"An alcoholic is someone you don’t like, who drinks as much as you do”
                              Dylan Thomas (1914-1953)

I get asked a lot about the health effects of drinking, especially over the festive season.  “Oh, but now you doctors say that drinking is GOOD for you, so another one (two, three) won’t hurt, will it?”

Now that the holiday season is almost over, it’s as good a time as any to evaluate the latest evidence about the effects of alcohol on health. Especially as you may be thinking of 'going on the wagon' for a week or two.

Understandably, people are confused. I was a bit confused until I did the research for this article.  Over the past five years various studies have suggested that imbibing wine (red, in particular) is good for cardiovascular health, among other things.  Some were even going so far as to suggest that middle aged people who don’t already drink should take up the habit, and add a daily glass of red to promote healthy longevity. The newspapers are very good at picking up on this type of research, but not so good at putting the results into context.

So what is safe drinking, how much is too much, and can any amount be doing you good?

Alcohol consumption is interwoven into the social and cultural fabric of the Australian population.  Four fifths of men and two thirds of women drink alcohol.  About 20% of Australian adults drink above the recommended limit on a regular basis, and  slightly less than 5% are dependent on alcohol. Globally, alcohol consumption has increased in recent decades, with the highest consumption in Europe and North America. Australia is not far behind.

Some definitions:
Until last month, the recommendations for safe alcohol intake were four standard drinks per day for men, and two for women.  However, the National Health and Medical Research Council has revised its guidelines,  to no more than two standard drinks per day for both men and women, and preferably no more than one for women. Total abstinence is advised for pregnant women and those planning a pregnancy. Abstinence is also advised for breastfeeding mothers - so there goes that nightcap feed for baby.  The NH&MRC doesn’t change guidelines on a whim, so there is obviously some substance there. The changes are at least partly based on the latest report of the World Cancer Research Fund.  This is the culmination of five years' work by scientists in nine universities from four countries, and was released in November 2007.  This group has assessed all the original research findings  related to dietary intake and cancer according to a standard protocol.

What is a standard drink?

The short answer is: a lot less than you probably pour yourself at home.

A ‘standard drink’ is

·         100mls of wine (five tablespoonfuls)

·         A middy of beer (285 ml)

·         A nip of spirits (30 ml)

·         One schooner of beer is 1.5 standard drinks; as is a can of beer (375 ml) or one stubby.

Last week, the  smallest wine glass I could find available in two major Sydney department stores was 250 ml, and the largest was 450 ml (don’t say I don’t do my research!). The average restaurant glass of wine is just less than 200 mls, and a pub measure of wine is 125ml.  (Do you ever feel hard done by when the waiter only fills your glass to that little line?)

At home, most people are much less parsimonious, so you need to check the size of your domestic glasses.  You may well be regularly drinking a lot more than you imagine.

What is problem drinking?

The WHO has a table of six symptoms; if you have three or more of these, you are “alcohol dependant':

1.Compulsion to drink

2. Loss of control when drinking (doing things you may not later be proud of)

3. Tolerance (needing more and more to get the same effect)

4. Alcohol taking priority over other activities

5. Withdrawal symptoms (anxiety about not drinking, for instance, or indigestion, diarrhoea, nausea)

6. Persistent drinking despite harm (physical or psychological)

I see a lot of executive-types who rely on alcohol for stress relief.  They look forward to having a drink when they get home from work, often continue drinking over dinner and after, then go to sleep on the sofa.  Once in bed, they sleep heavily until the early hours of the morning, then wake up and can’t get back to sleep. They usually don’t see this as a problem, but it is in fact the pattern of problem drinking.  If this sounds like you, then you need to seriously re-think your habits.  Drinking more than the recommended amounts, and needing to increase the ‘dose’ to get the same effects (eg, relaxation), equates to  tolerance or habituation. Look for a healthier mechanism to manage stress. Alcohol is a dangerous method, as it is more or less socially acceptable ('What a day...boy do I need a drink!”), and its effects are insidious.  Effects on your body, your brain, on your relationships and social functioning.

You also need to have at least one, and preferably two, sequential alcohol-free days (‘AFDs”) per week, to help stop tolerance developing.  If you can’t manage this, then cut back your daily drinks to one.  Treat you glass of alcohol as if it is a medicinal tonic, rather than a thirst quencher or a reward.

White or red?

Five years ago, red wine was considered more beneficial than white, which in turn was more beneficial than beer and spirits.  The latest evidence, however, suggests that white and red wine are equally as good, as they both contain 'phenolics'.  These are an array of molecules contained in the skin and pulp of grapes, which have a positive effect on blood fats, platelets and clot formation, and are anti-oxidants. They also appear to have an overall anti-inflammatory effect on the body, as well as improving insulin sensitivity.  Red wine, being made from the grape skins as well as the pulp, contains more of these phenolics than white, but it has been found that those contained in the skins are less well absorbed.  Research on rats has shown red and white wines are equally cardio- protective. Grape juice and de-alcoholised wine have similar effects, though these perhaps lack the elegance and aesthetic appeal of a  glass of good wine.

A landmark study from the University of Newcastle, NSW, looked at 11,000 men and women who had had heart attacks.  Men who had one or two drinks of (any type of) alcohol on five or six days per week, and females who had one or two on three or four days a week, had about 40% the risk of having a heart attack, compared to non-drinkers.  Any more alcohol drunk gave less benefit.

Indeed ‘moderate’ drinking, defined as two or less standard drinks on most days, is fairly reliably shown to decrease the risk of heart attack, heart failure, peripheral vascular disease and ischaemic stroke.  This is possibly because it makes  the blood less likely to clot and  increases  the ‘good’ cholesterol, or HDL.  It also seems to preserve cognitive function for longer. Moderate drinking  appears to decrease total (all cause) mortality by about 18%. 

However, it is a  very thin-edged wedge.

“Excessive’ alcohol, simply defined as more than that described above, increases the risk of motor vehicle accidents, suicide, stroke, cardiomyopathy (a big, floppy, inefficient heart), abnormal heart rhythms (= sudden death),  and cancer.  Cancers especially related to alcohol use are breast and uterus, and any of the gastrointestinal tract, including mouth, throat, oesophagus, stomach, pancreas and bowel.  As well, it increases the risk of sleep apnoea, cirrhosis, which predisposes to liver cancer, and foetal alcohol syndrome.

Women have a lower tolerance than men, so the current vogue for  women  to drink to 'keep up with the boys' will have disastrous effects, long term. Alcohol mixes with water in the body, and women have less body water, so their serum alcohol level is higher for the ingestion of any given amount, and increases more quickly.  Alcohol is thought to slow the breakdown of oestrogens, hence the increased risks of breast and uterine cancer, especially in post menopausal women who have less progesterone to oppose these effects.  A small amount of alcohol slows bone loss, therefore helps to protect against osteoporosis, but too much speeds it up.  In young women, this effect seems to persist into later life, even if they stop drinking.  In men, it has an 'oestrogenising' effect on the body, with the growth of breast tissue (gynacomastia), erectile impotence and sub-fertility.

Binge drinking has increased as a problem in Australia over the past ten years, and seems to be a worldwide phenomenon.  This is defined as six or more standard drinks once or twice per week.  It therefore includes those people who refrain from alcohol all week, then pour six or seven drinks down their throats on Friday or Saturday.  We know from research in Scotland, Finland and ex-Eastern Europe, that binge drinking is clearly associated with increased rates of stroke, high blood pressure heart attacks and abnormal heart rhythms.  The average life expectancy of a Russian man is currently 58 years, predominantly due to excess alcohol.  A recent study from the UK has shown a substantial increase of strokes in young men who binge drink.  Many young people I see think that having six drinks in one 'session' is a normal part of weekend socialising.  Wrong again.

Yes. As you may have gathered, there is a “J”  shaped curve describing the effects of alcohol on health.  Light to moderate drinkers have reduced risk, compared to non-drinkers, of morbidity (illness) and mortality (death), but heavier drinkers are at much higher risk of morbidity and mortality.  A small amount of alcohol ingested regularly seems to induce positive health changes.

This seems to be at the heart of the 'French Paradox', which is that the French have a relatively low rate of heart disease and stroke, despite being world leaders in gastonomic hedonism.  I recommend that you carry out a field study  for yourself, and observe them at close quarters. If you do decide to go Mediterranean, and partake of a small glass of wine with lunch, be aware that alcohol is more potent when taken  before dusk.  There is in fact a circadian rhythm in the metabolism of alcohol, so the impression you may already have that you get tipsier more quickly at lunch is entirely true.  However, if you are a non-drinker, these positive advantages are not significant enough for you to consider taking up drinking.  There is a risk that you will enjoy it too much, and live a shorter, and riskier, life.

Postscript:  This article has a flippant tone, in keeping with the holiday season, but excessive drinking is a big and real problem.  If you would like more specific (confidential) advice on what to do if you think you have a problem, feel free to email me.