Shaken, not Stirred: The Intersection of Alcohol, Gender, and Health · 2014. 3. 7. · Management Sciences for Health 1 Stronger health systems. Greater health impact. Shaken, not

1 Management Sciences for Health

Stronger health systems. Greater health impact.

Shaken, not Stirred: The Intersection of Alcohol, Gender, and Health

13th Global Health Mini-University

George Washington University, Washington, DC

7th March, 2014

Niranjan Konduri MS, MPH, CHA


Learning objectives

• Recognize the strong association between alcohol and chronic diseases

• particularly cancer and cardiovascular diseases

• Highlight the enormous challenges in low- and middle income countries (LMICs) compared to high-income countries

• learn about ongoing global efforts

• Recognize gender differences


Traditionally interventions have targeted….

Each country, within its national context, establishes its priorities

• Alcoholism/use disorders

• Alcohol dependence; poisoning

• Binge drinking (especially among adolescents/youth)

• Prevention of drunk driving/road accidents

• Law and order; violence

• Mitigating domestic violence

• Special sub-populations

• Pricing, availability, taxation, etc.


Alcohol is the 3rd largest of 67 risk factors for death and disease (all ages; DALYs)

Risk Factors Global Rank MEN WOMEN

High blood pressure 1 2 1

Smoking 2 1 4

Household air pollution 3 5 2

Low fruit intake 4 4 6

Alcohol use 5 3 11*

High body-mass index 6 7 3

High fasting plasma glucose 7 6 5

Childhood underweight 8 9 7

Ambient PM pollution 9 8 9

Physical inactivity 10 11 8

Global Burden of Disease Study (2010) – http://www.thelancet.com/themed/global-burden-of-disease

http://www.healthmetricsandevaluation.org/gbd/visualizations/gbd-2010-leading-causes-and-risks-region-heat-map

* In women ages 15-39, alcohol is among the top 5 risk factors


Alcohol use remains the No. 1 risk factor, when considering….

Age group

• 15 to 45 years (both genders)

– surpassed smoking and drug use

Geographic location – among men, all ages

• Eastern Europe

• Latin America

• South Sub-Saharan Africa

http://www.healthmetricsandevaluation.org/gbd/visualizations/gbd-2010-leading-causes-and-risks-region-heat-map

Global Health Risks (2009)

2.3 million deaths, annually

(individually, more than

AIDS, TB or malaria)

http://www.who.int/mediacentre/factsheets/fs349/en/

Alcohol was rated as the most

dangerous drug in the UK –

over heroin and cocaine

http://www.economist.com/blogs/dailychart/2010/11/drugs_cause_most_harm


“Evidence that alcoholic drinks cause cancers

of the mouth, pharynx, larynx, esophagus,

colorectum (men), and breast is convincing.”

“They are probably a cause of liver cancer, and of colorectal cancer in women.”

2007. In: 4.8 Alcoholic drinks. Page 157-71


Ethanol, the ingredient in all alcoholic beverages is a human carcinogen

(Group 1)

Expert group meeting 2007. Document published 2010

IARC - The evaluations of carcinogenic risk are made by international

Working groups of independent scientists and are qualitative in nature.

No recommendation is given for regulation or legislation.


Slow, but steady global momentum


Alcohol as a global health threat: a population perspective

• “There is enormous focus on the law and order aspects of drink, but what is being overlooked are the medical consequences,” Ian Gilmore, UK Royal College of Physicians

• Resolution on Harmful use of alcohol adopted by the World Health Assembly (May 2010)*

* Resolution WHA 63.13


What is “harmful” use of alcohol?

the negative public health effects of consumption of alcoholic beverages…

…without prejudice to religious beliefs and cultural norms in any way

WHO. Global Status Report on Alcohol and Health (2011)


Societal Factors

Drinking culture

Alcohol Policy

Drinking

Environment

Healthcare

System

Population Group

Gender

Age

Poverty

marginalization

Mortality by cause

Incidence & disability:

Chronic diseases and condition

Health outcomes

Alcohol Consumption

Volume Patterns Quality

Causal model of alcohol consumption, intermediate mechanisms, and long-term consequences, as well as of the influence of societal and

demographic factors on alcohol consumption and alcohol-related harms resulting in chronic diseases and conditions.

Alcohol consumption as a risk factor for chronic diseases and conditions

Shield KD (2014). Alcohol Res. 35(2); 155-171


Alcohol consumption – relation to chronic diseases

Haas SL et al (2012).Curr Opin Clin Nutr Metab Care.15(5):457-67 Parry CD et al (2011). Addiction.106(10):1718-24

Detrimentally linked to cardiovascular outcomes – e.g. hemorrhagic stroke, atrial fibrillation

fatty liver, alcoholic hepatitis

Clear correlation between chronic consumption and gastrointestinal carcinogenesis

Rehm J, et al (2013). J Hepatol. 59(1):160-8


Total adult per capita consumption in liters of pure alcohol, 2010

Rehm J, et al (2013).J Hepatol. 59(1):160-8

Copyright © 2013 European Association for the Study of the Liver


http://ss.utpb.edu/falcon-wellness-u/addictions/alcohol/

Unprotected sex

Poor medication adherence

Biological

Factors

Increased susceptibility to infection

Comorbid conditions

Worsening of disease course Causal

Linkage

Cross-sectional data on global association between frequency of alcohol use and

risk of HIV infection seem to have “reached a point of saturation”

Alcohol’s effect on HIV epidemic

Woolf-King SE et al (2013). International Journal of Alcohol and Drug Research.1(2):99-110


Adherence to ARVs

• 11% of health workers reported that alcohol/drug abuse was one of several reasons for patients to skip ARV doses

• 26% of adherence counselors reported that alcohol misuse accounted for skipping doses

Tjituka, F et al (2013). Namibia Antiretroviral Therapy Adherence Baseline Survey Report. USAID funded Systems for Improved Access to Pharmaceuticals and

Services (SIAPS) Program. Arlington, VA: MSH


HEAVY ALCOHOL USE

ALCOHOL USE DISORDERS

• Susceptibility to TB

• Strongly influences both incidence and outcome of disease

• Altered pharmacokinetics of medicines used in TB treatment

• Higher rates of re-infection, treatment default, and development of MDR-TB

10% of global TB cases attributable to alcohol

Rehm J et al (2009). BMC Public Health.9:450. Miller AC et al (2012). Int J Tuberc Lung Dis. 16(7):891-6.


Warren KR et al (2011).Alcohol Res Health.34(1):4-14

High-burden in isolated communities

1 in every

100 live births

worldwide

http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(13)70173-6/fulltext


Let us see the situation specifically in high-income countries


Alcohol attributable cancer deaths and years of potential life lost in the U.S.

First comprehensive study since 1978 • 20,000 cancer deaths annually- about 3.5% of all cancer

deaths

• 15% of breast cancer deaths among women

• 1.5 drinks per day or less accounted for 30% of all alcohol attributable cancer deaths

• “Alcohol is a big preventable cancer risk factor that has been hiding in plain sight”

Nelson DE, et al (2013). Am J Public Health. 103(4):641-8.


25% of Russian men die from harmful use of alcohol before they are 55

Zaridze D (2014).Lancet.pii: S0140-6736(13)62247-3.


Until 2012, beer was classified as “foodstuff”

in Russia?

Did you know?

http://www.rawstory.com/rs/2012/05/01/putin-medvedev-toast-may-day-at-soviet-pub/


So what changed?

• 2009 – Russian government declared war on alcoholism – “National Disgrace”

• 2010 – Plan to cut alcohol consumption in half by year 2020

• 2011 – Beer classification changed to “alcoholic beverage.” Earlier, any drink with less than 10% alcohol was considered “foodstuff”

Russian Beerfest goes Flat for Brewers – http://online.wsj.com/news/articles/SB10001424127887323446404579010562098511876 http://news.bbc.co.uk/2/hi/europe/8432271.stm


Low to moderate alcohol intake and cancer incidence in women

Million Women Study (UK)

• The increased risk of cancer over the 7-year follow-up was about 6% per 10g of alcohol consumed daily.

Million Women Study Collaborators (2009).J Natl Cancer Inst.4;101(5):296-305

This was a cohort study which aimed to look at the relationship between low-to-moderate levels of

alcohol intake in women (typically fewer than three drinks per day or 21 drinks per week) and overall

risk of cancer and of cancer at specific sites.


Is the cardioprotective action of alcohol a myth? Evaluating confounders

Health follow-up of 149,733 subjects (97k men and 52k women) over a six-year period

“In conclusion, our data show that mild and moderate drinkers display a more favorable health status and a lower CV risk profile”

“It is clearly premature to promote alcohol consumption as the basis of CV protection until such a time as the causal role of alcohol in cardioprotection is fully proven”

Hansel B, et al (2010). Eur J Clin Nutr. 64(6):561-8.


For cancer prevention, AICR recommends not to drink alcohol

“However, our expert report recognizes that modest amounts of alcohol may have a protective effect on coronary heart disease.”

“If consumed at all, limit alcoholic drinks to 2/day for men and 1/day for women.” (no “safe threshold” specified)

“The evidence that all types of alcoholic drinks increase the risk of a number of cancers is now stronger than it was in the mid-1990s. “

American Institute for Cancer Research

http://www.aicr.org/reduce-your-cancer-risk/recommendations-for-cancer-prevention/recommendations_06_alcohol.html


Key messages from two systematic reviews and meta-analysis

• Beneficial effects for those who consume light to moderate amounts of alcohol (2.5 to 14.9 grams/day), or about < 1”• drink a day) – in “selected subsets of patients”

• “Even at low levels, a cardioprotective effect cannot be assumed. More evidence on overall benefit-risk ratio is needed to inform the general public or physicians about low-risk drinking levels”

Alcohol: “a heart disease-cancer balancing act”

Ronksley PE et al (2011).BMJ. 22;342:d671. Roerecke M & Rehm J (2012).Addiction. 107(7):1246-60



Cancer tidal wave on horizon – fueled by alcohol, smoking, and obesity

Extend “tobacco-style” restrictions on alcohol and sugar

http://www.bbc.com/news/health-26014693


WHO Alcohol Policy Guidelines for National Action (2011)

• Leadership, awareness, and commitment

• Health services' response

• Community action

• Drink-driving policies and countermeasures

• Availability of alcohol

• Monitoring and surveillance

• Reduce the negative consequences of drinking and alcohol intoxication

• Reduce the public health impact of illicit alcohol and informally produced alcohol

• Marketing of alcoholic beverages

• Pricing policies


“Public health must also contend with Big Food, Big Soda, and Big Alcohol.”

“All of these industries fear regulation and protect themselves by using the same tactics.”

“It is not just Big Tobacco anymore”

8th Global Conference on Health Promotion, Helsinki, Finland (June-2013)


Correlation of unhealthy non-food and unhealthy food commodities with sales (80 countries)

Lancet NCD Action Group (2013). 381(9867):670-9

Unhealthy non-food

commodities

Unhealthy

food commodities


A world converging within a generation

• An essential package of population-based interventions

• Taxation is a powerful lever to reduce risks from exposure to or consumption of unhealthy products

• Tax increases are a highly cost-effective approach to reduce total alcohol consumption and the number of episodes of heavy drinking, especially in young people.

The Lancet Commission 2013; 382:1898-1955. Copyright © Elsevier Ltd


The illusion of righteousness: Big Alcohol’s argument

• Industry prefers to press the value of

– Voluntary regulation

– Educational approaches

– Emphasizing personal responsibility

• “Tax increases and restrictions on sales and marketing, often have unintended, harmful consequences in the long term.” (lack of evidence in this statement)

Anderson P. (2009) Curr Opin Psychiatry.22(3):253-7

http://blogs.plos.org/speakingofmedicine/2013/09/25/partnerships-of-peril-keeping-food-alcohol-and-beverage-industries-out-of-global-health-governance/

Yoon S et al (2013). BMC Public Health.3;13:630

http://blog.norml.org/2009/02/23/norml-breaking-news-california-assemblyman-introduces-legislation-to-tax-and-regulate-marijuana-like-alcohol/


Why prevention, health warnings, cessation, etc.

matter


Reduction in risk of esophageal cancer following alcohol cessation

• Risk is reversible following drinking cessation

• About 16 years are required until all elevated risk (especially for heavy drinkers) has disappeared

Jarl J AT AL (2012). Addiction. 107(7):1234-43


15% risk reduction in 5 years

Risk decline of laryngeal (A) and pharyngeal (B) cancer over 40 years after drinking cessation

Ahmad Kiadaliri A, et al (2013)

PLoS ONE 8(3): e58158.


Why Thailand’s attempt did not make it past World Trade Organization in 2010

http://online.wsj.com/article/SB20001424052748704392104575475513718846130.html

http://www.eurocare.org/library/updates/thailand_notifies_wto_members_of_plans_to_introduce_alcohol_warning_labels


http://www.theguardian.com/society/2012/jul/13/alcohol-packaging-graphic-health-warning

2012- UK Faculty of Public Health


WHO’s concern with youth, especially in LMICs, being

targeted in alcohol marketing


Sport star endorsement of alcohol: Civil society protest

“I know that I have influence on youngsters and I don’t feel that I want them

to think if I should endorse these products I want them to use them.”

Pele, famous Brazilian Football Player (In – biography by Joe Marcus)

Turned down 3-year US $13 million

offer to endorse Indian liquor brand

http://news.outlookindia.com/items.aspx?artid=818930

http://alcoholfreecricket.blogspot.com/


Were James Bond’s drinks shaken because of alcohol-induced tremor?

http://www.primermagazine.com/2012/learn/booze-like-bond-007s-other-drinks

http://www.movies.com/movie-news/james-bond-heineken/7326

Johnson G et al (2013).BMJ.12;347:f7255

“We advise reduction in alcohol

consumption to safe levels.”

©2013 by British Medical Journal Publishing Group Johnson G et al (2013).BMJ.12;347:f7255


Decline of tobacco in U.S. movies: 1996-2009

Bergamini E at al (2013). JAMA Pediatr.167(7):634-9

Note – Another study showed increase in smoking

exposures in US movies for year 2010-2011

Glantz SA et al (2012). Smoking in top-grossing US movies,

2011. Prev Chronic Dis.9:120170.

WHY MEDIA AND

MARKETING MATTER


Increase in alcohol brand exposure in youth-rated U.S. movies

Bergamini E at al (2013). JAMA Pediatr.167(7):634-9


“With West Flat, Big Brewers Peddle Cheap Beer in Africa” (WSJ)

Product Cover Artist: Sylvia van Overschot-Gerssen

E-book by Andrea Rossouw (Nov-2011)

http://online.wsj.com/news/articles/SB10001424127887324034804578348533702226420

“Alcohol and Beer are not good for health but they bring revenue.” Mozambique revenue authority


A framework convention on alcohol control? Not yet!!


Alcohol

• Alcohol formally considered a global health threat

• Regulation and accessibility in LMICs vs. high-income countries

• Younger generation more prone to drinking

Gender

• Not only do more men than women drink, but they also drink more than women

• Both genders at risk for health-related DALYs

• Alcohol use patterns are embedded in the social, cultural, and gender norms of a given society

Health

• Impact of harmful use of alcohol on health, in particular on cancers, liver and cardiovascular diseases, and injuries

• Global health and national health programs must consider feasible interventions in context

In summary


QUESTIONS?

Thank you!


Chronic diseases – MSH approach

At Management Sciences for Health (MSH), we are committed to addressing the rising burden of chronic disease by focusing on people at all levels of the health system: individuals who make decisions about their health, community health workers who bring services close to the home, facility health workers who administer essential health services, and government officials who set standards and allocate resources.

With a people-centered, health systems approach and a vision toward universal health coverage, we can better understand chronic diseases and help people have better access to the health care they need.

http://www.msh.org/resources/chronic-diseases-brochure








About the MSH approach to health impact

Strengthening health systems is the most sustainable way of improving health and saving lives at large scale.

MSH pursues its mission of saving lives and improving health by building high impact, sustainable, locally-owned health

systems. To create greater health impact we engage in four practices, applying our expertise across six health systems building blocks, as identified by the world Health Organization,

to achieve lasting, tangible results in five priority health areas.

MSH Strategic Roadmap

http://www.msh.org/resources/msh-strategic-roadmap-2017










Additional Information


Countries age limits for serving or selling alcohol

WHO. Global Status Report on Alcohol and Health (2011)


Alcohol, gender and drinking problems: Perspectives from LMICs

• Heavy drinking among poor

• Alcohol consumption & HIV

• Negative relationship consequences

Mexico

India

Brazil

Costa Rica

Argentina

Uganda

Sri Lanka Consumption habits and

the social and health

consequences of drinking

Social problems

Men vs. women

Drinking patterns and

alcohol problems among

women

Contexts of drinking Country Evidence

Nigeria

• Women more likely to be abstainers

• “Role” of women in society

• Age gap vs. alcohol consumption

• Daily drinking

WHO. Alcohol, gender and drinking problems: perspectives from low and middle income countries. 2005.


http://www.theguardian.com/commentisfree/2011/feb/21/drinks-companies-liver-disease-mosquitoes-malaria

Reframing this issue as an industrial epidemic


Alcohol, tobacco, obesity

• Largest risk seen in people who both drink alcoholic beverages and consume tobacco in smoking and smokeless forms

• In addition to the tobacco epidemic, alcohol drinking emerges as serious public health program in LMICs – synergistic risk increase with obesity

Pednekar MS, et al (2012) Alcohol.;46(2):139-46.


Interaction of alcohol with medicines

• Alters availability, increases toxicity

• Inadequate knowledge, especially among elderly

• Alcohol interferes with these therapeutic classes:

• Anesthetics

• Antibiotics

• Anticoagulants

• Antidepressants

• Antidiabetics

• Antihistamines

• Antipsychotics

• Anticonvulsants

• Antiulcer agents

• Cardiovascular agents

• Narcotic/non-narcotic pain relievers

• Sedatives/hypnotics

Zanjani F, et al (2013). Drug Healthc Patient Saf. 2013;5:13-27


Stronger health systems. Greater health impact.

Saving lives and improving the health

of the world’s poorest and most vulnerable people

by closing the gap between knowledge and action in public health.

Documents

Shaken, not Stirred: The Intersection of Alcohol, Gender, and Health · 2014. 3. 7. · Management Sciences for Health 1 Stronger health systems. Greater health impact. Shaken, not