The World Health Organization Risk Drinking Levels Measure of Alcohol Consumption: Prevalence and Health Correlates in Nationally Representative Surveys of U.S. Adults, 2001–2002 and 2012–2013
Abstract
Objective:
Little is known about change over time in the prevalence of World Health Organization (WHO) risk drinking levels (very high, high, moderate, low) and their association with health conditions, overall and by gender. The authors used two sets of nationally representative U.S. survey data to determine whether changes over time varied by gender and to examine whether health conditions related to alcohol were associated with WHO risk drinking level within each survey, and whether these associations differed by gender.
Methods:
Data on current drinkers from the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; N=26,655) and the 2012–2013 NESARC-III (N=25,659) were analyzed using logistic regression. Prevalence differences between surveys were estimated for each drinking level overall and by gender. Within each survey, prevalence differences by WHO risk drinking level were estimated for alcohol use disorder (AUD), drug use disorders, functional impairment, liver disease, and depressive and anxiety disorders.
Results:
In the 2012–2013 survey, the prevalences of moderate, high, and very high risk drinking were 5.9%, 3.2%, and 3.5%, respectively, representing significant increases from the prevalences in the 2001–2002 survey, which were 1.0%, 0.6%, and 0.9%, respectively. The increase for very high risk drinking among men (0.5%) was smaller than the increase among women (1.4%). Within both surveys, compared with low risk, health conditions were significantly associated with very high risk (range of prevalence differences, 2.2%–57.8%), high risk (2.6%–41.3%), and moderate risk (0.6%–29.8%) drinking. Associations were similar by gender, except that there were stronger effects for AUD in men and for functional impairment and depressive and anxiety disorders in women.
Conclusions:
The increase in potentially problematic drinking levels among U.S. adults emphasizes the need for better prevention and treatment strategies. The study results support the validity of the WHO risk drinking levels, which show clinical utility as nonabstinent drinking reduction treatment goals. Such goals could engage more people in treatment, improving public health by decreasing personal and societal consequences of risk drinking.
Heavy drinking and alcohol use disorder (AUD) contribute substantially to morbidity and mortality worldwide (1, 2), mainly through liver disease, injury, cancer, cardiovascular disease, and impaired psychosocial functioning (3, 4). However, few individuals receive treatment for problematic drinking (5–8), often because they are not interested in abstinence, the goal most commonly offered in treatment settings (9–11). Recently, nonabstinent drinking reduction treatment goals, which may be more attainable and engage more people in treatment, have gained attention (12, 13). Psychopharmacological treatments successfully reduce drinking to nonabstinent levels (14–16), and reductions are maintained over time (17) and are associated with decreased mortality (14), improved health, and reduced negative consequences of drinking in clinical and general population samples (17–23). In these studies, drinking reduction was measured using the World Health Organization (WHO) risk drinking levels, a gender-specific metric indicating the level of risk associated with the average daily amount of alcohol consumed: very high risk, high risk, moderate risk, and low risk (24).
Recent studies and a meta-analysis (25) of time trends in alcohol consumption among U.S. adults show increases in any alcohol use (25–27) and in heavy use (binge drinking) (25, 26), specifically among women (25, 26, 28, 29). However, none of these studies measured consumption using the WHO risk drinking level definitions. What is known about the prevalences of the WHO levels was estimated in older data (2001–2002), in which 2.5% of current drinkers were at very high risk, 2.5% at high risk, 4.8% at moderate risk, and 90.2% at low risk (18). However, more recent prevalence data are lacking, and whether the prevalences of WHO risk drinking levels have changed over time and whether there are differences between men and women remain unknown. Furthermore, reports on the relationships between the WHO risk drinking levels and clinically important drinking consequences—for example, alcohol dependence (18), drug dependence (23), reduced quality of life (19, 21), mental health functional impairment (18), impaired liver function (17, 21), liver disease (20), and anxiety and depressive disorders (22)—used data collected over 15 years ago. Additionally, the relationships between alcohol use and its consequences differ in men and women (30). Given the many changes in U.S. society and the prevalence of alcohol-related conditions (26, 31–41), updated information is needed on the associations of health conditions with the WHO risk drinking levels, overall and by gender.
To examine these issues, we used data on U.S. adults from two nationally representative surveys, the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) (42) and the 2012–2013 NESARC-III (8). First, we determined whether prevalence of WHO risk drinking levels changed between the 2001–2002 and 2012–2013 surveys, as well as whether changes varied by gender. Second, we examined whether health conditions related to alcohol (alcohol dependence, AUD, drug dependence, drug use disorders, functional impairment, liver disease, and depressive and anxiety disorders) were associated with WHO risk drinking level within each survey and whether these associations differed by gender.
Methods
Sample and Procedures
NESARC (42) and NESARC-III (8) are nationally representative surveys of civilian adults (age ≥18 years), sampled from households and group quarters using multistage probability sampling designs. Sample weights adjusted the data for nonresponse and selection probabilities to represent the U.S. civilian population based on the 2000 Census for NESARC (43) and the 2012 American Community Survey for NESARC-III (44). The surveys utilized similar rigorous field procedures, including structured interviewer training, ongoing supervision, and quality control assurance (8, 42–45). The methodological similarities of the surveys have enabled their use in examining change over time in health outcomes (26, 31–34, 46–48). The National Institute on Alcohol Abuse and Alcoholism (NIAAA) sponsored the surveys, and the field work was carried out by large survey organizations (NESARC by the U.S. Census Bureau and NESARC-III by Westat). Institutional review boards from the U.S. Census Bureau and Office of Management and Budget (for NESARC), NIAAA (for both surveys), and Westat (for NESARC-III) approved the protocol and consent procedures. All respondents gave informed consent after receiving a complete description of the study. Interviews were conducted in 2001 and 2002 for NESARC and in 2012 and 2013 for NESARC-III, with overall response rates of 81.2% and 60.1%, respectively. The total analyzed sample (N=52,314) included current drinkers for whom information about drinks per day was available from NESARC (N=26,655) and NESARC-III (N=25,659). Among all current drinkers (N=52,724), daily drinking information was missing for 410 respondents (0.78%), who were excluded from the analysis.
Measures
Both surveys used the Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS) to assess drinking, AUD, drug use disorders, sociodemographic variables, and other health conditions. The AUDADIS is a fully structured computer-assisted diagnostic interview. AUDADIS-IV (49) was used for NESARC and AUDADIS-5 (50) for NESARC-III.
WHO Risk Drinking Levels
In both surveys, identical questions assessed alcohol use (26), which were used to estimate average ethanol consumed per day in the past year. AUDADIS measures of past-year average daily ethanol consumption showed substantial to excellent reliability (intraclass correlation coefficients, 0.68–0.92) (51–53). Average daily ethanol consumption was used to categorize respondents into the WHO very high risk, high risk, moderate risk, and low risk categories (see Table S1 in the online supplement), as in recent studies (18, 20, 22, 23). For men, very high risk was defined as >100 g/day or >7.1 U.S. standard drinks; high risk as >60 to 100 g/day or >4.3 to 7.1 drinks; moderate risk as >40 to 60 g/day or >2.9 to 4.3 drinks; and low risk as 1 to 40 g/day or 1 to 2.9 drinks. For women, very high risk was defined as >60 g/day or >4.3 standard drinks; high risk as >40 to 60 g/day or >2.9 to 4.3 drinks; moderate risk as >20 to 40 g/day or >1.4 to 2.9 drinks; and low risk as 1 to 20 g/day or 1 to 1.4 drinks.
The WHO risk level variable was the outcome for the first aim (change between surveys in risk level prevalence) and a predictor for the second aim (association with health conditions).
Health Conditions
Alcohol use disorder (AUD).
For consistency across surveys, DSM-IV criteria were used, and past-year AUD diagnoses were positive if respondents had alcohol dependence or abuse in the past year. Dependence required at least three of seven DSM-IV dependence criteria, and abuse required at least one of four DSM-IV abuse criteria. Because extensive evidence indicates that all 11 criteria reflect a single continuum (54), dependence and abuse were combined into one variable (AUD). Most of the symptom items used to assess criteria in both surveys were identical, and the few trivial differences could not account for the changes in AUD prevalence across the two surveys (26). Alcohol dependence was included as a separate outcome because WHO drinking risk levels were previously associated with alcohol dependence (18). The reliability and validity of AUDADIS DSM-IV AUD and alcohol dependence diagnoses have been found to be substantial to excellent (kappa values >0.60) in national and international studies, in general and clinical populations (51–53, 55–61).
Drug use disorders.
Similarly, past-year drug use disorders (dependence or abuse) were diagnosed using the DSM-IV criteria for marijuana, cocaine, heroin, prescription opioids, sedative/tranquilizers, hallucinogens, stimulants, inhalants, and club drugs. Respondents who were positive for any drug use disorder were considered positive for the drug use disorder variable. As with alcohol, the small differences in operationalization between the surveys had little effect on prevalence for marijuana (31), heroin (32), prescription opioids (35), and cocaine use disorders (34). Any drug dependence was included as a separate outcome, because WHO drinking risk levels were previously associated with drug dependence (23). In multiple studies, the reliability and validity of any AUDADIS DSM-IV drug use disorder/drug dependence as well as drug-specific disorders have been found generally to be substantial to excellent (52, 53, 55–60).
Functional impairment.
Both surveys included the Medical Outcomes Study 12-Item Short Form Health Survey, version 2 (SF-12) (62), a valid measure of general functioning used in clinical (63) and general population surveys (64). The SF-12 was used to calculate a standardized mental component summary score (mean=50; standard deviation=10), shown to be related to AUD (5, 8). Functional impairment was defined as ≥1 standard deviation below the mean, that is, scores ≤40, as has been done previously (18).
Liver disease.
The two surveys asked identical questions about whether respondents had cirrhosis of the liver or another form of liver disease in the past year. As has been done previously, liver disease was considered positive if a doctor or health professional confirmed to the respondent that they had cirrhosis or other liver disease (20).
Depressive and anxiety disorders.
AUDADIS-IV provided diagnoses of past-year DSM-IV anxiety disorders (generalized anxiety, panic, agoraphobia, social or specific phobia) and depressive disorders (major depression, dysthymia). Reliability was moderate for anxiety disorders (kappa values, 0.40–0.52) (51) and moderate to substantial for depressive disorders (kappa values, 0.50–0.73) (51, 55). AUDADIS-5 provided DSM-5 diagnoses of the depressive and anxiety disorders, which showed fair to moderate reliability (kappa values, 0.39–0.51) (65) and validity (kappa values, 0.32 and 0.40 for any anxiety disorder and any depressive disorder, respectively) (66), but not DSM-IV diagnoses. Because depressive and anxiety disorders show high comorbidity (67–69) and cluster together on the internalizing dimension of the transdiagnostic model (70), they were combined into one variable, any depressive and anxiety disorder, as has been done previously (22). An additional variable was defined as positive for respondents with any depressive and anxiety disorder not due to substances or illness.
Sociodemographic Variables
Covariates were measured identically in both surveys: gender (men, women), age group (18–29 years, 30–44 years, 45–64 years, and ≥65 years), education (less than high school, high school, some college, college degree or higher), race/ethnicity (Hispanic; non-Hispanic: White, Black, American Indian/Alaska Native, Asian/Native Hawaiian/Pacific Islander), current smoking (yes, no), and health insurance (any, none). These covariates were used in previous studies of WHO risk levels in NESARC data (18, 20, 22, 23).
Statistical Analysis
As in previous studies of substance-related trends (26, 31–34, 47, 48), the two data sets were concatenated, and a survey variable (2001–2002 or 2012–2013) was added. SUDAAN, version 11.0.1, was used for analysis to incorporate survey weights and adjust for complex sampling (71). Weighted prevalence was evaluated for WHO risk drinking levels, health conditions, and sociodemographic covariates, by survey.
To test for change in the prevalence of WHO risk levels over time (between surveys), we used multinomial logistic regression to model the risk level variable (outcome) as a function of time (survey), adjusting for covariates (gender, age, race/ethnicity, education, smoking status, insurance). In each survey, weighted model-predicted marginal prevalence estimates (back-transformed from log odds) and standard errors were generated (72) for each risk level. For each risk level, the prevalence difference between the 2012–2013 and 2001–2002 surveys indicated time trends. A prevalence difference significantly greater than 0 indicated that prevalence was higher in the 2012–2013 than the 2001–2002 survey, that is, it increased over time; a prevalence difference significantly lower than 0 indicated a decrease. To determine whether prevalence difference differed by gender, an interaction term of survey by gender was included in the model. Prevalence differences (trends) were estimated for men and women, and the difference in trends for men versus women (difference-in-prevalence differences) was evaluated. A difference-in-differences significantly different from 0 indicated differential trends for men and women. To adjust for potentially different covariate effects in men and women, this model also included gender-by-covariate interaction terms.
To evaluate association of WHO risk level and health conditions within each survey, we used logistic regression to model each health condition (outcome) as a function of WHO risk level, survey, and risk level-by-survey interaction, adjusting for covariates. To adjust for potentially different covariate effects in the different risk levels, risk level-by-covariate interactions were also included. (Both surveys were included in the same model so that adjustments would be consistent across surveys.) For each outcome, weighted model-predicted marginal prevalence estimates and standard errors were generated within each survey and each risk level. Within each survey, association is indicated by the prevalence difference between each risk level and the reference (low risk level). To determine whether association differed by gender, a three-way interaction term of risk level by survey by gender was included in the model (as well as survey by gender). In each survey, association was estimated in men and women, and contrasts were used to determine whether these differed.
All tests were two-tailed, with the significance threshold set at 0.05, as indicated by 95% confidence intervals not including 0.
Results
Sample Characteristics
As shown in Table 1, both surveys had ∼50% men, ∼80% with any insurance, ∼30% current smokers, and about two-thirds with at least some college education. The 2012–2013 sample was older on average (∼50% ages 18–44) than the 2001–2002 sample (∼60% ages 18–44) and had a higher prevalence of minorities (∼30%) than the 2001–2002 sample (∼25%) and of health conditions (ranging from 1.1% for liver disease to 22.5% for depressive and anxiety disorders) than the 2001–2002 sample (ranging from 0.6% for liver disease to 17.3% for depressive and anxiety disorders).
| 2001–2002 (N=26,655) | 2012–2013 (N=25,659) | |||||
|---|---|---|---|---|---|---|
| Prevalence | Prevalence | |||||
| Measure | N | % | SE | N | % | SE |
| Gender | ||||||
| Male | 12,886 | 52.5 | 0.43 | 11,935 | 50.7 | 0.37 |
| Female | 13,769 | 47.5 | 0.43 | 13,724 | 49.3 | 0.37 |
| Age group | ||||||
| 18–29 years | 6,076 | 24.3 | 0.41 | 6,384 | 23.8 | 0.45 |
| 30–44 years | 9,373 | 34.0 | 0.38 | 7,839 | 28.2 | 0.38 |
| 45–64 years | 7,858 | 30.5 | 0.36 | 8,451 | 34.7 | 0.39 |
| ≥65 years | 3,348 | 11.2 | 0.29 | 2,985 | 13.3 | 0.42 |
| Race/ethnicity | ||||||
| White | 16,562 | 75.3 | 1.44 | 14,236 | 68.5 | 0.73 |
| Black | 4,129 | 9.0 | 0.59 | 5,102 | 10.7 | 0.58 |
| Hispanic | 4,899 | 10.6 | 1.13 | 4,868 | 14.3 | 0.63 |
| Asian/Native Hawaiian/Pacific Islander | 660 | 3.2 | 0.41 | 1,092 | 4.9 | 0.42 |
| American Indian/Alaska Native | 405 | 1.9 | 0.15 | 361 | 1.6 | 0.13 |
| Health insurance | ||||||
| Any | 21,677 | 81.8 | 0.55 | 20,466 | 82.8 | 0.48 |
| None | 4,978 | 18.2 | 0.55 | 5,193 | 17.2 | 0.48 |
| Current smoker | ||||||
| Yes | 8,436 | 33.0 | 0.61 | 8,248 | 30.9 | 0.53 |
| No | 18,219 | 67.0 | 0.61 | 17,411 | 69.1 | 0.53 |
| Education | ||||||
| Less than high school | 1,097 | 3.4 | 0.24 | 858 | 2.8 | 0.17 |
| High school | 9,499 | 34.9 | 0.61 | 8,604 | 31.2 | 0.65 |
| Some college | 6,057 | 22.9 | 0.39 | 6,035 | 22.7 | 0.36 |
| College degree | 10,002 | 38.8 | 0.66 | 10,162 | 43.3 | 0.78 |
| WHO risk drinking level | ||||||
| Low risk | 23,984 | 89.7 | 0.29 | 22,202 | 87.5 | 0.32 |
| Moderate risk | 1,314 | 4.9 | 0.17 | 1,561 | 5.9 | 0.19 |
| High risk | 686 | 2.7 | 0.15 | 865 | 3.1 | 0.16 |
| Very high risk | 671 | 2.7 | 0.15 | 1,031 | 3.4 | 0.17 |
| Health conditions | ||||||
| Alcohol dependence | 1,457 | 5.8 | 0.21 | 2,493 | 9.0 | 0.27 |
| Alcohol use disorderb | 3,283 | 12.9 | 0.35 | 4,571 | 17.4 | 0.40 |
| Any drug dependencec | 218 | 0.9 | 0.08 | 577 | 2.1 | 0.13 |
| Any drug use disorderb,c | 689 | 2.8 | 0.15 | 1,393 | 5.1 | 0.19 |
| Liver disease | 154 | 0.6 | 0.06 | 268 | 1.1 | 0.09 |
| Functional impairment | 2,759 | 9.5 | 0.23 | 3,957 | 13.7 | 0.31 |
| Depressive or anxiety disordersd, any | 4,771 | 17.3 | 0.40 | 5,989 | 22.7 | 0.44 |
| Depressive or anxiety disordersd, not substance or illness induced | 4,595 | 16.7 | 0.39 | 5,692 | 21.6 | 0.42 |
TABLE 1. Characteristics of the NESARC and NESARC-III samples in a study of WHO risk drinking levelsa
Prevalence of WHO Risk Drinking Levels Over Time
Overall, compared with the 2001–2002 prevalence, significant increases were observed in the 2012–2013 prevalence of moderate risk (+1.0%), high risk (+0.6%), and very high risk drinking (+0.9%), with a concomitant decrease in prevalence of low risk drinking (−2.5%) (Table 2). Trends over time differed by gender. Among women, there were significant increases in moderate (+1.1%), high (+0.5%), and very high (+1.4%) levels. In contrast, among men, a significant increase was seen in moderate risk (+0.9%). In the very high risk group, the increase among men (0.5%) was significantly smaller (−1.0%) than the increase among women (+1.4%) (Table 3).
| 2001–2002 (N=26,655) | 2012–2013 (N=25,659) | |||||
|---|---|---|---|---|---|---|
| Prevalence | Prevalence | Prevalence Difference | ||||
| WHO Risk Level | % | SE | % | SE | % | 95% CI |
| Very high risk | 2.6 | 0.14 | 3.5 | 0.17 | +0.9 | 0.49, 1.31 |
| High risk | 2.6 | 0.15 | 3.2 | 0.16 | +0.6 | 0.17, 1.03 |
| Moderate risk | 4.9 | 0.16 | 5.9 | 0.19 | +1.0 | 0.51, 1.49 |
| Low risk | 89.8 | 0.28 | 87.4 | 0.32 | –2.5 | –3.34, –1.66 |
TABLE 2. Change over time (trend) in WHO risk drinking levels, 2001–2002 (NESARC) to 2012–2013 (NESARC-III), overalla
| Men (N=24,821) | Women (N=27,493) | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2001–2002 | 2012–2013 | 2001–2002 | 2012–2013 | |||||||||||
| Prevalence | Prevalence | Prevalence Difference | Prevalence | Prevalence | Prevalence Difference | Trend Differences, Men Versus Womenb | ||||||||
| WHO Risk Level | % | SE | % | SE | % | 95% CI | % | SE | % | SE | % | 95% CI | % | 95% CI |
| Very high | 3.3 | 0.19 | 3.7 | 0.24 | +0.5 | −0.09, 1.09 | 1.8 | 0.18 | 3.3 | 0.17 | +1.4 | 0.93, 1.87 | −1.0 | −1.69, −0.31 |
| High | 3.4 | 0.21 | 4.0 | 0.24 | +0.6 | −0.03, 1.23 | 1.7 | 0.15 | 2.2 | 0.17 | +0.5 | 0.05, 0.95 | +0.1 | −0.59, 0.79 |
| Moderate | 4.1 | 0.21 | 5.0 | 0.25 | +0.9 | 0.27, 1.53 | 5.8 | 0.25 | 6.8 | 0.29 | +1.1 | 0.36, 1.84 | −0.2 | −1.16, 0.76 |
| Low | 89.2 | 0.38 | 87.2 | 0.38 | –2.0 | −3.02, −0.98 | 90.7 | 0.35 | 87.7 | 0.42 | −3.0 | −4.08, −1.92 | +1.0 | −0.27, 2.27 |
TABLE 3. Trends in WHO risk drinking levels, 2001–2002 (NESARC) to 2012–2013 (NESARC-III), by gendera
Association of WHO Risk Levels With Health Conditions
DSM-IV alcohol use disorders.
In the 2001–2002 survey, the prevalence of alcohol dependence was significantly greater among very high risk (+40.4%), high risk (+21.4%), and moderate risk (+12.3%) drinkers than among low risk drinkers (Table 4). Similarly, in the 2012–2013 survey, the prevalence was significantly greater among very high risk (+49.7%), high risk (+32.0%), and moderate risk (+20.1%) drinkers than among low risk drinkers. Significant associations were observed for men and women, with a stronger association for moderate risk among men than women (Table 5). Similar results were observed for AUD (Tables 4, 5, 6).
| 2001–2002 (N=26,655) | 2012–2013 (N=25,659) | |||||||
|---|---|---|---|---|---|---|---|---|
| Prevalence of Condition | Prevalence Difference | Prevalence of Condition | Prevalence Difference | |||||
| Heath Condition and Risk Level | % | SE | % | 95% CI | % | SE | % | 95% CI |
| Alcohol dependence | ||||||||
| Very high risk | 43.4 | 2.49 | 40.4 | 35.56, 45.24 | 54.6 | 2.45 | 49.7 | 44.90, 54.50 |
| High risk | 24.4 | 2.11 | 21.4 | 17.24, 25.56 | 36.9 | 2.35 | 32.0 | 27.40, 36.61 |
| Moderate risk | 15.3 | 1.07 | 12.3 | 10.21, 14.40 | 25.0 | 1.43 | 20.1 | 17.30, 22.90 |
| Low risk | 3.0 | 0.14 | Ref. | 4.9 | 0.19 | Ref. | ||
| Alcohol use disorderb | ||||||||
| Very high risk | 56.6 | 2.77 | 47.7 | 42.29, 53.11 | 70.4 | 2.32 | 57.8 | 53.25, 62.35 |
| High risk | 40.9 | 2.24 | 32.0 | 27.55, 36.45 | 53.9 | 2.38 | 41.3 | 36.56, 46.04 |
| Moderate risk | 33.2 | 1.52 | 24.3 | 21.40, 27.20 | 42.3 | 1.41 | 29.8 | 26.92, 32.68 |
| Low risk | 8.9 | 0.25 | Ref. | 12.6 | 0.34 | Ref. | ||
| Any drug dependencec | ||||||||
| Very high risk | 5.6 | 0.99 | 5.0 | 3.06, 6.94 | 7.7 | 0.96 | 6.1 | 4.24, 7.96 |
| High risk | 1.1 | 0.39 | 0.6 | –0.18, 1.38 | 4.2 | 0.79 | 2.6 | 1.05, 4.15 |
| Moderate risk | 1.2 | 0.30 | 0.6 | 0.01, 1.19 | 2.9 | 0.38 | 1.2 | 0.42, 1.98 |
| Low risk | 0.6 | 0.07 | Ref. | 1.7 | 0.13 | Ref. | ||
| Any drug use disorderb,c | ||||||||
| Very high risk | 13.0 | 1.48 | 11.0 | 8.08, 13.92 | 17.4 | 1.62 | 13.1 | 9.96, 16.24 |
| High risk | 5.7 | 0.98 | 3.7 | 1.84, 5.56 | 11.1 | 1.23 | 6.8 | 4.37, 9.23 |
| Moderate risk | 4.7 | 0.74 | 2.8 | 1.39, 4.21 | 7.9 | 0.70 | 3.6 | 2.23, 4.97 |
| Low risk | 2.0 | 0.12 | Ref. | 4.3 | 0.19 | Ref. | ||
| SF-12 functional impairment | ||||||||
| Very high risk | 21.9 | 2.24 | 13.0 | 8.57, 17.43 | 25.2 | 1.75 | 11.9 | 8.37, 15.43 |
| High risk | 12.0 | 1.59 | 3.1 | 0.01, 6.20 | 16.5 | 1.52 | 3.1 | 0.02, 6.18 |
| Moderate risk | 11.4 | 1.05 | 2.6 | 0.54, 4.66 | 13.8 | 0.99 | 0.4 | –1.62, 2.42 |
| Low risk | 8.9 | 0.23 | Ref. | 13.3 | 0.33 | Ref. | ||
| Liver disease | ||||||||
| Very high risk | 3.4 | 0.98 | 2.9 | 0.98, 4.82 | 3.1 | 0.85 | 2.2 | 0.51, 3.89 |
| High risk | 0.9 | 0.37 | 0.4 | –0.33, 1.13 | 2.3 | 0.80 | 1.4 | –0.17, 2.97 |
| Moderate risk | 0.6 | 0.28 | 0.2 | –0.35, 0.75 | 1.1 | 0.30 | 0.2 | –0.43, 0.83 |
| Low risk | 0.5 | 0.06 | Ref. | 0.9 | 0.09 | Ref. | ||
| Any depressive or anxiety disorderd | ||||||||
| Very high risk | 25.8 | 2.16 | 9.2 | 4.95, 13.45 | 29.8 | 1.87 | 7.1 | 3.47, 10.73 |
| High risk | 19.5 | 1.92 | 2.9 | –0.84, 6.64 | 24.7 | 1.78 | 2.0 | –1.57, 5.57 |
| Moderate risk | 17.6 | 1.25 | 1.0 | –1.45, 3.45 | 22.4 | 1.22 | –0.3 | –2.81, 2.21 |
| Low risk | 16.6 | 0.36 | Ref. | 22.7 | 0.47 | Ref. | ||
| Any depressive or anxiety disorderd, not substance or illness induced | ||||||||
| Very high risk | 24.2 | 2.13 | 8.2 | 4.03, 12.37 | 28.8 | 1.80 | 7.1 | 3.47, 10.73 |
| High risk | 18.6 | 1.85 | 2.7 | –0.91, 6.31 | 23.6 | 1.74 | 1.9 | –1.61, 5.41 |
| Moderate risk | 17.2 | 1.25 | 1.2 | –1.25, 3.65 | 21.3 | 1.20 | –0.4 | –2.85, 2.05 |
| Low risk | 16.0 | 0.36 | Ref. | 21.7 | 0.45 | Ref. | ||
TABLE 4. Association of WHO risk drinking level with health conditions, 2001–2002 (NESARC) and 2012–2013 (NESARC-III)a
| Men (N=12,886) | Women (N=13,769) | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Prevalence of Condition | Prevalence Difference | Prevalence of Condition | Prevalence Difference | Difference in Prevalence Differences, Men Versus Women | ||||||
| Health Condition and Risk Level | % | SE | % | 95% CI | % | SE | % | 95% CI | % | 95% CI |
| Alcohol dependence | ||||||||||
| Very high risk | 45.7 | 2.91 | 42.0 | 36.32, 47.68 | 39.4 | 3.66 | 37.3 | 30.15, 44.45 | 4.7 | –3.79, 13.29 |
| High risk | 27.6 | 2.64 | 23.9 | 18.73, 29.07 | 20.6 | 3.64 | 18.5 | 11.37, 25.63 | 5.4 | –3.38, 14.18 |
| Moderate risk | 16.1 | 1.68 | 12.4 | 9.09, 15.71 | 14.1 | 1.37 | 12.0 | 9.31, 14.69 | 0.4 | –3.97, 4.77 |
| Low risk | 3.7 | 0.20 | Ref. | 2.1 | 0.17 | Ref. | ||||
| Alcohol use disorderb | ||||||||||
| Very high risk | 60.7 | 3.09 | 48.8 | 42.72, 54.88 | 52.2 | 4.54 | 46.7 | 37.80, 55.60 | 2.1 | –8.15, 12.35 |
| High risk | 48.0 | 2.91 | 36.1 | 30.36, 41.84 | 31.9 | 3.76 | 26.4 | 18.97, 33.83 | 9.8 | 0.24, 19.36 |
| Moderate risk | 39.1 | 2.33 | 27.2 | 22.63, 31.77 | 26.9 | 1.70 | 21.3 | 18.05, 24.55 | 5.9 | 0.53, 11.27 |
| Low risk | 11.9 | 0.38 | Ref. | 5.6 | 0.27 | Ref. | ||||
| Any drug dependencec | ||||||||||
| Very high risk | 5.5 | 1.18 | 4.8 | 2.49, 7.11 | 5.7 | 1.47 | 5.3 | 2.42, 8.18 | –0.5 | –3.99, 2.99 |
| High risk | 1.7 | 0.61 | 1.0 | –0.22, 2.22 | 0.3 | 0.19 | –0.2 | –0.61, 0.21 | 1.1 | –0.19, 2.39 |
| Moderate risk | 1.4 | 0.46 | 0.8 | –0.10, 1.70 | 0.9 | 0.34 | 0.5 | –0.21, 1.21 | 0.3 | –0.84, 1.44 |
| Low risk | 0.7 | 0.11 | Ref. | 0.4 | 0.07 | Ref. | ||||
| Any drug use disorderb,c | ||||||||||
| Very high risk | 12.1 | 1.68 | 9.7 | 6.39, 13.01 | 13.7 | 2.39 | 12.3 | 7.60, 17.00 | –2.6 | –8.24, 3.04 |
| High risk | 7.2 | 1.43 | 4.8 | 2.04, 7.56 | 3.3 | 1.20 | 1.9 | –0.45, 4.25 | 2.9 | –0.88, 6.68 |
| Moderate risk | 5.1 | 0.95 | 2.7 | 0.84, 4.56 | 4.2 | 0.98 | 2.8 | 0.86, 4.74 | –0.2 | –2.65, 2.25 |
| Low risk | 2.4 | 0.18 | Ref. | 1.4 | 0.13 | Ref. | ||||
| SF-12 functional impairment | ||||||||||
| Very high risk | 15.8 | 2.22 | 9.5 | 5.11, 13.89 | 25.9 | 3.38 | 14.1 | 7.38, 20.82 | –4.6 | –12.05, 2.85 |
| High risk | 8.5 | 1.44 | 2.2 | –0.60, 5.00 | 16.7 | 3.21 | 4.9 | –1.45, 11.25 | –2.7 | –9.64, 4.24 |
| Moderate risk | 8.0 | 1.17 | 1.6 | –0.79, 3.99 | 15.3 | 1.73 | 3.5 | 0.13, 6.87 | –1.9 | –6.00, 2.20 |
| Low risk | 6.4 | 0.25 | Ref. | 11.8 | 0.37 | Ref. | ||||
| Any depressive or anxiety disorderd | ||||||||||
| Very high risk | 18.4 | 2.07 | 7.3 | 3.20, 11.40 | 30.5 | 3.71 | 7.8 | 0.49, 15.11 | –0.5 | –8.77, 7.77 |
| High risk | 13.6 | 1.79 | 2.5 | –1.03, 6.03 | 27.0 | 3.82 | 4.3 | –3.21, 11.81 | –1.8 | –10.07, 6.47 |
| Moderate risk | 11.2 | 1.39 | 0.0 | –2.70, 2.70 | 24.6 | 1.97 | 1.9 | –2.02, 5.82 | –1.9 | –6.49, 2.69 |
| Low risk | 11.1 | 0.37 | Ref. | 22.7 | 0.56 | Ref. | ||||
| Any depressive or anxiety disorderd, not substance or illness induced | ||||||||||
| Very high risk | 16.8 | 2.03 | 6.1 | 2.10, 10.10 | 29.5 | 3.64 | 7.6 | 0.43, 14.77 | –1.5 | –9.61, 6.61 |
| High risk | 13.0 | 1.73 | 2.3 | –1.11, 5.71 | 26.0 | 3.74 | 4.1 | –3.25, 11.45 | –1.8 | –9.97, 6.37 |
| Moderate risk | 11.0 | 1.38 | 0.4 | –2.29, 3.09 | 23.8 | 1.96 | 2.0 | –1.88, 5.88 | –1.6 | –6.09, 2.89 |
| Low risk | 10.7 | 0.37 | Ref. | 21.9 | 0.55 | Ref. | ||||
TABLE 5. Association of WHO risk drinking level with health conditions in 2001–2002 (NESARC), by gendera
| Men (N=11,935) | Women (N=13,724) | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Prevalence of Condition | Prevalence Difference | Prevalence of Condition | Prevalence Difference | Difference in Prevalence Differences, Men Versus Women | ||||||
| Health Condition and Risk Level | % | SE | % | 95% CI | % | SE | % | 95% CI | % | 95% CI |
| Alcohol dependence | ||||||||||
| Very high risk | 55.1 | 3.17 | 49.7 | 43.47, 55.93 | 54.3 | 3.18 | 49.9 | 43.73, 56.07 | –0.2 | –8.16, 7.76 |
| High risk | 40.7 | 2.78 | 35.4 | 29.95, 40.85 | 32.8 | 3.39 | 28.4 | 21.76, 35.04 | 7.0 | –0.72, 14.72 |
| Moderate risk | 30.2 | 2.28 | 24.9 | 20.41, 29.39 | 19.8 | 1.57 | 15.4 | 12.30, 18.50 | 9.5 | 4.21, 14.79 |
| Low risk | 5.3 | 0.27 | Ref. | 4.4 | 0.25 | Ref. | ||||
| Alcohol use disorderb | ||||||||||
| Very high risk | 73.7 | 2.86 | 58.2 | 52.57, 63.83 | 66.9 | 3.16 | 57.6 | 51.33, 63.87 | 0.6 | –7.19, 8.30 |
| High risk | 59.6 | 2.63 | 44.0 | 38.65, 49.35 | 48.7 | 3.70 | 39.4 | 32.03, 46.77 | 4.7 | –3.65, 13.05 |
| Moderate risk | 49.1 | 2.28 | 33.5 | 28.84, 38.16 | 35.2 | 1.65 | 25.9 | 22.47, 29.33 | 7.6 | 1.82, 13.38 |
| Low risk | 15.5 | 0.38 | Ref. | 9.3 | 0.35 | Ref. | ||||
| Any drug dependencec | ||||||||||
| Very high risk | 7.7 | 1.12 | 6.0 | 3.86, 8.14 | 7.8 | 1.35 | 6.2 | 3.57, 8.83 | –0.3 | –3.22, 2.62 |
| High risk | 5.2 | 1.21 | 3.4 | 1.01, 5.79 | 3.3 | 0.91 | 1.8 | –0.00, 3.60 | 1.7 | –1.20, 4.60 |
| Moderate risk | 3.4 | 0.65 | 1.7 | 0.35, 3.05 | 2.2 | 0.49 | 0.6 | –0.36, 1.56 | 1.0 | –0.80, 2.80 |
| Low risk | 1.7 | 0.18 | Ref. | 1.5 | 0.16 | Ref. | ||||
| Any drug use disorderb,c | ||||||||||
| Very high risk | 16.0 | 2.08 | 10.8 | 6.74, 14.86 | 19.0 | 2.13 | 15.8 | 11.64, 19.96 | –5.0 | –10.29, 0.29 |
| High risk | 12.9 | 1.78 | 7.7 | 4.13, 11.27 | 9.4 | 1.65 | 6.2 | 3.01, 9.39 | 1.5 | –3.24, 6.24 |
| Moderate risk | 9.3 | 1.15 | 4.1 | 1.75, 6.45 | 6.3 | 0.80 | 3.2 | 1.75, 4.65 | 0.9 | –1.90, 3.70 |
| Low risk | 5.2 | 0.27 | Ref. | 3.2 | 0.21 | Ref. | ||||
| SF-12 functional impairment | ||||||||||
| Very high risk | 15.7 | 1.78 | 5.6 | 1.99, 9.21 | 36.3 | 2.91 | 19.3 | 13.42, 25.18 | –13.6 | –20.26, –6.94 |
| High risk | 13.1 | 1.58 | 3.0 | –0.19, 6.19 | 19.8 | 2.83 | 2.8 | –2.88, 8.48 | 0.2 | –6.39, 6.79 |
| Moderate risk | 10.5 | 1.38 | 0.4 | –2.44, 3.24 | 17.5 | 1.50 | 0.5 | –2.54, 3.54 | –0.1 | –4.37, 4.17 |
| Low risk | 10.1 | 0.43 | Ref. | 17.0 | 0.48 | Ref. | ||||
| Any depressive or anxiety disorderd | ||||||||||
| Very high risk | 18.4 | 2.07 | 2.4 | –1.28, 6.08 | 43.3 | 3.15 | 13.0 | 6.57, 19.43 | –10.6 | –17.81, –3.39 |
| High risk | 18.9 | 1.69 | 3.1 | –0.41, 6.61 | 30.5 | 3.12 | 0.2 | –5.92, 6.32 | 2.9 | –3.80, 9.60 |
| Moderate risk | 17.5 | 1.71 | 1.7 | –1.79, 5.19 | 28.1 | 1.80 | –2.2 | –5.87, 1.47 | 3.9 | –1.20, 9.00 |
| Low risk | 15.8 | 0.50 | Ref. | 30.3 | 0.66 | Ref. | ||||
| Any depressive or anxiety disorderd, not substance or illness induced | ||||||||||
| Very high risk | 17.6 | 1.77 | 2.7 | –0.83, 6.23 | 41.7 | 3.14 | 12.6 | 6.41, 18.79 | –9.9 | –17.09, –2.71 |
| High risk | 18.0 | 1.66 | 3.2 | –0.19, 6.59 | 29.1 | 3.09 | 0.1 | –6.05, 6.25 | 3.1 | –3.64, 9.84 |
| Moderate risk | 16.3 | 1.66 | 1.5 | –1.85, 4.85 | 27.0 | 1.77 | –2.1 | –5.71, 1.51 | 3.5 | –1.42, 8.42 |
| Low risk | 14.9 | 0.46 | Ref. | 29.1 | 0.67 | Ref. | ||||
TABLE 6. Association of WHO risk drinking level with health conditions in 2012–2013 (NESARC-III), by gendera
DSM-IV drug use disorders.
In the 2001–2002 survey, the prevalence of any drug dependence was significantly greater among very high (+5.0%) and moderate risk (+0.6%) drinkers than among low risk drinkers (Table 4). In the 2012–2013 survey, the prevalence was significantly greater among very high (+6.1%), high (+2.6%), and moderate (+1.2%) than low risk drinkers. Similar results were observed for any drug use disorder, except that the prevalence was also significantly greater among high risk (+3.7%) than low risk drinkers in the 2001–2002 survey. Similar associations were observed for men and women (Tables 5, 6).
Functional impairment.
In the 2001–2002 survey, the prevalence of functional impairment was significantly greater among very high (+13.9%), high (+3.1%), and moderate (+2.6%) drinkers than among low risk drinkers (Table 4). In the 2012–2013 survey, the prevalence was significantly greater among very high (+11.9%) and high (+3.1%) risk drinkers than among low risk drinkers. In men and women, significant associations were observed with very high risk (Tables 5, 6), with a significantly stronger association for women than men (Table 6).
Liver disease.
In both the 2001–2002 and 2012–2013 surveys, the prevalence of liver disease was significantly greater among very high risk drinkers (+2.9% and +2.2%, respectively) than among low risk drinkers (Table 4). Differences by gender were not estimated because of the low prevalence of liver disease among women in NESARC.
Any depressive or anxiety disorder.
In both the 2001–2002 and 2012–2013 surveys, the prevalence of any depressive or anxiety disorder was significantly greater among very high risk drinkers (+9.2% and +7.1%, respectively) than low risk drinkers (Table 4). Significant associations with very high risk were observed for women in both surveys but for men in the 2001–2002 survey only (Tables 5, 6). Similar results were observed for any depressive or anxiety disorder, excluding those occurring only during periods of substance use or illness (Tables 4, 5, 6).
Discussion
In previous studies, the WHO risk drinking levels (very high, high, moderate, and low) were associated with physical, mental, and social functioning and reduction in the WHO risk drinking categories predicted improvement in these conditions (17–23). Thus, the WHO risk levels show potential clinical utility as a treatment outcome measure (14–17, 19, 21). However, important epidemiological information was lacking, namely, whether the prevalence of the WHO risk levels changed over time, associations of these levels with clinical correlates of heavy drinking in newer data, and whether results differed by gender. In adult general population current drinkers, the prevalence of moderate, high, and very high risk levels was significantly greater in the 2012–2013 survey than in the 2001–2002 survey, with a greater increase in prevalence of the very high risk drinking level among women than among men. Health conditions (AUD, drug use disorders, functional impairment, liver disease, depressive and anxiety disorders) were associated with risk levels within each survey, among men and women.
Increases over time in moderate, high, and very high risk drinking are similar to results from other U.S. national studies, which show increases in alcohol consumption, specifically binge drinking (any or weekly), particularly among women (25, 26, 28, 29). Increases in heavy drinking among women are concerning, as women are less likely to receive treatment (73) yet may be more likely than men to develop health consequences at comparable consumption levels (30). Additional studies should identify the drivers of these patterns (41). Inconsistent with previous studies, the present study showed an increase in moderate drinking among men. This study differs from the others in two key ways: an important and widely recognized consumption measure and analysis conducted in current drinkers. One previous study of current drinkers showed no increase in binge drinking in men or women (28), suggesting that binge drinking and the WHO risk drinking levels measure alcohol consumption differently. As a metric of alcohol consumption, the WHO levels are particularly useful, as they categorize drinkers on the basis of intensity and frequency of drinking and identify which drinkers are at greatest risk for alcohol-related consequences (24).
In both surveys, higher WHO risk drinking levels were associated with clinically important health conditions (alcohol dependence/AUD, drug dependence/drug use disorders, functional impairment, liver disease, and depressive and anxiety disorders), similar to previous studies (18, 20, 22, 23), suggesting that they are a valid characterization of alcohol consumption. Alcohol dependence, AUD, drug dependence, and drug use disorders were associated with all three risk levels (moderate, high, and very high versus low). Functional impairment was associated with very high and high risk, the categories of greatest clinical concern (18). Liver disease and depressive and anxiety disorders were associated with very high risk drinking. Generally, the prevalence of these health conditions was greater in the very high and high risk levels, indicating that increased drinking shows increased risk, and suggesting that reducing drinking to moderate or low risk levels could reduce such conditions.
Associations were generally similar for women and men, with some differences, mainly in the 2012–2013 survey. Women showed stronger relationships of very high risk drinking to functional impairment and depressive and anxiety disorders than men, similar to previous studies in AUD samples (74–76). Men showed a stronger relationship of moderate risk drinking to AUD than women. These differences may reflect the fact that, generally, men show higher prevalence of AUD and women show higher prevalence of depression and anxiety, emphasizing the need for further studies in women examining the relationship between drinking and functional impairment, depression, and anxiety.
While causality cannot be determined in these cross-sectional data sets, modeling alcohol consumption as preceding the outcomes (health conditions) is supported by the following. By definition, drinking precedes AUD. Drinking has an impact on liver function, causes liver disease, and exacerbates liver disease due to other causes (3). Heavy drinking/AUD leads to functional impairment due to mental health issues (77). Drug use disorders and depressive and anxiety disorders are highly comorbid with alcohol use/AUD (5, 8, 42, 67, 78), with some (but not all) studies showing alcohol use/AUD preceding the comorbid disorders (79). In longitudinal studies, reduction in drinking was found to be associated with reduced likelihoods of these outcomes (18, 20, 22, 23), justifying the inference about directionality modeled here. Further studies are warranted to better understand the complex and possibly reciprocal relationships between drinking and these conditions.
This study had several limitations. While the direction of effect modeled was well supported, cross-sectional data cannot determine causality. Data were based on self-report, leading to the possibility that response bias could contribute to the findings. A higher response rate for NESARC-III would be preferred, since survey respondents may be healthier than nonrespondents (80), and thus the prevalence of risky drinking and health conditions may be underestimated. Diagnoses were not made by clinicians, because clinician-administered interviews are not feasible in large-scale epidemiological surveys. Future studies of health conditions could incorporate direct examinations or medical record variables. Participants were not asked whether alcohol was the cause of their liver disease, but even in those with liver disease from other causes, alcohol use leads to further damage and a worse prognosis (3). Liver disease had low prevalence, especially among women. For depressive and anxiety disorders, the diagnostic systems could not be perfectly aligned, because DSM-IV diagnoses were used in the 2001–2002 survey and DSM-5 diagnoses in the 2012–2013 survey. However, the effect of these DSM differences should be small for a combined depressive/anxiety disorder variable, because some diagnoses would be made in both systems (81).
The study had several strengths as well: nationally representative data were used, with a sample large enough to include all the WHO risk drinking levels; there was representation of participants by gender, age, race/ethnicity, and socioeconomic status; the assessment of alcohol consumption and health conditions was detailed, rigorous, and consistent; and diagnoses were reliable and valid.
Conclusions
This study provides important information about the WHO risk drinking levels. The prevalence of moderate, high, and very high risk drinking increased over time, pointing to the increasing public health burden of individuals with potentially problematic drinking. Association of the WHO risk drinking levels with health conditions in both surveys, among men and women, shows their relevance as valid measures of drinking, since increased drinking was associated with increased risk. Thus, from the public health perspective, this metric of alcohol consumption is useful, and it can be adopted internationally by translating amounts of alcohol into country-specific standardized drinks. This metric also has clinical utility, since nonabstinent drinking reduction, that is, reducing consumption by one or two WHO risk drinking levels, leads to significant physical, psychological, and emotional improvement (14, 17–23). If clinicians and the general public became more aware that nonabstinent drinking reduction is feasible, sustainable, and beneficial to health, more individuals could be engaged in treatment, which is of great public health importance. The WHO risk drinking levels can be leveraged in prevention and intervention strategies for the public health goal of decreasing the personal and societal toll of risky alcohol use.
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