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  • A Lancet study suggests moderate alcohol use over time can “significantly shorten your life
  • Experts call for the study’s findings to be widely disseminated and discussed
  • A 2010 Lancet study suggested alcohol is more harmful than heroin or crack cocaine
  • Alcohol related harm is a global epidemic caused by a commercial product
  • There are 3.3m deaths each year caused by alcohol use
  • Policies to reduce the harmful effects of alcohol are palliative rather than preventative
  • A few giant alcohol beverages corporations dominate the global market
  • But 50% of the market is in the hands of informal small-scale producers
  • There is a dearth of reliable information on the alcohol beverages industry
  • Public health research has not kept up with the industry’s ability for innovative marketing
  • British drinkers contribute more in alcohol-related taxes than the direct costs of alcohol-related health and crime issues
  
Moderate alcohol use can kill
 
Just when you thought you knew everything there is to know about the harmful effects of alcohol, a study published in the April 2018 edition of The Lancet, brings new evidence to suggest that even modest alcohol use over time is as dangerous as smoking and can “significantly shorten your life”.  The study reinforces the fact that alcohol-related harm is a ‘global epidemic’ caused by a commercial product, which is aggressively marketed throughout the world. Policies aimed at reducing the harmful effects of alcohol have a limited effect and alcohol use continues to be a significant challenge to medicine and society.  
 
In this Commentary

This Commentary discusses some of the reasons why public policies to limit alcohol use fail to dent the vast and escalating burden caused by alcohol use. We begin by describing the findings of The Lancet 2018 study, which highlights the association between regular modest drinking and early death. The study’s findings motivated healthcare professionals to renew calls for lower limits on alcohol use. A study published in The Lancet in 2010 suggested alcohol is more harmful than heroin or crack cocaine. Public policies to reduce the harmful effects of alcohol use are compromised by the competing interests of the principal industry stakeholders. Such policies tend to be orientated towards the demand side of the market and focus on individual consumers and are less engaged with the supply side and large producers. This results in: (i) public policies that are more palliative than preventative, (ii) alcohol use continuing to be a major healthcare and social challenge, (iii) giant alcohol beverages producers receiving a “free pass”, and (iv) governments enhancing their “political capital” by pointing to the millions spent to correct the drinking habits of vulnerable individuals. This ecosystem is further influenced by: (i) the duty and tax revenues governments collect from alcohol use, (ii) public research failing to keep pace with the sophisticated marketing strategies of large drinks companies, and (iii) well resourced, and smart producers’ marketing strategies out-maneuverering government bureaucracies in endeavours to influence the tastes and preferences of individuals.
 
The Lancet study

The contribution of alcohol use to premature death is less well recognised than the connection between smoking, lung cancer and early death. The Lancet 2018 study helps to redress this by improving on previous meta-analyses to define low-risk drinking thresholds, and to suggest that people who consume more than 7 drinks a week can expect to die sooner than those who drink less. According to a February 2018 World Health Organization (WHO) report, an estimated 3.3m people a year worldwide die as a result of alcohol misuse. The harmful effects of alcohol ranks among the top 5 risk factors for disease, disability and death globally, and alcohol misuse is the 5th leading risk factor for premature death and disability worldwide. Most people who die because of their drinking patterns are not alcoholics, but are people who drink regularly over a number of years.
 
The Lancet 2018 study is significant because of its size and methodological robustness.  There is a high degree of comparability in the datasets used by the authors, which combined data from 83 previous studies undertaken in 19 countries, which yielded a cohort of 600,000 current drinkers for analysis. The previous studies used by the researchers to attain their cohort employed similar methods to quantify alcohol use, cardiovascular risk factors, and cardiovascular disease outcomes and cause-specific deaths. All participants in the cohort were from developed industrial economies, displayed similar patterns of alcohol use and none had a known history of cardiovascular disease.
 
The study’s findings imply that drinking alcohol is as harmful as smoking and suggest that there is a significant increase in all causes of death when more than 100g of alcohol (equivalent to about 4 large glasses of wine) is consumed weekly over a period of time. Every glass of wine or pint of beer over the daily recommended limit - the upper “safe” limit in the UK is 5 standard 175ml glasses of wine or 5 pints of beer a week - will cut 30 minutes from the expected lifespan of a 40-year-old and increase the risk of stroke, fatal aneurysm (a ruptured artery in the chest), heart failure and death. A 40-year-old who drinks up to twice that amount (200g or 8 large glasses of wine per week) will shorten their life expectancy by 6 months. Drinking between 200g and 350g (8 to 20 large glasses of wine) a week will reduce their life expectancy by 1 to 2 years, and 40-year-olds who drink more than 350g (>20 large glasses of wine) a week over a period, shorten their lives by 4 to 5 years.
 
Lowering the recommended limits of alcohol consumption
 
According to Angela Wood, from the University of Cambridge in the UK and lead author of the 2018 study, “The key message of this research for public health is that, if you already drink alcohol, drinking less may help you live longer and lower your risk of several cardiovascular conditions.” Although moderate drinking is commonly associated with reducing your chance of a non-fatal heart attack, “This must be balanced against the higher risk associated with other serious, and potentially fatal cardiovascular diseases,” says Wood. According to the researchers the study’s findings support, “limits for alcohol consumption that are lower than those recommended in most current guidelines [and add] long-term reduction of alcohol consumption from 196g per week (the upper limit recommended in US guidelines) to 100g per week or below was associated with about 1–2 years of longer life expectancy at age 40 years”. Co-author Naveed Sattar, Professor of Metabolic Medicine at the University of Glasgow’s Institute of Cardiovascular and Medical Science in Scotland said: "This study provides clear evidence to support lowering the recommended limits of alcohol consumption in many countries around the world."

 
Experts call for lower limits on alcohol use

Commenting on the study’s findings, Tim Chico, Professor of Cardiovascular Medicine at the University of Sheffield,UK, said, smokers lose on average 10 years of their life. “However, we think from previous evidence that it is likely that people drinking a lot more than 43 units (about 14 large glasses of wine a week) are likely to lose even more life expectancy, and I would not be surprised if the heaviest drinkers lost as many years of life as a smoker. . . The study makes clear that on balance there are no health benefits from drinking alcohol, which is usually the case when things sound too good to be true.”

In a commentary in the same edition of The LancetJason Connor and Wayne Hall both professors from the University of Queensland Centre for Youth Substance Abuse Research in Australia, anticipated that the suggestion to lower recommended drinking limits would be opposed by giant alcohol beverages corporations. “The drinking levels recommended in this study will no doubt be described as implausible and impracticable by the alcohol industry and other opponents of public health warnings on alcohol. Nonetheless, the findings ought to be widely disseminated and they should provoke informed public and professional debate,” say Connor and Hall.

 
A 2010 study published in The Lancet claims alcohol is more harmful that heroin

In the November 2010 edition of The Lancet David Nutt, Professor of Neuropharmacology at Imperial College London and co-author of the study suggested that alcohol is more harmful than heroin or crack cocaine when the overall dangers to the individual and society are considered. Nutt was the clinical scientific lead on the 2004-5 UK Government Foresight initiative “Brain science, addiction and drugs”. The Lancet 2010 study suggested that if drugs were classified on the basis of the harm they do, alcohol would be a class ‘A’ drug, alongside heroin and crack cocaine. In 2006 Nutt was dismissed for challenging the UK Government’s refusal to take the advice of the official Advisory Council on the Misuse of Drugs,  which he then chaired.

In answer to The Lancet 2010 study a UK government Department of Health spokesperson said: "In England, most people drink once a week or less. If you're a woman and stick to 2 to 3 units a day, or a man and drink up to 3 or 4 units, you are unlikely to damage your health".
No agreed international limits for alcohol use
 
The reality is that there are no internationally agreed limits on alcohol use and current recommended limits vary significantly between nations. In a study published in the June 2012 edition of the Drug and Alcohol Review  researchers from the University of SussexUK, examined government issued guidelines on alcohol limits in 57 countries and found, “a remarkable lack of agreement about what constitutes harmful or excessive alcohol consumption on a daily basis, a weekly basis and when driving”.

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Alcohol use and dementia

In 2016 the UK Government updated its 1995 guidelines  for limits on alcohol use and recommended that neither men nor women should drink more that 14 units of alcohol per week. A unit in the UK is equivalent to 8g of pure alcohol. This means British men are now being told they should drink less than those in Ireland (21.2 British units), Denmark (21), New Zealand (19) and considerably less than the recommended upper limit for men in Spain (35).
 
 
The supply side of the alcohol industry

Current public policies and industry pledges
Although public policies to reduce the harmful effects of alcohol use are aimed at both the individual and population levels, they tend to orientate towards individual problem drinkers. Among the most effective policy options are alcohol taxes, restrictions on alcohol availability and drink-driving countermeasures. The giant alcohol beverages corporations advocate responsible drinking and pledge their commitment to, “supporting balanced initiatives that are linked to their core business functions and those that address wider social and public health issues, relying on initiatives that are evidence based, culturally sensitive, and collaborative.” The drinks producers support the WHO’s Global Strategy to reduce the harmful Effects of Alcohol, and are committed to: (i) reducing under-age drinking, (ii) strengthening and expanding marketing codes of practice, (iii) providing consumer information and responsible product innovation, (iv) reducing drinking and driving, and (v) enlisting the support of retailers to reduce harmful drinking.  

Growth of service economies and the importance of individual preferences
Despite public policies and industry pledges to limit alcohol use, the large and escalating burden of alcohol problems continue to present significant challenges to medicine and public health. In part, this is because population-based public health policies tend to be overlooked in favour of policies oriented towards individual drinkers. This orientation can be explained by globalization.
 
Over the past 40 years globalization has shifted the economic base of developed nations from manufacturing to services, which places greater emphasis on consumer markets and individual preferences. In such a context, efforts to reduce the harmful effects of alcohol use are mainly focused on the demand side of the market, emphasising individual behaviours and preferences; and less focused on the supply side, which is dominated by producers. As a consequence, public policies to limit alcohol use tend to focus on the choices of vulnerable individual drinkers and call for responsible drinking. In effect this provides producers with a “free pass” to pursue and develop their strategies to sustain consumption.
 
50% of alcohol production is in the hands of “informal” small producers
Shifting the policy emphasis to focus equally on the demand and supply side of the alcohol beverages market is not straightforward. Although nearly half of the of the world's alcohol supply is dominated by giant producers, more than 50% is in the hands of ‘informal’ home and local producers. At the national level the industry comprises large and small beer, wine or spirit producers or importers, as well as bars, restaurants and a variety of retail outlets, which markets alcohol to the public. These players have diverging interests as well as interests in common in regard to policy frameworks. There is a dearth of reliable information on the industry and the principal sources of information come from market research firms and business journalism.  
 
Large global fast-growing market
The alcohol beverages market is large, global and fast growing. According to an April 2018 report by Transparency Market Research, in 2017 the market was worth US$1,205bn and is expected to expand at a CAGR of 6.4% and reach US$2,000bn by the end of 2025. Recent consolidation in the industry puts a significant and increasing proportion of alcohol production, distribution and marketing in the hands of a few giant corporations, which dominate national, regional and global markets and wield considerable political influence. Mergers and acquisitions are expected to continue, so the consolidation of the industry is expected to continue.

The market is driven by increasing urbanization, the global young-adult demographic, high and growing disposable incomes and increasing consumer demand for premium and super premium beverages. The latest figures suggest that the average alcohol use in the UK is about 9.7 litres per adult, which compares with 8.8 litres for adults in 34-member countries of the Organisation for Economic Co-operation and Development  (OEDC), and ranks the UK 16th out of the OEDC countries. Since 1970, alcohol consumption has decreased by an average of 15% across OEDC countries, while in the UK it has risen 14% over the same period. Alcohol use has declined 69% in Italy, 48% in France, 36% in Spain and 30% in Germany, but has increased 51% in Ireland. Consumption of alcohol per head in the UK has fallen by about 17% since its recent peak in 2004. But that followed a steep rise.

A study reported in 2015 in the International Journal of Advertising suggests that advertising has little impact on how much we drink, but it is effective at influencing what we drink. ‘Premiumization’ is a term used in the industry to describe how spirit brands have had success convincing consumers that they should drink “higher quality” and more expensive beverages. An example of this is the recent boom in the sale of gin, which corresponded with the industries premiumization strategies that linked gin with “fashionable” early 20th century style.
 
UK alcohol taxes far exceed the costs to public services
 
The “free-pass” enjoyed by alcohol beverages corporations is strengthened by the relative lack of public scrutiny they receive. This might be partly explained by the fact that governments benefit significantly from alcohol related taxes and duty. Consider Britain. In 2016 the UK government made nearly £3.4bn in tax revenue from spirits; beer sales made the UK government £3.3bn in 2017. Some 60% of the price of a pint of beer is taken in VAT and alcohol duty, while VAT on the price of a bottle of gin is 76%. Wine is the biggest earner for the UK exchequer yielding over £4bn in taxes from sales in 2016. These sums accord with a September 2015 Institute of Economic Affairs (IEA) study on alcohol taxes, which suggests that the annual revenue generated from alcohol taxes in the UK is  “illogical and excessive.”  Rather than tax alcohol the UK government taxes drinks. For instance, a unit of alcohol is taxed at 28p if it happens to be in a glass of whisky but only 8p if it is in a pint of cider. Further, if the cider is strong, the tax is 7p but if it is fizzy the tax is 34p. The tax on a unit of alcohol in a glass of wine is 20p, but if wine is sparkling, the tax is 25p. Confused? The structure of alcohol excise taxes is partly restricted by an EU Directive, which sets out different tax rates for different alcoholic beverages.

Revenues from UK alcohol taxes and duty far exceed the actual direct costs of alcohol-related health and crime issues. According to the IEA study, the UK exchequer collects about £10bn a year in alcohol taxes while the direct costs of alcohol related problems to the health, police, prison services, welfare system and judiciary, amount to some £4.6bn per year. Although studies that report cost-of-alcohol data are notoriously unreliable, the IEA suggests that British drinkers contribute about £6.5bn each year to the UK exchequer and believes that, even within the current constraints, the UK tax system could more effectively target problem drinking. In a February 2017 paper the IEA describes a suggested reform of the UK’s alcohol tax policy.

 
Takeaways
 
Findings of the 2018 study published in The Lancet suggest that risks from alcohol start from any level of regular drinking and rise with the amount being consumed and any amount of regular alcohol use can significantly shorten your life. This echoes a 2010 study also published in The Lancet, which suggested that because alcohol is so widely available it is more harmful than heroin and crack cocaine.

This commentary reaffirms the global epidemic of disease, injury, social problems and death caused by alcohol and suggests an explanation why for decades governments have failed to effectively limit alcohol use.
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  • Dementia has emerged as one of the biggest killer diseases of the 21st century
  • Studies suggest that moderate alcohol use significantly increases the risk of dementia
  • There are no treatments that slow or stop the progression of dementia
  • There are 50m people worldwide living with dementia, by 2050 there will be 132m
  • 0.85m people in the UK are living with dementia and this is expected to rise to 1m by 2025
  • Public policies alone are not sufficient to limit and control alcohol use
  • This increases the importance of a medical solution for dementia
  • Recent innovative research on neurodegenerative disorders provide some hope for future dementia sufferers
 
Alcohol use and dementia

Two significant recent studies described in this Commentary link alcohol use and the onset of dementia. One study published in the June 2017 edition of the British Medical Journal (BMJ) suggests that moderate alcohol use increases the risk of adverse brain outcomes and a steeper decline in cognitive abilities. The other, published in the February 2018 edition of the Lancet Public Health, suggests that excessive alcohol consumption is a significant risk of early onset dementia.

Dementia is a chronic progressive disorder, which has emerged as one of the biggest killers and the only leading cause of death without a treatment that can slow or stop its progression. Of the 529,655 deaths recorded in the UK in 2015, dementia accounted for 61,686 (11.6%): the majority are women, 41,283, compared to 20,403 men.

 
In this Commentary
 
In this Commentary we outline how alcohol affects you, explain its misuse and describe some of the UK’s drinking patterns and their consequent costs. We then suggest that public policies alone, which are aimed at both the individual and population levels to reduce and control alcohol use in order to save lives and reduce healthcare costs, are insufficient. This shifts the burden of a solution for alcohol related dementia onto potential medical treatments. We describe dementia and provide a few epidemiological facts before describing the findings of the 2 studies. We suggest that the studies are significant because there are no effective treatments or cures for dementia despite the vast amounts of money spent on neurodegenerative diseases over the past 2 decades. We end by mentioning a couple of significant UK-based innovative dementia research initiatives, which signal hope for future dementia sufferers.

 

How alcohol affects you and its misuse

Alcohol is a dependence-producing psychoactive beverage, which has been widely used throughout the world for centuries. Problems associated with the consumption of alcohol have been around since the beginning of recorded history. There are 3 mechanisms by which alcohol can affect you: (i) alcohol has toxic effects on your brain and other organs and tissue, (ii) alcohol has intoxicating effects, which manifest themselves in physical and mental impairment and (iii) you may become dependent of alcohol, which means control over your drinking habit is impaired. Alcohol’s harmful impact is influenced by, (i) the volume you consume, (ii) your pattern of drinking and (iii) the quality of the alcohol. When your body takes in more alcohol than it can metabolize, the excess builds up in your bloodstream. Your heart circulates the blood alcohol throughout your body leading to changes in your body’s chemistry and normal functions. 

Studies have consistently suggested that heavy alcohol consumption is detrimental to health and a leading preventable cause of death. There is an increasing awareness of the harmful impact of alcohol misuse on individuals and societies. According to the 2011 World Health Organization’s (WHO) Global status report on alcohol and health, only about 50% of the world's population consumes alcohol, and most users are in the wealthier northern hemisphere countries, although alcohol use is increasingly becoming a problem in emerging economies. Eastern European countries have the highest consumption, riskiest patterns of drinking and the highest levels of alcohol-related deaths and disabilities. According to a February 2018 WHO report, an estimated 3.3m people a year worldwide die as a result of alcohol misuse, which accounts for about as much death and disability worldwide as tobacco and hypertension. 
 
Drinking in the UK and its costs
 
The latest available data suggest that the total alcohol consumption in the UK is 9.5 litres per person aged 15 years and older and 7.8 litres per person on average throughout the entire population in 2015. This forms part of a recent downward trend from a peak of 11.6 and 9.5 litres per head respectively in 2004 and positions the UK 16th out of the 34 OEDC countries. 21m people in the UK do not drink alcohol. According to NHS Digital, in 2014 there were 1.1m hospital admissions in England wholly or partially attributable to alcohol use: more than double the number recorded a decade earlier. In 2014 about 6,600 people in England died from causes related to alcohol and about 115,000 adults received specialist alcohol treatment. Treating alcohol related conditions is estimated to cost NHS England about £3.5bn per year: around 3.6% of its annual budget. About 6% of adults in England are dependent on alcohol. 195,000 prescriptions were written in 2014 by the NHS to treat alcohol dependence at a cost of £3.4m. Over the past decade these prescription costs, measured in 2014 prices, have increased by nearly 80% from £1.9m in 2004.
 
Public policies to curb alcohol use are insufficient

In May 2018, Scotland became the first country in the world to introduce legislation for minimum pricing on cheap, high-strength alcohol. The government said it was an endeavour to cut the consumption of alcohol and save lives. For several decades, similar alcohol reduction and prevention measures have been available at both the individual and population levels in the UK and elsewhere. The most effective include alcohol taxes, restrictions on alcohol availability, and drink-driving countermeasures. Despite the success of these policies, alcohol problems continue to present a major challenge to medicine and public health. In part, this is because population-based public health alcohol control policies tend to be overlooked in favour of approaches aimed at the individual and these have tended to be more palliative than preventative. It is reasonable to assume therefore that, in the near- to medium-term, alcohol related dementia will neither be significantly slowed nor reduced by public policies alone. This shifts the emphasis to a medical solution for alcohol related dementia.
 

Dementia

Dementia is an umbrella term, which describes a group of symptoms that impair your cognitive functions and behavioural abilities severely enough to interfere with your daily life and activities. It is a chronic, progressive and incurable disorder, which ranges in severity from ‘mild’, when it is just beginning to affect your functioning, to ‘severe’, when you depend completely on others for basic activities of living. Dementia involves damage of nerve cells in your brain, which can occur in several areas and affect people differently, depending on the area of the brain affected. Alzheimer's, a neurodegenerative disease, is the most common irreversible cause of dementia, accounting for 60% to 80% of all dementia cases.
The biggest risk factor for dementia is age. We are living in the age of the aged, which represents the successes of improved healthcare over the past century. There are some 50m people worldwide living with dementia. The total number of people with dementia worldwide is projected to increase to 75m by 2030 and 132m by 2050, with the largest proportion of these in low- and middle-income countries. There are 0.85m people diagnosed with dementia in the UK, with numbers set to rise to over 1m by 2025 and to 2m by 2050. 225,000 people in Britain will develop dementia this year. There is a similar story to be told in most wealthy developed countries. For example, in the US an estimated 6m people have Alzheimer's, which equates to 10% of people aged 65 and older. The current annual cost of dementia globally is estimated to be about US$1tr: 1% of global GDP. The annual cost of the condition in the US is US$259bn, which is expected to rise to US$1tr by 2025. Dementia costs the UK exchequer about £26bn each year.
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Drunkorexia: a devastating and costly growing condition


Dementia is not an inevitable part of ageing. The notion that dementia is a disease rather than a side-effect of aging has been around for 100 years. Early onset of the disease can begin when people are in their 30s, 40s, or 50s. For example, over 42,000 people under 65 have dementia in the UK. Age, family histories and heredity are factors of dementia that we cannot change. But lifestyle factors such as alcohol use are modifiable risks. There is no cure for the condition and no therapy that slows or stops its progression although some drug treatments may temporarily improve its symptoms.

 
The BMJ study

For some time, scientists have suggested that moderate alcohol consumption could delay the onset of cognitive impairments in ageing, but few studies have examined the effects of modest consumption of alcohol on the brain. This increases the significance on the BMJ study, which includes an analysis of the relationship between moderate alcohol consumption and dementia. Researchers from Oxford University  and University College London studied a cohort of 550 healthy adult civil servants over a 30 year period between 1985 and 2015. At the beginning of the study the average age of the cohort was 43 and none were dependent on alcohol. At regular intervals during the study tests were administered to assess participants’ levels of alcohol consumption and cognition. At the end of the study participants underwent an MRI brain scan, which enabled researchers to analyse correlations between average alcohol consumption, cognition and brain structure. Findings suggest that alcohol use is associated with reduced right hippocampal volume. The hippocampus is a small region of your brain associated with memory and spatial navigation. Poor memory is linked with small hippocampal volume as measured by an MRI scan. The more you drink, the more you are likely to have hippocampal atrophy, which is regarded as an early marker for dementia. Significantly, the study found that even moderate drinkers were 3 times more likely to have hippocampal atrophy than abstainers.

The principal strength of the study is that it is a longitudinal observational analysis of a specific cohort, which yielded detailed information on long term alcohol consumption and cognition and confounding variables. These are “extra” variables, which are important to know in order to avoid bias. Because this was an observational study the researchers were unable to draw any conclusions on cause and effect. Notwithstanding, they were able to conclude that moderate alcohol use is associated with adverse brain outcomes and, “Alcohol might represent a modifiable risk factor for cognitive impairment, and primary prevention interventions targeted to later life could be too late.” In an editorial note in the same BMJ, Killian Welch, a consultant neuropsychiatrist at the Royal Edinburgh Hospital suggests the findings of the study, “strengthen the argument that drinking habits many people regard as normal, have adverse consequences for health.”

 
The Lancet Public Health study
 
The second study from The Lancet Public Health presents findings of a large retrospective study predicated upon data of more than 1m adults diagnosed with dementia between 2008-2013 from the French National Hospital Discharge database. These data provide details on all hospital admissions, including patient demographics, reasons and durations for hospital stays and treatments received. Findings suggest that being hospitalised with alcohol dependence or a health issue caused by continuous heavy drinking is a significant risk factor for dementia. Although the condition is more common in people over the age of 65, the study identified and examined 57,000 cases, which presented with the onset of dementia before 65. Of these, 57% were heavy drinkers, 39% regularly consumed alcohol and 18% had an alcohol use disorder as an additional diagnosis. “Heavy drinkers” were found to be more than 3 times likelier to develop dementia. Excluding alcohol-related brain damage, alcohol use disorders were still found to be associated with a 2 times greater risk of dementia.

According to Michael Schwarzinger, the lead author of the study, who is the director of the French Translational Health Economics Network and a researcher at the Universite Paris Diderot, France, “Chronic heavy drinking was the most important modifiable risk factor for dementia onset in both genders and remained so after controlling for all known risk factors for dementia onset.” While other studies have reached similar conclusions, some research suggest that drinking one or two units of alcohol a day - a small glass of red wine particularly - could be of benefit to brain health and slow the onset cognitive deterioration. Indeed, the Lancet Commission on dementia, associates light to moderate alcohol use with a healthier brain. Schwarzinger and his colleagues however are clear, “Our findings suggest the burden of dementia attributable to alcohol use disorders is much larger than previously thought . . .. Chronic heavy drinking leads to irreversible brain damage [and even] heavy drinkers who got sober didn’t have a lower dementia risk than their peers who remained problem drinkers. . . Additionally, clinicians should be better aware of the role of alcohol use disorders in dementia onset over the lifetime, which seems to be a risk factor often omitted.”
 
Why there is no cure for dementia

Over the past 2 decades pharmaceutical companies, biotech’s, governments, universities and charities have devoted vast amounts of money, time and effort to the dementia challenge, but without being able to develop any credible treatment let alone cure. This partly reflects the complexity of neurodegenerative disorders. The brain is a complex organ, which scientists are still endeavouring to understand. This lack of understanding is one of the main obstacles preventing the development of effective treatments for dementia. The disorder seems to present as a result of an intricate interaction of genes, lifestyle factors and other environmental influences. But, without knowing the exact mechanisms that cause damage, especially in Alzheimer's, it is impossible to target the disease process effectively.

In addition to our rudimentary understanding of the brain there are some specific challenges faced by researchers into neurodegenerative disorders. One is the blood-brain barrier, which is formed by brain endothelial cells, which protect the brain by preventing toxins from reaching it. This presents dementia researchers with a significant challenge because the blood-brain barrier also prevents treatments getting through to the brain and working effectively. Newer immunotherapy drugs, also known as biologics, are large complex molecules or mixtures of molecules, which because of their size and shape may only partly cross the blood-brain barrier. This suggests that dangerous doses would be needed for them to work effectively. And even if the biologics could penetrate the blood-brain barrier and target the proteins causing damage to brain cells, dementia is irreversible and may have started to develop decades before the presentation of symptoms and before the administration of drugs. Further, there is no test for dementia, which means the disorder is difficult to diagnose. This leads some health professionals to suggest that with no effective treatments, early diagnosis has no benefits. A significant proportion of those living with dementia have not received a formal diagnosis, which presents further challenges not least for clinical studies.

 
The amyloid hypothesis

For the past 2 decades dementia drug development has been dominated by the ‘amyloid hypothesis’, which suggests that Alzheimer’s can be treated by attacking the sticky plaques of beta amyloid protein that builds up in patients’ brains. The pharmaceutical industry has lost billions in failed development of drugs designed to target amyloid, and there is still no treatment that affects the underlying progression of the disease. In January 2018 Pfizer, the world’s largest pharmaceutical company, which has spent billions on dementia R&D, announced that it was pulling out of research into drugs to treat complex neurological disorders. Notwithstanding, many pharmaceutical companies, driven by the potential financial gains from finding a medicine that can arrest the disease of 50m people, continue to work on treatments for neurodegenerative diseases.
 
Innovative research endeavours that target dementia

The UK’s 2013 presidency of the G8, (an inter-governmental political forum comprised of the major industrialized democracies) focused on dementia. This resulted in the condition rising up global political agendas and the UK Government unlocking more money for research into neurodegenerative disorders. In 2015 the UK government with the help of JP Morgan, an American multinational investment bank, set-up the Dementia Discovery Fund, with an initial investment of £15m and the commitment from several big pharmaceutical companies to invest. The fund’s strategy was to raise £100m for dementia R&D and move beyond the amyloid hypothesis. It has invested in some 12 start-ups and projects investigating novel ways to stop or reverse the complex biological processes that lead to dementia. In November 2017 the Bill and Melinda Gates Foundation invested US$50m into the fund, which took its total to £130m. Other well-funded novel research projects include the UK Dementia Research Institute, which brings together the Medical Research Council, Alzheimer’s Society and Alzheimer’s Research UK in a £250m initiative involving more than 400 scientists, who are leading efforts to transform the treatment and care for people with dementia.
 
Takeaways

Dementia is a 21st century Damocles Sword positioned to bankrupt healthcare systems in the developed world. Dementia is a vast, fast growing global killer disease effecting about 7% of people living in wealthy nations and costing billions. Despite billions spent on dementia R&D over the past 2 decades there are no viable treatments to either slow or stop the progression of the disorder. Alcohol use has been suggested as a significant contributory factor for the onset dementia. Public policies to curb the use of alcohol are insufficient to significantly dent the vast and escalating burden of dementia. This shifts the emphasis for a solution to medicine. Despite the dearth of medical solutions, things are beginning to change with some recent novel research initiatives specifically targeting neurodegenerative disorders, which might help to lift the Damocles Sword
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  • 'Drunkorexia' is a growing and dangerous trend among young people to eat less, purge or exercise excessively before binge drinking
  • Purging prior to drinking includes vomiting, laxatives or self-starvation
  • The intention is to save calories for binge-drinking
  • 41% of 18 to 24 year olds in a 2016 survey of 3,000 say they are not concerned about their overall health
  • Health providers are wasting millions on traditional healthcare education
  • Experts say we need to rethink how to encourage people to assume greater personal responsibility and accountability for their health
  • Healthcare providers have failed to leverage ubiquitous technologies and people’s changed lifestyles to engage and educate patients
  • To reduce the burden of drunkorexia healthcare providers will need to gain a better understanding of patients’ behaviors and ubiquitous 21st century technologies

Drunkorexia: a devastating and costly growing condition
 
Drunkorexia is using extreme weight control methods as a means to compensate for planned binge drinking. The French refer to it as alcoolorexie: l'ivresse sans les kilos. Manger moins pour être ivre plus vite et ne pas trop grossir. Drunkorexia is a term coined by the media to describe the combination of disordered eating and heavy alcohol consumption. The condition is gaining recognition in the fields of co-occurring disorders (people who have both substance use and mental health disorders), psychiatry, and addictionology. The term attempts to reconcile 2 conflicting cultures: binge drinking and a desire to be thin. The former involves ingesting significant amounts of unwanted extra calories, so people starve themselves in preparation for a night out drinking. Drunkorexia results in significant human costs from hypoglycaemia, depression, memory loss, and liver disease, and substantial and unnecessary costs to healthcare providers.
 
Experts argue that traditional methods to lower the burden of drunkorexia cost millions and are failing, and suggest there is an urgent need to, “rethink how we try and engage with people and try and encourage them to assume greater personal responsibility and accountability for their health.” This Commentary describes drunkorexia, reports some research findings on the condition, and suggests health providers would lower the large and growing burden of drunkorexia by leveraging ubiquitous technologies such as the Internet and smartphones.
 
Not an officially medical diagnosis

Drunkorexia is not an officially recognized medical condition. There is no mention of it in Mediline Plus, the US National Institutes of Health's online medical information service produced by the National Library of Medicine. It is not mentioned in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which is published by the American Psychiatric Association, and popularly known as  “The Psychiatrist’s Bible”. Neither is the condition included in the World Health Organization's International Classification of Disease; nor in WebMD, the UK’s NHS online, NHS Choices, and the UK’s General Medical Council’s (GMC) website.
Signs and symptoms
 
Signs and symptoms include calorie counting to ensure no weight is gained when binge drinking, missing meals to conserve calories so that they can be spent on the consumption of alcohol, over-exercising to counterbalance calorie intake, and binge drinking to vomit previously digested food.

A dangerous condition

Despite evidence to suggest that more people are turning away from alcohol and becoming teetotallers, the prevalence of drunkorexia is increasing.

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It is a dangerous trend, especially among young people, which can lead to an array of physical and psychological consequences. For example, drinking in a state of malnutrition can predispose you to a higher rate of blackouts, alcohol poisoning, alcohol-related injury, violence, or illness. Drinking on an empty stomach allows ethanol to reach the blood system more rapidly, and raises your blood alcohol content often with dangerous speed. This can render you more vulnerable to alcohol-related brain damage. In addition, alcohol abuse can have a detrimental impact on hydration and your body's retention of minerals and nutrients, further exacerbating the consequences of malnutrition, and damaging your cognitive faculties. This can lead to short and long-term cognitive problems, including difficulty concentrating and making decisions, which ultimately can have a negative impact on academic and work-related performance. Drunkorexia also increases the risk of developing more serious eating disorders and alcohol abuse problems. As binge drinking is involved there is also a greater risk of violence, of risky sexual behavior, alcohol poisoning, substance abuse and chronic disease later in life.
 
Research

Although much of the research on drunkorexia is focused on university students, the condition is believed to be more widely spread. A challenge for researchers is the attitudes of university administrators and parents who are reluctant to admit that there is a problem either in their institutions or homes. The condition is often dismissed as a rite-of-passage. Notwithstanding, there have been a number of research studies, which suggest that drunkorexia is significant, growing fast and dangerous.
 
University of Missouri study

A 2011 University of Missouri study of the relationship between alcohol misuse and disordered eating, including calorie restriction and purging, suggests that drunkorexia is predominately a young women’s condition, which could affect their long-term health. The study found that 16% of respondents reported restricting calories to "save them" for drinking. 67% of students who restrict calories prior to binge drinking did so to prevent weight gain, while 21% did so to facilitate alcohol intoxication. 3 times as many women reported engaging in the behavior than men, and their stated motivations included “preventing weight gain”, “getting intoxicated faster” and “saving money”, which could be either spent on food or to buy alcohol. According to Victoria Osborne, Professor of Social Work and Public Health at the university, and lead author of the study, drunkorexia can have dangerous cognitive, behavioural and physical consequences. It also puts people at risk for developing more serious eating disorders or addiction problems.
 
Australian study

In an Australian context, a 2013 study surveyed 139 female university students, aged between 18 and 29 to examine compensatory eating and behaviors in response to alcohol consumption to test for drunkorexia symptomatology. 79% of respondents engaged in characterized drunkorexia behavior. The study also found that social norms of drinking, and the social norms associated with body image and thinness, impacted significantly upon the motivation for these behaviors.
 
University of Houston study

Findings of a University of Houston study on drunkorexia presented at the 2016 annual meeting of the Research Society on Alcoholism in New Orleans, found that 80% of the 1,200 students surveyed had at least one heavy night of drinking in the previous month, and engaged in drunkorexic behavior. The methods of purging prior to drinking include vomiting, use of laxatives or missing meals. The study also reported that the condition is not limited to the US, and is present in both men and women.
 
Benenden’s National Health study
 
Healthcare group Benenden’s 2016 National Health Report suggests that drunkorexia is gaining ground among young people in the UK, and creating concerns among healthcare professionals. According to the study, young people in the UK prefer to eat less in order to “save” calories for alcohol consumption. Of the 3,000 people surveyed, 2 out of 5 (41%), between the ages of 18 and 24 said they eat healthily only to look good, but are not concerned about their overall health. According to the report, “Pressure to be slim, an awareness of exercising calorie control, and peer pressure to drink large amounts of alcohol are all factors in this phenomenon”, adding that a growing number of men are following this trend.

Survey participants were also asked general questions about healthy lifestyles. “By and large, the findings highlight that the public is in denial about how much they think they know about healthy eating, they claim to be near-experts, but when drilling down to real-life examples, the vast majority of respondents failed to choose the right answer to simple diet-related questions, or the healthier option when offered the choice between everyday food and drinks,” the report found.
 
There also seems to be a woeful lack of awareness about basic dietary advice, despite legislation and attempts by the food production and manufacturing industry. It isn't clear whether this is down to poor education or a lack of interest, but I think we need to rethink how we try and engage with people and try and encourage them to assume greater personal responsibility and accountability for their health," says Dr John Giles, Benenden’s medical director.

Traditional healthcare providers failing

Traditional healthcare providers continue to waste billions on failing traditional methods of engaging and educating patients. Increasing self-management of your health is relevant, especially as primary care resources are shrinking as the prevalence of drunkorexia is rapidly increasing. However, achieving effective education and self-management requires a fundamental transformation of the way healthcare is delivered. The majority of people living with drunkorexia regularly use their smartphones for 24-hour banking, education, entertainment, shopping, and dating. Health providers have failed to effectively leverage this vast and rapidly growing free infrastructure and people’s changed lifestyles to introduce effective educational support systems to enhance the quality of drunkorexia care, increase efficiency, and improve patient outcomes. Today, mobile technology is part of everyday life and people expect to be connected with their relevant healthcare providers 24-7, 365 days of the year from anywhere. 

Takeaways

A necessary pre-requisite for effective healthcare education to reduce the burden of drunkorexia is the actual engagement of people with the condition. Once patients are engaged, education should inform and empower people, and provide them with access to continuous self-management support. This is substantially different to the way traditional healthcare education is delivered as it transforms the patient–educator relationship into a continuous, rich, collaborative partnership. 
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3 years, 9 months ago

What causes breast and oral cancer, heart disease, strokes, liver cirrhosis, depression, memory impairment and reduced fertility? . . . . . . . . Alcohol.

More dangerous than heroine

NHS figures show that alcohol related hospital admissions peaked in 2010 when over a million people were admitted. Alcohol Concern predicts that by 2015, the annual number of hospital admissions due to alcohol will reach 1.5m, and cost the NHS £3.7bn a year. A 2010 study in The Lancet suggests that alcohol is more dangerous than heroine. A study by the Independent Scientific Committee on Drugs agrees, and ranks alcohol as three times more harmful than cocaine or tobacco.

The WHO’s 2014 Global Status Report on Alcohol and Health said that in 2012 there were 3.3m alcohol related deaths worldwide, and called on governments to implement policies to reduce the harmful use of alcohol.

Read more

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joined 4 years, 6 months ago

Justin Basquille

Consultant Psychiatrist

Dr Basquille has been a consultant since 2000 in General Adult Psychiatry with a specialism in Substance Misuse practising in the NHS in charge of a busy Assessment and Treatment Service, a University Hospital Liaison Service and an Alcohol Clinic.

He practises privately at the Capio Nightingale Hospital London and Harley Street.


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