Clusters within a general adult population of alcohol abstainers

Investigation of Alcohol-Drinking Levels in the Swiss Population: Differences in Diet and Associations with Sociodemographic, Lifestyle and Anthropometric Factors

Alcohol-drinking levels in Switzerland were investigated to identify dietary differences and explore the relationship between drinking levels and sociodemographic, lifestyle and anthropometric factors using the National Nutrition Survey menuCH (n = 2057, 18−75 years). After two 24 h dietary recalls (24HDRs), participants were categorized into four subgroups: abstainers (both self-declared alcohol avoidance and no alcohol reported); no alcohol reported; moderate drinkers (women/men < 12 g/<24 g mean daily alcohol, respectively); and heavy drinkers (women/men > 12 g/>24 g mean daily alcohol, respectively). Differences in diet between these groups were described by comparing daily total energy and non-alcohol energy intake, macronutrient energy contribution, food group intake, and diet quality (Alternate Healthy Eating Index excluding alcohol). The sociodemographic, anthropometric and lifestyle factors that determine alcohol-drinking levels were investigated using multinomial logistic regression. Abstainers reported the lowest daily energy intake (total and non-alcohol), heavy drinkers had the highest total energy intake and the lowest diet quality, and moderate drinkers had the highest non-alcohol energy intake. Sex, age, language region, body mass index, household size, smoking status, self-reported health status and following a diet were significantly associated with different alcohol-drinking subgroups. Results could facilitate interventions that target subgroups who exceed safe alcohol-drinking levels and lead unfavorable lifestyles.

Real-world colorectal cancer diagnostic pathways in Ontario, Canada: A population-based study

OBJECTIVE

This study aimed to identify colorectal cancer (CRC) diagnostic pathways and describe patients in those pathway groups.

METHODS

This was a cross-sectional study of CRC patients in Ontario, Canada, diagnosed 2009-2012 that used linked administrative data at ICES. We used cluster analysis on 11 pathway variables characterising patient presentation, symptoms, procedures and referrals. We assessed associations between patient- and disease-related characteristics and diagnostic pathway group. We further characterised the pathways by diagnostic interval and number of related physician visits.

RESULTS

Six diagnostic pathways were identified, with three adhering to provincial diagnostic guidelines: screening (N = 4494), colonoscopy (N = 10,066) and imaging plus colonoscopy (N = 3427). Non-adherent pathways were imaging alone (N = 2238), imaging and emergency presentation (N = 2849) and no pre-diagnostic workup (N = 887). Patients in adherent pathways were younger, had fewer comorbidities, lived in less deprived areas and had earlier stage disease. The median diagnostic interval length varied across pathways from 12 to 126 days, correlating with the number of CRC-related visits.

CONCLUSIONS

This study demonstrated substantial variations in real-world CRC diagnostic pathways and 25% were diagnosed through non-adherent pathways. Those patients were older, had more comorbid disease and had higher stage cancer. Further research needs to identify and describe the reasons for divergent diagnostic processes.

Health Risk Factors Associated with Lifetime Abstinence from Alcohol in the 1979 National Longitudinal Survey of Youth Cohort

BACKGROUND

The choice and definition of a comparison group in alcohol-related health studies remains a prominent issue in alcohol epidemiology due to potential biases in the risk estimates. The most commonly used comparison group has been current abstainers; however, this includes former drinkers who may have quit drinking due to health problems. Lifetime abstention could be the best option, but measurement issues, selection biases due to health and other risk factors, and small numbers in populations are important concerns. This study examines characteristics of lifetime abstention and occasional drinking that are relevant for alcohol-related health studies.

METHODS

This study used data from the National Longitudinal Survey of Youth 1979 cohort of 14 to 21 year olds followed through 2012 (n = 7,515). Definitions of abstinence and occasional drinking were constructed based on multiple measurements. Descriptive analyses were used to compare the definitions, and in further analysis, lifetime abstainers (n = 718) and lifetime minimal drinkers (n = 1,027) were compared with drinkers across demographics and early-life characteristics (i.e., religion, poverty, parental education, and family alcohol problems) in logistic regression models.

RESULTS

Using a strict measurement of zero drinks from adolescence to the 50s, only 1.7% of the sample was defined as lifetime abstainer compared to a broader definition allowing a total of 1 drink over the lifetime that included 9.5% and to lifetime minimal drinking (a total of 3 drinks or less a month), which accounted for 13.7%. Factors significantly associated with lifetime abstention and lifetime minimal drinking included religion, poverty, having no family alcohol problems, Hispanic ethnicity, foreign-born, and female gender. Importantly, work-related health limitations in early life were significantly associated, but not childhood physical and mental health problems.

CONCLUSIONS

Alcohol-related health studies should utilize lifetime classifications of drinkers and abstainers, and, in doing so, should account for early-life socioeconomic adversity and childhood health factors or consider these as unmeasured confounders.

Enhancing risk stratification for use in integrated care: a cluster analysis of high-risk patients in a retrospective cohort study

OBJECTIVE

To show how segmentation can enhance risk stratification tools for integrated care, by providing insight into different care usage patterns within the high-risk population.

DESIGN

A retrospective cohort study. A risk score was calculated for each person using a logistic regression, which was then used to select the top 5% high-risk individuals. This population was segmented based on the usage of different care settings using a k-means cluster analysis. Data from 2008 to 2011 were used to create the risk score and segments, while 2012 data were used to understand the predictive abilities of the models.

SETTING AND PARTICIPANTS

Data were collected from administrative data sets covering primary and secondary care for a random sample of 300 000 English patients.

MAIN MEASURES

The high-risk population was segmented based on their usage of 4 different care settings: emergency acute care, elective acute care, outpatient care and GP care.

RESULTS

While the risk strata predicted care usage at a high level, within the high-risk population, usage varied significantly. 4 different groups of high-risk patients could be identified. These 4 segments had distinct usage patterns across care settings, reflecting different levels and types of care needs. The 2008-2011 usage patterns of the 4 segments were consistent with the 2012 patterns.

DISCUSSION

Cluster analyses revealed that the high-risk population is not homogeneous, as there exist 4 groups of patients with different needs across the care continuum. Since the patterns were predictive of future care use, they can be used to develop integrated care programmes tailored to these different groups.

CONCLUSIONS

Usage-based segmentation augments risk stratification by identifying patient groups with different care needs, around which integrated care programmes can be designed.

Smoking and Drinking as Risk Indicators for Tooth Loss in Middle-Aged Danes

Objectives: To investigate tobacco and alcohol consumption as risk indicators for missing teeth in late middle-aged Danes. Method: In all, 1,517 Copenhagen Aging and Midlife Biobank (CAMB) participants received a clinical oral examination that included number of teeth. Information on smoking, drinking, and various covariates was obtained using self-administered, structured questionnaires. Descriptive statistics and logistic regression (dependent variable: 6+ vs. <6 missing teeth) were used to investigate smoking and drinking in relation to missing teeth. Results: Current smokers, persons who currently or previously smoked >15 tobacco units/day, and persons who had smoked for 27+ years had elevated mean scores of missing teeth and associated odds ratios (OR) compared with never smokers. Relative to nondrinkers, alcohol consumption was associated with reduced odds of missing 6+ teeth. Discussion: Our findings suggest that smoking is positively associated, while alcoholic beverage consumption is inversely related to tooth loss in middle-aged Danes.

Case-control study of lifetime alcohol intake and prostate cancer risk

PURPOSE

Alcohol consumption may be a modifiable risk factor for prostate cancer, but previous results have been inconsistent and limited by a lack of data on lifetime exposure and specific beverages. Furthermore, the effect of tumor stage and severity of disease on the association between alcohol and prostate cancer risk has not been fully investigated.

METHODS

We examined the relation between both current and lifetime alcohol intake and prostate cancer risk in a population-based case-control study in Alberta, Canada with 947 cases with stage T2 and higher prostate cancer diagnosed between 1997 and 2000 and frequency matched to 1,039 controls, identified through random digit dialing. Cases were classified on cancer stage and severity into 619 non-aggressive (Stage II and Gleason score <8) and 328 aggressive cases (Stage III/IV or Gleason score ≥8). In-person interviews were completed on current and lifetime history of alcohol consumption and all other prostate cancer risk factors.

RESULTS

Current alcohol intake did not increase prostate cancer risk but lifetime intake increased risk for both non-aggressive and aggressive cases, with an odds ratio of 1.78 (95 % CI 1.19-2.66) and 2.00 (95 % CI 1.19-3.36), respectively, for the highest intake quartile compared to non-drinkers with evidence for a linear trend. Associations with alcohol intake remained after exclusion of non-drinkers for non-aggressive prostate cancer cases. Only lifetime beer intake was significantly associated with increased risk, however, intakes of liquor and wine by participants were low.

CONCLUSIONS

Results support the evidence for an increased risk of prostate cancer from lifetime alcohol consumption.

Alcohol use and prostate cancer: a meta-analysis

Past reviews have concluded that there is no association between alcohol use and prostate cancer incidence. We performed a meta-analysis of existing epidemiological studies finding, in contrast, evidence to suggest that prostate incidence is positively linearly associated with heavier alcohol use. This finding was largely due to the contribution of population case-control studies and those measuring men recruited before age 60. No relationship between alcohol consumption and prostate cancer was found for cohort and hospital case-control studies. Analyses of design effects modestly suggests that population case-control studies were probably better suited to identify potential alcohol-prostate cancer relationships due to the close temporal proximity of the measurement of level of alcohol consumption to diagnosis. Future efforts should be made to exclude all ill subjects from control groups/baseline samples in addition to accounting for changes in consumption with advancing age and the onset of illness. The alcohol-prostate cancer association remained significant despite controlling for the degree to which studies endeavored to eliminate false negatives from their control groups.

Moderate alcohol use and reduced mortality risk: systematic error in prospective studies and new hypotheses

We have provided recent evidence suggesting that a systematic error may be operating in prospective epidemiological mortality studies that have reported "light" or "moderate" regular use of alcohol to be "protective" against coronary heart disease. Using meta-analysis as a research tool, a hypothesis first suggested by Shaper and colleagues was tested. Shaper et al suggested that people decrease their alcohol consumption as they age and become ill or frail or increase use of medications, some people abstaining from alcohol altogether. If these people are included in the abstainer category in prospective studies, it is reasoned that it is not the absence of alcohol elevating their risk for coronary heart disease (CHD) but, rather, their ill health. Our meta-analytic results indicate that the few studies without this error (i.e., those that did not contaminate the abstainer category with occasional or former drinkers) show abstainers and "light" or "moderate" drinkers to be at equal risk for all-cause and CHD mortality. We explore the history of this hypothesis, examine challenges to our meta-analysis, and discuss options for future research.

Alcohol consumption and out-patient services utilization by abstainers and drinkers

AIMS

Previous studies have found that abstainers utilize out-patient health services more than alcohol consumers. The aim of this study was to investigate this relationship further by including several confounding variables and effect modifiers. It was hypothesized that abstainers utilize more health services because they have less social resources, practice more risky health behaviours, have poorer self-reported health and suffer more from chronic diseases.

DESIGN AND PARTICIPANTS

Cross-sectional health survey of a random sample of adults aged 20-64 in Pomerania, Germany. The response rate was 68.8%. Alcohol consumption was assessed using a quantity-frequency measure and categorized into past-year abstainers, low-risk, medium-risk and high-risk drinkers. Confounders and effect modifiers included socio-demographic and health-related variables.

FINDINGS

Abstainers had a 43% higher rate (rate ratio = 1.43, 95% CI = 1.24, 1.63) of physician visits compared to low-risk drinkers, adjusting for age and gender. Medium-risk and high-risk drinkers did not differ from low-risk drinkers in terms of out-patient visits. Further regression adjustment for socio-economic covariates, self-reported health status and chronic diseases suggested that abstainers used more out-patient services because they were more ill than drinkers. The effect of mental health status and the number of chronic diseases on out-patient visits was greater for abstainers than drinkers.

CONCLUSIONS

The relation between alcohol consumption and out-patient services is explained partly by poorer health among the abstainers. Further research is needed to affirm these results, such as transferring this evidence to the utilization of in-patient health services.

Alcohol consumption is inversely associated with adherence to diabetes self-care behaviours

AIMS

Our aim was to examine the associations of alcohol consumption with six diabetes self-care behaviours.

METHODS

We determined levels of alcohol consumption and examined associations between alcohol consumption and six self-care behaviours in 65 996 adults with diabetes who received care through Kaiser Permanente Northern California and who responded to a 1994-1997 survey. Adherence with recommendations for self monitoring of blood glucose, HbA1c testing, and diabetes medications were determined from electronic records; smoking and use of diet and exercise to treat diabetes were self reported. Multiple logistic regression models were used to determine the associations between alcohol consumption (average number of drinks/day in the past year) and the probability of adherence to each self-care behaviour.

RESULTS

Current alcohol consumption was reported by 50.8% of adults with diabetes. In adjusted models, we observed a gradient of increasing risk for poor adherence to diabetes self-care behaviours with increasing alcohol consumption, starting with those who consume even one drink a day. Former drinkers had the greatest compliance with each self-care behaviour, except for current smoking.

CONCLUSIONS

Alcohol consumption is a marker for poorer adherence to diabetes self-care behaviours. These findings highlight the importance of routine assessment of alcohol intake in people with diabetes, particularly as half of adults with diabetes consume alcohol. Given extant evidence that moderate alcohol intake may have cardiovascular benefits for patients with diabetes, examination of the trade-offs between cardiovascular benefits vs. potential risk of lower adherence with self-care behaviours deserves study.

Lower cognitive test scores observed in alcohol abstainers are associated with demographic, personality, and biological factors: the PATH Through Life Project

AIMS

To identify variables that explain the association between alcohol abstention and cognitive performance. We hypothesized that demographic and personality variables would be important for explaining the association in all age cohorts, but that health variables would be more important in the older age-cohorts.

DESIGN

Three age cohorts (20-24, 40-44, 60-64 years) were sampled randomly, yielding a total of 7485 participants, with data from 602 alcohol abstainers and 4158 light or moderate drinkers used in this study. Setting The sample was drawn from the cities of Canberra and Queanbeyan, Australia.

MEASUREMENTS

Scales measuring demographic, health and personality variables and cognitive and physical tests were administered. Participants drinking at hazardous or harmful levels were excluded from the analysis.

FINDINGS

A range of demographic and physical function measures were found to explain partially the finding of abstainers having lower cognitive test scores. The effects of independent variables were largest in the 60-64-year-old age group with a trend for physical variables such as lung function and grip strength to become more important in the older age groups. In the 20-24-year-olds, the majority of the effect remained unexplained.

CONCLUSION

There is evidence that poorer cognitive test performance by abstainers reflects in part selection effects and poorer physical functioning, but does not appear to be due to mental or physical health conditions or personality.

Impact of alcohol consumption upon medical care utilization and costs in men: 4-year observation of National Health Insurance beneficiaries in Japan

AIMS

The purpose of the present study was to examine the association between alcohol consumption and in-patient and out-patient care utilization and its costs, respectively.

DESIGN AND PARTICIPANTS

The present data were derived from a 4-year prospective observation of National Health Insurance beneficiaries in rural Japan. A total of 17 497 men aged 40-79 years were analysed, after excluding subjects who at the baseline reported having had at least one of four chronic diseases: stroke, myocardial infarction, liver disease and cancer. Alcohol intake was classified into five groups, not including ex-drinkers: life-long abstainers and ethanol intakes of 1-149 g/week, 150-299 g/week, 300-449 g/week, and > or = 450 g/week.

FINDINGS

The hospital days and in-patient care cost showed a U-shaped relationship with alcohol consumption. In-patient cost was highest for those consuming more than 450 g/week [ pound 74.96, 95% confidence interval (CI): 54.39, 95.52] and for life-long abstainers ( pound 69.16, 95% CI: 62.08, 77.83), and lowest for those consuming 150-299 g/week ( pound 51.69, 95% CI: 45.33, 58.04). In-patient use by age specific analysis also showed a U-shape at all ages, and was lowest for those consuming 1-149 g/week in youngest age group. In contrast, the number of physician visits and out-patient cost showed an inverse linear relationships with alcohol consumption.

CONCLUSIONS

This study suggests that in-patient use shows a U-shaped curve and out-patient use shows an inverse linear relationship to alcohol consumption.

Generalized Additive Models applied to analysis of the relation between amount and type of alcohol and all-cause mortality

The J-shaped relation between alcohol intake and mortality is well established, whereas the nadir of the curve is not determined. Due to non-linearity of the relation, categorical alcohol variables have been used to model the relation. In Generalized Additive Models (GAM) non-linear relations can be modelled without the disadvantages of categorization and without assumptions regarding the functional form. The aim of this study was to use GAM to evaluate the relation between alcohol intake, amount and type, and mortality. The relation was investigated using data from the Copenhagen City Heart Study (11,920 participants of whom 5552 died during 20 years follow-up). Using GAM, a smooth J-shaped relation between alcohol and mortality was found. However, if non-drinkers were categorized separately there was a positive association between alcohol and mortality even for low alcohol intake. For equal total alcohol intake, men and women drinking wine or spirits had lower mortality than beer drinkers. The nadir of the relation between alcohol and mortality was sensitive to the handling of non-drinkers. When non-drinkers were categorized separately we found no indication of a beneficial influence of low alcohol intake on mortality.

Are stress related factors associated with alcohol intake?

Moderate alcohol consumption is related to reduced risks of coronary heart disease and all-cause mortality. Our goal is to advance our understanding of the associations between stress-related factors and alcohol consumption, using cutoff points for alcohol intake that reflect health benefits rather than health risks. Cross-sectional data were used from 4,131 respondents (age 20-65 years) participating in a cohort study in the Netherlands on psychosocial factors and cancer risk. Analyses were performed among drinkers only, for men and women separately. Heavy alcohol intake (>/= 3 glasses per day for men, >/= 2 glasses per day for women) was associated with only a few stress-related factors in multivariate analyses. No significant associations between the total amount of stressors and alcohol intake were found. We conclude that stress-related factors are only marginally associated with a heavy alcohol intake compared with fair drinking, using the safe limits of drinking as cutoff point.