Alcohol consumption guidelines: relative safety vs absolute risks and benefits

Review and Recommendations for the Component Tests in the Liver Function Test Profile

Pathology laboratories group some tests that they perform on their high throughput biochemistry analysers into profiles of tests that are associated with different organs (e.g. liver function tests-LFT). The components of these profiles are historic and often vary between different laboratories. This can lead to confusion and begs the question of what should be in a particular profile. In community medicine profiles may be used as screening tests but some of the components of the profiles may have low sensitivity and specificity and may produce both false positives and negatives. The LFT may include components which are poor liver function tests but are sensitive to fatty liver and hence elevations may cause unnecessary concern. Harmonisation of clinical chemistry reference intervals and units is occurring now so it is time to consider a similar process for components of a profile. A proposed list of analytes to be performed in the LFT profile is given.

Synergistic association between alcohol intake and body mass index with serum alanine and aspartate aminotransferase levels in older adults: the Rancho Bernardo Study

BACKGROUND

The association between body-mass-index (BMI), alcohol consumption and their joint effect in increasing the risk of elevated serum alanine (ALT) and aspartate (AST) is unclear in older community-dwelling adults.

AIM

To determine the association between alcohol, BMI, and their combined effect with serum ALT and AST in older community-dwelling adults in the United States.

METHODS

A cross-sectional, population-based study in participants (n = 2364) from the Rancho Bernardo Study (54% women; mean age: 70 years, BMI: 25 kg/m(2), alcohol users: 63%) who attended a research visit in 1984-87. BMI was recorded by a trained nurse and alcohol use ascertained by a validated questionnaire. Odds-ratio (OR) and 95% confidence intervals (CI) of elevated serum ALT and AST (defined as > or =30 U/L in men and > or =19 U/L in women) were calculated for alcohol and BMI separately and their joint exposure using logistic regression models.

RESULTS

In multivariate logistic regression models adjusted for age, alcohol use, total cholesterol, serum triglycerides, fasting plasma glucose, systolic blood pressure, and diabetes mellitus, obesity independently increased the odds of elevated ALT in this cohort of older men and women by 3.0 (95% CI, 1.7-5.3) and 1.8 (95% CI, 1.1-2.7) respectively. Joint effects of consuming >3 alcoholic drinks/day and obesity raised the odds of elevated ALT by 8.9 (95% CI, 2.4-33.1) and AST by 21-fold (95% CI, 2.6-170.1), demonstrating synergism. Obese participants had higher odds of elevated ALT even at 0 < or = 1 drink/day.

CONCLUSIONS

In older men and women, the combination of obesity with alcohol is synergistic in increasing the risk of liver injury.

The lifestyle of patients with chronic fatigue syndrome and the effect on fatigue and functional impairments

BACKGROUND

Little is known about the lifestyle of patients with chronic fatigue syndrome (CFS) and its influence on symptoms of CFS. The present study aimed to investigate the lifestyle of patients with CFS, and to assess whether lifestyle factors are related to fatigue and functional impairments.

METHODS

Two hundred and forty-seven patients fulfilling the Center for Disease Control criteria for CFS were included. Validated questionnaires were used to collect data on lifestyle factors, smoking, intake of alcohol, fat, fibres, fruit and vegetables, body mass index (BMI), fatigue severity and functional impairments.

RESULTS

Of the CFS patients, 23% smoked, 32% had an unhealthy BMI, and none had an unhealthy alcohol intake. A majority had an unhealthy food intake: 70% had unhealthy fat, fruit and vegetable intake, and 95% had unhealthy fibre intake. Compared with the general Dutch population, significantly fewer CFS patients were overweight. Significantly more female CFS patients abstained from alcohol, and fewer male CFS patients smoked. Unhealthy lifestyle factors were not significantly associated with fatigue severity or functional impairments.

CONCLUSIONS

CFS patients tend to lead a healthier lifestyle compared to the general Dutch population. However, no relationship was found between lifestyle factors and fatigue severity and functional impairments in CFS.

ALCOHOL IS BAD FOR BLOOD PRESSURE

1. The regular consumption of alcohol elevates blood pressure, with global estimates that the attributable risk for hypertensive disease from alcohol is 16%. 2. The increase in blood pressure is approximately 1 mmHg for each 10 g alcohol consumed and is largely reversible within 2-4 weeks of abstinence or a substantial reduction in alcohol intake. 3. This increase in blood pressure occurs irrespective of the type of alcoholic beverage. In particular, the postulated effects of vasodilator flavonoid components of red wine to lessen or reverse alcohol-related hypertension have not been borne out in intervention studies. 4. Heavy drinking, especially a binge pattern of drinking, is linked to a higher incidence of cerebral thrombosis, cerebral haemorrhage and coronary artery disease deaths, although a role for alcohol-related hypertension in the causal pathway is not well defined. 5. In contrast, the light to moderate intake of alcohol has been consistently linked to a reduced risk of atherosclerotic vascular disease end-points. Such a protective effect may also extend to hypertensive subjects. 6. However, the magnitude of any protective effect appears to have been exaggerated because of unmeasured confounders, especially diet, lifestyle and patterns of drinking. Furthermore, a decrease in overall mortality with drinking appears confined to older subjects and to populations with a high background cardiovascular risk profile. 7. Any putative cardiovascular benefits from drinking need to be carefully considered against the effects of alcohol to elevate blood pressure, together with many other adverse health consequences from drinking. Maximum cardiovascular benefit occurs at relatively low levels of consumption (i.e. one to two standard drinks a day in men (10-20 g alcohol) and up to one a day in women (10 g alcohol)). In hypertensive subjects, consumption beyond these levels would be unwise.

A brief behavioral feedback intervention in hospital outpatients with a high cardiovascular risk

OBJECTIVE

Examining the prevalence of risk behavior and motivation to change among hospital outpatients with a high cardiovascular risk, and the implementation and results of a brief behavioral feedback intervention by internists.

METHODS

One hundred and sixty-one patients completed a lifestyle questionnaire and were given personalized feedback on the results by their internists. The delivery of the feedback was monitored. In an ad hoc non randomized comparison after four months, 68 patients who received an intervention were compared with 40 who did not receive it.

RESULTS

Ninety-six percent of the patients demonstrated at least one risk behavior and 73% were not contemplating change. The intervention was correctly given to 62%. The patients who received the intervention reported more lifestyle changes and altered their motivation to change more often.

DISCUSSION

Given the prevalence of risk behavior lifestyle interventions are worthwhile. Internists delivered the intervention to most patients. Small effects of the intervention were found, but the non-experimental nature of the study should be taken into account.

CONCLUSION

Implementation of a behavioral feedback intervention seems to be feasible and can lead to worthwhile lifestyle changes for patients at risk for cardiovascular disease.

PRACTICE IMPLICATIONS

Training and education can improve the intervention. Also a nurse practitioner can perform part of it.

How many alcoholic drinks might benefit an older person with hypertension?

Lowering alcohol intake reduces blood pressure and hence cardiovascular risk. However, abstainers have an increase in cardiovascular risk and the advice to reduce intake to low levels may not be sound. This review examines the effects of lowering alcohol consumption in terms of blood pressure and coronary heart disease (CHD). The relationship between both CHD and stroke and alcohol consumption, and the benefits and disadvantages of alcohol consumption in the general population, are discussed. Where available, the results of large meta-analyses are reported. It is concluded that the hypertensive patient over the age of 60 who drinks over 16 drinks per week should be advised to reduce his or her alcohol intake but a daily drink may be advisable and the patient should not stop drinking entirely. It is not suggested that the non-drinker should start drinking, but most hypertensives are over the age of 60 when community studies suggest that drinking alcohol does more good than harm.

ADDING PSYCHOLOGIST'S INTERVENTION TO PHYSICIANS' ADVICE TO PROBLEM DRINKERS IN THE OUTPATIENT CLINIC

AIMS

To test the effectiveness of a brief psychological intervention for problem drinking among outpatients in a hospital setting.

METHODS

Over a period of 3 years physicians screened patients who visited an outpatient clinic for general internal medicine for problem drinking. Of the 4728 patients screened, 284 (6%) scored positive on problem drinking of whom 123 participated in the study. They received a computerized baseline assessment and were randomly allocated to a brief psychosocial intervention given by a psychologist (Dutch version of W. R. Millers' Drinker's Check-Up) (n = 61) or to 'care as usual' (n = 62). They were followed up at 6 months. The outcome measures were alcohol consumption and the increase in motivation to reduce alcohol consumption.

RESULTS

Most patients reduced their alcohol consumption over time, but no differences were found between the intervention and control groups. A slightly, but not significantly, larger proportion of patients who received the intervention increased their motivation to change.

CONCLUSIONS

No conclusive evidence was found for the effectiveness of adding a brief psychological intervention to the physician's advice for problem drinking among outpatients in a hospital setting.

Are stress related factors associated with alcohol intake?

Moderate alcohol consumption is related to reduced risks of coronary heart disease and all-cause mortality. Our goal is to advance our understanding of the associations between stress-related factors and alcohol consumption, using cutoff points for alcohol intake that reflect health benefits rather than health risks. Cross-sectional data were used from 4,131 respondents (age 20-65 years) participating in a cohort study in the Netherlands on psychosocial factors and cancer risk. Analyses were performed among drinkers only, for men and women separately. Heavy alcohol intake (>/= 3 glasses per day for men, >/= 2 glasses per day for women) was associated with only a few stress-related factors in multivariate analyses. No significant associations between the total amount of stressors and alcohol intake were found. We conclude that stress-related factors are only marginally associated with a heavy alcohol intake compared with fair drinking, using the safe limits of drinking as cutoff point.

Gender differences in the use of alcohol and psychotropics in a Brazilian population

This cross-sectional, interview-based survey aimed to assess the use of licit substances in terms of gender and sociodemographic factors in the city of Pelotas, southern Brazil. Subjects aged 15 years and over and living in urban areas were eligible and a total of 1277 subjects were interviewed. The prevalence of alcohol consumption was 54.2%; 11.9% (21.7% of men and 4.1% of women) reported potentially harmful levels of alcohol use ("at-risk alcohol intake"); 4.2% were classified as manifesting alcohol dependence by CAGE questionnaire. At-risk alcohol intake and subjects with a positive CAGE score were more common among males aged 35-54 yrs. Among the youngest age group, the prevalence of CAGE positive score was similar for males and females, while subjects with lower educational levels showed a higher prevalence. Women were more likely than men to report the use of psychotropic drugs (15% vs. 7%). These results highlight the importance of substance use in Brazil, and suggest that gender differences must to be taken into consideration when planning intervention programs in developing countries.

Alcohol consumption and incidence of dementia in a community sample aged 75 years and older

To explore the relationship between light to moderate alcohol consumption and risk of dementia and Alzheimer's disease in very old people, a community-based dementia-free cohort (n = 402) was followed for almost 6 years to detect incident dementia using the Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition-Revised criteria. Data from the entire cohort and a subpopulation of those with baseline Mini-Mental State Examination score > or =24 (n = 317) were analyzed with Cox models. In the entire population, light to moderate drinking was significantly associated with a decreased risk of incident dementia and Alzheimer's disease compared with nondrinking (adjusted relative risk 0.5, 95% confidence interval 0.3 to 0.7). In the analysis of the subpopulation, however, the inverse association between light to moderate drinking and risk of incident dementia and Alzheimer's disease was less evident and no longer statistically significant. This study suggested that light to moderate alcohol drinking might protect against dementia and Alzheimer's disease among old people, although the possibility that such an association may be due to information bias cannot be totally ruled out.

Clustering of lifestyle risk factors in a general adult population

BACKGROUND

The objective of the study was to evaluate the degree of clustering of common lifestyle risk factors in a general adult population and to define subgroups with elevated clustering.

METHODS

Data on lifestyle risk factors (smoking, low vegetable and fruit consumption, excessive alcohol intake, and low physical activity), sociodemographics, and health perception were collected by questionnaire from 16,789 men and women aged 20 to 59.

RESULTS

About 20% of the subjects had at least three lifestyle risk factors. Prevalence of risk factors was higher among unemployed, low-educated subjects and those who had experienced health deterioration. All lifestyle risk factors showed significant clustering, except for low physical activity and excessive alcohol consumption. The strongest association was observed for alcohol and smoking (prevalence odds ratio (POR): 2.38; 95% confidence interval: 2.18-2.61). Clustering of smoking and alcohol consumption was strongest among the young subjects (POR: 3.78) and, although moderately, clustering of lifestyle risk factors was elevated in subjects who had experienced a deterioration in health.

CONCLUSIONS

These findings suggest that common lifestyle risk factors cluster among adult subjects. The tendency for risk factors to aggregate has important implications for health promotion. Information on high-risk groups will help in planning future preventive strategies.

Drug & alcohol intervention for older women: a pilot study

Pretest and posttest information was gathered from 26 older women attending educational programs related to alcohol and drug use. The goals of the study were to determine current knowledge about alcohol and drugs among older women and to gather some initial information about the potential for alcohol and drug interactions and misuse. The intervention included a 60-minute presentation on the metabolism of alcohol and drugs in the aging body, the potential for alcohol-drug interactions, and a discussion of healthy lifestyles (e.g., diet, exercise). Older women, especially those who were moderate to heavy drinkers, were found to have many misconceptions about alcohol and drug use, but their knowledge improved dramatically after the brief educational intervention. This finding may suggest that most of the women had knowledge deficits rather than deeply entrenched attitudes about alcohol and drug use or alcohol dependence. Therefore, simple educational interventions may be very effective with this subset of women.

Effects of dietary modification and treatment of obesity. Emphasis on improving vascular outcomes

This article has considered a vast literature attesting to the efficacy of dietary intervention on risk factors and on vascular outcomes. Rather than rely solely on pharmacotherapy to improve risk factors and vascular outcomes, physicians, nurses, dietitians, pharmacists, and medical providers should emphasize the benefits of a well-balanced, nutritionally sound dietary program. It should be low in SFA; controlled in calories to avoid (or reduce) obesity; and rich in fruits, vegetables, whole-grain products, and good sources of protein. Emphasis on foods rich in n-3 fatty acids shows promise for reducing cardiovascular outcomes. Further studies using these and antioxidants are eagerly awaited.

The effects of drinking on health of older adults

As part of a larger health-promotion project focused on safer use of alcohol and medications by older people, 826 persons living in a small community in Eastern Ontario participated in a survey conducted by nurses in the participant's home. The survey interview varied in length from 30 to 210 minutes and covered alcohol use, medication use, health status, and other aspects of life. This report examines the relationship between drinking practices and self-reported health (overall rating of health, hospital admissions, etc.) as identified by the survey. Among survey participants who abstained from alcohol during the 12 months prior to the survey, former drinkers reported significantly poorer health than did lifetime abstainers and previous drinkers who happened to abstain in the previous year but considered themselves to be infrequent drinkers rather than former drinkers. Among current drinkers, poorer health was associated with drinking more on each occasion of drinking and with a greater total overall volume of alcoholic beverages consumed (as estimated from the drinker's usual weekly consumption), but not with more frequent drinking. Even when controlling for sex, age, education, and depressant medication use, quantity of alcoholic beverage consumption per occasion and overall volume consumed were found to contribute significantly to predicting perceived health. The implications of the findings are discussed in terms of the best ways to assess the risk level of alcohol use among older people, and with recommendations for safer alcohol use.

[Wine and heart]

Many epidemiological studies have shown that moderate alcohol intake, from 10 to 30 g of ethanol a day, decreases cardiovascular mortality from atherosclerotic ischaemic heart disease and ischaemic stroke as compared to non-drinkers. This beneficial effect outweighs the risks of alcohol consumption in subgroups of people with a higher risk of atherosclerosis: the elderly, people with coronary risk factors and patients with previous coronary events. It has not been demonstrated that alcohol intake, even in moderate amounts, is beneficial for the general population, in particular, men under the age of 40 and women under 50, because it raises mortality due to other causes, especially injury, cirrhosis of the liver and some types of cancer, thereby outweighing the benefits for coronary artery disease. Thus, alcohol consumption should not be recommended as a prophylaxis for the general population. Guidelines on alcohol drinking habits--whether to continue, to start, to modify or to stop--must be given on an individual basis, taking into account the relative risks and benefits for each patient. The benefits of moderate alcohol consumption on the cardiovascular system seem to be exerted fundamentally through its effects on plasma lipoproteins, principally by raising high density lipoprotein (HDL) cholesterol and to a lesser degree, by decreasing low density lipoprotein (LDL) cholesterol. It appears to exert additional beneficial effects on the heart by decreasing platelet aggregability and by bringing about changes in the clotting-fibrinolysis system. Although there has been some debate about the relative superiority of different types of alcoholic beverages (wine, beer or hard liquor), and to a greater extent, about different types of wine, there is no current evidence of any kind of beneficial effect from other components of the beverage besides ethanol. Thus, it does not seem appropriate to recommend any particular type of alcoholic drink, except for sociocultural reasons. The added benefits from some components of different types of wine with a high antioxidant activity on plasma lipoproteins remain only an interesting hypothesis. Meanwhile, encouraging a healthy diet, flavonoid rich and with a predominance of natural ingredients (fruit, legumes, cereals and seeds), in the general population should stop the current tendency of Southern European countries from abandoning the Mediterranean diet. Because of the multifactorial nature of coronary heart disease, it is necessary to remember that atherosclerotic risk reduction is achieved by behavior modification of multiple risk factors present in individual patients and in the general population. Therefore, guidelines regarding alcohol intake should always be linked to pertinent recommendations about other atherosclerotic risk factors.

College students' binge drinking at a beach-front destination during spring break

Four hundred forty-two women and 341 men were surveyed at Panama City Beach, Florida, to assess the effects of gender, age, fraternity or sorority membership, and travel motivation on alcohol consumption and binge drinking during spring break. The mean number of drinks consumed the previous day was 18 for men and 10 for women; 91.7% of the men and 78.1% of the women had participated in a binge-drinking episode during the previous day. Respondents less than 21 years old consumed less alcohol and reported significantly lower frequencies of intoxication than those over 21. The men's reported levels of alcohol consumption, binge drinking, and intoxication to the point of sickness were significantly higher than the women's, but fraternity or sorority membership was not associated with higher levels of consumption. Students motivated to visit the specific destination because of its "party" reputation consumed significantly more alcohol than students who cited other reasons for going there.

Alcohol and drug use in UK university students

BACKGROUND

Alcohol and illicit drug use are increasing among school children and young adults in the UK. Such increases have also been noted among university students and there is a need for a large survey across different universities and faculties. We report such a survey.

METHODS

Information about drinking, use of cannabis and other illicit drugs, other lifestyle variables, and subjective ratings of anxiety and depression was obtained by questionnaire in a cross-faculty sample of 3075 second-year university students (1610 men, 1447 women, 18 sex not stated) from ten UK universities. The questionnaire was personally administered during scheduled lecture hours and almost all the students participated. The sample reflected the interfaculty and sex distribution and the proportion of non-white students at UK universities.

FINDINGS

11% of the students were non-drinkers. Among drinkers, 61% of the men and 48% of the women exceeded "sensible" limits of 14 units per week for women and 21 for men. Hazardous drinking (> or = 36 units per week for women, > or = 51 for men) was reported by 15% of the drinkers. Binge drinking was declared by 28% of drinkers. 60% of the men and 55% of the women reported having used cannabis once or twice and 20% of the sample reported regular cannabis use (weekly or more often). Experience with other illicit drugs was reported by 33% of the sample, most commonly LSD (lysergic acid diethylamide), amphetamines, Ecstasy (methylenedioxymethamphetamine), and amyl/butyl nitrate which had each been used by 13-18% of students. 34% of these had used several drugs. Drug use had started at school in 46% of the sample; 13% began after entering university. The overwhelming reason given for taking alcohol or drugs was pleasure. Subjective ratings of anxiety on the hospital anxiety depression scale were high, and sleep difficulties were common, but neither related to alcohol or drug use.

INTERPRETATION

There is a need for better education about alcohol, drugs, and general health in universities. Such education should include all faculties. It remains unclear whether university students' lifestyles are carried over into later life.