Advertisement

Managing excessive alcohol consumption at a population level: The earlier the better

  • Alexandre Louvet
    Correspondence
    Corresponding author. Address: Service des maladies de l’appareil digestif, Hôpital Huriez, Rue Polonowski, 59037 Lille cedex, France. Tel.: +33 320445597; fax: +33 320445564.
    Affiliations
    Service des maladies de l’appareil digestif, Hôpital Huriez, Rue Polonowski, 59037 Lille cedex, France
    Search for articles by this author
  • Aleksander Krag
    Affiliations
    Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
    Search for articles by this author
Published:January 22, 2018DOI:https://doi.org/10.1016/j.jhep.2017.12.015
      In the 2014 global status report on alcohol and health, the World Health Organization estimated that alcohol was responsible for 5.9% of deaths worldwide or 3.3 million people annually. Alcohol-related cirrhosis is responsible for 493,300 deaths.
      • Rehm J.
      • Samokhvalov A.V.
      • Shield K.D.
      Global burden of alcoholic liver diseases.
      Thus, alcohol is the leading cause of cirrhosis and liver-related deaths.
      • Sheron N.
      Alcohol and liver disease in Europe - Simple measures have the potential to prevent tens of thousands of premature deaths.
      • Stein E.
      • Cruz-Lemini M.
      • Altamirano J.
      • et al.
      Heavy daily alcohol intake at the population level predicts the weight of alcohol in cirrhosis burden worldwide.
      Despite the huge disease burden, there are no approved treatments for alcoholic liver disease. Yet, theoretically, alcohol-related disease is 100% preventable, which makes the role of preventive measures central in decreasing the impact of excessive alcohol consumption on society. Liver fibrosis is a condition that progresses slowly, and it usually takes decades before cirrhosis develops or decompensation occurs. However, the natural history of alcoholic liver disease has not been fully elucidated. Population data are crucial to help create evidence-based health policies to reinforce efforts to reduce alcohol related injury. In this issue of the Journal of Hepatology, Hagström et al. analyze the relationship between alcohol consumption in men at the time of conscription (aged 18–20) and the probability of severe liver disease 40 years later. They found drinking patterns were associated with a higher probability of alcohol-related liver damage. However, interestingly, there was no evidence for a “safe” threshold in this initial analysis, as the risk was significant for daily alcohol consumption as low as 6 g/day (less than one unit). In a second analysis, after adjustment for body mass index, tobacco consumption, the use of narcotics, cardiovascular fitness and cognitive ability, the association between alcohol consumption and risk of severe liver disease became significant for daily consumptions of >31 g/day.
      Several of the findings from this study warrant discussion. Although the relationship between the dose of alcohol consumed and the probability of cirrhosis is evident, the study did not support a threshold cut-off that could be regarded as safe in the non-adjusted analysis. The definition of safe cut-offs is difficult to set. For instance, Rehm
      • Rehm J.
      • Taylor B.
      • Mohapatra S.
      • et al.
      Alcohol as a risk factor for liver cirrhosis: a systematic review and meta-analysis.
      and Corrao,
      • Corrao G.
      • Bagnardi V.
      • Zambon A.
      • et al.
      Meta-analysis of alcohol intake in relation to risk of liver cirrhosis.
      have shown that levels of consumption as low as 12–25 g/day can be regarded as deleterious in men at a population level. Below these thresholds, the deleterious impact of alcohol on the liver is controversial and this has led EASL to be very cautious about this point in their guidelines.
      EASL clinical practical guidelines: management of alcoholic liver disease.
      The present study shows that the hazard ratio of severe liver damage becomes significant at 6 g/day, suggesting that any daily alcohol consumption should be avoided. These findings are similar to the Danish study published by Askgaard et al.
      • Askgaard G.
      • Gronbaek M.
      • Kjaer M.S.
      • et al.
      Alcohol drinking pattern and risk of alcoholic liver cirrhosis: a prospective cohort study.
      which reported that daily alcohol consumption increased the risk of alcoholic cirrhosis and that this was independent of the amount of alcohol consumed. However, in this latter study the impact on the liver of drinking at a young age was questioned, while this risk was clearly demonstrated by Hagström et al. in their study.
      The adjusted analysis underlines the role of cofactors in the progression of fibrosis in chronic alcohol drinkers. Indeed, after adjustment, the cut-off for an increased risk of severe liver disease is set at 31 g/day. This suggests that factors included in the adjustment have a deleterious impact on the liver in those who consume alcohol daily. The role of body mass index has been extensively studied and overweight/obese patients are more likely to develop alcohol-related cirrhosis than non-overweight individuals.
      • Hart C.L.
      • Morrison D.S.
      • Batty G.D.
      • et al.
      Effect of body mass index and alcohol consumption on liver disease: analysis of data from two prospective cohort studies.
      • Naveau S.
      • Giraud V.
      • Borotto E.
      • et al.
      Excess weight risk factor for alcoholic liver disease.
      In addition, the negative impact of tobacco on alcoholic liver disease has been shown by a large study in 125,000 individuals.
      • Klatsky A.L.
      • Morton C.
      • Udaltsova N.
      • et al.
      Coffee, cirrhosis, and transaminase enzymes.
      In terms of public health recommendations, the study by Hagström et al. suggests that young adults should limit their alcohol intake, but also refrain from smoking and becoming overweight, a recommendation that is sometimes difficult to promote in a population which generally does not feel sick.
      Unfortunately, the study by Hagström did not evaluate the phenomenon of binge drinking, which has become increasingly frequent in the past few years. The present study is based on data collected in 1969–1970 in men aged 18–20. Patterns of drinking alcohol have changed in Europe since then,
      • Sheron N.
      Alcohol and liver disease in Europe - Simple measures have the potential to prevent tens of thousands of premature deaths.
      • Leon D.A.
      • McCambridge J.
      Liver cirrhosis mortality rates in Britain from 1950 to 2002: an analysis of routine data.
      even if the burden of alcohol mortality has remained relatively stable in Sweden.
      • Sheron N.
      Alcohol and liver disease in Europe - Simple measures have the potential to prevent tens of thousands of premature deaths.
      In Southern Europe, daily alcohol consumption, and morbidity and mortality related to cirrhosis have decreased, whereas mortality and binge drinking have largely increased in Northern Europe, especially in Scandinavia and the United Kingdom.
      • Leon D.A.
      • McCambridge J.
      Liver cirrhosis mortality rates in Britain from 1950 to 2002: an analysis of routine data.
      • Kuntsche E.
      • Rehm J.
      • Gmel G.
      Characteristics of binge drinkers in Europe.
      While the direct link between binge drinking and alcoholic cirrhosis is still the subject of debate and must be scientifically demonstrated, growing evidence suggests that alcohol-related problems start at an early age. For example, in an English study published in 2009, patients diagnosed with alcoholic cirrhosis at the age of 50 had begun drinking alcohol excessively at 16 and declared more frequent episodes of binge drinking than control patients who had cirrhosis from other causes.
      • Hatton J.
      • Burton A.
      • Nash H.
      • et al.
      Drinking patterns, dependency and life-time drinking history in alcohol-related liver disease.
      Moreover, binge drinking during adolescence is a risk factor for the development of alcohol dependence as an adult.
      • Bonomo Y.A.
      • Bowes G.
      • Coffey C.
      • et al.
      Teenage drinking and the onset of alcohol dependence: a cohort study over seven years.
      Although the study by Hagström et al. did not specifically address the question of alcohol binge drinking, it is tempting to hypothesize that the role of binge drinking is important in this population of young men and that the influence of this phenomenon on liver mortality has increased over the last years.
      A previous study has shown that alcohol consumption early in life (thirties and forties) is associated with an increased risk of cirrhosis.
      • Rehm J.
      • Taylor B.
      • Mohapatra S.
      • et al.
      Alcohol as a risk factor for liver cirrhosis: a systematic review and meta-analysis.
      The present study adds to our knowledge about the risks of chronic alcohol consumption at a younger age. Most data have addressed relatively short-term alcohol-related disorders. In this setting, morbidity and mortality are mainly related to acute alcohol intoxication: violence, driving under the influence, unintentional injuries, etc.
      • Mathurin P.
      • Deltenre P.
      Effect of binge drinking on the liver: an alarming public health issue?.
      More recently, an English retrospective study
      • Herbert A.
      • Gilbert R.
      • Cottrell D.
      • et al.
      Causes of death up to 10 years after admissions to hospitals for self-inflicted, drug-related or alcohol-related, or violent injury during adolescence: a retrospective, nationwide, cohort study.
      has shown that the risk of alcohol-related-deaths was 3.53 in boys admitted for adversity-related injury compared to adolescents admitted for accident-related injury (control population). A total of 4,782 patients died during the 10-year follow-up (0.5% of the total study population). The study by Hagström et al. specifically addresses the issue of liver disease, an endpoint which has long been neglected in previous studies.
      Despite a long follow-up period and a very low rate of missing data, this study has some limitations which are discussed by the authors. One concern is the absence of data regarding alcohol drinking over time. Indeed, cirrhosis develops after several years of excessive alcohol consumption, and the analysis of its occurrence must take the individual’s behavior over time into account. In this setting, drinking at a young age and/or binge drinking is only one part of a lifetime of alcohol consumption.
      • Andersen A.
      The life-course approach to research on heavy alcohol drinking.
      As stated by Hagström et al. in their conclusion, safe levels of alcohol consumption must be revised for the general population and public health policies must be adapted accordingly. General recommendations by physicians must be accompanied by alcohol-control policies, especially access to alcohol, prices and advertising.
      • Sheron N.
      Alcohol and liver disease in Europe - Simple measures have the potential to prevent tens of thousands of premature deaths.
      • Burton R.
      • Henn C.
      • Lavoie D.
      • et al.
      A rapid evidence review of the effectiveness and cost-effectiveness of alcohol control policies: an English perspective.
      Indeed, education and information are not sufficient to reduce alcohol consumption in the general population.
      • Burton R.
      • Henn C.
      • Lavoie D.
      • et al.
      A rapid evidence review of the effectiveness and cost-effectiveness of alcohol control policies: an English perspective.
      However, targeted interventions aimed at identifying and advising excessive drinkers are useful on an individual level.

      Financial support

      The authors received no financial support to produce this manuscript.

      Conflict of interest

      The authors declare no conflicts of interest that pertain to this work. Please refer to the accompanying ICMJE disclosure forms for further details.

      Supplementary data

      References

        • Rehm J.
        • Samokhvalov A.V.
        • Shield K.D.
        Global burden of alcoholic liver diseases.
        J Hepatol. 2013; 59: 160-168
        • Sheron N.
        Alcohol and liver disease in Europe - Simple measures have the potential to prevent tens of thousands of premature deaths.
        J Hepatol. 2016; 64: 957-967
        • Stein E.
        • Cruz-Lemini M.
        • Altamirano J.
        • et al.
        Heavy daily alcohol intake at the population level predicts the weight of alcohol in cirrhosis burden worldwide.
        J Hepatol. 2016; 65: 998-1005
        • Rehm J.
        • Taylor B.
        • Mohapatra S.
        • et al.
        Alcohol as a risk factor for liver cirrhosis: a systematic review and meta-analysis.
        Drug Alcohol Rev. 2010; 29: 437-445
        • Corrao G.
        • Bagnardi V.
        • Zambon A.
        • et al.
        Meta-analysis of alcohol intake in relation to risk of liver cirrhosis.
        Alcohol Alcohol. 1998; 33: 381-392
      1. EASL clinical practical guidelines: management of alcoholic liver disease.
        J Hepatol. 2012; 57: 399-420
        • Askgaard G.
        • Gronbaek M.
        • Kjaer M.S.
        • et al.
        Alcohol drinking pattern and risk of alcoholic liver cirrhosis: a prospective cohort study.
        J Hepatol. 2015; 62: 1061-1067
        • Hart C.L.
        • Morrison D.S.
        • Batty G.D.
        • et al.
        Effect of body mass index and alcohol consumption on liver disease: analysis of data from two prospective cohort studies.
        BMJ. 2010; 340: c1240
        • Naveau S.
        • Giraud V.
        • Borotto E.
        • et al.
        Excess weight risk factor for alcoholic liver disease.
        Hepatology. 1997; 25: 108-111
        • Klatsky A.L.
        • Morton C.
        • Udaltsova N.
        • et al.
        Coffee, cirrhosis, and transaminase enzymes.
        Arch Intern Med. 2006; 166: 1190-1195
        • Leon D.A.
        • McCambridge J.
        Liver cirrhosis mortality rates in Britain from 1950 to 2002: an analysis of routine data.
        Lancet. 2006; 367: 52-56
        • Kuntsche E.
        • Rehm J.
        • Gmel G.
        Characteristics of binge drinkers in Europe.
        Soc Sci Med. 2004; 59: 113-127
        • Hatton J.
        • Burton A.
        • Nash H.
        • et al.
        Drinking patterns, dependency and life-time drinking history in alcohol-related liver disease.
        Addiction. 2009; 104: 587-592
        • Bonomo Y.A.
        • Bowes G.
        • Coffey C.
        • et al.
        Teenage drinking and the onset of alcohol dependence: a cohort study over seven years.
        Addiction. 2004; 99: 1520-1528
        • Mathurin P.
        • Deltenre P.
        Effect of binge drinking on the liver: an alarming public health issue?.
        Gut. 2009; 58: 613-617
        • Herbert A.
        • Gilbert R.
        • Cottrell D.
        • et al.
        Causes of death up to 10 years after admissions to hospitals for self-inflicted, drug-related or alcohol-related, or violent injury during adolescence: a retrospective, nationwide, cohort study.
        Lancet. 2017; 390: 577-587
        • Andersen A.
        The life-course approach to research on heavy alcohol drinking.
        Addiction. 2004; 99: 1489-1490
        • Burton R.
        • Henn C.
        • Lavoie D.
        • et al.
        A rapid evidence review of the effectiveness and cost-effectiveness of alcohol control policies: an English perspective.
        Lancet. 2017; 389: 1558-1580

      Linked Article

      • Alcohol consumption in late adolescence is associated with an increased risk of severe liver disease later in life
        Journal of HepatologyVol. 68Issue 3
        • Preview
          Alcohol consumption is a known risk factor for the development of cirrhosis.1,2 Alcohol has been reported to account for 85,000 deaths per year in the US3 and as many as 50% of all deaths from liver cirrhosis on a global scale.4 The exact amount of alcohol needed to inflict liver damage is unclear and is affected by internal factors including genetics5 and external factors including drinking patterns, type of alcohol and diet.6 Some evidence points to a cut-off around 30 grams of pure alcohol per day for men and 20 grams per day for women,1,6–8 although data from two meta-analyses indicate that the cut-off might be lower at 20–25 grams per day.
        • Full-Text
        • PDF