Critique 047: Overall health effects of alcohol consumption. Comments on a WHO report – 10 July 2011

Global status report on alcohol and health.  World Health Organization 2011.  ISBN 978 92 4 156415 1 (NLM classification: WM 274)

Overiew

The World Health Organization (WHO) has released its global status report on alcohol and health for 2011.  The first section of this lengthy report deals with indices of alcohol consumption in different countries, trends in consumption, and comments on drinking among the young and on patterns of alcohol consumption.  The second section is entitled, Consequences, starting with a statement on alcohol and health and then a variety of topics describing the adverse health and societal effects of abusive drinking.  The last section of the report is entitled Policies and Interventions.  Comments by the Forum will deal primarily with section 2 of the report, relating alcohol consumption to health.

Forum Comments

Background: The International Scientific Forum on Alcohol Research (ISFAR) was established in 2010 by a group of scientists and medical practitioners whose work/research relates to adverse and beneficial health effects of alcohol use and misuse.  The purpose of the Forum is to provide, on its open web-site www.bu.edu/alcohol-forum or alcoholforum4profs.org, timely critiques and comments by its members on emerging scientific publications and policy statements related to alcohol and health.   Its overall goal is to assure that scientifically sound and balanced information on this topic is available to the public and to organizations and governmental agencies involved in setting alcohol policy.  The members of the Forum are requested periodically to provide commentaries on what are considered to be important emerging research or policy reports related to alcohol.  Forum members receive no compensation for their services.

Comments on the WHO report:  The recent report from the World Health Organization (WHO), prepared by the Management of Substance Abuse Team in the Department of Mental Health and Substance Abuse of WHO, was released as the 2011 “Global Status Report on Alcohol and Health.”  Forum members generally agreed with the discussion of the serious health and societal problems associated with the misuse of alcohol, which contributes to accidents, many diseases, and premature deaths.  On the other hand, Forum members were disturbed that the report was limited almost exclusively to abusive drinking, was based primarily on out-dated information, and minimized any beneficial effects of alcohol consumption.

To a large extent, the WHO report disregards the massive amount of scientific data indicating that in all developed countries, moderate consumers of alcohol are at much lower risk of essentially all of the diseases of ageing: coronary heart disease, ischemic stroke, diabetes, dementia, and osteoporosis.  And the report does not describe the decrease in total mortality among middle-aged and elderly people associated with moderate alcohol consumption, which has been found consistently in studies throughout the world.

The Forum reviewers point out that the references chosen by the WHO team to support their contentions represent a biased appraisal of the scientific literature.  Reviewers cited a number of very comprehensive meta-analyses which clearly contradict the WHO report: that of Maclure,¹ Corrao et al,² Di Castelnuovo et al,³ and Ronksley et al.⁴ Further, a comprehensive recent report by Fuller⁵ provides data from more than 120,000 subjects showing considerably lower all-cause mortality rates for moderate drinkers than for abstainers.  And these reports only add to data from thousands of experimental and epidemiologic studies over the past few decades, including many that describe mechanisms that explain the beneficial health effects associated with the moderate intake of alcohol.  This topic was recently reviewed well by Brien et al.⁶

Even if the authors of the WHO report did not have access to or did not review many recent papers on this topic, Ronksley et al⁴ in their 2011 paper from the BMJ stated: “When studies were summarized chronologically, we found that the overall association between drinking and cardiovascular disease and coronary heart disease became apparent at least a decade ago, and ongoing studies have done little to revise the estimated associations.”  Those authors added, “In cumulative meta-analyses of cardiovascular disease and coronary heart disease outcomes there was little variation in the relative risk associated with alcohol consumption on cardiovascular disease mortality or incident coronary heart disease with addition of new studies after 1999; for coronary heart disease mortality, this plateau in incremental change from new studies occurred as early as 1992-1993.⁴”  Thus, it would appear that the primarily negative statements regarding alcohol in the WHO report are not due only to the exclusion of recent publications.

One Forum reviewer commented: “Even the title of this report is misleading, as the ‘status’ reported does not reflect the current status of research.  Further, it is not about ‘alcohol and health’ but is almost exclusively about abuse.  It turns out to be a prohibitionary polemic.”  Another Forum reviewer added: “The WHO report notes (I think approvingly) that nine countries completely ban alcohol: Afghanistan, Brunei Darussalam, Iran, Maldives, Mauritania, Pakistan, Saudi Arabia, Somalia, Sudan.  The authors of the report, it seems to me, would like to consider reducing or eliminating alcohol use everywhere, by any means.”  Given the beneficial health effects of moderate drinking, world-wide prohibition of alcohol would not be in the best health interests of the population.

Using balanced scientific data for determining alcohol policy:  Forum reviewers believe that it is especially problematic that the report appears to stray so far from well-established science that it could seriously discredit the standing of WHO.  The Forum hopes that, in the future, WHO will undertake a careful and open-minded review of concurrent data to ensure that their recommendations are supported by the strongest science available.  Published status reports giving an incomplete summary of the scientific data tend to be used selectively by certain groups⁷ that seem to be so concerned about problems associated with alcohol abuse (which everyone condemns) that they may exclude information on the beneficial health and social benefits associated with moderate drinking.  In contrast, the recently published Dietary Guidelines for Americans 2010⁸ presents advice that seems to reflect current scientific data more accurately.  Another Forum reviewer comments, “It is essential to present an objective appraisal of alcohol consumption and health; simply focusing on the effects of alcohol abuse is a disservice to the readership.  It is easier for people to make informed decisions when they are presented with balanced and accurate information on alcohol and health that reflect concurrent research.  Such an approach is used, for example, by the US Food & Drug Administration in that it highlights both benefits and adverse effects of prescription drugs.”

One Forum reviewer suggested that policy makers should consider using sources such as Connor et al⁹ for a more balanced and scientifically sound basis for making decisions.  He stated: “This is a fairly obscure paper, and not often referenced overseas because it is specific to New Zealand, but is quite balanced, describing the increased morbidity and mortality from alcohol (primarily from excessive drinking) among the young compared with a net benefit from moderate alcohol drinking among the elderly.”  The results in that report⁹ are similar to those reported previously for Canada by Rehm et al:¹⁰ even among drinkers who on average consumed alcohol moderately, there were higher death rates in the young, fewer deaths in older people.  It is especially enlightening that the report from Canada showed that when binge-drinkers were excluded from the “moderate-drinking” group, most of the excess deaths in the young were no longer seen, and the net mortality effect of moderate alcohol use in the population was beneficial.¹⁰

References from Forum  Review:

1.  Maclure M.  Demonstration of deductive meta-analysis: ethanol intake and risk of myocardial infarction.  Epidemiol Review 1993;15:328-351.

2.  Corrao G, Rubbiati L, Bagnardi V, Zambon A, Poikolainen K.  Alcohol and coronary heart disease: a meta-analysis.  Addiction. 2000;95:1505-1523.

3.  Di Castelnuovo A, Costanzo S, Bagnardi V, Donati MB, Iacoviello L, de Gaetano G. Alcohol dosing and total mortality in men and women: an updated meta-analysis of 34 prospective studies.  Arch Intern Med 2006;166:2437-2445.

4.  Ronksley PE, Brien SE, Turner BJ, Mukamal KJ, Ghali WA.  Association of alcohol consumption with selected cardiovascular disease outcomes: a systematic review and meta-analysis.  BMJ 2011;342:d671; doi:10.1136/bmj.d671.

5.  Fuller TD.  Moderate alcohol consumption and the risk of mortality.  Demography 2011.  DOI 10.1007/s13524-011-0035-2.

6.  Brien SE, Ronksley PE,Turner BJ, Mukamal KJ, Ghali WA.  Effect of alcohol consumption on biological markers associated with risk of coronary heart disease: systematic review and meta-analysis of interventional studies.  BMJ 2011;342:d636; doi:10.1136/bmj.d636.

7.  Summary of evidence.  Antioxidants in food, drinks and supplements for cardiovascular health.  2010.  National Heart Foundation of Australia. ABN 98 008 419 761.  ISBN: 978-1-921226-91-5.

8.  2010 Dietary Guidelines for Americans, US Departments of Agriculture and Health & Human Services, 2011.  www.dietaryguidelines.gov.

9.  Connor J, Broad J, Rehm J, Vander Hoorn S, Jackson R.  The burden of death, disease, and disability due to alcohol in New Zealand. N Z Med J 2005;118(1213):U1412.

10.  Rehm J, Patra J, Taylor B.  Harm, benefits, and net effects on mortality of moderate drinking of alcohol among adults in Canada in 2000.  Ann Epidemiol 2007;17(Suppl):S81-S86.

Forum Summary

The World Health Organization (WHO) has released its global status report on alcohol and health for 2011.  Forum members largely agreed with the discussion in the report of the serious health and societal problems associated with the misuse of alcohol, which contributes to accidents, many diseases, and premature deaths.  On the other hand, Forum members were disturbed that the report was limited almost exclusively to abusive drinking, was based primarily on out-dated information, and overall suggested a bias against alcohol.  To a large extent, the WHO report disregarded a massive amount of scientific data indicating that in all developed countries, moderate consumers of alcohol are at much lower risk of essentially all of the diseases of ageing: coronary heart disease, ischemic stroke, diabetes, dementia, and osteoporosis.  And conspicuously absent from the WHO report is a description of the decrease in total mortality among middle-aged and elderly people associated with moderate alcohol consumption, a finding that has been found consistently throughout the world.

Scientific data over many decades have shown that while excessive or irresponsible alcohol use has severe adverse health and societal effects, moderate drinking is associated with lower risk of cardiovascular disease and other diseases of ageing.  And a very large number of experimental studies, including results from human trials, have described biological mechanisms for the protective effects of both alcohol and the polyphenolic components of wine.  A number of comprehensive meta-analyses are cited by Forum reviewers which they consider to provide much more accurate, up to date, and scientifically balanced views of the current “status” of the health effects of alcohol consumption.  Such documents may be better sources of data upon which policy decisions should be based.

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Comments by the International Scientific Forum on Alcohol Research on this paper have been provided by the following members:

Maria Isabel Covas, DPharm, PhD, Cardiovascular Risk and Nutrition Research Group, Institut Municipal d´Investigació Mèdica, Barcelona, Spain.

Giovanni de Gaetano, MD, PhD, Research Laboratories, Catholic University, Campobasso, Italy.

Luc Djoussé, MD, DSc, Dept. of Medicine, Division of Aging, Brigham & Women’s Hospital and Harvard Medical School, Boston, MA, USA.

R. Curtis Ellison, MD, 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, Dept. of Cardiology, University of Arizona School of Medicine, Tucson, Arizona, USA.

Ulrich Keil, MD, PhD, Institute of Epidemiology and Social Medicine, University of Münster, Münster, Germany.

Ross McCormick PhD, MSC, MBChB, Associate Dean, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.

Francesco Orlandi, MD, Dept. of Gastroenterology, Università degli Studi di Ancona. Italy.

Erik Skovenborg, MD, Scandinavian Medical Alcohol Board, Practitioner, Aarhus, Denmark.

Creina Stockley, clinical pharmacology, Health and Regulatory Information Manager, Australian Wine Research Institute, Glen Osmond, South Australia, Australia.

Arne Svilaas, MD, PhD, general practice and lipidology, Oslo University Hospital, Oslo, Norway.

Pierre-Louis Teissedre, PhD, Faculty of Oenology – ISVV, University Victor Segalen Bordeaux 2, Bordeaux, France.

Gordon Troup, MSc, DSc, School of Physics, Monash University, Victoria, Australia.

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

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

David Vauzour, PhD, Senior Research Associate, Department of Nutrition, Norwich Medical School, University of East Anglia, Norwich, UK.

Andrew L. Waterhouse, PhD, Marvin Sands Professor, Department of Viticulture and Enology, University of California, Davis. USA.