Improving alcohol management in primary health care in Mexico: A return-on-investment analysis.

INTRODUCTION: Alcohol screening, brief advice and referral to treatment (SBIRT) in primary health care is an effective strategy to decrease alcohol consumption at population level. However, there is relatively scarce evidence regarding its economic returns in non-high-income countries. The current paper aims to estimate the return-on-investment of implementing a SBIRT program in Mexican primary health-care settings. METHODS: Empirical data was collected in a quasi-experimental study, from 17 primary health-care centres in Mexico City regarding alcohol screening delivered by 145 health-care providers. This data was combined with data from a simulation study for a period of 10 years (2008 to 2017). Economic investments were calculated from a public sector health-care perspective as clinical consultation costs (salary and material costs) and program costs (set-up, adaptation, implementation strategies). Economic return was calculated as monetary gains in the public sector health-care, estimated via simulated reductions in alcohol consumption, dependent on population coverage of alcohol interventions delivered to primary health-care patients. RESULTS: Results showed that scaling up a SBIRT program in Mexico over a 10-year period would lead to positive return-on-investment values ranging between 21% in scenario 4 (confidence interval -8.6%, 79.5%) and 110% in scenario 5 (confidence interval 51.5%, 239.8%). Moreover, over the 10-year period, up to 16,000 alcohol-related deaths could be avoided as a result of implementing the program. DISCUSSION AND CONCLUSIONS: SBIRT implemented at national level in Mexico may lead to substantial financial gains from a public sector health-care perspective.

Reduced alcohol consumption during the COVID-19 pandemic: Analyses of 17 000 patients seeking primary health care in Colombia and Mexico.

Background: During the COVID-19 pandemic, an increase of heavy alcohol use has been reported in several high-income countries. We examined changes in alcohol use during the pandemic among primary health care (PHC) patients in two middle income countries, Colombia and Mexico. Methods: Data were collected during routine consultations in 34 PHC centres as part of a large-scale implementation study. Providers measured patients' alcohol consumption with the three item 'Alcohol Use Disorders Identification Test' (AUDIT-C). Generalized linear mixed models were performed to examine changes in two dependent variables over time (pre-pandemic and during pandemic): 1) the AUDIT-C score and 2) the proportion of heavy drinking patients (8+ on AUDIT-C). Results: Over a period of more than 600 days, data from N = 17 273 patients were collected. During the pandemic, the number of patients with their alcohol consumption measured decreased in Colombia and Mexico. Each month into the pandemic was associated with a 1.5% and 1.9% reduction in the mean AUDIT-C score in Colombia and Mexico, respectively. The proportion of heavy drinking patients declined during the pandemic in Colombia (pre-pandemic: 5.4%, 95% confidence interval (CI) = 4.8% to 6.0%; during the pandemic: 0.8%, 95% CI = 0.6% to 1.1%) but did not change in Mexico. Conclusions: Average consumption levels declined and the prevalence of heavy drinking patterns did not increase. In addition to reduced opportunities for social drinking during the pandemic, changes in the population seeking PHC and restrictions in alcohol availability and affordability are likely drivers for lower levels of alcohol use by patients in this study.

Costs of an Alcohol Measurement Intervention in Three Latin American Countries.

Alcohol measurement in health care settings is an effective intervention for reducing alcohol-related harm. However, in many countries, costs related to alcohol measurement have not yet been transparently assessed, which may hinder its adoption and implementation. Costs of an alcohol measurement programme in three upper-middle-income Latin American countries were assessed via questionnaires and compared, as part of the quasi-experimental SCALA study. Additional to the intervention costs, the costs of three implementation strategies: standard training and clinical package, intensive training and clinical package, and community support, were assessed and subsequently translated into costs per additional alcohol measurement session. Results demonstrated that costs for one alcohol measurement session ranged between Int$ 0.67 and Int$ 1.23 in Colombia, Int$ 1.19 and Int$ 2.57 in Mexico, and Int$ 1.11 and Int$ 2.14 in Peru. Costs were mainly driven by the salaries of the health professionals. Implementation strategies costs per additional alcohol measurement session ranged between Int$ 1.24 and Int$ 6.17. In all three countries, standard training and a clinical package may be a promising implementation strategy with a relatively low cost per additional alcohol measurement session.

Training primary health care providers in Colombia, Mexico and Peru to increase alcohol screening: Mixed-methods process evaluation of implementation strategy.

Background: Initial results from the SCALA study demonstrated that training primary health care providers is an effective implementation strategy to increase alcohol screening in Colombia, Mexico and Peru, but did not show evidence of superior performance for the standard compared to the shorter training arm. This paper elaborates on those outcomes by examining the relationship of training-related process evaluation indicators with the alcohol screening practice. Methods: A mix of convergent and exploratory mixed-methods design was employed. Data sources included training documentation, post-training questionnaires, observation forms, self-report forms and interviews. Available quantitative data were compared on outcome measure - providers' alcohol screening. Results: Training reach was high: three hundred fifty-two providers (72.3% of all eligible) participated in one or more training or booster sessions. Country differences in session length reflected adaptation to previous topic knowledge and experience of the providers. Overall, 49% of attendees conducted alcohol screening in practice. A higher dose received was positively associated with screening, but there was no difference between standard and short training arms. Although the training sessions were well received by participants, satisfaction with training and perceived utility for practice were not associated with screening. Profession, but not age or gender, was associated with screening: in Colombia and Mexico, doctors and psychologists were more likely to screen (although the latter represented only a small proportion of the sample) and in Peru, only psychologists. Conclusions: The SCALA training programme was well received by the participants and led to half of the participating providers conducting alcohol screening in their primary health care practice. The dose received and the professional role were the key factors associated with conducting the alcohol screening in practice.Plain Language Summary: Primary health care providers can play an important role in detecting heavy drinkers among their consulting patients, and training can be an effective implementation strategy to increase alcohol screening and detection. Existing training literature predominantly focuses on evaluating trainings in high-income countries, or evaluating their effectiveness rather than implementation. As part of SCALA (Scale-up of Prevention and Management of Alcohol Use Disorders in Latin America) study, we evaluated training as implementation strategy to increase alcohol screening in primary health care in a middle-income context. Overall, 72.3% of eligible providers attended the training and 49% of training attendees conducted alcohol screening in practice after attending the training. Our process evaluation suggests that simple intervention with sufficient time to practice, adapted to limited provider availability, is optimal to balance training feasibility and effectiveness; that booster sessions are especially important in context with lower organizational or structural support; and that ongoing training refinement during the implementation period is necessary.

Assessing Sustainable Development Goal Target Indicator 3.5.2: Trends in alcohol per capita consumption in the Americas 1990–2016

[ABSTRACT]. The objective of this study was to estimate trends in alcohol per capita consumption from 1990 to 2016 in the Region of the Americas, covering 35 Member States. Data from the WHO Global Information System on Alcohol and Health were used to calculate the annual percent change of alcohol per capita consumption in each of the 35 countries of the Americas. The Americas as a whole showed no change in the total period, with a slight decrease in the period 2010–2016. From 1990 to 2016, all the countries that presented a trend of annual increase in annual percent change of alcohol per capita consumption were in the Caribbean and Central America. Large increases were found in the recent years in Cuba, Colombia, Uruguay, El Salvador, and several countries of the Non-Latin Caribbean. In conclusion, alcohol use remains a significant obstacle to the achievement of Sustainable Development Goal 3.5. To date, the policy response has been inadequate in protecting the people in the Americas from alcohol-attributable harms. Improving country capacity to collect and analyze data on alcohol per capita consumption is urgently needed to monitor progress on the Sustainable Development Goals and to serve to promote proven alcohol policies for reducing the harmful use of alcohol.

[RESUMEN]. El objetivo de este estudio es estimar las tendencias en el consumo per cápita de alcohol desde 1990 hasta el 2016 en 35 Estados Miembros de la Región de las Américas. Se emplearon datos del Sistema Mundial de Información sobre el Alcohol y la Salud de la OMS para calcular la variación porcentual por año del consumo per cápita de alcohol en cada uno de los 35 países de la Región. En general, la Región no mostró cambio en todo el período, salvo una disminución leve entre el 2010 y el 2016. De 1990 al 2016, todos los países que registraron una tendencia al alza en la variación anual porcentual del consumo per cápita de alcohol se encontraban en el Caribe y Centroamérica. En los últimos años se observó un aumento importante en Cuba, Colombia, Uruguay, El Salvador y varios países del Caribe no latino. En conclusión, el consumo de alcohol sigue siendo un obstáculo significativo para lograr el Objetivo de Desarrollo Sostenible 3.5. Hasta la fecha, la respuesta de las políticas ha sido inadecuada para proteger a la población de la Región de los daños atribuibles al alcohol. Es necesario mejorar de manera urgente la capacidad a nivel de país para recopilar y analizar datos sobre el consumo per cápita de alcohol a fin de monitorear el progreso de los Objetivos de Desarrollo Sostenible y promover políticas relativas al alcohol cuya eficacia en cuanto a la reducción del consumo nocivo ha sido comprobada.

[RESUMO]. O objetivo deste estudo foi estimar as tendências do consumo de álcool per capita de 1990 a 2016 na Região das Américas, cobrindo os 35 Estados Membros. Dados do Sistema Mundial de Informação sobre Álcool e Saúde da OMS foram usados para calcular a mudança percentual anual do consumo de álcool per capita de cada um dos 35 países das Américas. As Américas, como um todo, não mostraram mudança alguma no período total, com uma diminuição leve no período entre 2010 e 2016. De 1990 a 2016, todos os países que apresentaram uma tendência de aumento anual na mudança percentual anual do consumo de álcool per capita estão no Caribe e na América Central. Um grande aumento foi encontrado nos anos recentes em Cuba, Colômbia, Uruguai, El Salvador e vários países não latinos do Caribe. Em conclusão, o consumo de álcool continua sendo um obstáculo significativo para o cumprimento do Objetivo de Desenvolvimento Sustentável 3.5. Até o momento, a resposta política foi inadequada para proteger a população nas Américas dos danos atribuíveis ao álcool. Melhorar a capacidade dos países de coletar e analisar dados sobre o consumo de álcool per capita é urgentemente necessário para monitorar o progresso dos Objetivos de Desenvolvimento Sustentável e para promover políticas comprovadas de redução do consumo nocivo de álcool.

Primary care-based screening and management of depression amongst heavy drinking patients: Interim secondary outcomes of a three-country quasi-experimental study in Latin America.

INTRODUCTION: Implementation of evidence-based care for heavy drinking and depression remains low in global health systems. We tested the impact of providing community support, training, and clinical packages of varied intensity on depression screening and management for heavy drinking patients in Latin American primary healthcare. MATERIALS AND METHODS: Quasi-experimental study involving 58 primary healthcare units in Colombia, Mexico and Peru randomized to receive: (1) usual care (control); (2) training using a brief clinical package; (3) community support plus training using a brief clinical package; (4) community support plus training using a standard clinical package. Outcomes were proportion of: (1) heavy drinking patients screened for depression; (2) screen-positive patients receiving appropriate support; (3) all consulting patients screened for depression, irrespective of drinking status. RESULTS: 550/615 identified heavy drinkers were screened for depression (89.4%). 147/230 patients screening positive for depression received appropriate support (64%). Amongst identified heavy drinkers, adjusting for country, sex, age and provider profession, provision of community support and training had no impact on depression activity rates. Intensity of clinical package also did not affect delivery rates, with comparable performance for brief and standard versions. However, amongst all consulting patients, training providers resulted in significantly higher rates of alcohol measurement and in turn higher depression screening rates; 2.7 times higher compared to those not trained. CONCLUSIONS: Training using a brief clinical package increased depression screening rates in Latin American primary healthcare. It is not possible to determine the effectiveness of community support on depression activity rates due to the impact of COVID-19.

Perceived appropriateness of alcohol screening and brief advice programmes in Colombia, Mexico and Peru and barriers to their implementation in primary health care - a cross-sectional survey.

BACKGROUND: Providing alcohol screening and brief advice (SBA) in primary health care (PHC) can be an effective measure to reduce alcohol consumption. To aid successful implementation in an upper middle-income country context, this study investigates the perceived appropriateness of the programme and the perceived barriers to its implementation in PHC settings in three Latin American countries: Colombia, Mexico and Peru, as part of larger implementation study (SCALA). METHODS: An online survey based on the Tailored Implementation for Chronic Diseases (TICD) implementation framework was disseminated in the three countries to key stakeholders with experience in the topic and/or setting (both health professionals and other roles, for example regional health administrators and national experts). In total, 55 respondents participated (66% response rate). For responses to both appropriateness and barriers questions, frequencies were computed, and country comparisons were made using Chi square and Kruskal-Wallis non-parametric tests. RESULTS: Alcohol SBA was seen as an appropriate programme to reduce heavy alcohol use in PHC and a range of providers were considered suitable for its delivery, such as general practitioners, nurses, psychologists and social workers. Contextual factors such as patients' normalised perception of their heavy drinking, lack of on-going support for providers, difficulty of accessing referral services and lenient alcohol control laws were the highest rated barriers. Country differences were found for two barriers: Peruvian respondents rated SBA guidelines as less clear than Mexican (Mann-Whitney U = -18.10, P = 0.001), and more strongly indicated lack of available screening instruments than Colombian (Mann-Whitney U = -12.82, P = 0.035) and Mexican respondents (Mann-Whitney U = -13.56, P = 0.018). CONCLUSIONS: The study shows the need to address contextual factors for successful implementation of SBA in practice. General congruence between the countries suggests that similar approaches can be used to encourage widespread implementation of SBA in all three studied countries, with minor tailoring based on the few country-specific barriers.

Actual and predicted prevalence of alcohol consumption during pregnancy in Latin America and the Caribbean: systematic literature review and meta-analysis / Prevalencia real y prevista del consumo de alcohol durante el embarazo en América Latina y el Caribe: revisión bibliográfica sistemática y metanálisis / Prevalência real e prevista do consumo de álcool na gravidez na América Latina e Caribe: revisão sistemática da literatura e meta-análise

Objective. To estimate the prevalence of alcohol consumption during pregnancy among the general population of Latin America and the Caribbean, by country, in 2012. Methods. Three steps were taken: a comprehensive, systematic literature search; meta- analyses, assuming a random-effects model for countries with published studies; and regression modelling (data prediction) for countries with either no published studies or too few to obtain an estimate. Results. Based on 24 existing studies, the pooled prevalence of alcohol consumption during pregnancy among the general population was estimated for Brazil (15.2%; 95% confidence interval [95%CI]: 10.4%–20.8%) and Mexico (1.2%; 95%CI: 0.0%–2.7%). The prevalence of alcohol consumption during pregnancy among the general population was predicted for 31 countries and ranged from 4.8% (95%CI: 4.2%–5.4%) in Cuba to 23.3% (95%CI: 20.1%– 26.5%) in Grenada. Conclusions. Greater prevention efforts and measures are needed in the countries of Latin America and the Caribbean to prevent pregnant women from consuming alcohol during pregnancy and decrease the rates of Fetal Alcohol Spectrum Disorder. Additional high quality studies on the prevalence of alcohol consumption during pregnancy in Latin America and the Caribbean are also needed.

Objetivo. Calcular la prevalencia del consumo de alcohol durante el embarazo en la población general de América Latina y el Caribe desglosada por país y para el año 2012. Métodos. Se siguieron tres pasos: 1) una búsqueda bibliográfica sistemática y amplia; 2) metanálisis, en los que se supuso un modelo de efectos aleatorios respecto de los países sobre los que se disponía de estudios publicados; y 3) el modelado de regresión (predicción de datos) respecto de los países sobre los que no se disponía de ningún estudio publicado o estos eran demasiado escasos para obtener estimaciones. Resultados. Sobre la base de los 24 estudios existentes, se calculó la prevalencia combinada del consumo de alcohol durante el embarazo en la población general de Brasil (15,2 %; intervalo de confianza [IC] del 95 %: 10,4-20,8 %) y México (1,2 %; IC del 95 %: 0,0-2,7 %). También se calculó la prevalencia prevista del consumo de alcohol durante el embarazo en la población general de 31 países, cálculo que arrojó datos comprendidos entre 4,8 % (IC del 95 %: 4,2-5,4 %) en Cuba y 23,3 % (IC del 95%: 20,1-26,5 %) en Granada. Conclusiones. Es preciso redoblar los esfuerzos de prevención e intensificar las medidas en los países de América Latina y el Caribe para impedir que las embarazadas consuman alcohol durante el embarazo a fin de reducir las tasas de los trastornos del espectro alcohólico fetal. También se deben realizar más estudios de buena calidad sobre la prevalencia del consumo de alcohol durante el embarazo en América Latina y el Caribe.

Objetivo. Estimar a prevalência do consumo de álcool na gravidez na população geral da América Latina e Caribe, por país, em 2012. Métodos. Três etapas foram realizadas: (i) uma busca sistemática abrangente da literatura científica, (ii) meta-análises a partir de um modelo de efeitos aleatórios para os países com estudos publicados e (iii) modelos de regressão (predição de dados) para os países sem nenhum estudo publicado ou com um número muito pequeno de estudos para obter uma estimativa. Resultados. Com base em 24 estudos identificados, estimou-se a prevalência conjunta do consumo de álcool na gravidez na população geral no Brasil (15,2%; intervalo de confiança de 95% [IC 95%] 10,4%–20,8%) e no México (1,2%; IC 95% 0,0%–2,7%). A prevalência do consumo de álcool na gravidez na população geral foi prevista em 31 países, variando de 4,8% (IC 95% 4,2%–5,4%) em Cuba a 23,3% (IC 95% 20,1%–26,5%) em Granada. Conclusões. Um grande esforço de prevenção com a adoção de medidas preventivas se faz necessário nos países da América Latina e Caribe para prevenir o uso de álcool entre gestantes durante a gravidez e reduzir os índices de transtornos do espectro alcoólico fetal. Também são necessários outros estudos de alta qualidade da prevalência do consumo de álcool na gravidez na América Latina e no Caribe.

Actual and predicted prevalence of alcohol consumption during pregnancy in Latin America and the Caribbean: systematic literature review and meta-analysis / Prevalência real e prevista do consumo de álcool na gravidez na América Latina e Caribe: revisão sistemática da literatura e meta-análise / Prevalencia real y prevista del consumo de alcohol durante el embarazo en América Latina y el Caribe: revisión bibliográfica sistemática y metanálisis

ABSTRACT Objective To estimate the prevalence of alcohol consumption during pregnancy among the general population of Latin America and the Caribbean, by country, in 2012. Methods Three steps were taken: a comprehensive, systematic literature search; meta-analyses, assuming a random-effects model for countries with published studies; and regression modelling (data prediction) for countries with either no published studies or too few to obtain an estimate. Results Based on 24 existing studies, the pooled prevalence of alcohol consumption during pregnancy among the general population was estimated for Brazil (15.2%; 95% confidence interval [95%CI]: 10.4%–20.8%) and Mexico (1.2%; 95%CI: 0.0%–2.7%). The prevalence of alcohol consumption during pregnancy among the general population was predicted for 31 countries and ranged from 4.8% (95%CI: 4.2%–5.4%) in Cuba to 23.3% (95%CI: 20.1%–26.5%) in Grenada. Conclusions Greater prevention efforts and measures are needed in the countries of Latin America and the Caribbean to prevent pregnant women from consuming alcohol during pregnancy and decrease the rates of Fetal Alcohol Spectrum Disorder. Additional high quality studies on the prevalence of alcohol consumption during pregnancy in Latin America and the Caribbean are also needed.

RESUMO Objetivo Estimar a prevalência do consumo de álcool na gravidez na população geral da América Latina e Caribe, por país, em 2012. Métodos Três etapas foram realizadas: (i) uma busca sistemática abrangente da literatura científica, (ii) meta-análises a partir de um modelo de efeitos aleatórios para os países com estudos publicados e (iii) modelos de regressão (predição de dados) para os países sem nenhum estudo publicado ou com um número muito pequeno de estudos para obter uma estimativa. Resultados Com base em 24 estudos identificados, estimou-se a prevalência conjunta do consumo de álcool na gravidez na população geral no Brasil (15,2%; intervalo de confiança de 95% [IC 95%] 10,4%–20,8%) e no México (1,2%; IC 95% 0,0%–2,7%). A prevalência do consumo de álcool na gravidez na população geral foi prevista em 31 países, variando de 4,8% (IC 95% 4,2%–5,4%) em Cuba a 23,3% (IC 95% 20,1%–26,5%) em Granada. Conclusões Um grande esforço de prevenção com a adoção de medidas preventivas se faz necessário nos países da América Latina e Caribe para prevenir o uso de álcool entre gestantes durante a gravidez e reduzir os índices de transtornos do espectro alcoólico fetal. Também são necessários outros estudos de alta qualidade da prevalência do consumo de álcool na gravidez na América Latina e no Caribe.

RESUMEN Objetivo Calcular la prevalencia del consumo de alcohol durante el embarazo en la población general de América Latina y el Caribe desglosada por país y para el año 2012. Métodos Se siguieron tres pasos: 1) una búsqueda bibliográfica sistemática y amplia; 2) metanálisis, en los que se supuso un modelo de efectos aleatorios respecto de los países sobre los que se disponía de estudios publicados; y 3) el modelado de regresión (predicción de datos) respecto de los países sobre los que no se disponía de ningún estudio publicado o estos eran demasiado escasos para obtener estimaciones. Resultados Sobre la base de los 24 estudios existentes, se calculó la prevalencia combinada del consumo de alcohol durante el embarazo en la población general de Brasil (15,2 %; intervalo de confianza [IC] del 95 %: 10,4-20,8 %) y México (1,2 %; IC del 95 %: 0,0-2,7 %). También se calculó la prevalencia prevista del consumo de alcohol durante el embarazo en la población general de 31 países, cálculo que arrojó datos comprendidos entre 4,8 % (IC del 95 %: 4,2-5,4 %) en Cuba y 23,3 % (IC del 95%: 20,1-26,5 %) en Granada. Conclusiones Es preciso redoblar los esfuerzos de prevención e intensificar las medidas en los países de América Latina y el Caribe para impedir que las embarazadas consuman alcohol durante el embarazo a fin de reducir las tasas de los trastornos del espectro alcohólico fetal. También se deben realizar más estudios de buena calidad sobre la prevalencia del consumo de alcohol durante el embarazo en América Latina y el Caribe.

Policy implications of marked reversals of population life expectancy caused by substance use.

BACKGROUND: Life expectancy has been increasing steadily over the past century in most countries, with only a few exceptions such as during wartimes. DISCUSSION: Marked reversal of life expectancy has been linked to substance use and related policies. Three such examples are discussed herein, namely the double reversal of life expectancy trends (first to positive, then to negative) associated with reducing alcohol supply in the then Union of Soviet Socialist Republics (USSR), followed by a rapid increase in availability; the impact of the rapid increase of prescription opioids on white non-Hispanics in the US; and the systemic impact of the violence accompanying the drug war in Mexico on the life expectancy of men. Alcohol policies were crucial to initiate the positive reversal in the USSR, and different substance use policies could have avoided the negative impacts on life expectancy of the described large groups or nations. Substance use policies can be responsible for abrupt negative changes in life expectancies. An orientation of such policies towards the goals of public health and societal well-being can help avoid such changes.

Alcohol consumption and burden of disease in the Americas in 2012: implications for alcohol policy / El consumo de alcohol y la carga de morbilidad en la región de las Américas en el 2012: implicaciones para las políticas relacionadas con el consumo de alcohol

OBJECTIVE:To describe the volume and patterns of alcohol consumption up to and including 2012, and to estimate the burden of disease attributable to alcohol consumption as measured in deaths and disability-adjusted life years (DALYs) lost in the Americas in 2012. METHODS: Measures of alcohol consumption were obtained from the World Health Organization (WHO) Global Information System on Alcohol and Health (GISAH). The burden of alcohol consumption was estimated in both deaths and DALYs lost based on mortality data obtained from WHO, using alcohol-attributable fractions. Regional groupings for the Americas were based on the WHO classifications for 2004 (according to child and adult mortality). RESULTS: Regional variations were observed in the overall volume of alcohol consumed, the proportion of the alcohol market attributable to unrecorded alcohol consumption, drinking patterns, prevalence of drinking, and prevalence of heavy episodic drinking, with inhabitants of the Americas consuming more alcohol (8.4 L of pure alcohol per adult in 2012) compared to the world average. The Americas also experienced a high burden of disease attributable to alcohol consumption (4.7% of all deaths and 6.7% of all DALYs lost), especially in terms of injuries attributable to alcohol consumption. CONCLUSIONS: Alcohol is consumed in a harmful manner in the Americas, leading to a high burden of disease, especially in terms of injuries. New cost-effective alcohol policies, such as increasing alcohol taxation, increasing the minimum legal age to purchase alcohol, and decreasing the maximum legal blood alcohol content while driving, should be implemented to decrease the harmful consumption of alcohol and the resulting burden of disease.

OBJETIVO:Describir el volumen y los modelos de consumo de alcohol hasta el año 2012 incluido, y calcular la carga de morbilidad atribuible al consumo de alcohol medida según el número de defunciones y los años de vida ajustados en función de la discapacidad (AVAD) perdidos en la Región de las Américas en el 2012. MÉTODOS: Los datos sobre el consumo de alcohol se obtuvieron a partir del Sistema Mundial de Información sobre el Alcohol y la Salud (GISAH, por sus siglas en inglés) de la Organización Mundial de la Salud (OMS). La carga del consumo de alcohol se calculó según la mortalidad y según los AVAD perdidos con base en los datos de mortalidad obtenidos de la OMS, tomando en consideración las fracciones atribuibles al alcohol. La división en subregiones se basó en las clasificaciones de la OMS del año 2004 (según la mortalidad en niños y adultos). RESULTADOS: Se observaron variaciones regionales en el volumen total de alcohol consumido, la proporción del mercado del alcohol atribuible al consumo de alcohol no registrado, los hábitos de consumo, la prevalencia del consumo y la prevalencia de los episodios de consumo excesivo de alcohol. Los habitantes de la Región de las Américas consumieron más alcohol (8,4 litros de alcohol puro por adulto en el 2012) en comparación con el promedio mundial. La Región también experimentó una alta carga de morbilidad atribuible al consumo de alcohol (4,7% de las defunciones y 6,7% de los AVAD perdidos), especialmente en forma de lesiones atribuibles al consumo de alcohol. CONCLUSIONES: El alcohol se consume de una manera perjudicial en la Región de las Américas y ello comporta una alta carga de morbilidad, especialmente en forma de lesiones. Con objeto de disminuir el consumo perjudicial de bebidas alcohólicas y la carga de morbilidad resultante, es preciso introducir nuevas políticas en materia de consumo de alcohol que sean eficaces en función de los costos, tales como el incremento de los impuestos sobre el alcohol, el aumento de la edad mínima legal para adquirir alcohol, y la disminución de la concentración máxima legal de alcohol en sangre mientras se conduce.

Alcohol consumption and burden of disease in the Americas in 2012: implications for alcohol policy / El consumo de alcohol y la carga de morbilidad en la Región de las Américas en el 2012: implicaciones para las políticas relacionadas con el consumo de alcohol

Objective. To describe the volume and patterns of alcohol consumption up to and including 2012, and to estimate the burden of disease attributable to alcohol consumption as measured in deaths and disability-adjusted life years (DALYs) lost in the Americas in 2012. Methods. Measures of alcohol consumption were obtained from the World Health Organization (WHO) Global Information System on Alcohol and Health (GISAH). The burden of alcohol consumption was estimated in both deaths and DALYs lost based on mortality data obtained from WHO, using alcohol-attributable fractions. Regional groupings for the Americas were based on the WHO classifications for 2004 (according to child and adult mortality). Results. Regional variations were observed in the overall volume of alcohol consumed, the proportion of the alcohol market attributable to unrecorded alcohol consumption, drinking patterns, prevalence of drinking, and prevalence of heavy episodic drinking, with inhabitants of the Americas consuming more alcohol (8.4 L of pure alcohol per adult in 2012) compared to the world average. The Americas also experienced a high burden of disease attributable to alcohol consumption (4.7% of all deaths and 6.7% of all DALYs lost), especially in terms of injuries attributable to alcohol consumption. Conclusions. Alcohol is consumed in a harmful manner in the Americas, leading to a high burden of disease, especially in terms of injuries. New cost-effective alcohol policies, such as increasing alcohol taxation, increasing the minimum legal age to purchase alcohol, and decreasing the maximum legal blood alcohol content while driving, should be implemented to decrease the harmful consumption of alcohol and the resulting burden of disease.

Objetivo. Describir el volumen y los modelos de consumo de alcohol hasta el año 2012 incluido, y calcular la carga de morbilidad atribuible al consumo de alcohol medida según el número de defunciones y los años de vida ajustados en función de la discapacidad (AVAD) perdidos en la Región de las Américas en el 2012. Métodos. Los datos sobre el consumo de alcohol se obtuvieron a partir del Sistema Mundial de Información sobre el Alcohol y la Salud (GISAH, por sus siglas en inglés) de la Organización Mundial de la Salud (OMS). La carga del consumo de alcohol se calculó según la mortalidad y según los AVAD perdidos con base en los datos de mortalidad obtenidos de la OMS, tomando en consideración las fracciones atribuibles al alcohol. La división en subregiones se basó en las clasificaciones de la OMS del año 2004 (según la mortalidad en niños y adultos). Resultados. Se observaron variaciones regionales en el volumen total de alcohol consumido, la proporción del mercado del alcohol atribuible al consumo de alcohol no registrado, los hábitos de consumo, la prevalencia del consumo y la prevalencia de los episodios de consumo excesivo de alcohol. Los habitantes de la Región de las Américas consumieron más alcohol (8,4 litros de alcohol puro por adulto en el 2012) en comparación con el promedio mundial. La Región también experimentó una alta carga de morbilidad atribuible al consumo de alcohol (4,7% de las defunciones y 6,7% de los AVAD perdidos), especialmente en forma de lesiones atribuibles al consumo de alcohol. Conclusiones. El alcohol se consume de una manera perjudicial en la Región de las Américas y ello comporta una alta carga de morbilidad, especialmente en forma de lesiones. Con objeto de disminuir el consumo perjudicial de bebidas alcohólicas y la carga de morbilidad resultante, es preciso introducir nuevas políticas en materia de consumo de alcohol que sean eficaces en función de los costos, tales como el increment de los impuestos sobre el alcohol, el aumento de la edad mínima legal para adquirir alcohol, y la disminución de la concentración máxima legal de alcohol en sangre mientras se conduce.

[Alcohol consumption pattern and coronary heart disease risk in metropolitan São Paulo: analyses of GENACIS Project]. / Consumo de álcool e risco para doença coronariana na região metropolitana de São Paulo: uma análise do Projeto GENACIS.

OBJECTIVES: To examine the association between patterns of drinking and coronary heart disease (CHD) risk in a populational sample. METHODS: A population-based cross-sectional study carried out from January 2006 to June 2007, in Metropolitan São Paulo, Brazil, in conjunction with the international collaborative GENACIS project (Gender, Alcohol, and Culture: an International Study), with PAHO support. The subjects (1,501; 609 men, 892 women) of this study were residents of randomly chosen households aged 30 years and above who consented to provide information. The dependent variable was cardiac risk as assessed by the WHO Rose Angina Questionnaire. Logistic Regression analysis was used and the data were adjusted for Body Mass Index (BMI) and smoking. RESULTS: The response rate was 75%. Being female, older, African-American, a current smoker, and having a greater BMI were associated with higher risk of coronary heart disease. Lifetime abstainers (OR = 2.22) and former drinkers (OR = 2.42) had greater CHD risk than those who consumed up to 19g pure alcohol per day, with no binge. Among those who had binged weekly or more there was a tendency toward higher risk (OR = 3.95, p = .09). CONCLUSIONS: Our findings suggest a lower risk for CHD among moderate drinkers. It is important, in studies which were investigating cardiac risk, assess heavy alcohol use, since it can change that risk. Also, effective public policies are needed to reduce harmful drinking and related morbidity in Brazil.

Consumo de álcool e risco para doença coronariana na região metropolitana de São Paulo: uma análise do Projeto GENACIS / Alcohol consumption pattern and Coronary Heart Disease risk in Metropolitan São Paulo: analyses of GENACIS Project

OBJETIVOS: Examinar a associação entre consumo de álcool e risco para doença coronariana em amostra populacional. MÉTODOS: Estudo transversal, de base populacional, conduzido de janeiro/2006 a junho/2007, na região metropolitana de São Paulo, como parte do estudo internacional (Gender, Alcohol, and Culture: an International Study). Os sujeitos (1.501, sendo 609 homens e 892 mulheres) eram residentes da região metropolitana de São Paulo, tinham 30 anos ou mais de idade e foram selecionados aleatoriamente, a partir de amostragem complexa por conglomerados. Todos os indivíduos consentiram em participar da pesquisa. A variável dependente foi risco cardíaco avaliado através do WHO Rose Angina Questionnaire. A análise multivariada consistiu em regressão logística, tendo sido realizado ajuste para uso de tabaco e índice de massa corpórea. RESULTADOS: A taxa de resposta foi 75%. Ser mulher, ter mais idade, ser negro, fumante e ter um índice de massa corpórea elevado, foram associados a maior risco para doença coronariana. Indivíduos que nunca beberam na vida (OR = 2,22) e ex-bebedores (OR = 2,42) tiveram maior risco de doença cardíaca do que aqueles que informaram beber até 19 g de álcool por dia, sem episódios de beber excessivo. Entre os que tiveram episódios de embriaguês observou-se uma tendência a maior risco (OR = 3,95, p = 0,09). CONCLUSÕES: Nossos achados sugerem um menor risco para doença coronariana entre os bebedores moderados. Destaca-se que os estudos que avaliam o impacto do álcool sobre doença cardíaca precisam identificar o padrão de uso de álcool dos sujeitos, visto que este aspecto pode modificar o risco. Políticas públicas são necessárias para reduzir ...

OBJECTIVES: To examine the association between patterns of drinking and coronary heart disease (CHD) risk in a populational sample. METHODS: A population-based cross-sectional study carried out from January 2006 to June 2007, in Metropolitan São Paulo, Brazil, in conjunction with the international collaborative GENACIS project (Gender, Alcohol, and Culture: an International Study), with PAHO support. The subjects (1,501; 609 men, 892 women) of this study were residents of randomly chosen households aged 30 years and above who consented to provide information. The dependent variable was cardiac risk as assessed by the WHO Rose Angina Questionnaire. Logistic Regression analysis was used and the data were adjusted for Body Mass Index (BMI) and smoking. RESULTS: The response rate was 75%. Being female, older, African-American, a current smoker, and having a greater BMI were associated with higher risk of coronary heart disease. Lifetime abstainers (OR = 2.22) and former drinkers (OR = 2.42) had greater CHD risk than those who consumed up to 19g pure alcohol per day, with no binge. Among those who had binged weekly or more there was a tendency toward higher risk (OR = 3.95, p = .09). CONCLUSIONS: Our findings suggest a lower risk for CHD among moderate drinkers. It is important, in studies which were investigating cardiac risk, assess heavy alcohol use, since it can change that risk. Also, effective public policies are needed to reduce harmful drinking and related morbidity in Brazil. .

Alcohol, diabetes, and public health in the Americas / Alcohol, diabetes y salud pública en las Américas

This article describes epidemiological evidence on the association between alcohol use and diabetes, and the implications for clinical management and public health policies in the Americas. Heavy alcohol use is a risk factor for both diabetes and poor treatment adherence, despite evidence that moderate drinking can protect against type 2 diabetes under some circumstances. The burden of disease from diabetes associated with excessive alcohol consumption warrants both clinical and public health measures. On the clinical level, research on early interventions to prevent hazardous drinking shows that new screening, brief intervention, and referral techniques are effective ways to manage hazardous drinking in primary care settings. On the population level, restrictions on alcohol marketing and other alcohol control policies reduce the frequency and intensity of alcohol consumption in at-risk populations. These policy actions are recommended within the context of the World Health Organization's global strategy to reduce the harmful use of alcohol

Este artículo describe las pruebas epidemiológicas de la asociación entre el consumo de alcohol y la diabetes, así como sus implicaciones para el manejo clínico y las políticas de salud pública en las Américas. Aunque existe evidencia de que, en determinadas circunstancias, el consumo moderado de alcohol puede proteger contra la diabetes de tipo políticas de control reducen la frecuencia y la intensidad del consumo de alcohol en las poblaciones en riesgo. Estas acciones de política se recomiendan en el contexto de la estrategia mundial de la Organización Mundial de la Salud para reducir el consumo de alcohol nocivo

Cancer risk assessment of ethyl carbamate in alcoholic beverages from Brazil with special consideration to the spirits cachaça and tiquira.

BACKGROUND: Ethyl carbamate (EC) is a multi-site carcinogen in experimental animals and probably carcinogenic to humans (IARC group 2A). Traces of EC below health-relevant ranges naturally occur in several fermented foods and beverages, while higher concentrations above 1 mg/l are regularly detected in only certain spirits derived from cyanogenic plants. In Brazil this concerns the sugarcane spirit cachaça and the manioc (cassava) spirit tiquira, which both regularly exceed the national EC limit of 0.15 mg/l. This study aims to estimate human exposure in Brazil and provide a quantitative risk assessment. METHODS: The human dietary intake of EC via alcoholic beverages was estimated based on WHO alcohol consumption data in combination with own surveys and literature data. This data comprises the EC contents of the different beverage groups cachaça, tiquira, other spirits, beer, wine, and unrecorded alcohol (as defined by the WHO; including alcohol which is not captured in routine government statistics nor taxed). The risk assessment was conducted using the margin of exposure (MOE) approach with benchmark doses obtained from dose-response modelling of animal experiments. Lifetime cancer risk was calculated using the T25 dose descriptor. RESULTS: Considering differences between pot-still and column-still cachaça, its average EC content would be 0.38 mg/l. Tiquira contained a considerably higher average EC content of 2.34 mg/l. The whole population exposure from all alcoholic beverages was calculated to be around 100 to 200 ng/kg bw/day, with cachaça and unrecorded alcohol as the major contributing factors. The MOE was calculated to range between 400 and 2,466, with the lifetime cancer risk at approximately 3 cases in 10,000. An even higher risk may exist for binge-drinkers of cachaça and tiquira with MOEs of up to 80 and 15, respectively. CONCLUSIONS: According to our risk assessment, EC poses a significant cancer risk for the alcohol-drinking population in Brazil, in addition to that of alcohol alone. Model calculations show that the implementation of the 0.15 mg/l limit for cachaça would be beneficial, including an increase of the MOE by a factor between 3 to 6. The implementation of policy measures for tiquira and unrecorded alcohol also appears to be advisable.

Artisanal alcohol production in Mayan Guatemala: chemical safety evaluation with special regard to acetaldehyde contamination.

There is a lack of knowledge regarding the composition, production, distribution, and consumption of artisanal alcohol, particularly in the developing world. In Nahualá, an indigenous Mayan municipality located in highland Guatemala, heavy alcohol consumption appears to have had a significant negative impact on health, a major role in cases of violence and domestic abuse, and a link to street habitation. Cuxa, an artisanally, as well as commercially produced sugarcane alcohol, is widely consumed by heavy drinkers in this community. Cuxa samples from all distribution points in the community were obtained and chemically analyzed for health-relevant constituents and contaminants including methanol, acetaldehyde, higher alcohols, and metals. From those, only acetaldehyde was confirmed to be present in unusually high levels (up to 126 g/hl of pure alcohol), particularly in samples that were produced clandestinely. Acetaldehyde has been evaluated as "possibly carcinogenic" and has also been identified as having significant human exposure in a recent risk assessment. This study explores the reasons for the elevated levels of acetaldehyde, through both sampling and analyses of raw and intermediary products of cuxa production, as well as interviews from producers of the clandestine alcohol. For further insight, we experimentally produced this alcohol in our laboratory, based on the directions provided by the producers, as well as materials from the town itself. Based on these data, the origin of the acetaldehyde contamination appears to be due to chemical changes induced during processing, with the major causative factors consisting of poor hygiene, aerobic working conditions, and inadequate yeast strains, compounded by flawed distillation methodology that neglects separation of the first fractions of the distillate. These results indicate a preventable public health concern for consumers, which can be overcome through education about good manufacturing practices, as well as financial incentives to separate the acetaldehyde-rich fractions during distillation.