Combined alcohol use and weight status effects on mortality risk among adults: Analysis of the National Health Interview Survey linked mortality files, 2001–2015
Introduction
Nearly 95,000 annual deaths in the United States (U.S.), about 261 per day, are attributable to excessive alcohol use with about half of those due to health effects of drinking, including various types of cancer, liver disease, and heart disease (CDC, 2021). Similarly, obesity has a strong association with all-cause and specific-cause mortality (Di Angelantonio et al., 2016) and after adjusting for other health indicators (i.e., age, sex, smoking, and hypertension), both low and high body mass index (BMI) scores are associated with mortality risk (Prospective Studies Collaboration, 2009) suggesting a U-shaped relationship (Luijckx et al., 2019, Romero-Corral et al., 2006). Alcohol use may vary as a function of weight status as overeating behaviors and alcohol compete to stimulate brain reward sites (Kleiner et al., 2004), and their combined effects can increase the risk for adverse health outcomes, including premature mortality.
BMI scores indicating obesity (BMI > 30) and underweight (BMI < 18.5) are indicative of an imbalance between caloric intake and energy expenditure. Obesity is a disease with multifaceted etiology (Conway and Rene, 2004) that has been identified as an underlying chronic health problem contributing to numerous top causes of morbidity and mortality in the U.S. and the world (Abdelaal et al., 2017, Mehrzad, 2020). From 2000 to 2018, the prevalence of adult obesity increased from 30.5% to 42.4% (Hales et al., 2020) and is considered one of the three leading actual causes of death in the U.S. along with tobacco and alcohol use (Danaei et al., 2009, Mokdad et al., 2005, Mokdad et al., 2004). The medical complications associated with obesity are vast including, for example, hypertension, sleep apnea, diabetes, heart disease, and certain types of cancer. While a significant body of literature has documented the health risks of obesity (Nuttall, 2015, Reilly et al., 2003), there is considerably less research examining the long-term health effects of being underweight.
Unlike obesity, epidemiological evidence is mixed regarding the relationship between low BMI and increased risk for all-cause mortality (Flegal et al., 2014, Freedman et al., 2006, Ma et al., 2011, Park et al., 2017). In comparison, relatively little information exists on the health risks of people with low BMI and observed higher mortality has been attributed to the effects of preexisting illnesses or health behaviors, like smoking, suggesting reverse causation (Flegal et al., 2011, Flegal et al., 2007). Previously, Roh et al. (2014) suggested that increased mortality among those with underweight status may be due to risk from external causes. Although smoking and weight status have been examined extensively with results indicating increased risk of mortality due to their combined effects (Freedman et al., 2006, Roos et al., 2017), there is less work examining the combined effects of alcohol and weight status on mortality—a gap filled by the present study.
Alcohol use is the most prevalent psychoactive substance used in the U.S. with 85.6% of adults ages 18 and older reporting lifetime use and 54.9% reporting current use (NIAAA, 2020). Heavy alcohol use, defined as drinking 15 or more drinks per week for men and 8 or more drinks per week for women, presents numerous long-term health problems and increases the risk for premature mortality (Plunk et al., 2014, Rehm et al., 2017). Several studies have linked alcohol consumption to increased risk of mortality among obese individuals. One early cohort study of 8006 Japanese American men suggested a significant quadratic (J-shaped) relationship between BMI and alcohol intake (Chyou et al., 1997). The authors further contended that moderate and high alcohol intake is especially harmful among those with low BMI, possibly due to the low intake of nutrients. A recent, large retrospective cohort study (Peeraphatdit et al., 2020) found moderate alcohol consumption was associated with lower mortality among normal and overweight participants, but not in those who are obese (BMI >= 30). Other research has suggested that while moderate alcohol consumption is associated with decreased mortality in normal-weight (BMI > 18.5 & < 25) individuals the same is not true for underweight or obese individuals (Matheson et al., 2012).
The relationship between alcohol use, weight status and mortality remains largely understudied compared to work on smoking and obesity or the effects of living with multiple chronic health problems, and more work is needed to identify patterns of risk that can be addressed through preventive interventions. Using nationally representative cross-sectional data and linked mortality records, this analysis fills in the gaps. Therefore, the objective of the present study was to examine mortality risk from the combined effect of alcohol use and weight status. We hypothesized that alcohol consumption status would be associated with the risk of (i) all-cause mortality, (ii) CVD mortality, and (iii) cancer mortality, and that this association would be exacerbated in individuals with either underweight (BMI < 18.5) or obese (BMI > 30) BMI status.
Section snippets
Data
For this study, nationally representative data from the public-use National Health Interview Survey-Linked Mortality Files (NHIS-LMF), 2001–2011, linked to prospective mortality follow-up through December 2015 were retrieved from IPUMS NHIS online data repository (Blewett et al., 2019). The NHIS is an annual, cross-sectional, nationally representative survey of non-institutionalized residents of the U.S. Computer-assisted personal interviews are conducted continuously throughout the year by
All-cause and cause-specific mortality
The outcome measures were all-cause mortality and cause-specific mortality for the two leading causes of death—diseases of the heart/cardiovascular and cancer—as reported by the U.S. Center for Disease Control and Prevention (CDC) (Heron, 2019) through 113 causes of death groupings, based on the International Classification of Diseases, 10th revision (Anderson et al., 2001). Follow-up time was calculated as the number of years from the date of the original interview to either the date of death
Analysis
We conducted weighted bi-variate chi-square (χ2) tests of each variable by alcohol drinking categories to see if the distribution across these categories is significantly different or not. We also used age-period-cohort Cox proportional hazards models for all-cause and cause-specific mortality, with a complex survey design to account for the clustering, stratification, and multistage sampling of the NHIS data. All covariates were included in the analysis. Results are reported as hazard ratios
Bivariate descriptive results
All bivariate associations had statistically significant differences (all p < 0.001) across the five categories of alcohol drinking status (Table 1). The mean age of adults in this study is 56 years with a mean follow-up period of 8.3 years. On average, light/moderate and heavy drinkers are comparatively younger (~ 52 years) than other alcohol drinking categories. More males (53.3%) reported heavy drinking from the sampled individuals than females (46.7%), and more females were lifetime
Discussion
In this study, we found that alcohol consumption status and BMI status were independently associated with all-cause, CVD and cancer mortality in adults aged 35 years and older. We also found evidence to support our hypothesis that BMI status significantly modifies the alcohol-mortality association. While lifetime abstainers, former drinkers, and current heavy drinkers generally had higher mortality risks than light/moderate drinkers, the risk was especially pronounced among underweight
Conclusion
We found that both alcohol consumption status and BMI status were associated with all-cause and cause-specific mortality and that the associations between alcohol consumption categories and mortality are modified by BMI status. These results support the hypothesis that increased mortality risks for lifetime abstainers, former drinkers, and current heavy drinkers, in comparison to light/moderate drinkers, are exacerbated in underweight and obese individuals. Findings of this study could be
CRediT authorship contribution statement
Muntasir Masum: Conceptualization, Methodology, Investigation, Data analysis, Writing, and Validation of the original draft. Jeffrey T. Howard: Conceptualization, Methodology, Investigation, Data analysis, Writing, and Validation of the original draft. Timothy J. Grigsby: Conceptualization, writing – review & editing.
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements
The work described was supported by T32 DA017629 from the National Institute on Drug Abuse (NIDA). The content is the sole responsibility of the authors and does not necessarily represent the official position of NIDA or the National Institutes of Health.
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