Epidemiology of alcohol and burden of disease related to non-communicable diseases in the Americas

1. Jürgen Rehm Centre for Addiction and Mental Health, Toronto, Canada Dalla Lana School of Public Health, University of Toronto, Canada Technische Universität Dresden, Clinical Psychology and Psychotherapy Epidemiology of alcohol and burden of disease related to non-communicable diseases in the Americas

2. Overview: alcohol is the most important risk factor for burden of disease in the Americas This includes all disease and injury categories

3. Global leading causes of attributable global mortality and burden of disease, 2004 Attributable Mortality Attributable DALYs % • High blood pressure 12.8 • Tobacco use 8.7 • High blood glucose 5.8 • Physical inactivity 5.5 • Overweight and obesity 4.8 • High cholesterol 4.5 • Unsafe sex 4.0 • Alcohol use 3.8 • Childhood underweight 3.8 • Indoor smoke from solid fuels 3.3 59 million total global deaths in 2004 % • Childhood underweight 5.9 • Unsafe sex 4.6 • Alcohol use 4.5 • Unsafe water, sanitation, hygiene 4.2 • High blood pressure 3.7 • Tobacco use 3.7 • Suboptimal breastfeeding 2.9 • High blood glucose 2.7 • Indoor smoke from solid fuels 2.7 • Overweight and obesity 2.3 1.5 billion total global DALYs in 2004

4. Leading causes of attributable global mortality and burden of disease, 2004, in the Americas Attributable Mortality Attributable DALYs % • Tobacco use 14.0 • High blood pressure 13.4 • Overweight and obesity 9.5 • High blood glucose 8.1 • Physical inactivity 7.3 • Alcohol use 5.6 • High cholesterol 5.5 • Low fruit andvegetable intake 3.0 • Urban outdoor air pollution 2.3 • Unsafe sex 1.7 6.16 million total deaths in 2004 % • Alcohol use 9.1 • Tobacco use 6.2 • Overweight and obesity 5.5 • High blood glucose 4.3 • High blood pressure 3.8 • Physical inactivity 3.0 • High cholesterol 2.5 • Unsafe sex 2.2 • Illicit drug use 2.2 • Suboptimal breastfeeding 1.7 143.2 million total global DALYs in 2004 But what is the impact of NCD?

5. Necessary elements to do these calculations • Exposure to alcohol • Establishment of causality • Risk relations

6. Alcohol consumption in the Americas 2005 Characteristics and differences

7. Global consumption

8. And in the Americas

9. Patterns of consumption 1: Least hazardous; Regular drinking, often with meals and without heavy drinking bouts 4: Most hazardous: Infrequent but heavy drinking

10. Prevalence of abstention

11. Summary for exposure • Compared to global high per capita consumption • Drinkers are the majority: • Americas A: 34% • Americas B: 47% • Americas D: 51% • Overall, high consumption per drinker and high level of binge drinking!

12. Risk relations to NCD CVD categories Cancers Digestive Diseases

13. The relationship between alcohol consumption, NCD, and other harm • Detrimental impact of amount of alcohol consumed on various cancers (head and neck cancers, liver cancer, colorectal cancer, female breast cancer), haemorrhagic stroke, hypertensive disease, conduct disorders, liver cirrhosis and pancreatitis (monotone dose-response relationships) • Impact of drinking on ischaemic heart disease, stroke and diabetes (complex relationship) • In addition, impact of harmful use of alcohol on other diseases (TB, HIV/AIDS, pneumonia), alcohol use disorders, injuries and alcohol-related social harm (family, violence, worklife, etc.)

14. For many NCDs: the more alcohol consumed the higher the risk • See the next few slides based on the meta-analyses described in Rehm et al., 2010 Rehm, J., Baliunas, D., Borges, G.L.G., Graham, K., Irving, H.M., Kehoe, T., Parry, C.D., Patra, J., Popova, S., Poznyak,V., Roerecke, M., Room, R., Samokhvalov, A.V., & Taylor, B. (2010). The relation between different dimensions of alcohol consumption and burden of disease - an overview. Addiction, 105(5). 817-843.

15. Riskfunction and confidence interval for oesophagus cancer

16. Riskfunction and confidence Interval for colon cancer

17. Risk relation and confidence interval for liver cancer

18. Risk relation and confidence interval for femalebreastcancer

19. Risk relations and confidence interval for hypertension

20. Risk relations and confidence interval for livercirrhosismortality

21. Risk relations and confidence interval for pancreatitis

22. But what about the protective effect on ischaemic disease and diabetes? • There is a protective effect and a J-shaped curve for • Ischaemic heart disease • Ischaemic stroke • Diabetes • See ischemic stroke as example

23. Alcohol consumption and stroke

24. The impact of heavy drinking (RR of irregular heavy drinking at least once monthly vs. not) controlled for volume on ischaemic heart disease

25. Roerecke & Rehm, 2010, meta-analysis Contrary to a cardioprotective effect of moderate regular alcohol consumption, accumulating evidence points to a detrimental effect of irregular heavy drinking occasions (> 60 grams pure alcohol or 5+ drinks per occasion at least monthly) on ischemic heart disease (IHD) risk, even among drinkers whose average consumption is moderate. The authors systematically searched electronic databases from 1980 – 2009 for case-control or cohort studies examining the association of irregular heavy drinking occasions on IHD risk. Studies were included if they reported either a relative risk (RR) estimate for intoxication or frequency of 5+ drinks stratified by or adjusted for total average alcohol consumption. The search identified 14 studies (including 31 risk estimates), containing 4,718 IHD events (morbidity and mortality). Using a standardized protocol, RR estimates and their variance in addition to study characteristics were extracted. In a random-effects model, the pooled RR of irregular heavy drinking occasions compared to regular moderate drinking was 1.45 (95% confidence interval: 1.24 – 1.70) with significant between-study heterogeneity (I2 = 53.9%). Results were robust in several sensitivity analyses. The authors conclude that the cardioprotective effect of moderate alcohol consumption disappears when on average light to moderate drinking is mixed with irregular heavy drinking occasions.

26. Conclusion • The protective effects for ischaemic heart disease disappear if there are irregular heavy drinking occasions • As the biological mechanism is the same for ischaemic stroke, the same effects should apply

27. And the effect of alcohol on worsening the disease course • In addition to causing certain categories of NCD, alcohol worsens the disease course by • Disrupting medication regimes • Weakening the immune system (both innate and acquired)

28. Consequences for burden of disease

30. Summary • Alcohol has a causal impact on NCDs which is overall negative • Alcohol policy could contribute to prevent NCDs

31. A framework for NCDs (Lancet NCD group)

32. The Lancet NCD Action Group and The NCD Alliance Priority actions for the NCD crisis

33. Poverty, NCD and development goals Source: Beaglehole R, Bonita R, Horton R, et al for The Lancet NCD Action Group and the NCD Alliance. Priority actions for the NCD crisis. Lancet 2011; 377:1438-47

34. Best buys, especially for low and middle income countries • very cost-effective ($ per DALY prevented < GDP per person) • very low cost in implementation and in principle feasible