Age, Period, and Cohort Effects in Alcohol Use in the United States in the 20th and 21st Centuries: Implications for the Coming Decades

Alcohol Use Disorder and Dementia: A Review

PURPOSE

By 2040, 21.6% of Americans will be over age 65, and the population of those older than age 85 is estimated to reach 14.4 million. Although not causative, older age is a risk factor for dementia: every 5 years beyond age 65, the risk doubles; approximately one-third of those older than age 85 are diagnosed with dementia. As current alcohol consumption among older adults is significantly higher compared to previous generations, a pressing question is whether drinking alcohol increases the risk for Alzheimer's disease or other forms of dementia.

SEARCH METHODS

Databases explored included PubMed, Web of Science, and ScienceDirect. To accomplish this narrative review on the effects of alcohol consumption on dementia risk, the literature covered included clinical diagnoses, epidemiology, neuropsychology, postmortem pathology, neuroimaging and other biomarkers, and translational studies. Searches conducted between January 12 and August 1, 2023, included the following terms and combinations: "aging," "alcoholism," "alcohol use disorder (AUD)," "brain," "CNS," "dementia," "Wernicke," "Korsakoff," "Alzheimer," "vascular," "frontotemporal," "Lewy body," "clinical," "diagnosis," "epidemiology," "pathology," "autopsy," "postmortem," "histology," "cognitive," "motor," "neuropsychological," "magnetic resonance," "imaging," "PET," "ligand," "degeneration," "atrophy," "translational," "rodent," "rat," "mouse," "model," "amyloid," "neurofibrillary tangles," "α-synuclein," or "presenilin." When relevant, "species" (i.e., "humans" or "other animals") was selected as an additional filter. Review articles were avoided when possible.

SEARCH RESULTS

The two terms "alcoholism" and "aging" retrieved about 1,350 papers; adding phrases-for example, "postmortem" or "magnetic resonance"-limited the number to fewer than 100 papers. Using the traditional term, "alcoholism" with "dementia" resulted in 876 citations, but using the currently accepted term "alcohol use disorder (AUD)" with "dementia" produced only 87 papers. Similarly, whereas the terms "Alzheimer's" and "alcoholism" yielded 318 results, "Alzheimer's" and "alcohol use disorder (AUD)" returned only 40 citations. As pertinent postmortem pathology papers were published in the 1950s and recent animal models of Alzheimer's disease were created in the early 2000s, articles referenced span the years 1957 to 2024. In total, more than 5,000 articles were considered; about 400 are herein referenced.

DISCUSSION AND CONCLUSIONS

Chronic alcohol misuse accelerates brain aging and contributes to cognitive impairments, including those in the mnemonic domain. The consensus among studies from multiple disciplines, however, is that alcohol misuse can increase the risk for dementia, but not necessarily Alzheimer's disease. Key issues to consider include the reversibility of brain damage following abstinence from chronic alcohol misuse compared to the degenerative and progressive course of Alzheimer's disease, and the characteristic presence of protein inclusions in the brains of people with Alzheimer's disease, which are absent in the brains of those with AUD.

Alcohol and Binge Drinking Frequency and Hypertension: a national cross-sectional study in the U.S

INTRODUCTION

The relationship between alcohol consumption and hypertension is multifaceted and a major public health concern. The association becomes even more complicated when hypertension is undiagnosed. This study investigates how alcohol consumption patterns are linked to measured, diagnosed, undiagnosed, and composite hypertension (any indications of hypertension from blood pressure readings, professional diagnosis, or reported medication use) in the United States.

METHODS

Data from the National Health and Nutrition Examination Survey (NHANES) 2015-2020, a nationally representative cross-sectional study, were analyzed in 2023-24. The final analytic sample was 12,950 participants. Complex-survey weighted multivariable linear and logistic regression models estimated the effect of different alcohol consumption levels on hypertension.

RESULTS

Descriptive findings show that those who consumed alcohol more than three times weekly exhibited the highest prevalence of measured (52.5%), undiagnosed (27.0%), and composite hypertension (69.4%) compared to other levels of alcohol drinking. Multivariable linear regression analysis indicated a notable elevation in systolic (4.8 unit) and diastolic (2.46 unit) blood pressure among individuals with frequent binge drinking episodes compared to individuals with infrequent drinking. Logistic regression models estimated that drinking over three times weekly increases the odds of measured, undiagnosed, and composite hypertension by 64%, 70%, and 54%, respectively, while frequent binge drinking episodes raise these odds by 82%, 65%, and 47%.

CONCLUSIONS

Contrary to some studies suggesting moderate alcohol intake has protective cardiovascular effects, the findings did not corroborate a "J-shaped" curve. This underscores the importance of regular blood pressure monitoring among individuals with binge drinking episodes and emphasizes the need for public health interventions to mitigate alcohol consumption and its associated hypertension risks.

Demographic disparities in the limited awareness of alcohol use as a breast cancer risk factor: empirical findings from a cross-sectional study of U.S. women

BACKGROUND

Alcohol use is an established yet modifiable risk factor for breast cancer. However, recent research indicates that the vast majority of U.S. women are unaware that alcohol use is a risk factor for breast cancer. There is limited information about the sociodemographic characteristics and alcohol use correlates of awareness of the alcohol use and breast cancer link, and this is critically important for health promotion and intervention efforts. In this study, we assessed prevalence of the awareness of alcohol use as a risk factor for breast cancer among U.S. women and examined sociodemographic and alcohol use correlates of awareness of this link.

METHODS

We conducted a 20-minute online cross-sectional survey, called the ABLE (Alcohol and Breast Cancer Link Awareness) survey, among U.S. women aged 18 years and older (N = 5,027) in the fall of 2021. Survey questions assessed awareness that alcohol use increases breast cancer risk (yes, no, don't know/unsure); past-year alcohol use and harmful drinking via the Alcohol Use Disorders Identification Test (AUDIT); and family, health, and sociodemographic characteristics. We conducted multivariate multinomial regression analysis to identify correlates of awareness that alcohol use increases breast cancer risk.

RESULTS

Overall, 24.4% reported that alcohol use increased breast cancer risk, 40.2% reported they were unsure, and 35.4% reported that there was no link between alcohol use and breast cancer. In adjusted analysis, awareness of alcohol use as a breast cancer risk factor, compared to not being aware or unsure, was associated with being younger (18-25 years old), having a college degree, and having alcohol use disorder symptoms. Black women were less likely than white women to report awareness of the alcohol use and breast cancer link.

CONCLUSIONS

Overall, only a quarter of U.S. women were aware that alcohol use increases breast cancer risk, although 40% expressed uncertainty. Differences in awareness by age, level of education, race and ethnicity and level of alcohol use offer opportunities for tailored prevention interventions, while the overall low level of awareness calls for widespread efforts to increase awareness of the breast cancer risk from alcohol use among U.S. women.

Trends in binge drinking in the United States by LGBTQ+ identity, gender, and age, 2014-2022

BACKGROUND

People who identify as lesbian, gay, bisexual, transgender, or queer/questioning (LGBTQ+) have higher rates of risky drinking than their cisgender, heterosexual peers. It is unknown to what extent recent age and gender trends in binge drinking vary by LGBTQ+ identity.

METHODS

We used nationally representative, serial, cross-sectional surveys from men and women in the 2014-2022 Behavioral Risk Factor Surveillance System (N = 2,099,959) to examine trends in past-month binge drinking by LGBTQ+ identity, gender, and age (18-29, 30-44, 45 and older). We estimated stratum-specific prevalence ratios for an average 1-year increase in prevalence of past-month binge drinking using survey-weighted log-binomial models, controlling for education, race/ethnicity, marriage, and parenthood status.

RESULTS

In the beginning of the study period, LGBTQ+ women endorsed binge drinking at higher prevalences than their cisgender, heterosexual peers (i.e., 2014 predicted probability for women ages 30-44: 0.22 for LGBTQ+, 0.15 for cisgender, heterosexual). LGBTQ+ disparities in women's drinking attenuated over the study period among women in midlife (30-44 age group) due to increases in binge drinking among cisgender, heterosexual women (Prevalence Ratio [PR]: 1.025, 95% CI 1.018-1.033). Among men, we saw no evidence of LGBTQ+ disparities in binge drinking probabilities or in binge drinking trends across all age groups.

CONCLUSIONS

Disparities in mid-life binge drinking between LGBTQ+ and cisgender women have begun to diminish. These disparities are closing not because LGBTQ+ women are binge drinking less, but because cisgender, heterosexual women in midlife are binge drinking more.

One-month assessment of Th-cell axis related inflammatory cytokines, IL-17 and IL-22 and their role in alcohol-associated liver disease

Introduction

Changes in the expression of cyto- and chemokines due to alcohol-associated liver disease (ALD) have been reported to be both protective and pathogenic. This study examined plasma levels of two key cytokines, Il-17 and Il-22, which construct the proinflammatory vs. anti-inflammatory axes across the spectrum of alcohol use disorder (AUD) and ALD including alcohol-associated hepatitis (AH) to determine the underlying status of the inflammation.

Methods

Forty-two males and females aged 25-63 yrs. were grouped as healthy controls (HV[n=8]), AUD with no liver injury (AUDNLI [n=8]), AUD with liver injury (AUDLI [n=8]), non-severe alcohol-associated hepatitis (NSAH [n=9]), and severe alcohol-associated hepatitis (SAH [n=9]). Demographic, drinking, and clinical data were collected. Blood samples were collected at baseline (BL, all subjects) and during week 4 (W4, only patients) for IL-17 and IL-22; and statistically analyzed.

Results

IL-17 was highly elevated in the SAH group both at BL and post-SOC. LTDH and BL IL-22 in non-severe AH patients were associated significantly. LTDH significantly predicted W4 IL-22 levels, positively (increasing) in NSAH and inversely (lowering) in SAH patients. BL and W4 IL-22 levels were significantly higher (4-fold, p≤0.001) in all AH patients compared to all AUD patients (AUROC=0.988, p≤0.001). IL-22 showed significant affinity with AST, AST: ALT ratio, total bilirubin, INR, and PT both at BL and W4. IL-22 was inversely associated with IL-1β; and positively with TNF-α and IL-8 both at BL, and W4. BL IL-17 showed a positive correlation with MELD (p=0.017) in all AH patients. In SAH, > 2-fold W4 IL-17 level compared to BL showed significant within subjects' effects, p=0.006. In AUD patients without AH, the drop in IL-17 at W4 vs. BL showed a significant within subjects' effect, p=0.031.

Discussion

Drinking chronicity predicted opposite effects in IL-22 levels in NSAH (antiinflammatory) and SAH (pro-inflammatory) patients at post-SOC. BL IL-22 levels differentiated AH patients robustly from the AUD patients (with or without liver injury); and showed corresponding increases stepwise with the stages of ALD. IL-22 was closely associated with progression and injury markers of the liver; and response to the cytokines of pro-inflammatory nature. Pro-inflammatory indicator of IL-17 cell axis, IL-17 showed a strong positive association with MELD, a severity indicator of AH.

Multi-omics analysis of alcohol effects on the liver in young and aged mice

Excessive alcohol consumption has detrimental effects on the entire organism, especially on the liver. The toxicity is partly dependent on age, as older individuals metabolize alcohol more slowly leading to increased cellular injury. This study aimed to investigate the effects of moderate binge drinking on the liver of young and aged mice in a genome-wide multi-omics approach. We determined DNA methylation (DNAm) using the Illumina MouseMethylation array and gene expression by RNA sequencing in 18 female Balb/c mice in a 2 × 2 design. The animals underwent three moderate binge drinking cycles (ethanol vs. vehicle) and liver tissue was harvested at 4 or 19 months of age. We tested differential gene expression (DE) and DNAm associated with ethanol intake in linear models separately in young and aged mice, performed enrichment analyses for pathways and GWAS signatures of problematic alcohol use, and analysed the overlap of DNAm and gene expression. We observed DE in young and aged animals and substantial overlap in genes such as Bhlhe40, Klf10, and Frmd8. DE genes in aged animals were enriched for biological processes related to alcohol metabolism, inflammation, liver fibrosis, and GWAS signatures of problematic alcohol use. We identified overlapping signatures from DNAm and gene expression, for example, Frmd8 in aged and St6galnac4 in young mice. This study offers converging evidence of novel age-related targets in a moderate alcohol consumption model highlighting dysregulations in genes related to alcohol metabolism, inflammation, and liver fibrosis. Future studies are needed to confirm these results and elucidate the underlying mechanisms.

Alcohol use disorder: Neuroimaging evidence for accelerated aging of brain morphology and hypothesized contribution to age-related dementia

Excessive alcohol use curtails longevity by rendering intoxicated individuals vulnerable to heightened risk from accidents, violence, and alcohol poisoning, and makes chronically heavy drinkers vulnerable to acceleration of age-related medical and psychiatric conditions that can be life threatening (Yoon, Chen, Slater, Jung, & White, 2020). Thus, studies of factors influencing age-alcohol interactions must consider the potential that the alcohol use disorder (AUD) population may not represent the oldest ages of the unaffected population and may well have accrued comorbidities associated with both AUD and aging itself. Herein, we focus on the aging of the brains of men and women with AUD, keeping AUD contextual factors in mind. Knowledge of the potential influence of the AUD-associated co-factors on the condition of brain structure may lead to identifying modifiable risk factors to avert physical declines and may reverse or arrest further AUD-related degradation of the brain. In this narrative review, we 1) describe quantitative, controlled studies of brain macrostructure and microstructure of adults with AUD, 2) consider the possibility of recovery of brain integrity through harm reduction with sustained abstinence or reduced drinking, and 3) speculate on the ramifications of accelerated aging in AUD as contributing to age-related dementia.

Acceptability of Primary Care Counseling and Brief Educational Messages to Increase Awareness about Alcohol and Breast Cancer Risks among Bisexual and Lesbian Women

This research had two aims: (1) to assess how often bisexual and lesbian women self-report screening and counseling for alcohol use in primary care settings; and (2) understand how bisexual and lesbian women respond to brief messages that alcohol increases breast cancer risk. The study sample consisted of 4891 adult U.S. women who responded to an online, cross-sectional Qualtrics survey in September-October 2021. The survey included the Alcohol Use Disorders Identification Test (AUDIT), questions about alcohol screening and brief counseling in primary care, and questions assessing awareness of the link between alcohol use and breast cancer. Bivariate analyses and logistic regression were conducted. Bisexual and lesbian women had higher odds of harmful drinking (AUDIT score ≥ 8) than heterosexual women (adjusted odds ratio [AOR] = 1.26, 95% confidence interval [CI] = 1.01-1.57 for bisexual women; AOR =1.78, 95% CI = 1.24-2.57 for lesbian women). However, bisexual and lesbian women were no more likely than heterosexual women to be advised about drinking in primary care. In addition, bisexual, lesbian, and heterosexual women had similar reactions to messages highlighting that alcohol is a risk factor for breast cancer. Women across all three sexual orientations who are harmful drinkers more often agreed to search for more information online or talk to a medical professional compared to non-harmful drinkers.

A critical review of recent knowledge of alcohol's effects on the immunological response in different tissues

Alcohol misuse contributes to the dysregulation of immune responses and multiorgan dysfunction across various tissues, which are associated with higher risk of morbidity and mortality in people with alcohol use disorders. Organ-specific immune cells, including microglia in the brain, alveolar macrophages in the lungs, and Kupffer cells in the liver, play vital functions in host immune defense through tissue repair and maintenance of homeostasis. However, binge drinking and chronic alcohol misuse impair these immune cells' abilities to regulate inflammatory signaling and metabolism, thus contributing to multiorgan dysfunction. Further complicating these delicate systems, immune cell dysfunction associated with alcohol misuse is exacerbated by aging and gut barrier leakage. This critical review describes recent advances in elucidating the potential mechanisms by which alcohol misuse leads to derangements in host immunity and highlights current gaps in knowledge that may be the focus of future investigations.

Causal Inference with Case-Only Studies in Injury Epidemiology Research

Purpose of Review

We review the application and limitations of two implementations of the "case-only design" in injury epidemiology with example analyses of Fatality Analysis Reporting System data.

Recent Findings

The term "case-only design" covers a variety of epidemiologic designs; here, two implementations of the design are reviewed: (1) studies to uncover etiological heterogeneity and (2) studies to measure exposure effect modification. These two designs produce results that require different interpretations and rely upon different assumptions. The key assumption of case-only designs for exposure effect modification, the more commonly used of the two designs, does not commonly hold for injuries and so results from studies using this design cannot be interpreted. Case-only designs to identify etiological heterogeneity in injury risk are interpretable but only when the case-series is conceptualized as arising from an underlying cohort.

Summary

The results of studies using case-only designs are commonly misinterpreted in the injury literature.

The Impact of Social Supports on the Excessive Alcohol Use of the Middle-Aged Adults in South Korea: Do All Types of Social Supports Have Positive Effects on Excessive Alcohol Users?

The purpose of the study is to discuss the necessity of interventions on excessive alcohol use among middle-aged adult Koreans and attempt to investigate the effect of social supports including family support and friend support on excessive alcohol use. To achieve these goals, a self-administered online survey was conducted on middle-aged adult Koreans from 40 to 59 years old sampled through the convenience allocation extraction method, with responses of a total of 767 samples analyzed. The results from the analysis was that the support of the family reduced excessive alcohol use, whereas the support of friends provoked excessive alcohol use. Based on these results, the necessity of a distinction in the different types of social supports for interventions in excessive alcohol use was revealed. In addition, several practical and political implications for the alleviation of excessive alcohol use among middle-aged adults are recommended.

Illustration of Gut-Thyroid Axis in Alcohol Use Disorder: Interplay of Gut Dysfunction, Pro-Inflammatory Responses, and Thyroid Function

(1) Background: Heavy and chronic alcohol drinking leads to altered gut dysfunction, coupled with a pro-inflammatory state. Thyroid-associated hormones and proteins may be dysregulated by heavy and chronic alcohol intake; however, the mechanism for altered gut-derived changes in thyroid function has not been studied thus far. This study investigates the role of alcohol-induced gut dysfunction and pro-inflammatory cytokine profile in the thyroid function of patients with alcohol use disorder (AUD). (2) Methods: Male and female AUD patients (n = 44) were divided into Gr.1, patients with normal thyroid-stimulating hormone (TSH) levels (n = 28, 0.8 ≤ TSH ≤ 3 mIU/L); and Gr.2, patients with clinically elevated TSH levels (n = 16, TSH > 3 mIU/L). Demographics, drinking measures, comprehensive metabolic panels, and candidate thyroid markers (TSH, circulating triiodothyronine (T3), and free thyroxine (fT4)) were analyzed. Gut-dysfunction-associated markers (lipopolysaccharide (LPS), LPS-binding protein (LBP), and soluble LPS-induced pathogen-associated protein (sCD14)), and candidate pro-inflammatory cytokines (IL-1β, TNF-α, IL-6, IL-8, MCP-1, PAI-1) were also evaluated. (3) Results: Patients in both groups presented with a borderline overweight BMI category. Gr.2 reported numerically higher indices of chronic and heavy drinking patterns than Gr.1. The fT4 levels were elevated, while T3 was within normal limits in both groups. The gut dysfunction markers LBP and sCD14 were numerically elevated in Gr.2 vs. Gr.1, suggesting subtle ongoing changes. Candidate pro-inflammatory cytokines were significantly elevated in Gr.2, including IL-1 β, MCP-1, and PAI-1. Gr.2 showed a strong and statistically significant effect on the gut–immune–thyroid response (r = 0.896, 36 p = 0.002) on TSH levels in a multivariate regression model with LBP, sCD14, and PAI-1 levels as upstream variables in the gut–thyroid pathway. In addition, AUROC analysis demonstrated that many of the cytokines strongly predicted TSH in Gr.2, including IL-6 (area = 0.774, 39 p < 0.001) and TNF-α (area = 0.708, p = 0.017), among others. This was not observed in Gr.1. Gr.2 demonstrated elevated fT4, as well as TSH, which suggests that there was subclinical thyroiditis with underlying CNS dysfunction and a lack of a negative feedback loop. (4) Conclusions: These findings reveal the toxic effects of heavy and chronic drinking that play a pathological role in thyroid gland dysregulation by employing the gut–brain axis. These results also emphasize potential directions to carefully evaluate thyroid dysregulation in the overall medical management of AUD.

Labor force status as a buffer against mortality risks associated with alcohol consumption: A study of adult U.S. women, 2001-2015

The association between women's labor force participation, their alcohol consumption patterns, and mortality risk is unclear. This study assessed all-cause mortality risk among women in the United States, considering their labor force status and alcohol drinking. This study used discrete-time hazard models to examine this association using 2001-2015 National Health Interview Survey-Linked Mortality Files (NHIS-LMF) data (n = 147,714) for women aged 25 to 65 with 5725 deaths in this sample. Complex survey-weighted adjustments and E-values calculations were used to limit quantitative and observational biases. Alcohol consumption and labor force status together lead to substantial mortality risks. There is a statistically significant mortality risk among unemployed women (HR 2.15, 95% CI 1.18-3.91) and women not in labor force (HR 2.38, 95% CI 1.87-3.01). In the stratified models, non-Hispanic blacks (HR 1.48, 95% CI 1.30-1.67) and Asians (HR 1.93, 95% CI 1.54-2.44) have heightened mortality risks borne out of employment. Women with higher psychological distress have a 26% higher risk of all-cause mortality when not in labor force. With the help of cross-sectional data, this study demonstrates that women not in labor force and unemployed women are more likely to be affected by their drinking habits, and their employment status is associated with lower mortality risk. Further research should be focused on cause-specific mortality, gender roles and norms, reasons for unemployment, and comorbidities using more recent data, causal modeling techniques, and an extended mortality follow-up period.

Alcoholic liver disease: a new insight into the pathogenesis of liver disease

Excessive alcohol consumption contributes to a broad clinical spectrum of liver diseases, from simple steatosis to end-stage hepatocellular carcinoma. The liver is the primary organ that metabolizes ingested alcohol and is exquisitely sensitive to alcohol intake. Alcohol metabolism is classified into two pathways: oxidative and non-oxidative alcohol metabolism. Both oxidative and non-oxidative alcohol metabolisms and their metabolites have toxic consequences for multiple organs, including the liver, adipose tissue, intestine, and pancreas. Although many studies have focused on the effects of oxidative alcohol metabolites on liver damage, the importance of non-oxidative alcohol metabolites in cellular damage has also been discovered. Furthermore, extrahepatic alcohol effects are crucial for providing additional information necessary for the progression of alcoholic liver disease. Therefore, studying the effects of alcohol-producing metabolites and interorgan crosstalk between the liver and peripheral organs that express ethanol-metabolizing enzymes will facilitate a comprehensive understanding of the pathogenesis of alcoholic liver disease. This review focuses on alcohol-metabolite-associated hepatotoxicity due to oxidative and non-oxidative alcohol metabolites and the role of interorgan crosstalk in alcoholic liver disease pathogenesis.