Science and Technology Committee HC 1536 Alcohol GuidelinesWritten evidence submitted by Dr Richard Harding (AG 13)
1. I was a member of the Inter-Departmental Working Group on Sensible Drinking, which reported in December 1995.1 This Working Group was set up in 1994 to review the Government’s sensible drinking message in the light of the latest evidence which indicated that drinking alcohol might give protection from coronary heart disease.
2. The terms of reference for the Group were:
(i)
(ii)
3. The Working Group comprised officials from a range of Government Departments with an interest in Government policy on alcohol. At the time I worked in the Consumers and Nutrition Policy Division in the Ministry of Agriculture, Fisheries and Food. I hold qualifications in chemistry, food science and law, and I worked for a number of years in the food industry before joining the Ministry of Agriculture, Fisheries and Food in 1975. I subsequently moved to the Food Standards Agency on its creation in 2000, and left Government service in 2006.
4. In preparation for this 1995 review, I read the scientific literature extensively and met with leading experts in the UK, USA and France.
5. The four questions posed by the Committee are addressed in turn.
What evidence are Government’s guidelines on alcohol intake based on, and how regularly is the evidence base reviewed?
6. The sensible drinking message in 1994 was that drinking less than 21 units per week by men and 14 units per week for women is unlikely to damage health. It was by no means clear at the time on what evidence this advice was based, so the Working Group examined in detail the evidence for both harmful effects and beneficial effects of alcohol consumption, and then to reflect both aspects of alcohol consumption in a public health message. The Working Group also had the benefit of 89 submissions and took oral evidence from six experts in the field. To my best knowledge the current alcohol guidelines are based on this analysis of the evidence base, since I am not aware of any subsequent analysis. The Committee will be able to read the Report on Sensible Drinking for themselves, but here is a summary.
Harmful Effects of Alcohol
7. This is set out in Chapter 6 of the Report, and covers the following topics.
Intoxication
8. Clearly much alcohol related harm resulted from intoxication, from accidents and social harm.
Cirrhosis of the liver
9. Long-term heavy drinking increases the risk of liver cirrhosis.
Cancer
10. The advice of the Department of Health’s Expert Committee on Carcinogenicity was sought, and their conclusions are set out in the Report.
Hypertension
11. It was known that alcohol consumption increases blood pressure, to the extent of 1–2mm for each 10g/day. However, it was also clear that moderate consumption of alcohol was overall protective for most of the chronic diseases (except haemorrhagic stroke) for which high blood pressure is a risk factor.
Haemorrhagic Stroke
12. The studies showed that there was an increase in risk of haemorrhagic stroke with alcohol consumption, from a consumption of of 16g/day (2 units).
Reproduction, Pregnancy and Infant Development
13. The advice of the Department of Health’s Expert Committee on Toxicity was sought, and their conclusions are set out in section 6.19 of the Report.
Mental Illness and Neurological Disorders
14. Extremely heavy drinking (consumption of over 80g/day) over long periods of time was strongly associated with a number of significant psychiatric disorders, notably depression and suicide, and with psychological and physical dependence.
Beneficial Effects of Alcohol
15. Many population studies since the early 1970s had shown a marked beneficial effect of moderate consumption of alcohol, for a number of conditions. Most studies showed a J or U shaped curve, ie a marked drop in risk compared to abstainers for low levels of consumption (1–2 units/day), then the benefit is sustained over an increased level of consumption (typically 3–4 units/day for men, more in some studies), and then a progressive increase in risk as alcohol consumption increases.
Coronary Heart Disease (CHD)
16. The size of benefit is significant, with moderate consumers enjoying a drop in risk of 30–50% compared with abstainers. An early finding (1972) of the Framingham study in the USA identified abstinence from alcohol as one of the four major risk factors for CHD, along with high blood cholesterol, high blood pressure and smoking. The researchers were prevented from publishing this at the time.2
17. There were convincing hypotheses to explain this benefit, of which two seemed to be the most important. Alcohol consumption increases HDL cholesterol (“good cholesterol”), thereby lowering the HDL/LDL ratio and inhibiting formation of coronary artery atheroma. Further, alcohol directly affects advantageously a number of mechanisms associated with blood clotting and thrombosis, thereby inhibiting a heart attack.
Ischaemic Stroke
18. As with CHD, moderate drinkers had a 50% reduction in risk compared to non-drinkers, because of the same mechanisms.
Gallstones
19. The studies showed that moderate alcohol consumption up to 40g/day (5 units) confers protection against cholesterol gallstones.
Other benefits
20. The studies also showed that moderate alcohol consumption conferred protection against other forms of heart disease (eg peripheral vascular disease). The studies also showed that alcohol consumption in the range of 15–40g/day (2–5 units) reduced the risk of type 2 diabetes (formerly known as non-insulin dependent diabetes mellitus). There were also indications that alcohol consumption increased bone mineral density by 10–20%, thereby conferring protection against osteoporosis.
General Public Health Advice
21. The basic rationale for previous public health messages on alcohol seemed to be that alcohol was fundamentally undesirable in society, and consumption should be generally discouraged, but if people choose to drink, then consumption of 21 units (168g)/week for men and 14 units (112g)/week for women should not do too much harm. Further, the advice was to abstain from alcohol for two days a week.
22. The Working Party took a different approach. Clearly excessive consumption of alcohol does a great deal of social and public health damage in society through intoxication and any public health message must address that. Further, long term excessive consumption leads to serious chronic disease and death through liver cirrhosis, some cancers, high blood pressure, cardiovascular disease, addiction, mental illness, and obviously should be similarly strongly deterred. Additionally, the evidence for the beneficial effects of moderate consumption was sufficiently strong to warrant inclusion.
23. The Working Party also considered the Whole Population Theory as applied to alcohol, first proposed by the French mathematician Ledermann. He argued that there was a fixed relationship between average per capita consumption of alcohol, the number of heavy drinkers in the population and the amount of alcohol related harm. He predicted that doubling or tripling average consumption would lead to a four or nine fold increase in the number of problem drinkers. This led to the idea of manipulating average consumption through price and access controls to reduce the incidence of problem drinking. It had been argued3 that the purpose of a sensible drinking message should be to bring down everyone’s level of consumption so as to prevent increase in the numbers of heavy drinkers—in other words, moderate drinkers need to reduce their consumption (or not increase it) in order to prevent someone else from becoming a problem drinker, because the mean would increase. The Working Party noted that there are examples, like that of drinking and driving, which show that public education can change undesirable behaviour without lowering the level of drinking by the population as a whole.
24. There were, and are, sound grounds for different advice to men and women. On average women weigh less than men, they have proportionately more body fat, and metabolise alcohol more slowly. Women also have differences in patterns of pathology disease compared with men, and in relation to coronary heart disease, are protected by their hormones until the menopause. Further, alcohol (other than at very low levels) was associated with particular risks to fetal and early development. Evidence was also emerging of an association of alcohol consumption with breast cancer. The Working Group advised that if further evidence of this association emerged, the relationship between alcohol and breast cancer should be kept under careful review.
25. While the evidence can support benchmarks to enable people to monitor their own drinking levels, there is large variation among individuals, for example, in body weight. Further, the scientific evidence itself did not and does not support rigid limits that are universally applicable. Therefore advice couched as a range of intake can be justified but rigid limits cannot.
26. The Working Party thought it sensible to move away from advice based on weekly consumption in favour of daily consumption. Weekly drinking can mask episodes of heavy drinking (21 units/week could be consumed in two binges of 10 units each). Further, it is difficult for individuals to keep account of their own consumption over a week, having to remember what they drank a few days earlier. Also, there was evidence that showed there could be benefit in regular drinking, so long it is moderate. Therefore the Working Party decided to couch advice in terms of daily drinking.
27. Paragraphs 10.19 to 10.30 of the Report set out the conclusions of the Working Party’s work. There are three main elements.
(i)
(ii)
(iii)
28. The central advice on sensible drinking was as follows:
Men
The health benefit from drinking relates to men aged over 40 and the major part of this can be obtained at levels as low as one unit a day, with the maximum health advantage lying between 1 and 2 units a day.
Regular consumption of between 3 and 4 units a day by men of all ages will not accrue significant health risk.
Consistently drinking 4 or more units a day is not advised as a sensible drinking level because of the progressive health risk it carries.
Women
The health benefit from drinking for women relates to postmenopausal women and the major part of this can be obtained at levels as low as one unit a day, with the maximum health advantage lying between 1 and 2 unit a day.
Regular consumption of between 2 and 3 units a day by men of all ages will not accrue significant health risk.
Consistently drinking 3 or more units a day is not advised as a sensible drinking level because of the progressive health risk it carries.
Changes to the Sensible Drinking Message Since 1995
29. A campaign followed the publication of the Sensible Drinking Report in 1995, with the message, “There is more to a drink than you think.” However, the message on the beneficial aspects of moderate consumption was dropped within a few years of 1995, but to my knowledge this was not on the basis of any new review of the evidence or ministerial decision.
Evidence that has Emerged Since 1995
30. There is a considerable body of evidence on the effect of moderate alcohol consumption on disease that has emerged since 1995. A summary of the current position can be found in a chapter in a recent book.5 The key findings are:
Clear evidence that the frequency of drinking is as important as, or even more important than, the amount of alcohol consumed. All epidemiological studies show that the more frequent drinkers, including daily drinkers, have lower risks for many diseases than do individuals reporting less frequent drinking. Further, data are increasingly demonstrating harmful biological effects (as well as the well known adverse social effects) of “binge drinking”, based on the number of drinks consumed per occasion or the rate at which alcohol is consumed.
Firmer evidence for the protective effect of moderate alcohol consumption for coronary heart disease, as well as further clarification of the mechanisms for the protective effect.
Evidence for an approximately 30% reduction in risk for type 2 diabetes for moderate drinkers.
Evidence that moderate drinkers have less osteoporosis and a lower risk of fractures in the elderly compared to abstainers.
Evidence that light to moderate drinking is associated with a significantly reduced risk of dementia in older people.
Evidence that drinkers may have a somewhat increased risk of breast cancer in comparison with abstainers.
Increasing evidence that moderate drinking should be considered as an important constituent of a “healthy lifestyle”. A recent US study6 found that four characteristics of a healthy lifestyle (never smoked, healthy diet, adequate physical activity, and moderate alcohol consumption) were each significantly associated with less disability and a reduced risk of mortality. Those who adopted all four characteristics were chronologically 11 years younger than those who had none. This is consistent with an earlier UK study,7 where the figure was 14 years.
Could the evidence base and sources of scientific advice to Government on alcohol be improved?
31. All of the relevant information is published in the literature. What is needed is a mechanism that brings it all together in a fair and balanced way, so that sensible public health messages can be crafted. Within the medical profession, alcohol tends to be dealt with by those who specialise in alcohol misuse and addiction, and therefore the public health messages that emerge tend to be from that perspective and that perspective alone. Doctors seem to be influenced more by those who walk through their consulting room doors rather than those who do not. While not wishing to diminish the enormous importance of alcohol misuse to public health policy, it is not the whole story. The challenge is to reduce alcohol-related harm in the population as a whole, while at the same time taking advantage of the beneficial aspects of the moderate consumption of alcohol. The UK has a growing and aging population. The chronic diseases for which moderate alcohol consumption offers significant protection are coronary heart disease, ischaemic stroke, type 2 diabetes, osteoporosis, and dementia. These are the common diseases of aging. The potential gain is large both for public health, the health of individuals, and the public purse.
32. The time is certainly overdue for a review of the relationship between alcohol consumption and disease. Much has been published since 1995, and it all needs to be brought together by a multidisciplinary team, involving experts in the appropriate fields—eg alcohol misuse, epidemiology, public health, heart disease, dementia, and social science—who are knowledgeable about the current scientific data and who are capable of taking a broad overview.
How well does the Government communicate its guidelines and the risks of alcohol intake to the public?
33. In the short term, giving guidance to specific groups in the general population (men, women, young people, middle aged and the elderly) is probably the best governments can do. In the longer term, Government could try to effect a culture change in society’s attitudes to alcohol, eg to make intoxication more socially unacceptable, in much the same way as attitudes to drinking and driving have changed over the past 50 years.
How do the Government’s guidelines compare to those provided in other countries?
34. World-wide recommendations on alcohol consumption show wide disparity among countries.4 This is in some ways surprising, given that the science is the same everywhere. But the objective of those who frame such guidance is to influence their target populations. It follows therefore that several factors then become relevant, eg the behaviour that is thought to be in need of change, the culture and mindset of the target population, and the kind of message that is likely to be effective.
35. Therefore the best approach is to formulate advice firmly based on and argued from the science, but that which is also appropriate to the problems that the UK face and is likely to be effective, and not to take much notice of what other governments or health bodies recommend.
Declaration of Interest
36. Since leaving Government, I have worked as a consultant, including one study for the wine industry on labelling in 2007, but I have done no work on the health aspects of alcohol consumption. Further, I am not seeking further consultancy work. I have given presentations on alcohol and health at two international conferences for which my flights and hotel were provided, but I received no fee.
September 2011
References
1. Sensible Drinking. Report of an Inter-Departmental Working Group. Department of Health 1995. ISBN 1 85839 621 2
2. Selzer, C C. “Conflicts of Interest” and “Political Science”. Journal of Clinical Epidemiology 50(5), 627-629 (1997).
3. Alcohol and the heart in perspective—Sensible limits reaffirmed. Report of a joint working group. Royal College of Physicians, Royal College of Psychiatrists, Royal College of General Practitioners. June 1995. ISBN 1 86016 019 0.
4. Harding, R and Stockley, C. Communicating through Government Agencies. Annals of Epidemiology 2007; 17: S98-S102.
5. Ellison, R C. Effects of Alcohol on Cardiovascular Disease Risk. Chapter 18 of “Preventive Cardiology: Companion to Braunwald’s Heart Disease by Blumenthal”, R, Foody, J, Wong, N. 2011, Elsevier. ISBN 978-1-4377-1366-4.
6. Ford, ES, Zhao, G, Tsai, J, Chaoyang, L. Low-Risk Lifestyle Behaviors and all-cause mortality: Findings from the National Health and Nutrition Examination Survey III Mortality Study. American Journal of Public Health 18 August 2011: e1-e8. doi:10.2105/AJPH.2011.300167.
7. Khaw, K-T, Wareham, N, Bingham, S, Welsh, A, Luben, R, Day, N. Combined impact of health behaviours and mortality in men and women: The EPIC-Norfolk Prospective Population Study. PLoS Med. 2008; 5(1):e12.