Thank you again for this kind invitation to discuss the global burden, social and economic impact of alcoholic liver disease. So alcohol, if you believe the ads, is nutritious, health-giving, and a friend. And if you look at advertising across the globe, here it is, it's healthy, it's nutrition, it's health-giving, it's a friend of mine, and it makes everything go well in the evenings. And so alcohol remains the only psychoactive and dependence-producing substance with significant global impact on population health that is not really controlled at the international level by legally binding regulatory frameworks. The goal is sort of twofold. One is to sort of discuss the current global burden. We'll talk about the consumption patterns, we'll talk about morbidity and mortality, and then trends that may impact future global burden. Wealth disparities between countries, demographic shifts, as well as the impact of chronic conditions. So let's just talk about the global burden first. 2.3 billion people are current drinkers. 2.3 billion. This shows different regions, Africa, Americas, Eastern Mediterranean region, European, South Asian-Asian, Western Pacific, and the world. So if we just look at the world, the colors are current drinkers, former drinkers, as well as lifetime abstainers. So as you can see, about 40% of the world currently drinks. And in certain regions, such as Europe, Western Pacific, and Americas, the number of people who are currently drinking is over 50%. How much does everybody drink? The annual per capita consumption is between 6 and 15 liters. So if you look at just overall in the world, it's about 6.4 liters of alcohol, annual consumption per year. This was 5.7 in 2000, and the 6.4 is projected to be 6.6 or 7 liters per capita by 2025. And if you look at drinkers only, so this is everybody. But if you look at drinkers only, that's 15.1 liters per year. For the US audience, I mean, that's four gallons right here of actual alcohol every single year by our drinkers. And if you look at the current drinkers, it's about 43%. And if you look at heavy episodic drinking just over the world, 40% of drinkers drink heavily. So out of these 2.3 billion people, about 300 to 350 million are heavy current drinkers. So that's a huge group. Drinking patterns, most of it is spirits, beers, one third, wine, and other. But keep in mind that this is only recorded based on sales. So 25% of alcohol consumption is unrecorded. What about alcohol use disorders? Again, showing you the different regions. If we just look at the world, about 5% of the population has alcohol use disorders. Most of it being driven by harmful, sorry, equally driven by harmful use, as well as alcohol dependence. Demographics. If we look at the young, one fourth of all kids aged between 15 and 19 drink. And the percentage of young ones drinking heavier is 46% as compared to 39% overall. So one fourth drinking 15 to 19, as well as drinking in a heavy pattern. Even amongst women, the prevalence of current drinkers is definitely lower for women, less than men. Women do drink less than men, and the prevalence has decreased. But if you look at overall global burden, the absolute number of currently drinking women has increased over the world. And I'll get back to this in another scenario. What about deaths? This shows the top 20 causes of death worldwide. Cirrhosis is considered the number 11 cause of death. Liver cancer is considered the number 16 cause of death. So if you just combine it, that's about 2.1 million deaths per year based on liver disease. So instead of being the 11th cause of death, liver is probably one of the top five causes of death globally, specifically alcohol. And sorry, let me go back again. And what I want you to keep in mind is liver disease is competing against COPD, as well as heart disease. And we'll come back to this theme of CHF versus COPD versus liver disease in a second. What about liver related mortality within this? So if 1.2 million deaths are because of liver, alcohol is about 300,000. For liver cancer, here's the breakdown. So overall, about 560,000 deaths globally are related to alcohol related, and this is likely underestimated. This comes out to about 1% of deaths worldwide are related to alcohol related liver disease. If you just look at alcohol in general, whether it's suicide or other things, this is probably as high as 5%. So instead of 1 out of 100, 1 out of 20 deaths worldwide may be related to alcohol in some form or the other. There's a geographic disparity. You see different ranges, but some of the highest rates of recorded is in the Africa and Western Pacific region. There are certain countries with really higher age standardized death rates. As a reference point, if you look at the global death rate related to alcohol, it's 16 per 100,000. And as you can see, in many of these countries, for men as well as in women, this rate is four to five times that. So there are certain countries which are higher at risk. What about age and mortality of premature mortality? What you have on the x-axis is the different ages, and on the y-axis is the percentage of deaths related to alcohol consumption. And these different rows right here are different regions. What you can see is a large amount of the peak is sort of in this area right here. Premature mortality is defined as deaths in anybody 69 or younger. But if you just look at 20 to 39 age, 13% of all deaths worldwide are related to alcohol. This is one peak we should keep in mind, but there's also a second peak which I will get to in a little bit. Disability-wise, 5% of all disability-associated life years are related to alcohol, and this includes both years of life lost due to premature mortality as well as years of lives lived with a disability. And this, again, is the worldwide. What about trends that may impact global burden? The pattern of drinking. So pattern of drinking is really hard to quantify, especially in a research basis, or even have consistent definitions across countries. Yes, there's an association with per capita alcohol consumption across the world, but what about the association of alcohol consumption with use of other psychoactive substances, opioids, and benzodiazepines? It's hard to really quantify. Something as simple as mixed energy drinks. These things won't be recorded as a concomitant thing, but as an example, a survey of, this is not my college, of mixing alcohol with energy drinks, 24% of drinkers mixed alcohol with energy drinks, and the goal is so that you can drink more and you're awake for that. And so there were twice as many episodes of weekly drunkenness. You drink more, 5.8 drinks versus 4.5 drinks per session. So again, contribution of these kind of patterns or even binge drinking is really hard to quantify is some of the impact that we're seeing just driven by changes in the way we drink now compared to before. Wealth does play a role. Let me walk you through all the numbers here. So this is at the country level or region level divided between low and lower middle income compared to high and upper middle income. So low income, high income. If you look at the annual per capita alcohol consumption, alcohol consumption is lower in low income as compared to high income. However, that is just recorded because if you look at the unrecorded, the unrecorded amount of alcohol is higher in low income as compared to high income. The point being is people are people. Everybody will drink. And so this probably is the same by income. The impact becomes in terms of how much harm does this cause. Again, a busy slide, but what I want you to concentrate on is the first two are low income and here are sort of the high income. And look at only the orange. The impact of alcohol, even if it's equivalent, has a higher impact for liver-related mortality for the low income as compared to the high income. So even if you balance out and say people drink about the same amount, the harm per liter is probably higher for low income as compared to high income. At the individual level, as societies become more affluent, the level of alcohol consumption increases. Alcohol production may be freed with economic development. But there's often a lag in complications, but the complications do catch up. So hence this concept that I introduced, which is harms per liter, that is harms from a given amount of drinking are higher for poor drinkers than for richer drinkers because many other things that are going on. So affluent are less at risk for complications. And 60%, as an example in South Africa, 60% of all alcohol attributable debts occurred in the lower 30% of the socioeconomic distribution. This figure describes the interaction between alcohol and socioeconomic status. And I'll walk you through it. On the y-axis is the hazard ratio of mortality. On the x-axis are different parameters. So first we look at education, deprivation, social class, income. So if we sort of walk through this, there is a baseline risk of death. Everybody will die. There's a risk attributed to socioeconomic status, which is the red. There's a risk associated with alcohol, which is the green. And once you combine both of them, there is a synergistic excess risk, which is just attributed to the interaction between them. Similarly, there's an education interaction, deprivation interaction, interaction with social class, as well as interaction with income. Another way to look at this data, and again, I'll walk you through this, is just look at this first column right here. We're talking about different quintiles of income. What you can see is the hazard for increased mortality increases as the amount of income decreases. It increases with being more unskilled as compared to skilled, area-based deprivation, as well as worse education. So less education, more deprivation, lower defined unskilled class, as well as lower income are all associated with increased impact of alcohol. And even after you adjust in the second column for consumption amount, binge drinking, or even if you have to adjust for body mass index and smoking, the same kind of impact, even though it's attenuated, still persists. So this does become an important factor. Third thing, in a subset of patients, alcohol-related hepatitis. This is some of the trends that we're seeing in the United States. This is some of the unpublished data that we have from the Dallas-Fort Worth region. The x-axis is the years. On the y-axis is the standardized incidence rate per 100,000. Alcohol-related hepatitis is higher in men, but there's been a sevenfold increase in women. Similarly, in this figure, if we look at young, yes, the burden is still in the 30s and 40s. But if you look at this curve right here, for the 25 to 30s, this is increasing. We talked about this first peak, which was well-characterized, and now concentrating on the second peak that I was telling you about, is overall, our patients are getting sicker. Patients who we see in the healthcare system now, at least in the United States, have more diabetes, heart disease, hypertension, obesity, dyslipidemia, chronic kidney disease, and the interaction with many of these comorbidities will continue. Third thing is comparing our burden to other chronic diseases. So as we started off, and I told you that the top five causes, the first one is heart disease, second one is COPD, fifth one is liver disease. And again, you see the same kind of themes, that if you look over a 15-year period and just look at hospitalization, maybe because we've done such a good job with heart failure, the hospitalizations related to heart failure have stabilized. Yes, CLD is half the amount of CHF, but if you can just imagine this curve going up, at some point, this may start mirroring the congestive heart failure population. My wife's a cardiologist, so I can get away by saying this. Two more points to bring up is HCC-related mortality. This is, again, based on some of the data we're presenting here. If you look at death-related mortality related to HCC, and look at the annual percentage change, just breaking it down into hep C versus non-hep C related HCC, hep C, because of some of the progress that we've made, or maybe just the age effect, is stabilizing, but the non-hep C continues to increase. Part of this is being driven by alcohol, part of this with alcohol and obesity, and part of it just obesity. Final concept is just global trends in obesity. If we look at the prevalence of obesity in different regions, Asia, high-income Western countries, Latin American, within each of the regions between 1976 to 2015, you can see obesity increasing in terms of the recorded prevalence within all these areas, and the interaction with alcohol and obesity will continue. This figure on the left shows you three different levels of alcohol consumption, the green being about 11 drinks per week for women. At low BMI, here's your risk, but as the BMI goes up, for the same amount of alcohol, the effect is worse. Another way to look at it from a different study is here's your baseline risk of just dying, I'm sorry, of relative risk. Here's what BMI adds, here's what alcohol adds, and then combining both of them, here's the excess risk. This will continue going on. The key points are that there are about 2.3 billion drinkers worldwide, 0.9 billion who drink heavy. We drink about six liters per capita, I guess, per person in this room. For the heavy drinkers, which is a subset of us, or outside, it's about 15 liters per year. One out of four kids aged between 15 and 19 is drinking. One third of all liver-related deaths are related to alcohol. One percent of all deaths worldwide are related to alcohol, with higher deaths in the 20 to 39. We expect that there would probably be two peaks, one with younger women and alcohol-related hepatitis, the other one with older patients with multiple comorbidities and HCC. They're evolving risk patterns with obesity epidemic, patterns of drinking, and socioeconomic status. So I had the easy task, but in terms of the solution, I will leave it up to the speakers that will come after this. And then finally, many of the things that we're talking about are at the society level, at the country level, but changes at the individual level will be difficult. And to really impact that single individual who has alcohol-related problems, you need a circle of interventions, which are currently lacking. Thank you.

alcoholic liver disease

health consequences

alcohol consumption trends

comprehensive interventions

socioeconomic status