Aug 242011
 

This is the 1st of a 3-part discussion on alcohol drinking guidelines:
Part 1: This article
Part 2: Alcohol consumption – science and politics
Part 3: Alcohol consumption – discussion

In June 2011, the Royal College of Psychiatrists published a report “Our invisible addicts” which contained some sloppy analysis that was rightly ridiculed in the media. The Daily Mail has re-opened the discussion, perhaps to fill up spare column-inches: Why an extra glass of wine (or three) does more harm to older drinkers. This gives me an excuse to post some analysis I did before I started this blog.

Sloppy scholarship by the Royal College of Psychiatrists

I am commenting just on the subset of  “Our invisible addicts” covering alcohol guidelines for older people, identified as “aged 65 and over”. Probably most of the report is OK.

I suspect that many journalists got no further than the press release, which said:

“The Working Group makes a series of key recommendations including …. The government issues separate guidance on alcohol consumption for older people. Current recommended ‘safe limits’ are based on work in younger adults. Since there are physiological and metabolic changes associated with aging, these limits are too high for older people. Evidence suggests the upper ‘safe limit’ for older men is 1.5 units per day or 11 units per week, and for women 1 unit per day or 7 units per week.”

There is no such evidence! The report does something that no academic paper should ever do: it attributes to one of its references a position not held.

Of the 60 pages of the report, (mainly concerned with  mental issues, as expected of psychiatrists), about 1 page deals with the physical consequences of aging on alcohol tolerance. On page 35 it states:

“The concept of ‘sensible limits’ in assessing harm from alcohol is now more than 15 years old. Over the past 5 years, new evidence has emerged that suggests that guidelines for people aged 65 and over should be changed. The original concept of drinking over ‘sensible limits’ arose from a consensus statement from a working group of the Royal Colleges of Physicians, Psychiatrists and General Practitioners in 1995, defining recommended weekly limits of 21 units of alcohol for men and 14 units for women (Royal College of Physicians, 1995)….

“More recent evidence from the USA, based on alcohol-related harm/alcohol misuse, has defined ‘at-risk’ drinking in older people as being more than 1.5 units of alcohol on any one day or more than 11 units per week for both men and women (National Institutes of Health, 2005).”

(I’ll deal with their erroneous statement about when and how the ‘sensible limits’ arose below). The References section lists: “National Institutes of Health (2005) Helping Patients Who Drink Too Much: A Clinician’s Guide. NIH.” That document  does not even hint at a 1.5 unit (or 1 unit) limit! It says “For healthy women (and healthy men over age 65) – no more than 3 drinks in a day AND no more than 7 drinks in a week” (These are USA drinks, not the smaller UK units).

The paper trail

In June I emailed Ilana Chrome, the report’s lead author, (and have not received a response):

Where is “at risk” defined as 1.5 units for older people?

With reference to “Our invisible addicts”: Page 35, “Alcohol misuse and older people: should guidelines for ‘sensible limits’ be modified?”, says: “More recent evidence from the USA, based on alcohol-related harm/alcohol misuse, has defined ‘at-risk’ drinking in older people as being more than 1.5 units of alcohol on any one day or more than 11 units per week for both men and women (National Institutes of Health, 2005)”.

This reference is: “Helping Patients Who Drink Too Much: A Clinician’s Guide”. NIH. It does not contain any indication of such daily or weekly numbers of units. Indeed, I have been unable to find such definitions of “at risk” anywhere else either. I would be grateful if you would please identify the paper(s) that define “at risk” in this manner. Thank you in advance for your help.

After much frustrating searching through the literature, I suspect that the basis of the above statements came from one or both of:

Alcohol and the elderly. (1992). Dufour MC, Archer L, Gordis E; National Institute on Alcohol Abuse and Alcoholism (NIAAA).

Alcohol in the elderly. (1995). Dufour M, Fuller RK; National Institute on Alcohol Abuse and Alcoholism (NIAAA).

Mary C Dufour was deputy director of the NIAAA, a daughter organisation of the NIH, the organisation that published the referenced 2005 document. Instead of “Over the past 5 years, new evidence has emerged“, and “More recent evidence from the USA …“, the paper trail appears to lead back to 1992 and/or 1995, and to a lead author whose results may have had influence because of her organisational position not warranted by the weight of the research itself. Those papers were much-cited, but apparently not significantly confirmed by other work. It would interesting to know whether the same applies to the “Our invisible addicts” report, perhaps being unduly influenced by one person (Ilana Chrome?) instead of a consensus of the Royal College of Psychiatrists’ working group?

I am speculating, and may be wrong, but this reveals why it is so important for academic papers and reports to have accurate references. This recommendation may mislead government and health agencies, and certainly should not stand without additional confirmation.

The origins of the UK’s alcohol guidelines

Timeline

See: “The sensible drinking message in the UK since the 1970s“. Here are extracts:

“The Health Education Council … published “That’s the limit” in 1984. This gave advice on ‘sensible drinking’, which was described as the amounts well within the ‘safe limits’ to which people should limit their drinking. The safe limits were defined as 18 ‘standard drinks’ (equivalent to units) per week for men and nine per week for women. ‘Too much’ was 56 standard drinks a week for men and 35 for women.

“In 1987, a new edition of “That’s the limit” used the term ‘units’, and further redefined the sensible limit as “the amount to which people should limit their drinking in order to avoid damaging their health”. The limits were now set at 21 units a week for men and 14 units a week for women. ‘Too much’ was refined to 36 units a week for men and 22 for women.

“The Government set up an interdepartmental group in 1994 to review the sensible drinking message, prompted by evidence that drinking alcohol might give protection from coronary heart disease. Its terms of reference were:

    • to review current medical and scientific evidence and its interpretation on the long-term effects of drinking alcohol;
    • to consider whether the sensible drinking message should be reviewed in the light of this, taking into account current government policies on the short-term effects of drinking alcohol and any other factors considered relevant.

“The current guidelines were introduced in 1995.”

The numbers

From The Times, October 20, 2007: “How ‘safe drinking’ experts let a bottle or two go to their heads“; here are extracts:

“A collective shudder of dismay rattled wine glasses on middle-class dining tables this week when a report labelled some of Britain’s most affluent towns as sozzled dens of “hazardous drinking” iniquity….

“When the report defined any man who drinks more than 21 units of alcohol a week, or woman who consumes more than 14, as a hazardous drinker, the authors were relying on limits that have been set in stone for the past 20 years. Yet these guidelines have no basis in science. Rather, in the words of a member of the committee that drew them up, they were simply “plucked out of the air”.

“The safe limits were introduced in 1987 after the Royal College of Physicians produced its first health report on alcohol misuse. In A Great and Growing Evil: The Medical Consequences of Alcohol Abuse, the college warned that a host of medical problems – including liver disease, strokes, heart disease, brain disease and infertility – were associated with excessive drinking. The report was the most significant study into alcohol-related disorders to date.

“But Richard Smith, the former editor of the British Medical Journal and a member of the college’s working party on alcohol, told The Times yesterday that the figures were not based on any clear evidence. He remembers “rather vividly” what happened when the discussion came round to whether the group should recommend safe limits for men and women.

“”David Barker was the epidemiologist on the committee and his line was that ‘We don’t really have any decent data whatsoever. It’s impossible to say what’s safe and what isn’t’. “And other people said, ‘Well, that’s not much use. If somebody comes to see you and says ‘What can I safely drink?’, you can’t say ‘Well, we’ve no evidence. Come back in 20 years and we’ll let you know’. So the feeling was that we ought to come up with something. So those limits were really plucked out of the air. They weren’t really based on any firm evidence at all. It was a sort of intelligent guess by a committee.”"

Science

To this date, there has never been a scientific paper that identifies the “proper” drinking guidelines. There can’t be – it is not that sort of problem.

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