barcelona . spain - European Association for the Study of the Liver

BARCELONA . SPAIN
12 POSTGRADUATE COURSE SYLLABUS ALCOHOLIC LIVER DISEASE 13
APRIL 18 - 19/2012 THE INTERNATIONAL LIVER CONGRESS TM 2012
PREVALENCE AND TRENDS IN ALCOHOL CONSUMPTION AND ALCOHOLIC LIVER DISEASE
The trends in alcohol consumption and alcohol-related harm vary significantly among different countries
and areas of Europe as well as according to policies and interventions in each country. In fact, in the period
1990‒2006, there have been substantial fluctuations with decrease, increase and then stabilization. There
is evidence of a very marked disparity in alcohol consumption trends among different countries, with a
predominance of Eastern European countries experiencing an increase. Also, the financial crisis in the
European Union is probably going to result in an increase in alcohol-related harm. In fact, already a more
than three per cent increase in unemployment is associated with as much as a 28 per cent increase in
deaths from alcohol use disorders (3).
It is difficult to estimate the true prevalence of alcoholic liver disease in the population. A population based
study in France, using transient elastography as a screening tool, found that alcohol was the probable
cause of one third of the cases of excess fibrosis (4). However, we really need further studies combining
serum markers, ultrasound and elastography to better define the real prevalence of compensated and
decompensated alcoholic liver disease. Further studies also need more detailed alcohol drinking pattern,
since that may have implications on the risk of liver disease. In fact, it is still unclear if the risk is different
when alcohol consumption concentrates on one or two days of the week, or if it distributes homogeneously
during the week. Also, the effect of binge drinking (by definition more than 5 drinks for men, and more than
4 drinks for women in two hours) on the risk of progression to more advanced forms of ALD is yet ill-defined.
Since binge drinking is steeply increasing, mostly in young people, and in some countries, the information
would be of great importance.
Liver cirrhosis mortality remains the best tool to evaluate the burden and trends of alcoholic liver disease,
although it is still subject to important bias, including differences in death certificates accuracy according to
different countries, and the reluctance to include alcohol in the death certificate due to legal implications.
During the last 30 years, mortality due to liver cirrhosis followed a pattern similar to alcohol consumption,
with a large disparity between countries. In fact, it was well shown that per capita alcohol consumption is
strongly correlated with liver cirrhosis mortality rates across countries.
There have been sharp declines in liver cirrhosis mortality in about half the countries in Europe, mostly
Western European countries, such as Austria, France, Germany, Italy, Portugal and Spain, but also in
Eastern countries such as Hungary and Romania. On the opposite, impressive increases in liver mortality
cirrhosis are seen in Eastern countries, such as Russia, Lithuania, Estonia and Polonia, but also in some
Western countries such as United Kingdom and Ireland and Finland (Figure 3). It is of interest that these
differences are more evident in the group older than 45 years. Also, incidence of ALD is 2 to 3 times higher
in males than females, although frequency between males and females tend to correlate in every country
and for each level of consumption (5).
Data from the European Liver Transplantation Registry showed that alcohol represents one third of
the causes of cirrhosis leading to liver transplantation and is the second cause for liver transplantation
(Figure 4). These numbers underscore the importance of alcohol as a cause of liver disease, although still
underestimating it, since alcoholics are probably less transplanted than other patients. Also, and according
to the same study, there has been a recent increase in the number of patients transplanted due to alcoholic
liver disease (6).
Another important issue is the recent change in the pattern of alcohol consumption, and how is it going to
affect the risk of liver disease. In fact, recent years have shown an increase in the binge drinking pattern,
particularly in young people, and there is evidence that binge-drinking can cause liver cirrhosis, with the
risk increasing with the number of binge episodes (7). This evidence comes from experimental as well
as epidemiological studies. Besides from the effect on the liver, binge has also been associated with an
increased risk of atrial fibrillation and ventricular arrhythmias, myocardial infarction, as well as haemorrhagic
and ischaemic strokes.
Besides from the effect on the liver, it is increasingly recognized that alcohol has a very important role
in several other diseases, such as cardiovascular diseases, showing a very strong risk association with
hypertension, hemorrhagic stroke and cancer. Indeed, alcohol metabolism produces acetaldehyde,
strongly involved in alcohol-associated carcinogenesis; in addition, ethanol itself stimulates carcinogenesis
by inhibiting DNA methylation and by interacting with retinoid metabolism. The importance of alcohol as
a risk for cancer, namely of the oral cavity, pharynx, esophagus, liver, colon, rectum, larynx and female
breast have been well recognized. According to the WHO estimates for global burden of disease, more
than 389,000 cases of cancer were attributable to alcohol drinking worldwide, thus representing 3.6% of
all cancers, (5.2% in men, and 1.7% in women). Similar results were found by the International Agency for
Research on Cancer, that alcohol is a risk factor for upper aerodigestive tract cancer (oral cavity, pharynx,
hypopharynx, larynx, and esophagus), liver cancer, colorectal cancer, and breast cancer. In fact, it was
only recently that the increased risk for breast cancer, even for very low consumptions, was highlighted and
documented, with breast cancer comprising 60% of alcohol-attributable cancers, in women. It is also of note
that alcohol consumption and smoking has a synergistic effect on the risk of some of these cancers. Alcoholassociated
changes in behavior, is also a major cause of intentional and unintentional injuries, either to the
drinker or to others. It is also an important cause of professional absenteeism and low performance, as
well as family violence and disruption. Alcohol is also a potent teratogen and a cause of neurological and
psychiatric disturbances.
ECONOMIC BURDEN
It was estimated that the total tangible costs of alcohol to the EU in 2003 were about €125 billion (€79bn-
€220bn), equivalent to 1.3% (0.9–2.4%) of gross domestic product (GDP). Actual spending on alcoholrelated
problems accounts for €66 billion of this, while potential production not realized due to absenteeism,
unemployment and premature mortality accounts for a further €59 billion. This amount largely exceeds
the reported contribution of around 9 billion euros to the goods account balance for the EU. Furthermore,
it seems to contribute to health inequalities between and within European Member States, due to more
frequent risky alcohol use in lower socioeconomic groups and also to greater mortality from directly alcoholrelated
conditions (8).
HOW TO DEAL WITH THE PROBLEM
Since alcohol is indeed a major health risk factor and simultaneously a heavy economic burden, it becomes
obvious that measures need to be taken to change/reduce the pattern of consumption. One the major
problems regarding control of alcohol consumption is that drinking alcohol can be harmless and is very
strongly rooted in our Society. In fact, it is not constantly harmful as for example tobacco smoking, and this
duality results in difficulty in delineating measures to reduce consumption and to implement them.
One of the first controversies is what the safe-drinking limit is In what regards the threshold for liver
cirrhosis, Rehm et al. found in a recent meta-analysis, an increased risk of mortality from liver cirrhosis
among men and women drinking 12-24g/ethanol per day (9), and a large epidemiological study on Italy,
found that there was an increased risk of cirrhosis in those drinking 30 g/ethanol per day. More difficult and
controversial is to find a threshold in the case of binge-drinking (7). It is possible that for some diseases
there is not a safe limit. For example, in breast cancer, a recent meta-analysis that included 98 studies
reported a 10% increase in breast cancer risk per 10 g of alcohol con¬sumed per day, with no definition of
a safe threshold.
Alcohol policies and their effectiveness
Several policy targeted areas have been developed, including information and education, health
sector response, community programmes, drink driving policies, availability of alcohol, marketing of
alcohol beverages, pricing policies, harm reduction, and reducing the effect of illegal produced alcohol.
Regarding interventions on information and education, they are not expensive, but systematic reviews of
this programmes showed that they do not particularly affect consumption levels or health outcomes (10),
although they are important to convey awareness and knowledge of the problem. Other policies, like drinkdriving,
seem to be quite effective, mostly if they are efficiently implemented and rigorously enforced (10).
Also, brief interventions to those at-risk seem to be useful.
One of the most effective measures is reducing availability of alcohol, either through the pricing policies
or the hours and places of sale and minimum purchase age laws (8). In fact, laws that set a minimum age
for the purchase of alcohol show clear reduction in drink-driving casualties and other alcohol-related harm.