.2 %12.2 %

Unsafe sexUnsafe sex 10.2 %10.2 % Blood pressureBlood pressure 5.0 %5.0 % Blood pressureBlood pressure 10.9 %10.9 %

Unsafe water & Unsafe water & sanitationsanitation 5.5 %5.5 % TobaccoTobacco 4.0 %4.0 % AlcoholAlcohol 9.2 %9.2 %

Indoor smoke (solid Indoor smoke (solid fuels)fuels) 3.6 %3.6 % UnderweightUnderweight 3.1 %3.1 % CholesterolCholesterol 7.6 %7.6 %

Zinc deficiencyZinc deficiency 3.2 %3.2 % Body mass indexBody mass index 2.7 %2.7 % Body mass indexBody mass index 7.4 %7.4 %

Iron deficiencyIron deficiency 3.1 %3.1 % CholesterolCholesterol 2.1 %2.1 % Low fruit & vegetable Low fruit & vegetable intakeintake 3.9 %3.9 %

Vitamin A deficiencyVitamin A deficiency 3.0 %3.0 % Low fruit & vegetable intakeLow fruit & vegetable intake 1.9 %1.9 % Physical inactivityPhysical inactivity 3.3 %3.3 %

Blood pressureBlood pressure 2.5 %2.5 % Indoor smoke from solid Indoor smoke from solid fuelsfuels 1.9 %1.9 % Illicit drugsIllicit drugs 1.8 %1.8 %

TobaccoTobacco 2.0 %2.0 % Iron deficiencyIron deficiency 1.8 %1.8 % Unsafe sexUnsafe sex 0.8 %0.8 %

CholesterolCholesterol 1.9 %1.9 % Unsafe water & sanitationUnsafe water & sanitation 1.8 %1.8 % Iron deficiencyIron deficiency 0.7 %0.7 %

Disease conditions Males Females Total% of all alcohol-

attributable deaths

Conditions arising during the perinatal period

2 1 3 0%

Malignant neoplasm 269 86 355 20%

Neuro-psychiatric conditions 91 19 111 6%

Cardiovascular diseases 392 -124 268 15%

Other non-communicable diseases (diabetes, liver cirrhosis)

193 49 242 13%

Unintentional injuries 484 92 577 32%

Intentional injuries 206 42 248 14%

Alcohol-related mortality burden all causes

1,638 166 1,804 100.0%

All deaths 29,232 26,629 55,861 In comparison: estimate for 1990: 1.5%

% of all deaths which are alcohol-attributable 5.6% 0.6% 3.2%

Global mortality burden (deaths in 1000s) attributable to alcohol by major disease categories - 2000

Disease conditions Males Females Total% of all alcohol-

attributable DALYs

Conditions arising during the perinatal period

68 55 123 0%

Malignant neoplasm 3,180 1,021 4,201 7%

Neuro-psychiatric conditions 18,090 3,814 21,904 38%

Cardiovascular diseases 4,411 -428 3,983 7%

Other non-communicable diseases (diabetes, liver cirrhosis)

3,695 860 4,555 8%

Unintentional injuries 14,008 2,487 16,495 28%

Intentional injuries 5,945 1,117 7,062 12%

Alcohol-related disease burden all causes (DALYs)

49,397 8,926 58,323 100%

All DALYs 755,176 689,993 1,445,169 In comparison: estimate for 1990: 3.5%% of all DALYs which are

alcohol-attributable 6.5% 1.3% 4.0%

Global burden of disease (DALYs in 1000s) attributable to alcohol by major disease categories - 2000

Future

Increase in alcohol-related burden for two reasons:– The disease categories related to alcohol are

relatively increasing: chronic disease, accidents and injuries

– Alcohol consumption is increasing in the most populous parts of the world

– Patterns are stable if not getting worse

If there are no interventions!!!