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Critique 219: A global overview of alcohol consumption and health – 3 September 2018

Investigators working with data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 have combined data from 195 locations around the world, from 1990 to 2016, for both sexes and for 5-year age groups between the ages of 15 years and 95 years and older. Their purpose was to determine how estimates of the prevalence of current drinking, abstention, the distribution of alcohol consumption among current drinkers in standard drinks daily (defined as 10 g of pure ethyl alcohol) relate to alcohol-attributable deaths and disability-adjusted lifeyears (DALYs). The paper does not present estimates of the effects of alcohol on a key outcome, total mortality.

The paper presents a huge number of analyses with data specific for each contributing center. However, the Forum considers that real problems emerge when they attempt to combine data from many divergent cultures to determine a single association between alcohol consumption and health. Many lifestyle and cultural factors strongly modify the relation of a given amount of alcohol to health and diseases. Such modifying factors include especially the socio-economic status of the individual, circumstances such as drinking with or without food, the pattern of drinking (regular moderate versus binge drinking), the type of beverage (e.g., wine versus spirits), the intention of the individual (drinking to get drunk versus drinking to enhance meals), level of physical activity, etc. When such modifying factors are not taken into consideration, the estimated intake of a given amount of alcohol (even if accurate), provides an incomplete assessment of the effects of alcohol on health.

The authors spend much of their paper focusing on their contention that these analyses have large implications for setting alcohol policy around the world. They then expand primarily on ways of decreasing alcohol intake world-wide through changes in guidelines. However, their failure to consider specifics of the culture for which the policy is being formulated, such as evaluating other lifestyle factors, the pattern of drinking, underreporting of alcohol intake, cultural factors, etc., negates their ability to provide useful information that is applicable to any single population: their guidelines end up applying to no one. And, their specific statement that zero consumption would be preferable everywhere is sharply contradicted by consistent reports from very large, well-done cohort studies (where individual data are available) which indicate that non-drinkers have higher risks of cardiovascular disease and total mortality than regular moderate drinkers who do not binge drink.

Setting guidelines for the public regarding alcohol consumption requires information not only on the reported intake but on other health conditions, as well as genetic, lifestyle, and cultural factors that may modify the effects of alcohol. Further, advice differs by age and the key problems within a country that the guidelines are directed toward improving. In the opinion of the Forum, despite the massive amount of work done by the investigators in the preparation of this paper, the overall combined results from such divergent populations have little applicability in setting guidelines that would lead to avoidance of alcohol abuse in any specific group of people around the world — they apply to no specific population.

Reference: GBD 2016 Alcohol Collaborators. Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. www.thelancet.com Published online August 23, 2018 http://dx.doi.org/10.1016/S0140-6736(18)31310-2

For the full critique of this paper by members of the International Scientific Forum on Alcohol Research, please go to www.alcoholresearchforum.org/critique-219

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