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Alcohol: applying All Our Health - GOV.UK (www.gov.uk)Alc

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The Public Health England team leading this policy transitioned into the Office for Health Improvement and Disparities (OHID) on 1 October 2021.

This 'All Our Health' alcohol information has been created to help all health professionals:

understand specific activities and interventions that can prevent alcohol harm

think about the resources and services available in your area, that can help increasing or higher risk drinkers

Access the alcohol e-learning session

An interactive e-learning version of this topic is now available to use. The Office for Health Improvements and Disparities ( OHID) and Health Education England's 'e-Learning for Healthcare' have developed this content to increase the confidence and skills of health and care professionals, to embed prevention in their day-to-day practice.

Working to reduce alcohol harm in your professional practice

Since the early 1980s, alcohol sales and the amount that people drink has steadily increased, until peaking in 2008 and declining slightly since.

Some of this decline is due to more adults choosing to be teetotal, as well as fewer under 18's drinking alcohol.

However, drinking behaviour is different for different groups. It's largely the people who already tend to drink less that are cutting back, while many of those who are at high risk of health conditions, because they drink heavily, are drinking more now than they did before.

In England, over 10 million people consume alcohol at levels above the UK CMOs' low-risk drinking guidelines and increase their risk of alcohol-related ill health.

Alcohol misuse contributes (wholly or partially) to 200 health conditions, with many leading to hospital admission. This is due either to acute alcohol intoxication or to the toxic effect of alcohol misuse over time.

These conditions include some cancers, cardiovascular conditions, depression and liver disease. In 2017 to 2018, there were over 1.1 million admissions related to alcohol, of which alcohol was the main reason for admission for about 338,000 cases.

Taking action as a front-line health and care professional

You can access free alcohol identification and brief advice e-learning to become confident in identifying those at risk from alcohol and delivering brief advice to change behaviour.

You should ask patients about alcohol and provide simple, brief advice and support to help them minimise harmful alcohol consumption.

Identifying risk usually means asking a set of questions from a validated alcohol use screening tests and scoring the answers (or giving patients an AUDIT-C scratch card (PDF, 388KB) to self-complete) then feeding back to the patient what their score indicates about their health risk.

You should also:

encourage patients to think about their health risk (and cut back if indicated) and provide a patient information leaflet for calculating alcohol units

direct patients who are drinking above low risk to trusted sources of information such as the NHS website and Better Health or apps such as 'Drink Free Days'

make yourself aware of local specialist services via your local authority public health team, or use this alcohol addiction services search facility

check that patients with alcohol problems are registered with a GP and receiving primary health care, vaccinations and screening programmes

ask who is leading delivery of the screening and brief advice for alcohol and tobacco use in inpatient settings in your trust, know what's involved and become a champion

ask who is leading delivery of the screening and brief advice for alcohol and tobacco use in inpatient settings in your trust, know what's involved and become a champion

If your patients show signs of alcohol dependence, refer them to specialist services.

Read our blog about brief advice, motivational interviewing and health coaching to help you have non-judgemental conversations that are tailored to individual patients.

Read our blog about the type of local services that may be available, and how to find them.

Taking action as a team leader or manager

Ensure the teams you manage are aware of alcohol services and interventions in your local area.

Promote a team culture where all staff know that they should talk to their patients about healthy lifestyles - 'Making Every Contact Count' initiatives should include alcohol screening and advice.

Taking action as a senior or strategic leader

Consider whether your local alcohol partnership would benefit from undertaking an evidence-based self-assessment of systems and services.

Ensure the standard contract requirement for screening and brief advice for alcohol and tobacco use in inpatient settings is being fulfilled.

Facilitate the successful delivery of screening and brief advice for alcohol and tobacco use in inpatient settings by ensuring that there is strong leadership at all levels of the trust, and that staff members feel supported to deliver identification and brief advice as part of usual care.

Ensure there is a system in place to record the interventions in patient notes and report to the board on performance.

Be aware of the structures and interventions which are likely to exist at a local population level, which include alcohol as a part of Health and Wellbeing Boards' Joint Strategic Needs Assessment ( JSNA) and that there are commissioned services to address the needs of the population.

Ensure commissioned alcohol services adhere to clinical and public health standards (see NICE Alcohol-use disorders: diagnosis and management quality standard QS11).

Ensure health concerns are represented in local alcohol licensing process and decisions.

Ensure data is shared between health, social care and community safety organisations to target prevention activity and coordinate care.

Understanding local needs

Measures of the impact of alcohol harm on a population are Public Health Outcomes Framework indicators: see entries 'admission episodes for alcohol-specific conditions - under 18s' and 'alcohol-related mortality'.

The harm caused by alcohol misuse is so far-reaching; it also impacts significantly on a range of other outcomes for individuals and communities.

Fingertips combines a series of products that provide local data alongside national comparisons to support local health improvement including local alcohol profiles for England (LAPE) which provide information for local government, health organisations, commissioners and other agencies to monitor the impact of alcohol on local communities, and to monitor the services and initiatives that have been put in place to prevent and reduce the harmful impact of alcohol.

The public health dashboard makes data about many aspects of alcohol use accessible to everyone. It sets out our best current local prevalence estimates alongside the key performance measures for treatment services, including recovery outcomes.

Alcohol profiles: indicators

Mortality indicators include:

years of life lost due to alcohol (1.02)

alcohol-specific mortality (2.01)

mortality from chronic liver disease (3.01)

alcohol-related mortality (4.01)

Hospital admissions indicators include:

admission episodes for alcohol-specific conditions (6.02)

admission episodes for alcohol-related conditions (Broad) (9.01)

admission episodes for alcohol-related conditions (Narrow) (10.01)

Age groups indicators include:

admission episodes for alcohol-specific conditions - under 18s (5.02)

admission episodes for alcohol-related conditions (Narrow) - under 40s (10.06)

admission episodes for alcohol-related conditions (Narrow) - 40 to 64 years (10.07)

admission episodes for alcohol-related conditions (Narrow) - over 65s (10.08)

Alcohol-related conditions indicators include:

admission episodes for alcohol-related cardiovascular disease (Broad) (9.03)

admission episodes for mental and behavioural disorders due to use of alcohol (Broad) (9.04)

admission episodes for alcoholic liver disease (Broad) (9.05)

admission episodes for alcohol-related unintentional injuries condition (Narrow) (10.03)

admission episodes for mental and behavioural disorders due to use of alcohol (Narrow) (10.04)

admission episodes for intentional self-poisoning by and exposure to alcohol (Narrow) (10.05)

incidence rate of alcohol-related cancer (13.01)

Other impact indicators include:

claimants of incapacity benefits - working age (11.01)

alcohol-related road traffic accidents (12.01)

Treatment indicators include:

number in treatment at specialist alcohol misuse services (14.01)

successful completion of treatment for alcohol (15.01)

proportion waiting more than 3 weeks for alcohol treatment (16.01)

Consumption and availability indicators include:

volume of pure alcohol through the off-trade: all alcohol sales (17.01)

percentage of adults who abstain from drinking alcohol (19.01)

percentage of adults binge drinking on heaviest drinking day (19.02)

percentage of adults drinking over 14 units of alcohol a week (19.03)

Measuring impact

As a health professional, there are a range of reasons why it makes sense to measure your impact and demonstrate the value of your contribution. This could be about sharing what has worked well in order to benefit your colleagues and local people or help you with your professional development.

The Everyday Interactions measuring impact toolkit provides a quick, straightforward and easy way for healthcare professionals to record and measure their public health impact in a uniform and comparable way.

The alcohol impact pathway is recommended for healthcare professionals to record and measure actions undertaken as part of routine care which impact on adult obesity.

Guidance and resources

NICE PH24 provides guidance for health and social care professionals on preventing alcohol use disorders.

A recent Cochrane review presents the evidence for alcohol brief interventions in primary care settings.

Advice for patients and the public

NHS.UK provides information about alcohol for the public.

Professional resources and tools

A range of alcohol and drug misuse prevention and treatment resources have been produced to support the commissioning of alcohol services, support around social return on investment, the case for investing in alcohol interventions, and the impact of commissioning decisions on outcomes.

The adult alcohol and drug treatment commissioning tool supports areas in estimating local spend on treatment interventions and cost-effectiveness. The Tool also includes prevalence data for alcohol and opiate users, estimates of met need and a future scenario planning function.

NICE alcohol-use disorders pathways set out a structured approach to identify alcohol-related harm through the use of risk factors, screening tools and effective interventions.

Good practice examples

Case studies are available from a mental health provider and an acute provider.

# data[].attributes.attachment_link.description
The Public Health England team leading this policy transitioned into the Office for Health Improvement and Disparities (OHID) on 1 October 2021. This 'All Our Health' alcohol information has been created to help all health professionals: understand specific activities and interventions that can prevent alcohol harm think about the resources and services available in your area, that can help increasing or higher risk drinkers An interactive e-learning version of this topic is now available to use.

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Association between Ultra-processed foods & Diabetes Type 2 

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Association between Ultra-processed foods & Diabetes Type 2 

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UPF-T2D.pdf (imperial.ac.uk)

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The Risks Associated With Alcohol Use and Alcoholism - PMC (nih.gov)

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Abstract

Alcohol consumption, particularly heavier drinking, is an important risk factor for many health problems and, thus, is a major contributor to the global burden of disease. In fact, alcohol is a necessary underlying cause for more than 30 conditions and a contributing factor to many more. The most common disease categories that are entirely or partly caused by alcohol consumption include infectious diseases, cancer, diabetes, neuropsychiatric diseases (including alcohol use disorders), cardiovascular disease, liver and pancreas disease, and unintentional and intentional injury. Knowledge of these disease risks has helped in the development of low-risk drinking guidelines. In addition to these disease risks that affect the drinker, alcohol consumption also can affect the health of others and cause social harm both to the drinker and to others, adding to the overall cost associated with alcohol consumption. These findings underscore the need to develop effective prevention efforts to reduce the pain and suffering, and the associated costs, resulting from excessive alcohol use.

Keywords: alcohol and other drug (AOD) use, alcohol use disorders, alcoholism, heavy drinking, AOD induced risk, AOD effects and consequences, health, disease cause, disease factor, disease risk and protective factors, burden of disease, health care costs, injury, social harm, drinking guidelines, prevention

Alcohol consumption has been identified as an important risk factor for illness, disability, and mortality ( Rehm et al. 2009b). In fact, in the last comparative risk assessment conducted by the World Health Organization (WHO), the detrimental impact of alcohol consumption on the global burden of disease and injury was surpassed only by unsafe sex and childhood underweight status but exceeded that of many classic risk factors, such as unsafe water and sanitation, hyper-tension, high cholesterol, or tobacco use ( WHO 2009). This risk assessment evaluated the net effect of all alcohol consumption-that is, it also took into account the beneficial effects that alcohol consumption (primarily moderate consumption) can have on ischemic diseases1 and diabetes ( Baliunas et al. 2009; Corrao et al. 2000; Patra et al. 2010; Rehm et al. 2004). Although these statistics reflect the consequences of all alcohol consumption, it is clear that most of the burden associated with alcohol use stems from regular heavier drinking, defined, for instance, as drinking more than 40 grams of pure alcohol per day for men and 20 grams of pure alcohol per day for women2 ( Patra et al. 2009; Rehm et al. 2004). In addition to the average volume of alcohol consumption, patterns of drinking-especially irregular heavy-drinking occasions, or binge drinking (defined as drinking at least 60 grams of pure alcohol or five standard drinks in one sitting)-markedly contribute to the associated burden of disease and injury ( Gmel et al. 2010; Rehm et al. 2004). This article first defines which conditions necessarily are caused by alcohol use and for which conditions alcohol use is a contributing factor. It then looks more closely at the most common disease risks associated with excessive alcohol use, before exploring how these risks have influenced guidelines for drinking limits. The article concludes with a discussion of the alcohol-related risk of harm to people other than the drinker.

Disease and Injury Conditions Associated With Alcohol Use

Conditions for Which Alcohol Is a Necessary Cause

More than 30 conditions listed in the WHO's International Classification of Diseases, 10th Edition (ICD-10) ( WHO 2007) include the term "alcohol" in their name or definition, indicating that alcohol consumption is a necessary cause underlying these conditions (see table 1 ). The most important disease conditions in this group are alcohol use disorders (AUDs), which include alcohol dependence and harmful use or alcohol abuse.3 AUDs are less fatal than other chronic disease conditions but are linked to considerable disability ( Samokhvalov et al. 2010d). Overall, even though AUDs in themselves do not rank high as a cause of death globally, they are the fourth-most disabling disease category in low- to middle-income countries and the third-most disabling disease category in high-income countries ( WHO 2008). Thus, AUDs account for 18.4 million years of life lost to disability (YLDs), or 3.5 percent of all YLDs, in low- and middle-income countries and for 3.9 million YLDs, or 5.7 percent of all YLDs, in high-income countries. However, AUDs do not affect all population subgroups equally; for example, they mainly affect men, globally representing the second-most disabling disease and injury condition for men. In contrast, AUDs are not among the 10 most important causes of disabling disease and injury in women ( WHO 2008).

Table 1

ICD-10 Code

Disease

E24.4

Alcohol-induced pseudo-Cushing's syndrome

F10

Mental and behavioral disorders attributed to use of alcohol

G31.2

Degeneration of nervous system attributed to alcohol

G62.1

Alcoholic polyneuropathy

G72.1

Alcoholic myopathy

I42.6

Alcoholic cardiomyopathy

K29.2

Alcoholic gastritis

K70

Alcoholic liver disease

K85.2

Alcohol-induced acute pancreatitis

K86.0

Alcohol-induced chronic pancreatitis

O35.4

Maternal care for (suspected) damage to fetus from alcohol

P04.3

Fetus and newborn affected by maternal use of alcohol

Q86.0

Fetal alcohol syndrome (dysmorphic)

R78.0

Finding of alcohol in blood

T51

Toxic effect of alcohol

X45

Accidental poisoning by and exposure to alcohol

X65

Intentional self-poisoning by and exposure to alcohol

Y15

Poisoning by and exposure to alcohol, undetermined intent

Y90

Evidence of alcohol involvement determined by blood alcohol level

Alcoholic liver disease and alcohol-induced pancreatitis are other alcohol-specific disease categories that are of global importance. However, no global prevalence data on these disease categories exist because they cannot be validly assessed on a global level. Thus, these conditions are too specific to assess using verbal autopsies and other methods normally used in global-burden-of-disease studies ( Lopez et al. 2006; pancreatitis can be estimated indirectly Rajaratnam et al. 2010). Nevertheless, via the prevalence of alcohol exposure the prevalence of alcohol-attributable and relative risk for the wider, unspecific liver cirrhosis and alcohol-induced disease categories ( Rehm et al. 2010a).

Conditions for Which Alcohol Is a Component Cause

Disease and injury conditions for which alcohol consumption is a component cause contribute more to the global burden of disease than do alcohol-specific conditions. Overall, the following are the main disease and injury categories impacted by alcohol consumption (listed in the order of their ICD-10 codes):

Neuropsychiatric disease;

Liver and pancreas disease; and

Unintentional and intentional injury.

For all chronic disease categories for which detailed data are available, those data show that women have a higher risk of these conditions than men who have consumed the same amount of alcohol; however, the differences are small at lower levels of drinking ( Rehm et al. 2010a). The following sections will look at these disease categories individually.

Individual Disease and Injury Conditions Associated With Alcohol Use

Infectious Diseases

Although infectious diseases were not included in the WHO's comparative risk assessments for alcohol conducted in 2000 ( Rehm et al. 2004) and 2004 ( Rehm et al. 2009b), evidence has been accumulating that alcohol consumption has a detrimental impact on key infectious diseases ( Rehm et al. 2009a, 2010a), such as tuberculosis ( Lönnroth et al. 2008; Rehm et al. 2009c), infection with the human immunodeficiency virus (HIV) ( Baliunas et al. 2010; Shuper et al. 2010), and pneumonia ( Samokhvalov et al. 2010c). In fact, recent studies (Rehm and Parry 2009; Rehm et al. 2009a) found that the overall impact of alcohol consumption on infectious diseases is substantial, especially in sub-Saharan Africa.

One of the pathways through which alcohol increases risk for these diseases is via the immune system, which is adversely affected by alcohol consumption, especially heavy drinking ( Rehm et al. 2009c; Romeo et al. 2010). As a result, although risk for infectious diseases does not differ greatly for people drinking less than 40 grams of pure alcohol per day compared with abstainers, this risk increases substantially for those who drink larger amounts or have been diagnosed with an AUD ( Lönnroth et al. 2008; Samokhvalov et al. 2010c). In addition, alcohol consumption is associated with poorer outcomes from infectious disease for heavy drinkers by way of social factors. Thus, people with alcohol dependence often are stigmatized and have a higher chance of becoming unemployed and destitute; as a result, they tend to live in more crowded quarters with higher chances for infection and lower chances of recovery ( Lönnroth et al. 2009).

The relationship between alcohol consumption and HIV infection and acquired immunodeficiency syndrome (AIDS) is different from that with other infectious diseases. To become infected with HIV, people must exchange body fluids, in most cases either by injecting drugs with a contaminated needle or, more commonly in low-income societies, engaging in unsafe sex. Thus, although significant associations exist between alcohol use, especially heavy drinking, and HIV infection via alcohol's general effects on the immune system ( Baliunas et al. 2010; Kalichman et al. 2007; Shuper et al. 2009, 2010), it cannot be excluded that other variables, including personality characteristics, psychiatric disorders, and situational factors may be responsible for both risky drinking and unsafe sex ( Shuper et al. 2010). Researchers frequently have pointed out that personality characteristics, such as a propensity for risk-taking, sensation-seeking, and sexual compulsivity, may be involved in the risk of HIV infection. Indeed, a recent consensus meeting determined that there is not yet sufficient evidence to conclude that alcohol has a causal impact on HIV infection ( Parry et al. 2009). However, it can be argued that experimental studies in which alcohol consumption led to a greater inclination to engage in unsafe sex indicate that some causal relationship between alcohol and HIV infection exists (e.g., George et al. 2009; Norris et al. 2009).

Once a person is infected with HIV, alcohol clearly has a detrimental impact on the course of the disease, especially by interfering with effective antiretroviral treatment ( Pandrea et al. 2010). A recent meta-analysis found that problem drinking-defined as meeting the National Institute on Alcohol Abuse and Alcoholism (NIAAA)'s criteria for at-risk drinking or having an AUD-was associated with being less than half as likely to adhere to antiretroviral treatment guidelines ( Hendershot et al. 2009). Because the level of adherence to the treatment regimen affects treatment success as well as outright survival, alcohol consumption clearly is associated with negative outcomes for people living with HIV and AIDS.

Cancer

Recently, the Monograph Working Group of the International Agency for Research on Cancer concluded that there was sufficient evidence for the carcinogenicity of alcohol in animals and classified alcoholic beverages as carcinogenic to humans ( Baan et al. 2007). In particular, the group confirmed, or newly established, the causal link between alcohol consumption and cancer of the oral cavity, pharynx, larynx, esophagus, liver, colorectum, and female breast. For stomach and lung cancer, carcinogenicity was judged as possible but not established. For all sites where alcohol's causal role in cancer is established, there is evidence of a dose-response relationship, with relative risk rising linearly with an increasing volume of alcohol consumption ( Corrao et al. 2004).

The molecular and biochemical mechanisms by which chronic alcohol consumption leads to the development of cancers of various organs are not fully understood. It has been suggested that these mechanisms differ by target organ and include variations (i.e., polymorphisms) in genes encoding enzymes responsible for ethanol metabolism (e.g., alcohol dehydrogenase, aldehyde dehydrogenase, and cytochrome P450 2E1), increased estrogen concentrations, and changes in folate metabolism and DNA repair ( Boffetta and Hashibe 2006; Seitz and Becker 2007). In addition, the International Agency for Research on Cancer group concluded that acetaldehyde-which is produced when the body breaks down (i.e., metabolizes) beverage alcohol (i.e., ethanol) but also is ingested as a component of alcoholic beverages- itself is carcinogenic. It likely plays an important role in the development of cancers of the digestive tract, especially those of the upper digestive tract ( Lachenmeier et al. 2009; Seitz and Becker 2007).

Diabetes

The relationship between alcohol consumption and diabetes is complex. A curvilinear relationship exists between the average volume of alcohol consumption and the inception of diabetes ( Baliunas et al. 2009)-that is, lower alcohol consumption levels have a protective effect, whereas higher consumption is associated with an increased risk. The greatest protective effect has been found with a consumption of about two standard drinks (28 grams of pure alcohol) per day, and a net detrimental effect has been found starting at about four standard drinks (50 to 60 grams of pure alcohol) per day.

Neuropsychiatric Disorders

With respect to neuropsychiatric disorders, alcohol consumption has by far the greatest impact on risk for alcohol dependence. However, alcohol also has been associated with basically all mental disorders (e.g., Kessler et al. 1997), although the causality of these associations is not clear. Thus, mental disorders may be caused by AUDs or alcohol use, AUDs may be caused by other mental disorders, or third variables may be causing both AUDs and other mental disorders. This complex relationship makes it difficult to determine the fraction of mental disorders actually caused by alcohol consumption (see Grant et al. 2009).

The relationship between alcohol and epilepsy is much clearer. There is substantial evidence that alcohol consumption can cause unprovoked seizures, and researchers have identified plausible biological pathways that may underlie this relationship ( Samokhvalov et al. 2010a). Most of the relevant studies found that a high percentage of heavy alcohol users with epilepsy meet the criteria of alcohol dependence.

Cardiovascular Diseases

The overall effect of alcohol consumption on the global cardiovascular disease burden is detrimental (see table 2 ). Cardiovascular disease is a general category that includes several specific conditions, and alcohol's impact differs for the different conditions. For example, the effect of alcohol consumption on hypertension is almost entirely detrimental, with a dose-response relationship that shows a linear increase of the relative risk with increasing consumption ( Taylor et al. 2009). A similar dose-response relationship exists between alcohol consumption and the incidence of atrial fibrillation4 ( Samokhvalov et al. 2010b). On the other hand, for heart disease caused by reduced blood supply to the heart (i.e., ischemic heart disease), the association with alcohol consumption is represented by a J-shaped curve ( Corrao et al. 2000), with regular light drinking showing some protective effects. Irregular heavy drinking occasions, however, can nullify any protective effect. In a recent systematic review and meta-analysis comparing the effects of different drinking patterns in people with an overall consumption of less than 60 grams of pure alcohol per day, Roerecke and Rehm (2010) found that consumption of 60 grams of pure alcohol on one occasion at least once a month eliminated any protective effect of alcohol consumption on mortality. The authors concluded that the cardio-protective effect of moderate alcohol consumption disappears when light to moderate drinking is mixed with irregular heavy-drinking occasions. These epidemiological results are consistent with the findings of biological studies that-based on alcohol's effects on blood lipids and blood clotting-also predict beneficial effects of regular moderate drinking but detrimental effects of irregular heavy drinking ( Puddey et al. 1999; Rehm et al. 2003).

Table 2

Disease Category

World

M

W

T

%M

%W

%

Diabetes

0*

28

28

0.0

0.2

0.0

Total detrimental effects attributable to alcohol
68,938

12,536

81,474

100.0

100.0

100.0

Total beneficial effects attributable to alcohol
−1,075

−1,246

−2,321

100.0

100.0

100.0

All alcohol-attributable net DALYs 67,863 11,290 79,153

All DALYs
799,536

730,631

1,530,168

Percentage of all net DALYs attributable to alcohol 8.5% 1.5% 5.2%

For comparison without infectious disease 7.6% 1.4% 4.6%

The effects of alcohol consumption on ischemic stroke5 are similar to those on ischemic heart disease, both in terms of the risk curve and in terms of biological pathways ( Patra et al. 2010; Rehm et al. 2010a). On the other hand, alcohol consumption mainly has detrimental effects on the risk for hemorrhagic stroke, which are mediated at least in part by alcohol's impact on hypertension.

Overall, the effects of alcohol consumption on cardiovascular disease are detrimental in all societies with large proportions of heavy-drinking occasions, which is true for most societies globally ( Rehm et al. 2003a). This conclusion also is supported by ecological analyses or natural experiments. For example, studies in Lithuania ( Chenet et al. 2001) found that cardiovascular deaths increased on weekends, when heavy drinking is more common. Also, when overall consumption was reduced in the former Soviet Union (a country with a high proportion of heavy-drinking occasions) between 1984 and 1994, the death rate from cardiovascular disease declined, indicating that alcohol consumption had an overall detrimental effect on this disease category ( Leon et al. 1997).

Diseases of the Liver and Pancreas

Alcohol consumption has marked and specific effects on the liver and pancreas, as evidenced by the existence of disease categories such as alcoholic liver disease, alcoholic liver cirrhosis, and alcohol-induced acute or chronic pancreatitis. For these disease categories, the dose-response functions for relative risk are close to exponential ( Irving et al. 2009; Rehm et al. 2010b), although the risks associated with light to moderate drinking (i.e., up to 24 grams of pure alcohol per day) are not necessarily different from the risks associated with abstention. Thus, the incidence of diseases of the liver and pancreas is associated primarily with heavy drinking.

It is important to note that given the same amount of drinking, the increase in the risk for mortality from these diseases is greater than the increase in risk for morbidity, especially at lower levels of consumption. This finding suggests that continued alcohol consumption, even in low doses, after the onset of liver or pancreas disease, increases the risk of severe consequences.

Unintentional Injuries

The link between alcohol and almost all kinds of unintentional injuries has long been established. It depends on the blood alcohol concentration (BAC) and shows an exponential dose-response relationship ( Taylor et al. 2010). Alcohol affects psychomotor abilities, with a threshold dose for negative effects generally found at BACs of approximately 0.04 to 0.05 percent (which typically are achieved after consuming two to three drinks in an hour); accordingly, injury resulting from alcohol's disruption of psychomotor function could occur in people with BACs at this level ( Eckardt et al. 1998). However, the epidemiological literature shows that even at lower BACs, injury risk is increased compared with no alcohol consumption ( Taylor et al. 2010).

The acute effects of alcohol consumption on injury risk are mediated by how regularly the individual drinks. People who drink less frequently are more likely to be injured or to injure others at a given BAC compared with regular drinkers, presumably because of less tolerance ( Gmel et al. 2010). This correlation was demonstrated with respect to traffic injuries in a reanalysis ( Hurst et al. 1994) of a classic study conducted in Grand Rapids, Michigan ( Borkenstein et al. 1974). It also is important to realize that even if the absolute risk for injury may be relatively small for each occasion of moderate drinking (defined as drinking up 36 grams pure alcohol in one sitting), the lifetime risks from such drinking occasions sums up to a considerable risk for those who often drink at such a level ( Taylor et al. 2008).

Intentional Injuries

Alcohol consumption is linked not only to unintentional but also to intentional injury. Both average volume of alcohol consumption and the level of drinking before the event have been shown to affect suicide risk ( Borges and Loera 2010). There also is a clear link between alcohol consumption and aggression, including, but not limited to, homicides ( Rehm et al. 2003b). Several causal pathways have been identified that play a role in this link, including biological pathways acting via alcohol's effect on receptors for the brain signaling molecules (i.e., neurotransmitters) serotonin and γ-aminobutyric acid or via alcohol's effects on cognitive functioning ( Rehm et al. 2003b). Cultural factors that are related to both differences in drinking patterns and beliefs and expectations about the effects of alcohol also influence the relationship between drinking and aggression ( Bushman and Cooper 1990; Graham 2003; Leonard 2005; Room and Rossow 2001).

Implications of Alcohol-Related Risks for Drinking Guidelines

Overall, the various risks associated with alcohol use at various levels can be combined to derive low-risk drinking guidelines. Such analyses found that overall, any increase in drinking beyond one standard drink on average per day is associated with an increased net risk for morbidity and mortality in high-income countries ( Rehm et al. 2009). Moreover, at any given consumption level this risk increase is larger for women than for men. NIAAA has translated the epidemiological findings into low-risk drinking limits of no more than 14 standard drinks per week for men and 7 standard drinks per week for women ( NIAAA 2010). These guidelines also specify that to limit the risk of acute consequences, daily consumption should not exceed four standard drinks for men and three for women ( NIAAA 2010).

Overall Global Impact of Alcohol Consumption on Burden of Disease

The most recent systematic overview on the effects of alcohol on global burden of disease was based on data for the year 2004 ( Rehm et al. 2009a, b) (see table 2 ). The analyses found that although AUDs (which constitute the major part of the neuropsychiatric disorders listed in the table) clearly are important contributors to global burden of disease, they only account for less than one-third of the overall impact of alcohol consumption. Almost equally important are the acute effects of alcohol consumption on the risk of both unintentional and intentional injury. In addition, alcohol has a sizable effect on the burden of disease associated with infectious diseases, cancer, cardiovascular disease, and liver cirrhosis. However, alcohol consumption also has beneficial effects on the burden of disease, mainly on diabetes and the ischemic disease subcategory of cardiovascular diseases. Yet these effects are by far outweighed by the detrimental consequences of alcohol consumption.

Effects of Alcohol on People Other Than the Drinker

So far, the discussion has centered on alcohol's effects on health as measured by indicators that primarily are based on the records of hospitals and health systems. Reflecting the information contained in those records, most of the effects considered refer to the health of the drinker. However, this analytic approach omits two large classes of adverse consequences of alcohol: social harm to the drinker and social and health harms to others that result from the drinker's alcohol consumption. According to the Constitution of the WHO ( WHO 1946), health is "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" (p. 100); this definition therefore takes into account not just physical and mental harms but also social harms, both for the drinker and for others.

A few examples of harm to others are included in the analysis of alcohol's contribution to the global burden of disease listed in table 2 . These include perinatal conditions attributable to the mother's drinking during pregnancy and injuries, particularly assault injuries. However, the scope of alcohol-related social harm and of harm to others stretches well beyond these items. Thus, a recent study in Australia ( Laslett et al. 2010) identified the following harms to others associated with drinking:

Harms identified based on records-these included deaths and hospitalizations (e.g., attributed to traffic injuries because of driving under the influence), child abuse or neglect cases involving a caregiver's drinking, and domestic and other assaults; and

Harms based on survey reports-these included negative effects on coworkers, household members, other relatives and friends, strangers, and on the community as a whole.

These effects were quite prevalent. Thus, the researchers estimated that within 1 year, more than 350 deaths were attributed to drinking by others, and more than 10 million Australians (or 70 percent of all adults) were negatively affected by a stranger's drinking ( Laslett et al. 2010).

Social Harm

Drinkers also experience a range of social harms because of their own drinking, including family disruption, problems at the workplace (including unemployment), criminal convictions, and financial problems ( Casswell and Thamarangsi 2009; Klingemann and Gmel 2001). Unfortunately, assessment of these problems is much less standardized than assessment of health problems, and many of these harms are not reported continuously. Social-cost studies provide irregular updates of alcohol-attributable consequences in selected countries (for an overview, see Rehm et al. 2009b; Thavorncharoensap et al. 2009). These studies regularly find that health care costs comprise only a small portion of the overall costs associated with alcohol use and that most of the alcohol-associated costs are attributable to productivity losses. In total, the costs associated with alcohol use seem to amount to 1 to 3 percent of the gross domestic product in high-income countries; the alcohol-associated costs in South Korea and Thailand, the only two mid-income countries for which similar studies are available, were at about the same level.

Conclusions

As this review has shown, alcohol use is associated with tremendous costs to the drinker, those around him or her, and society as a whole. These costs result from the increased health risks (both physical and mental) associated with alcohol consumption as well as from the social harms caused by alcohol. To reduce alcohol's impact on the burden of disease as well as on other social, legal, and monetary costs, it therefore is imperative to develop effective interventions that can prevent or delay initiation of drinking among those who do not drink, particularly adolescents, and limit consumption to low-risk drinking levels among those who do consume alcohol. The remaining articles in this journal issue present several such intervention approaches that are being implemented and evaluated in a variety of settings and/or are targeted at different population subgroups. Together with alcohol-related prevention policies, the implementation of specific interventions with proven effectiveness can help reduce the pain and suffering, and the associated costs, resulting from excessive alcohol use.

Acknowledgments

Financial support for this study was provided by NIAAA contract HHSN267200700041C to conduct the study titled "Alcohol- and Drug-Attributable Burden of Disease and Injury in the U.S."

The views expressed here do not necessarily reflect the views of the funding agency.

Footnotes

Financial Disclosure
Jürgen Rehm, Ph.D., received a salary and infrastructure support from the Ontario Ministry of Health and Long-Term Care. No potential conflicts of interest relevant to this article were reported.

¹ Ischemic diseases are all conditions that are related to the formation of blood clots, which prevent adequate blood flow to certain tissues.

² In the United States, a standard drink usually is considered to contain 0.6 fluid ounces (or 14 grams) of pure alcohol. This is the amount of ethanol found in approximately 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of distilled spirits. However, many drinks, as actually poured, contain more alcohol. Thus, for example, a glass of wine often contains more than 5 fluid ounces and therefore may correspond to one and a half or even two standard drinks.

³The condition referred to as "harmful use" in the ICD-10 loosely corresponds to "alcohol abuse," as defined in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Diseases, 4th Edition (DSM-IV).

⁴ Atrial fibrillation is an abnormal heart rhythm involving the two upper chambers (i.e., atria) of the heart.

⁵ A stroke is the disruption of normal blood flow to a brain region. In the case of an ischemic stroke, this is caused by blockage of a blood vessel that prevents the blood from reaching neighboring brain areas. In the case of a hemorrhagic stroke, rupture of a blood vessel and bleeding into the brain occurs, which prevents normal blood supply to other brain regions.

References

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Gmel G, Kuntsche E, Rehm J. Risky single occasion drinking: Bingeing is not bingeing. Addiction. 2010 Oct. doi: 10.1111/j.1360-0443.2010.03167.x. Published online: [[PubMed] [CrossRef] Google Scholar]

Pandrea I, Happel KI, Amedee AM, et al. Alcohol's Role in HIV Transmission and Disease Progression. Bethesda, MD: NIAAA; 2010. [[PMC free article] [PubMed] Google Scholar]

Patra J, Taylor B, Rehm J. Deaths associated with high-volume drinking of alcohol among adults in Canada in 2002: A need for primary care intervention? Contemporary Drug Problems. 2009;36(2):283-301. [Google Scholar]

Rehm J, Zatonski W, Taylor B, et al. Epidemiology and alcohol policy in Europe. Addiction. 2011 [Epub ahead of print] [Google Scholar]

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World Health Organization (WHO) Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference; New York. 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization no. 2, p. 100) and entered into force on 7 April 1948. Available at [http://www.who.int/about/definition/en/print.html; accessed 2/18/2011. Google Scholar]

Articles from Alcohol Research & Health are provided here courtesy of National Institute on Alcohol Abuse and Alcoholism

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The Risks Associated With Alcohol Use and Alcoholism

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Alcohol consumption, particularly heavier drinking, is an important risk factor for many health problems and, thus, is a major contributor to the global burden of disease. In fact, alcohol is a necessary underlying cause for more than 30 conditions and ...

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Centers for Disease Control and Prevention

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Browse through tobacco-related data, statistics, and other information from various sources, such as CDC surveillance systems, journal articles, and reports.

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Food and mood: how do diet and nutrition affect mental wellbeing? | The BMJ

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1. Joseph Firth , research fellow 1 2,

2. James E Gangwisch , assistant professor 3 4,

3. Alessandra Borsini , researcher 5,

4. Robyn E Wootton , researcher 6 7 8,

5. Emeran A Mayer , professor 9 10

Correspondence to: J Firth joseph.firth{at}manchester.ac.uk

Poor nutrition may be a causal factor in the experience of low mood, and improving diet may help to protect not only the physical health but also the mental health of the population, say Joseph Firth and colleagues

Key messages

Healthy eating patterns, such as the Mediterranean diet, are associated with better mental health than "unhealthy" eating patterns, such as the Western diet

The effects of certain foods or dietary patterns on glycaemia, immune activation, and the gut microbiome may play a role in the relationships between food and mood

More research is needed to understand the mechanisms that link food and mental wellbeing and determine how and when nutrition can be used to improve mental health

Mood and carbohydrates

Consumption of highly refined carbohydrates can increase the risk of obesity and diabetes. 5 Glycaemic index is a relative ranking of carbohydrate in foods according to the speed at which they are digested, absorbed, metabolised, and ultimately affect blood glucose and insulin levels. As well as the physical health risks, diets with a high glycaemic index and load (eg, diets containing high amounts of refined carbohydrates and sugars) may also have a detrimental effect on psychological wellbeing; data from longitudinal research show an association between progressively higher dietary glycaemic index and the incidence of depressive symptoms. 6 Clinical studies have also shown potential causal effects of refined carbohydrates on mood; experimental exposure to diets with a high glycaemic load in controlled settings increases depressive symptoms in healthy volunteers, with a moderately large effect. 7

Although mood itself can affect our food choices, plausible mechanisms exist by which high consumption of processed carbohydrates could increase the risk of depression and anxiety-for example, through repeated and rapid increases and decreases in blood glucose. Measures of glycaemic index and glycaemic load can be used to estimate glycaemia and insulin demand in healthy individuals after eating. 8 Thus, high dietary glycaemic load, and the resultant compensatory responses, could lower plasma glucose to concentrations that trigger the secretion of autonomic counter-regulatory hormones such as cortisol, adrenaline, growth hormone, and glucagon. 5 9 The potential effects of this response on mood have been examined in experimental human research of stepped reductions in plasma glucose concentrations conducted under laboratory conditions through glucose perfusion. These findings showed that such counter-regulatory hormones may cause changes in anxiety, irritability, and hunger. 10 In addition, observational research has found that recurrent hypoglycaemia (low blood sugar) is associated with mood disorders. 9

The hypothesis that repeated and rapid increases and decreases in blood glucose explain how consumption of refined carbohydrate could affect psychological state appears to be a good fit given the relatively fast effect of diets with a high glycaemic index or load on depressive symptoms observed in human studies. 7 However, other processes may explain the observed relationships. For instance, diets with a high glycaemic index are a risk factor for diabetes, 5 which is often a comorbid condition with depression. 4 11 While the main models of disease pathophysiology in diabetes and mental illness are separate, common abnormalities in insulin resistance, brain volume, and neurocognitive performance in both conditions support the hypothesis that these conditions have overlapping pathophysiology. 12 Furthermore, the inflammatory response to foods with a high glycaemic index 13 raises the possibility that diets with a high glycaemic index are associated with symptoms of depression through the broader connections between mental health and immune activation.

Diet, immune activation, and depression

Studies have found that sustained adherence to Mediterranean dietary patterns can reduce markers of inflammation in humans. 14 On the other hand, high calorie meals rich in saturated fat appear to stimulate immune activation. 13 15 Indeed, the inflammatory effects of a diet high in calories and saturated fat have been proposed as one mechanism through which the Western diet may have detrimental effects on brain health, including cognitive decline, hippocampal dysfunction, and damage to the blood-brain barrier. 15 Since various mental health conditions, including mood disorders, have been linked to heightened inflammation, 16 this mechanism also presents a pathway through which poor diet could increase the risk of depression. This hypothesis is supported by observational studies which have shown that people with depression score significantly higher on measures of "dietary inflammation," 3 17 characterised by a greater consumption of foods that are associated with inflammation (eg, trans fats and refined carbohydrates) and lower intakes of nutritional foods, which are thought to have anti-inflammatory properties (eg, omega-3 fats). However, the causal roles of dietary inflammation in mental health have not yet been established.

Nonetheless, randomised controlled trials of anti-inflammatory agents (eg, cytokine inhibitors and non-steroidal anti-inflammatory drugs) have found that these agents can significantly reduce depressive symptoms. 18 Specific nutritional components (eg, polyphenols and polyunsaturated fats) and general dietary patterns (eg, consumption of a Mediterranean diet) may also have anti-inflammatory effects, 14 19 20 which raises the possibility that certain foods could relieve or prevent depressive symptoms associated with heightened inflammatory status. 21 A recent study provides preliminary support for this possibility. 20 The study shows that medications that stimulate inflammation typically induce depressive states in people treated, and that giving omega-3 fatty acids, which have anti-inflammatory properties, before the medication seems to prevent the onset of cytokine induced depression. 20

However, the complexity of the hypothesised three way relation between diet, inflammation, and depression is compounded by several important modifiers. For example, recent clinical research has observed that stressors experienced the previous day, or a personal history of major depressive disorders, may cancel out the beneficial effects of healthy food choices on inflammation and mood. 22 Furthermore, as heightened inflammation occurs in only some clinically depressed individuals, anti-inflammatory interventions may only benefit certain people characterised by an "inflammatory phenotype," or those with comorbid inflammatory conditions. 18 Further interventional research is needed to establish if improvements in immune regulation, induced by diet, can reduce depressive symptoms in those affected by inflammatory conditions.

Brain, gut microbiome, and mood

A more recent explanation for the way in which our food may affect our mental wellbeing is the effect of dietary patterns on the gut microbiome-a broad term that refers to the trillions of microbial organisms, including bacteria, viruses, and archaea, living in the human gut. The gut microbiome interacts with the brain in bidirectional ways using neural, inflammatory, and hormonal signalling pathways. 23 The role of altered interactions between the brain and gut microbiome on mental health has been proposed on the basis of the following evidence: emotion-like behaviour in rodents changes with changes in the gut microbiome, 24 major depressive disorder in humans is associated with alterations of the gut microbiome, 25 and transfer of faecal gut microbiota from humans with depression into rodents appears to induce animal behaviours that are hypothesised to indicate depression-like states. 25 26 Such findings suggest a role of altered neuroactive microbial metabolites in depressive symptoms.

In addition to genetic factors and exposure to antibiotics, diet is a potentially modifiable determinant of the diversity, relative abundance, and functionality of the gut microbiome throughout life. For instance, the neurocognitive effects of the Western diet, and the possible mediating role of low grade systemic immune activation (as discussed above) may result from a compromised mucus layer with or without increased epithelial permeability. Such a decrease in the function of the gut barrier is sometimes referred to as a "leaky gut" and has been linked to an "unhealthy" gut microbiome resulting from a diet low in fibre and high in saturated fats, refined sugars, and artificial sweeteners. 15 23 27 Conversely, the consumption of a diet high in fibres, polyphenols, and unsaturated fatty acids (as found in a Mediterranean diet) can promote gut microbial taxa which can metabolise these food sources into anti-inflammatory metabolites, 15 28 such as short chain fatty acids, while lowering the production of secondary bile acids and p-cresol. Moreover, a recent study found that the ingestion of probiotics by healthy individuals, which theoretically target the gut microbiome, can alter the brain's response to a task that requires emotional attention 29 and may even reduce symptoms of depression. 30 When viewed together, these studies provide promising evidence supporting a role of the gut microbiome in modulating processes that regulate emotion in the human brain. However, no causal relationship between specific microbes, or their metabolites, and complex human emotions has been established so far. Furthermore, whether changes to the gut microbiome induced by diet can affect depressive symptoms or clinical depressive disorders, and the time in which this could feasibly occur, remains to be shown.

Priorities and next steps

In moving forward within this active field of research, it is firstly important not to lose sight of the wood for the trees-that is, become too focused on the details and not pay attention to the bigger questions. Whereas discovering the anti-inflammatory properties of a single nutrient or uncovering the subtleties of interactions between the gut and the brain may shed new light on how food may influence mood, it is important not to neglect the existing knowledge on other ways diet may affect mental health. For example, the later consequences of a poor diet include obesity and diabetes, which have already been shown to be associated with poorer mental health. 11 31 32 33 A full discussion of the effect of these comorbidities is beyond the scope of our article (see fig 1), but it is important to acknowledge that developing public health initiatives that effectively tackle the established risk factors of physical and mental comorbidities is a priority for improving population health.

Further work is needed to improve our understanding of the complex pathways through which diet and nutrition can influence the brain. Such knowledge could lead to investigations of targeted, even personalised, interventions to improve mood, anxiety, or other symptoms through nutritional approaches. However, these possibilities are speculative at the moment, and more interventional research is needed to establish if, how, and when dietary interventions can be used to prevent mental illness or reduce symptoms in those living with such conditions. Of note, a recent large clinical trial found no significant benefits of a behavioural intervention promoting a Mediterranean diet for adults with subclinical depressive symptoms. 34 On the other hand, several recent smaller trials in individuals with current depression observed moderately large improvements from interventions based on the Mediterranean diet. 35 36 37 Such results, however, must be considered within the context of the effect of people's expectations, particularly given that individuals' beliefs about the quality of their food or diet may also have a marked effect on their sense of overall health and wellbeing. 38 Nonetheless, even aside from psychological effects, consideration of dietary factors within mental healthcare may help improve physical health outcomes, given the higher rates of cardiometabolic diseases observed in people with mental illness. 33

At the same time, it is important to be remember that the causes of mental illness are many and varied, and they will often present and persist independently of nutrition and diet. Thus, the increased understanding of potential connections between food and mental wellbeing should never be used to support automatic assumptions, or stigmatisation, about an individual's dietary choices and their mental health. Indeed, such stigmatisation could be itself be a casual pathway to increasing the risk of poorer mental health. Nonetheless, a promising message for public health and clinical settings is emerging from the ongoing research. This message supports the idea that creating environments and developing measures that promote healthy, nutritious diets, while decreasing the consumption of highly processed and refined "junk" foods may provide benefits even beyond the well known effects on physical health, including improved psychological wellbeing.

Footnotes

Contributors and sources: JF has expertise in the interaction between physical and mental health, particularly the role of lifestyle and behavioural health factors in mental health promotion. JEG's area of expertise is the study of the relationship between sleep duration, nutrition, psychiatric disorders, and cardiometabolic diseases. AB leads research investigating the molecular mechanisms underlying the effect of stress and inflammation on human hippocampal neurogenesis, and how nutritional components and their metabolites can prevent changes induced by those conditions. REW has expertise in genetic epidemiology approaches to examining casual relations between health behaviours and mental illness. EAM has expertise in brain and gut interactions and microbiome interactions. All authors contributed to, read, and approved the paper, and all the information was sourced from articles published in peer reviewed research journals. JF is the guarantor.

Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following: JF is supported by a University of Manchester Presidential Fellowship and a UK Research and Innovation Future Leaders Fellowship and has received support from a NICM-Blackmores Institute Fellowship. JEG served on the medical advisory board on insomnia in the cardiovascular patient population for the drug company Eisai. AB has received research funding from Johnson & Johnson for research on depression and inflammation, the UK Medical Research Council, the European Commission Horizon 2020, the National Institute for Health Research (NIHR) Biomedical Research Centre at South London and Maudsley NHS Foundation Trust, and King's College London. REW receives funding from the National Institute for Health Research Biomedical Research Centre at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol. EAM has served on the external advisory boards of Danone, Viome, Amare, Axial Biotherapeutics, Pendulum, Ubiome, Bloom Science, Mahana Therapeutics, and APC Microbiome Ireland, and he receives royalties from Harper & Collins for his book The Mind Gut Connection. He is supported by grants from the National Institute of Diabetes and Digestive and Kidney Diseases, and the US Department of Defense. The views expressed are those of the authors and not necessarily those of the organisations above.

Provenance and peer review: Commissioned; externally peer reviewed.

This article is part of series commissioned by The BMJ. Open access fees are paid by Swiss Re, which had no input into the commissioning or peer review of the articles. T he BMJ thanks the series advisers, Nita Forouhi, Dariush Mozaffarian, and Anna Lartey for valuable advice and guiding selection of topics in the series.

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Food and mood: how do diet and nutrition affect mental wellbeing?

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Poor nutrition may be a causal factor in the experience of low mood, and improving diet may help to protect not only the physical health but also the mental health of the population, say Joseph Firth and colleagues ### Key messages Depression and anxiety are the most common mental health conditions worldwide, making them a leading cause of disability.1 Even beyond diagnosed conditions, subclinical symptoms of depression and anxiety affect the wellbeing and functioning of a large proportion of the population.2 Therefore, new approaches to managing both clinically diagnosed and subclinical depression and anxiety are needed.

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Adult substance misuse treatment statistics 2020 to 2021: report - GOV.UK (www.gov.uk)

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1.1 Trends in treatment numbers

There were 275,896 adults in contact with drug and alcohol services between April 2020 and March 2021. This is a small rise compared to the previous year (270,705).

The number of adults entering treatment in 2020 to 2021 was 130,490, which is similar to the previous year's figure (132,124). The number of people entering treatment continues to be relatively stable after falling steadily since 2013 to 2014.

1.2 Trends in substance use treatment

The number of people in treatment for opiate use was very similar to last year (going up slightly from 140,599 to 140,863). Over half (51%) of the adults in treatment were there for problems with opiates, and this remains the largest substance group. Section 2 (People in treatment) has more information about what the different substance groups are.

People in treatment for alcohol alone make up the next largest group (28%) of all adults in treatment. The number of those rose by 3% from the previous year (from 74,618 to 76,740) but this small increase comes after a decline from a peak of 91,651 in 2013 to 2014.

There were increases in the other 2 substance groups (a 9% increase in the non-opiate group and 1% in the non-opiate and alcohol group). This follows a similar small rise last year.

In contrast to previous years, there has been a fall in the number of adults entering treatment for crack cocaine. This includes people who are using crack with opiates (25,043 to 21,308) and those who are using crack without opiates (4,651 to 4,545).

The number of people entering treatment for crack is now at the lowest level since 2016 to 2017.

People starting treatment in 2020 to 2021 with powder cocaine problems decreased by 10% (from 21,396 to 19,209). This ends a rising trend over the last 9 years, which began in 2011 to 2012.

New entrants with cannabis and benzodiazepine problems increased again this year, with a 5% increase in cannabis (from 25,944 in 2019 to 2020 to 27,304 this year) and a 6% increase in benzodiazepines (from 4,083 in 2019 to 2020 to 4,321 this year).

Although the numbers are relatively low, there was an increase in adults entering treatment in 2020 to 2021 with ketamine problems (from 1,140 in 2019 to 2020 to 1,444 this year). This is a 27% rise in one year and is part of a trend in rising numbers entering treatment over the last 7 years. The total is now nearly 3.5 times higher than it was in 2014 to 2015.

1.3 Housing and mental ill health

Over one-sixth (17%, or 22,493) of adults entering treatment last year said they had a housing problem. This proportion varied by substance group, ranging from 1 in 10 (10%, or 4,941) of those starting treatment for alcohol problems alone, to almost a third (30%, or 11,286) of those starting treatment for problems with opiate use. As in previous years, people starting treatment for problems with new psychoactive substances ( NPS) had the highest proportion of housing need of any substance group (45%).

Nearly two-thirds (63%, or 82,613) of adults starting treatment said they had a mental health treatment need. This is part of a trend of rising numbers over the previous 2 years (from 53% in 2018 to 2019). Over half of new starters in all substance groups needed mental health treatment. This need ranged from 57% in the opiate group to nearly three-quarters (71%) of the non-opiates and alcohol group.

1.4 Treatment exits and deaths in treatment

There were 110,095 people who exited the drug and alcohol treatment system in 2020 to 2021. Half (50%) of those left having successfully completed their treatment, free from dependence. This is an increase in the proportion of people who successfully completed treatment since the previous year (47%).

The total number of people who died while in contact with treatment services in 2020 to 2021 was 3,726 (1.4% of all adults in treatment). This represents a 27% increase of deaths in treatment compared to last year (2,929, or 1.1% of all adults in treatment).

Last year, all substance groups except opiate users saw a decrease in deaths in treatment compared to the previous year. By contrast, there were increases in the proportion of people dying while in treatment in all substance groups this year. There were increases in the:

opiate group by 20%

non-opiate only group by 36%

non-opiate and alcohol group by 37%

alcohol only group by 44%

Drug use is a significant cause of premature death in England, as the Office for National Statistics (ONS) drug poisoning data has shown. In England, the number of deaths from drug misuse registered in 2020 was 2,830, the highest level since records began.

1.5 Smoking among people in treatment

Over 51,000 people (56%) said they had smoked tobacco in the 28 days before starting treatment. Across all substance groups, the level of smoking for men and women was substantially higher than the smoking rate of the general adult population (15.9% for men and 12.5% for women).

Despite the high levels of smoking, only 2% of people were recorded as having been offered referrals for smoking cessation interventions. This was down from 3% in 2019 to 2020.

Like other services, drug and alcohol treatment services were affected by the need to protect their staff and service users in the pandemic, especially in the early stages. Most services had to restrict face-to-face contact, which affected the types of interventions that service users received. For example, most patients whose opioid substitute consumption was supervised before the pandemic were given take-home doses from March 2020, after a risk assessment. Fewer service users were able to access inpatient detoxification for alcohol and drugs. Testing and treatment for blood-borne viruses and liver disease were also greatly reduced.

These and other changes to service provision during the pandemic may have affected many of the indicators included in this report.

It's likely that a number of factors will have contributed to the increase in the number of service users who died while in treatment during 2020 to 2021. These include changes to alcohol and drug treatment, reduced access to other healthcare services, changes to lifestyle and social circumstances during lockdowns, and COVID-19 itself.

2. People in treatment: substance, sex, age

2.1 Overview

The National Drug Treatment Monitoring System ( NDTMS) statistics report presents information on adults (aged 18 and over) who were receiving help in England for problems with drugs and alcohol in the period between 1 April 2020 and 31 March 2021.

Many people experience difficulties with alcohol and drugs and receive treatment for both substances. While they often share many similarities, they also have clear differences, so this report divides people in treatment into 4 substance groups:

1. Opiate: people who are dependent on or have problems with opiates, mainly heroin.

2. Non-opiate: people who have problems with non-opiate drugs only, such as cannabis, crack and ecstasy.

3. Non-opiate and alcohol: people who have problems with both non-opiate drugs and alcohol.

4. Alcohol only: people who have problems with alcohol but do not have problems with any other substances.

See below for a text description of the flowchart showing how people are classified into substance reporting groups after entering treatment and undergoing initial assessment.

People with an opiate problem are placed in the 'opiate' substance group regardless of whether other substances are also problematic. For all other individuals, they are categorised as 'non-opiate only', 'non-opiate and alcohol' or 'alcohol only'.

Person enters treatment.

Question 1: does the person have problems with opiates?

Yes: person is classified into the opiate substance group

No: go to question 2

Question 2: does the person have a problem with non-opiate drugs?

Yes: go to question 3

No: go to question 4

Question 3: does the person have problems with alcohol?

Yes: person is classified into non-opiate and alcohol substance group

No: person is classified into non-opiate only substance group

Question 4: does the person have problems with alcohol?

Yes: person is classified into alcohol only substance group

2.2 Substance use, sex and age of people in treatment

Table 1: people in treatment by sex and substance group

There were 275,896 people in contact with drug and alcohol services between 1 April 2020 and 31 March 2021. Over half of all adults (51%) received treatment for problems with opiates. A further 21% had problems with other drugs, and over a quarter (28%) had problems with alcohol only. These proportions are similar to previous years and you can find more detailed information on trends in chapter 13 (Trends over time).

More than two-thirds of people in treatment were men and less than one-third were women (68% men to 32% women). This proportion varies greatly by substance group. For the drug groupings, men make up over two-thirds (opiate 72%, non-opiate only 68%, non-opiate and alcohol 70%). But in the alcohol only group the divide is smaller with men making up 58% and women 42%.

2.3 Problem substances for people in treatment

Figure 3 shows a breakdown of the substances reported by people in treatment in 2020 to 2021, split into the 4 treatment groups. Up to 3 substances can be recorded at the start of treatment, so one person could be counted for several substances within their substance group (for example, somebody who uses cocaine, cannabis and alcohol, would appear in the non-opiate and alcohol group for these 3 substances).

The numbers show that opiates were the most frequently reported drug with slightly more people using opiates alone compared to opiates along with crack. Out of all people in treatment, 54% said they had a problem with opiates, crack or both. Almost half (48%) of people said they had problems with alcohol, with most of these being in the alcohol only group. One-fifth (20%) said they used cannabis, most commonly in the opiate substance group. Cocaine was reported by 12% of people, the largest proportion of these being categorised into the non-opiate and alcohol substance group. The next most frequently reported substances were benzodiazepines at 6% and amphetamines (excluding ecstasy) at 3%.

You can find a more detailed breakdown of reported substances in the data tables.

2.4 Age groups

Figure 4 shows that the age of people in treatment has continued the trend from previous years showing an increase in older age groups. More than half of the people in treatment (56%) were over 40 years old (compared to 55% in 2019 to 2020 and 51% in 2016 to 2017), with:

47,294 people in the 40 to 44 age group

41,617 people in the 45 to 49 age group

31,172 people in the 50 to 54 age group

19,266 people in the 55 to 59 age group

15,466 people aged 60 and over

Less than 10% of people in treatment for opiates or alcohol only were under 30 (7% for opiates and 9% for alcohol only). Across all substance groups there were:

22,289 people in the 25 to 29 age group

12,944 people in the 20 to 24 age group

3,615 people aged 18 or 19

The median age of people in treatment in the 4 substance groups ranged from 46 for the alcohol only group to 30 for non-opiates only. People in treatment for opiates had a median age of 42. You can find a detailed breakdown of age statistics in the accompanying data tables.

The distribution of ages of people in treatment is similar to patterns in estimates of prevalence of drug and alcohol use. The latest estimates of opiate and crack use prevalence for 2016 to 2017 show a significant increase in those aged 35 and over who use opiates (130,628 in 2010 to 2011 and 175,452 in 2016 to 2017), reflecting an ageing group.

A large proportion of opiate users in treatment will have started using heroin in the epidemics of the 1980s and 1990s and are now over 40 years old. In 2017 to 2018, 69% said they first used heroin before 2001 and only 9% first used heroin since 2011.

People who reported using substances other than opiates or alcohol tended to be younger. You can find more information about this in the ONS Drug misuse in England and Wales report.

3. Meeting the needs of people who are dependent on alcohol and drugs

The NDTMS treatment figures only show us how many people dependent on alcohol and drugs are in treatment. We can compare this data to prevalence data to get an idea of how people's needs are met nationally and in each local area.

The main prevalence data we use is:

3.1 Opiate and crack use

The opiate and crack use prevalence estimates show that in 2016 to 2017 (the most recent data available) there were an estimated 313,971 people in England aged 15 to 64 who use one or both drugs. This is made up of 261,294 opiate users and 180,748 crack cocaine users.

Nearly two-thirds of these people are between 35 and 64 years old. The proportion of estimated opiate users who are not in treatment has continued to rise from 40.8% in 2014 to 2015 to 46.7% in 2019 to 2020. The proportion of crack users who are not in treatment is 58.0%.

Figure 5 shows how levels of opiate and crack use vary across England. Prevalence rates ranged from 2 people per thousand of the population in Rutland in the East Midlands to 26 people per thousand in Middlesbrough. Many of the highest prevalence rates are in the north of England. In London, the highest prevalence rates tend to be in the inner boroughs such as Tower Hamlets and Hackney, and the lowest rates are in the outer boroughs like Bexley, Kingston upon Thames and Richmond upon Thames.

Opiate and crack use are also strongly linked to deprivation. We saw 56% of people in treatment for crack and/or opiates living in areas ranked in the 30% most deprived areas in England.

Public Health England ( PHE) published the latest opiate and crack prevalence estimates for each local authority in England.

You can also see how local areas compare on the numbers of opiate users and dependent drinkers who are not in treatment in the Public Health Dashboard.

3.2 Alcohol dependence

There were an estimated 602,391 adults with alcohol dependency in need of specialist treatment in 2018 to 2019 (the most recent figures available). This is a rise of 2.6% from the previous year and is the first time these estimates have risen since 2015 to 2016.

There were 107,428 people in treatment for alcohol in 2020 to 2021 (the total of alcohol only plus the non-opiate and alcohol groups). So, based on these estimates, there was an estimated 82% of adults in need of specialist treatment for alcohol who were not receiving it.

Figure 6 shows how levels of alcohol dependence vary across England. Like the opiate and crack prevalence rates, the higher prevalence rates are concentrated in the north of England. Rates ranged from 6 per 1000 in Wokingham in the South East to 35 per 1000 in Blackpool. In London, alcohol dependence again followed the same pattern as opiate and crack prevalence. The highest rates tended to be in the inner boroughs such as Islington and Hackney, and the lowest rates were in outer boroughs like Redbridge and Richmond upon Thames. PHE published the latest prevalence estimates for alcohol dependence for each local authority in England.

You can also see how local areas compare on the numbers of dependent drinkers who are not in treatment on the Public Health Dashboard.

4. People starting treatment: substances, age and referral source

4.1 Substances reported by people starting treatment

In 2020 to 2021, 130,490 people started treatment for drug and alcohol problems. This is where a person started a new treatment journey, either for the first time or returning to treatment having had a break of over 21 days.

Of the people starting treatment:

60% said they had a problem with alcohol

29% said they had a problem with opiates

20% said they had a problem with crack cocaine

21% said they had a problem with cannabis

15% said they had a problem with cocaine

Also, of the people who said they had a problem with alcohol, 60% (52,220) said it was their only problem substance.

Figure 7 shows the number of people starting treatment who reported problems with each substance, divided into the 4 substance groups. Most people with alcohol problems were in the alcohol only group. However, alcohol was the most frequently reported substance in the non-opiate and alcohol group, and the third most frequently reported substance in the opiate group.

In the non-opiate and alcohol group, cocaine was the second most frequently reported drug, followed closely by cannabis. Cannabis was the most frequently reported drug in the non-opiate substance group, followed by cocaine. The numbers show that most people in the opiates group used both opiates and crack. Opiates without crack was the second most commonly reported substance in this group.

People starting treatment with cannabis and benzodiazepine problems increased again this year, with a 5% increase in cannabis (from 25,944 in 2019 to 2020 to 27,304 this year) and a 6% increase in benzodiazepines (from 4,083 in 2019 to 2020 to 4,321 this year).

Although the numbers are relatively low, there was an increase in adults entering treatment in 2020 to 2021 with ketamine problems (from 1,140 in 2019 to 2020 to 1,444 this year). There was also a small rise in methamphetamine treatment numbers this year (from 467 last year to 505), which has been increasing gradually since reporting began in 2005 to 2006.

You can find more information on the breakdown of club drugs by substance group in the accompanying data tables.

4.2 Age of people starting treatment

Figure 8 shows the number of people starting treatment in each age group, categorised into the 4 substance groups. The most common age group was 35 to 39, with 21,305 people starting treatment. This was followed by the 30 to 34 age group, with 20,259 people, then the 40 to 44 age group with 18,916 people. Within these 3 groups, the opiate substance group was the largest. Nearly half of people starting treatment (48%) were 40 years and over. Of those aged 55 years and over, 86% said they had problems with alcohol only. This is an increase of 9% compared to the previous year.

The non-opiate only and non-opiate and alcohol groups had the largest proportion of people under 30 years old starting treatment, at 46% and 33% respectively.

4.3 Referral sources

Of the people starting treatment in 2020 to 2021, 61% self-referred (which could have been following advice from a healthcare professional) or were referred by family and friends. This was the most common referral source in all 4 substance groups.

Referral from healthcare was the second most common referral source and made up 15% overall. This includes referrals from GPs, which accounted for 6% of all referrals, but was higher in the alcohol only group at 8%. Hospitals made up 4% of all referrals while only 3% of referrals came from social services. Referrals from healthcare varied between the individual substance groups. Only 8% of opiate referrals came from healthcare compared to 21% of alcohol only referrals.

Collectively, referrals from the criminal justice system made up 12%. But there was a big difference between substance groups, with 23% of opiate referrals coming from the criminal justice system compared to just 6% for those with only alcohol problems. Prison referrals accounted for 5% of all referrals. You can find a further breakdown of these groups in the accompanying data tables.

Around 1 in 9 people (12%) starting treatment said they had a housing problem and a further 6% had an urgent problem. For people with opiate problems, the proportion with a housing problem was 17% and an additional 13% had an urgent housing problem.

Figure 10 shows the numbers of people starting treatment who had a housing problem or an urgent housing problem, separated into the 4 substance groups. The opiate substance group had the highest number with 11,286 people saying they had a housing problem or an urgent housing problem. The alcohol only group had the second highest numbers with 3,886 people saying they had a housing problem and 1,055 people saying they had an urgent housing problem.

The people in treatment with NPS problems had the highest proportion of housing need, with 45% saying they had a housing problem (urgent or otherwise) when starting treatment.

Figure 11 shows the proportion of people with NPS problems who reported housing problems, compared to the proportion of all people starting treatment. It shows that 23% of people with NPS problems said they had an urgent housing problem compared to 6% of all people starting treatment. For non-urgent housing problems, the proportions were 22% of people with NPS problems and 12% for all people starting treatment.

6. Mental health

Nearly two-thirds of people starting treatment said they had a mental health need (63%). When looking at the 4 substance groups, the proportions of people reporting a mental health need were:

57% of people in the opiates group

64% of people in the non-opiate only group

64% of people in the alcohol only group

71% of people in the non-opiate and alcohol group

A quarter (25%) of people who had a mental health need were not receiving any treatment to meet this need. Of those receiving mental health treatment, over half (55%) received it in a primary care setting, such as a GP surgery.

7. Injecting status

Nineteen percent of all people starting treatment were currently injecting or had previously injected drugs. This is much higher for people with opiate problems, with 22% currently injecting and 32% having previously injected. In the other 3 substance groups, over 90% of people had never injected drugs. In the non-opiate only and non-opiate and alcohol groups, 5% and 6% said they had previously injected, respectively. Only very small numbers outside of the opiate substance group were currently injecting with just 2% of people in the non-opiate only group, and 1% of the non-opiate and alcohol group. Only 2% of people with alcohol only problems had previously injected drugs.

This year, injecting status also includes data from outcomes, so there is an additional category for people not currently injecting but whose injecting history was not known. These people accounted for less than 1% of those starting treatment.

8. Parental status and safeguarding children

8.1 Parental status

In 2020 to 2021, 21% (27,208) of people starting treatment were living with children, either their own or someone else's. A further 21% were parents who were not living with their children. This was highest among women in treatment for opiates, where 28% were parents who were not living with their children.

Twenty-nine percent of women reported either living with a child, or being a parent when they started treatment, compared to 17% of men.

The average number of children per household where people in treatment live with a child was 1.9.

The total number of children of people starting treatment was 51,328. This includes children who:

live with parents in treatment

have parents in treatment that they do not live with

are living with someone in treatment who is not their parent

Seventy percent of these children were receiving no early help. In contrast, 12% of the children of all people starting treatment had a child protection plan and this figure was highest in the non-opiate group, at 20%.

Over 51,000 people (56%) said they had smoked tobacco in the 28 days before starting treatment. This is based on information collected at the start of treatment and a 6 month review using the treatment outcomes profile, published by PHE as part of a set of outcome monitoring forms.

Across all substance groups, men and women reported smoking at similar levels. And in all cases, the level of smoking was substantially higher than the smoking rate of the general adult population (15.9% for men and 12.5% for women).

Despite the high levels of smoking, only 2% of people were recorded as having been offered referrals for smoking cessation interventions.

10. Treatment interventions

Note: we have excluded settings with proportions of less than 1% from this figure, but the information is available in the accompanying data tables.

Almost all (99%) people in treatment received some form of structured treatment. You can find a definition of structured treatment in the NDTMS business definitions guidance.

Of the people that did receive structured treatment:

98% received a community-based treatment

7% received treatment in a primary care setting

3% received treatment in an inpatient setting

1% received treatment in a residential setting

The number of people receiving treatment in inpatient and residential settings has continued to fall. In 2020 to 2021, there were 13,214 people in those settings, down from 15,161 in the previous year, a 13% drop. This year's figure is 49% lower than 2014 to 2015 (25,847).

Figure 18 shows the breakdown of the main type of intervention received, either prescribing or psychosocial interventions, by people in treatment for the four main substance groups.

Ninety-nine percent of people received a psychosocial intervention while 55% received at least one prescribing intervention.

Over 99% of people in the non-opiate only, non-opiate and alcohol, and alcohol only groups received a psychosocial intervention. People with problems with opiates had the lowest proportion of people receiving a psychosocial intervention, with 98%.

Of those who received a prescribing intervention:

95% were in the opiate group

17% were in the alcohol only group

12% were in the non-opiate group

6% were in the non-opiate only group

Of the people starting treatment, 98% did so within 3 weeks of being referred to treatment.

11. Treatment outcomes

11.1 Treatment exits and successful completion of treatment

A total of 110,095 people left drug and alcohol treatment in 2020 to 2021.

Of the people who left treatment, 50% completed their treatment successfully and were discharged as 'treatment completed'. The alcohol only group had the highest rate of treatment completed at 62%. This was closely followed by the non-opiate group (57%) and the non-opiate and alcohol group (55%). The opiate only group had a rate of 25%.

A third (33%) of people left treatment without completing it, while 12% left either due to unsuccessful transfers between services or the person declining further treatment.

On average, people who completed treatment successfully did so within a year of starting treatment (283 days). The average time in treatment for people with opiate problems was around 2.5 years (930 days) and around 6 months for the other substance groups (164 days for non-opiate only, 201 days for non-opiate and alcohol and 197 days for alcohol only).

11.2 Deaths in treatment

Every year, people die while they are in an alcohol and drug treatment programme, but these deaths might not be alcohol or drug related.

Figure 20 is a map showing the local authorities where the number of deaths of people in drug and alcohol treatment are higher or lower than, or similar to the number of deaths in treatment we would see in that local authority if the mortality rate was the same as England overall. This data includes deaths in treatment between April 2018 and March 2021. Figures used in this map were calculated as indirectly age-standardised ratios for each local authority and are available in the data tables that accompany this report.

Ratios greater than 1.0 show a higher mortality rate than the overall mortality rate for England and ratios lower than 1.0 show a lower mortality rate. The higher mortality ratios are concentrated in the north west and north east of England. Ratios ranged from 0.2 in Redbridge to 2.0 in Gateshead. In London, higher ratios tended to be in the inner boroughs such as Camden and Southwark, and the lower ratios were in outer boroughs like Redbridge and Waltham Forest.

Mortality ratio data for each local authority can also be found on the Public Health Dashboard.

There were 3,726 recorded deaths in treatment in 2020 to 2021, which represented 1.4% of all people in treatment. People with opiate problems accounted for nearly two-thirds (65%) of these deaths, and the alcohol only group a further 29%.

Over a third (34%) of deaths among opiate users were people living in the most deprived 10% of areas in England. In the non-opiate treatment group, there was a similar proportion, with 31% of people who died in treatment living in these most deprived areas.

Data from the ONS shows that rates of drug misuse deaths continue to be higher among people born in the 1970s, with the highest rate in those aged 45 to 49. Among men, there were 109.7 drug poisoning deaths registered per million in 2020 (3,108 registered deaths), compared with 49.8 deaths per million among women (1,453 deaths).

11.3 Self-reported outcomes: substance use

The Office for Health Improvement and Disparities ( OHID) collects information about the outcomes for people who use drug and alcohol treatment services. This includes the treatment outcomes profile, which measures change and progress in important areas of their lives.

People with opiate problems reported a fall in the average number of days they used opiates in the last 28 days, from 23.2 at the start of treatment to 7.3 after 6 months of treatment.

The alcohol only group reported a fall in the number of days that they used alcohol in the last 28 days before their 6 month review, from 21.2 to 11.5.

12. Self-reported outcomes: education, employment and injecting

For people in education at the start treatment and at their 6 month review, the average number of days that they reported being in education rose from 11.2 at the start to 11.3 at the review.

For people in employment at the start of treatment and at their 6 month review, the average number of days they were in employment in the last 28 days increased. This rose from 17.6 days at the start of treatment to 17.7 days at their review.

For people with opiate problems who were injecting at the start of treatment, the average number of days of injecting dropped from 20.9 days per month at the start of treatment to 6.1 days per month at the 6 month review.

13. Trends over time

13.1 Numbers in treatment

The overall number of people in treatment increased by 2% since last year, with 275,896 people in treatment, the highest amount since 2016 to 2017.

The non-opiate group saw the highest number of people (27,605) in treatment since 2006 to 2007 (28,777). The non-opiate and alcohol group continued an upward trend from 27,684 in 2017 to 2018, to 30,688 this year, an 11% increase. The opiate group and alcohol only group have remained stable since 2017 to 2018 with a 0.2% decrease and 1% increase respectively.

Numbers for people in treatment who said they had a problem with alcohol only are shown from 2009 to 2010 onwards when national alcohol treatment data collection started.

These trends over time can be found on using the ViewIt tool. You can choose to display either England or local authority level data, as well as split the data by substance, sex and age groups.

13.2 People leaving treatment

The percentage of people leaving treatment free of dependence rose in 2020 to 2021 to 50.4%. This is the highest proportion since 2015 to 2016 (50.5%). For the first time since 2011 to 2012 there were increases in each group's successful completion rate. The increases were most pronounced in the non-opiate (3.6% increase) and non-opiate and alcohol groups (4.0% increase). The alcohol only group had its highest proportion of people leaving treatment free of dependence (62%) on record.

13.3 Trends in substance use

The number of people entering treatment for problems with opiates but not crack continued on a downward trend that started in 2009 to 2010. It has decreased by 52% over the last 11 years.

The number of people entering treatment for both crack and opiates dropped by 15% this year, and it is now at 21,308, which is the lowest number since 2015 to 2016. The number of people entering treatment for crack without opiates has been stable since 2018 to 2019 but has increased 58% since the lowest point in 2014 to 2015. The number in treatment for crack without opiates (6,794) has remained stable compared with the previous year but is higher than in the previous 10 years.

The number of people starting treatment for NPS (1,283 this year) has remained stable since 2017 to 2018 (1,223).

The number of people with ecstasy problems continued to fall, with 693 people starting treatment this year compared to a high of 2,399 in 2007 to 2008.

There was a continued rise in ketamine numbers, with 1,444 people coming to treatment, compared to 426 in 2014 to 2015. The number of people with methamphetamine problems also rose to 505, compared to 131 in 2011 to 2012.

You can find more detailed data on the drugs people had problems with in the accompanying data tables.

13.4 Deaths in treatment

In 2020 to 2021, the proportion of deaths of people in treatment increased from 1.1% to 1.4%. This is the largest increase in the proportion of people dying in treatment since NDTMS data has been collected. This trend has increased from 711 deaths in 2005 to 2006 to 3,726 deaths in 2019 to 2020, which is more than a 5 fold increase.

13.5 Deaths in treatment by substance

This year, the proportion of deaths in treatment increased in all substance groups. There were increases in the:

opiate group from 1.4% to 1.7%

non-opiate only group from 0.2% to 0.3%

non-opiate and alcohol group from 0.4% to 0.6%

alcohol only group from 1.0% to 1.4%

14. A 16-year analysis

14.1 People in treatment

In the 16 years of treatment data starting from 2005 to 2006, there has been a total of 1,057,687 people in contact with drug and alcohol treatment services. By 31 March 2021:

155,860 (15%) were still engaged in treatment

413,538 (39%) had left before they completed their treatment and had not returned

488,289 (46%) had completed their treatment and not returned

14.2 Treatment journeys

Of the people still in treatment at the end of March 2021, well over a third (41%) have had 4 or more treatment journeys. Over a quarter (26%) have been in treatment continuously since their treatment started, 50% of those people started treatment in 2020 to 2021, and 31% have been in treatment for 5 years or more

You can find more information on the methodology of this analysis in the NDTMS annual statistics quality and methodology document.

15. Background and policy context

15.1 Background to the data

This report presents statistics on the availability and effectiveness of alcohol and drug treatment in England and the profile of people accessing this treatment.

The statistics in this publication come from analysis of the NDTMS. The NDTMS collects data from about 600 sites providing structured alcohol and drug treatment interventions, covering every local authority in England.

Treatment centres returning data include:

community-based drug and alcohol services

specialist outpatient services

GP surgeries

residential rehabilitation centres

inpatient units

The data collected includes information on the demographics and personal circumstances of people receiving treatment, as well as details of the interventions delivered and their outcomes.

You can find more details on the methodology used in the report in the NDTMS annual statistics quality and methodology document.

Alcohol and drug treatment statistics reports for previous years can be found in the OHID Alcohol and drug misuse and treatment statistics collection.

15.2 Policy context

Alcohol and drug treatment in England is commissioned by local authorities using the public health grant. They are responsible for assessing local need for treatment and commissioning a range of services and interventions to meet that need.

The public health grant conditions make it clear that:

A local authority must, in using the grant, have regard to the need to improve the take up of, and outcomes from, its drug and alcohol misuse treatment services based on an assessment of local need and a plan which has been developed with local health and criminal justice partners.

OHID works with local authorities and provides them with bespoke data, guidance, tools and other support to help them commission services more effectively.

Guidance for alcohol and drug treatment is available in the Alcohol and drug misuse prevention and treatment guidance collection.

A wide range of NDTMS data is available at the NDTMS website, including some data reports that are only available to local authority commissioners (via login).

In July 2021, the Department of Health and Social Care published the second part of a major independent review by Professor Dame Carol Black into the misuse of illegal drugs in England.

The report contains 32 recommendations for change across various government departments and other organisations, to improve the effectiveness of drug prevention and treatment and to help more people recover from dependence.

OHID is working with other government departments and stakeholders to implement the review's recommendations.

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Adult substance misuse treatment statistics 2020 to 2021: report

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There were 275,896 adults in contact with drug and alcohol services between April 2020 and March 2021. This is a small rise compared to the previous year (270,705). The number of adults entering treatment in 2020 to 2021 was 130,490, which is similar to the previous year's figure (132,124).

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UK Chief Medical Officers' Physical Activity Guidelines (publishing.service.gov.uk)

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The Eatwell Guide shows how much of what we eat overall should come from each food group to achieve a healthy, balanced diet.
You do not need to achieve this balance with every meal, but try to get the balance right over a day or even a week.

Most of us still are not eating enough fruit and vegetables. They should make up just over a third of the food we eat each day.

Aim to eat at least 5 portions of a variety of fruit and veg each day. Choose from fresh, frozen, tinned, dried or juiced.

Remember that fruit juice and smoothies should be limited to no more than a combined total of 150ml a day.

Fruit and vegetables are a good source of vitamins, minerals and fibre.
Find out more about how to get your 5 A Day

Starchy food should make up just over a third of the food we eat. Choose higher fibre or wholegrain varieties, such as wholewheat pasta and brown rice, or simply leave the skins on potatoes.

There are also higher fibre versions of white bread and pasta.

Starchy foods are a good source of energy and the main source of a range of nutrients in our diet.
Find out more about starchy foods

These foods are good sources of protein, vitamins and minerals. Pulses, such as beans, peas and lentils, are good alternatives to meat because they're low in fat and they're a good source of fibre and protein, too.

Choose lean cuts of meat and mince, and eat less red and processed meat like bacon, ham and sausages.

Aim for at least 2 portions (2 x 140g) of fish every week, 1 of which should be oily, such as salmon, sardines or mackerel.

Find out about fish and meat.

Milk, cheese, yoghurt and fromage frais are good sources of protein and some vitamins, and they're also an important source of calcium, which helps keep our bones healthy.

Try to go for lower-fat and lower-sugar products where possible, like semi-skimmed, skimmed or 1% fat milk, reduced-fat cheese or plain low-fat yoghurt.
Find out more about milk and dairy foods

Unsaturated fats are healthier fats and include vegetable, rapeseed, olive and sunflower oils.

Remember all types of fat are high in energy and should be eaten in small amounts.
Find out more about the different types of fat in our diet

These foods include chocolate, cakes, biscuits, sugary soft drinks, butter, ghee and ice cream.

They're not needed in our diet, so should be eaten less often and in smaller amounts.
Get tips on cutting down on sugar

Water, lower-fat milks, lower-sugar or sugar-free drinks and tea and coffee all count.

Fruit juice and smoothies also count towards your fluid consumption, but they contain free sugars that can damage teeth, so limit these drinks to a combined total of 150ml a day.
Find out more about water, drinks and your health

How does the Eatwell Guide work?

The Eatwell Guide divides the foods and drinks we consume into 5 main food groups.

Try to choose a variety of different foods from each of the groups to help you get the wide range of nutrients your body needs to stay healthy.

It's important to get some fat in your diet, but foods that are high in fat, salt and sugar have been placed outside of the main Eatwell Guide as they're not necessary as part of a healthy, balanced diet and most of us need to cut down on these.

Unsaturated fats from plant sources (for example, vegetable oil or olive oil) are healthier types of fat.

But all types of fat are high in energy (calories), so they should only be eaten in small amounts.

On average, women should have around 2,000 calories a day (8,400 kilojoules) and men should have around 2,500 calories a day (10,500 kilojoules). We all need different amounts of energy (or calories) from food to be a healthy weight. How much you need depends on lots of things, including how active you are.

Find out how food labels can help you choose between foods and pick those lower in fat, saturated fat, sugar and salt.

Combination foods

Many foods, such as pizzas, casseroles, pasta dishes and sandwiches, are combinations of the food groups in the Eatwell Guide.

With these meals, check the ingredients and think about how these fit with the sections on the guide to help you achieve a balanced diet.

Does the Eatwell Guide apply to everyone?

The Eatwell Guide applies to most of us, whether we're a healthy weight or overweight, whether we eat meat or are vegetarian, and no matter what our ethnic origin.

Anyone with special dietary requirements or medical needs might want to check with a registered dietitian on how to adapt the Eatwell Guide to meet their individual needs.

Children under the age of 2

The Eatwell Guide does not apply to children under the age of 2 because they have different nutritional needs.

Between the ages of 2 and 5, children should gradually move to eating the same foods as the rest of the family in the proportions shown in the Eatwell Guide.

Read more about babies, toddlers and young children's nutritional needs in Your baby's first solid foods.

Download the Eatwell Guide booklet

For more information, including details of which foods are included in the food groups, download GOV.UK's The Eatwell Guide.

Healthy eating support

Food and diet advice on the NHS website includes:

# data[].attributes.attachment_link.description
The Eatwell Guide shows how much of what we eat overall should come from each food group to achieve a healthy, balanced diet. You do not need to achieve this balance with every meal, but try to get the balance right over a day or even a week.

# data[].attributes.attachment_link.readable_text
The Eatwell Guide shows how much of what we eat overall should come from each food group to achieve a healthy, balanced diet.
You do not need to achieve this balance with every meal, but try to get the balance right over a day or even a week.

Most of us still are not eating enough fruit and vegetables. They should make up just over a third of the food we eat each day.

Aim to eat at least 5 portions of a variety of fruit and veg each day. Choose from fresh, frozen, tinned, dried or juiced.

Remember that fruit juice and smoothies should be limited to no more than a combined total of 150ml a day.

Fruit and vegetables are a good source of vitamins, minerals and fibre.
Find out more about how to get your 5 A Day

Starchy food should make up just over a third of the food we eat. Choose higher fibre or wholegrain varieties, such as wholewheat pasta and brown rice, or simply leave the skins on potatoes.

There are also higher fibre versions of white bread and pasta.

Starchy foods are a good source of energy and the main source of a range of nutrients in our diet.
Find out more about starchy foods

These foods are good sources of protein, vitamins and minerals. Pulses, such as beans, peas and lentils, are good alternatives to meat because they're low in fat and they're a good source of fibre and protein, too.

Choose lean cuts of meat and mince, and eat less red and processed meat like bacon, ham and sausages.

Aim for at least 2 portions (2 x 140g) of fish every week, 1 of which should be oily, such as salmon, sardines or mackerel.

Find out about fish and meat.

Milk, cheese, yoghurt and fromage frais are good sources of protein and some vitamins, and they're also an important source of calcium, which helps keep our bones healthy.

Try to go for lower-fat and lower-sugar products where possible, like semi-skimmed, skimmed or 1% fat milk, reduced-fat cheese or plain low-fat yoghurt.
Find out more about milk and dairy foods

Unsaturated fats are healthier fats and include vegetable, rapeseed, olive and sunflower oils.

Remember all types of fat are high in energy and should be eaten in small amounts.
Find out more about the different types of fat in our diet

These foods include chocolate, cakes, biscuits, sugary soft drinks, butter, ghee and ice cream.

They're not needed in our diet, so should be eaten less often and in smaller amounts.
Get tips on cutting down on sugar

Water, lower-fat milks, lower-sugar or sugar-free drinks and tea and coffee all count.

Fruit juice and smoothies also count towards your fluid consumption, but they contain free sugars that can damage teeth, so limit these drinks to a combined total of 150ml a day.
Find out more about water, drinks and your health

How does the Eatwell Guide work?

The Eatwell Guide divides the foods and drinks we consume into 5 main food groups.

Try to choose a variety of different foods from each of the groups to help you get the wide range of nutrients your body needs to stay healthy.

It's important to get some fat in your diet, but foods that are high in fat, salt and sugar have been placed outside of the main Eatwell Guide as they're not necessary as part of a healthy, balanced diet and most of us need to cut down on these.

Unsaturated fats from plant sources (for example, vegetable oil or olive oil) are healthier types of fat.

But all types of fat are high in energy (calories), so they should only be eaten in small amounts.

On average, women should have around 2,000 calories a day (8,400 kilojoules) and men should have around 2,500 calories a day (10,500 kilojoules). We all need different amounts of energy (or calories) from food to be a healthy weight. How much you need depends on lots of things, including how active you are.

Find out how food labels can help you choose between foods and pick those lower in fat, saturated fat, sugar and salt.

Combination foods

Many foods, such as pizzas, casseroles, pasta dishes and sandwiches, are combinations of the food groups in the Eatwell Guide.

With these meals, check the ingredients and think about how these fit with the sections on the guide to help you achieve a balanced diet.

Does the Eatwell Guide apply to everyone?

The Eatwell Guide applies to most of us, whether we're a healthy weight or overweight, whether we eat meat or are vegetarian, and no matter what our ethnic origin.

Anyone with special dietary requirements or medical needs might want to check with a registered dietitian on how to adapt the Eatwell Guide to meet their individual needs.

Children under the age of 2

The Eatwell Guide does not apply to children under the age of 2 because they have different nutritional needs.

Between the ages of 2 and 5, children should gradually move to eating the same foods as the rest of the family in the proportions shown in the Eatwell Guide.

Read more about babies, toddlers and young children's nutritional needs in Your baby's first solid foods.

Download the Eatwell Guide booklet

For more information, including details of which foods are included in the food groups, download GOV.UK's The Eatwell Guide.

Healthy eating support

Food and diet advice on the NHS website includes:

# data[].attributes.attachment_link.description
The Eatwell Guide shows how much of what we eat overall should come from each food group to achieve a healthy, balanced diet. You do not need to achieve this balance with every meal, but try to get the balance right over a day or even a week.

# data[].attributes.body
Physical activity: applying All Our Health - GOV.UK (www.gov.uk)

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The Public Health England team leading this policy transitioned into the Office for Health Improvement and Disparities ( OHID) on 1 October 2021.

Introduction

This guide is part of 'All Our Health', a resource which helps health professionals prevent ill health and promote wellbeing as part of their everyday practise. The information below will help front-line health and care staff use their trusted relationships with patients, families and communities to promote the benefits of physical activity.

We also recommend important actions that managers and staff holding strategic roles can take.
View the full range of 'All Our Health' topics
Access the physical activity e-learning session

An interactive e-learning version of this topic is now available to use.

The Office for Health Improvement and Disparities ( OHID) and Health Education England's 'e-Learning for Healthcare' have developed this content to increase the confidence and skills of health and care professionals, to embed prevention in their day-to-day practise.

Physical inactivity is associated with 1 in 6 deaths in the UK and is estimated to cost the UK £7.4 billion annually (including £0.9 billion to the NHS alone).

Unfortunately, our population is around 20% less active than in the 1960s. If current trends continue, it will be 35% less active by 2030.

Many people don't realise that physical activity has significant benefits for health, both physical and mental, and can help to prevent and manage over 20 chronic conditions and diseases, including some cancers, heart disease, type 2 diabetes and depression.

Around 1 in 3 (34%) of men and 1 in 2 (42%) of women are not active enough for good health.

Men are more likely to report being active at the recommended level than women.

Physical activity varies with age and life stage. People tend to get less active with age, especially in older years.

And people with disabilities or long-term conditions are twice as likely not to be active enough for good health.

However, one in four people would be more active if advised by a healthcare professional so this presents a unique opportunity for you to support people to be more active.

The UK Chief Medical Officers' Guidelines recommend each week adults do:

at least 150 minutes moderate intensity activity, 75 minutes' vigorous activity, or a mixture of both

strengthening activities on two days

reducing extended periods of sitting

Core principles for healthcare professionals

This 'All Our Health' physical activity information has been created to help all health professionals:

understand specific activities and interventions that can prevent physical inactivity

think about the resources and services available in your area that can help people get active

Taking action

If you're a front-line health professional:

speak to your patients about the benefits of physical activity and risks of inactivity, referring them to information or services if necessary

read our blogs about brief advice, motivational interviewing and health coaching to help you have non-judgemental conversations tailored to individual patients

find out about the resources and services in your area that can help people get active, such as local referral pathways, including exercise/activity on referral schemes

make yourself familiar with local physical activity options, for example local Walking for Health schemes

read our blogs about the type of local services that may be available and how to find them

familiarise yourself with key physical activity messages and understand where to access trusted advice for your patients - we recommend NHS Choices which has information for adults, older people, children and people with disabilities

promote physical activity campaigns like Change4Life (information for children) and Better Health (for adults aged 40 to 60)

offer online activities or health apps such as Better Health's ACTIVE10 which encourages 10 minutes of brisk walking every day or 'Couch to 5k' which helps people take up running

become a physical activity role model; increasing your own activity levels will improve your own health and make it easier for you to discuss physical activity with other people

If you're a team leader or manager:

ensure the teams you manage are aware of physical activity services and interventions in your local area

promote a team culture where staff know that they should talk to their patients about healthy lifestyles - 'Making Every Contact Count' initiatives should include physical activity

create a culture where all staff understand the benefits of measuring their impact and demonstrating the value of their work

consider working within your own organisation, or with local businesses, to promote active workplaces

encourage high-level, executive staff to act as physical activity role models

If you're a senior or strategic leader:

work to ensure physical activity is promoted prominently within commissioned healthcare services

include physical activity in health and wellbeing boards' Joint Strategic Needs Assessment (JSNA)

consider the physical activity needs of the local workforce to create a culture change towards a more active workforce

look at the education and training needs of the workforce, to equip them to deliver high-quality physical activity advice and interventions

encourage high-level, executive staff to act as physical activity role models

Understanding local needs

The Physical Activity Data Sources document provides information on what can be found in each data source, including geographical areas reported (including national, regional and local authority), demographics of respondents (age, sex, ethnicity, sexuality, socio-economic status, religion, disability) and frequency of updates to the data.

The 2 main sources of national level physical activity data are the Health Survey for England (HSE) and the Active Lives Survey (ALS).

The HSE is used by central government to monitor trends in the national physical activity estimates, with most recent data available from HSE 2016. Data from ALS is used for the Public Health Outcomes Framework and Physical Activity tools to support local monitoring of performance against the government's Sport Strategy and Chief Medical Officer guidelines, with PHE producing physical activity estimates for each local authority in England.

Measuring impact

As a health professional there are a range of reasons why it makes sense to measure your impact and demonstrate the value of your contribution. This could be about sharing what has worked well in order to benefit your colleagues and local people, or help you with your professional development.

The general practice physical activity questionnaire (GPPAQ) is a simple, validated screening tool to assess adult physical activity and the associated risk of cardiovascular disease and all-cause mortality within primary care.

The Everyday Interactions measuring impact toolkit provides a quick, straightforward and easy way for health care professionals to record and measure their public health impact in a uniform and comparable way.

The physical activity impact pathway is recommended for healthcare professionals to record and measure actions undertaken as part of routine care which impact on physical activity levels.

Further reading, resources and good practice

Advice for patients and the public

NHS Choices has a range of information and support to help people get and keep fit

Better Health has information and support to help people stay active

Active 10 app helps individuals build 10 minutes of brisk walking into their routine

Couch to 5k helps people take up running

the Activity Alliance provides advice for disabled people to get active

Professional resources and tools

The UK CMOs' Start active, stay active report on physical activity provides detail and evidence on the recommended guidelines for physical activity and is supported by a number of infographics showing the guidelines and the benefits, including:

physical activity for pregnant women infographic and evidence briefing

physical activity for children and young people (aged 5 to 18)

physical activity for early years (birth to 5 years old)

physical activity for disabled adults

OHID has created a longer-length physical activity and health e-learning course to help healthcare professionals to champion physical activity across the life course. The course covers the science, the UK Chief Medical Officers' physical activity guidelines, the underpinning evidence base and how to incorporate physical activity into daily clinical care. It also includes a resource on motivational interviewing.

NICE guidance and pathways are available to support evidence based practice to promote physical activity.

OHID and BMJ Learning have published 8 modules on physical activity in the treatment of long-term conditions, as well as one on motivational interviewing in brief consultations.

OHID provides free peer training and online resources to healthcare professionals, via the Moving Healthcare Professionals Programme, to empower them with the skills and confidence to have quality conversations with patients about physical activity.

Moving Medicine is a free, online resource for healthcare professionals to promote and support patients with long-term conditions to get more active. Led by the Faculty of Sport and Exercise Medicine UK (FSEM), in partnership with Public Health England and Sport England, the toolkit provides what is needed for a 1-minute, 5-minute and longer conversations with patients.

Macmillan Cancer Support's Move More is a guide to helping people with cancer to be more active, with ongoing digital support.

Parkrun organises free weekly 5k run events.

Good practice examples

# data[].attributes.attachment_link.title
Physical activity: applying All Our Health

# data[].attributes.attachment_link.description
The Public Health England team leading this policy transitioned into the Office for Health Improvement and Disparities ( OHID) on 1 October 2021. This guide is part of 'All Our Health', a resource which helps health professionals prevent ill health and promote wellbeing as part of their everyday practise.

# data[].attributes.body
Physical activity: applying All Our Health - GOV.UK (www.gov.uk)

# data[].attributes.attachment_link.readable_text
The Public Health England team leading this policy transitioned into the Office for Health Improvement and Disparities ( OHID) on 1 October 2021.

Introduction

This guide is part of 'All Our Health', a resource which helps health professionals prevent ill health and promote wellbeing as part of their everyday practise. The information below will help front-line health and care staff use their trusted relationships with patients, families and communities to promote the benefits of physical activity.

We also recommend important actions that managers and staff holding strategic roles can take.
View the full range of 'All Our Health' topics
Access the physical activity e-learning session

An interactive e-learning version of this topic is now available to use.

The Office for Health Improvement and Disparities ( OHID) and Health Education England's 'e-Learning for Healthcare' have developed this content to increase the confidence and skills of health and care professionals, to embed prevention in their day-to-day practise.

Physical inactivity is associated with 1 in 6 deaths in the UK and is estimated to cost the UK £7.4 billion annually (including £0.9 billion to the NHS alone).

Unfortunately, our population is around 20% less active than in the 1960s. If current trends continue, it will be 35% less active by 2030.

Many people don't realise that physical activity has significant benefits for health, both physical and mental, and can help to prevent and manage over 20 chronic conditions and diseases, including some cancers, heart disease, type 2 diabetes and depression.

Around 1 in 3 (34%) of men and 1 in 2 (42%) of women are not active enough for good health.

Men are more likely to report being active at the recommended level than women.

Physical activity varies with age and life stage. People tend to get less active with age, especially in older years.

And people with disabilities or long-term conditions are twice as likely not to be active enough for good health.

However, one in four people would be more active if advised by a healthcare professional so this presents a unique opportunity for you to support people to be more active.

The UK Chief Medical Officers' Guidelines recommend each week adults do:

at least 150 minutes moderate intensity activity, 75 minutes' vigorous activity, or a mixture of both

strengthening activities on two days

reducing extended periods of sitting

Core principles for healthcare professionals

This 'All Our Health' physical activity information has been created to help all health professionals:

understand specific activities and interventions that can prevent physical inactivity

think about the resources and services available in your area that can help people get active

Taking action

If you're a front-line health professional:

speak to your patients about the benefits of physical activity and risks of inactivity, referring them to information or services if necessary

read our blogs about brief advice, motivational interviewing and health coaching to help you have non-judgemental conversations tailored to individual patients

find out about the resources and services in your area that can help people get active, such as local referral pathways, including exercise/activity on referral schemes

make yourself familiar with local physical activity options, for example local Walking for Health schemes

read our blogs about the type of local services that may be available and how to find them

familiarise yourself with key physical activity messages and understand where to access trusted advice for your patients - we recommend NHS Choices which has information for adults, older people, children and people with disabilities

promote physical activity campaigns like Change4Life (information for children) and Better Health (for adults aged 40 to 60)

offer online activities or health apps such as Better Health's ACTIVE10 which encourages 10 minutes of brisk walking every day or 'Couch to 5k' which helps people take up running

become a physical activity role model; increasing your own activity levels will improve your own health and make it easier for you to discuss physical activity with other people

If you're a team leader or manager:

ensure the teams you manage are aware of physical activity services and interventions in your local area

promote a team culture where staff know that they should talk to their patients about healthy lifestyles - 'Making Every Contact Count' initiatives should include physical activity

create a culture where all staff understand the benefits of measuring their impact and demonstrating the value of their work

consider working within your own organisation, or with local businesses, to promote active workplaces

encourage high-level, executive staff to act as physical activity role models

If you're a senior or strategic leader:

work to ensure physical activity is promoted prominently within commissioned healthcare services

include physical activity in health and wellbeing boards' Joint Strategic Needs Assessment (JSNA)

consider the physical activity needs of the local workforce to create a culture change towards a more active workforce

look at the education and training needs of the workforce, to equip them to deliver high-quality physical activity advice and interventions

encourage high-level, executive staff to act as physical activity role models

Understanding local needs

The Physical Activity Data Sources document provides information on what can be found in each data source, including geographical areas reported (including national, regional and local authority), demographics of respondents (age, sex, ethnicity, sexuality, socio-economic status, religion, disability) and frequency of updates to the data.

The 2 main sources of national level physical activity data are the Health Survey for England (HSE) and the Active Lives Survey (ALS).

The HSE is used by central government to monitor trends in the national physical activity estimates, with most recent data available from HSE 2016. Data from ALS is used for the Public Health Outcomes Framework and Physical Activity tools to support local monitoring of performance against the government's Sport Strategy and Chief Medical Officer guidelines, with PHE producing physical activity estimates for each local authority in England.

Measuring impact

As a health professional there are a range of reasons why it makes sense to measure your impact and demonstrate the value of your contribution. This could be about sharing what has worked well in order to benefit your colleagues and local people, or help you with your professional development.

The general practice physical activity questionnaire (GPPAQ) is a simple, validated screening tool to assess adult physical activity and the associated risk of cardiovascular disease and all-cause mortality within primary care.

The Everyday Interactions measuring impact toolkit provides a quick, straightforward and easy way for health care professionals to record and measure their public health impact in a uniform and comparable way.

The physical activity impact pathway is recommended for healthcare professionals to record and measure actions undertaken as part of routine care which impact on physical activity levels.

Further reading, resources and good practice

Advice for patients and the public

NHS Choices has a range of information and support to help people get and keep fit

Better Health has information and support to help people stay active

Active 10 app helps individuals build 10 minutes of brisk walking into their routine

Couch to 5k helps people take up running

the Activity Alliance provides advice for disabled people to get active

Professional resources and tools

The UK CMOs' Start active, stay active report on physical activity provides detail and evidence on the recommended guidelines for physical activity and is supported by a number of infographics showing the guidelines and the benefits, including:

physical activity for pregnant women infographic and evidence briefing

physical activity for children and young people (aged 5 to 18)

physical activity for early years (birth to 5 years old)

physical activity for disabled adults

OHID has created a longer-length physical activity and health e-learning course to help healthcare professionals to champion physical activity across the life course. The course covers the science, the UK Chief Medical Officers' physical activity guidelines, the underpinning evidence base and how to incorporate physical activity into daily clinical care. It also includes a resource on motivational interviewing.

NICE guidance and pathways are available to support evidence based practice to promote physical activity.

OHID and BMJ Learning have published 8 modules on physical activity in the treatment of long-term conditions, as well as one on motivational interviewing in brief consultations.

OHID provides free peer training and online resources to healthcare professionals, via the Moving Healthcare Professionals Programme, to empower them with the skills and confidence to have quality conversations with patients about physical activity.

Moving Medicine is a free, online resource for healthcare professionals to promote and support patients with long-term conditions to get more active. Led by the Faculty of Sport and Exercise Medicine UK (FSEM), in partnership with Public Health England and Sport England, the toolkit provides what is needed for a 1-minute, 5-minute and longer conversations with patients.

Macmillan Cancer Support's Move More is a guide to helping people with cancer to be more active, with ongoing digital support.

Parkrun organises free weekly 5k run events.

Good practice examples

# data[].attributes.attachment_link.title
Physical activity: applying All Our Health

# data[].attributes.attachment_link.description
The Public Health England team leading this policy transitioned into the Office for Health Improvement and Disparities ( OHID) on 1 October 2021. This guide is part of 'All Our Health', a resource which helps health professionals prevent ill health and promote wellbeing as part of their everyday practise.

# data[].attributes.body
s1047-2797_2801_2900263-020210725-19589-10b3u1r-libre.pdf (d1wqtxts1xzle7.cloudfront.net)