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• W4309487212 abstract "We appreciate the efforts of the GBD 2020 Alcohol Collaborators1Bryazka D Reitsma MB Griswold MG et al.Population-level risks of alcohol consumption by amount, geography, age, sex, and year: a systematic analysis for the Global Burden of Disease Study 2020.Lancet. 2022; 400: 185-235Summary Full Text Full Text PDF PubMed Scopus (18) Google Scholar to develop region-specific, sex-specific, and age-specific thresholds of alcohol consumption that indicate the lowest health risks. The authors’ approach considers the population distribution of health outcomes causally affected by alcohol consumption, such as injuries, gastrointestinal diseases, and cardiovascular diseases. Furthermore, younger populations are more likely to die from injuries than to have cardiovascular diseases or cancer. Considering that the risk of injury increases even after consuming small amounts of alcohol,2Cherpitel CJ Witbrodt J Ye Y Korcha R A multi-level analysis of emergency department data on drinking patterns, alcohol policy and cause of injury in 28 countries.Drug Alcohol Depend. 2018; 192: 172-178Crossref PubMed Scopus (7) Google Scholar estimates of the theoretical minimum risk exposure level (TMREL) and non-drinker equivalence (NDE) are close to zero for people aged 15–39 years, suggesting that abstinence is best for the health of people in this age range. Moreover, the findings implicate that for adults aged 45 and older, drinking half a standard drink daily is beneficial for their health and the daily consumption of up to two standard drinks for 55-year-olds and four standard drinks for 80-year-olds is associated with similar health risks as abstaining from alcohol. Despite the comprehensive efforts of tailoring drinking thresholds to the health risks faced by different populations, we have concerns about the methodology used in the study and the interpretation of the findings. The relative risks (RRs) and measures of alcohol exposure used in the model have numerous limitations. Firstly, as acknowledged as a limitation, drinking patterns were not considered in the analyses. Heavy episodic drinking (HED), often defined as the intake of 60 g or more of ethanol on one occasion, is reported by more than one in three drinkers.3Manthey J Shield KD Rylett M Hasan OSM Probst C Rehm J Global alcohol exposure between 1990 and 2017 and forecasts until 2030: a modelling study.Lancet. 2019; 393: 2493-2502Summary Full Text Full Text PDF PubMed Scopus (313) Google Scholar Moreover, drinking patterns are key for understanding injury risks,2Cherpitel CJ Witbrodt J Ye Y Korcha R A multi-level analysis of emergency department data on drinking patterns, alcohol policy and cause of injury in 28 countries.Drug Alcohol Depend. 2018; 192: 172-178Crossref PubMed Scopus (7) Google Scholar and for understanding the possible protective effects of alcohol consumption. Among moderate drinkers, HED increases the risk of ischaemic diseases, which are a major contributor to alcohol-attributable diseases in middle-aged (aged 40–59 years) and older (60 years or older) adults.4Roerecke M Rehm J Irregular heavy drinking occasions and risk of ischemic heart disease: a systematic review and meta-analysis.Am J Epidemiol. 2010; 171: 633-644Crossref PubMed Scopus (220) Google Scholar Thus, the J-shaped curve indicating a protective effect of moderate alcohol use on ischaemic heart disease, which is apparently significant for up to nine standard drinks per day,1Bryazka D Reitsma MB Griswold MG et al.Population-level risks of alcohol consumption by amount, geography, age, sex, and year: a systematic analysis for the Global Burden of Disease Study 2020.Lancet. 2022; 400: 185-235Summary Full Text Full Text PDF PubMed Scopus (18) Google Scholar vanishes when considering HED.5Roerecke M Rehm J Alcohol consumption, drinking patterns, and ischemic heart disease: a narrative review of meta-analyses and a systematic review and meta-analysis of the impact of heavy drinking occasions on risk for moderate drinkers.BMC Med. 2014; 12: 182Crossref PubMed Scopus (200) Google Scholar The importance of utilising HED can also be seen when comparing RRs from Russia with those of other countries, because no protective effect of alcohol on ischaemic diseases is observed in Russia, where HED used to be very prevalent.6Shield KD Rehm J Russia-specific relative risks and their effects on the estimated alcohol-attributable burden of disease.BMC Public Health. 2015; 15: 482Crossref PubMed Scopus (31) Google Scholar Taken together, the TMREL and NDE for middle-aged and older adults are probably overestimated, and their interpretation without considering HED is a flawed oversimplification. Secondly, the methodology of applying weights to universal risk curves appears to be one-sided because known age-dependent effects of alcohol and regional differences were not considered. For example, the risk-elevating effect of alcohol consumption on stroke mortality appears to be more pronounced among younger populations (aged 40–59 years).7WHOGlobal status report on alcohol and health 2018.https://www.who.int/publications/i/item/9789241565639Date: 2018Date accessed: July 7, 2022Google Scholar Moreover, the same disease-specific dose–response curves were used for all regions, despite ample evidence that such curves differ by region. For example, the risk for oesophageal cancer in Japan and in some other Asian countries is much higher due to genetic variations.6Shield KD Rehm J Russia-specific relative risks and their effects on the estimated alcohol-attributable burden of disease.BMC Public Health. 2015; 15: 482Crossref PubMed Scopus (31) Google Scholar, 8Roerecke M Shield KD Higuchi S et al.Estimates of alcohol-related oesophageal cancer burden in Japan: systematic review and meta-analyses.Bull World Health Organ. 2015; 93 (38C): 329Crossref PubMed Scopus (27) Google Scholar Thus, considering region and age in the absolute risk but not in the RR will introduce another bias. Thirdly, RRs are known to be affected by bias introduced by people who choose to quit drinking due to health conditions. Although the models used in the study do control for the reference group being lifetime non-drinkers only, current epidemiological studies do not account for people who quit drinking due to health conditions being removed from the exposure group, therefore biasing the RR of moderate alcohol consumption towards a protective effect. Furthermore, according to the authors, the presented findings “can aid in setting effective consumption guidelines”. In addition to the outlined methodological concerns, we also think that disability-adjusted life-year-weighted risk curves do not constitute an appropriate tool for defining drinking guidelines. Because there is solid evidence that the consumption of one standard drink daily increases some health risks,9Rovira P Rehm J Estimation of cancers caused by light to moderate alcohol consumption in the European Union.Eur J Public Health. 2021; 31: 591-596Crossref PubMed Scopus (4) Google Scholar a more cautious approach to defining drinking guidelines is warranted, which also includes the risk of cumulative exposure. Instead, the findings and the proposed interpretation by the GBD 2020 Alcohol Collaborators provide a unique opportunity for the alcohol industry to promote moderate consumption of up to two standard drinks per day for middle-aged adults and up to four standard drinks per day for older adults, which are the age groups that have the most alcohol-related harms. Thus, the implications of these findings, which are published in a prestigious journal with a global audience, are potentially detrimental to achieving the international goals of reducing alcohol consumption and harms. Unrelated to the present work, JM has worked as a consultant for public health agencies (WHO and the European Monitoring Centre for Drugs and Drug Addiction) and has further received honoraria for presentations, workshops, or manuscripts funded by various public health bodies (German Ministry of Health, Fachstelle NÖ, and Socidrogalcohol). KS and JR declare no competing interests." @default.
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• W4309487212 title "Alcohol and health" @default.
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