I'm handing over my blog this week to Dr Jonathan Tricker, a practising GP. We were discussing the new UK Government guidelines on alcohol on the train the other day and he offered to share his perspective as a doctor who is also a winelover.
"I enjoy drinking wine. I enjoy that first sip after getting in from clinic; I enjoy bubbles on Fridays and sherry on Saturdays. I most especially enjoy the conviviality and friendship around a shared bottle.
A couple of weeks ago the Chief Medical Officer issued new draft guidelines on alcohol. This suggested a reduction in the recommended amount of alcohol in men from 21 units a week to 14. The recommendations for women have stayed at 14 units per week. They advise to have these drinks over 3 or more days, and avoid regular episodes of heavy drinking. They additionally recommend you should not drink during pregnancy.
For the most part, by staying within these guidelines the risks of harm from alcohol are brought down to the level of risk associated with other normal everyday activities (like driving). You may choose to drink more, and that’s okay, but the choice should be an informed one.
Do I drink too much? Sometimes. This last year I’ve woken up a few with that decidedly dusty feeling, with heartburn, and even collywobbles. Some weeks I have drunk over the old male weekly recommendations of 21 units. Most weeks I am at, or close to, the new recommendations of 14 units. I’ve certainly had more than the 5-7 units of an evening that could have put me at risk of acute injury and accidents.
I have traded of the enjoyment of alcohol against the short and longer term risks. Though I suppose I may have felt differently if I’d tripped and broken my arm, or developed an irregular heart rhythm or vomited up blood.
I sit in clinic and most days will see the associated problems of alcohol* Usually the problems are covert. Could my patient’s high blood pressure be related to their alcohol consumption? Possibly. What about obesity or depression? Probably. Sleep problems? Could well be and that in turn may lead to poor concentration. That colon cancer? Perhaps.
What about the benefits? There’s the enjoyment, the pleasure and the community around drinking. Perhaps you needed some Dutch courage to talk to someone at the bar? That’s a benefit of sorts. For me, it’s my hobby. But unfortunately the health benefits of alcohol have probably been overstated, and are marginal at best (see below**).
Might you be drinking too much?
* Most people underestimate how much they are drinking
* A unit isn’t much wine. A small (125ml) glass of 12.5% wine is actually 1.5 units. (Click here to work out how many units you are drinking.)
* If you think you are drinking too much, then you probably are.
* You may want to complete the AUDIT questionnaire here. If you are concerned, perhaps it would best to speak with a health professional. Be honest with yourself. It’s relatively easy to creep into the ‘increasing risk’ category. For what it’s worth, I scored 9.
* You might still wonder why I drink at all when I’m so conscious of the risks. I guess it's worth reiterating that with alcohol it’s dose-related. Drink judiciously and the risks remain low. *** And I choose to accept the small increase in risk, just as I do if I go coasteering, or horse riding.
How to cut down the amount you drink
* Buy better wine. Better quality wine will hopefully have greater length - that often-delicious lingering taste, that can stay with you for minutes after a sip. Also, if it’s more expensive you’re likely to buy less of it. (There’s a close relationship with the cost of alcohol and how much is consumed).
* Think about buying half bottles. There’s a temptation with normal bottles to pour larger glasses or, not wanting it to go to waste, polishing it off.
* Try pouring less into your glass. You want the wine to be able to aerate. The aromas will collect in the glass, and it’ll probably taste better.
* All too often a pub/bar/restaurant will overfill a glass. A large (250ml) glass is 1/3 bottle. Try ordering a smaller glass. (See point 3, and, as I understand it, they are legally obliged to provide you with a 125ml serving if you ask).
* Aim to have more days off drinking than on.
* Don’t forget that alcohol is a significant source of calories. In fact a greater source of calories per gram than sugar. (1 gram sugar = 4 calories, 1 gram alcohol = 7 calories, a unit of alcohol contains 56 calories). I have had patients lose a considerable amount of weight just by stopping drinking.
* Specific goals may help. Rather than saying ‘this week I’ll drink less’; you could set yourself a target: ‘this week I’ll only have a drink on 4 days, and I won’t have more than one small glass of wine each time’.
* It may be a help to enlist the support of your friends and family.
* There are about 30 health conditions directly attributed to alcohol, including: alcohol dependence, alcohol withdrawal, acute intoxication, alcoholic gastritis (irritation lining of stomach), alcoholic polyneuropathy (damage to the small nerves of the hands and feet), alcoholic cardiomyopathy (alcohol causing the heart to become like a floppy bag), various effects on the liver such as hepatitis (inflammation), to cirrhosis (permanent damage to the liver, which can no longer perform its vital functions for the body)
Then there’s a whole load of chronic conditions that cannot be wholly attributed to alcohol but there’s sufficient evidence of a causal relationship. This is a big list but includes cancers of mouth/oropharynx, oesophagus, stomach, colon, liver, breast and perhaps lung; depression; high blood pressure; Other conduction disorders of the heart (where the hearts electric circuits get messed up and can led to abnormal heart rhythm), pneumonias caught outside hospital; pancreatitis…
And finally there are acute conditions where alcohol is a component cause. These include: road traffic accidents, drownings, falls.
For the most part in these conditions there’s a dose-response relationship. That is, the more alcohol you consume the greater the risk.
**Most of the reported health benefits have been linked with a reduction of death from ischaemic heart disease [IHD] (that is the disease process which leads to most angina and heart attacks). Most of these effects can be achieved with alcohol of less 12g (that’s 1.5 units) every other day. If you have experienced IHD then a pattern of low dose drinking may reduce risk of recurrence. There is some biological evidence to potentially back this up. Particularly that low dose alcohol can improve one’s lipid (fats + cholesterol) profile, particularly with an increase of fats call HDL (high density lipoproteins, but usually referred by GP as ‘good-fats’ or ‘good-cholesterol’ ) and there’s a link between better lipid profile and reduced rates of IHD.
But, and it’s a pretty big but, most of these big studies have tended to use ’non-drinkers’ or ‘abstainers’ as their control, against which they compare light/moderate/heavy drinkers. But non-drinkers tend to include ex-drinkers (such as people who have stopped drinking due to ill health), and we know that these people can have much worse health outcomes. What this can do in give the control group worse outcomes and artificially inflate the benefit of drinking. Some studies (the most recent in BMJ in February 2015) tries to take this into account, and separate ex-drinkers and non-drinkers, and when this is done the beneficial effect of alcohol largely disappears.
Additionally most of the studies have looked at average alcohol intake rather than drinking habits. In studies that have shown beneficial effect for light drinking, but no benefit or detrimental effects with heavy drinking episodes (even if you are a regular light drinker)
*** Sometimes the portrayal of the statistics can be alarming. They present it as ‘Relative Risk’. So relative risk of oesophageal cancer (that’s the food pipe) if you’re a moderate to heavy drinker is something like 100%. Sounds alarming. But the baseline chance of oesophageal cancer may be 1/75 (1.3%) so ‘absolute risk’ in a drinker might be 1/38 (2.6%). Personally I think these statistics should presented as absolute risks.
Top image © dancar at Fotolia.com