How should we set consumption thresholds for low risk drinking guidelines? Achieving objectivity and transparency using evidence, expert judgement and pragmatism

Abstract

Most high-income nations issue guidelines on low-risk drinking to inform individuals' decisions about alcohol consumption. However, leading scientists have criticized the processes for setting the consumption thresholds within these guidelines for a lack of objectivity and transparency. This paper examines how guideline developers should respond to such criticisms and focuses particularly on the balance between epidemiological evidence, expert judgement and pragmatic considerations. Although concerned primarily with alcohol, our discussion is also relevant to those developing guidelines for other health-related behaviours. We make eight recommendations across three areas. First, recommendations on the use of epidemiological evidence: (1) guideline developers should assess whether the available epidemiological evidence is communicated most appropriately as population-level messages (e.g. suggesting reduced drinking benefits populations rather than individuals); (2) research funders should prioritize commissioning studies on the acceptability of different alcohol-related risks (e.g. mortality, morbidity, harms to others) to the public and other stakeholders; and (3) guideline developers should request and consider statistical analyses of epidemiological uncertainty. Secondly, recommendations to improve objectivity and transparency when translating epidemiological evidence into guidelines: (4) guideline developers should specify and publish their analytical framework to promote clear, consistent and coherent judgements; and (5) guideline developers' decision-making should be supported by numerical and visual techniques which also increase the transparency of judgements to stakeholders. Thirdly, recommendations relating to the diverse use of guidelines: (6) guideline developers and their commissioners should give meaningful attention to how guidelines are used in settings such as advocacy, health promotion, clinical practice and wider health debates, as well as in risk communication; (7) guideline developers should make evidence-based judgements that balance epidemiological and pragmatic concerns to maximize the communicability, credibility and general effectiveness of guidelines; and (8) as with scientific judgements, pragmatic judgements should be reported transparently.

Maintaining guideline transparency and pragmatism in the post‐truth era

“…The pitfalls are well reviewed by Holmes et al . , who ask who are they aimed at, what level of risk should be accepted and do they reflect the uncertainty in any guidelines, given the imprecisions inherent in the methodology? How relevant are population statistics when it comes to the individual with his or her own peculiarities?…”

Developing accurate and transparent low‐risk drinking guidelines: implications for providers, patients and health information consumers

“…However, few can be as difficult-and bound to have a rocky ride-as 'sensible' drinking limits, and certainly the latest 2016 guidelines from the UK Chief Medical Officers (CMOs) [1] have exemplified this. However, few can be as difficult-and bound to have a rocky ride-as 'sensible' drinking limits, and certainly the latest 2016 guidelines from the UK Chief Medical Officers (CMOs) [1] have exemplified this.…”

“…Health messaging for the public is an area fraught with difficulty, even when it is simple and intuitively sensiblesuch as the fruit and vegetable 'five a day' backed by the World Health Organization. However, few can be as difficult-and bound to have a rocky ride-as 'sensible' drinking limits, and certainly the latest 2016 guidelines from the UK Chief Medical Officers (CMOs) [1] have exemplified this. The pitfalls are well reviewed by Holmes et al [2], who ask who are they aimed at, what level of risk should be accepted and do they reflect the uncertainty in any guidelines, given the imprecisions inherent in the methodology?…”

“…Holmes et al [1] present several recommendations for improving the accuracy and relevance of low-risk guidelines and the transparency of methods used in their development. Holmes et al [1] present several recommendations for improving the accuracy and relevance of low-risk guidelines and the transparency of methods used in their development.…”

“…Health-care providers monitoring patients' alcohol intake, and patients themselves, often rely on low-risk guidelines to assess whether drinking amounts are likely to have adverse health effects and/or to inform the need for intervention. Holmes et al [1] present several recommendations for improving the accuracy and relevance of low-risk guidelines and the transparency of methods used in their development. In this commentary, we highlight several of these recommendations and extend their potential importance to helping health-care providers to optimize the use of low-risk drinking guidelines in clinical settings.…”