Nature’s medicine?

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Drinks: Drinks

The issue of alcohol and health is far more nuanced than either the drinks industry or the health lobby would have us believe. As the UK heads into January detox, medical expert Dr Erik Skovenborg puts some of the common myths on the subject under the microscope


Illustration: Jode Thompson

The feeding chain of headlines for your daily newspaper is a brew of a few ounces of facts topped up with a pint of myths. Those newspapers all want your attention and time in a world bursting with news around the clock, and they all want to sell their stories.

That goes for scientists (who must publish or perish), scientific journal editors (who must boost the journal’s reputation), journalists (whose wages depend on headlines and bylines) and editors (who must sell plenty of newspapers to survive).

No wonder that so often the facts are twisted or ignored in the interests of an attention-grabbing story. As recently as October, The Guardian ran a story (on the back of a British Medical Journal report) claiming that ‘just five alcoholic drinks a week could reduce sperm quality’. In fact, the key word here is ‘could’ since the study proved no link either one way or the other.

So let’s look at a few more common alcohol and health stories, and examine the truth behind the headlines.


This only tells half the story. In 1842, when Abraham Lincoln addressed the temperance folks in Springfield, Illinois, he famously said that ‘none seemed to think the injury arose from the use of a
bad thing, but from the abuse of a very good thing’. The belief that, in alcohol, we are dealing with the use of a ‘bad thing’ continues to dominate policy.

In fact, the risks of alcohol intake are not easy to estimate, not least because risk levels vary depending on the outcome we are interested in. Life span is the most interesting result. Alcohol shares a fate with vitamins A and D and the minerals salt and iron: a small amount will do you good and add years
to your life, but a large dose could kill you.

In contrast to vitamins and minerals, alcohol is not necessary for survival – you can live a perfectly happy life as a teetotaler. However, all else being equal, the average lifespan of a lifetime abstainer has been found to be around two years shorter than the lifespan of his moderately drinking fellow man.

In the Whitehall II Study, healthy behaviours were defined as never smoking, doing physical activity, eating fruits and vegetables daily and consuming alcohol moderately. The chance of successful ageing increased by 30% per increment of healthy behaviour. Civil servants engaging in all four healthy behaviours had 3.3 times greater odds of successful ageing (1).

Moderate drinking will not guarantee perfect health, but it will decrease the risk of ill health. Alcoholism, on the other hand, will reduce life expectancy by 10 to 12 years, and the earlier people begin drinking heavily, the greater their risk of developing serious illnesses later on (2).


Well, yes and no. Your risk of drinking problems and your chance of health benefits depends on whether you consume your 21 drinks on a Saturday night out, or you have some wine or beer with meals most days of the week.

In the Russian Federation vodka accounts for over 80% of all alcohol consumed, and weekend binge-drinking is a favourite pastime of Russian men. The result: a 50% increased risk of early death (3). Contrast this with Czech men. Even though the latter drink far more alcohol per year (8.5 litres, as opposed to 4.6 litres), their rates of problem drinking and negative consequences resulting from drinking are far lower (19% and 10% respectively), as opposed to Russian men (35% and 18%).

This is because the Russians drink less often – 67 drinking sessions per year on average, compared with 179 sessions for Czech men – but drink more alcohol per session (71g for Russians, 46g for Czechs) (4).

Finnish professor Kari Poikolainen has scrutinised and reanalysed popular interpretations of alcohol-related research evidence and found the optimal level for enjoying health benefits of alcohol consumption to be 14-22g per day (1.5-2.5 units). A slow speed of drinking is preferable, and you should adjust your drinking so that you sleep well and feel well in the morning – also watch your weight (5).


The Government certainly thinks so. The definition of binge drinking used by the NHS is drinking more than double the lower risk guidelines for alcohol in one session. So binge drinking for men is drinking more than eight units of alcohol (about three pints of strong beer). For women, it is drinking more than six units of alcohol (two large glasses of wine) (6).

However, there’s no consensus about what the cut-off should be, and proposed cut-offs have been criticised for being too simplistic and lacking scientific basis (7). The majority of bar managers define binge drinking as ‘drinking with the intention of getting drunk’, and relate it less to units consumed than to behaviours resulting from intoxication, such as loss of control or aggression.

In the short term, binge drinking is associated with injuries, risky sex and even risk of fatal arrhythmias from alcohol poisoning. In the long run, binge drinkers don’t get the increase of protective HDL cholesterol enjoyed by regular drinkers; instead the level of dangerous LDL cholesterol is increased.
A study of alcohol intake patterns in Northern Ireland and France showed that regular and moderate intake of wine throughout the week, the typical consumption pattern in middle-aged French men, is associated with a low risk of coronary heart disease, whereas the binge drinking pattern prevalent in Belfast doubled the risk of developing heart attacks (8).

We are left, though, with the question of where the boundary lies between protective and hazardous drinking. Since alcohol is drunk in different situations and will affect different people in different ways, there is no fixed relationship between the amount drunk and its consequences.

Regular, moderate drinking with occasional Saturday evening binges while dining with friends is a common consumption pattern in Denmark. Among Danish light-to-moderate drinkers reporting occasional binge drinking, the risk of coronary heart disease and total mortality showed no difference compared to light-to-moderate drinkers reporting no binge drinking (9).

It is, however, probably not helpful to lump together those who have drunk six to nine glasses of wine with their meal with those who have drunk considerably more on an empty stomach and are extremely intoxicated.


The antioxidant content of red wine is believed to play a role in the health benefits derived from drinking wine. In test tube studies, red wine polyphenols perform well as antioxidants — some of the best you will ever come across in food or drinks. Reports abound of animal studies where rats and mice live long and happy lives on daily supplements of red wine polyphenols such as resveratrol.

The problem is that a person would have to drink hundreds of glasses of red wine a day to match the amounts used in resveratrol studies. Even if red wine polyphenols have been shown to dilate arteries and reduce clot formation in lab studies of humans, it has been hard to find solid evidence of real world benefits. In large population studies from all over the world, a moderate regular consumption of beer works just as well as wine (10).

Several large population studies have shown that red wine drinkers fare better than beer or spirits drinkers do. As a Danish physician, I’m well aware of the Copenhagen City Heart Study (11), where the risk of dying steadily decreased as intake of wine increased – from a relative risk for subjects who never drank wine, to just half the risk for those who drank three to five glasses a day.

Intake of beer and spirits, however, did not reduce the risks of heart diseases. Indeed, no significant interactions existed between risk reduction and sex, age, education, income, smoking, or body mass index.

However, it is likely that any particular benefit of wine consumption is further complicated by diet and socioeconomic factors. Using data from supermarkets in Denmark – 3.5m transactions over a period of six months – my colleagues and I have shown that wine buyers purchase more healthy food items than people who buy beer (12).

Wine buyers bought more olives, fruit and vegetables, poultry, cooking oil, and low-fat cheese, milk, and meat, while beer buyers bought more ready-cooked dishes, sugar, cold cuts, chips, pork, butter or margarine, sausages, lamb, and soft drinks.

In other words, eating a healthy Mediterranean diet is a significant part of the reason why Danish wine drinkers have a lower risk of myocardial infarctions than their beer-drinking neighbours.


Slash drinking limits for the over-65s to protect their bodies and minds, say doctors.’ This headline from The Guardian (22 June 2011) quoted a working group of the Royal College of Psychiatrists. However the idea that people turn into frail individuals with low alcohol tolerance when they reach the age of 65 is a myth made up of plain ignorance, ageism prejudice and political correctness, mixed with a minuscule amount of facts.

The group suggested halving the limits of alcohol consumption to 1.5 units a day for men (around half a pint of beer) and just one unit for women over 65 (a small glass of wine) (13). To substantiate this, psychiatrists invoked a progressive reduction in total body water (TBW) in the elderly: ‘The ageing body contains less water and more fat, meaning smaller amounts of alcohol can do more damage.’

If it were true, such a reduction might lend credibility to the suggestion of a much lower alcohol limit for the elderly. However, the list of references of the report did not present a shred of evidence for that actually happening. Recent studies show that from age 20-29 to 70-79, men’s TBW dropped from 45.6 litres to 44.1 litres. In women the reduction was even smaller, from 32 litres to 30.9 litres.

A further claim from the report: ‘As we age, increasing memory problems and physical health problems, and less of an ability to get rid of alcohol from the blood stream means that the effect of what we would currently call the safe limits is actually more damaging for older people.’

Apart from the fact that most people maintain pretty good health and a rather good memory for a number of years after their 65th birthday, what do we know of the ability to break down alcohol in the liver in old age? Well, here is the conclusion of the only relevant reference in the report: ‘Age had no effect on observed rates of ethanol elimination after a standard meal’ (14).

Here is a true fact that doctors could perhaps give older drinkers instead: ‘The effect of alcohol intake on mortality does not differ between middle-aged (50-64 years) and elderly men and women (more than 64 years old).’

In his marvellously titled book L’Éloge de l’Ivresse (The Praise of Drunkenness, 1714) or Wherein is Authentically and Most Evidently Proved the Necessity of Frequently Getting Drunk, French author Albert Hendrick de Sallengre enumerates some ‘rules to be followed in getting drunk’ that you might want to observe when enjoying your favourite tipple:
– Not forcing a person to drink
– Not too often
– In good company
– With good alcohol
– At an appropriate time
– Knowing your limits

Even though it was written 300 years ago, it probably contains more useful and balanced advice than much of what makes it into the press…


Dr Erik Skovenborg is a Danish specialist in family medicine. He has been a member of the Social, Scientific and Medical Council of AIM (Alcohol in Moderation) since 1992, and is a founding member of the Scandinavian Medical Alcohol Board. He has published numerous scientific papers, and chaired many committees and symposia on the subject of alcohol and health in the past 20 years. He regularly writes about wine for publications around the world.


References:

1. Sabia S, Singh-Manoux A, Hagger-Johnson G et al. Influence of individual and combined healthy behaviours on successful aging. CMAJ 2012;184(18):1985-92.
2. John U, Rumpf HJ, Bischof G et al. Excess mortality of alcohol-dependent individuals after 14 years and mortality predictors based on treatment participation and severity of alcohol dependence. Alcohol Clin Exp Res 2013;37(1):156-63.
3. Nicholson A, Bobak M, Murphy M, Rose R, Marmot M. Alcohol consumption and increased mortality in Russian men and women: a cohort study based on the mortality of relatives. Bull World Health Organ. 2005;83(11):812-9.
4. Bobak M, Room R, Pikhart H et al. Contribution of drinking patterns to differences in rates of alcohol related problems between three urban populations. J Epidemiol Community Health 2004;58(3):238-42.
5. Kari Poikolainen. Perfect Drinking and its Enemies. Mill City Press, Minneapolis, 2014.
6. Drink Aware
7. Herring R, Berridge V, Thom B. J Epidemiol Community Health 2008;62(6):476-9. Binge drinking: an exploration of a confused concept.
8. Ruidavets JB, Ducimetière P, Evans A et al. Patterns of alcohol consumption and ischaemic heart disease in culturally divergent countries: the Prospective Epidemiological Study of Myocardial Infarction (PRIME). BMJ 2010;341:c6077.
9. Skov-Ettrup LS, Eliasen M, Ekholm O, Grønbæk M, Tolstrup JS. Binge drinking, drinking frequency, and risk of ischaemic heart disease: a population-based cohort study. Scand J Public Health 2011;39(8):880-7.
10. Ronksley PE, Brien SE, Turner BJ, Mukamal KJ, Ghali WA. Association of alcohol consumption with selected cardiovascular disease outcomes: a systematic review and meta-analysis. BMJ 2011;342:d671.
11. Grønbaek M, Deis A, Sørensen TI et al. Mortality associated with moderate intakes of wine, beer, or spirits. BMJ 1995;310(6988):1165-9.
12. Johansen D, Friis K, Skovenborg E, Grønbaek M. Food buying habits of people who buy wine or beer: cross sectional study. BMJ 2006;332(7540):519-22.
13. Older Persons’ Substance Misuse Working Group. Our Invisible Addicts (College Report CR165). Royal College of Psychiatrists, 2011 (http://www.rcpsych.ac.uk/files/pdfversion/CR165.pdf).
14. Beresford, T. P. & Lucey, M. R. (1995) Ethanol metabolism and intoxication in the elderly. In Alcohol and Aging (eds T. Beresford & E. Gomberg): pp. 117–127. Oxford University Press.

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