Alcohol drinking patterns and liver cirrhosis risk: analysis of the prospective UK Million Women Study

Rising hospital admissions for alcohol-related cirrhosis and the impact of sex and comorbidity - a data linkage study

OBJECTIVES

International studies have shown shifting demographic data and rising hospitalizations for alcohol-related cirrhosis (ARC), with a paucity of data from Australia. We examined hospitalizations, mortality and demographic data for people admitted with ARC over the last decade in Queensland, Australia.

STUDY DESIGN

Data linkage study.

METHODS

A retrospective analysis of adults hospitalized with ARC during 2008-2019 was performed using state-wide admissions data. International Classification of Diseases, 10th revision, codes identified admissions with the principal diagnosis of ARC based on validated algorithms. Comorbidity was assessed using the Charlson Comorbidity Index.

RESULTS

A total of 7152 individuals had 24,342 hospital admissions with ARC (16,388 were for ARC). There was a predominance of males (72.6%) and age ≥50 years (80.4%) at index admission. Females were admitted at a significantly younger age than men (59% of women and 43% of men were aged <60 years, P < 0.001). Comorbidities were common, with 45.1% of people having at least one comorbidity. More than half (54.6%) of the patients died over the study period (median follow-up time was 5.1 years; interquartile range 2.4-8.6). Women had significantly lower mortality, with 47.6% (95% confidence interval [CI] 45.0-50.2) probability of 5-year survival, compared with 40.1% (95% CI 38.5-41.6) in men. In multivariable analysis, this was attributable to significantly lower age and comorbidity burden in women. Significantly lower survival was seen in people with higher comorbidity burden. Overall, the number of admissions for ARC increased 2.2-fold from 869 admissions in 2008 to 1932 in 2019.

CONCLUSIONS

Hospital admissions for ARC have risen substantially in the last decade. Females were admitted at a younger age, with fewer comorbidities and had lower mortality compared with males. The association between greater comorbidity burden and higher mortality has important clinical implications, as comorbidity-directed interventions may reduce mortality.

EASL-EASD-EASO Clinical Practice Guidelines on the Management of Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD)

Metabolic dysfunction-associated steatotic liver disease (MASLD), previously termed non-alcoholic fatty liver disease (NAFLD), is defined as steatotic liver disease (SLD) in the presence of one or more cardiometabolic risk factor(s) and the absence of harmful alcohol intake. The spectrum of MASLD includes steatosis, metabolic dysfunction-associated steatohepatitis (MASH, previously NASH), fibrosis, cirrhosis and MASH-related hepatocellular carcinoma (HCC). This joint EASL-EASD-EASO guideline provides an update on definitions, prevention, screening, diagnosis and treatment for MASLD. Case-finding strategies for MASLD with liver fibrosis, using non-invasive tests, should be applied in individuals with cardiometabolic risk factors, abnormal liver enzymes, and/or radiological signs of hepatic steatosis, particularly in the presence of type 2 diabetes (T2D) or obesity with additional metabolic risk factor(s). A stepwise approach using blood-based scores (such as FIB-4) and, sequentially, imaging techniques (such as transient elastography) is suitable to rule-out/in advanced fibrosis, which is predictive of liver-related outcomes. In adults with MASLD, lifestyle modification - including weight loss, dietary changes, physical exercise and discouraging alcohol consumption - as well as optimal management of comorbidities - including use of incretin-based therapies (e.g. semaglutide, tirzepatide) for T2D or obesity, if indicated - is advised. Bariatric surgery is also an option in individuals with MASLD and obesity. If locally approved and dependent on the label, adults with non-cirrhotic MASH and significant liver fibrosis (stage ≥2) should be considered for a MASH-targeted treatment with resmetirom, which demonstrated histological effectiveness on steatohepatitis and fibrosis with an acceptable safety and tolerability profile. No MASH-targeted pharmacotherapy can currently be recommended for the cirrhotic stage. Management of MASH-related cirrhosis includes adaptations of metabolic drugs, nutritional counselling, surveillance for portal hypertension and HCC, as well as liver transplantation in decompensated cirrhosis.

EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD)

Metabolic dysfunction-associated steatotic liver disease (MASLD), previously termed non-alcoholic fatty liver disease (NAFLD), is defined as steatotic liver disease (SLD) in the presence of one or more cardiometabolic risk factor(s) and the absence of harmful alcohol intake. The spectrum of MASLD includes steatosis, metabolic dysfunction-associated steatohepatitis (MASH, previously NASH), fibrosis, cirrhosis and MASH-related hepatocellular carcinoma (HCC). This joint EASL-EASD-EASO guideline provides an update on definitions, prevention, screening, diagnosis and treatment for MASLD. Case-finding strategies for MASLD with liver fibrosis, using non-invasive tests, should be applied in individuals with cardiometabolic risk factors, abnormal liver enzymes, and/or radiological signs of hepatic steatosis, particularly in the presence of type 2 diabetes (T2D) or obesity with additional metabolic risk factor(s). A stepwise approach using blood-based scores (such as FIB-4) and, sequentially, imaging techniques (such as transient elastography) is suitable to rule-out/in advanced fibrosis, which is predictive of liver-related outcomes. In adults with MASLD, lifestyle modification - including weight loss, dietary changes, physical exercise and discouraging alcohol consumption - as well as optimal management of comorbidities - including use of incretin-based therapies (e.g. semaglutide, tirzepatide) for T2D or obesity, if indicated - is advised. Bariatric surgery is also an option in individuals with MASLD and obesity. If locally approved and dependent on the label, adults with non-cirrhotic MASH and significant liver fibrosis (stage ≥2) should be considered for a MASH-targeted treatment with resmetirom, which demonstrated histological effectiveness on steatohepatitis and fibrosis with an acceptable safety and tolerability profile. No MASH-targeted pharmacotherapy can currently be recommended for the cirrhotic stage. Management of MASH-related cirrhosis includes adaptations of metabolic drugs, nutritional counselling, surveillance for portal hypertension and HCC, as well as liver transplantation in decompensated cirrhosis.

Sex and gender in alcohol use disorder and alcohol-associated liver disease in the United States: A narrative review

Over the last 20 years, there has been an alarming increase in alcohol use and AUD prevalence among women, narrowing the historical gender gap. Concurrently, there has also been a significant rise in alcohol-associated liver disease (ALD) prevalence, severity, and mortality among women. Despite this, there are no recent reviews that have sought to evaluate both sex and gender differences at the intersection of AUD and ALD. In this narrative review, we address the escalating rates of ALD and AUD in the United States, with a specific focus on the disproportionate impact on women. Sex and gender play an important and well-known role in the pathogenesis and epidemiology of ALD. However, sex and gender are also implicated in the development and prevalence of AUD, as well as in the treatment of AUD, all of which have important consequences on the approach to the treatment of patients with ALD and AUD. A better understanding of sex and gender differences in AUD, ALD, and the intersection of the 2 is essential to enhance prevention, diagnosis, and management strategies. These data underscore the urgent need for awareness and preventive efforts to mitigate the potential long-term health consequences.

Long-term Risks of Cirrhosis and Hepatocellular Carcinoma Across Steatotic Liver Disease Subtypes

INTRODUCTION

The prospective study aimed to investigate the long-term associated risks of cirrhosis and hepatocellular carcinoma (HCC) across various subtypes of steatotic liver disease (SLD).

METHODS

We enrolled 332,175 adults who participated in a health screening program between 1997 and 2013. Participants were categorized into various subtypes, including metabolic dysfunction-associated SLD (MASLD), MASLD with excessive alcohol consumption (MetALD), and alcohol-related liver disease (ALD), based on ultrasonography findings, alcohol consumption patterns, and cardiometabolic risk factors. We used computerized data linkage with nationwide registries from 1997 to 2019 to ascertain the incidence of cirrhosis and HCC.

RESULTS

After a median follow-up of 16 years, 4,458 cases of cirrhosis and 1,392 cases of HCC occurred in the entire cohort, resulting in an incidence rate of 86.1 and 26.8 per 100,000 person-years, respectively. The ALD group exhibited the highest incidence rate for cirrhosis and HCC, followed by MetALD, MASLD, and non-SLD groups. The multivariate adjusted hazard ratios for HCC were 1.92 (95% confidence interval [CI] 1.51-2.44), 2.91 (95% CI 2.11-4.03), and 2.59 (95% CI 1.93-3.48) for MASLD, MetALD, and ALD, respectively, when compared with non-SLD without cardiometabolic risk factors. The pattern of the associated risk of cirrhosis was similar to that of HCC (all P value <0.001). The associated risk of cirrhosis for ALD increased to 4.74 (95% CI 4.08-5.52) when using non-SLD without cardiometabolic risk factors as a reference.

DISCUSSION

This study highlights elevated risks of cirrhosis and HCC across various subtypes of SLD compared with non-SLD, emphasizing the importance of behavioral modifications for early prevention.

Alcohol-associated liver disease-Global epidemiology

Alcohol-associated liver disease (ALD), as highlighted in this narrative review, is a major public health concern, increasingly impacting global disease burden and premature mortality. In 2019, ALD accounted for the loss of 11 million life-years worldwide. The rising number of deaths and disability-adjusted life-years attributed to ALD, particularly pronounced in the United States, are alarming. Projections suggest that the economic impact of ALD, as seen in the United States, could potentially double by 2040. ALD is increasingly prevalent among younger adults (20-45 y) and has become the leading cause of liver transplantation in both United States and Europe. During the COVID-19 pandemic, the existing trend was further amplified as high-risk drinking patterns coincided with a rise in hospital admissions for alcohol-associated hepatitis and increased ALD-related mortality. The prevalence of ALD is estimated at 3.5% in the general population, 26.0% among hazardous drinkers, and 55.1% among those with alcohol use disorders. Alarmingly, 5-year mortality rates for patients with ALD exceed 50%, with even higher rates in more advanced disease stages. Methodological challenges, such as underreporting, diagnostic difficulties, and variability in registry data quality, complicate the accurate assessment of the impact of ALD. Additionally, the contribution of alcohol to the progression of other liver diseases is often under acknowledged in health care registries, leading to a significant underestimation of its broader implications for liver health. Addressing the growing ALD concern requires robust public health initiatives, heightened awareness, refined diagnostic techniques, and comprehensive epidemiological studies. These measures are vital to tackle the increasing prevalence of ALD and mitigate its extensive impact on individuals and health care systems.

Disentangling the contributions of alcohol use disorder and alcohol-related liver disease towards dementia: A population-based cohort study

AIMS

The aim of the study was to disentangle the contributions of alcohol and alcohol-related liver disease (ALD) towards dementia by independently measuring the association between alcohol use disorder (AUD) alone and ALD with dementia.

DESIGN

This was a nation-wide cohort study.

SETTING

The study was conducted in Sweden from 1987 to 2020.

PARTICIPANTS

DELIVER (DEcoding the epidemiology of LIVER disease in Sweden) cohort, containing administrative codes on patients with chronic liver disease from the National Patient Register and other registers between 1987 and 2020.

MEASUREMENTS

International Classification of Disease 9th (ICD-9) and 10th (ICD-10) version codes were used to define the presence of AUD, ALD and dementia. The associations of AUD alone and ALD with incident dementia were estimated using Cox regression models adjusting for potential confounders. Cumulative incidences were also calculated accounting for competing risks of death.

FINDINGS

A total of 128 884 individuals with AUD alone, 17 754 with ALD and 2 479 049 controls were identified. During a median follow-up of 8.9 years, 13 395 (10.4%), 2187 (12.3%) and 138 925 (5.6%) dementia cases were identified in these groups, respectively. Dementia rates were increased in AUD alone [adjusted hazard ratio (aHR) = 4.6, 95% confidence interval (CI) = 4.5-4.6] and in ALD (aHR = 8.6, 95% CI = 8.3-9.0) compared with controls. AUD alone was also associated with increased rates of vascular dementia (aHR = 2.3, 95% CI = 2.2-2.5) and Alzheimer's disease (aHR = 1.4, 95% CI = 1.3-1.4), while ALD was only associated with vascular dementia (aHR = 2.7, 95% CI = 2.3-3.2). The median age at dementia diagnosis was 67 years [interquartile range (IQR) = 56-76] in AUD alone and 63 years (IQR = 56-71) in ALD compared with 85 years (IQR = 79-89) in controls.

CONCLUSION

In Sweden, patients with alcohol use disorder (AUD) appear to have increased rates of dementia and diagnosis at a younger age, compared with patients without AUD. Concurrent alcohol-related liver disease appears to increase the diagnosis rate and lower the median age further.

Nutritional deficiencies in alcohol use disorder/alcohol-associated liver disease

PURPOSE OF REVIEW

To delineate common and uncommon dietary and nutritional deficiencies in individuals with chronic heavy alcohol use and alcohol use disorder and to highlight important advances in the nutrition field in patients ranging from those with alcohol use disorder (AUD) and no liver disease to those with decompensated alcohol-associated liver disease (ALD).

RECENT FINDINGS

Patients with AUD may have nutritional deficiencies, especially isolated nutrient deficiencies, such as thiamine or zinc deficiencies. This should not be surprising, as alcohol is a major source of "empty calories." It is devoid of critical macronutrients, such as protein, and micronutrients including important vitamins and minerals. Patients with AUD frequently drink much more than often appreciated (10-20 drinks a day). Patients with AUD and early ALD often begin to develop more apparent nutritional deficiencies. Healthcare providers need to be aware of the presenting features of individual nutrient deficiencies, such as thiamine deficiency, and to provide prompt treatment. In patients with more advanced liver disease, malnutrition correlates with severity of liver disease. It is important to understand the value of nutritional support throughout the spectrum of AUD.

SUMMARY

We review nutritional deficiencies in the spectrum of patients with AUD and ALD and highlight new information and recommendations.

Socioeconomic position indicators and risk of alcohol-related medical conditions: A national cohort study from Sweden

BACKGROUND

Alcohol consumption contributes to excess morbidity and mortality in part through the development of alcohol-related medical conditions (AMCs, including alcoholic cardiomyopathy, hepatitis, cirrhosis, etc.). The current study aimed to clarify the extent to which risk for these outcomes differs as a function of socioeconomic position (SEP), as discrepancies could lead to exacerbated health disparities.

METHODS AND FINDINGS

We used longitudinal Swedish national registries to estimate the individual and joint associations between 2 SEP indicators, educational attainment and income level, and risk of AMC based on International Classification of Diseases codes, while controlling for other sociodemographic covariates and psychiatric illness. We conducted Cox proportional hazards models in sex-stratified analyses (N = 1,162,679 females and N = 1,196,659 males), beginning observation at age 40 with follow-up through December 2018, death, or emigration. By the end of follow-up, 4,253 (0.37%) females and 11,183 (0.93%) males had received an AMC registration, corresponding to overall AMC incidence rates among females and males of 2.01 and 5.20, respectively. In sex-stratified models adjusted for birth year, marital status, region of origin, internalizing and externalizing disorder registrations, and alcohol use disorder (AUD) registration, lower educational attainment was associated with higher risk of AMC in both females (hazard ratios [HRs] = 1.40 to 2.46 for low- and mid-level educational attainment across 0 to 15 years of observation) and males (HRs = 1.13 to 1.48). Likewise, risk of AMC was increased for those with lower income levels (females: HRs = 1.10 to 5.86; males: HRs = 1.07 to 6.41). In secondary analyses, we further adjusted for aggregate familial risk of AUD by including family genetic risk scores for AUD (FGRSAUD), estimated using medical, pharmacy, and criminal registries in extended families, as covariates. While FGRSAUD were associated with risk of AMC in adjusted models (HR = 1.17 for females and HR = 1.21 for males), estimates for education and income level remained largely unchanged. Furthermore, FGRSAUD interacted with income level, but not education level, such that those at higher familial liability to AUD were more susceptible to the adverse effect of low income. Limitations of these analyses include the possibility of false negatives for psychiatric illness registrations, changes in income after age 40 that were not accounted for due to modeling restrictions, restriction to residents of a high-income country, and the inability to account for individual-level alcohol consumption using registry data.

CONCLUSIONS

Using comprehensive national registry data, these analyses demonstrate that individuals with lower levels of education and/or income are at higher risk of developing AMC. These associations persist even when accounting for a range of sociodemographic, psychiatric, and familial risk factors. Differences in risk could contribute to further health disparities, potentially warranting increased screening and prevention efforts in clinical and public health settings.

Is There a Safe Alcohol Consumption Limit for the General Population and in Patients with Liver Disease?

Excessive alcohol consumption represents an important burden for health systems worldwide and is a major cause of liver- and cancer-related deaths. Alcohol consumption is mostly assessed by self-report that often underestimates the amount of drinking. While alcohol use disorders identification test - version C is the most widely used test for alcohol use screening, in patients with liver disease the use of alcohol biomarker could help an objective assessment. The amount of alcohol that leads to significant liver disease depends on gender, genetic background, and coexistence of comorbidities (i.e., metabolic syndrome factors). All patients with alcohol-associated liver disease are recommended to follow complete abstinence and they should be treated within multidisciplinary teams. Abstinence slows down and even reverses the progression of liver fibrosis and can help recompensate patients with complicated cirrhosis. Whether there is a safe amount of alcohol in the general population is a matter of intense debate. Large epidemiological studies showed that the safe amount of alcohol to avoid overall health-related risks is lower than expected even in the general population. Even one drink per day can increase cancer-related death. In patients with any kind of chronic liver disease, especially in those with metabolic-associated steatotic liver disease, no alcohol intake is recommended. This review article discusses the current evidence supporting the deleterious effects of small-to-moderate amounts of alcohol in the general population and in patients with underlying chronic liver disease.

Involuntary social isolation and alcohol consumption: an ecological momentary assessment in Germany amid the COVID-19 pandemic

AIMS

Alcohol consumption often occurs in a social setting, which was affected by social distancing measures amid the coronavirus disease-2019 (COVID-19) pandemic. In this study, we examine how involuntary social isolation (i.e. comparing a no-lockdown stage with a lockdown stage) affects the association between loneliness, social activities, and drinking behavior.

METHOD

We performed an ecological momentary assessment eight times per day for 7 days amid the COVID-19 pandemic in Germany. We recruited 280 participants and assessed their trait loneliness, daily state loneliness, social activities, and drinking behaviors.

RESULTS

We found that a lockdown condition moderates the association between trait and daily state loneliness and alcohol consumption. During a lockdown stage, trait loneliness was positively associated, whereas state loneliness was negatively associated with alcohol consumption. During a no-lockdown stage, trait and state loneliness were both negatively associated with alcohol consumption. For both no-lockdown and lockdown stages, duration of social interaction, male gender, and weekends was positively associated with alcohol consumption.

CONCLUSION

Our study suggests that an involuntary social isolation condition (i.e. a lockdown stage) changes how trait loneliness is associated with alcohol consumption.

ACG Clinical Guideline: Alcohol-Associated Liver Disease

ABSTRACT

Alcohol-associated liver disease (ALD) is the most common cause of advanced hepatic disease and frequent indication for liver transplantation worldwide. With harmful alcohol use as the primary risk factor, increasing alcohol use over the past decade has resulted in rapid growth of the ALD-related healthcare burden. The spectrum of ALD ranges from early asymptomatic liver injury to advanced disease with decompensation and portal hypertension. Compared with those with other etiologies of liver disease, patients with ALD progress faster and more often present at an advanced stage. A unique phenotype of advanced disease is alcohol-associated hepatitis (AH) presenting with rapid onset or worsening of jaundice, and acute on chronic liver failure in severe forms conveying a 1-month mortality risk of 20%-50%. The model for end stage disease score is the most accurate score to stratify AH severity (>20 defined as severe disease). Corticosteroids are currently the only available therapeutic with proven efficacy for patients with severe AH, providing survival benefit at 1 month in 50%-60% of patients. Abstinence of alcohol use, a crucial determinant of long-term outcomes, is challenging to achieve in ALD patients with concurrent alcohol use disorder (AUD). As patients with ALD are rarely treated for AUD, strategies are needed to overcome barriers to AUD treatment in patients with ALD and to promote a multidisciplinary integrated care model with hepatology, addiction medicine providers, and social workers to comprehensively manage the dual pathologies of liver disease and of AUD. Liver transplantation, a definitive treatment option in patients with advanced cirrhosis, should be considered in selected patients with AH, who are unresponsive to medical therapy and have a low risk of relapse to posttransplant alcohol use. Level of evidence and strength of recommendations were evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations system. This guideline was developed under the American College of Gastroenterology Practice Parameters Committee.

Binge-pattern alcohol consumption and genetic risk as determinants of alcohol-related liver disease

Alcohol-related liver disease (ARLD) represents a major public health burden. Identification of high-risk individuals would allow efficient targeting of public health interventions. Here, we show significant interactions between pattern of drinking, genetic predisposition (polygenic risk score, PRS) and diabetes mellitus, and risk of incident ARLD, in 312,599 actively drinking adults in UK Biobank. Binge and heavy binge drinking significantly increase the risk of alcohol-related cirrhosis (ARC), with higher genetic predisposition further amplifying the risk. Further, we demonstrate a pronounced interaction between heavy binge drinking and high PRS, resulting in a relative excess risk due to interaction (RERI) of 6.07. Diabetes consistently elevates ARC risk across all drinking and PRS categories, and showed significant interaction with both binge patterns and genetic risk. Overall, we demonstrate synergistic effects of binge drinking, genetics, and diabetes on ARC, with potential to identify high-risk individuals for targeted interventions.

The effectiveness of workplace interventions for the prevention of alcohol use: A meta-analysis

BACKGROUND AND AIMS

Previous research has pointed to the potential of workplace interventions addressing alcohol consumption. However, there is still no systematic overview of the effects of these interventions. Therefore, we aimed to quantify the effectiveness of workplace interventions addressing alcohol use by conducting a meta-analysis.

METHODS

A systematic literature search for randomized controlled trials of workplace alcohol interventions published between 1995 and 2020 was conducted in five databases. Studies were included if they were performed in the workplace and reported universal or selective interventions aiming for alcohol use reduction. Primary outcomes were any measures of alcohol use. Standardized mean effect sizes were used to calculate the meta-analytic random-effects-model. Additional analyses were carried out to identify potential moderators and to examine the amount of heterogeneity and publication bias.

RESULTS

Twenty studies with 4484 participants were integrated into the meta-analysis. Results revealed a significant overall mean effect indicating a reduction of alcohol use in favor of the treatment group (d = -0.16, 95% CI = [-0.2715; -0.0511]). Heterogeneity within the data structure was found to be moderate to substantial (I2  = 75.9%, Q-test P < 0.001, τ2 = 0.0375). Additional moderator analyses only showed a significant effect for length of measurement period (P = 0.049).

CONCLUSIONS

Alcohol-related prevention programs conducted in the workplace have a statistically significant and favorable effect on alcohol consumption. Although the overall mean effect is considered to be small, it underlines the effectiveness of workplace interventions targeting a reduction in alcohol use.

Nonheavy Alcohol Use Associates With Liver Fibrosis and Nonalcoholic Steatohepatitis in the Framingham Heart Study

BACKGROUND AND AIMS

While heavy alcohol use consistently associates with liver disease, the effects of nonheavy alcohol consumption are less understood. We aimed to investigate the relationship between nonheavy alcohol use and chronic liver disease.

METHODS

This cross-sectional study included 2629 current drinkers in the Framingham Heart Study who completed alcohol use questionnaires and transient elastography. We defined fibrosis as liver stiffness measurement (LSM) ≥8.2 kPa. We defined at-risk nonalcoholic steatohepatitis (NASH) as FibroScan-aspartate aminotransferase (FAST) score >0.35 (90% sensitivity) or ≥0.67 (90% specificity). We performed logistic regression to investigate associations of alcohol use measures with fibrosis and NASH, adjusting for sociodemographic and metabolic factors. Subgroup analysis excluded heavy drinkers (>14 drinks per week for women or >21 for men).

RESULTS

In this sample (mean age 54.4 ± 8.9 years, 53.3% women), mean LSM was 5.6 ± 3.4 kPa, 8.2% had fibrosis, 1.9% had NASH by FAST ≥0.67, and 12.4% had NASH by FAST >0.35. Participants drank 6.2 ± 7.4 drinks per week. Total drinks per week and frequency of drinking associated with increased odds of fibrosis (adjusted odds ratio [aOR], 1.18; 95% confidence interval [CI], 1.04-1.33; and aOR, 1.08; 95% CI, 1.01-1.16, respectively). Risky weekly drinking, present in 17.4%, also associated with fibrosis (aOR, 1.49; 95% CI, 1.03-2.14). After excluding 158 heavy drinkers, total drinks per week remained associated with fibrosis (aOR, 1.16; 95% CI, 1.001-1.35). Multiple alcohol use measures positively associated with FAST >0.35.

CONCLUSIONS

In this community cohort, we demonstrate that nonheavy alcohol use associates with fibrosis and NASH, after adjustment for metabolic factors. Longitudinal studies are needed to determine the benefits of moderating alcohol use to reduce liver-related morbidity and mortality.

Global Epidemiology of Cirrhosis: Changing Etiological Basis and Comparable Burden of Nonalcoholic Steatohepatitis between Males and Females

INTRODUCTION

The etiology of liver diseases has changed significantly, but its impact on the comparative burden of cirrhosis between males and females is unclear. We estimated sex differences in the burden of cirrhosis across 204 countries and territories from 2010 to 2019.

METHODS

We analyzed temporal trends in the burden of cirrhosis using the methodology framework of the 2019 Global Burden of Disease study. We estimated annual frequencies and age-standardized rates (ASRs) of cirrhosis incidence, death, and disability-adjusted life-years (DALYs) by sex, region, country, and etiology.

RESULTS

In 2019, the frequency of incident cases, deaths, and DALYs due to cirrhosis was 1,206,125, 969,068, and 31,781,079 in males versus 845,429, 502,944, and 14,408,336 in females, respectively. From 2010 to 2019, the frequency of cirrhosis deaths increased by 9% in males and 12% in females. Incidence ASRs remained stable in males but increased in females, while death ASRs declined in both. Death ASRs for both sexes declined in all regions, except in the Americas where they remained stable. In 2019, alcohol was the leading cause of cirrhosis deaths in males, and hepatitis C in females. Death ASRs declined for all etiologies in both sexes, except in nonalcoholic steatohepatitis (NASH). The ratio of female-to-male incidence ASRs in 2019 was lowest in alcohol(0.5), and highest in NASH(1.3), while the ratio of female-to-male death ASRs was lowest in alcohol(0.3) and highest in NASH(0.8).

CONCLUSION

The global burden of cirrhosis is higher in males. However, incidence and death ASRs from NASH cirrhosis in females are comparable to that of males.

Alcohol consumption and cancer incidence in women: interaction with smoking, body mass index and menopausal hormone therapy

BACKGROUND

Alcohol consumption has been associated with increased risks of certain site-specific cancers and decreased risks of some other cancers. There is, however, little reliable evidence as to whether the alcohol-associated risks for specific cancers are modified by smoking, body mass index (BMI) and menopausal hormone therapy (MHT) use.

METHODS

In the prospective UK Million Women Study, 1,233,177 postmenopausal women without prior cancer, mean age 56 (SD 5) years, reported their alcohol consumption in median year 1998 (IQR 1998-1999), and were followed by record-linkage for incident cancer. 438,056 women who drank no alcohol or < 1 drink/week were excluded. Cox regression yielded adjusted relative risks (RRs) and 95% confidence intervals (CIs) for 21 cancers by alcohol amount; statistical significance of interactions with smoking, BMI and MHT use was assessed after allowing for multiple testing.

RESULTS

In 795,121 participants, mean consumption was 6.7 (SD 6.4) alcoholic drinks/week. During 17 (SD 5) years of follow-up, 140,203 incident cancers were recorded. There was strong evidence for a substantial association between alcohol intake and risk of upper aero-digestive cancers (oesophageal squamous cell carcinoma, oral cavity, pharynx and larynx; RR per 1 drink/day = 1.38 [95% CI 1.31-1.46]). There was also strong evidence for more moderate positive associations with breast, colorectal and pancreatic cancer (RRs per 1 drink/day = 1.12 [1.10-1.14], 1.10 [1.07-1.13], 1.08 [1.02-1.13] respectively), and moderate negative associations with thyroid cancer, non-Hodgkin's lymphoma, renal cell carcinoma and multiple myeloma (RRs per 1 drink/day = 0.79 [0.70-0.89], 0.91 [0.86-0.95], 0.88 [0.83-0.94], 0.90 [0.84-0.97] respectively). Significant interactions between alcohol and smoking were seen for upper aero-digestive cancers (RRs per 1 drink/day = 1.66 [1.54-1.79], 1.23 [1.11-1.36], 1.12 [1.01-1.25] in current, past, and never smokers respectively). BMI and MHT did not significantly modify any alcohol-associated risks.

CONCLUSIONS

These findings provide robust evidence that greater alcohol intake, even within relatively moderate ranges, increases the risk of cancers of the aerodigestive tract, breast, colorectal and pancreatic cancer, and probably decreases the risk of thyroid cancer, non-Hodgkin's lymphoma, renal cell carcinoma and multiple myeloma. Associations of alcohol intake with cancer risk were not modified by MHT use, adiposity or smoking, except in the case of upper aero-digestive cancers, where the alcohol-associated risk was largely confined to smokers.

Immune microenvironment changes of liver cirrhosis: emerging role of mesenchymal stromal cells

Cirrhosis is a progressive and diffuse liver disease characterized by liver tissue fibrosis and impaired liver function. This condition is brought about by several factors, including chronic hepatitis, hepatic steatosis, alcohol abuse, and other immunological injuries. The pathogenesis of liver cirrhosis is a complex process that involves the interaction of various immune cells and cytokines, which work together to create the hepatic homeostasis imbalance in the liver. Some studies have indicated that alterations in the immune microenvironment of liver cirrhosis are closely linked to the development and prognosis of the disease. The noteworthy function of mesenchymal stem cells and their paracrine secretion lies in their ability to promote the production of cytokines, which in turn enhance the self-repairing capabilities of tissues. The objective of this review is to provide a summary of the alterations in liver homeostasis and to discuss intercellular communication within the organ. Recent research on MSCs is yielding a blueprint for cell typing and biomarker immunoregulation. Hopefully, as MSCs researches continue to progress, novel therapeutic approaches will emerge to address cirrhosis.

Management of alcohol use disorder in patients with chronic liver disease

Alcohol use disorder (AUD) rates have risen dramatically in the United States, resulting in increasing rates of alcohol-associated liver disease (ALD), but many patients struggle to access alcohol use treatment. AUD treatment improves outcomes, including mortality, and represents the most urgent means by which care can be improved for those with liver disease (including ALD and others) and AUD. AUD care for those with liver disease involves 3 steps: detecting alcohol use, diagnosing AUD, and directing patients to alcohol treatment. Detecting alcohol use can involve questioning during the clinical interview, the use of standardized alcohol use surveys, and alcohol biomarkers. Identifying and diagnosing AUD are interview-based processes that should ideally be performed by a trained addiction professional, but nonaddiction clinicians can use surveys to determine the severity of hazardous drinking. Referral to formal AUD treatment should be made, especially where more severe AUD is suspected or identified. Therapeutic modalities are numerous and include different forms of one-on-one psychotherapy, such as motivational enhancement therapy or cognitive behavior therapy, group therapy, community mutual aid societies (such as Alcoholics Anonymous), inpatient addiction treatment, and relapse prevention medications. Finally, integrated care approaches that build strong relationships between addiction professionals and hepatologists or medical providers caring for those with liver disease are crucial to improving care for this population.

Alcohol consumption and risks of more than 200 diseases in Chinese men

Alcohol consumption accounts for ~3 million annual deaths worldwide, but uncertainty persists about its relationships with many diseases. We investigated the associations of alcohol consumption with 207 diseases in the 12-year China Kadoorie Biobank of >512,000 adults (41% men), including 168,050 genotyped for ALDH2- rs671 and ADH1B- rs1229984 , with >1.1 million ICD-10 coded hospitalized events. At baseline, 33% of men drank alcohol regularly. Among men, alcohol intake was positively associated with 61 diseases, including 33 not defined by the World Health Organization as alcohol-related, such as cataract (n = 2,028; hazard ratio 1.21; 95% confidence interval 1.09-1.33, per 280 g per week) and gout (n = 402; 1.57, 1.33-1.86). Genotype-predicted mean alcohol intake was positively associated with established (n = 28,564; 1.14, 1.09-1.20) and new alcohol-associated (n = 16,138; 1.06, 1.01-1.12) diseases, and with specific diseases such as liver cirrhosis (n = 499; 2.30, 1.58-3.35), stroke (n = 12,176; 1.38, 1.27-1.49) and gout (n = 338; 2.33, 1.49-3.62), but not ischemic heart disease (n = 8,408; 1.04, 0.94-1.14). Among women, 2% drank alcohol resulting in low power to assess associations of self-reported alcohol intake with disease risks, but genetic findings in women suggested the excess male risks were not due to pleiotropic genotypic effects. Among Chinese men, alcohol consumption increased multiple disease risks, highlighting the need to strengthen preventive measures to reduce alcohol intake.

A comprehensive review of the benefits of drinking craft beer: Role of phenolic content in health and possible potential of the alcoholic fraction

Currently, there is greater production and consumption of craft beer due to its appreciated sensory characteristics. Unlike conventional beer, craft beers provide better health benefits due to their varied and high content of phenolic compounds (PCs) and also due to their alcohol content, but the latter is controversial. The purpose of this paper was to report on the alcoholic fraction and PCs present in craft beers and their influence on health. Despite the craft beer boom, there are few studies on the topic; there is a lot of field to explore. The countries with the most research are the United States > Italy > Brazil > United Kingdom > Spain. The type and amount of PCs in craft beers depends on the ingredients and strains used, as well as the brewing process. It was determined that it is healthier to be a moderate consumer of alcohol than to be a teetotaler or heavy drinker. Thus, studies in vitro, with animal models and clinical trials on cardiovascular and neurodegenerative diseases, cancer, diabetes and obesity, osteoporosis and even the immune system suggest the consumption of craft beer. However, more studies with more robust designs are required to obtain more generalizable and conclusive results. Finally, some challenges in the production of craft beer were detailed and some alternative solutions were mentioned.

Smoking, alcohol consumption, and 24 gastrointestinal diseases: Mendelian randomization analysis

Background

Whether the positive associations of smoking and alcohol consumption with gastrointestinal diseases are causal is uncertain. We conducted this Mendelian randomization (MR) to comprehensively examine associations of smoking and alcohol consumption with common gastrointestinal diseases.

Methods

Genetic variants associated with smoking initiation and alcohol consumption at the genome-wide significance level were selected as instrumental variables. Genetic associations with 24 gastrointestinal diseases were obtained from the UK Biobank, FinnGen study, and other large consortia. Univariable and multivariable MR analyses were conducted to estimate the overall and independent MR associations after mutual adjustment for genetic liability to smoking and alcohol consumption.

Results

Genetic predisposition to smoking initiation was associated with increased risk of 20 of 24 gastrointestinal diseases, including 7 upper gastrointestinal diseases (gastroesophageal reflux, esophageal cancer, gastric ulcer, duodenal ulcer, acute gastritis, chronic gastritis, and gastric cancer), 4 lower gastrointestinal diseases (irritable bowel syndrome, diverticular disease, Crohn's disease, and ulcerative colitis), 8 hepatobiliary and pancreatic diseases (non-alcoholic fatty liver disease, alcoholic liver disease, cirrhosis, liver cancer, cholecystitis, cholelithiasis, and acute and chronic pancreatitis), and acute appendicitis. Fifteen out of 20 associations persisted after adjusting for genetically predicted alcohol consumption. Genetically predicted higher alcohol consumption was associated with increased risk of duodenal ulcer, alcoholic liver disease, cirrhosis, and chronic pancreatitis; however, the association for duodenal ulcer did not remain statistically significant after adjustment for genetic predisposition to smoking initiation.

Conclusions

This study provides MR evidence supporting causal associations of smoking with a broad range of gastrointestinal diseases, whereas alcohol consumption was associated with only a few gastrointestinal diseases.

Funding

The Natural Science Fund for Distinguished Young Scholars of Zhejiang Province; National Natural Science Foundation of China; Key Project of Research and Development Plan of Hunan Province; the Swedish Heart Lung Foundation; the Swedish Research Council; the Swedish Cancer Society.

The Changing Epidemiology of Alcohol-Associated Liver Disease: Gender, Race, and Risk Factors

Cases of alcohol-associated liver disease (ALD) are increasing at a steady rate in the United States with more patients presenting with alcohol-associated hepatitis and alcohol-associated cirrhosis. While alcohol use has increased across many demographic groups, women are suffering from a greater increase in alcohol use disorder (AUD), and are at a greater risk of ALD due to pathophysiological differences which include absorption of alcohol, first pass metabolism, and hormonal differences. Differences across race have also been found with Native Americans and Hispanics suffering from some of the largest increases in ALD rates. Younger adults are heavily impacted by rising rates of both AUD and ALD. Comorbidities such as obesity and NASH have been shown to augment the deleterious effects of AUD and ALD, resulting in more advanced liver disease. Finally, COVID-19 and policies related to the pandemic have resulted in increased AUD across many cohorts, which have resulted in marked increases in ALD. In conclusion, ALD rates are rising, with young people and women particularly impacted.

Inter-ethnic differences in self-reported alcohol-related harm to children in Han vs. Yi ethnic minority households in Yunnan Province, China

China is a multi-ethnic country, but inter-ethnic disparities in alcohol-related harm to children have not been described. In this study, we assessed differences in prevalence of self-reported alcohol-related harm to children in Yi and Han households in Chuxiong Yi Prefecture, Yunnan Province, China. We conducted a cross-sectional study among caregivers in households with a child age less than 18 years using structured questionnaire interview. Participants included 241 Yi caregivers and 610 Han caregivers (overall refusal rate = 1.1%). Heavy drinking was more common in Yi households than Han households (41.9% vs. 30.8%, respectively), but there was no difference in alcohol-related harm to children (21.2% vs. 17.9%; Adjusted OR = 0.98; 95% CI = 0.65, 1.46). Caveats such as social desirability in reporting sensitive issues and the cross-sectional study design should be considered in the interpretation of the study findings.

Effects of beer, wine, and baijiu consumption on non-alcoholic fatty liver disease: Potential implications of the flavor compounds in the alcoholic beverages

Non-alcoholic fatty liver disease (NAFLD) is one of the most common causes of chronic liver disease and its global incidence is estimated to be 24%. Beer, wine, and Chinese baijiu have been consumed worldwide including by the NAFLD population. A better understanding of the effects of these alcoholic beverages on NAFLD would potentially improve management of patients with NAFLD and reduce the risks for progression to fibrosis, cirrhosis, and hepatocellular carcinoma. There is evidence suggesting some positive effects, such as the antioxidative effects of bioactive flavor compounds in beer, wine, and baijiu. These effects could potentially counteract the oxidative stress caused by the metabolism of ethanol contained in the beverages. In the current review, the aim is to evaluate and discuss the current human-based and laboratory-based study evidence of effects on hepatic lipid metabolism and NAFLD from ingested ethanol, the polyphenols in beer and wine, and the bioactive flavor compounds in baijiu, and their potential mechanism. It is concluded that for the potential beneficial effects of wine and beer on NAFLD, inconsistence and contrasting data exist suggesting the need for further studies. There is insufficient baijiu specific human-based study for the effects on NAFLD. Although laboratory-based studies on baijiu showed the antioxidative effects of the bioactive flavor compounds on the liver, it remains elusive whether the antioxidative effect from the relatively low abundance of the bioactivate compounds could outweigh the oxidative stress and toxic effects from the ethanol component of the beverages.

Global epidemiology of alcohol-associated cirrhosis and HCC: trends, projections and risk factors

Heavy alcohol consumption is a major cause of morbidity and mortality. Globally, alcohol per-capita consumption rose from 5.5 litres in 2005 to 6.4 litres in 2016 and is projected to increase further to 7.6 litres in 2030. In 2019, an estimated 25% of global cirrhosis deaths were associated with alcohol. The global estimated age-standardized death rate (ASDR) of alcohol-associated cirrhosis was 4.5 per 100,000 population, with the highest and lowest ASDR in Africa and the Western Pacific, respectively. The annual incidence of hepatocellular carcinoma (HCC) among patients with alcohol-associated cirrhosis ranged from 0.9% to 5.6%. Alcohol was associated with approximately one-fifth of global HCC-related deaths in 2019. Between 2012 and 2017, the global estimated ASDR for alcohol-associated cirrhosis declined, but the ASDR for alcohol-associated liver cancer increased. Measures are required to curb heavy alcohol consumption to reduce the burden of alcohol-associated cirrhosis and HCC. Degree of alcohol intake, sex, older age, obesity, type 2 diabetes mellitus, gut microbial dysbiosis and genetic variants are key factors in the development of alcohol-associated cirrhosis and HCC. In this Review, we discuss the global epidemiology, projections and risk factors for alcohol-associated cirrhosis and HCC.

Liver holidays? A meta-analysis of drinking the same amount of alcohol daily or non-daily and the risk for cirrhosis

INTRODUCTION

Several alcohol drinking guidelines indicate that daily alcohol consumption should be avoided because of its negative impact on the liver and to avoid the development of alcohol use disorders. Evidence that supports this recommendation is scarce. Our aim was to compare daily versus non-daily drinking and its association with liver cirrhosis.

METHODS

We conducted a review using PubMed/Medline and Embase as databases, selecting longitudinal or case control studies. A random effects meta-analysis was conducted.

RESULTS

Five mainly large-scale studies were retrieved. Daily drinking was associated with a significant increase in risk of liver cirrhosis compared to non-daily drinking, with a pooled relative risks of 1.71 (95% confidence interval 1.23-2.23) for men and 1.56 (95% confidence interval 1.39-1.74) for women.

DISCUSSION AND CONCLUSIONS

The consistent exposure to acetaldehyde and other toxins for daily drinkers may explain our findings. There should be days of abstinence to allow the liver to recover, especially for heavier drinkers.

Moderate alcohol drinking with meals is related to lower incidence of type 2 diabetes

BACKGROUND

Previous studies on alcohol drinking and health largely have ignored the potential impact of the timing of drinking.

OBJECTIVES

We aimed to investigate the joint associations of the timing of alcohol intake with respect to meals (i.e., with meals or outside of meals) and the amount of alcohol consumed with the risk of type 2 diabetes (T2D).

METHODS

A total of 312,388 current drinkers from the UK Biobank without T2D at baseline were included. Cox proportional hazards models were used to examine the association between the timing of alcohol intake with respect to meals and the risk of T2D.

RESULTS

During a median of 10.9 y of follow-up, 8598 incident cases of T2D were documented. After adjustment for covariates and the amount of alcohol consumed, consuming alcohol with meals was significantly associated with a 12% lower risk of T2D (HR: 0.88; 95% CI: 0.83, 0.93) than was consuming alcohol outside of meals. In addition, we found that the timing of alcohol intake with respect to meals significantly modified the relations between the amount of alcohol consumed and risk of T2D (P-interaction = 0.017); the beneficial association of moderate drinking with T2D risk was only observed in participants who consumed alcohol with meals, but not in others. Further analyses on various types of alcoholic beverages indicated that the beneficial associations between alcohol drinking with meals and T2D were mainly driven by wine consumption. Moreover, we found that when consumed together with meals, drinking more wine, rather than other alcoholic beverages, was related to lower concentrations of C-reactive protein.

CONCLUSIONS

In current drinkers, moderate drinking of alcohol, especially wine, with meals is associated with a lower risk of T2D.

Mediterranean Alcohol-Drinking Patterns and All-Cause Mortality in Women More Than 55 Years Old and Men More Than 50 Years Old in the "Seguimiento Universidad de Navarra" (SUN) Cohort

BACKGROUND

Most of the available epidemiological evidence on alcohol and chronic disease agrees on recommending alcohol abstention to young people, but some controversy exists about the most appropriate recommendation for alcohol abstention for people of older ages. A growing body of evidence suggests that the pattern of alcohol consumption is likely to be a strong effect modifier. The Mediterranean Alcohol Drinking Pattern (MADP) represents a score integrating several dimensions of drinking patterns (moderation, preference for red wine, drinking with meals, and avoiding binge drinking). Our aim was to clarify this issue and provide more precise recommendations on alcohol consumption.

METHODS

We prospectively followed-up 2226 participants (men older than 50 years and women older than 55 years at baseline) in the Seguimiento Universidad de Navarra (SUN) cohort. We classified participants into three categories of adherence to the MADP score (low, moderate, and high), and we added a fourth category for abstainers. Cox regression models estimated multivariable-adjusted hazard ratios (HR) of all-cause death and 95% confidence intervals (CI) using low MADP adherence as the reference category.

RESULTS

The strongest reduction in risk of mortality was observed for those with high adherence to the MADP, with an HR of 0.54 (95% CI: 0.37-0.80). The moderate adherence group (HR = 0.65, 95% CI: 0.44-0.96) and the abstention group (HR = 0.60, 95% CI: 0.36-0.98) also exhibited lower risks of mortality than the low MADP adherence group.

CONCLUSIONS

based on the available evidence, a public health message can be provided to people older than 50 years as follows: among those who drink alcohol, high adherence to the MADP score could substantially reduce their risk of all-cause mortality.

Clinical and Safety Evaluation of Liv.52 in Alcoholic Liver Disease: A Review

Alcoholic liver disease (ALD) has been a growing concern in developed and developing nations. Oxidative stress and lipid peroxidation are the most common cause of the development and progression of ALD. Due to paucity in the number and efficacy of hepatoprotective drugs currently available, and with the easy availability of natural therapy and herbal medicines, ALD is managed using a combination of pharmaceutical interventions and herbal medications. However, the effectiveness of these hepatoprotectives is controversial. Preclinical and clinical studies have demonstrated that Liv.52 modulates the lipotropic activity of hepatocytes, reduces inflammation, enhances alcohol and acetaldehyde metabolism, and protects the hepatic parenchyma by restoring the antioxidant levels of hepatocytes. Clinical studies further support that there is improvement in the subjective symptoms of patients as well as improvements in liver function test parameters. Studies suggest that Liv.52 is well tolerated and has no reported side effects.

Analysis of alcohol use, consumption of micronutrient and macronutrients, and liver health in the 2017-2018 National Health and Nutrition Examination Survey

BACKGROUND

Alcohol use is a major global healthcare burden that contributes to numerous adverse health outcomes, including liver disease. Many factors influence individual susceptibility to alcohol-associated diseases, including nutritional factors. The objective of the current study was to examine inter-relations among alcohol, dietary micronutrients and macronutrient consumption, and liver health by analyzing data from the 2017-2018 National Health and Nutrition Examination Survey (NHANES).

METHODS

Based on self-reported alcohol consumption, NHANES respondents were assigned to one of four categories: never drinkers (lifetime abstainers), non-drinkers (past-year abstainers), moderate drinkers (1/2 drinks per day for females/males, respectively), and heavy drinkers (>1/>2 drinks per day for females/males, respectively, and/or frequent binge drinking). Survey-weighted regression analyses (adjusted for gender, age, race, education, and body mass index) were performed to examine associations between alcohol intake, dietary, and liver health characteristics.

RESULTS

Individuals categorized as heavy drinkers were significantly younger, most often well-educated males with low incidences of diabetes and other comorbidities. They consumed the most overall calories and various micronutrients, indicating a diet that was not necessarily nutrient poor. Neither moderate nor heavy drinkers had liver steatosis or fibrosis as measured by liver elastography, although heavy drinkers had modestly elevated plasma biomarkers of liver injury, including ALT, AST, and GGT, compared with the other groups.

CONCLUSIONS

Our findings suggest that the category of heavy drinkers in the 2017-2018 NHANES consisted of generally healthy individuals with high-energy intake and no evidence of liver steatosis or fibrosis. However, slightly increased plasma liver markers may indicate a risk of future progression to more advanced stages of liver disease over time in some individuals. Several limitations should be considered when interpreting these data, including the potential misclassification of drinking categories and the lack of standardized cutoff scores for fatty liver as assessed by elastography, among others.

Gender-related associations between psychiatric disorders and alcohol use disorder: Findings from the french "Mental health in the general population" survey

Women with alcohol use disorder (AUD) might be particularly vulnerable to psychiatric comorbidities. However, population surveys have yielded disparate findings. We used data from the French Mental Health in the General Population survey to investigate gender-related risks of psychiatric comorbidities associated with AUD. A cross-sectional survey based on face-to-face interviews, including the Mini International Neuropsychiatric Interview, was conducted among 38,717 subjects. Logistic regression models were used to assess risks of psychiatric comorbidities associated with AUD. After adjustment for socio-demographics and other psychiatric disorders, both women and men with AUD were at higher risk of comorbid depressive disorder (odds ratio [OR] = 2.6, 95% confidence interval [CI]: 2.0-3.4 in women, and OR = 2.0, 95% CI: 1.7-2.4 in men), bipolar I disorder (2.5; 1.4-4.4 in women vs. 2.6; 1.9-3.4 in men), and psychotic disorder (1.6; 1.01-2.5 in women vs. 1.8; 1.4-2.3 in men). Women with AUD exhibited an increased risk of comorbid panic disorder (OR = 1.6, 95% CI: 1.1-2.2) while the increased risk of post-traumatic stress disorder (PTSD) was significant in men only (OR = 2.6, 95% CI: 1.6-4.2). The increased risk of comorbid substance use disorder (SUD) was more elevated in women, compared to men (12.9; 8.1-18.1 vs. 4.8; 4.0-5.8 in men). Most of psychiatric conditions were over-represented in both women and men with AUD, relative to controls. Gender-specific findings were that women with AUD had an increased risk of comorbid SUD or panic disorder, while men had a significantly higher risk of comorbid PTSD.

Smoking causes the disorder of glucose metabolism under different levels of blood pressure in male occupational population

Smoking is an important modifiable factor in the risk of type 2 diabetes. Type 2 diabetes and hypertension overlap in the population. The present study investigated effects of smoking on glucose metabolism under different blood pressure (BP) levels in occupational population. A smoking survey among occupational groups was conducted in 2018. The general linear model was used to analyze the differences of glucose metabolism indexes and BP indexes influenced by different smoking intensity (never 0, mild <10, moderate <20, heavy ≥20 pack‐years). Odds ratios of developing diabetes and β‐cell deficiency were analyzed by using logistic regression model. BP was further taken into account in the relationship between smoking and glucose metabolism. As a result, 1730 male workers aged 21 to 60 years were included in the analysis finally. Compared to never smokers, heavy smokers had significantly increased fasting plasma glucose. Moderate and above smokers had significantly increased glycosylated hemoglobin, decreased fasting plasma insulin and β‐cell function, after adjustment for covariates. Further, smoking intensity was found to have a dose‐dependent relationship with impaired β‐cell function and diabetes. In conclusion, smoking has a positive dose‐dependent relationship with β‐cell deficiency and diabetes. Male smoking workers, especially the moderate or higher smoking, with high‐normal and high BP levels are at high risk of abnormal glucose metabolism.

Alcohol Intake in Patients With Cardiomyopathy and Heart Failure: Consensus and Controversy

Alcohol is often cited to be a common cause of cardiomyopathy and heart failure. However, in most available population-based studies, a modest-to-moderate alcohol consumption has been associated with favorable effects on the cardiovascular system, including a lowered risk of heart failure, compared with no alcohol consumption. Available genetic epidemiological data have not supported a causal association between alcohol consumption and heart failure risk, suggesting that alcohol may not be a common cause of heart failure in the community. Data linking alcohol intake with cardiomyopathy risk are sparse, and the concept of alcoholic cardiomyopathy stems mainly from case series of selected patients with dilated cardiomyopathy, where a large proportion reported a history of excessive alcohol intake. This state-of-the-art paper addresses the current knowledge of the epidemiology of alcoholic cardiomyopathy and the role of alcohol intake in patients with non-alcohol-related heart failure. It also offers directions to future research in the area. The review questions the validity of current clinical teaching in the area. It is not well known how much alcohol is needed to cause disease, and the epidemiological pathways linking alcohol consumption to cardiomyopathy and heart failure are not well understood. Until more evidence becomes available, caution is warranted before labeling patients as having alcoholic cardiomyopathy due to a risk of neglecting other contributors, such as genetic causes of cardiomyopathy. In non-alcohol-related heart failure, it is unknown whether total abstinence is improving outcomes (compared with moderate drinking). Ideally, randomized clinical trials are needed to answer this question.

Morbimortality Associated with Liver Cirrhosis in Peru: An Ecological Analysis for the Period of 2004-2016

Liver cirrhosis (LC) is an irreversible, chronic disease and constitutes the last clinical stage of many different liver diseases. The main cause of death is upper gastrointestinal bleeding caused by esophageal variceal rupture. We aim to depict the trend and estimate the morbimortality. For this, we conducted an ecological study and analyzed data from 2004-2016 using the public information provided by the Peruvian Ministry of Health (Ministerio de Salud del Perú, MINSA). Morbidity and mortality were presented according to 5-year groups. Regions were divided according to age quintiles for each studied year, and standardized morbidity and mortality rates were calculated for each natural geographic region; we found that LC-related morbidity per 100,000 people was 52.3 in 2004 and 117.9 in 2016. LC-related mortality had increased from 13.6 deaths per 100,000 people in 2004-2005 to 16.8 deaths per 100,000 people in 2015-2016. Morbidity showed an upward trend in Peru, especially in the departments of Callao, Ica, and Tumbes, whereas mortality showed an upward trend in the departments of Lambayeque, Ica, and Callao.

Alcohol, Drinking Pattern, and Chronic Disease

This review discusses the inconsistent recommendations on alcohol consumption and its association with chronic disease, highlighting the need for an evidence-based consensus. Alcohol is an addictive substance consumed worldwide, especially in European countries. Recommendations on alcohol consumption are controversial. On one hand, many nonrandomized studies defend that moderate consumption has a beneficial cardiovascular effect or a lower risk of all-cause mortality. On the other hand, alcohol is associated with an increased risk of cancer, neurological diseases, or injuries, among others. For years, efforts have been made to answer the question regarding the safe amount of alcohol intake, but controversies remain. Observational studies advocate moderate alcohol consumption following a Mediterranean pattern (red wine with meals avoiding binge drinking) as the best option for current drinkers. However, agencies such as the IARC recommend abstention from alcohol as it is a potent carcinogen. In this context, more randomized trial with larger sample size and hard clinical endpoints should be conducted to clarify the available evidence and provide clinicians with support for their clinical practice.

The Role of Cumulative Mean Arterial Pressure Levels in First Stroke Events Among Adults with Hypertension: A 10-Year Prospective Cohort Study

Background

Mean arterial pressure (MAP) has been proved to be an independent risk factor for stroke. In this study, we explored whether cumulative exposure of MAP in patients with hypertension is more associated with the occurrence of stroke.

Methods

In this prospective follow-up cohort study of hypertension from June 2010 to May 2020, 9136 participants without previous stroke at recruitment were included, of whom 492 (5.4%) had a first incident stroke during the study period (418 ischemic strokes and 74 hemorrhagic strokes). The study exposure factor was cumulative MAP, and was quartered from low to high (Q1, Q2, Q3, Q4). We analyzed the risk of first stroke using multivariable adjusted Cox regression models and used stratified analysis to further explore the risk of stroke in hypertensive patients with different characteristics.

Results

Increased cumulative MAP in patients with hypertension were associated with risk for ischemic stroke (HR, Q2, 1.23 [95% CI, 0.91–1.67]; Q3, 1.35 [95% CI, 1.01–1.82]; Q4, 1.55 [95% CI, 1.15–2.10]; P=0.035). Furthermore, this trend persisted after stratified analysis in men (HR, Q3, 1.76[1.10–2.82]; Q4, 2.05[1.28–3.28]), aged 60 or above (HR, Q4, 1.63[1.13–2.35]) and higher body mass index (BMI) populations (HR, Q3, 1.48[1.02–2.14]; Q4, 1.59[1.09–2.32]). In contrast, cumulative MAP was not significantly associated with stroke in women, age under 60, and non-obese individuals.

Conclusion

Increased cumulative MAP is an independent risk factor of ischemic stroke in patients with hypertension. Special attention should also be paid to men, aged 60 or older, or those with a higher BMI.

Synergistic and Detrimental Effects of Alcohol Intake on Progression of Liver Steatosis

Nonalcoholic fatty liver disease (NAFLD) and alcoholic liver disease (ALD) are the most common liver disorders worldwide and the major causes of non-viral liver cirrhosis in the general population. In NAFLD, metabolic abnormalities, obesity, and metabolic syndrome are the driving factors for liver damage with no or minimal alcohol consumption. ALD refers to liver damage caused by excess alcohol intake in individuals drinking more than 5 to 10 daily units for years. Although NAFLD and ALD are nosologically considered two distinct entities, they show a continuum and exert synergistic effects on the progression toward liver cirrhosis. The current view is that low alcohol use might also increase the risk of advanced clinical liver disease in NAFLD, whereas metabolic factors increase the risk of cirrhosis among alcohol risk drinkers. Therefore, special interest is now addressed to individuals with metabolic abnormalities who consume small amounts of alcohol or who binge drink, for the role of light-to-moderate alcohol use in fibrosis progression and clinical severity of the liver disease. Evidence shows that in the presence of NAFLD, there is no liver-safe limit of alcohol intake. We discuss the epidemiological and clinical features of NAFLD/ALD, aspects of alcohol metabolism, and mechanisms of damage concerning steatosis, fibrosis, cumulative effects, and deleterious consequences which include hepatocellular carcinoma.

Diagnostic challenges in patients with alcohol-related liver disease

Alcohol is globally the leading risk factor for cirrhosis and is subsumed under the term alcohol-related liver disease (ALD). However, only ca. 10% of people with harmful alcohol consumption (>40 gram alcohol per day) develop cirrhosis, while 15% have normal liver histology. Unfortunately, laboratory parameters and ultrasound hold little value to neither rule-in nor rule out alcohol related liver fibrosis. While several indices with combinations of liver associated markers such as FIB4 seem to be promising, non-invasive test strategies are urgently needed with cut-off's that can be applied to guide clinical decision making. The aims of this review article are to highlight novel developments for the diagnosis of ALD and to identify topics of controversy and potential future directions. In the last 15 years, elastography to measure liver stiffness (LS) has significantly improved our screening strategies for cirrhosis. LS values below 6 kPa are considered as normal and exclude ALD. LS of 8 and 12.5 kPa represent generally accepted cut-off values for F3 and F4 fibrosis. Especially, transient elastography (TE) has been assessed in numerous studies, but similar performance can be obtained with point shear wave elastography, 2 SD shear wave elastography or MR elastography. Important confounders of elevated LS such as inflammation should also be considered and alcohol withdrawal not only improves liver inflammation but also LS. Liver stiffness measurement has signficiantly improved early diagnosis and follow-up of fibrosis in patients with ALD and patients with diagnosed manifest but clinically compensated cirrhosis should undergo further clinical examinations to rule out complications of portal hypertension. In addition, surveillance for the occurrence of hepatocellular carcinoma is recommended in all cirrhotic patients.

Management of alcohol use disorder in patients with cirrhosis in the setting of liver transplantation

The prevalence of alcohol use disorder (AUD) has been steadily increasing over the past decade. In parallel, alcohol-associated liver disease (ALD) has been increasing at an alarming rate, especially among young patients. Data suggest that most patients with ALD do not receive AUD therapy. Although liver transplantation is the only curative therapy for end-stage ALD, transplant candidacy is often a matter of debate given concerns about patients being under-treated for AUD and fears of post-transplantation relapse affecting the allograft. In this Review, we discuss diagnosis, predictors and effects of relapse, behavioural therapies and pharmacotherapies, and we also propose an integrative, multidisciplinary and multimodality approach for treating AUD in patients with cirrhosis, especially in the setting of liver transplantation. Notably, this approach takes into account the utility of AUD pharmacotherapy in patients on immunosuppressive medications and those with renal impairment after liver transplantation. We also propose a comprehensive and objective definition of relapse utilizing contemporary biomarkers to guide future clinical trials. Future research using the proposed approach and definition is warranted with the goal of optimizing AUD treatment in patients with cirrhosis, the transplant selection process and post-transplantation care of patients with AUD.

Liver cirrhosis

Cirrhosis is widely prevalent worldwide and can be a consequence of different causes, such as obesity, non-alcoholic fatty liver disease, high alcohol consumption, hepatitis B or C infection, autoimmune diseases, cholestatic diseases, and iron or copper overload. Cirrhosis develops after a long period of inflammation that results in replacement of the healthy liver parenchyma with fibrotic tissue and regenerative nodules, leading to portal hypertension. The disease evolves from an asymptomatic phase (compensated cirrhosis) to a symptomatic phase (decompensated cirrhosis), the complications of which often result in hospitalisation, impaired quality of life, and high mortality. Progressive portal hypertension, systemic inflammation, and liver failure drive disease outcomes. The management of liver cirrhosis is centred on the treatment of the causes and complications, and liver transplantation can be required in some cases. In this Seminar, we discuss the disease burden, pathophysiology, and recommendations for the diagnosis and management of cirrhosis and its complications. Future challenges include better screening for early fibrosis or cirrhosis, early identification and reversal of causative factors, and prevention of complications.

Socioeconomic inequalities in the incidence of alcohol-related liver disease: A nationwide Danish study

Background

There is socio-economic inequality in total alcohol-related harm, but knowledge of inequality in the incidence of specific alcohol-related diseases would be beneficial for prevention. Registry-based studies with nationwide coverage may reveal the full burden of socioeconomic inequality compared to what can be captured in questionnaire-based studies. We examined the incidence of alcohol-related liver disease (ALD) according to socioeconomic status and age.

Methods

We used national registries to identify patients with an incident diagnosis of ALD and their socioeconomic status in 2009-2018 in Denmark. We computed ALD incidence rates by socioeconomic status (education and employment status) and age-group (30-39, 40-49, 50-59, 60-69 years) and quantified the inequalities as the absolute and relative difference in incidence rates between low and high socioeconomic status.

Findings

Of 17,473 patients with newly diagnosed ALD, 78% of whom had cirrhosis, 86% had a low or medium-low educational level and only 20% were employed. ALD patients were less likely to be employed in the 10 years prior to diagnosis than controls. The incidence rate of ALD correlated inversely with educational level, from 181 (95% CI, 167-197) to 910 (95% CI, 764-1086) per million person-years from the highest to the lowest educational level. By employment status, the incidence rate per million person-years was 211 (95% CI, 189-236) for employed and 3449 (95% CI, 2785-4271) for unemployed. Incidence rates increased gradually with age leading to larger inequalities in absolute numbers for older age-groups. Although ALD was rare in the younger age-groups, the relative differences in incidence rates between high and low socioeconomic status were large for these ages. The pattern of socioeconomic inequality in ALD incidence was similar for men and women.

Interpretation

This study showed substantial socioeconomic inequalities in ALD incidence for people aged 30-69 years.

Funding

The study was supported by grants from the Novo Nordisk Foundation (NNF18OC0054612) and the Research Fund of Bispebjerg Hospital.

Alcohol drinking and risks of liver cancer and non-neoplastic chronic liver diseases in China: a 10-year prospective study of 0.5 million adults

BACKGROUND

Alcohol consumption is an important risk factor for hepatic neoplastic and non-neoplastic diseases. Questions remain, however, about the relevance to disease risk of drinking patterns and alcohol tolerability, which differ appreciably between Chinese and Western populations.

METHODS

The prospective China Kadoorie Biobank included 512,715 adults (41% men) aged 30-79 years recruited from ten areas during 2004-2008, recording alcohol intake, drinking patterns, and other characteristics. After median 10 years' follow-up, 2531 incident liver cancer, 2040 liver cirrhosis, 260 alcoholic liver disease (ALD), and 1262 non-alcoholic fatty liver disease (NAFLD) cases were recorded among 492,643 participants without prior cancer or chronic liver disease at baseline. Cox regression was used to estimate adjusted hazard ratios (HR) relating alcohol intake and drinking patterns to each disease.

RESULTS

Overall, 33% of men and 2% of women drank alcohol regularly (i.e. at least weekly) at baseline. Among male current regular drinkers, alcohol consumption showed positive dose-response associations with risks of several major chronic liver diseases, with HRs per 280 g/week (i.e. around four drinks/day) higher usual alcohol intake of 1.44 (95% CI 1.23-1.69) for liver cancer (n = 547), 1.83 (1.60-2.09) for liver cirrhosis (n = 388), 2.01 (1.77-2.28) for ALD (n = 200), 1.71 (1.35-2.16) for NAFLD (n = 198), and 1.52 (1.40-1.64) for total liver disease (n = 1775). The association with ALD appeared stronger among men reporting flushing (i.e., with low alcohol tolerance). After adjustment for the total amount of weekly alcohol consumption, daily drinkers had significantly increased risk of ALD (2.15, 1.40-3.31) compared with non-daily drinkers, and drinking without meals was associated with significantly greater risks of liver cancer (1.32, 1.01-1.72), liver cirrhosis (1.37, 1.02-1.85), and ALD (1.60, 1.09-2.33) compared with drinking with meals. Female current regular drinkers had significantly higher risk of ALD, but not other liver diseases, than female abstainers.

CONCLUSIONS

In Chinese men, alcohol intake was associated with significantly increased risks of several major chronic liver diseases, and certain drinking patterns (e.g. drinking daily, drinking without meals) may further exacerbate the disease risks.

'Joining the Dots': Individual, Sociocultural and Environmental Links between Alcohol Consumption, Dietary Intake and Body Weight-A Narrative Review

Alcohol is energy-dense, elicits weak satiety responses relative to solid food, inhibits dietary fat oxidation, and may stimulate food intake. It has, therefore, been proposed as a contributor to weight gain and obesity. The aim of this narrative review was to consolidate and critically appraise the evidence on the relationship of alcohol consumption with dietary intake and body weight, within mainstream (non-treatment) populations. Publications were identified from a PubMed keyword search using the terms 'alcohol', 'food', 'eating', 'weight', 'body mass index', 'obesity', 'food reward', 'inhibition', 'attentional bias', 'appetite', 'culture', 'social'. A snowball method and citation searches were used to identify additional relevant publications. Reference lists of relevant publications were also consulted. While limited by statistical heterogeneity, pooled results of experimental studies showed a relatively robust association between acute alcohol intake and greater food and total energy intake. This appears to occur via metabolic and psychological mechanisms that have not yet been fully elucidated. Evidence on the relationship between alcohol intake and weight is equivocal. Most evidence was derived from cross-sectional survey data which does not allow for a cause-effect relationship to be established. Observational research evidence was limited by heterogeneity and methodological issues, reducing the certainty of the evidence. We found very little qualitative work regarding the social, cultural, and environmental links between concurrent alcohol intake and eating behaviours. That the evidence of alcohol intake and body weight remains uncertain despite no shortage of research over the years, indicates that more innovative research methodologies and nuanced analyses are needed to capture what is clearly a complex and dynamic relationship. Also, given synergies between 'Big Food' and 'Big Alcohol' industries, effective policy solutions are likely to overlap and a unified approach to policy change may be more effective than isolated efforts. However, joint action may not occur until stronger evidence on the relationship between alcohol intake, food intake and weight is established.

Alcohol Consumption Levels as Compared With Drinking Habits in Predicting All-Cause Mortality and Cause-Specific Mortality in Current Drinkers

OBJECTIVE

To investigate the joint associations of amounts of alcohol consumed and drinking habits with the risks of all-cause mortality and cause-specific mortality.

PATIENTS AND METHODS

A total of 316,627 healthy current drinkers, with baseline measurements between March 13, 2006, and October 1, 2010, were included in this study. We newly created a drinking habit score (DHS) according to regular drinking (frequency of alcohol intake ≥3 times/wk) and whether consuming alcohol with meals (yes).

RESULTS

During a median follow-up of 8.9 years, we documented 8652 incident cases of all-cause death, including 1702 cases of cardiovascular disease death, 4960 cases of cancer death, and 1990 cases of other-cause death. After adjustment confounders and amount of alcohol consumed, higher DHS was significantly associated with a lower risk of all-cause mortality, cardiovascular disease mortality, cancer mortality, or other-cause mortality (P_trend<.001, P_trend=.03, P_trend<.001, and P_trend<.001, respectively). We observed that the amount of alcohol consumed have different relationships with the risks of all-cause mortality and cause-specific mortality among participants with distinct drinking habits, grouped by DHS. For example, in the joint analyses, a J-shaped association between the amount of alcohol consumed and all-cause mortality was observed in participants with unfavorable DHS (P_{quadratictrend}=.02) while the association appeared to be U-shaped in participants with favorable DHS (P_{quadratictrend}=.003), with lower risks in those consuming greater than or equal to 50 g/wk and less than 300 g/wk.

CONCLUSION

Our results indicate that alcohol consumption levels have different relationships with the risk of mortality among current drinkers, depending on their drinking habits.

The combined effect of alcohol and body mass index on risk of chronic liver disease: A systematic review and meta-analysis of cohort studies

BACKGROUND & AIMS

Increasingly populations are both overweight/obese and consume alcohol. The risk of liver disease from the combination of these factors is unclear. We performed a systematic review and meta-analysis to address this important gap in evidence. Protocol registered with PROSPERO(CRD42016046508).

METHODS

We performed electronic searches of Ovid Medline, Embase Classic + Embase, until 17th June 2020 for cohort studies of adults without pre-existing liver disease. Primary outcome was morbidity/mortality from chronic liver disease. Exposures were alcohol consumption categorised as within or above UK recommended limits (14 units/112 g per week) and BMI categorised as normal, overweight or obese. Non-drinkers were excluded. A Poisson regression log-linear model was used to test for statistical interaction between alcohol and BMI and to conduct a one-stage meta-analysis.

RESULTS

Searches identified 3129 studies-16 were eligible. Of these, nine cohorts (1,121,514 participants) had data available and were included in the analysis. The Poisson model showed no significant statistical interaction between alcohol consumption and BMI on the risk of chronic liver disease. Compared to normal weight participants drinking alcohol within UK recommended limits, relative risk of chronic liver disease in overweight participants drinking above limits was 3.32 (95% CI 2.88 to 3.83) and relative risk in obese participants drinking above limits was 5.39 (95% CI 4.62 to 6.29).

CONCLUSIONS

This meta-analysis demonstrated a significantly increased risk of chronic liver disease in participants who were both overweight/obese and consumed alcohol above UK recommended limits. This evidence should inform advice given to patients and risk stratification by healthcare professionals.