Aug 292011
 

This is the 2nd of a 3-part discussion on alcohol drinking guidelines:
Part 1: Alcohol consumption at the Royal College of Psychiatrists
Part 2: This article
Part 3: Alcohol consumption – discussion

Via Twitter, 2020Health say they will publish a report ‘Risky drinking’ in October. The Daily Mail and Telegraph have written about it, perhaps from a press release. I’m confident that it won’t say anything significant that I don’t already know, but if it does I’ll comment eventually.

Lack of information

Are the following questions reasonable?

“If my alcohol drinking pattern and quantity is X, what is my increased mortality rate?”
“How much alcohol can I drink for an increased mortality rate of X?”

I think they are reasonable and sensible questions. I wouldn’t expect accurate numbers, (the science isn’t yet good enough), but rules of thumb would do. Yet nothing available from government departments or front-line health professionals approximates to answers to those questions. It is impossible to make informed decisions about the personal risk of drinking. These articles explore why not, and what is actually known about the effects of alcohol.

Dose-response curves

For any illness influenced by alcohol, the risk typically changes with alcohol consumption according to one of the following curves. The curve on the left is a “J Curve” (sometimes called a “U Curve”). The curve on the right is a monotonic curve.

By Ian R. White, Dan R. Altmann and Kiran Nanchahal

There is massive evidence that a range of important illnesses conform to the “J Curve”: moderate amounts of alcohol reduce their risk, while often (although not always) lots of alcohol increases their risk. Many other illnesses conform to the monotonic curve: any alcohol increases their risk. (Partial lists of such illnesses are provided below.)

When all possible alcohol-related illness risks for any person are summed, the overall risk of dying from any of these illnesses typically conforms to one of these curves. Depending on various factors, abstention may carry more risk than moderate drinking, but not always.

This is about risk, not magnitude. You may drink a little and get mouth cancer, or drink a lot and not get it. (You are unlikely to get any particular illness even if you drink heavily; the individual risks are small). If you get such a cancer, it is bad, whether you drank a little or a lot.

There is a huge amount of scientific literature that attempts to analyse the responses for particular illnesses for different population groups. And a huge amount more that examines the overall mortality risks, for all illnesses, for different population groups. And lots more that examines the public-health consequences, including government expenditure requirements, for different policies and interventions.

Selective quotes

These quotes are not intended to be representative. They are intended to prove that there is published research that will confuse or disconcert almost anyone!

Alcohol intake and survival in the elderly: a 77 month follow-up in the Dubbo study (Simons LA et al) (1999):
“… the hazard ratio (HR) for all-causes mortality in male drinkers, compared with abstainers, was 0.75 at one-seven drinks/week, 0.76 at eight-14 drinks/week, 0.69 at 15-28 drinks/week and 0.49 at > 28 drinks/week …, an inverse relationship. In female drinkers, HR was 0.78 at one-seven drinks/week, 0.49 at eight-14 drinks/week … and 0.62 at 15-28 drinks/weeks, potentially a U shaped relationship.”

Alcohol consumption and mortality: modelling risks for men and women at different ages (Ian R White et al) 2002:
“Men would be advised to limit their drinking to 1 unit a day up to age 34, 2 units a day up to age 44, 3 units a day up to age 54, 4 units a day up to age 84, and 5 units a day over age 85. These levels are similar to current limits at older ages but considerably lower at younger ages.”

A comparison of the alcohol-attributable mortality in four European countries (Britton A et al) 2003:
“It was estimated that there are approximately 2% fewer deaths annually in England and Wales than would be expected in a non-drinking population”

Benefits of Drinking Outweigh Harm from Abuse (David J. Hanson) (2004):
“The NIAAA calculates that if all drinkers in the U.S. became abstainers, there would be an additional 80,000 deaths per year. Abstaining dramatically increases the risks of heart attack, ichemic stroke, and many other diseases and life-threatening conditions.”

A healthy dose of scepticism: Four good reasons to think again about protective effects of alcohol on coronary heart disease (TANYA CHIKRITZHS et al) (2009):
“Popular perceptions regarding the strength of evidence for alcohol’s protective effect on a growing number of conditions might be misguided.”

Alcohol intake and the risk of coronary heart disease in the Spanish EPIC cohort study (L Arriola et al) (2009):
“Moderate, high and very high consumption was associated with a reduced risk of CHD in men: hazard ratio 0.90 … for former drinkers, 0.65 … for low, 0.49 … for moderate, 0.46 … for high and 0.50 … for very high consumers. A negative association was found in women …”

Don’t Blame Me! – Alcohol is the only way to prevent Alzheimer’s (Stanton Peele) (2011):
“One modern scourge that all of us seniors fear is Alzheimer’s Disease …. And there is no known way to prevent it — except for consuming alcohol, which NO ONE is going to tell you.”

Our invisible addicts (Royal College of Psychiatrists) (2011):
“More recent evidence from the USA, based on alcohol-related harm/alcohol misuse, has defined ‘at-risk’ drinking in older people as being more than 1.5 units of alcohol on any one day or more than 11 units per week for both men and women”

If you can see clear conclusions, please respond!

Epidemic?

Statistics show that perhaps 10,000 people die of alcohol-related causes in the UK each year. In fact, being generous with the categorisation suggests perhaps 15,000 per year. That is lot of grief. (Let’s temporarily ignore the fact that, each year, lots of people didn’t die, because they had been protected by alcohol!)

But … more than 500,000 people die in the UK each year. So (this link is just for England) about 3% (over 4% for men) of all deaths are alcohol-related. It is not the epidemic that special interest groups, or papers trying to fill column inches, might suggest. Suppose that alcohol in moderation really does have a protective effect against several important illnesses: perhaps we should think of it as a medicine with significant side-effects. Perhaps the healthiest society we could have would inevitably suffer from some side-effects.

Illnesses

I tried to identify which illnesses had some protection from alcohol, and which had an increased risk from alcohol. Without medical knowledge I stood no chance of finding out reliably. I don’t even know whether some of the illnesses I read about were the same or different from one-another. And some illnesses were in both categories, so perhaps they conformed to the “J Curve”, or perhaps no-one actually knows. Here are a pair of (incomplete) lists which anyone would be stupid to rely upon!

Some evidence of protection Attributable (or partly so) in deaths
Diabetes mellitus (type II) Diabetes mellitus (type II)
Ischaemic stroke Ischaemic stroke
Peripheral Artery Disease Haemorrhagic stroke
Coronary Heart Disease Ischaemic heart disease
Heart Attacks (Acute Myocardial Infarctions) Heart failure
Cardiovascular / coronary artery disease Alcohol-induced pseudo-Cushing’s syndrome
Metabolic Syndrome Alcoholic polyneuropathy
Duodenal ulcer Alcoholic myopathy
Gallstones Alcoholic cardiomyopathy
Entric infections Alcoholic gastritis
Osteoporosis Alcoholic liver disease
Cancer of kidney Cancer of lip, oral cavity and pharynx
Cancer of thyroid Cancer of oesophagus
Non-Hodgkin Lymphoma (blood cancer) Cancer of colon
Hodgkin’s Lymphoma (blood cancer) Cancer of rectum
Alzheimer’s Disease Cancer of liver and intrahepatic bile ducts
Other senile dementia Cancer of larynx
Rheumatoid Arthritis Cancer of breast
Osteoarthritis Acute and chronic pancreatitis
Reactive arthritis Epilepsy and Status epilepticus
Psoriatic arthritis Psoriasis
Spondylarthropathy Gastro-oesophageal laceration-haemorrhage
Benign prostate enlargement Cholelithiasis
Gallbladder Disease Ethanol poisoning

Some interesting sources: Is alcohol in moderation good for you?; Alcohol-attributed fractions for England

Politics

The various participants have their own separate agendas. This is not sinister – they have different roles and values. So drinkers, front-line health professionals, and politicians, can be expected to pull in different directions.

Health professionals, and the drinks industry (not a single coherent entity), both lobby the government over alcohol policy. (I don’t know if religious groups do as well). Perhaps drinkers need to lobby independently of both of those groups.

Politicians do need to manage the cost of the NHS. Even though alcohol accounts for little than 3% of the deaths in the UK, there can be ill-health associated with alcohol before death, and sometimes there are many repeat visits that cost money and effort. A reduction in the overall level of alcohol consumption is expected to help.

There is also a set of social costs associated with intoxication. Intoxication causes a separate set of problems for politicians compared with the mere consumption of alcohol – intoxicated drinkers can harm or kill other people. (Drink-driving; domestic violence; rioting; violence; other public disorder). These are sometimes listed under the label “binge drinking”, but there are (silly) efforts to define this in terms of the quantity consumed instead of the degree of intoxication. (I could drink a bottle of wine in a day and not get intoxicated, or drink half-a-bottle of wine and get intoxicated. The social consequences would be different). However, there is a general view that drinking to get intoxicated in public is typically bad, because it isn’t a private matter.

Much depends on the ideologies of the politicians. “Free for all” or “nanny state”? “Moral panic” (related to puritanism)? “Tax for social control”? “Restrict by law” or “nudge” or “advise”? Across the world, all of these and many more have been tried, and there is no consensus about what should be done. Even where there is evidence that a particular policy achieves a particular effect, there typically isn’t a consensus about what effect is wanted; that comes back to ideology.

A special problem arises from the protective effects of alcohol in some illnesses. These are often illnesses of old-age, see above. If alcohol is taxed to reduce its overall consumption, should it then be offered on prescription to older people (who are often poorer) as a sort of medicine? And if not, why not?

Many people with special interests appear blind to something that most drinkers are fully aware of: the objective of life isn’t to live as long as possible! For example, there are those who see alcohol as a poison whose consumption needs to be reduced simply because it harms people. But:

I want the option of having a drug that is 100% certain to kill me in minutes, depending on my judgement of my quality of life!

Compared with “assisted dying”, for which I support the lobbying, the risk of drinking a level of alcohol that increases  my mortality rate by 5% in years to come, but gives me the pleasure of wine with my evening meal in the meantime, is a minor matter! This complicates things for politicians.

Drinking guidelines

There has never been a scientific paper that identifies the “proper” drinking guidelines. There can’t be – it is not that sort of problem. Look at the dose-response curves above – where should the guidelines be? What is “safe”? (Even abstention may not be safe!) And different people differ in their physical reaction to alcohol, and differ in their acceptance of risk.

Drinking guidelines are relatively arbitrary decisions made by committees for social engineering purposes. They do not relate to any specific drinker – it would be unethical to advise any person to adhere to them without investigating the physical and environmental conditions of that person first. It would be equivalent to advising medical intervention for someone without knowing about them.

I’ll discuss the drinking guidelines, and their exploitation, in Part 3: Alcohol consumption – discussion

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