**Please note: Professor Nick Sheron retains the copyright to these slides. If you wish to use the content further, please email Nick.Sheron@soton.ac.uk for advice and guidance** This presentation was delivered at Wessex AHSN's 2016 conference - Predict, Prevent, Adapt.

1. Alcohol related liver disease: prevention and prediction
Nick Sheron

2. 0
20
40
60
80
100
120
%
Years
Percentage change in standardised UK mortality rates (age 0-64) normalised to
100% in 1970
circulatory
ischaemic heart
cerebrovascular
neoplasms
respiratory
endocrine /
metabolic
Data from WHO-HFA database downloaded Oct 2013

3. 0
100
200
300
400
500
600
%
Years
Percentage change in standardised UK mortality rates (age 0-64) normalised to 100% in 1970
circulatory
ischaemic heart
cerebrovascular
neoplasms
respiratory
liver
endocrine / metabolic
diabetes
Data from WHO-HFA database downloaded Oct 2013

4. Sheron, Gilmore BMJ 2015 in press
Liver mortality Directly attributable alcohol mortality

5. Williams et al Lancet 2015
0100200300400500
1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010
%changesince1980
Trends in mortality from alcohol related liver disease in England and Wales , consumption of
spirits, wine, beer and cider, and changes in duty
Alcohol related liver deaths E&W %
White spirits consumption %
Whisky consumption %
Cider consumption %
Wine consumption %
Total lager / beer consumption alcohol %
Packaged strong lager %

6. Marketing theory - the four p’s
• Promotion
• Product
• Place of sale
• Price

7. Williams et al Lancet 2015
0100200300400500
1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010
%changesince1980
Trends in mortality from alcohol related liver disease in England and Wales , consumption of
spirits, wine, beer and cider, and changes in duty
Alcohol related liver deaths E&W %
White spirits consumption %
Whisky consumption %
Cider consumption %
Wine consumption %
Total lager / beer consumption alcohol %
Packaged strong lager %

8. 0
50
100
150
200
250
300
350
400
0
1
2
3
4
5
6
1992 1994 1996 1998 2000 2002 2004 2006 2008 2010
Thousandhectolitres
Units/week
Average consumption of alcopops and spirits by
10-15 year old schoolchildren in England,
overlay = total UK consumption of spirits
Children Spirits
Children Alcopops
Total UK white spirits
Total UK whisky
x 5
Sheron, Gilmore BMJ 2016 in press `

9. 0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
1941
1943
1945
1947
1949
1951
1953
1955
1957
1959
1961
1963
1965
1967
1969
1971
1973
1975
1977
1979
1981*
1983*
1985*
1987*
1989*
1991
1993*
1995
1997
1999*
2001
2003
2005
2007
2009*
2011*
On licenses Off licenses
BBPA handbook 2013
Numbers of licensed premises in the UK
Lancet 2015

10. Nick Sheron unpublished analysis
0
1000
2000
3000
4000
5000
6000
7000
8000
0
10
20
30
40
50
60
70
80
90
100
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012
E&Wdeathsfromchronicliverdiseaseandcirrhosis
£duty/Lpurealcohol
Changes in £ duty / L of alcohol adjusted for income and inflation
£ spirits / L alc £ beer / L alc
£ wine / L alc £ cider / L alc
E&W chronic liver disease and cirrhosis

11. 0
5
10
15
20
25
30
35
40
45
50
0 10 20 30 40 50 60 70 80 90 100 200 300 400
%
Weekly alcohol consumption
Sheron unpublished analysis, Scottish Health Survey and Soton data

12. 50p
Sheron et al, Clinical Medicine, 2014

13. MUP Policy modelling
150 units / week = 20 litres of Frosty Jack

14. MUP Policy modelling
15.5p / unit £23.25
70p / unit £105
Increase = £81.75 / week

15. The Pareto Principle or 80:20 rule
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% of 18+ population % of alcohol units consumed
Extreme - over 75 units
Higher risk - 35/50 to 75
Increasing risk 14 to 35/50
Lower risk <=14 units
non-drinkers

16. 0
50
100
150
200
250
300
350
400
450
%changesince1980
Spirits Afford Index Beer Afford Index Wine Afford Index
Cider Afford Index Alcohol related deaths E & W
2% tax
escalator

17. Nick Sheron, unpublished analysis
Survival of admissions to the Liver Unit Southampton
1/3
1/3
1/3

18. 76%
P<0.001
Prior liver outpatient referrals in 5,112 Southampton first admissions with cirrhosis
Nick Sheron unpublished analysis
¾ of people who will
die of cirrhosis
currently have no idea
they have a liver
problem

19. The Southampton Liver Traffic Light Test
4,343 subjects followed for up to 12 years
SLTL n = 4,343
Mortality ROC = 0.83
Fibroscan n = 2,052
Complications C stat = 0.8
Mortality C stat = 0.67
ELF n = 457
Complications ROC = 0.87

20. 30% reduced drinking to safe levels
65% harmful / dependent drinkers
reduced to safe levels
Traffic light test in 400 heavy drinkers in primary care, follow up after one year

21. Check viral serology in all
patients
Simple liver
disease
Complex liver disease Acute complex liver disease
Risk factors Alcohol, obesity, virus. Immune, metabolic Viruses, immune, drugs
Red Reduce risk factors, refer or
check for varices
Refer hepatology Traffic light may not be much
use for acute disease, check
for viral hepatitis and drugs.
Refer ALL seronegative
hepatitis urgently
Amber Reduce risk factors, repeat
traffic light 3-5 years
Liver ultrasound, refer if U/S
normal
Green Reduce risk factors Review carefully, liver
ultrasound, repeat traffic
light early

22. Data prodrome
Data prodrome
Nurse intervention
Control
10 GPM practices randomised to intervention / control
= audit of GP Read Codes

23. England
35.6m drinkers
10.4m risky drinkers
1.9m harmful drinkers
1.06m alcohol admissions
53,000 ALD admissions
6,592 alcohol related deaths
4,190 ALD deaths
Effectiveness Cost
Clinical Hepatology

24. LOCATE / ALLDeS teams
Miranda Kim
Magdy El-Gohari
Hazel Inskip
Colin Newell
Fangzhong Su
Emily Stimpson
Jo Dash
Tina Reinson
Jackie Hollis
Lucy Gruner
Maria Baggot
Natalie Stanton
Wendy O’Brien
Andrea Jarman
Mike Moore
Paul Roderick
Julia Sinclair
Maheswaran Naranjan
Topher Woelk
Richard Aspinall
Alan Knobel
Anonymised Hampshire Health Record Data:
HHRIGG
NHS SCW CSU