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Binge Drinking and the Risk of Liver Events: a Population-­Based Cohort Study

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Binge Drinking and the Risk of Liver Events: a Population-­Based Cohort Study Received: 10 January 2017 | Accepted: 26 February 2017 DOI: 10.1111/liv.13408 GENETIC AND METABOLIC LIVER DISEASE Binge drinking and the risk of liver events: A population- based cohort study Fredrik Åberg1 | Jaana Helenius-Hietala2 | Pauli Puukka3 | Antti Jula3 1Transplantation and Liver Surgery Clinic, Helsinki University Hospital, Helsinki Abstract University, Helsinki, Finland Background & Aims: Binge drinking or heavy episodic drinking is increasingly preva- 2 Department of Oral and Maxillofacial lent, but the health effects are incompletely understood. We investigated whether Diseases, Helsinki University Hospital, Helsinki University, Helsinki, Finland binge drinking increases the risk for liver disease above and beyond the risk due to 3Department of Health, National Institute for average alcohol consumption. Health and Welfare, Turku, Finland Methods: 6366 subjects without baseline liver disease who participated in the Finnish Correspondence population- based Health 2000 Study (2000- 2001), a nationally representative cohort. Fredrik Åberg, MD, PhD, Transplantation Follow- up data from national registers until 2013 were analysed for liver- related ad- and Liver Surgery Clinic, Helsinki University Hospital, Helsinki University, Helsinki, Finland. missions, mortality and liver cancer. Binge drinking (≥5 drinks per occasion, standard Email: [email protected] drink 12 g ethanol) was categorised as weekly, monthly, or as less often or none. Funding information Multiple confounders were considered. FÅ received research grants from Wilhelm and Else Stockmanns Foundation, Liv och Hälsa, Results: Eighty- four subjects developed decompensated liver disease. Binge drinking and Finska Läkaresällskapet. frequency showed a direct association with liver- disease risk after adjustment for aver- Handling Editor: Helena Cortez-Pinto age daily alcohol intake and age. After adjustment, the hazard ratios (HRs) for weekly and monthly binge drinking were 3.45 (P=.001) and 2.26 (P=.007) and were higher after excluding regular heavy drinkers. The HR for weekly binging was 6.82 (P=.02) in women; 2.34 (P=.03) in men; and 4.29 (P=.001) in subjects with the metabolic syndrome. Weekly binge drinking and the metabolic syndrome produced supra- additive increases in the risk of decompensated liver disease. Weekly, and to a lesser extent monthly, binging retained significance in sequential multivariate models that additionally adjusted for beverage preference and lifestyle, metabolic, and socioeconomic factors. Conclusions: Binge drinking is associated with an increased risk for liver disease inde- pendently of average alcohol intake and confounders. The rising prevalence of binge drinking and the metabolic syndrome is particularly concerning. KEYWORDS alcohol, chronic liver disease, cirrhosis, heavy drinking See Editorial on Page 1281 1 | INTRODUCTION liver conditions, and there are 170 000 annual deaths from liver cir- rhosis plus another 47 000 annual deaths from liver cancer.2 Chronic liver disease represents a major health burden worldwide.1,2 Alcohol is the strongest risk factor for liver cirrhosis. At the popula- In Europe alone, an estimated 29 million people suffer from chronic tion level, there is a clear dose- response relationship between alcohol consumption and the incidence of liver cirrhosis.3 However, only 15%- 20% of heavy alcohol drinkers develop liver cirrhosis.4-6 Therefore, aver- Abbreviations: GGT, gamma-glutamyl transferase; HR, hazards ratio. age alcohol exposure alone is insufficient to explain alcohol use as a risk Liver International. 2017;37:1373–1381. wileyonlinelibrary.com/journal/liv © 2017 John Wiley & Sons A/S. | 1373 Published by John Wiley & Sons Ltd 1374 | ÅBERG ET AL. factor for liver disease. Individual susceptibility to alcoholic liver disease and the effect of alcohol in the context of co- existent risk factors for liver Key points disease remain incompletely understood. The pattern of alcohol intake • At the population level, alcohol has a dose-related asso- and spirit type has been suggested to modify the risk of liver disease. ciation with risk of chronic liver disease, but individual The phenomenon of drinking too much too fast, termed binge drink- risk factors, such as binge drinking, remains unclear. ing, is growing in Western countries, especially in the UK and northern • We found that binge drinking (≥5 alcohol drinks per occa- 7 Europe. Although there is no standard definition of binge drinking, the sion) at least once monthly is associated with an elevated most widely used definition is the consumption of five or more drinks risk of incident liver disease independently of average on a single occasion or day, or sometimes modified to ≥5 drinks for men alcohol consumption. 7-10 and ≥4 drinks for women in about 2 hours. Around 20% of adults in • Binge drinking seems particularly harmful when the meta- 9 Europe and 17% in USA report binge drinking up to once a week. bolic syndrome co-exists. Most epidemiological studies of liver outcomes analyse average • Binge drinking should be considered in the assessment of alcohol intake; fewer specifically address binge drinking, and few of alcohol use and in the assessment of patients with liver these have been conducted in countries with a high prevalence of disease. binge drinking. It is widely acknowledged that the common quantity- frequency measures of alcohol intake used in most studies fail to cap- ture a habit of weekend binging superimposed on top of regular low intake on weekdays.7,8,11 informed consent for future registry linkage. The Epidemiology Ethics Animal studies suggest that binge drinking alone induces liver Committee of the Helsinki and Uusimaa Hospital Region approved the damage and increases liver injury in chronically alcohol- exposed liv- Health 2000 Study protocol, and all participants provided signed in- ers,9,12,13 but human data are limited. Several authors have noted the formed consent. need for further study to define the impact of binge drinking on the Respondents were asked to report how often they consumed risk of liver disease,9,10,12,14-16 and recent guidelines prioritise this alcoholic beverages during the previous 12 months and the average specific research topic.8 amount they consumed per week during the previous month. There Finland has a drinking culture that is characterised by irregular were separate questions for consumption of beer, wine and spirits. heavy drinking, typically concentrated on weekends and outside of Average alcohol consumption (g/d) and beverage- specific consump- mealtimes, and it has lower proportional wine consumption than in tion were calculated based on these data. Participants were also asked southern European countries.17 Metabolic risk factors are common if they had been abstinent their entire life (lifetime abstainer) or had in Finland, but the prevalence of chronic viral hepatitis is very low. used alcohol earlier and then stopped (current abstainer). When a Finland has one of the highest liver- mortality rates in Europe, and liver subject reported that a specific beverage, that is, beer, wine or spir- deaths are rising.2 There is a paucity of longitudinal Finnish studies its, constituted at least 50% of their total alcohol consumption, it was that look at liver- related outcomes. considered the predominant beverage type. We analysed the impact of binge drinking on the risk of liver- Binge drinking was defined as drinking five or more alcohol drinks related outcomes in a Finnish cohort that is representative of the per occasion, in line with previous studies.16,19 Respondents reported entire Finnish population with long- term follow- up. the number of times during the last 12 months that they consumed five or more drinks per occasion. A standard drink in Finland is con- sidered to have 12 g ethanol. Educational level was classified as basic, 2 | MATERIALS AND METHODS secondary or higher. The question about exercise asked how often the subject performs moderate- intensity or high- intensity physical exer- Baseline data were extracted from the Health 2000 Study, which was cise for at least half an hour. a multidisciplinary epidemiologic survey in Finland that involved a re- Metabolic syndrome was defined according to the Joint Interim gional two- stage stratified cluster sampling procedure to ensure that Statement criteria,20 which require three out of five metabolic com- the sample was representative of the entire Finnish population. The ponents for a diagnosis. These components include: waist circum- Health 2000 Study was conducted in 2000- 2001, was coordinated ference ≥94 cm for men and ≥80 cm for women; serum triglycerides by the National Public Health Institute (now known as the National ≥1.7 mmol/L; serum HDL- cholesterol <1.0 mmol/L for men and Institute for Health and Welfare), and originally comprised 8028 <1.3 mmol/L for women; blood pressure ≥130/85 mm Hg or anti- adults aged 30 years and over. Data were collected via structured hypertensive treatment; and fasting serum glucose ≥5.6 mmol/L or home or telephone interviews, self- report questionnaires, clinical diabetes medication. Diabetes was defined either by fasting serum glu- measurements (height, weight, blood pressure), blood tests, and by cose ≥7.0 mmol/L, taking diabetes medication, or a diabetes diagnosis. clinical examination by a physician. The Health- 2000- Study protocol Follow- up data for hospitalisations were obtained from the is described in detail elsewhere.18 National Hospital Discharge Register, which covers
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