To Drink or Not to Drink...The Light Alcohol Drinking Conundrum

“One peg of whiskey a day or one glass of red wine a day is good for the heart”, is a statement we hear quite often, both from the lay press as well as sometimes, doctors.

I like a drink now and then and it is always nice to believe that what we like can also help us live long, healthy.

So when a study [1] by Ding C and colleagues in the BMC Medicine, published last week concluded that drinking up to 7-8 gm of alcohol per day (a glass of wine a day or equivalent) has beneficial effects on all-cause and cardiovascular mortality, with a J-shaped curve, where the highest benefit accrues to those who drink lightly (7-8 gm/day) as compared to those who don’t drink or drink heavily, I decided I must write about this.

I then decided to go through all the recent literature on the benefits of drinking alcohol.

Clearly I was deluding myself.

Here is the current evidence.

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1. The cardioprotective effect, if at all,  is seen mainly in high income countries [2], and not in low and low middle income countries like India, where though the incidence of alcohol consumption as a percentage of the population is lower, the drinking pattens and habits are different and there are likely other environmental or genetic or unknown confounders at work. Perhaps the middle to high income population within India may behave like those in high income countries, but there is no evidence of that.
2. It is possible that there is a genomic influence [3] that links alcohol to improved risk, but is not truly “causal”…this means that a particular genomic pattern may make a person prone to drink and but may be associated with reduced risk, not the other way around.
3. Daily drinking is associated with increased mortality [4] even if we stick to the apparent low-risk limit of 7-8 gm/day or 100 gm/week. The lowest risk (and there is risk at all levels, which means the absolute “no risk” is when we don’t drink) is when the drinking (one glass of wine or equivalent) is restricted to 2-3 times / week, which is a stance also endorsed by the UK Chief Medical Officers’ Low Risk Drinking Guidelines.
4. Alcohol intake increases risk of injury [5], both accidents and self-harm.
5. Alcohol intake increases risk of cancer [6], especially esophageal, buccal, breast and colon, a statement endorsed strongly by the American Society of Clinical Oncology (ASCO). It also goes onto say that reducing alcohol consumption at a population level would lead to a considerable reduction in the worldwide incidence of cancer.
6. Resveratrol, found in in red wine has been linked with increased longevity in some studies in animals, but drinking red wine for the benefits of resveratrol [7] (which may explain the French paradox) has not shown any mortality or longevity benefit. Perhaps resveratrol supplementation orally may show a benefit in the future, if at all, but this would not be linked to alcohol intake.
7. Alcohol intake, especially in the poor, is associated with other habits such as eating fried food and smoking, which are both in turn deleterious to health.

The Global Burden of Disease paper [5] on alcohol use across 196 countries showed no benefit of alcohol consumption at any level. Alcohol is the 7th leading cause of death worldwide across all age groups and the 9th commonest cause of death in India in the 50-69 years age group. It is the third most important reversible cause of cancer. Above the age of 50, cancers are the commonest cause of death and disability due to alcohol, whereas in the younger population, it is injury. In low income countries, associated tuberculosis makes a difference.

So what is your matka here? If you like drinking, you should drink really light, which would mean not more than 2-3 times a week and not more than 1 glass of red wine or equivalent. If you drink more (which I do sometimes as well), then do it without getting drunk and without binging. However, you cannot justify drinking alcohol from a health perspective…there is no evidence that drinking at any level helps us live longer, healthier. This is one of those situations where we have to balance a fun activity with what is good for our health in a practical and common sensical manner.

Having said that…being drunk is not the same as “drinking”.  I will leave you with this prose from Charles Baudaliere for something to think about this Sunday morning…those who get drunk on air know what I am saying…

“One should always be drunk. That's all that matters; that's our one imperative need. So as not to feel Time's horrible burden that breaks your shoulders and bows you down, you must get drunk without ceasing.

But what with? With wine, with poetry, or with virtue, as you choose. But get drunk.

And if, at some time, on the steps of a palace, in the green grass of a ditch, in the bleak solitude of your room, you are waking up when drunkenness has already abated, ask the wind, the wave, a star, the clock, all that which flees, all that which groans, all that which rolls, all that which sings, all that which speaks, ask them what time it is; and the wind, the wave, the star, the bird, the clock will reply: 'It is time to get drunk! So that you may not be the martyred slaves of Time, get drunk; get drunk, and never pause for rest! With wine, with poetry, or with virtue, as you choose!’”

Footnotes

1. Ding C, O'Neill D, Bell S et al. Association of alcohol consumption with morbidity and mortality in patients with cardiovascular disease: original data and meta-analysis of 48,423 men and women. BMC Med. 2021 Jul 27;19(1):167. doi: 10.1186/s12916-021-02040-2. PMID: 34311738; PMCID: PMC8314518.

2. Smyth A, Teo KK, Rangarajan S, et al; PURE Investigators. Alcohol consumption and cardiovascular disease, cancer, injury, admission to hospital, and mortality: a prospective cohort study. Lancet. 2015 Nov 14;386(10007):1945-1954. doi: 10.1016/S0140-6736(15)00235-4. Epub 2015 Sep 17. PMID: 26386538.

3. Millwood IY, Walters RG, Mei XW et al; China Kadoorie Biobank Collaborative Group. Conventional and genetic evidence on alcohol and vascular disease aetiology: a prospective study of 500 000 men and women in China. Lancet. 2019 May 4;393(10183):1831-1842. doi: 10.1016/S0140-6736(18)31772-0. Epub 2019 Apr 4. PMID: 30955975; PMCID: PMC6497989.

4. Hartz SM, Oehlert M, Horton AC et al. Daily Drinking Is Associated with Increased Mortality. Alcohol Clin Exp Res. 2018 Nov;42(11):2246-2255. doi: 10.1111/acer.13886. Epub 2018 Oct 3. PMID: 30281161; PMCID: PMC6214719.

5. 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 Sep 22;392(10152):1015-1035. doi: 10.1016/S0140-6736(18)31310-2. Epub 2018 Aug 23. Erratum in: Lancet. 2018 Sep 29;392(10153):1116. Erratum in: Lancet. 2019 Jun 22;393(10190):e44. PMID: 30146330; PMCID: PMC6148333.

6. LoConte NK, Brewster AM, Kaur JS et al. Alcohol and Cancer: A Statement of the American Society of Clinical Oncology. J Clin Oncol. 2018 Jan 1;36(1):83-93. doi: 10.1200/JCO.2017.76.1155. Epub 2017 Nov 7. PMID: 29112463.

7. Semba RD, Ferrucci L, Bartali B et al. Resveratrol levels and all-cause mortality in older community-dwelling adults. JAMA Intern Med. 2014 Jul;174(7):1077-84. doi: 10.1001/jamainternmed.2014.1582. PMID: 24819981; PMCID: PMC4346286.