Life course trajectories of alcohol consumption in the United Kingdom using longitudinal data from nine cohort studies

Expanding our understanding of long-term trends in alcohol abstention and consumption in England (2001-19) using two age-period-cohort approaches

BACKGROUND AND AIMS

Alcohol consumption has decreased in England in recent decades, while alcohol-specific death rates have remained relatively stable. Age-period-cohort (APC) models offer the potential for understanding these paradoxical trends. This study aimed to use an APC model approach to measure long-term trends in alcohol abstention and consumption in England from 2001 to 2019.

DESIGN, SETTING AND PARTICIPANTS

The study used grouped and proxy-variable APC models of repeat cross-sectional survey data, set in England (2001-19). Participants were residents in England aged 13 years or over who took part in the Health Survey for England.

MEASUREMENTS

Outcome variables were alcohol abstention and consumption in units. We created nine age groups (13-15, 16-17, 18-24, 25-34, until 65-74 and 75+, reference 45-54 years), four periods (2001-04, 2005-09, 2010-14 to 2015-19, reference 2005-09) and 18 5-year birth cohorts (1915-19 to 2000-04, reference 1960-64). We proxied age effects (systolic and diastolic blood pressure), period effects (alcohol affordability, internet usage and household alcohol expenditure) and birth cohort effects (prevalence of smoking and prevalence of overweight).

FINDINGS

The odds of abstaining were considerably larger at young ages, 13-15 years [odds ratio (OR) = 5.38; 95% confidence interval (CI) = 4.50-6.43], were lowest during the first period, 2001-04 (OR = 0.83; 95% CI = 0.79-0.86) and had a U-shaped pattern by birth cohort. For units of alcohol, the incidence rate ratio (IRR) increased until age 18-24 years (IRR = 1.41, 95% CI = 1.34-1.48) and decreased afterwards, were highest during the first period, 2001-04 (IRR = 1.07; 95% CI = 1.05-1.08) and showed an inverted J-shape by birth cohort. Our proxy variable approach revealed that using blood pressure measures, alcohol affordability and prevalence of overweight as proxies resulted in APC effects that differed from our base-case model. However, internet usage, household expenditure on alcohol and smoking prevalence resulted in APC effects similar to our base-case model.

CONCLUSIONS

The discrepancy between decreasing alcohol consumption and increasing alcohol-related deaths observed in England from 2001 to 2019 may, in part, be explained by the halt in abstention trends since 2010 and a slight consumption decline since 2001.

Drinking motives and alcohol sensitivity mediate multi-dimensional genetic influences on alcohol use behaviors

Background

Genetic influences account for a substantial proportion of individual differences in alcohol use behaviors (AUBs). However, multiple distinct sets of genes are linked to different AUBs, which may explain their dramatic variability in risk factors and manifestations. In this study, we explore whether intermediate neurobiological traits and alcohol-related cognitions mediate the relationship between polygenic scores (PGS) and multiple AUBs, with the aim to better understand processes captured by different genetic profiles.

Methods

Using results from prior genome-wide association studies, we derived PGS for 6 AUBs in participants from Spit for Science, a longitudinal study of college students in the U.S. (n=4,549). Self-report measures included personality traits, alcohol expectancies, drinking motivations, and alcohol sensitivity measures as well as drinking frequency, drinking quantity, alcohol use disorder (AUD) symptoms, and maximum drinks in 24 hours. Using linear regression and multiple mediation models, we investigated the direct and indirect effects of PGS on AUBs.

Results

In univariable regression results, PGSs indexing broad AUB dimensions such as drinks per week (DPW) and AUD predicted higher levels of sensation-seeking and multiple drinking motives, while BeerPref PGSs (indexing a variable pattern of alcohol problems associated with a preference for beer) predicted higher negative urgency and lower alcohol sensitivity. Mediational models indicated strong direct and indirect effects of DPW PGSs on multiple AUBs via social/enhancement drinking motives and alcohol sensitivity, indirect effects of AUD PGSs on AUD symptoms via coping motives, and indirect effects of BeerPref PGS on all AUBs via the joint effect of mediators including alcohol sensitivity.

Conclusions

These findings provide initial evidence that the genetic influences on different AUBs are associated with and partially mediated by intermediate neurobiological and cognitive factors, which may be more amenable to intervention. Greater focus on drinking motives and alcohol sensitivity is warranted in genetic research, as well as attention to the heterogeneous pathways linking genes to alcohol use outcomes.

Overcoming Data Gaps in Life Course Epidemiology by Matching Across Cohorts

Life course epidemiology is hampered by the absence of large studies with exposures and outcomes measured at different life stages in the same individuals. We describe when the effect of an exposure ( A ) on an outcome ( Y ) in a target population is identifiable in a combined ("synthetic") cohort created by pooling an early-life cohort including measures of A with a late-life cohort including measures of Y . We enumerate causal assumptions needed for unbiased effect estimation in the synthetic cohort and illustrate by simulating target populations under four causal models. From each target population, we randomly sampled early- and late-life cohorts and created a synthetic cohort by matching individuals from the two cohorts based on mediators and confounders. We estimated the effect of A on Y in the synthetic cohort, varying matching variables, the match ratio, and the strength of association between matching variables and A . Finally, we compared bias in the synthetic cohort estimates when matching variables did not d-separate A and Y to the bias expected in the original cohort. When the set of matching variables includes all variables d-connecting exposure and outcome (i.e., variables blocking all backdoor and front-door pathways), the synthetic cohort yields unbiased effect estimates. Even when matching variables did not fully account for confounders, the synthetic cohort estimate was sometimes less biased than comparable estimates in the original cohort. Methods based on merging cohorts may hasten the evaluation of early- and mid-life determinants of late-life health but rely on available measures of both confounders and mediators.

Changes in Restless Sleep, Self-Control, and Alcohol-Related Problems with Police from Late Adolescence to Adulthood

Sleep quality is crucial for healthy adolescent brain development, which has downstream effects on self-control and involvement in risky behaviors, such as alcohol use. While previous studies have found that sleep and facets of self-control are associated with patterns of alcohol use, few have assessed whether these constructs are tied to alcohol-related problems with law enforcement during the transitional period from adolescence to adulthood. The current study uses self-report panel data from ages 16 to 27 from a population-based sample of U.S. youth (N = 956; 36.86% female). The goal of the current study is to assess the association between changes in restless sleep, impulsivity, sensation seeking, and problems with police during or shortly after consuming alcohol from adolescence to adulthood to begin to address this gap in the existing literature. Results from a multivariate latent growth curve model reveal that faster increases in restless sleep and slower declines in impulsivity are associated with slower declines in police contact. Correlated changes between restless sleep, impulsivity, and police contact are slightly greater from ages 16-21 than for ages 22-27, with males showing stronger associations. The reported results suggest that identifying developmental mechanisms between changes in poor sleep, impulsivity, and alcohol use behaviors during this life-course phase will be crucial moving forward to help divert youth away from alcohol-related contact with the police.

How well do DSM-5 criteria measure alcohol use disorder in the general population of older Swedish adolescents? An item response theory analysis

BACKGROUND

This study assesses the psychometric properties of DSM-5 criteria of AUD in older Swedish adolescents using item response theory models, focusing specifically on the precision of the scale at the cut-offs for mild, moderate, and severe AUD.

METHODS

Data from the second wave of Futura01 was used. Futura01 is a nationally representative cohort study of Swedish people born 2001 and data for the second wave was collected when participants were 17/18 years old. This study included only participants who had consumed alcohol during the past 12 months (n = 2648). AUD was measured with 11 binary items. A 2-parameter logistic item response theory model (2PL) estimated the items' difficulty and discrimination parameters.

RESULTS

31.8% of the participants met criteria for AUD. Among these, 75.6% had mild AUD, 18.3% had moderate, and 6.1% had severe AUD. A unidimensional AUD model had a good fit and 2PL models showed that the scale measured AUD over all three cut-offs for AUD severity. Although discrimination parameters ranged from moderate (1.24) to very high (2.38), the more commonly endorsed items discriminated less well than the more difficult items, as also reflected in less precision of the estimates at lower levels of AUD severity. The diagnostic uncertainty was pronounced at the cut-off for mild AUD.

CONCLUSION

DSM-5 criteria measure AUD with better precision at higher levels of AUD severity than at lower levels. As most older adolescents who fulfil an AUD diagnosis are in the mild category, notable uncertainties are involved when an AUD diagnosis is set in this group.

Reclaiming Pleasure: Does Satisfying Consensual Sexual Activity Predict Next-Day Positive Affect Among Women with a History of Sexual Assault?

Substantial research documents the psychosocial benefits of sexual activity, including heightened positive affect and lowered negative affect following sexual encounters. However, it is important to examine whether affective benefits of consensual sexual activity are present among individuals who have also experienced non-consensual sexual activity (i.e. sexual assault), given that sexual assault may have harmful consequences for sexual functioning and pleasure during consensual encounters. This study tested consensual sexual activity and satisfaction as predictors of next-day positive and negative affect among 82 women sexual assault survivors. Participants completed ecological momentary assessment measures for three weeks, including measures of past-day dyadic (i.e. partnered) sexual activity and satisfaction in the morning and current affect in the afternoon. As hypothesized, dyadic sexual activity and greater than usual sexual satisfaction predicted increased next-day positive affect after controlling for past-day positive affect. In contrast, and partially supporting hypotheses, sexual satisfaction, but not activity alone, predicted lowered next-day negative affect after controlling for past-day negative affect. At the between person level, greater sexual satisfaction (but not overall frequency of dyadic sexual activity) was associated with greater positive and lower negative affect on average after controlling for several covariates. Findings indicate that satisfying dyadic sexual encounters lead to relatively long-lasting positive affect changes in women who have experienced sexual assault.

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.

Patterns and predictors of alcohol misuse trajectories from adolescence through early midlife

We took a multilevel developmental contextual approach and characterized trajectories of alcohol misuse from adolescence through early midlife, examined genetic and environmental contributions to individual differences in those trajectories, and identified adolescent and young adult factors associated with change in alcohol misuse. Data were from two longitudinal population-based studies. FinnTwin16 is a study of Finnish twins assessed at 16, 17, 18, 25, and 35 years (N = 5659; 52% female; 32% monozygotic). The National Longitudinal Study of Adolescent to Adult Health (Add Health) is a study of adolescents from the United States, who were assessed at five time points from 1994 to 2018 (N = 18026; 50% female; 64% White, 21% Black, 4% Native American, 7% Asian, 9% Other race/ethnicity). Alcohol misuse was measured as frequency of intoxication in FinnTwin16 and frequency of binge drinking in Add Health. In both samples, trajectories of alcohol misuse were best described by a quadratic growth curve: Alcohol misuse increased across adolescence, peaked in young adulthood, and declined into early midlife. Individual differences in these trajectories were primarily explained by environmental factors. Several adolescent and young adult correlates were related to the course of alcohol misuse, including other substance use, physical and mental health, and parenthood.

Associations between alcohol use disorder polygenic score and remission in participants from high-risk families and the Indiana Biobank

BACKGROUND

In the United States, ~50% of individuals who meet criteria for alcohol use disorder (AUD) during their lifetimes do not remit. We previously reported that a polygenic score for AUD (PGSAUD ) was positively associated with AUD severity as measured by DSM-5 lifetime criterion count, and AUD severity was negatively associated with remission. Thus, we hypothesized that PGSAUD would be negatively associated with remission.

METHODS

Individuals of European (EA) and African ancestry (AA) from the Collaborative Study on the Genetics of Alcoholism (COGA) who met lifetime criteria for AUD, and two EA cohorts ascertained for studies of liver diseases and substance use disorders from the Indiana Biobank were included. In COGA, 12-month remission was defined as any period of ≥12 consecutive months without meeting AUD criteria except craving and was further categorized as abstinent and non-abstinent. In the Indiana Biobank, remission was defined based on ICD codes and could not be further distinguished as abstinent or non-abstinent. Sex and age were included as covariates. COGA analyses included additional adjustment for AUD severity, family history of remission, and AUD treatment history.

RESULTS

In COGA EA, PGSAUD was negatively associated with 12-month and non-abstinent remission (p ≤ 0.013, βs between -0.15 and -0.10) after adjusting for all covariates. In contrast to the COGA findings, PGSAUD was positively associated with remission (p = 0.004, β = 0.28) in the Indiana Biobank liver diseases cohort but not in the Indiana Biobank substance use disorder cohort (p = 0.17, β = 0.15).

CONCLUSIONS

PGSAUD was negatively associated with 12-month and non-abstinent remission in COGA EA, independent of behavioral measures of AUD severity and family history of remission. The discrepant results in COGA and the Indiana Biobank could reflect different ascertainment strategies: the Indiana Biobank participants were older and had higher rates of liver disease, suggesting that these individuals remitted due to alcohol-related health conditions that manifested in later life.

Parental Divorce and Trajectories of Alcohol Consumption in Men: A Genetically Informative Perspective

OBJECTIVE

Much of what is known about parental divorce and adult alcohol outcomes comes from cross-sectional comparisons of those who did and did not experience parental divorce. In contrast, far less is known about whether and how parental divorce is associated with alcohol consumption trajectories. We used a longitudinal perspective to investigate the associations between parental divorce and men's alcohol consumption trajectories as well as a genetically informative approach to evaluate whether the pattern of genetic and environmental influences on these trajectories differed for men who did and did not experience parental divorce.

METHOD

The sample included 1,614 adult men from a population-based twin registry in Virginia. Measures of parental divorce (before age 16) and alcohol consumption (between ages 10 and 40) came from interviews and life history calendars. Data were analyzed with growth curve and longitudinal biometric variance component models.

RESULTS

In total, 11% of the sample experienced parental divorce. Parental divorce was associated with higher alcohol consumption intercepts that were sustained over time but was not associated with the linear slope or quadratic curvature of men's alcohol consumption trajectories. Longitudinal biometric variance components modeling indicated that genetic influences on alcohol consumption were higher in adolescence and young adulthood among those who experienced parental divorce compared with those who did not.

CONCLUSIONS

Parental divorce is associated with the shape and relative influence of genetic and environmental factors on men's alcohol consumption trajectories from adolescence through adulthood.

Trends in alcohol-related liver disease mortality in Australia: An age-period-cohort perspective

BACKGROUND AND AIMS

There have been few systematic attempts to examine how alcohol-related mortality has changed in Australia, and no studies that have explored cohort effects in alcohol-related mortality. This study uses more than 50 years of data to measure age, period and cohort trends in alcohol-related liver disease (ALD) mortality.

DESIGN, SETTING AND CASES

This was a retrospective age-period-cohort analysis of total Australian ALD mortality data from 1968 to 2020 in Australia. There was a total of 35 822 deaths-27 208 men (76%) and 8614 women (24%).

MEASUREMENTS

Deaths from ALD were grouped into 5-year age groups and periods (e.g. deaths for 20-24-year-olds between 1968 and 1972 were combined).

FINDINGS

ALD mortality peaked in the late 1970s and early 1980s for both men and women. In age-period-cohort models, mortality was highest for cohorts born 1915-30. For example, men born between 1923 and 1927 had a relative risk of 1.58 [95% confidence interval (CI) = 1.52, 1.64] compared with men born between 1948 and 1952. For women, there was an increase in risk for cohorts born in the 1960s [e.g. the 1963-67 cohort had a relative risk (RR) of 1.16 (95% CI = 1.07, 1.25) compared with women born in 1948-52]. For men, there was a broad decline in mortality over time [e.g. in 2020, the RR was 0.87 (95% CI = 0.82, 0.92) compared with the reference year of 2000]. For women, mortality declined until 2000 and has been stable since.

CONCLUSIONS

Alcohol-related liver disease mortality has declined across the Australian population since the 1970s and 1980s partly due to cohort-specific shifts as the highest-risk birth cohorts age. For women, this decline had stalled by the year 2000, and cohorts of women born during the 1960s were at higher risk than earlier cohorts, suggesting the need for thoughtful interventions as this population enters its highest-risk years for ALD mortality.

The role of alcohol in the lives of midlife women living on the Northern Beaches of Sydney, Australia

Background

In Australia, midlife women are experiencing increasing levels of risky drinking behaviours and alcohol-related harms. This is despite the general population trend of decreasing alcohol consumption overall. In light of these diverging trends, this research explores the role of alcohol in the lives of midlife women from their own perspective.

Methods

Six semi-structured focus groups were conducted with 47 women aged 35-59 years of age. Residents from the Northern Beaches of Sydney, Australia were recruited, as this group of women appear to be experiencing heightened alcohol-related harms, with an alcohol-related hospitalisation rate 40 % higher than the NSW state average in 2017-18.

Results

Midlife women described the practical utility of drinking as a habit to relieve stress and escape trauma, as well as an effective method for creating and strengthening social connections within the parenthood life stage. Participants also described the act of moderation as a potent trigger for peer pressure and discussed the individual's tendency to prioritise the short term relieving effects of drinking, despite awareness of the long term health risks.

Conclusion

Findings around the pro-social role of alcohol as a woman and a parent should be explicitly considered when designing 'swap it' population health messages. Furthermore, the marked social penalty of moderation and tendency to discount long term health risks should also be factored into health promotion messages which seek to utilise moderation as a strategy to reduce alcohol-related harm for midlife women.

The contribution of health behaviour to socioeconomic inequalities in alcohol harm: Analysis of the UK biobank, a large cohort study with linked health outcomes

This is the first study to use the UK Biobank database to: 1) test whether participants of a low socioeconomic position (SEP) are less likely to drink, but more likely to suffer alcohol-related harm, and 2) test the contribution of behavioural factors. The database contains health-related information from 500,000 UK residents that were recruited aged 40-69 between 2006 and 2010. Our analysis focuses on participants resident in England (86% of the total sample). We obtained baseline demographics, survey data regarding alcohol consumption and other behaviours, and linked death and hospital-admission records. The primary outcome was time from study entry to experiencing an alcohol-attributable event (hospital admission or death). The relationship between alcohol-attributable harm and five measures of SEP (area-level deprivation, housing tenure, employment status, household income and qualifications) was investigated using time-to-event analysis. Average weekly alcohol consumption, other drinking behaviours (drinking history and beverage preference), and lifestyle factors (BMI and smoking status) were added incrementally as covariates in nested regression models to investigate whether they could explain the relationship between harm and SEP. 432,722 participants (197,449 men and 235,273 women) were included in the analysis with 3,496,431 person-years of follow-up. Those of a low SEP were most likely to be never/former drinkers or high-risk drinkers. However, alcohol consumption could not explain experiences of alcohol-attributable harm between SEP groups (Hazard Ratio (HR) 1.48; 95% Confidence Interval 1.45-1.51, after adjusting for alcohol consumption). Drinking history, drinking mostly spirits, an unhealthy Body Mass Index and smoking all increased the risk of alcohol-attributable harm. However, these factors only partially explain SEP differences in alcohol harm as the HR for the most deprived vs the least deprived was still 1.28 after adjustment. This suggests that improving wider health behaviour of the most deprived could reduce alcohol-related inequalities. However, a substantial proportion of the variance in alcohol harm remains unexplained.

Age- and Sex-Varying Associations Between Depressive Symptoms and Substance Use from Modal Ages 35 to 55 in a National Sample of U.S. Adults

It is important to examine normative age-related change in substance use risk factors across the lifespan, with research focusing on middle adulthood particularly needed. The current study examined time-varying associations between depressive symptoms and alcohol, cigarette, and marijuana use from modal ages 35 to 55 in a national sample of US adults, overall and by sex. Data were obtained from 11,147 individuals in the longitudinal Monitoring the Future study. Participants were in 12th grade (modal age 18) in 1976-1982 and (for the data reported in this study) were surveyed again at modal ages 35 (in 1993-1999), 40, 45, 50, and 55 (in 2013-2019). Weighted time-varying effect modeling was used to examine age-related change in associations among depressive symptoms, any and heavy use of cigarettes, alcohol, and marijuana. Across midlife, greater depressive symptoms were associated with decreased odds of any alcohol use during the 40 s and 50 s, but with increased odds of binge drinking from ages 35-40, and-at most ages-any and pack + cigarette use and any and frequent marijuana use. The association between depressive symptoms and substance use was generally similar for men and women. Results highlight the increased risk for binge drinking, smoking, and marijuana with higher levels of depressive symptoms and underscore the importance of screening and interventions for depressive symptoms and substance use in midlife.

Predictors of beverage-specific, alcohol consumption trajectories: A Swedish population-based cohort study

Aim: The aim of the study was to examine whether changes in alcohol consumption over time differ according to beverage types, and to what extent socioeconomic, lifestyle and health-related factors predict beverage-specific trajectories in Sweden. Study design: We included participants from the Stockholm Public Health Cohort who were surveyed repeatedly in 2002, 2010 and 2014. Alcohol consumption trajectories were constructed for 13,152 individuals with valid information on amount and frequency of drinking. Preferred beverage types (i.e., beer, wine or spirits) were defined based on the most consumed beverages. Multinomial logistic regression was used to quantify individual predictors of different trajectories, overall and by beverage type. Results: Overall 56.9% of respondents were women, the mean age was 49.2 years, SD (13.1). Wine was cited as the preferred beverage for 72.4% of participants, and stable moderate drinking was the most common trajectory regardless of beverage type (68.2%, 54.9% and 54.2% in individuals with wine, beer and spirits as preferred beverages, respectively). Associations between drinking trajectories and baseline lifestyle factors did not differ by beverage type. Lower socioeconomic position (SEP) was associated with unstable moderate wine drinking (for unskilled manual SEP: adjusted odds ratio [aOR] 1.54, 95% confidence interval [CI] 1.23, 1.93), unstable heavy beer drinking (for skilled manual SEP: aOR 1.99, 95% CI 1.14, 3.52; and unskilled manual SEP: aOR 1.72, 95% CI 1.05, 2.82), and former beer drinking trajectory (for skilled manual SEP: aOR 1.81; 95% CI 1.21, 2.72; and unskilled manual SEP: aOR 1.66; 95% CI 1.17, 2.37). Conclusion: Lower SEP was associated with unstable heavy drinking of beer, former beer drinking, and unstable moderate wine drinking trajectories indicating that targeted alcohol prevention programmes need to focus on these groups.

Through the wine glass: How biographical midlife transitions and women's affective interpretations interact with alcohol consumption

BACKGROUND

Women during midlife are consuming larger quantities of alcohol than any other age group of women and any other generation of midlife women previously. This is concerning given alcohol related-health risks coalesce with age-related health risks for women, in particular, breast cancer.

METHODS

In-depth interviews with 50 Australian midlife women (aged 45-64) from different social classes explored women's personal accounts of midlife transitions and their descriptions of the role of alcohol in navigating these life experiences; both daily occurrences as well as significant moments in the life course.

RESULTS

Our findings point to the complex, confusing and co-existing biographical transitions women experience during midlife (generational, embodied/physiological and material changes) that sharpen a role for alcohol in women's lives and are nuanced by social class (volumes of social, economic and cultural capital). We pay close attention to women's affective interpretations of these transitions and ways alcohol is used to feel robust in navigating daily life or easing their prospective futures. Critically, for women living with limited access to capital, and who could not 'measure up' to social ideals by comparison with the achievements and trajectories of other midlife women, alcohol reconciled their disappointment. Our exploration shows how the social class conditions that shape how women make sense of their transitions through midlife might be differently shaped to enable different options forreducing drinking.

CONCLUSIONS

Policy must address the social and emotional concerns women experience through midlife transitions that give alcohol a worthwhile place in their lives. A first step might be responding to the absence of community and leisure spaces for midlife women especially those that do not integrate alcohol, with benefits including addressing loneliness, isolation and feeling invisible, and enabling positive constructions of midlife identities. Structural barriers to participation and feelings of worth must be removed for women who lack social, cultural and economic resources.

Culturally Adapting Evidence on Dementia Prevention for Ethnically Diverse Communities: Lessons Learnt from co-design

OBJECTIVES

40% of dementia cases can be prevented by addressing 12 lifestyle factors. These risk factors have increased presence in ethnic minorities, yet dementia prevention messages have not reached these communities. This article investigates the experience of co-designing a dementia prevention animated film with 9 ethnic groups in Australia.

METHODS

Evidence-based recommendations were adapted through an iterative process involving workshops with a stakeholder advisory committee and nine focus groups with 104 participants from the Arabic-, Hindi-, Tamil-, Cantonese-, Mandarin-, Greek-, Italian-, Spanish-, and Vietnamese-speaking communities. Data were analyzed using the Normalization Process Theory.

RESULTS

Cultural adaptation involves consideration of the mode of delivery, imagery and tone of the resource being developed; ensuring cultural adequacy; anticipating the need of the end-users; and managing linguistic challenges associated with working across multiple languages.

CONCLUSIONS

Learnings from this co-design process offer valuable insights for researchers and program developers who work with ethnic minority groups.

CLINICAL IMPLICATIONS

• Adaptation across cultures and languages is a negotiation not a consensus building exercise• Linguistic adaptation requires consideration of the education levels, and linguistic and intergenerational preferences of community members• Co-designing across multiple languages and cultures risks "flattening out" key aspects of cultural specificity.

The impact of age on olfactory alcohol cue-reactivity: A functional magnetic resonance imaging study in adolescent and adult male drinkers

BACKGROUND

Adolescence is marked not only by rapid surges in the prevalence of alcohol use disorders (AUDs) but also by remarkable recovery rates, as most adolescent-onset AUDs naturally resolve over time. Little is known about the differential vulnerability of adolescents and adults. Therefore, this study aimed to unravel the moderating role of age by comparing neural alcohol cue-reactivity, an important AUD biomarker, between low-to-high beer-drinking adolescent (n = 50, 16 to 18 years), and adult (n = 51, 30 to 35 years) males matched on drinking severity.

METHODS

Associations between beer odor-induced brain activity and AUD diagnosis, severity of alcohol use-related problems, recent alcohol use, binge-drinking frequency, and task-induced craving were investigated across and between age groups in regions of interest thought to be central in alcohol cue-reactivity: the medial prefrontal cortex, anterior cingulate cortex, and striatal subregions (nucleus accumbens and caudate putamen). These analyses were complemented by exploratory whole-brain analyses.

RESULTS

Pre-task beer craving increased pre-to-post task in adolescents only. Individual differences in alcohol use, binge drinking, and craving did not relate to beer odor-induced activity. Although region-of-interest analyses did not reach significance, whole-brain analyses showed that adolescents with AUD, compared with adolescents without AUD and adults with AUD, had higher beer odor-induced activity in a large mesocorticolimbic cluster encompassing the right caudate, nucleus accumbens, orbitofrontal cortex, and the olfactory sulcus. Activity in the right caudate and putamen was positively associated with the severity of alcohol use-related problems in adolescents but negatively associated in adults.

CONCLUSION

These findings suggest a differential role of alcohol cue-reactivity in adolescents compared with adults with AUD and highlight the need for further studies investigating the role of age in the fundamental processes underlying the development of and recovery from of AUD.

Changes in Alcohol Consumption and Risk of Dementia in a Nationwide Cohort in South Korea

IMPORTANCE

The impact of serial changes in alcohol consumption on dementia risk has rarely been investigated to date.

OBJECTIVE

To investigate the association of comprehensive patterns of changes in alcohol consumption with the incidence of all-cause dementia, Alzheimer disease (AD), and vascular dementia (VaD).

DESIGN, SETTING, AND PARTICIPANTS

This is a retrospective cohort study. Data were obtained from the Korean National Health Insurance Service database. Adults aged 40 years and older underwent 2 health examinations in 2009 and 2011. The cohort was assessed until December 31, 2018, and statistical analysis was performed in December 2021.

EXPOSURES

Alcohol consumption level was categorized into none (0 g per day), mild (<15 g per day), moderate (15-29.9 g per day), and heavy (≥30 g per day) drinking. On the basis of changes in alcohol consumption level from 2009 to 2011, participants were categorized into the following groups: nondrinker, quitter, reducer, sustainer, and increaser.

MAIN OUTCOMES AND MEASURES

The primary outcome was newly diagnosed AD, VaD, or other dementia.

RESULTS

Among 3 933 382 participants (mean [SD] age, 55.0 [9.6] years; 2 037 948 men [51.8%]), during a mean (SD) follow-up of 6.3 (0.7) years, there were 100 282 cases of all-cause dementia, 79 982 cases of AD, and 11 085 cases of VaD. Compared with sustained nondrinking, sustained mild (adjusted hazard ratio [aHR], 0.79; 95% CI, 0.77-0.81) and moderate (aHR, 0.83; 95% CI, 0.79-0.88) drinking were associated with a decreased risk of all-cause dementia, whereas sustained heavy drinking was associated with an increased risk of all-cause dementia (aHR, 1.08; 95% CI, 1.03-1.12). Compared with sustained levels of drinking, reducing alcohol consumption from a heavy to a moderate level (aHR, 0.92; 95% CI, 0.86-0.99) and the initiation of mild alcohol consumption (aHR, 0.93; 95% CI, 0.90-0.96) were associated with a decreased risk of all-cause dementia. Increasers and quitters exhibited an increased risk of all-cause dementia compared with sustainers. The trends in AD and VaD remained consistent.

CONCLUSIONS AND RELEVANCE

In this cohort study of a Korean population, decreased risk of dementia was associated with maintaining mild to moderate alcohol consumption, reducing alcohol consumption from a heavy to a moderate level, and the initiation of mild alcohol consumption, suggesting that the threshold of alcohol consumption for dementia risk reduction is low.

Exploring sex-specific time trends in drinking patterns in the Greenlandic population from 1993 to 2014 - a large Arctic Indigenous population

A drinking pattern characterised by occasional excessive drinking is a key challenge for public health in Greenland. The objective was to examine sex-specific time trends in drinking patterns among Greenland Inuit. Cross-sectional and cohort data from geographically representative health surveys in 1993, 2005–2010 and 2014 were included (n = 4,938). Drinking patterns were defined as abstainer, non-problematic and occasional binge drinking. Patterns were analysed by sex-specific crude proportions and logistical analyses according to age, birth cohort and calendar time, accounting for region and settlement type. More than half of the men and one-third of the women had an occasional binge drinking pattern, while 22.6% of females and 15.1% of men were abstainers. Abstention increased with increasing age, while occasional binge drinking decreased among men. Younger male birth cohorts were less likely to have an occasional binge drinking pattern, while the youngest females had the highest odds ratio. A drinking pattern characterised by occasional excessive use remains a key challenge for public health in Greenland with age as a strong predictor. A high prevalence of abstainers co-exists with a high prevalence of occasional binge drinking. The increased odds ratio for occasional binge drinking among younger females should be addressed further.

Three-year trajectories of alcohol use among at-risk and among low-risk drinkers in a general population sample of adults: A latent class growth analysis of a brief intervention trial

Background

Few studies have assessed trajectories of alcohol use in the general population, and even fewer studies have assessed the impact of brief intervention on the trajectories. Especially for low-risk drinkers, it is unclear what trajectories occur, whether they benefit from intervention, and if so, when and how long. The aims were first, to identify alcohol use trajectories among at-risk and among low-risk drinkers, second, to explore potential effects of brief alcohol intervention and, third, to identify predictors of trajectories.

Methods

Adults aged 18-64 years were screened for alcohol use at a municipal registration office. Those with alcohol use in the past 12 months (N = 1646; participation rate: 67%) were randomized to assessment plus computer-generated individualized feedback letters or assessment only. Outcome was drinks/week assessed at months 3, 6, 12, and 36. Alcohol risk group (at-risk/low-risk) was determined using the Alcohol Use Disorders Identification Test-Consumption. Latent class growth models were estimated to identify alcohol use trajectories among each alcohol risk group. Sex, age, school education, employment status, self-reported health, and smoking status were tested as predictors.

Results

For at-risk drinkers, a light-stable class (46%), a medium-stable class (46%), and a high-decreasing class (8%) emerged. The light-stable class tended to benefit from intervention after 3 years (Incidence Rate Ratio, IRR=1.96; 95% Confidence Interval, CI: 1.14-3.37). Male sex, higher age, more years of school, and current smoking decreased the probability of belonging to the light-stable class (p-values<0.05). For low-risk drinkers, a very light-slightly increasing class (72%) and a light-increasing class (28%) emerged. The very light-slightly increasing class tended to benefit from intervention after 6 months (IRR=1.60; 95% CI: 1.12-2.28). Male sex and more years of school increased the probability of belonging to the light-increasing class (p-value < 0.05).

Conclusion

Most at-risk drinkers did not change, whereas the majority of low-risk drinkers increased alcohol use. There may be effects of alcohol feedback, with greater long-term benefits among persons with low drinking amounts. Our findings may help to identify refinements in the development of individualized interventions to reduce alcohol use.

Age at first alcohol-related hospital separation or emergency department presentation and rate of re-admission: A retrospective data linkage cohort of young Australians

INTRODUCTION

Alcohol is a leading risk factor for death and disease in young people. We compare age-specific characteristics of young people who experience their first ('index') alcohol-related hospitalisation or emergency department (ED) presentation, and whether age at index predicts 12-month rates of readmission.

METHODS

We used a retrospective linked-data cohort of 10,300 people aged 12-20 years with an index alcohol-related hospital and/or ED record in New South Wales, Australia from 2005 to 2013. Age group (early adolescent [12-14 years], late adolescent [15-17 years], young adult [18-20 years]) and diagnosis fields were used in logistic regression analyses and to calculate incidence rates with adjustment for year of index event, sex, socioeconomic disadvantage and residence remoteness.

RESULTS

People who experienced their index event in early adolescence (adjusted relative risk ratio [ARRR] 0.45 [95% confidence interval 0.39, 0.52]) or late adolescence (ARRR 0.82 [0.74, 0.90]) were less likely to be male compared to young adults. Early adolescents (ARRR 0.60 [0.51, 0.70]) and late adolescents (ARRR 0.84 [0.76, 0.93]) were less likely to have a hospitalisation index event. Early adolescents (adjusted incidence rate ratio 1.40 [1.15, 1.71]) and late adolescents (adjusted incidence rate ratio 1.16 [1.01, 1.34]) were more likely than young adults to have a subsequent 12-month non-poisoning injury ED presentation.

DISCUSSION AND CONCLUSIONS

We identified preventable hospital events in young people who have previously experienced an alcohol-related ED presentation or hospitalisation, with age-specific characteristics and outcomes that can be used to inform future health policy and service planning.

Healthy lifestyle over the life course: Population trends and individual changes over 30 years of the Doetinchem Cohort Study

For five health-related lifestyle factors (physical activity, weight, smoking, sleep, and alcohol consumption) we describe both population trends and individual changes over a period of 30 years in the same adult population. Dichotomous indicators (healthy/unhealthy) of lifestyle were analyzed for 3,139 participants measured every 5 years in the Doetinchem Cohort Study (1987-2017). Population trends over 30 years in physical inactivity and "unhealthy" alcohol consumption were flat (i.e., stable); overweight and unhealthy sleep prevalence increased; smoking prevalence decreased. The proportion of the population being healthy on all five lifestyle factors declined from 17% in the round 1 to 10.8% in round 6. Underlying these trends a dynamic pattern of changes at the individual level was seen: sleep duration and physical activity level changed in almost half of the individuals; Body Mass Index (BMI) and alcohol consumption in one-third; smoking in one-fourth. Population trends don't give insight into change at the individual level. In order to be able to gauge the potential for change of health-related lifestyle, it is important to take changes at the individual level into account.

A longitudinal evaluation of alcohol intake throughout adulthood and colorectal cancer risk

BACKGROUND

Alcohol intake is an established risk factor for colorectal cancer (CRC); however, there is limited knowledge on whether changing alcohol drinking habits during adulthood modifies CRC risk.

OBJECTIVE

Leveraging longitudinal exposure assessments on alcohol intake at different ages, we examined the relationship between change in alcohol intake and subsequent CRC risk.

METHODS

Within the European Prospective Investigation into Cancer and Nutrition, changes in alcohol intake comparing follow-up with baseline assessments were investigated in relation to CRC risk. The analysis included 191,180, participants and 1530 incident CRC cases, with exclusion of the first three years of follow-up to minimize reverse causation. Trajectory profiles of alcohol intake, assessed at ages 20, 30, 40, 50 years, at baseline and during follow-up, were estimated using latent class mixed models and related to CRC risk, including 407,605 participants and 5,008 incident CRC cases.

RESULTS

Mean age at baseline was 50.2 years and the follow-up assessment occurred on average 7.1 years later. Compared to stable intake, a 12 g/day increase in alcohol intake during follow-up was positively associated with CRC risk (HR = 1.15, 95%CI 1.04, 1.25), while a 12 g/day reduction was inversely associated with CRC risk (HR = 0.86, 95%CI 0.78, 0.95). Trajectory analysis showed that compared to low alcohol intake, men who increased their alcohol intake from early- to mid- and late-adulthood by up to 30 g/day on average had significantly increased CRC risk (HR = 1.24; 95%CI 1.08, 1.42), while no associations were observed in women. Results were consistent by anatomical subsite.

CONCLUSIONS

Increasing alcohol intake during mid-to-late adulthood raised CRC risk, while reduction lowered risk.

Risk Factors for Problematic Drinking in One's Thirties and Forties: A Longitudinal Analysis of the 1970 British Cohort Study

Alcohol drinking and risk factors for problematic drinking may vary across a lifespan. The objective of this study was to identify risk factors for problematic drinking in men and women in their thirties and forties. Alcohol drinking and potential risk factors for problematic drinking were assessed at ages 30, 34, 42, and 46 in the 1970 British Cohort Study. Multilevel models included 10,079 observations in 3880 men and 9241 observations in 3716 women. In men, formerly smoking, currently smoking, having a degree, having malaise, and having a mother who drank while pregnant were independently associated with increased risk of problematic drinking. In women, formerly smoking, currently smoking, being physically active in one's leisure time, having a degree, having a managerial or professional occupation, having malaise, and having a mother who drank while pregnant were independently associated with increased risk of problematic drinking. In men and women, cohabiting as a couple was associated with decreased risk of problematic drinking. This study suggests that several risk factors may be associated with problematic drinking in men and women in their thirties and forties. Policy makers should consider the role of modifiable risk factors in the prevention of problematic drinking.

Quality standards for the management of non-alcoholic fatty liver disease (NAFLD): consensus recommendations from the British Association for the Study of the Liver and British Society of Gastroenterology NAFLD Special Interest Group

Non-alcoholic fatty liver disease (NAFLD) is common, affecting approximately 25% of the general population. The evidence base for the investigation and management of NAFLD is large and growing, but there is currently little practical guidance to support development of services and delivery of care. To address this, we produced a series of evidence-based quality standard recommendations for the management of NAFLD, with the aim of improving patient care. A multidisciplinary group of experts from the British Association for the Study of the Liver and British Society of Gastroenterology NAFLD Special Interest Group produced the recommendations, which cover: management of people with, or at risk of, NAFLD before the gastroenterology or liver clinic; assessment and investigations in secondary care; and management in secondary care. The quality of evidence for each recommendation was evaluated by the Grading of Recommendation Assessment, Development and Evaluation tool. An anonymous modified Delphi voting process was conducted individually by each member of the group to assess the level of agreement with each statement. Statements were included when agreement was 80% or greater. From the final list of statements, a smaller number of auditable key performance indicators were selected to allow services to benchmark their practice. It is hoped that services will review their practice against our recommendations and key performance indicators and institute service development where needed to improve the care of patients with NAFLD.

Alcohol consumption trajectories over the Australian life course

BACKGROUND AND AIMS

Alcohol consumption changes markedly over the life course, with important implications for health and social development. Assessment of these patterns often relies on cross-sectional data, which cannot fully capture how individuals' drinking changes as they age. This study used data from 18 waves of a general population panel survey to measure drinking trajectories over the life course in Australia.

DESIGN AND SETTING

Longitudinal survey data from the Household, Income and Labour Dynamics in Australia (HILDA) survey between 2001 and 2018.

PARTICIPANTS

A total of 20 593 individuals ages 15 or above in two samples assessing quantity-frequency (n = 20 569, 52.0% female) and risky single occasion drinking (RSOD), respectively, (n = 17 340, 52.5% female), interviewed as part of HILDA.

MEASUREMENTS

Usual quantity of alcohol consumed per drinking occasion; frequency of drinking occasions per week; average daily consumption, calculated by combining reported usual quantity and frequency; and average reported frequency of RSOD per week.

FINDINGS

Multilevel, mixed effects models run with fractional polynomial terms found similar male and female alcohol consumption trajectories for quantity-frequency and RSOD measures. Usual quantity of alcohol consumed per drinking occasion (5.4 drinks for men, 3.8 for women) and RSOD frequency (0.56 occasions/week for men, 0.38 for women) peaked in young adulthood, whereas frequency of drinking occasions (2.5 occasions/week for men, 1.7 for women) peaked in middle age. Middle-age drinkers had the highest average daily consumption of alcohol (1.4 drinks/day for 54-year-old men, 0.6 drinks for 57-year-old women) and engaged in RSOD slightly less than young adults.

CONCLUSIONS

Alcohol consumption in Australia appears to vary substantially over the life course, with usual quantity per drinking occasion and frequency of risky single occasion drinking peaking during early adulthood and average daily consumption and frequency of consumption peaking in middle age.

Trajectories of alcohol consumption in relation to all-cause mortality in patients with cardiovascular disease: a 35-year prospective cohort study

BACKGROUND AND AIMS

Research into alcohol consumption and cardiovascular disease (CVD) patients' prognosis has largely ignored the longitudinal dynamics in drinking behaviour. This study measured the association between alcohol consumption trajectories and mortality risk in CVD patients.

DESIGN

Prospective cohort study.

SETTING

UK-based Whitehall II Study.

PARTICIPANTS

A total of 1306 participants with incident non-fatal CVD (coronary heart disease/stroke) events.

MEASUREMENTS

Up to eight repeated measures of alcohol intake were available for each patient from the most recent assessment phase pre-incident CVD and all subsequent phases post-incident CVD, spanning up to three decades. Six trajectory groups of alcohol consumption were identified using group-based trajectory modelling and related to the risk of all-cause mortality, adjusting for demographics and changes in life-style and health status.

FINDINGS

Three hundred and eighty deaths were recorded during a median follow-up of 5 years after patients' last alcohol assessment. Compared with patients who consistently drank moderately (≤ 14 units/week), former drinkers had a greater risk of mortality (hazard ratio = 1.74, 95% confidence interval = 1.19-2.54) after adjustment for covariates. There was no significantly increased risk of mortality in long-term abstainers, reduced moderate drinkers, stable or unstable heavy drinkers. Cross-sectional analyses based only on drinking information at patients' last assessment found no significant differences in mortality risk for abstainers, former or heavy drinkers versus moderate drinkers.

CONCLUSIONS

Cardiovascular disease patients who consistently drink ≤ 14 units/week appear to have a similar risk of mortality to those who are long-term abstainers, which does not support a protective effect of moderate drinking on total mortality. Cardiovascular disease patients who stop drinking appear to have increased mortality risk compared with continuous moderate drinkers, but this may be linked to poor self-rated health before cardiovascular disease onset.

Decline in attention-deficit hyperactivity disorder traits over the life course in the general population: trajectories across five population birth cohorts spanning ages 3 to 45 years

BACKGROUND

Trajectories of attention-deficit hyperactivity disorder (ADHD) traits spanning early childhood to mid-life have not been described in general populations across different geographical contexts. Population trajectories are crucial to better understanding typical developmental patterns.

METHODS

We combined repeated assessments of ADHD traits from five population-based cohorts, spanning ages 3 to 45 years. We used two measures: (i) the Strengths and Difficulties Questionnaire (SDQ) hyperactive-inattentive subscale (175 831 observations, 29 519 individuals); and (ii) scores from DSM-referenced scales (118 144 observations, 28 685 individuals). Multilevel linear spline models allowed for non-linear change over time and differences between cohorts and raters (parent/teacher/self).

RESULTS

Patterns of age-related change differed by measure, cohort and country: overall, SDQ scores decreased with age, most rapidly declining before age 8 years (-0.157, 95% CI: -0.170, -0.144 per year). The pattern was generally consistent using DSM scores, although with greater between-cohort variation. DSM scores decreased most rapidly between ages 14 and 17 years (-1.32%, 95% CI: -1.471, -1.170 per year). Average scores were consistently lower for females than males (SDQ: -0.818, 95% CI: -0.856, -0.780; DSM: -4.934%, 95% CI: -5.378, -4.489). This sex difference decreased over age for both measures, due to an overall steeper decrease for males.

CONCLUSIONS

ADHD trait scores declined from childhood to mid-life, with marked variation between cohorts. Our results highlight the importance of taking a developmental perspective when considering typical population traits. When interpreting changes in clinical cohorts, it is important to consider the pattern of expected change within the general population, which is influenced by cultural context and measurement.

Psychological distress from early adulthood to early old age: evidence from the 1946, 1958 and 1970 British birth cohorts

BACKGROUND

Existing evidence on profiles of psychological distress across adulthood uses cross-sectional or longitudinal studies with short observation periods. The objective of this research was to study the profile of psychological distress within the same individuals from early adulthood to early old age across three British birth cohorts.

METHODS

We used data from three British birth cohorts: born in 1946 (n = 3093), 1958 (n = 13 250) and 1970 (n = 12 019). The profile of psychological distress - expressed both as probability of being a clinical case or a count of symptoms based on comparable items within and across cohorts - was modelled using the multilevel regression framework.

RESULTS

In both 1958 and 1970 cohorts, there was an initial drop in the probability of being a case between ages 23-26 and 33-34. Subsequently, the predicted probability of being a case increased from 12.5% at age 36 to 19.5% at age 53 in the 1946 cohort; from 8.0% at age 33 to 13.7% at age 42 in the 1958 cohort and from 15.7% at age 34 to 19.7% at age 42 in the 1970 cohort. In the 1946 cohort, there was a drop in the probability of caseness between ages 60-64 and 69 (19.5% v. 15.2%). Consistent results were obtained with the continuous version of the outcome.

CONCLUSIONS

Across three post-war British birth cohorts midlife appears to be a particularly vulnerable phase for experiencing psychological distress. Understanding the reasons for this will be important for the prevention and management of mental health problems.

Predictors and prevalence of hazardous alcohol use in middle-late to late adulthood in Europe

Objectives: Even low to moderate levels of alcohol consumption can have detrimental health consequences, especially in older adults (OA). Although many studies report an increase in the proportion of drinkers among OA, there are regional variations. Therefore, we examined alcohol consumption and the prevalence of hazardous alcohol use (HAU) among men and women aged 50+ years in four European regions and investigated predictors of HAU.Methods: We analyzed data of N = 35,042 participants of the European SHARE study. We investigated differences in alcohol consumption (units last week) according to gender, age and EU-region using ANOVAs. Furthermore, logistic regression models were used to examine the effect of income, education, marital status, history of a low-quality parent-child relationship and smoking on HAU, also stratified for gender and EU-region. HAU was operationalized as binge drinking or risky drinking (<12.5 units of 10 ml alcohol/week).Results: Overall, past week alcohol consumption was 5.0 units (±7.8), prevalence of HAU was 25.4% within our sample of European adults aged 50+ years. Male gender, younger age and living in Western Europe were linked to both higher alcohol consumption and higher risks of HAU. Income, education, smoking, a low-quality parent-child relationship, living in Northern and especially Eastern Europe were positively associated with HAU. Stratified analyses revealed differences by region and gender.Conclusions: HAU was highly prevalent within this European sample of OA. Alcohol consumption and determinants of HAU differed between EU-regions, hinting to a necessity of risk-stratified population-level strategies to prevent HAU and subsequent alcohol use disorders.

Dietary Intake of Adults Who Participate in CrossFit® Exercise Regimens

Background: The combination of high-intensity aerobic and high-load resistance training, as in CrossFit®, exerts similar or superior benefits to other exercise modalities. This study aimed to assess dietary habits and characterize the nutritional goals, exercise habits, and clinical health outcomes of individuals who participate in CrossFit®. Methods: Adults who are 19 y or older, with >6 mo of CrossFit® participation, completed an electronic survey and the dietary health questionnaire III. In separate models, multiple stepwise linear regressions were performed to detect the associations between (i) dietary intake, (ii) exercise habits, (iii) clinical measures, and a priori selected predictors (sex, weight status, age, and exercise frequency) in each case. Odds ratios were detected between nutritional and fitness goals, clinical outcomes, and predictors. Results: In total, 449 respondents completed both questionnaires. Of these, 443 respondents were used for relative macronutrients assessment due to not reporting body weight. Dietary intake was associated with sex, weight status, age, exercise frequency, and nutritional goals. Nutritional and fitness goals and clinical outcomes were associated with sex, weight status, age, and exercise frequency. Conclusion: Nutritional goals are underlying factors that affect eating behaviors in non-competitive CrossFit® participants. It is imperative to consider the sex, age, exercise habits, and nutritional goals of CrossFit® participants when investigating and prescribing dietary outcomes.

Mendelian Randomization With Repeated Measures of a Time-varying Exposure: An Application of Structural Mean Models

Mendelian randomization (MR) is often used to estimate effects of time-varying exposures on health outcomes using observational data. However, MR studies typically use a single measurement of exposure and apply conventional instrumental variable (IV) methods designed to handle time-fixed exposures. As such, MR effect estimates for time-varying exposures are often biased, and interpretations are unclear. We describe the instrumental conditions required for IV estimation with a time-varying exposure, and the additional conditions required to causally interpret MR estimates as a point effect, a period effect or a lifetime effect depending on whether researchers have measurements at a single or multiple time points. We propose methods to incorporate time-varying exposures in MR analyses based on g-estimation of structural mean models, and demonstrate its application by estimating the period effect of alcohol intake, high-density lipoprotein cholesterol and low-density lipoprotein cholesterol on intermediate coronary heart disease outcomes using data from the Framingham Heart Study. We use this data example to highlight the challenges of interpreting MR estimates as causal effects, and describe other extensions of structural mean models for more complex data scenarios.

Trajectories of alcohol consumption up to 30 years before and after the diagnosis of cardiovascular diseases: a longitudinal case-control study of 12 502 participants

BACKGROUND

To examine the longitudinal trajectories of alcohol consumption prior to and following the diagnosis of cardiovascular diseases (CVD).

METHODS

We conducted a case-control study of 2501 incident cases of angina, myocardial infarction or stroke and 10 001 matched controls without the condition. Repeated measures of alcohol were centred on the date of diagnosis, spanning up to 30 years before and after CVD onset. Mean trajectories of weekly consumption were estimated using growth curve models.

RESULTS

For trajectories prior to diagnosis, mean volume of alcohol consumed among male cases increased over time, peaking at around 8 years before diagnosis at 95 (95% CI 60 to 130) g/week and declining afterwards. Trajectories following diagnosis showed mean consumption in male cases dropped from 87 (95% CI 54 to 120) g/week to 74 (95% CI 45 to 102) g/week after the date of diagnosis and then slightly rose to 78 (95% CI 40 to 116) g/week at the subsequent 3.5 years, before gradually declining to 31 (95% CI 2 to 61) g/week at 30 years after diagnosis. Mean consumption among female cases remained stable prior to diagnosis (at about 30 g/week), fell marginally to 25 (95% CI 20 to 30) g/week after the date of diagnosis and kept decreasing afterwards. Similar trajectories were obtained in cases and controls.

CONCLUSIONS

This is the first attempt to show how patients with CVD change their drinking volume over such a wide time span. Future research needs to establish insight into drinking behaviour in other ways (such as frequency and context) and address the impact of changes in drinking on patients with CVD.

Alcohol drinking in one's thirties and forties is associated with body mass index in men, but not in women: A longitudinal analysis of the 1970 British Cohort Study

Our objective was to investigate longitudinal associations between alcohol drinking and body mass index (BMI). Alcohol drinking (exposure), BMI (outcome), smoking habit, occupation, longstanding illness, and leisure time physical activity (potential confounders) were assessed at ages 30, 34, 42, and 46 in the 1970 British Birth Cohort Study. Multilevel models were used to cope with the problem of correlated observations. There were 15,708 observations in 5931 men and 14,077 observations in 5656 women. Drinking was associated with BMI in men. According to the regression coefficients, BMI was expected to increase by 0.36 (95% confidence interval: 0.11, 0.60) kg/m² per year in men who drank once a week and by 0.40 (0.14, 0.15) kg/m² per year in men who drank most days. In ten years, BMI was expected to increase by 5.4 kg/m² in men who drank and by 2.9 kg/m² in men who drank and were physically active. Drinking was not associated with BMI in women. Rather, BMI was expected to increase by 0.25 (0.07, 0.43) kg/m² per year in women who were former smokers. In ten years, BMI was expected to increase by 4.3 kg/m² in women who were former smokers and by 0.8 kg/m² in women who were former smokers and who were physically active. Associations between drinking and BMI were similar after further adjustment for problematic drinking and diet. These longitudinal data suggest that drinking is associated with BMI in men and that drinking is not associated with BMI in women independent of other lifestyle risk factors.

The association between unemployment trajectories and alcohol consumption patterns. Evidence from a large prospective cohort in The Netherlands

Unemployment is expected to influence alcohol consumption, but studies show mixed results, partly because most studies concentrate on current employment status. However, unemployment could be particularly consequential if it is part of a trajectory of employment precariousness. Moreover, the association between unemployment and alcohol consumption may not be homogeneous across the population, but differ by subgroups (e.g. socioeconomic status). This study longitudinally analyses the association between different employment trajectories and alcohol consumption, and examines if the association is moderated by socioeconomic status (SES), partner status, age and gender. Four waves of data of the Lifelines Cohort study are used. Sample consists of individuals from 18-50 years old, active in the labor market (n = 104,766) from the northern provinces of the Netherlands. Employment trajectories are defined by employment status in each wave, duration of unemployment, and number of exposures to unemployment. Drinking patterns are divided into "abstainers", "moderate drinking" (<1.5 drinks/day), "heavy drinking" (≥1.5 drinks/day) and "binge drinking" (≥5 drinks/occasion; 4 for women). The associations are estimated with multinomial logistic regression models. Results show that recent, long-term unemployment (≥ 6 months) is associated with higher rates of heavy drinking (RRR = 1.26 [95 % CI 1.03-1.54]), whereas short-term unemployment does not show any association with the outcome. Being continuously unemployed throughout the observation period shows a strong association with binge drinking (RRR = 1.43 [95 % CI 1.06-1.93]), as well as reporting 2 or more long unemployment spells (RRR = 1.49 [95 % CI 1.21-1.83]). The group of abstainers (77.95 % women) have significantly lower SES, and poorer health than their peers. For some individuals, recent unemployment increases the likelihood for abstinence (RRR = 1.23 [95 % CI 1.00-1.51]). Evidence suggests that length of unemployment is key in order to grasp its effects in terms of changing drinking patterns.

Combining Longitudinal Data From Different Cohorts to Examine the Life-Course Trajectory

Longitudinal data are necessary to reveal changes within an individual as he or she ages. However, rarely will a single cohort study capture data throughout a person's entire life span. Here we describe in detail the steps needed to develop life-course trajectories from cohort studies that cover different and overlapping periods of life. Such independent studies are probably from heterogenous populations, which raises several challenges, including: 1) data harmonization (deriving new harmonized variables from differently measured variables by identifying common elements across all studies); 2) systematically missing data (variables not measured are missing for all participants in a cohort); and 3) model selection with differing age ranges and measurement schedules. We illustrate how to overcome these challenges using an example which examines the associations of parental education, sex, and race/ethnicity with children's weight trajectories. Data were obtained from 5 prospective cohort studies (carried out in Belarus and 4 regions of the United Kingdom) spanning data collected from birth to early adulthood during differing calendar periods (1936-1964, 1972-1979, 1990-2012, 1996-2016, and 2007-2015). Key strengths of our approach include modeling of trajectories over wide age ranges, sharing of information across studies, and direct comparison of the same parts of the life course in different geographical regions and time periods. We also introduce a novel approach of imputing individual-level covariates of a multilevel model with a nonlinear growth trajectory and interactions.

Improving and maintaining healthy lifestyles are associated with a lower risk of diabetes: A large cohort study

AIMS

It is well known that healthy lifestyles measured at one time-point are inversely associated with diabetes risk. The impact of transitions in combined lifestyles in real settings remains unknown.

MATERIALS AND METHODS

The trajectory patterns of combined lifestyles over three years were identified using group-based trajectory modeling in 26,647 adults in Japan. Two types of indices (not having the unhealthy lifestyle [easy goal] and having healthiest lifestyles [challenging goal]) were developed using five lifestyle factors: smoking, alcohol consumption, exercise, sleep duration, and body weight control. This index was calculated using the yearly total score (0-5; higher score indicated healthier lifestyles). Diabetes was defined by high plasma glucose level, high hemoglobin A1c level, and self-report.

RESULTS

Five trajectory patterns were identified for each index and it was shown that healthier patterns are associated with a lower risk of type 2 diabetes during 6.6 years of average follow-up. For example, with a challenging-goal, compared with a persistently very unhealthy pattern, the adjusted hazard ratios (95% confidence intervals) were 0.65 (0.59, 0.73), 0.50 (0.39, 0.64), 0.43 (0.38, 0.48), and 0.33 (0.27, 0.41) for 'persistently unhealthy', 'improved from unhealthy to moderately healthy', 'persistently moderately healthy', and 'persistently mostly healthy' patterns, respectively.

CONCLUSIONS

Our data reinforce the importance of improving and maintaining health-related lifestyles to prevent diabetes.

The longitudinal associations between trajectory of and quantity of alcohol consumption and subsequent changes in blood pressure levels among non-hypertensive adults

Given the dynamic characteristic of an individual's drinking behaviours, comprehensive consideration of alcohol consumption variation using repeated measures may improve insight into the nature of its association with blood pressure (BP) change. We examined the association between longitudinal alcohol consumption (trajectory and quantity) and changes in BP and pulse pressure (PP) among Korean aged ≥ 40 years living in rural areas. Totally, 1682 hypertension-free participants who completed all three health examinations (median, 5·3 years) were included. All three visits were used to determine the cumulative trajectory of and quantity of alcohol consumption and the latest two visits and the last visit were used for the recent trajectory and the most recent quantity of alcohol consumption, respectively. Changes in BP and PP from the baseline to the third visit were used as outcome. In men, ≥30 ml/d cumulative average alcohol consumption was associated with the greatest increase in systolic BP (SBP) in both baseline outcome-unadjusted (2·9 mmHg, P = 0·032) and -adjusted models (3·6 mmHg, P = 0·001), and the given association for the most recent alcohol consumption was observed in the baseline outcome-adjusted model (3·9 mmHg, P = 0·003). For PP, similar associations were observed only in the baseline outcome-adjusted model. No meaningful associations in diastolic BP in men and any BP or PP in women existed. The quantity of alcohol consumption rather than the trajectory may be significantly related to raised SBP, and a possible short-term influence of the most recent alcohol consumption may exist when baseline SBP is adjusted in men.

Bayesian modelling of population trends in alcohol consumption provides empirically based country estimates for South Africa

Background

Alcohol use has widespread effects on health and contributes to over 200 detrimental conditions. Although the pattern of heavy episodic drinking independently increases the risk for injuries and transmission of some infectious diseases, long-term average consumption is the fundamental predictor of risk for most conditions. Population surveys, which are the main source of data on alcohol exposure, suffer from bias and uncertainty. This article proposes a novel triangulation method to reduce bias by rescaling consumption estimates by sex and age to match country-level consumption from administrative data.

Methods

We used data from 17 population surveys to estimate age- and sex-specific trends in alcohol consumption in the adult population of South Africa between 1998 and 2016. Independently for each survey, we calculated sex- and age-specific estimates of the prevalence of drinkers and the distribution of individuals across consumption categories. We used these aggregated results, together with data on alcohol production, sales and import/export, as inputs of a Bayesian model and generated yearly estimates of the prevalence of drinkers in the population and the parameters that characterise the distribution of the average consumption among drinkers.

Results

Among males, the prevalence of drinkers decreased between 1998 and 2009, from 56.2% (95% CI 53.7%; 58.7%) to 50.6% (49.3%; 52.0%), and increased afterwards to 53.9% (51.5%; 56.2%) in 2016. The average consumption from 52.1 g/day (49.1; 55.6) in 1998 to 42.8 g/day (40.0; 45.7) in 2016. Among females the prevalence of current drinkers rose from 19.0% (17.2%; 20.8%) in 1998 to 20.0% (18.3%; 21.7%) in 2016 while average consumption decreased from 32.7 g/day (30.2; 35.0) to 26.4 g/day (23.8; 28.9).

Conclusions

The methodology provides a viable alternative to current approaches to reconcile survey estimates of individual alcohol consumption patterns with aggregate administrative data. It provides sex- and age-specific estimates of prevalence of drinkers and distribution of average daily consumption among drinkers in populations. Reliance on locally sourced data instead of global and regional trend estimates better reflects local nuances and is adaptable to the inclusion of additional data. This provides a powerful tool to monitor consumption, develop burden of disease estimates and inform and evaluate public health interventions.

Association between Lifetime Tobacco Use and Alcohol Consumption Trajectories and Cardiovascular and Chronic Respiratory Diseases among Older People

Background: We identify representative types of simultaneous tobacco use and alcohol consumption trajectories across the life course and estimate their association with cardiovascular and chronic respiratory diseases (CVDs and CRDs) among older people in Chile. Methods: We used data from a population-representative, face-to-face and longitudinal-retrospective survey focused on people aged 65–75 (N = 802). To reconstruct trajectory types, we employed weighted multichannel sequence analysis. Then, we estimated their associations with CVDs and CRDs through weighted logistic regression models. Results: Long-term exposure to tobacco use and alcohol consumption across life are associated with the highest CVD and CRD risks. Long-term nonsmokers and nondrinkers do not necessarily show the lowest CVDs and CRDs risks if these patterns are accompanied by health risk factors such as obesity or social disadvantages such as lower educational levels. Additionally, trajectories showing regular consumption in one domain but only in specific periods of life, whether early or late, while maintaining little or no consumption across life in the other domain, lead to lower CVDs or CRDs risks than trajectories indicating permanent consumption in both domains. Conclusions: A policy approach that considers CVDs and CRDs as conditions that strongly depend on previous individual experiences in diverse life domains can contribute to the improved design and evaluation of preventive strategies of tobacco use and alcohol consumption across the life course.

Effect of body mass index on the association between alcohol consumption and the development of chronic kidney disease

The influence of body mass or metabolic capacity on the association between alcohol consumption and lower risks of developing chronic kidney disease (CKD) is not fully elucidated. We examined whether the body mass index (BMI) affects the association between drinking alcohol and CKD. We defined CKD as an estimated glomerular filtration rate decline < 60 mL/min/1.73 m² and/or positive proteinuria (≥ 1+). Participants were 11,175 Japanese individuals aged 40–74 years without baseline CKD who underwent annual health checkups. Daily alcohol consumption at baseline was estimated using a questionnaire, and the participants were categorized as “infrequent (occasionally, rarely or never),” “light (< 20 g/day),” “moderate (20–39 g/day),” and “heavy (≥ 40 g/day).” Over a median 5-year observation period, 936 participants developed CKD. Compared with infrequent drinkers, light drinkers were associated with low CKD risks; adjusted hazard ratios (95% confidence intervals) were 0.81 (0.69–0.95). Stratified by BMI (kg/m²), moderate drinkers in the low (< 18.5), normal (18.5–24.9), and high (≥ 25.0) BMI groups had adjusted hazard ratios (95% confidence intervals) of 3.44 (1.60–7.42), 0.75 (0.58–0.98), and 0.63 (0.39–1.04), respectively. Taken together, the association between alcohol consumption and CKD incidence was not the same in all the individuals, and individual tolerance must be considered.

Analyzing the Influence of Wine and Beer Drinking, Smoking, and Leisure Time Screen Viewing Activity on Body Weight: A Cross-Sectional Study in Germany

The increasing global prevalence of overweight and obesity highlights an urgent need to explore modifiable obesogenic factors. This study investigated the impact of lifestyle factors, such as beer and wine drinking, cigarette smoking, and leisure time screen viewing activities, on body weight and the development of obesity. Individual level data were selected from a random sample of 3471 German adults using a two-stage disproportionate random sampling procedure. The empirical analysis employed a two-stage equations system and combined the endogenous treatment effects model with the quantile regression technique. Our estimations showed that the decisions to smoke and consume wine and beer were positively interrelated, especially in women. Frequent beer/wine drinkers of normal weight were found to have a lower BMI in the male subsample. Quantile regression estimates indicated a significant influence of smoking on BMI in both genders, with smokers’ BMI following an upward trend, especially in the upper quantiles of the distribution. Leisure time screen activity was found to have a major impact on females’ BMI. Prolonged television viewing and regular computer gaming had a strong relationship with weight increase in overweight women, whereas internet surfing was inversely correlated with the BMI of normal weight and slightly overweight female participants. Nutrition and health policies should direct individuals toward alternative recreational activities in order to substitute screen usage and reduce sedentary time. This study also raised doubts about the general belief that smokers have a lower body weight. As unhealthy behaviors usually co-occur or cluster together, obesity prevention interventions might also contribute to a decrease in smoking.

Endorsement of specific alcohol use disorder criterion items changes with age in individuals with persistent alcohol use disorders in 2 generations of the San Diego Prospective Study

BACKGROUND

Diagnostic and Statistical Manual (DSM) alcohol use disorder (AUD) criteria are written in broad enough terms to apply to diverse populations. The current analyses evaluate whether the endorsement of criteria changes with increasing age in individuals with persistent AUDs.

METHODS

Data regarding AUDs persisting across 3 timepoints between average ages of 31 and 43 were gathered about every 5 years from 318 interviews for 106 San Diego Prospective Study (SDPS) AUD male probands. Similar data regarding persistent AUDs across 2 timepoints were obtained from 136 interviews with 68 SDPS AUD offspring between average ages of 21 and 27. Changes in the endorsement of each AUD criterion were evaluated using Cochran's Q test.

RESULTS

For AUD probands across time, significant decreases were observed in the proportions endorsing 4 criteria (tolerance, withdrawal, failure to fulfill obligations, and using alcohol in hazardous situations). Increased rates of endorsement were documented for 3 criteria (drinking alcohol in higher amounts or for longer periods of time, spending a great deal of time regarding alcohol, and continued use despite social or interpersonal problems). Significant increases in rates of endorsements for offspring were seen for spending a great deal of time regarding alcohol and giving up or reducing important activities in order to drink.

CONCLUSIONS

These data indicate that the salience of many DSM AUD criterion items changed significantly with age in both SDPS generations among individuals with persistent AUDs. The current results support the need for additional systematic research to determine whether specific criterion items might need to be weighted differently in evaluating older and younger individuals with persistent AUDs.

Early life mental health and problematic drinking in mid-adulthood: evidence from two British birth cohorts

PURPOSE

Accumulating evidence suggests that externalising problems are consistently associated with alcohol use behaviours, but findings are inconsistent regarding the role of internalising problems. We investigate whether externalising and internalising problems are associated with problematic drinking in mid-adulthood, and whether potential associations are modified by age, sex and cohort.

METHODS

The National Child Development Study (NCDS58, n = 17,633) and 1970 British Cohort Study (BCS70, n = 17,568) recruited new-borns in Great Britain in a single week in 1958 and 1970. Mental health was assessed with the Rutter Behaviour Questionnaire at ages 7, 11, and 16 in NCDS58 and ages 5, 10 and 16 in BCS70. Problematic drinking was measured with the CAGE questionnaire at age 33 in NCDS58 and age 34 in BCS70, and the AUDIT scale at age 44/45 in NCDS58 and age 46 in BCS70. Latent scores of externalising and internalising problems were added chronologically into lagged logistic regression models.

RESULTS

Externalising and internalising problems were associated in opposite directions with problematic drinking in mid-adulthood. Externalising was a risk factor (OR [95% CI] ranging from 1.06 [1.03, 1.10] to 1.11 [1.07, 1.15] for different ages), and internalising was a protective factor (OR [95% CI] ranging from 0.95 [0.92, 0.99] to 0.90 [0.86, 0.94] for different ages). Associations between early life mental health and mid-adulthood problematic drinking did not differ by developmental timing but were stronger in males.

CONCLUSION

Our study provides new insights on links of externalising and internalising difficulties with alcohol use and has implications for public policy in the UK.

Changes in Alcohol Use during the COVID-19 Pandemic among Young Adults: The Prospective Effect of Anxiety and Depression

Health measures instantiated to reduce the spread of COVID-19 have imposed significant constraints for the population and impacted on drinking habits and mental health. This study longitudinally compared changes in alcohol consumption before and after the COVID-19 outbreak and the impact of sociodemographic and mental health variables on such changes among a community sample of young adults. Data were collected in the context of a larger, ongoing longitudinal study. The sample consisted of 305 young adults from Spain aged between 18 and 26 years (mean age = 21.27, (SD = 2.21), female = 53.4%; college students = 61.6%) who completed first (November-2019 and February-2020; i.e., before the outbreak of COVID-19) and second follow-up questionnaires (March 2021, a year after the COVID-19 outbreak). Alcohol use (quantity and drinking frequency), depression and anxiety symptoms were measured. Quantity and frequency of alcohol use decreased from the pre- to post-COVID-19 period. A decrease in drinking frequency was observed among college students, but not in noncollege peers. Although we found no effect of pre-COVID-19 anxiety on alcohol use changes, those with more depressive symptoms at the pre-COVID assessment were more resistant to decreasing their drinking quantity and frequency after the COVID-19 outbreak. This information will be of value when designing interventions aimed at reducing harmful alcohol use and highlights the role of mental health status when identifying high risk populations of young-adults during this, and future, public health crises.

10-Year Trends of Emergency Department Visits, Wait Time, and Length of Stay among Adults with Mental Health and Substance use Disorders in the United States

This study examined if there was a change in the number of Emergency Department (ED) visits, wait time, and length of stay among adults with mental health and substance use disorders (MHSUD) in the United States from 2006 to 2015. From the National Hospital Ambulatory Medical Care Survey, a total of 17,488 ED visits by adults with MHSUD were identified. Linear regression and negative binomial regression analyses were conducted to assess statistically significant changes in trends of ED visits, wait time, and length of stay. Results indicated that ED visits by adults with MHSUD increased by 30.6% from 2006 to 2015. Wait time of ED visits by adults with MHSUD decreased for the same time period; however, length of stay did not change. Also, there were some differences in trends of wait time and length of stay by diagnosis. Specifically, wait time of ED visits by adults with psychotic disorders did not decrease. Length of stay of ED visits by adults with anxiety disorders statistically significantly increased from 2006 to 2015. More effort is needed to improve the quality of ED care for adults with MHSUD. In such an effort, diagnoses should be taken into consideration.

Long-Term Trends (1994-2011) and Predictors of Total Alcohol and Alcoholic Beverages Consumption: The EPIC Greece Cohort

The aim of this study was to evaluate the longitudinal changes in alcohol consumption (total alcohol and types of alcoholic beverages) of the Greek EPIC cohort participants (28,572) during a 17-year period (1994-2011), with alcohol information being recorded repeatedly over time. Descriptive statistics were used to show crude trends in drinking behavior. Mixed-effects models were used to study the consumption of total alcohol, wine, beer and spirits/other alcoholic beverages in relation to birth cohort, socio-demographic, lifestyle and health factors. We observed a decreasing trend of alcohol intake as age increased, consistent for total alcohol consumption and the three types of beverages. Older birth cohorts had lower initial total alcohol consumption (8 vs. 10 g/day) and steeper decline in wine, spirits/other alcoholic beverages and total alcohol consumption compared to younger cohorts. Higher education and smoking at baseline had a positive association with longitudinal total alcohol consumption, up to +30% (vs. low education) and more than +25% (vs. non-smoking) respectively, whereas female gender, obesity, history of heart attack, diabetes, peptic ulcer and high blood pressure at baseline had a negative association of -85%, -25%, -16%, -37%, -22% and -24% respectively. Alcohol consumption changed over age with different trends among the studied subgroups and types of alcohol, suggesting targeted monitoring of alcohol consumption.

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.