Critique 206: Importance of considering cultural factors in determining effects on health of alcohol consumption – 3 October 2017

Rehm J, Room R. The cultural aspect: How to measure and interpret epidemiological data on alcohol-use disorders across cultures.   Nordic Studies on Alcohol and Drugs 2017;34:330–341. DOI: 10.1177/1455072517704795.

Authors’s Abstract

Aims: To examine the cultural impact on the diagnosis of alcohol-use disorders using European countries as examples.

Design: Narrative review.

Results: There are strong cultural norms guiding heavy drinking occasions and loss of control. These norms not only indicate what drinking behaviour is acceptable, but also whether certain behaviours can be reported or not. As modern diagnostic systems are based on lists of mostly behavioural criteria, where alcohol-use disorders are defined by a positive answer on at least one, two or three of these criteria, culture will inevitably co-determine how many people will get a diagnosis.  This explains the multifold differences in incidence and prevalence of alcohol-use disorders, even between countries where the average drinking levels are similar. Thus, the incidence and prevalence of alcohol-use disorders as assessed by surveys or rigorous application of standardised instruments must be judged as measuring social norms as well as the intended mental disorder.

Conclusions: Current practice to measure alcohol-use disorders based on a list of culture-specific diagnostic criteria results in incomparability in the incidence, prevalence or disease burden between countries. For epidemiological purposes, a more grounded definition of diagnostic criteria seems necessary, which could probably be given by using heavy drinking over time.

Forum Comments

Our Forum has repeatedly pointed out that the effects on health of a reported given amount of alcohol consumption are markedly modified by the pattern of drinking, by other lifestyle factors, by socio-economic status, and by cultural factors.  These have been commented upon by the Forum in recent critiques: e.g., Smyth et al, Towers et al, Larsson et al, and Katikireddi et al.

Cultural differences in alcohol consumption: It has been clearly shown that presumably similar amounts of alcohol have different health effects in southern European countries (where wine with meals is common) than in more northern European countries, where beer and spirits are more likely to be consumed and not usually with food.  Some of these differences may relate to the beverage consumed, while others may relate especially to different patterns of consumption.  Drinking to intoxication also varies and, as the present paper indicates, the reporting of excess alcohol intake in epidemiologic studies also varies according to cultural aspects of populations.

In certain cultures, overt intoxication after drinking is expected and even tends to not be condemned. Further, if someone is drinking specifically to get intoxicated, he/she may be more likely to report that he/she became “drunk” on occasion; this would be considered acceptable by certain cultures.  In the typical Italian culture, however, it would not be socially acceptable for a guest at a family dinner to become overtly intoxicated.  In southern Europe during a prolonged meal with an aperitif, many glasses of wine with the meal, and even perhaps a digestive after the meal, the total amount of alcohol consumed may well be in excess of usual  guidelines, but drunkenness would not be considered appropriate, and probably less often reported in an epidemiologic study even if it had occurred.

Adjusting for more than just the amount of alcohol consumed in epidemiologic studies: Epidemiologists attempt to adjust for many SES and cultural factors by including data not only on the reported amount of alcohol consumption but also on the pattern of drinking, especially for binge drinking versus drinking regularly and with food.  However, the time during which the alcohol consumed in a given “drinking episode,” the rate of intake, is rarely known or reported.  [And everyone may not follow the guideline of our late friend and associate, Serge Renaud, who stated: “You drink water, but you sip wine.”]  Each factor surely has an effect on the peak blood alcohol concentration (BAC) achieved, which might be a better estimate of intake, but scientists generally do not have data on BAC in their studies.

Thus, we know that the net effect of alcohol consumption relates to the amount of alcohol, the type of beverage, the rapidity of consumption, whether drinking with or without food, and surely a number of genetic factors of the drinker. What we are often unsure about is what the cultural context of drinking is for an individual subject or subjects in a certain population: different cultures seem to help control, or not control, the risk of drinking excessively.  As pointed out by the present paper, these factors complicate the comparison of results of epidemiologic studies from different cultures.

As an example, Rehm and Room report in the present paper that in the EU in 2010, there was wide variation in estimates of prevalence of alcohol-use disorders, between less than 1% for Italy and Spain and more than 12% for Latvia (Rehm, Anderson, et al, 2015). On the other hand, the per capita consumption, or even the per drinker consumption, only varied by a factor of 3 (WHO 2014).  As the authors state: “So the incidence and prevalence of alcohol dependence and alcohol-use disorders as assessed by surveys or rigorous application of standardized instruments must be judged as measuring social norms as well as the intended mental disorder” (Rehm, Allamani, et al 2015; Rehm, Room, 2015). The same is true not only for indices of excessive use but for the protective effects of alcohol against cardiovascular disease, diabetes, and dementia.

While the authors of this paper point out many problems of assessing alcohol consumption and its effects in epidemiologic studies that extend across cultures, they do not present ready solutions to this problem.

Specific Comments by Forum Members

Reviewer Skovenborg noted: “The discussion of influences of cultural drinking norms on the country level diagnostic prevalence of alcohol use disorders is interesting and relevant, however, it might be a bit subtle (not to say sophistic) for a review; also the discussion of the subject is a bit clannish with the two authors of the present paper being listed as authors on 38 of the 81 references they provide.  What Rehm and Room do not seem to consider is the obvious possibility that cultural drinking norms like the Italian drinking patterns actually are protective against several kinds of alcohol harms.”

Reviewer Ellison thought that “While this paper deals primarily with identifying alcohol misuse, I think that it is important that we recognize and take into consideration cultural differences when we attempt to make inferences based on the results from individual studies. Failure to do so may bias our interpretation of potentially adverse as well as beneficial effects of moderate drinking.”

Reviewer Van Velden noted: “The pattern of alcohol consumption, with or without meals, cultural and social factors, as well as the genetic blueprint, all have a great influence on the health outcomes associated with alcohol consumption. Under reporting also has a role to play, and this complicates matters further.”

Reviewer Ursini stated: “It is hard to add a single word: education, economic status, cultural and religious occasions, and the intake of alcohol with food — all lead to ‘moderate’ intake. The biological rational is always the same.  A moderate amount of alcohol is better than too much and too little. Apparently, increasing the economic status and education would be the best way to prevent abuse of alcohol.   It is, however, easier and cheaper prohibit it.”

Forum member Thelle stated: “I don’t have much to add to the comments of others. However, the recent paper from our research unit (Tverdal et al) supports the benefits of moderate drinking on cardiovascular disease.  In our analyses of more than 100,000 subjects, the consumption of wine (but not beer or spirits) was the only beverage associated with protection against cardiovascular disease.”  Reviewer Ellison added that the Tverdal et al study also emphasizes the need to separate ex-drinkers from lifetime abstainers in the referent group.  Considering both the type of beverage usually consumed as well as accounting for ex-drinkers may help in judging the effects of cultural factors on health outcomes associated with drinking.”

Forum member Goldfinger had some relevant comments: “The topic addressed is interesting but appears less relevant to our interests in moderate alcohol intake and health consequences. Data consistently demonstrate that heavy drinking, usually defined as > 30 – 45 g/day of ethanol, is associated  with adverse health outcomes, although this definition of heavy drinking has been variable, and in my opinion toned down to appease those who negate benefits of alcohol at all.  Extrapolation of the J-shaped curve has suggested optimum benefits to cardiovascular health at up to 750 ml of wine daily (Di Castelnuovo et al).

“From a health perspective, we and most others have come to accept the benefits of the Italian model: wine drinking below the threshold of drunkenness, with a meal or at social events where food is also consumed. This pattern is associated with enhanced cardiovascular health, general health, and longer life — this falls within the cultural norms that most civilized societies accept.  Drinking for the purpose of getting intoxicated, overindulging at festive events, etc., is a pattern/behavior incomparable with the above Italian model, just as addictive alcoholism, drinking associated with depression, or drinking with evil intent (dating back to Noah) are not comparable.  Drinking patterns that clearly violate cultural norms of civility are, for the most part, obvious and should be factored in when studying potential health benefits.  In short, comparing varying patterns of drinking, just like comparing different types of alcoholic beverages, is far more complex, as we know, that looking at total ethanol consumed over a specified period of time.”

Forum member Mattivi also had some comments: “The Italian model is reported in questionable wording: ‘with a clear norm of not showing any loss of control and intoxication’ and again ‘due to the norm of not showing effects.’ It is true that there is a strong social stigma in Mediterranean countries on people drinking to intoxication.  Such people are seen as ‘frail’ and ‘losers’.  As a result, the Italian model strongly encourages people to stop drinking before reaching a level of consumption leading to loss of control.  This is quite different from ‘not showing any loss of control.’  To drink at intoxication while not showing any loss of control is an oxymoron!”

Mattivi continued: “These authors state: ‘In other words, current international comparisons on alcohol dependence or alcohol-use disorders are comparing apples with oranges, and not similar health states.’ Such statements indicate what is possibly the weakest point in the design of studies across different countries.  As we already stressed in several previous commentaries, the kind of beverage matters (>40% ethanol in water, such as in spirits, vs. <15% ethanol in a fermented fruit juice containing also all the beneficial components of the berry, such as in red wines) and the moment of consumption matters (as an example, the attenuation of postprandial oxidative stress due to the well-documented increase of plasma oxidized lipids is only achieved when the beverage is taken with meals) (Natella et al, 2001, 2011).  And finally, there is the need to combine the assessment of alcohol intake with a robust marker of ethanol consumption, such as the urinary ethyl glucuronide and ethyl sulfate.  Both biomarkers of intake may be detectable in urine for up to 96 hours, and account also for incidental exposure to ethanol from other, usually not reported, dietary sources.  Until these factors are considered, it is unlikely that we will have the chance to reach a finely tuned knowledge, capable to assess the cultural impact of alcohol-use disorders.”

References from Forum review

Di Castelnuovo A, Rotondo S, Iacoviello L, Donati MB, de Gaeteno G. Meta-analysis of wine and beer consumption in relation to vascular risk.  Circulation 2002;105:2836–2844.

Katikireddi SV, Whitley E, Lewsey J, Gray L, Leyland AH. Socioeconomic status as an effect modifier of alcohol consumption and harm: analysis of linked cohort data.  Lancet Public Health 2017.  Online publication May 10, 2017. Dx.doi.org/10.1016/S2468-2667/(17)30078-6.  (Forum review: (Forum review: www.alcoholresearchforum.org/critique-199).

Larsson SC, Kaluza J, Wolk A. Combined impact of healthy lifestyle factors on lifespan: two prospective cohorts.   J Int Med 2017.  Pre-publication.  Doi: 10.1111.joim.12637.  (Forum review: www.alcoholresearchforum.org/critique-201.)

Natella F, Ghiselli A, Guidi A, Ursini F, Scaccini C. Red wine mitigates the postprandial increase of LDL susceptibility to oxidation.  Free Radical Biology & Medicine 2001;30:1036–1044.

Natella F, Macone A, Ramberti A, Forte M, Mattivi F. Matarese RM, Scaccini C. Red wine prevents the postprandial increase in plasma cholesterol oxidation products: a pilot study. British Journal of Nutrition 2011;105:1718–1723.

Rehm J, Anderson P, Barry J, Dimitrov P, et al. Prevalence of and potential influencing factors for alcohol dependence in Europe.  European Addiction Research 2015;21:6–18.

Rehm J, Allamani A, Elekes Z, Jakubczyk A, et al. Alcohol dependence and treatment utilization in Europe: A representative cross-sectional study in primary care. BMC Family Practice 2015;16, 90.

Rehm J, Room R. Cultural specificity in alcohol use disorders. Lancet 2015. Advance online publication. doi:10.1016/S0140-6736(15)00123-3

Rehm J, Room R. The cultural aspect: How to measure and interpret epidemiological data on alcohol-use disorders across cultures.   Nordic Studies on Alcohol and Drugs 2017;34:330–341. DOI: 10.1177/1455072517704795.

Smyth A, Teo KK, Rangarajan S, O’Donnell M, Zhang X, Rana P, Leong DP, et al. Alcohol consumption and cardiovascular disease, cancer, injury, admission to hospital, and mortality: a prospective cohort study.  Lancet 2015.  Pre-publication.   http://dx.doi.org/10.1016/ S0140-6736(15)00235-4.  Online/Comment http://dx.doi.org/10.1016/ S0140-6736(15)00236-6.  (Forum review: www.bu.edu/alcohol-forum/critique-171).

Tverdal A, Magnus P, Selmer R, Thelle D. Consumption of alcohol and cardiovascular disease mortality: a 16 year follow-up of 115,592 Norwegian men and women aged 40–44 years.  Eur J Epidemiol 2017; Sep 21. doi: 10.1007/s10654-017-0313-4. [Epub ahead of print].

Towers A, Philipp M, Dulin P, Allen J. The “Health Benefits” of Moderate Drinking in Older Adults may be Better Explained by Socioeconomic Status.  Pre-publication: J Gerontol B Psychol Sci Soc Sci 2016.  doi:10.1093/geronb/gbw152.  (Forum review: www.bu.edu/alcohol-forum/critique-195.)

World Health Organization. Global Status.  World Health Organization.  Report on alcohol and health. Geneva, Switzerland: 2014.

Forum Summary

It has been clearly shown that presumably similar amounts of alcohol tend to have different health effects (both beneficial and adverse) in different cultures. Greater health benefits from moderate alcohol intake have been shown, for example, in southern European countries (where wine with meals is common) than in more northern European countries, where beer and spirits are more likely to be consumed and usually not with food.  Some of these differences may relate to the beverage consumed, while others may relate especially to different patterns of consumption.  Further, in certain cultures, intoxication after drinking is expected and even tends to not be condemned.  In the typical Italian culture, however, it would not be socially acceptable for a guest at a family dinner to become overtly intoxicated, and such would probably be less often reported in an epidemiologic study even if it had occurred.  Thus, similar rates of alcohol-use disorders would be ascertained differently in different countries.

We know that the net effect of alcohol consumption relates to the amount of alcohol, the type of beverage, the rapidity of consumption, whether drinking with or without food, and surely a number of genetic factors of the drinker. What we are often unsure about is what the cultural context of drinking is for an individual subject or subjects in a certain population: different cultures seem to help control, or not control, the risk of drinking excessively.  As pointed out by the present paper, these factors complicate the comparison of results of epidemiologic studies from different cultures.

In planning and interpreting results of epidemiologic studies, investigators now realize that simply estimating the average alcohol consumption over a period of time, usually a week, is inadequate to quantify alcohol exposure. The pattern of consumption (especially whether with or without food and whether regularly or in binges) is especially important.  And, as the present study points out, knowing about the cultural aspects of drinking for a specific population is also key to interpreting the results.  How best to do this, so that studies in different countries can be compared, remains difficult.

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Contributions to this critique by the International Scientific Forum on Alcohol Research have been provided by the following members:

Giovanni de Gaetano, MD, PhD, Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo NEUROMED, Pozzilli, Italy

R. Curtis Ellison, MD, Professor of Medicine, Section of Preventive Medicine & Epidemiology, Boston University School of Medicine, Boston, MA, USA

Harvey Finkel, MD, Hematology/Oncology, Boston University Medical Center, Boston, MA, USA

Tedd Goldfinger, DO, FACC, Desert Cardiology of Tucson Heart Center, University of Arizona School of Medicine, Tucson, AZ, USA

Fulvio Mattivi, MSc, CAFE – Center Agriculture Food Environment, University of Trento, via E. Mach 1, San Michele all’Adige, Italy

Erik Skovenborg, MD, specialized in family medicine, member of the Scandinavian Medical Alcohol Board, Aarhus, Denmark

Creina Stockley, PhD, MSc Clinical Pharmacology, MBA; Health and Regulatory Information Manager, Australian Wine Research Institute, Glen Osmond, South Australia, Australia

Dag S. Thelle, MD, PhD, Department of Biostatistics, Institute of Basic Medical Sciences, University of Oslo, Norway; Section for Epidemiology and Social Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden

Fulvio Ursini, MD, Dept. of Biological Chemistry, University of Padova, Padova, Italy

David Van Velden, MD, Dept. of Pathology, Stellenbosch University, Stellenbosch, South Africa