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Alcohol and Health
Nearly 110,000 people die every year from alcohol-related causes—more than four times the number of deaths from illicit drug use. 123 Indeed, alcohol-related mortality ranks third among causes of death in the United States, 124 and alcoholism is associated with 25 percent of all general hospital admissions. 125 One of the more common health problems associated with heavy drinking is liver disease, which affects more than 2 million Americans. Up to 40 percent of heavy drinkers develop alcohol cirrhosis (or scarring of the liver), a leading cause of death among young and middle-aged adults in the United States. 126 Heavy drinking is also associated with increased risk of high blood pressure, heart disease, stroke, certain forms of cancer and pancreatitis. 127 Moreover, alcohol depresses the immune system, which may increase susceptibility to infectious disease and cancer, according to the National Institute on Alcohol Abuse and Alcoholism (NIAAA). 128
Alcohol abuse has been linked with high-risk sexual behavior, which contributes to the spread of sexually transmitted diseases. According to NIAAA, alcohol abusers have an increased risk of exposure to HIV (the virus which causes AIDS), due to a higher number of sex partners and reduced likelihood of using condoms. 129 / 130 Alcohol is also a factor in 50 to 65 percent of suicides among youth. 131
Moderate DrinkingNIAAA defines "moderate drinking" as two drinks a day for men, and only one drink a day for women and anyone age 65 and over. Moderate drinking may decrease the risk of heart disease among those at greatest risk, such as men over age 50 and post-menopausal women. 132
The Federal government's Dietary Guidelines for Americans cites evidence of the lower risk of heart disease for moderate drinkers. However, moderate drinking can also increase the risk of other health problems (such as liver disease and cancer) 133. In 1999, the Bureau of Alcohol, Tobacco and Firearms decided to allow wine producers to put labels on their products recommending that consumers talk with their physicians about the health effects of drinking wine. According to a marketing manager for the wine company Robert Mondavi Coastal, "[Health] announcements are increasing consumption more than anything else." 134 Alcoholic beverages (primarily wine and beer) recently replaced coffee as Americans' favorite dinner drink. 135
As people age, their bodies are less able to break down alcohol; 136 what is considered moderate drinking in young adulthood can cause problems if continued later in life. While moderate drinking is believed to help prevent heart attacks in certain aging populations, rates of alcohol-related admissions for the elderly in some hospitals are comparable to admissions for heart attacks. 137 The message can be confusing: drink moderately to protect your health but not enough to endanger it. In addition, the elderly often use both prescription and over-the-counter medications, many of which can interact lethally with alcohol. 138 NIAAA advises those who take medications to abstain from alcohol. 139
According to NIAAA, all persons age 65 years and older should consume no more than one drink per day. Symptoms of alcohol problems among the elderly, such as stomach problems, delirium and falls, often are mistaken for other conditions associated with aging; as a result, alcohol abuse in this population tends to go undiagnosed. 140
A 1999 National Health and Nutrition Examination survey found that one in four people over age 65 are either binge drinkers or heavy drinkers. 141
The Role of Primary CareOne in five patients treated in general medical practices drink at levels that increase health risks. 142 Brief intervention, involving early detection of alcohol abuse, can be conducted in general health care settings by health professionals who do not specialize in addiction treatment. 143 The physician can convey information about health risks associated with drinking, recommend behavioral changes, and provide guidance for limiting alcohol use. Studies of these brief interventions show drops in alcohol consumption averaging 27 percent. 144 Brief interventions are also effective for motivating patients to enter treatment for alcohol dependence, 145 and reducing problem drinking among the elderly. An University of Wisconsin study found a nearly 75 percent reduction in binge drinking among patients aged 65 and older who received brief interventions from their physicians. 146
Since 11 million children live with an alcoholic parent, pediatricians should expect to encounter families with alcoholism regularly. 147 In 1997, a panel of experts led by the National Association for Children of Alcoholics developed materials to help health care professionals identify and assist these children. 148
Despite the success of brief intervention, in a 1998 national Peter Hart Poll conducted for the Recovery Institute, 82 percent of doctors said their peers avoid addressing alcohol problems with patients. 149 A possible explanation for physician inaction is denial by drinkers; seven in ten doctors said when they raise concerns about alcohol use, patient denial is the most common reaction.
According to the American Medical Association, several other factors also contribute to physicians' failure to address alcohol abuse among patients: lack of training, lack of time with patients, and lack of awareness of treatment availability and effectiveness. 150 Close to two-thirds of the doctors surveyed said their training in recognizing and responding to alcoholism is less than adequate, and nearly one-fifth said they received no such training in medical school. 151 Lack of training does not necessarily indicate a lack of interest; more than two-thirds of the doctors said they would welcome further training on alcohol problem intervention. 152
Health Impact on WomenWomen are at increased risk of developing certain alcohol-related health problems because of how they metabolize alcohol. For women, the risk of developing liver cirrhosis is significant at less than two drinks a day (1.6 oz. pure alcohol) 153, whereas for men the risk is not significant until they consume at least six drinks per day (6.2 oz. pure alcohol). Women also become intoxicated more easily than men for several reasons. First, women produce less dehydrogenase (an enzyme that breaks down alcohol), so that alcohol is more likely to be absorbed in its most potent form. 154 As women age, this enzyme gradually becomes less effective, allowing more and more undiluted alcohol into their systems. 155 Second, women usually have less body mass in which to distribute the alcohol than men. Third, estrogen enhances alcohol absorption, which is particularly important for women taking birth control pills or hormone replacement therapy. Because alcohol is so easily absorbed into women's bloodstreams 156, health complications tend to begin earlier in women—after 13 years of alcohol consumption compared to 22 years for men. 157
Women who drink also have an increased risk for breast cancer. According to a 1998 analysis by the Harvard School of Public Health, women consuming two to five drinks per day have a 41 percent greater risk for breast cancer than non-drinkers. 158 In addition, drinking is associated with fertility problems, even for women who have less than one drink a day. 159
Women of different ethnicities experience varying degrees of alcohol-related health problems. Although heavy drinking rates are comparable for African American and white women, alcoholic African American women are nearly twice as likely to die from cirrhosis. 160
Drinking by Pregnant WomenAccording to the CDC's Behavioral Risk Factor Surveillance System, the rate of drinking during pregnancy increased more than 60 percent between 1992 (9.5 percent) and 1995 (15.3 percent). 161 These women are unlikely to seek treatment due to the stigma attached to alcohol use during pregnancy. 162 The recent increase in drinking among pregnant women is a signal that health care providers must reinforce the message of abstinence during pregnancy and increase referrals to alcohol treatment programs. 163
To increase social pressure against drinking during pregnancy, the Federal government mandated that all alcoholic beverage containers carry warning labels regarding the dangers to pregnant women. But these messages compete with others which portray moderate drinking during pregnancy as benign. For example, The Girlfriend's Guide to Pregnancy, a popular, non-professional guide through pregnancy, tells its readers, "...women who are coming to the end of a healthy and uneventful pregnancy deserve an occasional glass of wine before bed. 164" In addition, the Wine Institute's website, under the heading of women's health, states, "...light drinking has not been associated with any harm to the health of the unborn child or mother." While it is unclear whether there is a minimum amount of alcohol that must be consumed before damage to the fetus occurs 165, there is also no proof that small amounts of alcohol are safe. 166
A 1998 study conducted at the University of Washington found that prenatal alcohol exposure is more predictive of adolescent drinking than is family history of alcohol problems. 167
Fetal Alcohol SyndromeWhen a pregnant woman drinks, blood alcohol levels in mother and fetus are almost equal within minutes after consumption. 168 In utero alcohol exposure, usually heavy drinking, can cause fetal alcohol syndrome (FAS), the leading preventable cause of birth defects in the United States. 169 FAS is a serious, lifelong condition characterized by facial abnormalities, arrested growth, central nervous system deficits including learning and developmental disorders, and mental retardation. 170 Alcohol exposure in utero also disrupts normal development of the immune system. 171 Lifetime costs associated with one case of FAS are estimated to be $1.4 million. 172 The cost of treating all FAS-affected children and adults in the United States for one year is estimated at $1.9 billion. 173
The prevalence of FAS is not really known since there is no single reporting system from which to calculate statistics. 174 NIAAA estimates that as many as 3 in every 1,000 children born in the United States has FAS—nearly double the incidence of Down's syndrome and almost five times that of spina bifida. 175 In addition, Fetal Alcohol Effects (FAE), a less severe cluster of abnormalities, are estimated to occur three times more often than FAS. 176 Studies suggest that genetics may play a role in susceptibility to FAS; risk of FAS is seven times higher among African Americans than whites, even when alcohol intake is comparable. Similarly, among some Native American populations, more than 10 in every 1,000 children are born with FAS. 177
Few physicians are trained to recognize FAS and FAE; the physical features are often hard to recognize at birth, and it can be years before the mental deficits are detectable. 178 According to the National Organization on Fetal Alcohol Syndrome, as many as two-thirds of all children in special education classes have been affected by alcohol in some way. 179
Many children with FAS and FAE are unable to understand cause-and-effect relationships and long-term consequences; in addition, damage to the central nervous system creates behavior problems for these children. 180 Under-reporting of the disorders makes it difficult to identify those needing intervention.
123. The Economic Costs of Alcohol and Drug Abuse in the United States, 1992. Prepared by the Lewin Group for the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism, May 1998.
124 . Improving the Delivery of Alcohol Treatment and Prevention Services: A National Plan for Alcohol Health Services Research. U.S. Department of Health and Human Services, National Institute on Alcohol Abuse and Alcoholism, 1997.
129 . Ninth Special Report to the U.S. Congress on Alcohol and Health. U.S. Department of Health and Human Services, National Institute on Alcohol Abuse and Alcoholism, June 1997.
130 . Frederick Stinson, Samar DeBakey, Bridget Grant and Deborah Dawson, "Association of alcohol problems with risk for AIDS in the 1988 National Health Interview Study." Alcohol Health and Research World, NIAAA, 16(3): 245-252, 1992.
141. A.A. Moore, R.D. Hays, G.A. Greendale, M. Damesyn, D.B. Reyben, "Drinking Habits among Older Persons: Findings from the NHANES I Epidemiologic Follow-up Study (1982-1984), National Health and Nutrition Examination Survey." Journal of the American Geriatrics Society, 47(4):412-6, 1999.
144 . T.H. Bien, W.R. Miller and J.S. Tonigan, "Brief Interventions for alcohol problems: A review." Addiction, 88(3):315-336, 1993.
145 . Ninth Special Report to the U.S. Congress on Alcohol and Health. U.S. Department of Health and Human Services, National Institute on Alcohol Abuse and Alcoholism, June 1997.
146. M.F. Fleming, L.B. Manwell, K.L. Barry, W. Adams and E.A. Stauffacher, "Brief physician advice for alcohol problems in older adults: a randomized community-based trial." Journal of Family Practice, 48(5):378-84, 1999.
147. Mark J. Werner, Alain Joffe and Antonnette V. Graham, "Screening, Early Identification, and Office-Based Intervention with Children and Youth Living in Substance-Abusing Families." Pediatrics, 103(5):1099-1111, 1999.
148. Hoover Adger, Jr., Donald Ian McDonald and Sis Wenger, "Core Competencies for Involvement of Health Care Providers in the Care of Children and Adolescents in Families Affected by Substance Abuse." Pediatrics, 103(5):1083-1084, May 1999 Supplement.
157. "Women and Alcohol Consumption: When should you say when." Transcript from the Today Show, January 18, 1999.
158 . S.A. Smith-Warner, D. Spiegelman, S.S. Yaun et al., "Alcohol and breast cancer in women: A pooled analysis of cohort studies." Journal of the American Medical Association, 279(7):535-540, 1998.
159 . T.K. Jensen, N.H. Hjullond, T.B. Henriksen et al., "Does moderate alcohol consumption affect fertility? Follow up study among couples planning first pregnancy." British Medical Journal, 317(7157):505-10, 1998.
161. "Alcohol consumption among pregnant and childbearing-aged women — United States, 1991 and 1995." Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention, 46(16):346-50, 1997.
163. S.H. Ebrahim, E.T. Luman, R.L. Floyd, C.C. Murphy, E.M. Bennett and C.A. Boyle, "Alcohol consumption by pregnant women in the United States during 1988-1995." Journal of Obstetrics and Gynecology, 92(2):187-92, 1998.
167 . John S. Baer, Helen M. Barr, Fred L. Bookstein, Paul D. Sampson, Ann P. Streissguth, "Prenatal Alcohol Exposure and Family History of Alcoholism in the Etiology of Adolescent Alcohol Problems." Journal of Studies on Alcohol, 59(5):533-43, 1998.
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