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Is Low to Moderate Alcohol Consumption Good?

Director Cardiology, Fortis Escorts Hospital
Mar 3, 2019 4:18 AM 5 min read

Alcohol is commonly perceived as a "social beverage" - a friendly drink to lighten up your mood, relieve tension, induce sound sleep, and to top it all...protect one from heart attacks! Could you have asked for more!


So, is low to moderate alcohol consumption really good...?


Alcohol has been part of our culture for nearly 5000 years (described as Sura in the Vedic period). According to the WHO Global Status Report on alcohol and health 2018nearly a third of the population of the world (age 15 years or more) - a mind-boggling 2.35 billion people (about 39% of males, 25% of females) consume alcohol. This is nearly twice the population of India. Just slightly more, about 2.4 billion are abstainers, while just over 2/3 of a billion are former drinkers who have now quit. Over a quarter of the world’s population between 15 -19 years, and 1/3 to over 1/2 of the 20-24 year old group, currently drink.


Studies conducted across the globe have common findings - low to moderate acohol consumption protects against heart attacks, and probably diabetes as well. Only high drinkers (> 4 drinks per day for men, > 3 drinks for women) have higher mortality, largely due to alcoholic liver diseases (fatty liver, cirrhosis, etc.) and rare higher volume drinkers risk the chance of a heart failure (alcoholic cardiomyopathy).


Can A Social Beverage Save Your Life: The Good, The Bad, and The Ugly Side of Alcohol


The common thread is the presence of a J-shaped curve, i.e., low to moderate drinkers are less prone to some diseases than always abstainers (non-drinkers). The risk rises once people start consuming high volumes of alcohol daily - the most consistent evidence being found for heart attacks or occurrence of Coronary Artery Disease (CAD). It would be interesting to note that some of the diseases apparently less likely in low-volume drinkers are deafness, hip fractures, common cold, dementia, cancers and even cirrhosis liver.


This concept came about from the so-called French Paradox. The French consumed large amounts of saturated fats and smoked regularly, yet had a much lesser risk of CAD than other populations. Wine was postulated to be one of the possible causes for this unexpected finding.


Guidelines have consistently permitted (even endorsed) low-volume alcohol consumption regularly as a protective measure against heart attacks (Coronary artery disease or CAD), while stopping short of recommending never drinkers to start drinking, as the data wasn’t solid enough. Red wine has been noted to have the maximum data, probably due to the presence of a compound called resvetarol, and some other compounds.


Can A Social Beverage Save Your Life: The Good, The Bad, and The Ugly Side of Alcohol


All-in-all, the overriding belief has been one of tangible benefits with modest regular consumption of alcohol, apart from its positive social implications. 


No wonder, a recent study conducted by AIIMS, New Delhi, reported alcohol as the most common drug used for substance abuse. Nearly 15% of the adult Indian population were regular drinkers, 1in 5 being addicted to or dependent on it.


Independent analysts, however, found these conclusions problematic. Subjects reporting self-consumption generally tend to under-report the amount of alcohol consumed. Moreover, data on patterns of drinking and binge drinking are often missing, and several health problems associated with alcohol tend to be ignored (uncontrolled blood pressure, accidents, inter-personal violence, depression, etc.). Many studies had been pooling previous drinkers who gave up drinking, often due to diseases, in the same group as never-drinkers, further confounding the analysis.


Can A Social Beverage Save Your Life: The Good, The Bad, and The Ugly Side of Alcohol


Recently however, a shift has been noted. Since it is a little tricky to collect data on huge numbers of individuals (hundreds of thousands, followed up over several years, in different age groups) to conclude benefit or harm with social drinking, combining results of multiple studies with similar design is a common statistical method used in clinical Medicine (meta-analysis and systematic review). This provides a rather unique look into the outcomes of millions of individuals from different parts of the world.


A major such analysis in 2016 on nearly 4 million individuals found no evidence of a survival benefit with alcohol. Next year, they analysed the impact on CAD events, and failed to find solid evidence of a positive effect on nearly 3 million subjects. This analysis found a protection against heart attacks in Whites over the age of 55 with low to moderate consumption, but none in individuals < 55 years of age, or in Asians.


So, to drink or not to drink, that is the question!


This was the background for the largest ever study on alcohol in 2016. Funded by a neutral organisation (Bill & Melinda Gates Foundation), the investigators reported on the outcomes associated with alcohol consumption in 28 million individuals from 195 countries and territories (in age group 15 years to 95 and above) from 1990-2016 by the Global Burden of Disease (GBD) 2016 Alcohol Collaborators in August, 2018.


They found that alcohol was associated with a disturbing 2.8 million deaths in 2016 vs 5.5 million associated with smoking, making it the seventh largest contributor to disease and mortality. Further, in the age group 15-49 years, it was the leading risk factor for disease burden worldwide, including 12.2% of all male deaths and 3.8% of female deaths. Apart from alcoholic liver disease, its regular consumption also increased the risk of uncontrolled hypertension, strokes (clot formation or bleeding inside the brain), tuberculosis, road accidents and several types of cancers. Data for interpersonal violence was missing, and may further increase the morbidity than what is reported here.


Some protection against heart attack was found in females > 50 years of age, and males > 60 years. This showed a J-shape curve, with the maximum benefit being for low-volume drinkers, consuming < 1 standard drink per day (10 g of ethyl alcohol). However, this benefit was offset by the much greater increase in risk of the above mentioned diseases, ultimately leading to no beneficial effect.


The investigators concluded that the net amount of alcohol correlating with minimum risk of disease or mortality is zero. As guidelines continue to uphold the cardio-protective effects of alcohol, a revision is urgently needed to correct this fallacy and prevent a big chunk of preventable diseases, just as for smoking.


In summary, alcohol is not the panacea it is often made out to be. Occasional social drinking, < 1 drink per week may be acceptable and even beneficial for the heart. Regular drinking is not better for heart attack prevention, and in fact, increases the risk of multiple other health issues, totally reversing all the putative cardiac benefits.


This is a recurring column published every Sunday. Click here to view my other articles on health, nutrition and exercise.