Good practice principles low rik drinking EU RARHA

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Annex 4Country snapshots:Development of national low risk drinking guidelinesSetting low risk drinking guidelines: the Italian experienceAndrea Ghiselli and Laura Rossi aIn Italy, the consumption of alcoholic beverages – almost exclusively wine up to some twenty yearsago – has been considered an integral part of culture and diet, to the extent that in the past alcoholwas seen as a way to supplement an energy-deficient diet. Over the past decades the perception ofthe role of alcoholic beverages in Italian food culture has shifted from potential benefit to potentialharm, an evolution reflected in the nutrition recommendations of the Italian Society of HumanNutrition (SINU) and in the guidelines for a healthy diet issued by the National Institute ofNutrition (currently CREA).Changes in alcohol intake guidelines from 1979 to 2014 are summarised in Table 1.Focus on benefit for healthThe first Italian policy document on nutrition intake, developed in 1979 by the National Institute ofNutrition in collaboration with the Ministry of Health, set a daily ration of 500 ml of wine for men and300 ml for women[ 1 ]. While a lesser amount was considered to suffice for older people, consumption of300 ml wine was suggested even for pregnant and lactating women.The nutrition recommendations (LARN) revised in 1987 highlighted risks of alcohol consumptionduring pregnancy and breastfeeding as well as risk of harm for young people under 18 years[ 2 ].Nevertheless, alcohol was still considered a nutrient with high energy value. The recommendation wasto limit the share of calories from alcohol to 10% of the total reference energy intake, which for menamounted to around 42g pure alcohol per day, for women around 30g, and for older people under 30g.Today alcohol is no longer considered a nutrient as the calories derived from alcohol are “empty”.Instead, it is categorized as a non-nutrient substance with nutritional interest – like dietary fibres, itcould have an effect on health and wellbeing[ 3 ].In 1986, the first Italian Guidelines for a healthy diet defined acceptable alcohol consumption as 1gof pure alcohol per 1Kg of body weight, corresponding to 450-600 ml of wine per day for men and 250-350 ml for women [ 4 ]. In the second edition of the Guidelines in 1997, daily consumption was lowered to450 ml for men but maintained at 350 ml for women[ 5 ]. This was in line with the nutritionrecommendations revised in 1996, which set the limit of alcohol intake to 40g pure alcohol per day formen and 30g for women[ 6 ].Epidemiological studies of the time showed lower mortality in moderate drinkers compared toheavy drinkers and to absainers (the J-shaped curve). Wine, especially red wine, was consideredbeneficial because of the antioxidants contained in it. Scientific literature tended to support, and evenpromote, moderate consumption of wine – and also beer – for protection against cardiovasculardisease. The public health message at that period was “alcoholic beverages: if yes, in moderation”.The idea of wine as more beneficial compared with other alcoholic beverages was maintained inthe next version of the dietary Guidelines for a healthy diet in 2003, even though with reservations. Therisk of interaction of alcohol with medications was highlighted. The concept of alcohol unit wasintroduced, defined as equivalent to 12 grams of pure alcohol. The guidelines regarding alcoholconsumption showed a downward trend and older people in particular were recommended to reducedrinking because of changes in metabolism[ 7 ].aThe national Food and Nutrition Research Center CREA66Good practice principles for low risk drinking guidelines
Table 1. Changes in alcohol intake guidelines in Italy from 1979 to 2014Nutritional LARN Dietary LARN Dietary Dietary LARNreferencesguidelineguideline guideline1979 1987 1986 1996 1997 2003 2014WinemlEthanolgWinemlEthanolgWinemlAlcoholunitsAlcoholunitsMen 500 43.5- 41.4 646-437 40 450 2-3 2Women 300 30,7 371-270 30 350 1-2 1Older men 220 28,5 311 30 1 -Older women 180 24,2 194 25 1 -Pregnant/lactating w. 300 0 - 0 0 0Focus on harm to healthThe LARN recommendations revised in 2014 marked a total change in the approach toward ethanoland alcoholic beverages. Ethanol was described for the first time as a toxic, carcinogenic andpsychoactive substance for which no intake level “recommended” or compatible with good health cande specified[ 8 ]. In line with international recommendations[ 9 ], alcohol consumption was described interms of increasing risk of harm, with low risk consumption defined as less than two units per day formen and less than one unit for women.• Low risk consumption: Less than 10 g/day (approximately 1 unit) for women and less than 20g/day (approximately 2 units) for men.• Hazardous consumption: A level or pattern of drinking likely to result in harm if presentdrinking habits persist (corresponding to a regular average consumption of 20-40 g/day forwomen and 40-60 g/day for men).• Harmful consumption: A pattern of drinking that causes damage to physical or mental health(corresponding to a regular average consumption of more than 40 g/day for women and morethan 60 g/day for men).• Alcohol dependence: A cluster of physiological, behavioural and cognitive phenomena inwhich the use of alcohol takes on a much higher priority for a given individual than otherbehaviours that once had greater value. The predominant trait is a constant desire to drink.The revised LARN recommendations avoided the term “moderation” because of a lack of anunequivocal definition. The epidemiological scenario was completely changed: there is no more riskfreealcohol consumption, only consumption involving lower risk. Alcohol is no more defined as foodbut considered toxic. Drinking guidelines should accordingly shift from potential benefit to potentialharm.These new concepts will inform the development of new dietary Guidelines to be published in2016. Key issues in the guidelines regarding alcohol consumption could be summarised as:• Alcoholic beverages, including wine and beer, are not protective but can be harmful to health.• If you decide to drink alcohol be aware of the risk for cancer and other illnesses.• Protection against cardiovascular disease can be better obtained by increasing fruit andvegetables and decreasing salt in diet, or by reducing overweight.Another important point arising from recent research is the causal relation between alcoholconsumption and cancer[ 10 ]. In 2014, the European code against cancer, developed by the WHO’sAgency for Research on Cancer, highlighted abstinence from alcohol as the best strategy to reducealcohol-related cancer risk: “If you drink alcohol of any type, limit your intake. Not drinking alcohol isbetter for cancer prevention.” bThere is a need to change the messages related to alcohol consumption and harm across differentlevels in the health sector, in particular in communication between health professionals and patients orbhttp://cancer-code-europe.iarc.fr/index.php/en/67Good practice principles for low risk drinking guidelines
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Good practice principlesfor low ris
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Table of contentsExecutive summary
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Executive summaryThe present public
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The Standard Drink concept and cons
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ForewordA recent flagship report by
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IntroductionThe present publication
Page 15 and 16: Chapter 1Joint Action on Reducing A
Page 17 and 18: Chapter 2Towards a common approach
Page 19 and 20: Graph 2. RARHA survey on low risk d
Page 21 and 22: replaced by daily guidelines in 199
Page 23 and 24: informed the UK 2016 review of drin
Page 25 and 26: Variability across population group
Page 27 and 28: the interpretation of low risk drin
Page 29 and 30: individual and public health, the r
Page 31 and 32: • Low risk drinking guidelines sh
Page 33 and 34: 35OECD (2015), Tackling Harmful Alc
Page 35 and 36: • A literature review into practi
Page 37 and 38: Graph 1. Uses of the Standard Drink
Page 39 and 40: link health messages to EU or natio
Page 41 and 42: warning in relation to consuming al
Page 43 and 44: in order to rduce risk of harm, the
Page 45 and 46: Chapter 4Guidance to reduce alcohol
Page 47 and 48: available in websites were mentione
Page 49 and 50: Restricting hours of sale and densi
Page 51 and 52: level of compliance with age limits
Page 53 and 54: Chapter 5Guidelines to support earl
Page 55 and 56: There is convincing evidence across
Page 57 and 58: standard routine health assessments
Page 59 and 60: Graph 3. Presence of multidisciplin
Page 61 and 62: 8Heather N. (2006) WHO Collaborativ
Page 63 and 64: ES Ministry of Health, Social Servi
Page 65: Annex 3Positive health effects of a
Page 69 and 70: A quarter of a century of alcohol c
Page 71 and 72: The percentages vary depending on t
Page 73 and 74: Review of adult drinking guidelines
Page 75 and 76: the addendum to the expert group re
Page 77 and 78: Guidance on alcohol consumption in
Page 79 and 80: Development of drinking guidelines
Page 81 and 82: 7Maa- ja metsätalousministeriö. (
Page 83 and 84: 83Title Report
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Good practice principles low rik drinking EU RARHA

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