Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Drinking Patterns are important
- Johannes G. Scholl (29 July 2002)
-
Alcohol and Life
- michael j fitzpatrick (29 July 2002)
-
Alcohol consumption and mortality: falls and the elderly.
- Robert Patton (30 July 2002)
-
Re: Alcohol consumption and mortality: modelling risks for men and women at different ages
- Moussa Sarr (2 August 2002)
-
Re: Re: Alcohol consumption and mortality: modelling risks for men and women at different ages
- Johannes G. Scholl (3 August 2002)
-
Long-term effects are more important than short-term
- Adam Jacobs (6 August 2002)
-
Risk and risky behaviour
- Andy M Wearn (8 August 2002)
-
A risky preventive approach
- Richard Saitz (19 September 2002)
|
|
|||
|
Johannes G. Scholl, Physician, Private Practice 65385 Ruedesheim, Germany
Send response to journal:
|
Letter to the BMJ è White, Ian R. et al., BMJ 2002; 325:191-197 In the conclusion of their thorough statistical analysis of the associations between alcohol, morbidity and mortality at different ages, White et al. mention the impact of drinking patterns. A common problem in studies assessing the alcohol consumption in drinks per week is, that they do not account for the differences in drinking patterns. Within the ECAS-2-Study , commissioned by the European Union, there was conducted a survey of drinking patterns and alcohol-related problems in 6 European countries (Finland, France, Germany, Italy, Sweden, and the U.K.). In countries with preferred wine consumption (France and Italy) people consumed alcohol rather on a regular basis with meals contrasting with the beer drinking countries, where alcohol consumption was unevenly distributed over the week, and a higher consumption mainly without meals was noticed at the weekends. Per drinking session the amount of alcohol was much smaller in France and Italy. On the other hand binge drinking was far more common in the beer drinking countries. Apart from the well known dietary variations between Eurpean countries it may be an effect of the drinking patterns which can explain the observed differences in the association between alcohol consumption and mortality in mediterranean and non-mediterranean countries. The cultural differences in drinking patterns are found as well in teenagers: The European School Project ESPAD examined alcohol consumption, cigarette smoking and illicit drug use among 15-16 year old boys and girls in 30 European countries. Considering the question about “drunkenness more than 2 times within the last 30 days”, beer drinking countries had much higher rates of drunkenness than wine drinking “mediterranean” countries (for instance U.K. 24% vs. Italy 3%). The same level of alcohol consumption per week can have a very different impact on alcohol-associated benefits and risks. A case-control study from the WHO MONICA project demonstrated, that regular consumption of 1-4 drinks on 5-6 days per week (= up to 24 drinks per week) lowered the risk for myocardial infarction by half or more, whereas 5-8 drinks on 1-2 occasions per week (= up to 16 drinks per week) had no effect and 9 or more drinks on 1-2 occasions per week (= more than 18 drinks per week) more than doubled infarction risk. After excessive alcohol consumption there is a rebound effect of plasma coagulability the following morning , which may explain, why binge drinking causes a higher cardiovascular mortality in people at higher risk of heart attacks. This may well be the reason for the observed overproportionally high myocardial infarction rate on Mondays in Scotland. The main problem with alcohol consumption in non-mediterranean countries (and especially among young people in the U.K.) is apparently not total alcohol consumption, but is binge drinking. It is therefore of great importance, that a public health message finds its way to the people. “Do not drink more than 21 units of alcohol per week” will not reach those, who drink 10 units per day on Fridays and Saturdays, because they think, this is still below the sensible drinking limits! So we should rather lay the emphasis on recommending moderate amounts per session and on alcohol consumption with meals to avoid the negative consequences of binge drinking. | |||
|
|
|||
|
michael j fitzpatrick, GP Barton House Health Centre, London N16 9JT
Send response to journal:
|
EDITOR-Re Alcohol consumption and mortality (27 July): What is already known on this topic: - drinking heavily is bad for your health; - drinking moderately improves the quality of life; - drinking behaviour is little influenced by concerns about health. What this study adds: - nothing. Michael Fitzpatrick General Practitioner |
|||
|
|
|||
|
Robert Patton, Research Associate Department of Psychological Medicine, Imperial College, London, W2 1PD
Send response to journal:
|
We agree with White et al1 that as levels of alcohol consumption increase so does the associated risk of illness, accident or injury, even within the current DoH limits. Indeed data from our current work at St Mary’s hospital indicates that about 5% of patients attending the AED who drink at or below recommended limits (men: 4 units/day, Women: 3 units/day) present with conditions that they believe are related to alcohol consumption. However, the authors imply that increased levels of alcohol consumption among older people should not increase mortality. Previous research (ONS, 1999)2 has found that up to two thirds of accidental deaths among women aged over 65 are as a result of falls, and that alcohol consumption may be implicated in the aetiology of falls (Bell et al. 2000)3. At St Mary’s AED considerable attention has been placed on identifying the extent of alcohol use among people presenting to the AED. Data on patients aged over 65 who present with falls suggests that over one third drink excessively. The extent to which alcohol may interact with the concurrent medication (such as benzodiazapines and antidepressants) of older drinkers remains uncertain, but we believe it is likely that such interaction may contribute to both mortality and morbidity. 1. White IR, Altmann DR, Nanchahal K. Alcohol consumption and mortality: modelling risks for men and women at different ages. British Medical Journal 2002: 325: 191. 2. Office for National Statistics. 1997 Mortality statistics: injury and poisons. London: Stationary Office, 1999. 3. Bell AJ, Talbot-Stern JK, Hennessey A. Characteristics and outcomes of older patients presenting to the emergency department after a fall: retrospective analysis. Medical Journal of Australia 2000; 174:179- 82 Robert Patton, Research Associate Department of Public Mental Health, Imperial College, London |
|||
|
|
|||
|
Moussa Sarr, Senior Study Director Westat, Inc., 1441 West Montgomery Blvd, WB466
Send response to journal:
|
In their recently published paper, White, Altmann and Nanchahal, BMJ 2002 (1) reported the existence of a direct dose-response relationship between alcohol consumption and risk of death in women aged 16-54 and in men aged 16-34, whereas at older ages the relation is U shaped. However a significant methodological issue related to the assessment of lifetime alcohol consumption that may affect the conclusions was not discussed in the paper. The non-drinkers group could be mainly composed of ex-heavy drinkers (2) (3), who became abstainers. And this is more likely to be true with the "old ages" group, where due to alcohol related health issues ex-drinkers may become "non-drinkers" (3). If the data used allows it, the "non-drinking" group should be separated into "ex-heavy drinkers", "ex-moderated drinkers", and "lifetime abstainers" or any other classification assessing former drinking patterns. If the data does not allow assessing former drinking behavior in the "non- drinking" group, the authors should discuss this as a limitation of they study. 1. White IR, Altmann DR, Nanchahal K. Alcohol consumption and mortality: modelling risks for men and women at different ages. British Medical Journal 2002: 325: 191. 2. Shaper AG. Alcohol and mortality: a review of prospective studies. Br J Addict 1990;85:837-47. 3. Sarr M. Re: "Alcohol consumption and coronary heart disease morbidity and mortality." (Letter). Am J Epidemiol 1999;149:682-3. |
|||
|
|
|||
|
Johannes G. Scholl, Physician, Private Practice 65385 Ruedesheim, Germany
Send response to journal:
|
The question of "ex-drinkers" in the abstinence group has been answered five years ago. So there is no need two pose this "old-fashioned" question again and again: In the Cancer Prevention II - Study (Thun et al., New Engl J Med 1997; 337: 1705-1714), there were about 200 000 people in the "non- drinkers" group. They had a higher mortality from all-causes than moderate drinkers, but the lowest mortality from alcohol-associated diseases (liver disease, accidents, breast cancer etc.), so they were definetely NOT a group of ex-drinkers. There ist no doubt, that in people with an elevated risk for cardiovascular disease, there is a small, but real benefit of moderate alcohol consumption on total mortality. The interesting question is, "how often and how much" is best at different ages, for men and women, and to combine this "optimum dosis" with other healthy lifestyle characteristics like a healthy (mediterranean -style) diet with large amounts of fruits and vegetables, plenty of fish and omega-3-fatty acids, carbohydrates with preferably a low glycemic index - and of course regular physical activity. |
|||
|
|
|||
|
Adam Jacobs, Director Dianthus Medical Limited, London SW19 3TZ
Send response to journal:
|
White et al briefly acknowledge in their discussion that considering a life course perspective of the effects of alcohol on mortality may offer more useful information than their assessment of short-term risks. I think this is a serious understatement. It is of little consequence to know that the risk of dying in the next 5 to 10 years is increased by alchohol in a 25-year-old. The absolute risk of imminent death in a healthy person of that age is tiny, and remains tiny even if doubled. On the other hand, the absolute risk of a 25 -year-old dying between the ages of 50 and 70 is far from negligible. A small decrease in the relative risk of dying at those later ages would surely more than offset a large increase in the relative risk of dying before the age of 30. A far more interesting question than looking at short-term risks would be to ask how alcohol consumption affects overall life expecancy at different ages. |
|||
|
|
|||
|
Andy M Wearn, Clinical Senior Lecturer Faculty of Medical & Health Sciences, University of Auckland, Auckland 1, New Zealand
Send response to journal:
|
As a simple measure of human nature, I suspect the initial impact of this paper will depend somewhat upon the age of the reader; falling into the 2 unit a week group (by a whisker of course) I was drawn to read the article in more depth. Issues of interpretation and the meaning of risk, as presented, have been discussed in other responses. Although it is clear what the paper adds, it is harder to decide how it affects what we do as health professionals and as part of society. The last comment made by the authors in the discussion is particularly pertinent; “Finally, as most deaths attributable to alcohol at younger ages are due to injuries, a greater focus could be placed on avoiding risky patterns of drinking rather than on reducing average alcohol consumption”. Accidents/injuries are a significant cause of death in young adults; even looking at all age death rates given in table 1, this category is the third largest cause of death. It would therefore be simplistic to respond to this paper by reviewing recommended alcohol intake alone and ignoring behaviour. Taking ‘drink driving’ as an obvious example, I have been interested to see the New Zealand (NZ) approach to this problem since moving here from the UK. Until recently, NZ had one of the highest per capita death rates for road traffic accidents in the world and alcohol played a large part in this (between 1987-1992, 35-46% of fatally injured drivers tested were over the limit – two-thirds to three quarters were tested)1. The majority of these alcohol related fatalities were in the age group 15-44 (peak 20-24 years) – reflecting the risk findings of the paper. One of the strategies that has probably helped to reduce this figure (20% of fatally injured drivers in 2000) has been to vary the legal alcohol limit by age. The legal limit under the age of 20 years is 30mg/100ml (blood) – this is effectively zero tolerance. Penalties at all ages are high; financially, through suspension and potential custodial sentence. With alcohol as the intervention and death as the outcome, one of the key consequences of this paper should be to continue to seek ways of minimising or avoiding the processes that link them together. 1. Land Transport safety Authority. Blood alcohol limits. http://www.ltsa.govt.nz/research/annual_statistics_2000/blood_alcohol.html |
|||
|
|
|||
|
Richard Saitz, Associate Professor of Medicine and Epidemiology Boston University School of Medicine, 91 E Concord Street #200, Boston, MA 02118-2393, USA
Send response to journal:
|
Based on well-done meta-analyses, White et al. confirmed that the protective effects of alcohol do not accrue to younger adults. But questions remain regarding the implications of the observed mortality benefits of moderate drinking. First, there are numerous examples in the literature of interventions thought to be effective based on observational studies later proven to be ineffective and even harmful by randomized clinical trials (most recently estrogen replacement). And observational studies do not allow conclusions regarding alcohol dose, since they often average intake over time and do not consider pattern of use. Second, prescription of moderate drinking for its health benefits would cause significant morbidity and death in some, while preventing it in others. For example, Single et al. found that in one year in Canada, alcohol prevented 7401 deaths but caused 6701. Alcohol caused more hospitalizations and years of potential life lost than it prevented or saved. White et al. are careful to present drinking limits rather than advice to drink. But the limits are of concern. For example, the limit for an 85-year-old is a dose that for many would be intoxicating, therefore risking injury. Given that alcohol (even at moderate levels) is 1) associated with cancers and other chronic diseases, 2) causes a significant number of deaths even while it prevents others, and 3) given that the exact doses for protective benefit of this substance with a narrow therapeutic index are not known, it is not time to prescribe alcohol as a preventive therapy. Even limits for sensible drinking should be interpreted with caution. Single E, Rehm J, Robson L, Truong MV. The relative risks and etiologic fractions of different causes of death and disease attributable to alcohol, tobacco and illicit drug use in Canada. CMAJ 2001;164:173-4. |
|||