Monday, September 12, 2011

Alcohol: Wine Not?


As physicians, we are consistently exposed to the deleterious effects of alcohol on our patients.  Whether these encounters take place in the clinic or hospital setting, the stories are strikingly similar, only differing in severity.  There is the story of Mr. W, a 62-year-old male battling alcohol abuse for 30 years that had led to his alcoholic liver disease.  He eventually ended up under our care in the intensive care unit in shock after experiencing several episodes of bloody vomitus from a ruptured vein in the lower portion of his esophagus. When blood flow to the liver is slowed secondary to disease processes such as cirrhosis from excessive alcohol consumption, these veins can form and can cause life threatening internal bleeding.  Mr. W was eventually discharged from the hospital, but after a prolonged hospital course requiring life support and suffering various complications including infections and kidney failure. 

Unfortunately, this is a very common story in the medical world. We as physicians believe alcoholism to be a preventable disease and hence, bear the responsibility of educating the general public about the safe practice of alcohol consumption.

I apologize for the morose story I just told, but this is the reality.  Alcohol in excess is bad for you.  The World Health Organization estimates approximately 2 billion people consume alcoholic beverages worldwide, 76.3 million have alcohol use disorders and alcohol causes 1.8 million deaths a year.  Acutely, alcohol can cause loss of judgment, loss of coordination, blurred vision, slurring of speech, loss of balance, unconsciousness, coma, and death.  Chronically, alcohol can cause liver failure, gastric ulcers, malnutrition, high blood pressure, certain types of cancer, epilepsy, nerve damage and heart failure.   

So what do I tell my family members, friends and patients when they ask about alcohol consumption?  I am willing to bet most doctors say something like “it’s best to drink in moderation.”  But what does that even mean?  What IS moderation and WHY is it good to drink in this manner?  Moderation is a very subjective term open to all kinds of interpretation. 

So what counts as a drink?


The following count as one drink: one mixed drink with 1.5 fl oz (44 milliliters) of 80-proof liquor such as vodka, gin, scotch, bourbon, brandy or rum), 5 fl oz (148 milliliters) of wine, or 12 fl oz (355 milliliters) of beer or wine cooler
  

So what IS so great about alcohol?  And this is the part I am oh so excited about because I, like many of you eagerly look forward to that glass of Pinot Noir with my dinner, that swig of Dogfish head 60 or better yet 120 minute hoppy IPA while watching the game and that lychee martini with my friends on the Rare View roof deck bar in NYC. 

My friends, alcohol in moderation is not only good for your heart, but the evidence shows that it can prolong survival.  That’s right!  Maybe one of the best things anyone has ever told you in your life.  Bottom line, moderate wine intake daily is associated with decreased vascular risk.  Furthermore, researchers concluded that low levels of alcohol intake meaning 1-2 drinks a day for women and 2-4 for men reduces total mortality in both genders. 

The Center for Disease Control recommendations on alcohol intake differs slightly.  According to their website, "There is no one definition of moderate drinking, but generally the term is used to describe a lower-risk pattern of drinking. According to the Dietary Guidelines for Americans, drinking in moderation is defined as having no more than 1 drink per day for women and no more than 2 drinks per day for men. This definition is referring to the amount consumed on any single day and is not intended as an average over several days."

I know, I know, the evidence did give a range of alcohol intake that proved beneficial (2-4 drinks for men, 1-2 drinks for women)...but it's best to exercise caution and lean on the conservative side of the definition of moderation since individual people's reactions to alcohol vary based on age, body frame, race, amount of food consumed prior to intake, use of medications and family history.  We all know that one martini will affect your 45-year-old cousin Bob (or in my case cousin Esfandyar pronounced Es-fan-dee-yar) much differently than your fragile 90-year-old grandma.

My hope was to elucidate some of the myths and facts of alcohol consumption so that you have the knowledge to make healthy decisions when it comes to drinking.  Alcohol has the power to devastatingly harm us through addiction and disease.  But it also has the power to benefit our health by reducing heart attacks, stroke, and death.  Life is full of decisions.  The small choices you make on a daily basis can have a huge impact on your overall health and longevity.

For those of you who are interested in the painful, nerdy details regarding the clinical data on this topic please continue to read on…


http://web.duke.edu/arc/academic_skills/exams.php



If you are reading this, you are a nerd like me.


There is an inverse association between alcohol and coronary artery disease by increasing HDL (good cholesterol), decreasing platelet aggregation and coagulation factors and beneficially affecting endothelial function and inflammation.  Feel free to click on the following links to read more if you are interested:

http://www.bmj.com/content/319/7224/1523.short

http://predimed.onmedic.es/Portals/0/2004%2013.pdf.


In 2002, a study was published in Circulation taking a look at the relationship between wine and beer consumption and vascular risk (http://circ.ahajournals.org/content/105/24/2836.full.pdf).  It was a meta-analysis investigating 26 studies.  Really, all this means is that this study looked at 26 studies that each individually addressed a related spectrum of research questions.  After looking at all the data, the researchers found that a quadratic model best fit their results and the complex relationship was described as a J-shaped curve.  So basically, there is an initial progressive decrease in vascular risk by increasing amounts of wine consumption.  However, as levels of consumption increase, the risk plateaus and reverts at higher levels of alcohol intake.  Specifically, a maximum reduction in relative risk was predicted at 750 milliliters of wine per day.  However, it is important to note that the study was statistically significant only up to 150 milliliters per day.  Moderate (aka less than 750 milliliters per day) wine intake daily is associated with decreased vascular risk

In 2006, researchers investigated the association of alcohol with mortality (http://archinte.ama-assn.org/cgi/content/full/166/22/2437).  Again, this was a meta-analysis looking at 34 studies with over one million subjects.  This is what they found:


Di Castelnuovo, A et al; Arch Intern Med. 2006;166:2437-2445



Again, we find ourselves dealing with a J-shaped curve.  Relative risk of mortality is on the y-axis (basically meaning death) and alcohol consumption (in drinks per day) is on the x-axis.  As you can see, after an initial decrease in mortality by increasing alcohol consumption, the curve reaches a plateau and reverts at higher amounts of alcohol consumption.  Specifically, the association with lower mortality was observed up to about 4 drinks per day, but the lowest mortality was observed at roughly half a drink daily. 


The researchers did all sorts of fancy things with this study, adjusting the results for men and women, and then for different countries.  They concluded that low levels of alcohol intake meaning 1-2 drinks a day for women and 2-4 for men are inversely associated with total mortality in both genders. 


These studies not only say it’s healthy to drink in moderation, but that doing so is better than not drinking AT ALL.  So just as we expected, another study came out criticizing this.  The “other guys” basically argued that positive health effects of moderate drinking might be an overestimation due to confounding factors.  Specifically they stated that the group abstaining from alcohol may include former problem drinkers with existing medical co-morbidities or that this group may be atypical compared to the drinking group with respect to sociodemographic and social behavioral factors.


And guess what the results showed?  Even though the confounding factors were significant, at the end of the day, the mortality benefit with moderate alcohol consumption did not change after these factors were adjusted for.....MU- AHAHAHA! (that was my evil laugh in case you were wondering) 
:-)

Now, I am exhausted.  I am going to have a glass of wine.  


Cheers

1 comment:

armyeye said...

Can't talk, drinking brunello...