Socioeconomic inequalities in the incidence of alcohol-related liver disease: A nationwide Danish study

Abstract

Summary Background There is socio-economic inequality in total alcohol-related harm, but knowledge of inequality in the incidence of specific alcohol-related diseases would be beneficial for prevention. Registry-based studies with nationwide coverage may reveal the full burden of socioeconomic inequality compared to what can be captured in questionnaire-based studies. We examined the incidence of alcohol-related liver disease (ALD) according to socioeconomic status and age. Methods We used national registries to identify patients with an incident diagnosis of ALD and their socioeconomic status in 2009–2018 in Denmark. We computed ALD incidence rates by socioeconomic status (education and employment status) and age-group (30–39, 40–49, 50–59, 60–69 years) and quantified the inequalities as the absolute and relative difference in incidence rates between low and high socioeconomic status. Findings Of 17,473 patients with newly diagnosed ALD, 78% of whom had cirrhosis, 86% had a low or medium-low educational level and only 20% were employed. ALD patients were less likely to be employed in the 10 years prior to diagnosis than controls. The incidence rate of ALD correlated inversely with educational level, from 181 (95% CI, 167–197) to 910 (95% CI, 764–1086) per million person-years from the highest to the lowest educational level. By employment status, the incidence rate per million person-years was 211 (95% CI, 189–236) for employed and 3449 (95% CI, 2785–4271) for unemployed. Incidence rates increased gradually with age leading to larger inequalities in absolute numbers for older age-groups. Although ALD was rare in the younger age-groups, the relative differences in incidence rates between high and low socioeconomic status were large for these ages. The pattern of socioeconomic inequality in ALD incidence was similar for men and women. Interpretation This study showed substantial socioeconomic inequalities in ALD incidence for people aged 30–69 years. Funding The study was supported by grants from the Novo Nordisk Foundation (NNF18OC0054612) and the Research Fund of Bispebjerg Hospital.

Applying an equity lens to liver health and research in Europe

“…The few exceptions that prove the rule Except for some countries such as the United Kingdom 16,17 or Denmark, 18 or cities where there is a strong tradition of social epidemiology research such as Barcelona 19,20 or Rotterdam, 21 it appears that Europe as a whole is overlooking the investigation of health inequality in liver disease. In addition, most studies are conducted by general epidemiologists who are not specifically devoted to liver disease analysis, while adopting an equity lens is a rarity amongst clinicians, i.e.…”

“…16 Danish citizens with the lowest education attainment presented 5-fold higher incidence of ALD. 18 The increase in liver-related mortality occurring at a global level between 1985 and 2015 was strongly associated with high levels of alcohol consumption as well as indicators of national wealth and government health expenditure on health. 42 Awareness campaigns on the harmful effects of alcohol consumption should be deployed from early ages in schools, particularly those located in socially deprived areas.…”

The stigma of alcohol-related liver disease and its impact on healthcare

“…92 On a societal level, both the incidence and mortality of ALD are linked to socio-economic inequality. People of lower socio-economic status showed a higher incidence of ALD in a Danish registry study, 93 while mortality was robustly related to both state-level inequality and individual income in a study from the United States. 94 Preventing ALD and improving ALD outcomes is a task that does not stop with the healthcare system.…”

The impact of alcohol taxation increase on all-cause mortality inequalities in Lithuania: an interrupted time series analysis

“…This measure has not only decreased affordability of alcoholic beverages [16], but has also been linked to lower all-cause mortality rates [17,18]. The reduction in national mortality rates were most notable among younger adults [19] and were also observed for liver cirrhosis and suicide deaths [20,21], which had shown the highest rates among the most socioeconomically disadvantaged populations in various high-income countries [22][23][24].…”