Michela Morleo Mark A. Bellis Clare Perkins Kerin L. Hannon Kirstie Clegg Penny A. Cook January 2010 Foreword by Dr Ruth Hussey OBE Obesity and the use of alcohol are two of the major threats to the public’s health. Both are linked to cancer, heart disease and a variety of other major killers that prematurely end many people’s lives and create years of poor health. All too often we address these issues in silos with expertise in food and in alcohol but with the overlap between the two being poorly understood by professionals and consequently under-utilised in the pursuit of improving the public’s health. Little professional understanding means the public are not in possession of the information they need to make healthy choices about food and alcohol. Encouraged by advertisements and marketing, consumers can adopt poor food and high alcohol diets without realising both will contribute to their risks of long term disease. Individuals may also skip food in order to get drunk more quickly or try to eat certain food types in order to delay inebriation but have little understanding of the health consequences of either action. It is essential that we consider food and alcohol together; improve our understanding of the substantial overlaps between these two issues; and ensure the public are aware of the dangers and benefits that food and alcohol together represent. This report is a first step in this process and, while it is far from comprehensive, outlines much shared territory which we need to understand. I hope people working on food, alcohol and generic public health issues find it of interest and that it leads to new opportunities to tackle the burden of ill health created by the widespread over consumption of food and drink. Dr Ruth Hussey, OBE Regional Director of Public Health / Senior Medical Director for NHS North West and DH North West Acknowledgements The authors would like to thank the following individuals for their help and guidance during the compiling of this document: Jane Thomas at Liverpool Primary Care Trust; Allan Hackett at the Centre for Tourism, Consumer and Food Studies, Liverpool John Moores University; and Zara Anderson, Gill Elliott, Karen Hughes, Penny Phillips-Howard and Lee Tisdall at the Centre for Public Health, Liverpool John Moores University. Contents Overview page 2 1. Introduction page 3 2. Alcohol as a food page 5 3. Combined consumption - the positive health effects? page 10 4. Harms related to both food and alcohol page 12 5. Interventions for promoting healthy food and alcohol consumption page 17 6. Discussion page 23 7. References page 25 1 Overview • In the UK, food and alcohol are often viewed as separate issues despite many of the biggest health challenges facing the UK relating to both. Public and professional understanding of the links between food and alcohol are generally poorly developed. Inconsistent and conflicting messages can inevitably influence choices people make about consumption. well as additives and other ingredients being consumed. • In the absence of information on calories and other nutrient content of alcohol products, myths about the benefits of drinking alcohol remain. For instance, it is widely reported that stout has a high iron content although it may take six pints to reach even the basic recommended daily allowance of iron. • Two large glasses of white wine equate to almost a fifth of a woman’s daily calorie requirements whilst three pints of lager equate to about a fifth of a man’s. However, public awareness of the calorie content of alcohol is relatively low. • The cardio-protective effects of alcohol when linked with fatty food consumption are poorly communicated. Evidence suggests that drinking less than one unit a day will provide protective effects and drinking more does not significantly increase protection. In fact, whether such protection occurs at all is still debated. • Drinking alcohol can affect levels of hunger and food preferences. Even moderate alcohol consumption may increase preferences for fatty and high sugar foods, with such cravings contributing to risks of obesity. Box 1: Government recommendations for energy intake and alcohol consumption • Lower risk drinking for adults is defined as no more than 2-3 units (1 unit = 10 mls of pure alcohol; see Table 1) per day for women, and no more than 3-4 units of alcohol per day for men.[2] One glass of wine would be approximately two to three units (depending on its volume and strength), or one and a half to two pints of lager for a man. Having a few days a week where alcohol is not consumed is also recommended.i • Many people have multiple behavioural health risks linked to eating, low physical activity and alcohol consumption. Together these are likely to reinforce and accelerate each other’s contributions to morbidity. In fact, a number of major diseases including cancer, cardiovascular and liver disease have strong links to both unhealthy eating patterns and alcohol misuse. However, links between these behaviours are poorly understood. • The NHS recommends an average daily calorie intake of 2,000 per day for women and 2,500 for men.ii Typically, a beef casserole with mash and vegetables would equate to approximately 500 calories.iii • Failure to recognise alcohol as a food (together with resistance from the alcohol industry) has meant that most alcoholic drinks are exempt from normal food labelling requirements. Consumers are, therefore, unaware of the calorie content of drinks as i ii iii See http://www.nhs.uk/chq/Pages/846.aspx?CategoryID=87&SubCategoryID=87. See http://www.nhs.uk/chq/Pages/1126.aspx?CategoryID=51&SubCategoryID=165. See http://www.nhs.uk/Livewell/Loseweight/Pages/Healthyfoodswaps.aspx. 2 • Eating food before or while drinking alcohol appears to reduce the rate of alcohol absorption into the bloodstream, potentially reducing the immediate risk of drunkenness. However, such information, rather than being used by nightlife patrons to reduce drunkenness, is often used to increase inebriation through fasting before drinking via an Eating is Cheating attitude. alcohol-related violence and generally provide high fat and calorie foods. • Off trade measures to combine alcohol and food typically focus on increasing sales of both. Offers such as a meal for two and a bottle of wine for £10 can suggest half a bottle of wine is a safe and acceptable amount to consume with a meal at night when consumption at such levels would actually mean exceeding the recommended daily maximums. • Coffee consumption appears to reduce the risk of developing alcoholic liver cirrhosis in drinkers. However, both coffee and alcohol may contribute to hypertensive disease and lowering alcohol consumption is a safer and more effective way of reducing risk. • UK policy must address the links between alcohol and food in order to maximise the effectiveness of public health responses and enable people to make better informed choices about eating and drinking. We urgently need to move away from seeing alcohol as a means to achieve inebriation to regarding it as an accompaniment to food with both being consumed in moderation. • Those on calorie controlled diets may dangerously reduce nutritious food intake to save calories that they wish to use for alcohol consumption. This has been termed drunkorexia. • The roots of food and alcohol problems have been linked to similar early life experiences. Poor education has been linked to low levels of activity, obesity and alcohol consumption problems in later life. Further, the ACE (Adverse Childhood Experiences) study has linked negative childhood experiences with early onset of alcohol,[1] higher levels of alcohol abuse as an adult and risk of obesity. 1 Introduction • Nightlife settings provide some key challenges for tackling food and alcohol issues. Although tapas-like food in bars may help reduce the rate at which individuals become intoxicated, the UK's typical provision of salty snacks (crisps and nuts) may (deliberately or otherwise) increase thirst and consequently alcohol consumption. Alcohol has been consumed for millennia both as a catalyst for social enjoyment at meals,[3] and as part of daily nutrition.[4] Until the seventeenth century, wine was the only storable drink as water was often unsafe and ale deteriorated quickly.[5] However, wine was an unaffordable luxury for most, leaving ale as one of the only safe drinks available to the masses until the widespread establishment of clean public water systems. • The design of many town and city centre bars is not conducive to the sale of more substantive food products or more relaxed drinking rates (with an absence of tables and seating). Fast food outlets, which can offer more substantive food, can be the focus of 3 ‘It [wine] makes the perfect drink with food, adding its own seasoning, cutting the richness of fat, making meat seem more tender and washing down dry pulses and unleavened bread without distending the belly.’ intrinsically linked to local culture. For many, alcohol is considered as a means to intoxication with food sometimes avoided either to hasten inebriation[15,16] or limit calorie intake whilst drinking.[16] There is no equivalent history of tapas provision in UK bars and it has even been suggested that the salty snacks (e.g. nuts and crisps) or meals frequently on sale in these establishments are a method of increasing thirst,[17] and therefore sales. However, some pubs are now allowing takeaways to be brought into and eaten in the pub primarily in an attempt to retain custom.[18] Johnson: The story of wine (1991; p: 5[3]) Patterns of consumption of food and drink should be considered as part of a healthy diet and lifestyle. Yet today, in Europe alone, there are marked differences in the extent to which alcohol and food are viewed as separate issues or considered together as an integral part of diet and lifestyle. The ‘Mediterranean’ approach to eating and drinking (which is caricatured as moderate alcohol consumption; low consumption of meat and meat products; and high consumption of vegetables, fruits, nuts and olive oil) has been seen as an ideal for a healthier society [6,7] and is associated with reduced mortality.[8] Consumption of non-processed Mediterranean foods including olive oil, fish, fresh fruit and vegetables has contributed to lower levels of chronic illnesses such as heart disease among older populations.[9,10] Alcohol may also play a role. In general, European wines have lower alcohol contents than those from the New World,[11] and their complex taste and higher tannin levels may encourage consumption with food.[12] Combined consumption of alcohol and food is customary in the Mediterranean[6,13,14] and in Spain, licensed premises have traditionally served small plates of food (tapas) with alcoholic drinks to avoid the effects of consumption on an empty stomach. The Government strategy for improving health and reducing health inequalities focuses on the wider determinants of health and seeks to address food and alcohol behaviour, along with physical activity and smoking. Despite recognition that these behaviours are inextricably linked, the relevant policies and interventions to improve health are often not. For example, national policies for reducing cancer and coronary heart disease either handle alcohol and obesity as separate issues [19] or mention them as contributory factors but do not suggest how prevention could follow a more combined approach.[20, 21] Equally, alcohol policy does not address the links with other foods.[2] In order to examine the public health potential in the UK for utilising intelligence on the relationship between food and alcohol, this review explores: • how consumption of food and consumption of alcohol are interrelated; • the benefits and consequences of combined consumption; In the United Kingdom, the definition of food encompasses all foodiv and drink products including those containing alcohol, and thus alcohol should be subject to basic food regulations. However, food and alcohol are often viewed as being separate issues by individuals, health professionals and policy-makers, and are not considered in the context of a lifestyle iv • the relationship between harms associated with alcohol consumption and unhealthy eating; and • interventions that aim to promote both healthy eating and lower risk alcohol consumption. “Food” is defined as any substance or product, whether processed, partially processed or unprocessed, intended to be, or reasonably expected to be, ingested by humans (see http://www.food.gov.uk/consultations/ukwideconsults/2004/foodsafetyuk2004). 4 2 Alcohol as a food 2.1 Box 2: Some factors affecting the speed of alcohol processing in the body 1. Weight: On average the liver processes around 0.1g of alcohol per hour per kilogram of body weight.[25] Thus, an average male of 83.6kg [26] would metabolise 8.4g of alcohol per hour (equivalent to approximately one unit). Processing alcohol in the body The process of breaking down or metabolising most food products (including alcohol) begins in the stomach but occurs throughout the digestive system until items are absorbed. Whilst the bloodstream exposes all tissues and organs to the alcohol absorbed, the liver is disproportionately exposed as it receives blood straight from the digestive tract.[22] A whole range of factors affect the rate of metabolism of alcohol such as body weight and food consumed (see Box 2). Thus, certain individuals may be more vulnerable to excessive consumption of alcohol and related harms, and the propensity for inebriation is not static. 2. Tolerance: Heavier drinkers process alcohol more quickly than occasional drinkers [22, 27, 28] as a drinker’s liver develops more enzymes for the destruction of alcohol. However, ultimately this can also damage the liver.[29] 3. Gender: Women are affected more by alcohol than men partly as a result of body size but also because they have lower levels of enzyme activity for alcohol breakdown.[22, 30] Thus, men may eliminate alcohol faster than women when comparing breathalyser results.[31] Those who drink excessively may suffer from hangovers as alcohol is metabolised, with the suggestion that hangovers may occur when the body’s blood alcohol concentration (BAC) returns to around zero (although empirical evidence for this is not provided).[23] Symptoms include: drowsiness, lack of concentration, dizziness, nausea, anxiety and gastro-intestinal complaints. In extreme cases, binge drinkers may suffer hypoglycaemia (i.e. low blood glucose). The precise mechanisms underpinning hangovers are still unknown. However, dehydration, and reduced sleep duration and quality may be involved, and factors such as food consumption may alleviate symptoms.[23, 24] 4. Age: Elderly people process alcohol more slowly due to a reduction in the effectiveness of the liver, and alcohol processing can slow further when individuals are on certain medications.[32] 5. Liver damage: The health of an individual’s liver affects alcohol processing as alcoholinduced liver damage can disrupt normal metabolism.[33] 6. Food consumption: Food in the stomach reduces the rate at which alcohol passes through the stomach to the small intestine where absorption is fastest (Section 3.4.5).[22] 7. Type of alcohol: Drinks aerated with carbon dioxide (champagne or those with soda) are absorbed into the blood more quickly.[22] The rate of absorption also increases with alcoholic strength from 10% to 20% ABV (alcohol by volume).[34] Up to 10% ABV, alcohol products may be insufficient to stimulate quick absorption. After 20% ABV, the rate of absorption declines due to increased secretion of stomach mucus in response to toxicity.[34] 5 2.2 Table 1). Exact calorific content will vary with alcoholic strength and between brands, but with no requirement for alcohol producers to place calorie information on their products (see Section 5.2.2), accurate assessment by consumers is impossible. This may explain why levels of awareness of the calorie content of drinks are relatively low: in a survey of 1,954 drinkers in England, two fifths (42%) of women did not know that the calorie contents of a glass of white wine could equate to a bag of crisps and two fifths (40%) of males were unaware that a pint of lager can have a similar number of calories to a sausage roll.[36] Alcohol and nutrition Historically, drinks such as beer were viewed as highly nutritious but changes in large scale manufacturing (for example, longer fermentation) have reduced nutritional content; although no specific details are available as to the extent of this.[4] Typically, many of today’s alcoholic drinks are highly calorific but provide relatively little other nutritional value (Table 1). A gram of alcohol provides 7.1 kilocalories (kcal), nearly as much as a gram of fat (9.1 kcal) and considerably more than protein or carbohydrate (4.1 kcal/gram).[35] Regular and binge drinkers can accumulate considerable quantities of calories from alcohol. 2.2.1 Alcohol is good for you? A female adult consuming two large glasses (250mls) of white wine (6.2 units) consumes 375 kcal or 18.8% of her daily energy requirement, whilst a male drinking three pints of lager (8.4 units) could have consumed a fifth (19.8%) of his daily energy requirement (494 kcal; Box 1; Table 1: Despite relatively low nutritional value (Table 1), some alcohol products have been associated with good health. In the earlier part of the twentieth century, a particular stoutv (Guinness) was advertised as being “good for you”.vi Pregnant women, nursing mothers, blood Approximate nutritional and alcohol content of selected drinks* Low alcohol Lager (568ml lager (568ml / / one pint) one pint) 568 568 165 57 689 238 23 68 86 9 Spirits: gin and vodka (25 ml) 15 56 232 0 0 Fresh orange Coca Cola juice (250ml) (250ml) *** 225 250 95 98 397 408 5 20 24 26 Red wine (250ml) White wine (250ml) Weight (g) Energy (kcal) Energy (KJ) Sodium (mg) Carbohydrate (g) 225 170 711 25 0 240 188 785 53 9 Protein (g) Fat (g) Vitamin B1 / Thiamine (mg) Vitamin B3 / Niacin (mg) 0.6 0 0.3 0 4 0 11 0 0 0 3 0 0 0 0 0 0 0 0 0 0 0.2 0 0 0.2 0.2 1.9 2.8 0 0.5 0 0 0 0 0.1 0.2 0 0.1 0 0 N/A N/A N/A N/A N/A N/A Vitamin B6 / Pyridoxine (mg) Number of units Energy (kcal) per unit 3.3 (for wine 3.1 (for wine 0.9 (for spirits 2.8 (for lager 1.1 (for lager at 13.2% at 12.3% at 37.5% at 5% ABV**) at 2% ABV**) ABV**) ABV**) ABV) 51.5 60.5 58.8 51.6 61.7 Diet cola (250ml) 250 3 10 13 0 * Individual drinks were weighed in order to calculate nutritional contents through Microdiet Plus. ** Alcohol by volume (ABV) is the percentage of alcohol content in a beverage, by volume. Average strength for wine was calculated in Table 2. Average strengths for lager and spirits were calculated by Drinkaware.com. *** Orange juice also contains other vitamins such as vitamin C; however this table has been limited to specific types of vitamin B for brevity. Source: Microdiet Plus for Windows (2001); Drinkaware.com. v vi Stouts are dark beers made using roasted malt. See http://www2.guinness.com/en-gb/Pages/Adsdetails.aspx?adid=26 for examples of historical Guinness adverts. 6 donors and post-operative patients were advised to drink it because of its supposed high iron content.[37] In fact, it would take six pints of stout to obtain the recommended daily allowance for males.vii Other foods, such as kidney beans, are much higher in iron. • Quantity consumed: Any such cardioprotective effects are established at drinking quantities below a unit a day and do not appear to increase significantly at higher levels of consumption.[41, 44] • Other conditions: For many drinkers, cardiovascular health gains will be cancelled out because of the negative impacts of alcohol consumption, even at lower levels, on the risk of conditions such as cancers (see Section 4).[45] Red wine has also been hypothesised as having beneficial effects. Compounds found in red wine such as polyphenols (e.g. Resveratrol) have been ascribed cardiovascular health benefits.[39] However, the levels of resveratrol that would need to be routinely consumed in order to affect cardiovascular health would be vast.[40] • Dietary factors: See Section 3.1. 2.3 It is hard to see how drinking, or even swimming in, red wine can provide sufficient resveratrol to reach protective levels. There are strong associations between increased alcohol consumption and elevated body weight, particularly in men. Research in Spain (n=15,630) showed a linear relationship between Body Mass Index (BMI)viii and alcohol for males, whereby increasing alcohol consumption was associated with obesity (p<0.001; the criteria for obesity were not specified).[41] In fact, alcohol consumption can contribute to weight gain directly through its involvement in overall energy intake (see Section 2.2). The links between alcohol and weight are highlighted below: Corder: The wine diet (2007; p.37 [40]) More recently, procyanidins (which are also found in foods including chocolate, and fruits such as cranberries and apples) have been suggested as being the protective substance.[40] However, recent research in Spain indicates that red wine has no cardio-protective abilities above those of any other alcoholic drink.[41] In fact, the much celebrated relationship between alcohol consumption and lower cardiovascular disease is also complicated by a variety of factors which suggest the benefits have been exaggerated if not erroneous: • Levels of alcohol consumption: High levels and more intense patterns of drinking are associated with indicators of obesity.[4951]ix For example, in a study of 23 pairs of identical twins (who were discordant for obesity), the obese twin was more likely to report overconsuming items such as alcohol compared with their lean twin (95.7% compared with 17.4% respectively; p<0.05).[50] However, some studies suggest moderate alcohol consumption can be associated with weight maintenance or even • Lifetime consumption: Individuals who are ill from conditions such as cardiovascular disease may give up alcohol but be classified as non-drinkers, thus creating the impression that abstinence carries a higher risk to health than drinking in [41-43] moderation. When such individuals are accounted for appropriately, cardiac protection associated with moderate alcohol consumption diminishes. vii viii ix Alcohol and weight Reports on the iron content of stout vary widely (from 0.11mg per pint to 1.1) and Microdiet does not provide estimates for iron contents. However, if we take the most generous report found, one pint of stout would contain 1.1mg of iron.[37] The estimated average daily iron requirement for an adult male in the UK is 6.7mg.[38] For women (18-50 years), the average daily requirement is 11.4 mg, and 6.7mg for older women. BMI can be used to calculate likelihood of an individual being underweight or overweight. Weight in kilograms is divided by height in metres squared. Having a BMI of less than 20 is seen as being underweight, and a BMI of over 30 is seen as obese.[46,47] However, BMI does not account for muscularity and is not appropriate for some ethnic groups, young people or pregnant women.[48] See http://www.nutrition.org.uk/home.asp?siteId=43§ionId=408&parentSection=321. Heavy drinkers are here defined as those consuming at least 21 units per week, and alcohol consumption levels are compared with central adiposity indicators (such as BMI).[49] More intense drinking patterns are where individuals do not necessarily drink everyday, but drink in much larger quantities when drinking does occur,[51] (such as binge drinkers). Dorn et al. compared alcohol consumption with abdominal height - the height of an individual’s abdomen when they are lying down.[51] 7 weight loss.[51,52] For example, daily consumption of less than one drinkx per drinking day was inversely associated with obesity in New York (USA; n=2,343), particularly for women and wine consumers (who were more likely to be women).[51] However, confounding factors may be present. Firstly, grape juice can have similar effects.[53]xi Secondly, non-drinkers may be more likely to report higher intake of sucrose, chocolate and candy (or sweets), the latter two being particularly the case for women.[52]xii Thus, lower levels of snacking amongst moderate drinkers may reduce their risk of weight gain when compared with non-drinkers. a calorie limit.[16] This has been labelled drunkorexia.[60] Further, those concerned about their weight may choose only to drink when they intend to become drunk, as doing otherwise could waste allotted calories.[16] “Alcohol has calories. If you plan on drinking, plan accordingly, even if that means skipping a meal (or two).” Joel: Losing weight: tips and tricks (2006).[57] • Alcohol consumption and eating disorders: Misuse of alcohol can be associated with eating disorders: a US survey of over 9,200 adults showed that a quarter of those suffering from anorexia nervosa and a third of bulimia sufferers reported alcohol abuse or dependence.[61]xiii • Type of alcoholic drink: Beer consumption has typically been associated with weight gain more than, for instance, wine [54] and has often been associated with gynecomastia (abnormal development of male mammary glands). Higher levels of gynecomastia have been found in chronic alcoholics (a study in India compared 200 alcoholics with matched controls).[55] However, not all studies agree that beer in particular is linked with either obesity or gynecomastia.[56] Instead, simply more intense or higher levels of alcohol consumption may contribute to risks.[51] “A female friend of mine would skip meals before going out and partying, she was really anorexic but she used to drink a lot.” Samantha, young female, USA.[16] • Alcohol consumption and fatigue: Increased levels of intoxication are associated with feelings of lethargy, at least in young people.[62] This may affect motivations for physical activity and, if this occurs regularly, can impact on weight maintenance. 2.4 • Substitution: Those dependent on alcohol may substitute alcohol for food, meaning that heavy drinking can be further complicated by malnutrition.[58] Other groups at risk of substitution include those suffering economic deprivation (for example, in South Africa[59]) and those on calorie controlled diets. Here, women in particular may substitute alcohol-derived energy for food in order to consume alcohol and remain within x xi xii xiii The impact of increased strength of drinks In Ancient Rome and Greece, it was considered “barbaric” to consume undiluted wine.[4] Yet, today this is the norm in the UK and the strength of many alcoholic drinks has increased in recent years, particularly wine [63] due, in part, to the use of riper fruits.[64,65] Typically, wines are approximately 12.8%ABV with higher levels of alcohol in red wine and in wines produced outside Europe (Table 2).[11] However, table wine Participants were provided with examples of containers typically used for alcohol and asked to identify potential beverage size for usual drinks.[51] Ethanol grams were then calculated by using the factors: wine 0.121, wine coolers 0.040, beer 0.045 and liquor (or spirits) 0.409. The effects of a diet where 10% of energy was derived from grape juice was compared against a diet where 10% of energy was derived from white wine.[53] Researchers studied questionnaires from 89,538 female, married, registered nurses involved in the Nurses’ Health Study in 1976 and 48,493 males aged 40-75 years involved in the Health Professionals Follow-up Study in 1986.[52] Diagnoses were categorised through the World Health Organization Composite International Diagnostic Interview (CIDI), which generates diagnoses according to the ICD10 (International Classification of Diseases) and the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders.[61] 8 can be as strong as 15%ABV whilst high strength lagers are available at 9%ABV (equivalent to lower strength wines). Quantities of alcohol consumed have also increased through a move towards larger measures. For example, wine glasses of 175ml or 250ml are served rather than 125ml.[66]xiv Because of such changes, national calculations of unit consumption have been adjusted to provide a Table 2: more accurate understanding of quantities consumed.[68] However, little information is available on how calorific content has altered with higher alcohol consumption. Certainly, little or no efforts have been made to communicate any changes to the public and most available information does not provide details of calorific or other content (e.g. sugar) other than the alcoholic strength of the drink. Strength of wine by region of origin and type of wine* Red wine Outside Europe Total Overall (red and white wine) Mean %ABV Mean number of units per 75 cl bottle Mean %ABV Mean number of units per 75 cl bottle Mean %ABV Mean number of units per 75 cl bottle (95%CI) (95%CI) (95%CI) (95%CI) (95%CI) (95%CI) 12.8 9.6 11.8 8.8 12.3 9.2 (12.7-13.0) (9.5-9.7) (11.4-12.2) (8.5-9.1) (12.0-12.5) (9.0-9.4) 13.5 10.1 12.8 9.6 13.2 9.9 (13.3-13.7) (10.0-10.3) (12.6-13.0) (9.5-9.8) (13.0-13.3) (9.8-10.0) 13.2 9.9 12.3 9.2 12.8 9.6 (13.0-13.3) (9.8-10.0) (12.1-12.5) (9.1-9.4) (12.6-12.9) (9.5-9.7) Region Europe White wine * A survey of 271 different types of red and white wine (75cl bottles) was conducted in October 2008, through Tesco’s online shopping facility. This table presents their mean %ABV and 95% confidence intervals (95%CI). The differences in ABV between both regions of origin and type of wine (red or white) were statistically significant (p<0.001). However, it should be noted that the UK guide to European Union wine regulations states that the percentage ABV provided can be within 0.8% of the actual strength and so the accuracy of the details provided it is not known.xv 2.5 Patterns of combined consumption USA (n=165,057) has shown that higher levels of consumption are associated with elevated BMI. Here, those who consumed an average of one drinkxvi per drinking day had a mean BMI of 25.8 (95% confidence interval (95%CI): 25.725.9) compared with those who drank four or more who had a mean BMI of 26.8 (95%CI: 26.7-27.0).[70] Consuming food before drinking alcohol can slow the absorption of alcohol into the bloodstream and subsequent levels of intoxication (see Box 2). Conversely, alcohol consumption (at 24g or three units) has been linked to higher levels of food consumption, with hunger potentially being increased up to six hours after drinking compared with baseline (although study sizes are small).[69] Low levels of alcohol consumption (for instance, 8g or one unit) do not appear to promote increased food intake,[69] supporting findings that moderate drinking (as part of an overall healthy lifestyle) may not necessarily result in weight gain. However, a cross-sectional national study in the 2.5.1 Combined consumption in childhood Childhood obesity may contribute towards early alcohol use. In a study of two nationally representative samples of girls in the USA,[71]xvii higher relative weight was associated with increased likelihood of having reached menarche earlier while early pubertal maturation xiv There has been a move away from the 125ml glasses in favour of the larger glass sizes and purchasing by the bottle (reported in: [67]). See http://www.food.gov.uk/multimedia/pdfs/euwineregs.pdf. xvi The term “drink” was not explicitly defined by the paper.[70] Participants were asked the number of drinks they had consumed in a given time period. xvii Data were extracted from cycles II and III of the National Health Examination Survey (NHES; 1963-70) and the Third National Health and Nutrition Examination Survey (NHANES III; 1988-1994).[71] Data from the NHES cycles related to girls aged 10 years old and above at last birthday and from girls aged 12-15 at last birthday respectively were used. For NHANES III, data from individuals aged 10-15 years were used. Combined, full data existed for 4,598 individuals. xv 9 predicted alcohol use disorders (in 1,420 males and females aged 9-13 years, Western North California[72]). Recent studies in the UK have also shown links between childhood obesity, early puberty and subsequent early alcohol consumption and drunkenness.[73] Importantly, as studies have better controlled for the differences between drinkers and non-drinkers, the protective effects of moderate alcohol consumption have diminished.[44] 3.2 Historically, alcohol (especially in the form of wine) was seen as the only safe and storable drink[5] with consumption reducing an individual's chances of contracting gastrointestinal infections that are associated with unclean water. Even today, alcohol consumption can be associated with a small reduction in the risk of food poisoning.[79-81] For instance in Spain, 51 people were infected by an acute salmonella outbreak at an event.[79] Compared with non-drinkers, those who drank up to 40g (up to five units) at the event were 23% less likely to have been affected and those who had consumed more than this were 43% less likely. In a similar incident, beverages with an alcoholic content up to 10%ABV appeared to offer the most protection compared with non-alcoholic drinks and those over 10%ABV.[82] There is a lack of understanding as to how this occurs; although removal of poison through a diuretic effect [83] and facilitating the eradication of the organism in the gastro-intestinal tract have both been postulated as likely mechanisms.[81] Critically, alcohol provides no guarantee of protection and high doses can be fatal through, for example, alcohol poisoning.[84] Furthermore, if an individual contracts food poisoning, alcohol should be avoided to prevent further dehydration.xviii 3 Combined consumption – the positive health effects? 3.1 Cardiovascular disease In France, the incidence of cardiovascular disease has historically been considerably lower than elsewhere even though their diet is not lower in saturated fat or cholesterol.[74] Whilst the cause is uncertain, one protective factor mooted is higher consumption of red wine.[75] Regardless, the much celebrated relationship between alcohol consumption and lower cardiovascular disease is complicated by a variety of factors, (see Section 2.2.1), including dietary factors: • Consumption with a meal: Any effects of red wine (or alcohol) may rely on whether alcohol is consumed with a meal: in New York (USA), Stranges et al. showed that participants mostly consuming alcohol without food were at a significantly higher risk of hypertension than lifetime abstainers or those who mostly drank alcohol with food (n=2,609).[76] • Diet: Wine drinkers tend to eat healthier diets, exercise more and occupy relatively affluent socio-economic groups compared with non-drinkers and other drinkers.[77, 78] Research in New York (USA; n=3,756, aged 35-79 years) showed that wine drinkers may consume higher quantities of fruit and vegetables than other drinkers.[78] xviii xix Food poisoning 3.3 Diabetes A meta-analysisxix of 15 prospective cohort studies has highlighted that alcohol may offer protective effects against type 2 diabetes.[85] Here, risk of type 2 diabetes was found to be lowest amongst those who drank 12-24g (1.5- Please see http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=411§ionId=11 for more information. A meta-analysis is a statistical technique which combines the results from a number of independent studies. This then provides an overall understanding of the impact of a given factor, such as the effect of alcohol on diabetes. 10 hypoglycaemia.[92] However, a systematic review concluded that there was no compelling evidence to suggest that such sugars could prevent or treat a hangover.[93]xx Further, regular application can contribute to weight gain. 3.0 units) per day compared with non-drinkers. For those consuming more than 48g per day (more than 6.0 units), risk was equivalent to non-drinkers. However, as with heart disease, it is likely that other factors such as lifestyle and diet are involved (see Section 3.1). 3.4 3.4.3 Dietary supplements Foods protective against the effects of alcohol misuse Alcohol consumption can lead to an imbalance of minerals and vitamins.[29] Thus, academic reviews of early research suggest that chronic alcohol consumption can be associated with a reduced intake of vitamin B1 (or thiamine).[94,95] Critically, vitamin B1 may play a key role in maintaining cognitive functioning [96,97] and in extreme cases a lack of this vitamin has been linked with the development of WernickeKorsakoff syndrome in heavy drinkers (Box 3). 3.4.1 Coffee Whilst coffee cannot provide sobriety, it has long been seen as an antidote to alcohol and, to some extent, can be used to restore controlled behaviour.[4,86,87] Further, coffee may offer some protection against liver cirrhosis,[88-90] that other caffeinated drinks such as tea do not.[88,90] In a US longitudinal study of 125,580 people (197885), the risk of developing alcoholic liver cirrhosis fell with increased coffee consumption: those drinking four or more cups of coffee per day were 80% less likely to develop alcoholic liver cirrhosis than non-coffee drinkers.[90] There was no such relationship for non-alcoholic liver cirrhosis. However, some participants who claimed lifelong abstinence (or very low levels of drinking) did in fact develop the condition. Importantly, abstinence from alcohol or low levels of consumption are far more effective at preventing liver disease than coffee.[90] Further, a systematic review concluded that increased regular caffeine consumption may be linked with high blood pressure for those already prone to hypertension,[91] a condition also linked with alcohol consumption (see Section 4.2). Box 3: Wernicke-Korsakoff syndrome Heavy drinkers are at risk of developing Wernicke-Korsakoff syndrome, where short term memory loss is experienced due to a lack of vitamin B1.[99,100] The severity of the extent of memory loss can result in institutionalisation as sufferers cannot process any new information. Heavy drinkers are at risk because of poor eating habits, frequent vomiting (reducing vitamin intake), and inflammation to the stomach lining (obstructing vitamin absorption). Although the condition tends to be seen in older men, women are also susceptible. Treatment is through abstinence and a healthy diet. In Australia in 1987, the National Health and Medical Research Council (NHMRC) recommended adding vitamin B1 to beer and flagon wine to tackle this.[100] However, this was rejected as it conflicts with sensible drinking health messages,[101] especially as those at risk are likely to be heavy drinkers already and such a tactic might provide an incentive to continue consumption. The population level effects of alcohol on memory are poorly studied but in a study of 15-16 year old drinkers (North West of England; n=9,833), 45% reported having 3.4.2 Sugary diets Excessive alcohol consumption can result in a fall in blood sugar levels and lead to fatigue, weakness, shakiness, mood disturbances and in extreme cases, hypoglycaemia.[24] Folk remedies to help sober up and treat hangovers include cola for rehydration and to boost sugar levels. Glucose can also help to prevent xx A systematic review identified 15 trials examining eight agents: fructose, glucose, propranolol, tropisetron, tolfenamic acid, and the dietary supplements Borago officinalis (borage), Cynara scolymus (artichoke) and Opuntia ficus-indica (prickly pear).[93] None were shown to be effective in preventing or treating a hangover. 11 drunkenness.[22,105] Carbohydrates, especially, are thought to slow the rate of absorption,[22] making individuals feel less drunk[106] and potentially reducing peaks in blood alcohol levels. However, all alcohol absorbed still has to be processed by the liver, regardless of how quickly absorption occurs. Further, a controlled experiment investigating the impact of different diets found no significant effect of carbohydrates compared with a high-fat or protein diet.[31]xxiii Researchers also compared the effects of eating a meal one hour before consuming alcohol with fasting for 12 hours before alcohol consumption. This showed alcohol elimination rates to be between 25% and 45% higher when participants had eaten beforehand compared with fasting. Alcohol elimination rates were significantly higher for males. Whether combining food with drink reduces or even increases risks such as liver disease remains unclear but some evidence suggests that the risk of hypertension may be lessened when drinking alcohol with food (compared with drinking it alone; see Section 3.1). Moreover, individuals may use knowledge of how food consumption can reduce inebriation by purposefully avoiding food to aide intoxication.[15,16] forgotten things after drinking with a greater prevalence in those drinking more and more often.[102] Some dietary supplements claim to reduce the unwanted side effects of alcohol including low energy levels.[103] Producers suggest that their ingredients, for example succinic and fumaric acids, help to metabolise alcohol and reduce toxic by-products. Another supplement claims to reduce alcohol levels identified through a breathalyser by more than 50% in 40 minutes by accelerating alcohol metabolism.xxi However, large-scale, independent and empirical studies on their effectiveness have yet to be undertakenxxii and any long term consequences of routinely utilising such products to accelerate alcohol metabolism are unknown. 3.4.4 Foetal alcohol syndrome Consumption of alcohol during pregnancy may cause a range of physical, behavioural, and cognitive abnormalities in the unborn child known as foetal alcohol spectrum disorders (FASD; see Section 4.7). Food consumed by the mother may reduce alcohol’s toxicity to the foetus and conversely, malnutrition (at least in animals) may increase risk because of impaired alcohol metabolism.[104] However, the safest way is to avoid alcohol consumption during pregnancy. 4 3.4.5 Intoxication “Me and my friend have a rule that if we go out, eating is cheating. If you eat it is going to soak up all the alcohol.” Harms related to both food and alcohol A number of diseases such as cancer and cardiovascular disease are associated with both alcohol consumption and unhealthy eating.[45,48] However, the relationships are complex and it can be difficult to ascribe particular cases to individual health behaviours.[107] In addition, excessive alcohol consumption can complicate conditions further because of its association Female, 18 - 20 years old.[15] Eating food before or with alcohol reduces the rate of alcohol absorption into the bloodstream and potentially reduces the immediate risk of xxi Sixty-four participants were involved in a placebo-controlled, randomized clinical trial. Pepp contains digestive and metabolic enzymes, organic acids, vitamins and nutrients. These aim to break down and reduce the effects of alcohol. See www.pepp-up.com. xxii To our knowledge no peer-reviewed published studies are available on their evaluation. xxiii In study one (n=20), the same subjects experienced two settings: firstly, alcohol elimination rates were studied after a 12-hour fast and secondly the rates were studied one hour after consuming a breakfast of 530 calories.[31] In the second study (n=8), four settings were compared: after a 12-hour fast; and one hour after a high-fat, high-protein or high-carbohydrate meal (each consisting of 530 calories). Breathalysers were used to monitor alcohol elimination rates. 12 with poor self care.[108] Regardless, highlighting the links between alcohol, unhealthy eating and harm is important in developing effective interventions. 4.1 approximately 1-2 mmHg (millimetres of mercury) for each 10g of alcohol (1.3 units) routinely consumed per day for those who drink over 30g per day (3.8 units),[115] and 1 mmHg for every 1.7kg increase in body weight for men or 1.25kg for women.[116]xxv. Even for children, US research shows that obese children (12-16 year olds with a BMI in the 95th percentile) are three times more at risk of hypertension than nonobese children (33% compared with 11%; n=2,460).[117] In England, a quarter of hypertension cases admitted to hospital in males and a tenth in females are estimated to be alcohol-related.[45] Research has also investigated the links with heart failure. In the USA, longitudinal research (n=5,881) has shown that obese individuals (BMI of 30 or more) are at double the risk of heart failure than non obese and that a rise in BMI by one increment increases the risk of heart failure by 5% for men and 7% for women.[118] For alcohol it is estimated that 0.4% of cases of heart failure for males and 0.2% for females are associated with alcohol consumption.[45] Thus, overall, hypertension and cardiovascular risks are highest in higher consumers of food and of alcohol. Cancer Approximately a third of the population in England and Wales develop cancer in their lifetime and it causes a quarter of all deaths.[109] Few studies report on the combined effect of alcohol and obesity for cancer, other than as a confounding variable[110] or within the same study but as isolated issues.[111] However, certain types of cancer are related to both alcohol use and obesity including: breast, colon, liver, oesophageal and stomach.[45,110] A 16-year longitudinal study in the USA (n=900,053) identified that fatalities from cancer in the morbidly obese (BMI of over 40) were 52% higher in males and 62% higher in females compared with those within the normal range (BMI=18.5-24.9).[110] For alcohol, the Million Women Study in the UK suggested that for every drink (10g) additionally consumed per day, the incidence of cancer for women (under 75 years) in developed countries increased by 11 per 1,000 for breast cancer, one per 1,000 for oral cavity and pharynx cancers, and 0.7 per 1,000 for oesophageal, larynx and liver cancers.[112]xxiv Thus, the World Report on Cancer expressly states that to avoid cancer, there are no safe levels of alcohol consumption.[113] 4.2 4.3 Incidents of choking can be brought on by eating too fast or through alcohol consumption. In an investigation of 133 choking mortalities in San Diego (USA) from 1994 to 2004, 14% of individuals had consumed alcohol prior to choking.[119] In 2005/06 in England, there were 364 person-specific hospital admissions due to inhalation of gastric contents that were related to alcohol.[45] Individuals suffering from alcohol poisoning (caused by excessive consumption) may experience a suppression of normal reflexes, unconsciousness, and nausea or vomiting.[62] In such circumstances, vomit may not be effectively eradicated from the body, Hypertension and Cardiovascular disease Conditions such as hypertension (or high blood pressure) and cardiovascular disease (including strokes, transient ischaemic attacks, angina and peripheral vascular disease) cause millions of premature deaths worldwide every year.[114] The links with alcohol and unhealthy eating patterns are evident. Blood pressure can rise by xxiv xxv Choking Allen et al. routinely followed 1,280,296 middle-aged women in the UK.[112] Doll et al.’s study was based on a sample population of 3,116 people aged between 35 and 64 years old who were not taking medication for hypertension.[116] Participants were recruited from both the Seychelles and Switzerland. 13 leading to suffocation.[120] In England in 2008, alcohol poisoning resulted in 149 deaths.[121] Young people may be particularly at risk.[62] 4.4 4.6 Mental health issues affect one in four families worldwide.[131] Conditions such as depression are related to excessive alcohol consumption, obesity, and eating disorders.[132-135] For example, in a sample of female inpatients (n=2,436) being treated for eating disorders in New Mexico (USA; 1995-2000), 97% showed one or more comorbid diagnoses such as unipolar depression, anxiety disorders and substance use disorders (including alcohol).[133] Relationships are also apparent between suicidal behaviour and eating disorders, obesity or alcohol consumption.[134,136,137] For example, an American study (n=40,829) showed that obese women (with a BMI of over 30) were more likely to report major depression (odds ratio (OR): 1.37; 95% CI: 1.09-1.73) and suicide ideation (OR: 1.20; 95% CI: 0.96-1.50) in the past year compared with those of average weight (BMI of 20.78-29.99).[134] Equally in 427 suicides in 1999 in Estonia, 10% of cases showed evidence of alcohol abuse and 51% of dependence (compared with 7% and 14% of control individuals selected at random from general practitioner records; p<0.001 and p<0.001 respectively).[136] Dental health Dental health affects health and wellbeing through its impacts on speech, self-esteem, and the ability to chew and swallow food.[122] Unhealthy alcohol and food consumption can both affect dental health. Heavy drinkers are more likely to experience gingival bleeding than those who consume less.[123]xxvi This can lead to periodontal disease. A study in Cleveland (USA) of 13,665 adults highlighted that those who are obese (BMI of 30 or more) are 1.8 times more at risk of periodontal disease.[124] In addition, dental erosion may be associated with frequent vomiting (defined here as being at least weekly).[125] Thus, bulimics and binge drinkers (who may vomit frequently) may be at higher risk. Of course, many non-alcoholic drinks are also related to poor dental health, especially those with a high sugar content.[125] 4.5 Liver conditions and other digestive disorders Rates of liver cirrhosis increased in Britain by 69% for males and 44% for females between 1987/1991 and 1997/2001, compared with declines in most other Western European countries.[126] Obesity and excessive alcohol consumption are strongly linked to fatty liver disease and liver cirrhosis.[45,127-129] For example, a meta-analysis highlighted how consumption of 25g (3.1 units) of alcohol daily tripled the risk of liver cirrhosis compared with non-drinkers.[128] Alcohol consumption and obesity are also linked with other digestive disorders including pancreatitis and digestive tract [45,110,128,130] cancers. xxvi Mental health 4.6 Nightlife harms Patterns of food and alcohol consumption in nightlife may present a number of harms: • Large numbers of people drinking in town and city centres can create competition between drunk individuals over late night resources (such as takeaways) and may lead to violence.[138,139] • US research highlighted that energy drinks containing caffeine and sugar can increase perceptions of stamina over a night out.[140] In fact, those who mix alcohol and energy drinks may be twice as likely to experience harms including accidents than those who do not.[141] In a study in Erie County, New York (USA; n=1,371 aged 25 years to 74),[123] those reported to be consuming five or more drinks per day were 1.65 times more likely to experience higher gingival bleeding (95% CI: 1.22-2.23) compared with those consuming less. One drink was defined as 12 ounces of beer, four ounces of wine or one ounce of hard liquor (spirits). 14 more than two alcoholic drinks.[36] Consumption of kebabs combined with average alcohol consumption on a night out equate to a calorie intake of 2,177 kcal for males, 87.1% of their recommended daily intake, and 1,731 kcal for females, 86.5% of their recommended daily intake (Table 3). Individuals consuming an unhealthy breakfast to ease their hangover (such as a fry-up or bacon sandwich, which 28% of drinkers reported doing in the above survey) further elevate their calorific intake. This contributes to risks of becoming overweight especially if such behaviour is routine. Further, as such food may be salty,xxvii they may increase thirst and so raise alcohol consumption. • Individuals who may want to remain within a calorie controlled diet while drinking[16] or simply look thinner when going out may choose not to eat that day (see also Section 2.3). “I am dead skinny when I am drunk, I would wear the skimpiest little bikini and I would look fab in it.” Female (21-24 yrs).[15] • Body image concerns can motivate alcohol consumption as individuals may drink to feel more comfortable with their size.[15] • Nightlife users may become hungry because of alcohol's appetite stimulant effects, craving fatty and high carbohydrate food with strong tastes. In a recent survey of English drinkers (n= 1,954), 29% reported that they ordered crisps, nuts or pork scratchings (although frequency is not provided) and 19% regularly consume a pizza, burger, chips or kebab when drinking 4.7 Reproductive health • Reproductive health: Both alcohol and obesity may be linked with cancers affecting the reproductive organs,[45,110] and infertility Table 3: Number of alcohol units and calories consumed on a typical night out in Liverpool by nightlife users aged 18-35 years (n=424)* and examples of food consumed** Males Females Mean number of units (95%CI) Mean number of kilocalories (95%CI) Mean number of units (95%CI) Mean number of kilocalories (95%CI) Alcohol consumed when pre-loading 4.0 (3.3-4.6) 232.5 (195.4-269.6) 4.4 (3.7-5.1) 243.5 (202.3-284.7) Alcohol consumed on a night out 19.2 (17.9-20.5) 1,141.2 (1,066.5-1,215.8) 11.5 (10.5-12.4) 677.2 (625.1-729.2) N/A 1,000 N/A 1,000 Total 23.2 (21.7-25.6) 2,176.5 15.9 (14.7-17.0) 1,730.5 Recommended daily intake (or maximum recommended for alcohol) Maximum: 3-4 units Recommended: 2,500 kcal Maximum 2-3 units: Recommended: 2,000 kcal Doner kebab (not including salad or sauces) * Data from a previous survey[143] were re-analysed using the unit and calorie estimates from Table 2. Calorie intake from mixers is not included. ** Mean number of kilocalories for kebabs was provided by a sample of 494 doner kebabs from across the UK.[142] Source: Alcohol data;[143] kebab calorie data;[142] Microdiet Plus for Windows (2001); Drinkaware.com. xxvii A UK sample of 494 doner kebabs (without sauce or salad) on average contained 98% of recommended daily salt allowance.[142] 15 issues.[144,145] This includes erectile dysfunction and/or impotence,[146-148] although here evidence is mixed.[147-149] related behaviour) also has links with poor sleep, with 45% of nearly 2,000 drinkers in a YouGov poll reporting experiencing tiredness the day after drinking.[162] Conversely, alcohol has also been used as an aid to sleep.[163,164] However, a review of earlier academic studies suggests that individuals can become tolerant to its sedative effects,[165] which may lead to increased alcohol consumption to achieve the same effect. Moreover, higher levels of consumption including those associated with alcoholism are linked with poor sleep quality.[164,166] • Risks to an unborn baby: Unhealthy consumption of both alcohol and food are linked with miscarriage and low birth weight.[150-152] For example, consumption of some cheeses during pregnancy can lead to listeriosis and even miscarriage,[153]xxviii whilst approximately one in five spontaneous abortions are thought to be caused by alcohol consumption.[45] In fact, prenatal alcohol consumption has been linked with a wide range of possible consequences for the unborn child such as FASD.[154] Understanding of the precise effects of prenatal alcohol consumption on the unborn baby is limited and in some cases contradictory;[155,156] as collecting evidence is fraught with methodological limitations.[155] 4.8 4.9 • Deprivation: Populations living in more deprived areas may be at elevated risk from harms relating to, for example, both harmful drinking (such as alcohol-related mortality) and obesity.[48,167,168] • Age: Ageing bodies are more susceptible to weight gain[169] and the effects of alcohol.[170] Sleep disorders Lack of sleep can be extremely disruptive, with fatigue elevating the risk of accidents[157] and conditions such as coronary heart disease (through increased arterial calcification[158]). Lack of sleep may be associated with increased appetite, which contributes towards the potential for obesity.[159] A cross-sectional study of 11-16 year olds in South East Texas (USA) suggested that for every hour of lost sleep, the likelihood of obesity increased by 80% (n=383).[160]xxix Further, a study amongst adults in Valencia (Spain; n=1,772), suggested a similar link with individuals reporting at least nine hours of sleep per day having a lower risk of obesity (BMI of 30 or more) than those sleeping for six or less hours (OR: 0.43; 95% CI: 0.27-0.67).[161] Whilst both studies acknowledge that this does not mean that lack of sleep is a causative factor for obesity, it does highlight a significant relationship. Alcohol consumption (and/or xxviii xxix xxx Examples of other ecological and demographic links • Education: A study in Copenhagen (Denmark; n=30,632) highlighted how those receiving less than eight years of education were significantly more likely to drink heavily, have low levels of physical activity and be obese.[171]xxx • Adverse childhood experiences: Research in California (US) has shown that adverse childhood experiences (such as child abuse, parental substance abuse) are strongly related to initiation of alcohol use before 14 years,[1] alcohol abuse as an adult[172] and adult obesity.[173] So, for example, adults (n=13,777; aged 19-92 years) who reported being often hit or injured as children (2.5% of sample) were 1.4 times more likely to have a BMI of 30 or more compared with those who reported no physical abuse (95% CI:1.2-1.6).[173] Kongo et al. looked at the effects of the Portuguese São Jorge cheese, a cheese made from raw cow’s milk. In this study, two of the raw milk samples (n=105) analysed tested positive for the pathogen.[153] Obesity was defined as having a BMI above the 85th percentile for sex and age according to the Centers for Disease Control and Prevention (CDC) growth charts, as well as having 25% body fat for boys and 35% for girls.[160] For the whole sample, the mean undisturbed sleep time was 7.68 hours (range 5.7-9.1 hours). The relationship between years in education and drinking heavily (that is consuming more than 42 drinks per week) was only significant for males.[171] Obesity was defined as having a BMI of more than 28. 16 • Smoking: Smoking has strong associations with both alcohol and weight issues. Individuals who drink often report an increased desire to smoke after consuming alcohol, especially in nightlife.[174] The smoking ban may have helped to curb this, but research carried out in Victoria (Australia) suggests that 75% of smokers frequenting nightlife did not intend to quit following the ban implemented there (n=409).[174] Whilst alcohol has been linked with increased food consumption, smoking can curb appetites and individuals who are attempting to stop smoking often find that their weight increases at least initially (for reviews on this, see: [175,176]). consumption as a whole. A combined approach would be more efficient as settings recommended for intervening are often the same: in schools, in health services (such as general practice), at the point of purchase, in communities, families, and the workplace.[2, 177] 5.1 Providing alternative options • Activities for young people: Providing physical activities can encourage weight loss and protect against risky drinking amongst young people.[178-180] Not only does physical exercise increase energy expenditure but may also raise self-esteem, as in the case of a residential weight loss programme (involving exercise).[181]xxxi This is important because low self-esteem associated with obesity in children may lead to an increased likelihood of drinking alcohol.[182] For alcohol, a survey of teenagers in the North West of England (n= 10,271; aged 15-16) found that drinkers who were members of a sports or youth team were less likely to drink frequentlyxxxii compared with those who were not.[180] However, activities must be affordable, attractive and accessible to all youths. 5 Interventions for promoting healthy food and alcohol consumption Achieving behavioural change at an individual, community and population level is challenging, especially in relation to food and alcohol where the behaviours may be enjoyable and rooted in local culture. Despite this, behaviour change is essential if harms are to be reduced. This section briefly outlines a number of interventions that could be used to tackle unhealthy xxxi xxxii • Activities for adults: Many of the studies surrounding activity provision focus on children; however, such an approach may also be relevant for adults. In UK town and city centres, nightlife is dominated by activities that involve alcohol and, to a lesser extent, eating with few activities available that do not involve consumption. Alternative activities (such as the theatre, dancing studios and so on) could be offered to encourage diversion from consumption and to encourage other groups into town and cities at night. Gateley et al compared 185 overweight children (mean age of 13.9 years) who were enrolled in a six-week residential course for weight loss between 1999 and 2002 with 94 children of similar ages not attending the course.[181] Drink frequently was defined as drinking alcohol at least twice a week.[180] 17 • Food in nightlife: Tapas were introduced in Spain to prevent alcohol consumption on an empty stomach and to reduce the risk of drunkenness (see Section 1).xxxiii Small plates of food are still served in many bars. In Blackburn, providing toast in nightlife environments has been reported to have contributed to reductions in the number of violent incidents; although no formal assessment has been undertaken.[183] Alternative possible foods include: non-salty products (salty foods may encourage further consumption due to thirst); carbohydrates, which may slow the absorption of alcohol into the bloodstream;[22] and fruit,[184] which is healthy and can aid [185] rehydration. provide food, some licensees allow people to eat takeaway meals with bought drinks.[18] However, this may encourage unhealthy consumption of processed foods where healthy takeaways are not always accessible or chosen. In supermarkets, environmental strategies could be utilised to distinguish food and alcohol consumption. For example, supermarkets used to have a dedicated separate section for alcohol, which could be closed off outside licensing hours. Today, however, alcohol is sold alongside all other food and drink products with few warnings of its effects and bright coloured posters and discounts to encourage sales. There have been renewed calls to separate alcohol from other food products in supermarkets through, for example, alcohol only checkouts where alcohol can only be sold by specially trained staff. It is hoped that this would reduce quantities purchased and prevent underage sales.[189] Those measures taken to combine alcohol and food are often offers aimed at selling more alcohol and food. Such measures may encourage individuals to exceed recommended maximum guidelines (e.g. £10 for a meal for two and a bottle of wine (see Box 4). • Alternative environmental strategies: Encouraging venues to supply tables and chairs can create a more relaxed environment and may even encourage slower drinking.xxxiv Such measures make the provision of food more economically attractive as the space and furniture required is already present. Further, mixed use venues may be more profitable over a longer period because they attract different clientele.[188] Although not all venues can xxxiii xxxiv Please see http://www.arrakis.es/~jols/tapas/index2.html for more information. Crowded, uncomfortable, and poorly managed nightlife settings contribute to elevated aggression,[186] increasing the potential for disorder. Venues that encourage vertical drinking (through a lack of seating) have been associated with increased disorder.[187] Licensing conditions can be used here to specify environmental measures because they have the potential to promote a reduction in crime and disorder (one of the aims of the Licensing Act 2003). 18 Box 4: Marketing strategies combining alcohol and food Alcohol Concern recently raised awareness of a marketing strategy being employed by Marks and Spencers, where consumers can purchase a meal for two people and a bottle of wine for £10.[190] Concern was raised because a bottle shared between two would equate to the individuals each consuming more than their recommended daily intake (a bottle of wine is approximately 10 units, using the calculations in Table 1). Further, the offer implied that consumption at such levels with a meal is a sensible consumption pattern. carbohydrate limit may be subject to substitution with members cutting back on food to save points for alcohol, increasing risk for slimmers (see Section 2.3). Guidance for one diet states: “Because there are no prohibited foods, both [alcohol and caffeine] are fine, but you'll have to give up food to make room for the wine.”xxxvi • Providing alternative drinks: A number of lower strength alcoholic drinks (e.g. lower strength beers or Sovio Zinfandel - an equivalent to wine with 5.5%ABV) have been launched, which may also have lower overall calorific content (see Table 1). Their use could help to decrease risk relating to both alcohol and obesity. However, such products typically struggle in the UK and do not reap the benefits of lower taxes and more favourable pricing seen in countries such as the USA and Australia.[63, 191] 5.2 • Diets which suggest reducing carbohydrate intake may inadvertently increase the appeal of stronger drinks (spirits and wine) as they contain fewer carbohydrates than, for instance, lager (see Table 1). Providing advice For alcohol, abstinence and moderation programmes encourage reduced alcohol intake but often have relatively little discussion on the role of food.[192,193] Yet, the North West Big Drink Debate (n=30,857) highlighted that three fifths (59%) of harmful drinkersxxxvii were concerned about the impacts of their consumption on their weight,[194] and national advice on healthy weight maintenance recommends reducing alcohol intake because of its calorific contents.[195] Importantly, such programmes represent an opportunity through which the impacts of alcohol misuse and obesity can be tackled together. 5.2.1 Consumption moderation programmes A key part of weight management programmes (such as Weightwatchers and Slimmers’ World) and weight loss diets is advice on food moderation, but they can also cover alcohol moderation.xxxv However, work is needed to ensure messages for alcohol and food consumption are not contradictory, as for example: • Weight loss diets stipulating that slimmers must stay within an overall points or xxxv GoodHousekeeping compared 14 different diets. The majority of these advocated alcohol moderation. Where this was defined, moderation was much lower than the recommended maximum weekly limits For more information, see http://www.goodhousekeeping.com/health/diet-comparison-results/?diet1=0&diet2=14. xxxvi For more information, see http://www.goodhousekeeping.com/health/diet-comparison-results/?diet1=0&diet2=14. xxxvii Harmful drinkers are defined as those who drink over 35 units per week for females and those who drink over 50 units per week for males.[194] 19 by-products such as gelatine, and whilst these are removed, the final product is not guaranteed to be vegetarian.[202,203] Traces of alcohol may be used to enhance flavour in products such as crisps, although the amounts likely to be present in the final product are tiny.[204] This may be of importance to non-drinkers. 5.2.2 Labelling The European Union (EU) plans to impose standard nutritional information on food labelling to counter obesity. Pre-packaged food will display, for example, quantities of sugar, salt and fat (including saturated).[197] Mixed drinks (alcopops) and drinks of less than 1.2% ABV are included in these regulations but other alcoholic products (wine, lager and spirits) will be exempt. In the UK, food must be labelled highlighting, for example, its ingredients to enable informed decisions (Box 5; Figure 1).[198] Alcohol is not included because it is believed that people are not interested in receiving this information for alcohol.[199,200] However, whilst the European study that informed the EU consultation on labelling [199] showed that participants were not interested in ingredients labelling for beer or wine, it was based on a small number of people across a large geographical area[200] and so cannot be said to be representative of all drinkers. Given the rising levels of obesity and the high calorific value of alcohol, it is difficult to understand why alcohol products do not have to display proper nutritional labelling. Box 5: The Food Standards Agency on labelling “Consumers should be able to be confident with their choice of foods and be able to buy according to their particular requirements, be it for diet and health, personal taste and preferences, or cost.... People who cannot eat certain foods because they are intolerant or allergic to them may suffer severe or life threatening reactions. It makes it much more difficult to avoid these foods if they have incorrect or inaccurate labels.”[196] Comprehensive labels should be provided for alcoholic products, ideally containing: • Nutritional information: This should include ingredients, number of calories and other nutritional properties (such as vitamins and minerals) in line with other food substances. • Strength of alcoholic drink and number of units: A mandatory code should be adopted which requires retailers to provide unit content and health guidelines on each bottle or container in the offlicensed trade. Suggestions for the licensed trade include ensuring such information is available on at least a representative sample of products.[201] • Manufacturing processes: Filtration processes for lager and wine can use animal 20 Figure 1: Labels currently in use Non-alcohol product (fruit juice) Mixed alcohol product (sangria) Alcohol product Labels for alcoholic products display very little nutritional information compared with a mixed alcohol product and food product. Note that the mixed alcohol product has ingredients but does not state the ingredients within wine. 5.2.3 Leaflets 5.3 Community-based lifestyle improvement programmes Leaflets are often used as a way of conveying health promotion messages on a wide variety of different issues including alcohol, smoking and obesity. They provide details on the dangers of risky behaviour, how such behaviours can be changed and support available. Information resources tackling both food and alcohol are rare. However, leaflets published by the Scottish Nutrition and Diet Resources Initiative (SNDRí) on vitamin B1 deficiency (see Section 3.4.3) provide information on the relationship between alcohol and diet, and how a balanced diet is essential to counteract the negative consequences of substitution (where individuals substitute food for alcohol; see Section 2.3).xxxviii No evaluation details were provided. xxxviii Community-based services are available for those who want to stop smoking, reduce alcohol consumption, and lose weight. For example, Connect 4 Life in Tameside and Glossop is a local targeted programme piloted to reduce health inequalities associated with alcohol, smoking, obesity and sedentary lifestyles amongst 50-64 year olds in areas at risk of chronic health problems (n=172).[205] The pilot trialled initiatives including health risk assessments, health coaching and phone support. Along with general health improvements, participants reported a reduction in alcohol intake and an increase in fruit and Copies of these leaflets are available at http://www.caledonian.ac.uk/sndri/index.html and are titled Moving On and Making Changes. 21 vegetable consumption after six months. Its evaluation estimates that if 10,000 people were engaged in the programme for ten years, it would prevent 99 premature deaths.[206] However, robust data on factors such as alcohol consumption and nutrition are so far not available.[205] 5.4 Pricing strategies for food and alcohol are often viewed in isolation from each other with supermarkets reported as having lowered the cost of alcohol but raised the cost of food [212] and little being published on how the price of one affects purchasing behaviour towards the other. In South Africa, high food costs in deprived areas helped to increase the purchasing of alcohol instead of food.[59] Promoting healthy consumption 5.4.2 Marketing campaigns 5.4.1 Price Some health promotion campaigns are bringing together alcohol and food, aiming to raise awareness of the calorific contents of alcohol and its links with weight gain. Pssst! in Liverpool has followed such a strategy, but its evaluation has not examined whether knowledge of calorie contents affected alcohol consumption (Box 6). Nevertheless, lessons could be learned from the alcohol industry in marketing combined consumption: for example, in order to combat the perceived loss in trade from the smoking ban, lower consumer spending and the small alcohol tax rises, licensed venues are increasingly investing in food sales.[213,214] Initiatives include: discounts on combined purchasing (Box 4; Figure 2);[190] opening for breakfast (enabled by the increased flexibility of hours since the Licensing Act 2003, although most early morning customers order coffee rather than alcohol);[215] providing snacks (the smoking ban may have increased snacking in licensed premises[216]); budget carveries and allyou-can-eat offers in pubs;[213] pubs without kitchens encouraging customers to order and eat their takeaways in the pub;xxxix and suggesting particular types of wine and/or beer to accompany specific meals. Price affects purchasing behaviour.[207,208] Modelled data estimate that a 10% price increase in alcohol could reduce the number of alcohol-specific deaths by 29% for males and 37% for females in the UK.[209] However, the timescale for this is not provided. Greater price rises have larger effects: a minimum price of 30p per unit could reduce total crimes by around 3,800 per annum in England whereas 40p could reduce the total number by 16,000 per annum.[207] For food, the situation may be more complex because of the vast choice available, and pricing strategies may be more successful in closed environments such as schools or the workplace.[210] Nevertheless, pricing strategies relating to food and alcohol can be implemented in a number of ways:[208,210] • through taxation increases, a minimum price or linked with the nature of the product (such as the strength of the drink); • through tax incentives for healthier products such as lower strength drinks or fresh produce - campaigners are currently calling for licensed venues to lower the costs of soft drinks (often sold at a similar price to alcoholic drinks) in order to discourage excessive consumption;[211] • using funds raised from increased prices to promote health; and • banning promotions, which encourage unhealthy consumption. xxxix See http://www.viewlondon.co.uk/pubsandbars/the-lion-review-13538.html for more details. 22 Box 6: Pssst! The Pssst! campaign was launched in Liverpool in November 2007 and aimed to change students’ drinking behaviour. Positive messages were provided on enjoying alcohol responsibly using a ‘Chill Out’ cabin sited in one of Liverpool’s key drinking areas, radio coverage and Bluetooth texts. The award-winning brand has been highlighted as an example of good practice.[217] However, whilst the campaign incorporated combined messages surrounding alcohol consumption and obesity, this aspect and its effects on consumption were not assessed under the evaluation.[218-220] Figure 2: Combined discounts on food and alcohol 6 Discussion there is little available research on the effects of combined consumption, and evaluations of combined lifestyle interventions aimed at improving health and reducing health inequalities are limited. Other countries such as those in the Mediterranean have maintained strong links between food and alcohol consumption in local cultures. However, in the UK, such links appear to be missing whilst This report has highlighted the intertwined nature of alcohol and food in relation to consumption and their short and long-term physical and sociological effects. Alcohol affects how we eat food and the food we choose to eat, and unhealthy consumption of alcohol and food contributes significantly to the numbers of people at risk from cardiovascular disease, cancer and liver disease in the UK. However, 23 harms continue to rise. In 2007, almost one in four adults in England were obese and trends suggest levels will continue to increase steeply.[221] Further, there was a 69% increase in alcohol-related admissions to hospital from 2002/03 to 2007/08. If this continues, by 2012, there will be over a million alcohol-related hospital admissions in England.[222] As such, reducing levels of obesity and alcohol-related harm are key priorities for the Government.[2, 177] Further, in order to tackle health inequalities, the Government has outlined the need to challenge the structural boundaries in policy organisation and service delivery (silo working) to promote a cross-cutting approach, ‘building in joined up action nationally and locally, vertically and horizontally’.[223] To date, there is little evidence of this in relation to food and alcohol policy. in reducing mortality and morbidity. Traditionally in the Mediterranean, children were introduced to alcohol gradually at the dinner table within a family setting.[13] Such parenting techniques have been suggested as a method to protect individuals from developing risky drinking patterns. Today, children in the UK are more likely to have drunk a glass of wine, beer or spirits before the age of 13 years than their Mediterranean counterparts but critically are also more likely to have been drunk by 15-16 years (for the latter, 66% in the UK compared with 49% for Europe overall).[225]xi This suggests that early exposure to alcohol alone does not discourage dangerous drinking and, in fact, small-scale US studies show that parental provision may increase risk if drinking is undertaken without establishing the parameters of acceptable behaviour.[226-228] However, in children that drink, parental provision accompanied by setting an example of moderate consumption with food and discussion of limits of responsible drinking may help develop healthier attitudes towards alcohol.[180,228,229] In children that do not drink there are no established benefits of introducing them to alcohol.[230] Many people are likely to have multiple behavioural health risks linked to obesity, smoking and alcohol behaviours,[224] which together are likely to reinforce and accelerate each other’s contributions to morbidity. The Department of Health has stated that it will commission a broader research programme to understand good and bad multiple health behaviours, cluster effects, the impacts of behaviour change, and how to intervene effectively to help people make positive changes and reduce risky behaviours.[223] Until such research becomes available, it would seem logical that initiatives which aim to simultaneously tackle clusters of health behaviours (such as alcohol, smoking, poor diet and obesity) are likely to have a stronger impact than those that address single behaviours.[224] Many current social marketing campaigns fail to realise this potential. In order to reduce levels of obesity and alcoholrelated harm, it may be necessary to adopt a more traditional Mediterranean-style diet and lifestyle in the UK, focusing on the consumption of alcohol as an accompaniment to other foods rather than a mechanism to achieve inebriation. In the UK, such a transition may be facilitated through the wide provision of low alcohol beers and lower alcoholic strength wine; more familyorientated pubs and restaurants with better facilities for children and young people; and food/alcohol outlets offering a healthier range of products, both seasonal and locally sourced. The beginning of this report outlined the perceived benefits of a Mediterranean-style diet xi Here, alcohol consumption refers to having consumed at least one glass of beer, wine or spirits.[225] 24 Encouraging such styles of consumption could be particularly important in young people who may be more likely to binge drink,[231] but may also be least likely to consume alcohol with food.[194] The UK is not alone in needing to promote more responsible diet and drinking behaviours as increases in obesity and evidence for binge drinking are now being reported in Mediterranean countries including Spain.[232,233] Academic reviews suggest this may be as a result of food globalisation, cultural contamination caused in part by increased travelling and improved economic conditions.[6, 7. Tierney J. (2006). 'We want to be more European': The 2003 Licensing Act and Britain's Night-Time Economy. Social Policy and Society, 5(04):453-60. 234] 13. Anderson B. (1968). 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Health and Social Care Information Centre, London. 30 Centre for Public Health Research Directorate Faculty of Health and Applied Social Sciences Liverpool John Moores University Kingsway House 5th Floor Hatton Garden L3 2AJ Tel: 0151 231 8790 Published January 2010 ISBN: 978-1-907441-14-1 (print version) ISBN: 978-1-907441-15-8 (pdf version)
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