I live in a country where alcohol belongs to almost every social event, from birthday celebrations, students associations parties, afterworks with colleagues, or Sunday lunch with the in-laws. It is also very common to have a glass of wine in the evening while cooking for the family or for oneself, to release the stress and tension accumulated during the day – because hey, we all have a very busy life.
But actually… Is alcohol good or bad for my organism?
Alcohol is a kind of Dr Jekyll and Mr Hyde case, with multiple research conducted over the past decades to define its role in our health. Good or bad? Should we all drink a glass of red wine per day or become totally abstinent? What are the long-term effects of one single or more binge drinking occasion(s)? The literature is overwhelmed with studies investigating the effects of alcohol on our health, with sometimes contradictive results, which makes it complicated to define consensus and draw clear conclusions.
Isn’t it also linked to the amount of alcohol consumed?
Absolutely. Alcohol also follows the golden rule first mentioned by Paracelsus some centuries ago: sola dosis facit venenum (and since no one nowadays is fluent in Latin anymore: the dose makes the poison).
High or chronic alcohol consumption, which means more than 60 g of alcohol per day, can have serious consequences such hepatic damages (liver cirrhosis, where the liver looks like a sponge and doesn’t function anymore) and increased risks of some cancers (upper aerodigestive tract, liver, colon, rectum and breast) [1]. We also all know that driving a car (bike/truck/scooter/limo/private jet) under the influence of alcohol is everything except a good idea.
However, moderate consumption of alcohol might lower the global mortality and show cardiovascular benefits (protection against heart disease, diabetes, etc). I intentionally use the term “might”, because this has been largely studied but strong scientific evidence is still missing, due to the experimental design used in such studies, which are usually based on self-reported survey data. “Moderate consumption” corresponds to roughly one drink per day for women and two drinks for men [2]. It is difficult to find a consensus between all the national recommendations, since the definition of “one serving size” (or “one unit of alcohol”) depends on the country. Switzerland for instance consider 10g/glass as one serving size, why the US base their recommendations on 14g per serving size. Overall, we can consider that “one serving size” is equivalent to 8 to 14g from pure alcohol.
A small recap’ with some numbers:
- High/chronic alcohol consumption: >60g/day
- Binge drinking: >48g in one occasion
- Moderate consumption: 10-14g/day for women, 20-28g/day for men (definition dependent on the countries)
- One serving size (one unit of alcohol): 8 to 14g from pure alcohol.
It seems that finding consensus on the definition of one serving size was difficult, but what about the daily recommendation?
That is indeed where the fun starts. Guidelines and recommendations might totally differ from one country to another, but they also tend to use a very vague terminology, which might be very confusing for a lambda user.
Let’s take different countries as an example, which have different behavior in terms of alcohol consumption, i.e., Switzerland, the U.S., The Netherlands and UK.
Switzerland (2018)
Adult men should not drink more than two standard glasses of alcohol per day and adult women not more than one glass. It is recommended to not drink alcohol on several days during the week. If alcohol is exceptionally consumed in larger quantities during several hours, adult men should not go beyond 5 glasses and women 4 glasses, respectively. One standard glass corresponds to 10 to 12g of pure alcohol. [3]
United States (2015-2020)
If alcohol is consumed, it should be in moderation—up to one drink per day for women and up to two drinks per day for men. The Dietary Guidelines does not recommend that individuals who do not drink alcohol start drinking for any reason. One alcoholic drink-equivalent is described as containing 14 g (0.6 fl oz) of pure alcohol. [2]
The Netherlands (2015)
Do not drink alcohol, or in any cases not more than one glass per day (which corresponds to approximately 10 g of pure alcohol). [4]
United Kingdom (2016)
The UK Chief Medical Officers’ guideline for both men and women is that to keep health risks from alcohol to a low level it is safest not to drink more than 14 units a week on a regular basis. If you regularly drink as much as 14 units per week, it’s best to spread your drinking evenly over three or more days. One unit is 8g of pure alcohol. [5]
This perfectly illustrates the multiple differences which can be observed in the recommendations:
- Some countries make a difference in their recommendations between men and women,
- Some refer to daily consumption while other prefer to give recommendations on weekly intake,
- Some consider one unit as 8g of alcohol, other 14 g – which is 75% higher!
- Some accepts a low to moderate consumption, The Netherlands mostly recommends to be abstinent,
- Some guidelines use very cautious terms (“should”, “it is safest not to drink”) while other are much more direct (“Do not drink alcohol”).
Apparently there is also no real accepted consensus when it comes to the recommendations, but why?
Probably because the current research – despite numerous – has not been able to clearly define which dose would make the poison (and which dose would give a possible protective effect). This is also because the metabolism and effects of alcohol are different for everyone and strongly depend on the gender, age, race, body mass index (BMI), genetics, co-medication and consumption habits.
This summer 2018, while most of us where enjoying a glass of [please add here your favorite alcoholic beverage] – thinking that a single glass or maybe two would thus not harm, a study published in The Lancet dropped a new bomb, basically showing that [6]
“the risk of all-cause mortality, and of cancers specifically, rises with increasing levels of consumption, and the level of consumption that minimizes health loss is zero”
“The level of consumption that minimizes health loss is zero”, seriously?
This study is a systematic analysis carried out in the frame of the Global Burden of Diseases, Injuries and Risk Factors Study 2016, conducted by researchers from the GBD 2016 Alcohol Collaborators. Usually it is here that I should write the name of the main authors, but since the list of authors fills in more than one page, using Times New Roman font size 9, this is not really an option. The article also contains two appendices. The first Appendix has 148 pages. I almost choked when I saw the 2187 pages of the second Appendix. The Lancet had an impact factor of 53 in 2017 (higher than both Science and Nature) and it is clearly THE world’s leading general medical journal focusing on human health.
You start to understand why this article deserves some attention.
Wait – the impact factor? What is that?
The “impact factor” is a numeric system used to rank journals by prestige. An impact factor of 53 roughly means that Lancet articles have been cited, on average, about 53 times each over the past two years. The higher this number, the more prestigious the journal is considered. Try not to mention this during your next dinner with your researcher friends: numerous scientists have a love-hate relationship with the impact factor. But this is a topic for another post.
Anyway, this systematic analysis includes the data from 195 countries between 1990 and 2016, in a population older than 15 years old. It would therefore be an understatement to say that it compiles a lot of data. The scientific community considers this study as “the most comprehensive estimate of the global burden of alcohol use to date” [7]. The authors used a novel and more accurate methodology to measure the relative risks of alcohol use, which for instance also took into account sales data to estimate the alcohol stock available and consumption by tourists. They followed 23 outcomes (read: a lot), in other words alcohol-related health problems, including breast cancer, epilepsy, tuberculosis, self-harm, ischemic heart disease, stroke, hypertension, liver cancer, etc. They suggest that in 2016, alcohol use was associated with nearly 10% of global deaths in people aged 15-49 years old (mostly due to road injuries, self-harm and tuberculosis), while for >50 years old people, cancers were the leading cause of alcohol-related deaths.
Nearly 10%!
Overall, this article highlights that if alcohol use has any protective effects for heart disease, they are offset by the increased risks of cancer, injuries and infectious diseases. In other words: the safest level of drinking is none. People and associations editing guidelines and recommendations have probably started to sweat when they read this paper (and not because we had a very warm summer).
This is very confusing. What am I supposed to do now, since there was already no real international consensus – and now there is this additional layer brought by this article? My glass of wine… *sigh*
Disclaimer: I am sure that this won’t be the first time that I will use those words for my take-home message, because this is something you can apply to multiple fields in your life.
Keywords are: information, self-reflection, decision, balance.
The following questions (in a random order) are always worth few minutes of attention:
- Why do I drink alcohol-containing drinks?
- Do I like the taste of alcohol?
- Do I have further disease-related risks? (inadequate lifestyle, genetic predisposition, etc.)
- Does alcohol use makes me happier?
I would strongly advise you not to use alcohol if your main reason is “because everyone does it and otherwise I’ll feel excluded”. I would also encourage you staying mostly abstinent if you don’t like alcohol and you don’t drink very often. Overall, whatever your decision, make sure you take it after having been sufficiently informed.
My own decision is that I enjoy drinking two types of alcohol-containing drinks: wine and whisky. For the taste, not for the alcohol content. My approach is “quality rather than quantity”, so I keep the consumption to a minimum but go for good stuff. I would rank my lifestyle as good enough, so I accept to take the potential risks. There are cardiovascular risks in the family, so I keep an eye on these ones. I am also fully aware of the consequences of alcohol on my own organism (which I will not describe here but involves some gastro-intestinal issues). I have observed that my metabolism has become slower over the years, something I also keep in mind when I define which quantity I will drink.
Conclusion: take your own decision, dare to drink sparkling water if you feel like it, dare to say no to a second glass, enjoy to say yes to a second glass, follow your own path and enjoy life.
Last but not least: stay even more informed if you are pregnant or on medication. These are two conditions where alcohol can have dramatic effects – stay tuned since this will be treated in two upcoming posts.
Dr. Iza
References
[1] S. Pasche, B. Broers, T. Favrod-Coune, Comment y voir clair face à toutes les recommandations relatives à la consommation d’alcool ? Rev Med Suisse 8 (2012) 1831.
[2] Dietary Guidelines for Americans 2015-2020, https://health.gov/dietaryguidelines/2015/guidelines/appendix-9/ (accessed Sept 2018)
[3] Eidgenössische Kommission für Alkoholfragen, https://www.bag.admin.ch/dam/bag/fr/dokumente/npp/alkohol/ekal/orientierungshilfe-alkohol-kurz.pdf.download.pdf/1-f-2015-reperes-consommation-alcool-abregee.pdf (accessed Sept 2018)
[4] Gezondheidsraad Richtlijnen goede voeding 2015, https://www.gezondheidsraad.nl/sites/default/files/201524_richtlijnen_goede_voeding_2015.pdf (accessed Sept 2018)
[5] UK Chief Medical Officer’s Low risk drinking guidelines 2016, https://www.drinkaware.co.uk/alcohol-facts/alcoholic-drinks-units/ (accessed Sept 2018)
[6] GBD 2016 Alcohol Collaborators, Alcohol use and burden for 195 countries and territories, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet (2018) doi: 10.1016/S0140-6736(18)31310-2
[7] R. Burton, N. Sheron, No level of alcohol consumption improves health. Lancet (2018) doi: 10.1016/S0140-6736(18)31571-X
