A safe level of alcohol consumption: the right answer demands the right question

Alcohol and arterial stiffness in middle-aged and older adults: Cross-sectional evidence from the UK Biobank study

BACKGROUND

The association between arterial stiffness and alcohol consumption is still controversial. We investigated this relationship by performing continuous analysis in men drinking only beer/cider, and women drinking only red wine.

METHODS

This cross-sectional study involved participants aged 40-69 years consisting of 9029 men who drank only beer/cider, and 6989 women drinking only red wine. Alcohol consumption was captured by self-reported questionnaire and reported as units per week, where one unit is equal 10 mL pure ethanol. Arterial stiffness index (ASI) was estimated using photoplethysmography.

RESULTS

In men consuming a mean 17.8 (5th and 95th percentiles, 2.6-76.7) units/week, ASI increased by heptiles (sevenths) of alcohol captured from beer/cider consumption and after adjusting for age (9.14, 9.40, 9.51, 9.53, 9.80, 9.80, 10.00 m/s; p-trend < 0.001) and after full adjustment (9.29, 9.46. 9.55, 9.55, 9.73, 9.73, 9.75 m/s; p-trend = 0.013). Similarly, in women consuming a mean 8.1 (1.6-29.3) units/week, ASI increased by heptiles of alcohol captured from red wine consumption and after adjusting for age (8.05, 8.05, 8.05, 8.11, 8.17, 8.30, 8.45 m/s; p-trend = 0.012) and borderline significant after full adjustment (8.05, 8.07, 8.05, 8.07, 8.11, 8.22, 8.43 m/s; p-trend = 0.055). These associations were confirmed in multivariable-adjusted regression analysis in all men, men younger and older than 50 years, and when consuming more than 14 units per week. Similarly, these associations were confirmed in all women, women older than 50 years, and in those consuming more than 14 units per week.

CONCLUSIONS

Positive linear relationships exist between arterial stiffness and alcohol, irrespective of whether captured from beer/cider consumption in men or red wine consumption in women. No evidence existed to support the notion that our arteries benefit from any level of alcohol consumption.

Effect of chronic alcohol consumption on oral microbiota in rats with periodontitis

Background

The imbalance of oral microbiota can contribute to various oral disorders and potentially impact general health. Chronic alcohol consumption beyond a certain threshold has been implicated in influencing both the onset and progression of periodontitis. However, the mechanism by which chronic alcohol consumption affects periodontitis and its association with changes in the oral microbial community remains unclear.

Objective

This study used 16S rRNA gene amplicon sequencing to examine the dynamic changes in the oral microbial community of rats with periodontitis influenced by chronic alcohol consumption.

Methods

Twenty-four male Wistar rats were randomly allocated to either a periodontitis (P) or periodontitis + alcohol (PA) group. The PA group had unrestricted access to alcohol for 10 weeks, while the P group had access to water only. Four weeks later, both groups developed periodontitis. After 10 weeks, serum levels of alanine aminotransferase and aspartate aminotransferase in the rats' serum were measured. The oral swabs were obtained from rats, and 16S rRNA gene sequencing was conducted. Alveolar bone status was assessed using hematoxylin and eosin staining and micro-computed tomography.

Results

Rats in the PA group exhibited more severe periodontal tissue damage compared to those in the periodontitis group. Although oral microbial diversity remained stable, the relative abundance of certain microbial communities differed significantly between the two groups. Actinobacteriota and Desulfobacterota were more prevalent at the phylum level in the PA group. At the genus level, Cutibacterium, Tissierella, Romboutsia, Actinomyces, Lawsonella, Anaerococcus, and Clostridium_sensu_stricto_1 were significantly more abundant in the PA group, while Haemophilus was significantly less abundant. Additionally, functional prediction using Tax4Fun revealed a significant enrichment of carbohydrate metabolism in the PA group.

Conclusion

Chronic alcohol consumption exacerbated periodontitis in rats and influenced the composition and functional characteristics of their oral microbiota, as indicated by 16S rRNA gene sequencing results. These microbial alterations may contribute to the exacerbation of periodontitis in rats due to chronic alcohol consumption.

Alcohol use disorders and liver fibrosis: an update

Alcoholic liver disease (ALD) is currently, worldwide, the second most common cause of human fatalities every year. Alcohol use disorders (AUDs) lead to 80% of hepatotoxic deaths, and about 40% of cases of cirrhosis are alcohol-related. An acceptable daily intake (ADI) of ethanol is hard to establish and studies somewhat controversially recommend a variety of dosages of ADI, whilst others regard any intake as dangerous. Steatohepatitis should be viewed as "the rate limiting step": generally, it can be overcome by abstinence, although in some patients, abstinence has little effect, with the risk of fibrosis, leading in some cases to hepatocellular carcinoma (HCC). Chronic alcoholism can also cause hypercortisolism, specifically pseudo-Cushing Syndrome, whose diagnosis is challenging. If fibrosis is spotted early, patients may be enrolled in detoxification programs to achieve abstinence. Treatment drugs include silybin, metadoxine and adenosyl methionine. Nutrition and the proper use of micronutrients are important, albeit often overlooked in ALD treatment. Other drugs, with promising antifibrotic effects, are now being studied. This review deals with the clinical and pathogenetic aspects of alcohol-related liver fibrosis and suggests possible future strategies to prevent cirrhosis.

Brief history of the alcohol biomarkers CDT, EtG, EtS, 5-HTOL, and PEth

This article traces the historical development of various biomarkers of acute and/or chronic alcohol consumption. Much of the research in this domain of clinical and laboratory medicine arose from clinics and laboratories in Sweden, as exemplified by carbohydrate deficient transferrin (CDT) and phosphatidylethanol (PEth). Extensive studies of other alcohol biomarkers, such as ethyl glucuronide (EtG), ethyl sulfate (EtS), and 5-hydroxytryptophol (5-HTOL), also derive from Sweden. The most obvious test of recent drinking is identification of ethanol in a sample of the person's blood, breath, or urine. However, because of continuous metabolism in the liver, ethanol is eliminated from the blood at a rate of 0.15 g/L/h (range 0.1-0.3 g/L/h), so obtaining positive results is not always possible. The widow of detection is increased by analysis of ethanol's non-oxidative metabolites (EtG and EtS), which are more slowly eliminated from the bloodstream. Likewise, an elevated ratio of serotonin metabolites in urine (5-HTOL/5-HIAA) can help to disclose recent drinking after ethanol is no longer measurable in body fluids. A highly specific biomarker of hazardous drinking is CDT, a serum glycoprotein (transferrin), with a deficiency in its N-linked glycosylation. Another widely acclaimed biomarker is PEth, an abnormal phospholipid synthesized in cell membranes when people drink excessively, having a long elimination half-life (median ~6 days) during abstinence. Research on the subject of alcohol biomarkers has increased appreciably and is now an important area of drug testing and analysis.

Ideal cardiovascular health and risk of death in a large Swedish cohort

BACKGROUND

Ideal cardiovascular health (CVH) can be assessed by 7 metrics: smoking, body mass index, physical activity, diet, hypertension, dyslipidemia and diabetes, proposed by the American Heart Association. We examined the association of ideal CVH metrics with risk of all-cause, CVD and non-CVD death in a large cohort.

METHODS

A total of 29,557 participants in the Swedish National March Cohort were included in this study. We ascertained 3,799 deaths during a median follow-up of 19 years. Cox regression models were used to estimate hazard ratios with 95% confidence intervals (95% CIs) of the association between CVH metrics with risk of death. Laplace regression was used to estimate 25th, 50th and 75th percentiles of age at death.

RESULTS

Compared with those having 6-7 ideal CVH metrics, participants with 0-2 ideal metrics had 107% (95% CI = 46-192%) excess risk of all-cause, 224% (95% CI = 72-509%) excess risk of CVD and 108% (31-231%) excess risk of non-CVD death. The median age at death among those with 6-7 vs. 0-2 ideal metrics was extended by 4.2 years for all-causes, 5.8 years for CVD and 2.9 years for non-CVD, respectively. The observed associations were stronger among females than males.

CONCLUSIONS

The strong inverse association between number of ideal CVH metrics and risk of death supports the application of the proposed seven metrics for individual risk assessment and general health promotion.

Should we remove wine from the Mediterranean diet?: a narrative review

Moderate alcohol intake (or, more specifically, red wine) represents one of the postulated beneficial components of the traditional Mediterranean diet. Many well-conducted nonrandomized studies have reported that light-to-moderate alcohol intake is not only associated with reduced risk of cardiovascular disease, but also of all-cause mortality. Nonetheless, alcohol is an addictive substance imposing huge threats for public health. Alcohol consumption is associated with increased risks of cancer, neurological harms, injuries, and other adverse outcomes. Both the Global Burden of Disease (2016) and Mendelian randomization studies recently supported that the healthiest level of alcohol intake should be 0. Therefore, despite findings of conventional observational epidemiologic studies supporting a potential beneficial role of wine in the context of a healthy Mediterranean dietary pattern, a strong controversy remains on this issue. Age, sex, and drinking patterns are likely to be strong effect modifiers. In this context, a new 4-y noninferiority pragmatic trial in Spain (University of Navarra Alumni Trialist Initiative or "UNATI"), publicly funded by the European Research Council, will randomly assign >10,000 current drinkers (males, 50-70 y; females, 55-75 y) to repeatedly receive advice on either abstention or moderation in alcohol consumption. The recruitment will begin in mid-2024. The primary endpoint is a composite of the main clinical outcomes potentially related to alcohol intake including all-cause mortality. Clinical trial registry number: PREDIMED, ISRCTN35739639, www.predimed.es; SUN, clinicaltrials.gov identifier: NCT02669602, https://medpreventiva.es/i2CmeL.

High-density lipoprotein functionality, cardiovascular health, and patterns of alcohol consumption: new insights and future perspectives

PURPOSE OF REVIEW

Cardiovascular diseases (CVD) pose a significant public health challenge, contributing to 422 million disability-adjusted life years in 2021. The role of high-density lipoproteins (HDL) and alcohol consumption, one of their major modifiable determinants, remains controversial. The objective of this review is to provide a comprehensive narrative overview of HDL functionality and its predictive value for CVD in relation to patterns of alcohol consumption.

RECENT FINDINGS

HDL phenotypes beyond HDL-cholesterol (HDL-c) such as distribution of HDL subspecies, HDL particle abundance, and reverse cholesterol transport capacity are promising indicators of atherosclerotic CVD risk. Low-to-moderate alcohol consumption seems to improve HDL functionality and reduce the incidence of CVD among primarily middle-aged men and postmenopausal women. Advancements in our understanding of HDL biogenesis, structure, and function hold promise for improving HDL-related measures and their predictive value for cardiovascular health.

SUMMARY

Low-to-moderate alcohol consumption appears to not only increase HDL-c concentration found in the HDL fraction of plasma but also enhance HDL functionality, providing insights into the underlying mechanisms linking alcohol exposure and cardiovascular health benefits. However, rigorous, well designed intervention trials of alcohol consumption on hard cardiovascular outcomes are needed to identify robust causal associations of HDL phenotypes and alcohol consumption with cardiovascular risk.

The effects of exceeding low-risk drinking thresholds on self-rated health and all-cause mortality in older adults: the Tromsø study 1994-2020

BACKGROUND

Based on findings of increasing alcohol consumption in older adults, it is important to clarify the health consequences. Using data from the Tromsø study, we aimed to investigate the relationship between different levels of alcohol consumption in old adulthood and self-rated health trajectories and all-cause mortality.

METHODS

This is an epidemiological study utilizing repeated measures from the Tromsø study cohort. It allows follow-up of participants from 1994 to 2020. A total of 24,590 observations of alcohol consumption were made in older adults aged 60-99 (53% women).

PRIMARY OUTCOME MEASURES

Self-rated health (SRH) and all-cause mortality. SRH was reported when attending the Tromsø study. Time of death was retrieved from the Norwegian Cause of Death Registry. The follow-up time extended from the age of study entry to the age of death or end of follow-up on November 25, 2020.

PREDICTOR

Average weekly alcohol consumption (non-drinker, < 100 g/week, ≥100 g/week). We fitted two-level logistic random effects models to examine how alcohol consumption was related to SRH, and Cox proportional hazards models to examine its relation to all-cause mortality. Both models were stratified by sex and adjusted for sociodemographic factors, pathology, biometrics, smoking and physical activity. In addition, all the confounders were examined for whether they moderate the relationship between alcohol and the health-related outcomes through interaction analyses.

RESULTS

We found that women who consumed ≥100 g/week had better SRH than those who consumed < 100 g/week; OR 1.85 (1.46-2.34). This pattern was not found in men OR 1.18 (0.99-1.42). We identified an equal mortality risk in both women and men who exceeded 100 g/week compared with those who consumed less than 100 g/week; HR 0.95 (0.73-1.22) and HR 0.89 (0.77-1.03), respectively.

CONCLUSIONS

There was no clear evidence of an independent negative effect on either self-rated health trajectories or all-cause mortality for exceeding an average of 100 g/week compared to lower drinking levels in this study with up to 25 years follow-up. However, some sex-specific risk factors in combination with the highest level of alcohol consumption led to adverse effects on self-rated health. In men it was the use of sleeping pills or tranquilisers and ≥ 20 years of smoking, in women it was physical illness and older age.

A machine-learning model to predict postoperative delirium following knee arthroplasty using electronic health records

BACKGROUND

Postoperative delirium is a challenging complication due to its adverse outcome such as long hospital stay. The aims of this study were: 1) to identify preoperative risk factors of postoperative delirium following knee arthroplasty, and 2) to develop a machine-learning prediction model.

METHOD

A total of 3,980 patients from two hospitals were included in this study. The model was developed and trained with 1,931 patients from one hospital and externally validated with 2,049 patients from another hospital. Twenty preoperative variables were collected using electronic hospital records. Feature selection was conducted using the sequential feature selection (SFS). Extreme Gradient Boosting algorithm (XGBoost) model as a machine-learning classifier was applied to predict delirium. A tenfold-stratified area under the curve (AUC) served as the metric for variable selection and internal validation.

RESULTS

The incidence rate of delirium was 4.9% (n = 196). The following seven key predictors of postoperative delirium were selected: age, serum albumin, number of hypnotics and sedatives drugs taken preoperatively, total number of drugs (any kinds of oral medication) taken preoperatively, neurologic disorders, depression, and fall-down risk (all p < 0.05). The predictive performance of our model was good for the developmental cohort (AUC: 0.80, 95% CI: 0.77-0.84). It was also good for the external validation cohort (AUC: 0.82, 95% CI: 0.80-0.83). Our model can be accessed at https://safetka.connecteve.com .

CONCLUSIONS

A web-based predictive model for delirium after knee arthroplasty was developed using a machine-learning algorithm featuring seven preoperative variables. This model can be used only with information that can be obtained from pre-operative electronic hospital records. Thus, this model could be used to predict delirium before surgery and may assist physician's effort on delirium prevention.

Increase in Serum MMP-9 and TIMP-1 Concentrations during Alcohol Intoxication in Adolescents-A Preliminary Study

Background: Alcohol consumption by adolescents is responsible for a number of adverse health and social outcomes. Despite the well-established effect of alcohol use on the development of alcoholic liver disease, the relationship between the pattern of alcohol consumption and liver fibrosis is still unclear. This study is a follow-up to work on liver damage from alcohol intoxication. The aim of our study was to explore the early effects of alcohol intoxication on liver fibrosis in adolescents. Methods: The prospective study included 57 adolescents aged 14−17 years admitted to the emergency department (ED) from February 2017 to June 2018 due to acute alcohol intoxication. Serum levels of amino terminal propeptide of type III procollagen (PIIINP), type IV collagen, matrix metallopeptidase 9 (MMP-9) and tissue inhibitor of metalloproteinase 1 (TIMP-1) were determined by enzyme-linked immunosorbent assays. Results: There were significant differences in MMP-9 (p = 0.02) and TIMP-1 (p = 0.007) levels between the study and control groups. Liver parameters and selected markers of fibrosis were similar in groups in terms of blood alcohol concentrations (BAC). MMP-9 was positively correlated with alanine aminotransferase (ALT) (r = 0.38; p = 0.004) and total bilirubin (r = 0.39; p = 0.004). Positive significant correlations were also found between TIMP-1 and ALT (r = 0.47; p < 0.001), AST (r = 0.29; p = 0.03) and total bilirubin (r = 0.32; p = 0.02). In receiver operating characteristic (ROC) analysis, MMP-9 (AUC = 0.67, p = 0.02) and TIMP-1 (AUC = 0.69, p = 0.003) allowed for the differentiation of patients with and without alcohol intoxication. Conclusion: Our results show that even a single episode of alcohol intoxication in adolescents can lead to imbalance in markers of fibrosis.

Alcohol and early mortality (before 65 years) in the 'Seguimiento Universidad de Navarra' (SUN) cohort: does any level reduce mortality?

The aim of this study was to assess the association between alcohol intake and premature mortality (younger than 65 years) and to explore the effect of potential alcohol underreporting by heavy drinkers. We followed-up 20 272 university graduates. Four categories of alcohol intake were considered (abstainer, light, moderate and heavy consumption). Repeated measurements of alcohol intake and updated information on confounders were used in time-dependent Cox models. Potential underreporting of alcohol intake by some heavy drinkers (likely misclassified as light or moderate drinkers) was explicitly addressed in an attempt to correct potential underreporting by using indirect information. During 12·3 years of median follow-up (interquartile range: 6·8-15·0), 226 participants died before their 65th birthday. A higher risk of early mortality was found for the highest category of alcohol intake (≥50 g/d) in comparison with abstention (multivariable-adjusted hazard ratio (HR) = 2·82, 95 % CI 1·38, 5·79). In analyses of alcohol as a continuous variable, the multivariable-adjusted HR was 1·17 (95 % CI 1·08, 1·26), for each 10 g/d of alcohol. This harmful linear association was present both in uncorrected models and in models corrected for potential underreporting. No significant inverse association between light or moderate alcohol intake and premature mortality was observed, even after correcting for potential misclassification. Alcohol intake exhibited a harmful linear dose-response association with premature mortality (<65 years) in this young and highly educated Mediterranean cohort. Our attempts to correct for potential misclassification did not substantially change these results.

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.

Alcohol Consumption and Cardiovascular Disease Risk: Placing New Data in Context

PURPOSE OF REVIEW

A clear link between excessive alcohol consumption and cardiovascular disease (CVD) has been established, but no consensus exists on the effects of moderate alcohol consumption on CVD.

RECENT FINDINGS

A lower risk of coronary heart disease and myocardial infarction among moderate drinkers compared to abstainers has been consistently observed in epidemiological studies and meta-analyses of these studies. However, ambiguity remains on the effect of alcohol on other CVDs and all-cause mortality. Short-term randomized controlled trials (RCT) have identified potentially beneficial effects of alcohol consumption on cardiovascular risk factors, but studies investigating genetic polymorphisms that influence alcohol consumption (i.e., Mendelian randomization) have yielded inconclusive results. To date, a long-term RCT providing causal evidence is lacking but urgently needed. Triangulation of evidence from different study designs, including long-term RCTs, pragmatic trials and the evaluation of policy measures, combined will lead to the best available evidence.

Development and validation of a knowledge, attitude, and practice questionnaire regarding cardiovascular diseases in an Iranian general population

Background

Studies on knowledge, attitude, and practice (KAP) can be valuable for public health to help to develop targeted educational programs and assess the effectiveness of intervention programs. The purpose of this study was to develop and examine the validity and reliability of a questionnaire on knowledge, attitude, and practice (KAP) regarding cardiovascular diseases (CVDs), their risk factors, and symptoms among an Iranian general population.

Methods

This cross-sectional study was conducted on an Iranian population older than 20 years referred to some of Tehran’s healthcare centers. An initial 62-item questionnaire was developed, and the face, content, and construct validities were assessed.

Results

In all, 300 adults with a mean age (SD) of 39.79 (12.1) years participated in this study. Based on the results of the content validity, a questionnaire with 30 essential items was designed. Exploratory factor analysis suggested a four-factor subscale with 29 finalized items (CVD-KAP29), and acceptable goodness of fit indices was demonstrated by confirmatory factor analysis. The Cronbach’s alpha and McDonald’s ω coefficients were higher than 0.60 for all domains except the nutrition and smoking subscales.

Conclusions

Results provided evidence of the validity of the CVD-KAP29 for KAP studies for cardiovascular diseases in the general population.

False negative AUDIT screening results among patients in rural primary care settings

Purpose: The objective of this study was to examine the incidence of false-negative screening results on a tool measuring alcohol use - the United States Alcohol Use Disorder Identification Test Consumption (US-AUDIT-C).Method: A sample of patients (n = 4,023) in Alabama completed the US-AUDIT-C prior to a medical visit as part of a screening, brief intervention, and referral to treatment (AL-SBIRT) program. We calculated the incidence of false negative US-AUDIT-C screens based on recommendations for safe alcohol consumption.Results: The false negative screening rate on the US-AUDIT-C was 1%. The false negative screening rate for (a) males aged > 65 years in the AL-SBIRT program was 0.64%, (b) males aged 18-65 years was 2.79%, and (c) all females was 2.29%.Discussion & Conclusions: Increasing alcohol-consumption-related health education and reducing the stigma of discussing alcohol consumption habits is an important step toward improving patient health. Clinicians can more accurately screen and provide brief intervention services for alcohol misuse by training on US-AUDIT-C response patterns.

The J-shaped curve-conceptual and methodological challenges

Purpose

The purpose of this paper is to review the conceptual and methodological challenges of a J-shaped association between alcohol consumption (AC), coronary heart disease (CHD) and all-cause mortality. In associated papers in this journal, Skovenborg et al., 2021 reviews the evidence for the J-shaped curve, and Ellison et al., 2021 examines the advantages and drawbacks of Mendelian randomization studies of the J-shaped curve.

Design/methodology/approach

A number of methodological problems are common in observational research in general, and some of the methodological problems suggested for the J-shaped alcohol-CHD-associations are discussed. The extent of the methodological problems in studies of the J-shaped curve is reviewed, and the possibility that the J-shaped curve is an artifact created by reverse causality and residual confounding is discussed. Further, the issue of interaction with drinking pattern and type of alcohol is discussed.

Findings

Imprecise categorization of alcohol intake information seems to have had little effect on the J-shaped alcohol-CHD-associations, nor has it affected the ability of these studies to show increasing mortality from a range of causes with increasing AC. The problem of “sick quitters” has been resolved by large studies using lifelong abstainers or infrequent drinkers as reference group. Many studies lack information on drinking patterns with regard to regular, moderate consumption versus binge drinking. Stratified analyses by important risk factors for CHD have not significantly changed the J-shaped association observed in most epidemiologic studies.

Originality/value

Potential biases and residual confounding probably do not overcome the J-shaped alcohol-CDH-association observed in most epidemiologic studies; however, the existence of a J-shaped curve is challenged by some degree of uncertainty. The actual review together with the associated papers by Skovenborg et al., 2021 and Ellison et al., 2021 offers a possibility to “update your priors” and achieve greater certainty when giving your patients information on the pros and cons of alcohol intake.