Med student here... Made the point as a 2nd year student (much to some of my classmates horror) that there was no evidence that minimal amounts of alcohol in pregnancy harmed the foetus... (eg drinking at recommended nonpregnant levels of drinking) The lecturer after googling agreed with me... All evidence of harm is for high levels of alcohol use...
The other intriguing point I note is that I have a brother-in-law who's recently been diagnosed at 70+ with the post-concussion dementia syndrome CTE (I know, I thought that was a post mortem diagnosis but tell that to the geriatrician!) - interesting that his brief professional boxing career is blamed for his memory issues, the full-on alcoholism of his youth is given a free pass... presumably because his neurologist/geriatricians are true believers in CTE and sporting concussions are the activity they're keen to demonise (heaps of publicity here in Australia) - social contagion or fads or call it what you will, if they didn't have concussion in their sights I think there would be a whole heap of EtOH moralising going on... Incidentally he's the fittest healthiest guy I know, runs every day, pescatarian, teetotaler since his misspent youth... but significantly impaired by dementia.
Despite our best efforts to remain neutral, by its very nature the human mind is biased toward confirmation of its pre-existing beliefs. That's why the gold standard of medical research is a randomized, placebo-controlled, double-blinded trial (RCT), where neither subjects nor researchers know who got the placebo until the study has been completed. That's something we don't have regarding the long-term health effects of alcohol.
The next best thing to the RCT is a Mendelian randomization study, especially those employing a doubly-ranked statistical approach. To date, this is the very best study we have on the dose versus health response of drinking alcohol:
This study concluded that there is no evidence for any protective benefits from modest levels of alcohol consumption.
If I were an alcohol apologist, I'd define "modest" as being more than the amount I personally consume. I'd then point to individual differences in susceptibility to alcohol's toxic effects, rationalize its use as an anxiolytic, sedative, or social lubricant, stress the psychological benefits of social drinking, and cite how its toxicity is ameliorated by consuming it along with food.
However, as a physician I am committed to first doing no harm. Applying the precautionary principle, if I have no convincing evidence that low doses of alcohol are clearly beneficial, I cannot in good conscience recommend consuming a known poison in any amount.
and Mendelian randomization studies (which assume that certain genes determine who will drink and how much they will drink, something which is questionable) don't show increased risk of breast cancer.
I find the linear association of alcohol's impact on all-cause mortality persuasive enough. We each get to choose our own poison, but when it comes to advising our patients, that's a whole other story.
As you said, entangling the effects of low alcohol consumption is probably impossible with observational data. What baffles me is the logic behind the recent push for zero alcohol. E.g. a Lancet Public Health comment from the WHO states: „To identify a safe level of alcohol consumption, scientific evidence is required to show the absence of increased risk of illness or injury associated with alcohol consumption at and below that level.“ This seems like a remarkable shift in the burden of proof. Even if someone would conduct an RCT, proving the abscence of harm of say, 10g per day, would require something like a non-inferiority study where the upper margin is zero harm. It would essentially have to show benefit of alcohol consumption. And btw: does anyone drink for their health?
My favorite philosopher Nietzsche discusses the Apollonian and Dionysian tendencies in culture and the mind and how both need to be understood and respected. The key is context and framing of the Dionysian. Your post is consistent with that.
As a cardiologist, I’d also mention alcohol intake can have a significant negative effect on blood pressure and triglycerides. Can be relevant for some people.
I used to drink fairly heavily when I was younger but I was not an alcoholic. For those people I think total abstinence is appropriate. In my later years I have reduced my consumption to one light beer in the evening. I am fully aware of afib and I am now in normal sinus rhythm.
I have no serious or evident health issues except arthritis which is fairly common in my age group. I exercise frequently and so far as I know have never had any heart issues.
I’ll continue to do as before and I NEVER eat fast food. 0bviously I don’t smoke.
It’s clear from the article I referenced that as part of funding a large RCT that would truly answer the questions on moderate alcohol and health he was going to accept some money from the alcohol industry but as he points out almost all drug trials are funded by pharmaceutical companies and we have found ways to make them trustworthy.
Too much of anything I guess causes harm. My N of one suggests that I could not use alcohol safely so I just don’t drink it. But I sure don’t mind if others do. I like pop tarts and I’m certain those are not good for my health. Ultimately, I just see alcohol as a mood altering drug and if I could use mood altering drugs, successfully, I would probably imbibe from time to time too. Took me 18 years to realize I can’t use them successfully. The past 25+ years have been much better for my health! But I won’t curse the drug just because of my inability to enjoy it
There is one mood-altering drug that almost everyone likes (at the right dosage) and that is caffeine. Fortunately, observational studies aren't showing caffeine linked to adverse outcomes. What if there was a caffeine temperance league? Would caffeine-abstaining scientists have manipulated the data to find negative associations?
And I have found a mood-altering drug that many like and which I don't particularly care for-THC
So much energy spent on a question that only has one answer. "What is the effect of one or two drinks a day on health and lifespan?" WE DON'T KNOW. There are no decent studies. I suggest diverting your attention to a more tractable, actionable, and perhaps beneficial question: Why do you need to depend on a drink or two to put you in a happy place and enhance your overall experience of living? Is there some way you could achieve these ends on your own, without depending on an external substance? If not, I feel bad for you (and the millions of decent people like you). Tough to spend most of your waking hours burdened by a frenetic brain, to be relieved by alcohol.
Over-simplifying the facts, or overstating them, for the benefit of “messaging”…is seemingly at epidemic levels. It’s not just found in public health messaging, but also often seen in latter day scientific guideline statements (HF guidelines are the ones that have irked me the most in the last 10 years).
Evidence for “diet” in general is weak and almost always confounded due to methodological limitations. The only compelling diet evidence I’m aware of for causally improving CV outcomes is the Mediterranean diet. Insofar as alcohol goes, there is some of that in there, but even then, any support for “dosage” is indirect and hence weak.
I no longer advise pts that alcohol specifically provides any CV health benefits. But neither do I advise complete avoidance due to causal evidence of harms. I include exceptions for alcoholic cardiomyopathy and AF, just as you do, where I agree that prohibition is scientifically justified.
The standard advice is to end consumption >1-2 hours prior to bedtime. My N=1 trials tell me to stop 1.5 hours before bedtime. This is to reduce the probability of GERD and to improve sleep quality.
Sounds a bit like hegseth and kavanaugh. “ I like beer!” “I can quit anytime!” “I don’t have a problem.” Unconvinced. And know so many people who deny, hide, or justify using (“a little”) too much (“occasionally”) . But there’s no saint like a reformed sinner, me.
this is an all-too-common pathway for activist scientists... to take over a narrative, make it a cause, get the media to blast it out and condemn any anti-scientists as going against science...
The HC academic mafia is probably the worst, though the climate scientists give them a run for their money, as have almost all social studies in academia.
I hope this fever is breaking and we get back to scientific normalcy which includes more humility, less authoritarianism, more debate, and just overall sanity. Some of the stuff you see in these fields are outright deranged.
Love it. I also love a glass of wine maybe two. Thank you for your skepticism. A correction the name Murthy is changed to Murphy in a few places probably AI. The province of India Murthy comes from Alcohol is totally banned not because of religion but the poor people spend the earnings on alcohol. The negative side is moonshine has gone up & regularly scores of people die in villages. In India the politicians who ban alcohol in specific states get elected. No science behind it but populism. There is nothing in Hinduism against intoxicants except a large part of the population in India is Muslim & there religion does not approve.
This is very similar to Salt & Hypertension debate (By the way I am a Cardiologist& I do enjoy your skepticism most of the time).
No AI was used in the creation of this post. I claim complete responsibility for Murphy. I corrected it the last time but failed to correct earlier misspellings.
I appreciate your clarification of Hindu and alcohol. I had actually asked a urologist colleague who comes from a Hindu background about this and he confirmed that it was not a teaching of Hindu but was widely practiced (?like vegetarianism).
And yes, too much and too little salt, like alcohol can be harmful
Thanks for this clearly written refutation of the nonsense that's been breathlessly reported in the media recently. While my consumption of 2 glasses of wine a day is considered above moderation for a woman, I am unapologetic about our 3 oz of Cava at the end of the day, when together we reflect on our day and 6 oz of red wine with dinner. I'm not making any changes. I'm in my 70s, and I see no upside to abandoning a ritual that gives us pleasure, an opportunity to sit together in contemplation each evening and enjoy a good glass of wine with our meal. We exercise daily, cycling and walking rather than using a car (I'm guessing that's an overall reduction in risk) and eat food I prepare from real ingredients. We can afford to purchase lots of fruits and vegetables and do so, sometimes without moderation. Oh - and as a Canadian, I will live 3 years longer than an American. Thanks to your cogent post, I will enjoy my glass of wine tonight just that much more.
Another aspect of nuance in alcohol messaging is that the manner in which it is consumed (with meals, with friends, versus alone or binge) is significantly associated with health outcomes. These data are not captured by most studies. Responsible drinkers like you are lumped in with reprobates who get wildly drunk on the weekend.
Med student here... Made the point as a 2nd year student (much to some of my classmates horror) that there was no evidence that minimal amounts of alcohol in pregnancy harmed the foetus... (eg drinking at recommended nonpregnant levels of drinking) The lecturer after googling agreed with me... All evidence of harm is for high levels of alcohol use...
The other intriguing point I note is that I have a brother-in-law who's recently been diagnosed at 70+ with the post-concussion dementia syndrome CTE (I know, I thought that was a post mortem diagnosis but tell that to the geriatrician!) - interesting that his brief professional boxing career is blamed for his memory issues, the full-on alcoholism of his youth is given a free pass... presumably because his neurologist/geriatricians are true believers in CTE and sporting concussions are the activity they're keen to demonise (heaps of publicity here in Australia) - social contagion or fads or call it what you will, if they didn't have concussion in their sights I think there would be a whole heap of EtOH moralising going on... Incidentally he's the fittest healthiest guy I know, runs every day, pescatarian, teetotaler since his misspent youth... but significantly impaired by dementia.
Despite our best efforts to remain neutral, by its very nature the human mind is biased toward confirmation of its pre-existing beliefs. That's why the gold standard of medical research is a randomized, placebo-controlled, double-blinded trial (RCT), where neither subjects nor researchers know who got the placebo until the study has been completed. That's something we don't have regarding the long-term health effects of alcohol.
The next best thing to the RCT is a Mendelian randomization study, especially those employing a doubly-ranked statistical approach. To date, this is the very best study we have on the dose versus health response of drinking alcohol:
https://academic.oup.com/ije/article/53/2/dyae046/7632292?login=false
This study concluded that there is no evidence for any protective benefits from modest levels of alcohol consumption.
If I were an alcohol apologist, I'd define "modest" as being more than the amount I personally consume. I'd then point to individual differences in susceptibility to alcohol's toxic effects, rationalize its use as an anxiolytic, sedative, or social lubricant, stress the psychological benefits of social drinking, and cite how its toxicity is ameliorated by consuming it along with food.
However, as a physician I am committed to first doing no harm. Applying the precautionary principle, if I have no convincing evidence that low doses of alcohol are clearly beneficial, I cannot in good conscience recommend consuming a known poison in any amount.
and Mendelian randomization studies (which assume that certain genes determine who will drink and how much they will drink, something which is questionable) don't show increased risk of breast cancer.
I find the linear association of alcohol's impact on all-cause mortality persuasive enough. We each get to choose our own poison, but when it comes to advising our patients, that's a whole other story.
As you said, entangling the effects of low alcohol consumption is probably impossible with observational data. What baffles me is the logic behind the recent push for zero alcohol. E.g. a Lancet Public Health comment from the WHO states: „To identify a safe level of alcohol consumption, scientific evidence is required to show the absence of increased risk of illness or injury associated with alcohol consumption at and below that level.“ This seems like a remarkable shift in the burden of proof. Even if someone would conduct an RCT, proving the abscence of harm of say, 10g per day, would require something like a non-inferiority study where the upper margin is zero harm. It would essentially have to show benefit of alcohol consumption. And btw: does anyone drink for their health?
My favorite philosopher Nietzsche discusses the Apollonian and Dionysian tendencies in culture and the mind and how both need to be understood and respected. The key is context and framing of the Dionysian. Your post is consistent with that.
As a cardiologist, I’d also mention alcohol intake can have a significant negative effect on blood pressure and triglycerides. Can be relevant for some people.
I can't stop myself from referencing the last time I heard Nietsche referenced in Cunk on Life...https://www.youtube.com/shorts/u817_SoqUyw
Likely an example of Dionysian art.
Yes, definitely have to pay attention to BP and trigs.
I used to drink fairly heavily when I was younger but I was not an alcoholic. For those people I think total abstinence is appropriate. In my later years I have reduced my consumption to one light beer in the evening. I am fully aware of afib and I am now in normal sinus rhythm.
I have no serious or evident health issues except arthritis which is fairly common in my age group. I exercise frequently and so far as I know have never had any heart issues.
I’ll continue to do as before and I NEVER eat fast food. 0bviously I don’t smoke.
I am 81 and active.
Erik Rimm, my former(and admirable) biostatistics professor, has accepted financial support from the alcohol industry. Buyer beware.
Do you think this biases him?
It’s clear from the article I referenced that as part of funding a large RCT that would truly answer the questions on moderate alcohol and health he was going to accept some money from the alcohol industry but as he points out almost all drug trials are funded by pharmaceutical companies and we have found ways to make them trustworthy.
Too much of anything I guess causes harm. My N of one suggests that I could not use alcohol safely so I just don’t drink it. But I sure don’t mind if others do. I like pop tarts and I’m certain those are not good for my health. Ultimately, I just see alcohol as a mood altering drug and if I could use mood altering drugs, successfully, I would probably imbibe from time to time too. Took me 18 years to realize I can’t use them successfully. The past 25+ years have been much better for my health! But I won’t curse the drug just because of my inability to enjoy it
There is one mood-altering drug that almost everyone likes (at the right dosage) and that is caffeine. Fortunately, observational studies aren't showing caffeine linked to adverse outcomes. What if there was a caffeine temperance league? Would caffeine-abstaining scientists have manipulated the data to find negative associations?
And I have found a mood-altering drug that many like and which I don't particularly care for-THC
Absolute truth regarding caffeine! Also one could argue that food is a mood altering drug. McDonald’s sure Banks on it.
So much energy spent on a question that only has one answer. "What is the effect of one or two drinks a day on health and lifespan?" WE DON'T KNOW. There are no decent studies. I suggest diverting your attention to a more tractable, actionable, and perhaps beneficial question: Why do you need to depend on a drink or two to put you in a happy place and enhance your overall experience of living? Is there some way you could achieve these ends on your own, without depending on an external substance? If not, I feel bad for you (and the millions of decent people like you). Tough to spend most of your waking hours burdened by a frenetic brain, to be relieved by alcohol.
Thank you Dr P for a most informative report and always looking forward to your support
Excellent post.
Over-simplifying the facts, or overstating them, for the benefit of “messaging”…is seemingly at epidemic levels. It’s not just found in public health messaging, but also often seen in latter day scientific guideline statements (HF guidelines are the ones that have irked me the most in the last 10 years).
Evidence for “diet” in general is weak and almost always confounded due to methodological limitations. The only compelling diet evidence I’m aware of for causally improving CV outcomes is the Mediterranean diet. Insofar as alcohol goes, there is some of that in there, but even then, any support for “dosage” is indirect and hence weak.
I no longer advise pts that alcohol specifically provides any CV health benefits. But neither do I advise complete avoidance due to causal evidence of harms. I include exceptions for alcoholic cardiomyopathy and AF, just as you do, where I agree that prohibition is scientifically justified.
Totally agree.
great summary of current level of certainty
Thoughts on best time of day to consume alcohol to avoid sleep disturbances?
The standard advice is to end consumption >1-2 hours prior to bedtime. My N=1 trials tell me to stop 1.5 hours before bedtime. This is to reduce the probability of GERD and to improve sleep quality.
Sounds a bit like hegseth and kavanaugh. “ I like beer!” “I can quit anytime!” “I don’t have a problem.” Unconvinced. And know so many people who deny, hide, or justify using (“a little”) too much (“occasionally”) . But there’s no saint like a reformed sinner, me.
C✔️
A✔️
G?
E?
(Two is enough)
this is an all-too-common pathway for activist scientists... to take over a narrative, make it a cause, get the media to blast it out and condemn any anti-scientists as going against science...
The HC academic mafia is probably the worst, though the climate scientists give them a run for their money, as have almost all social studies in academia.
I hope this fever is breaking and we get back to scientific normalcy which includes more humility, less authoritarianism, more debate, and just overall sanity. Some of the stuff you see in these fields are outright deranged.
Love it. I also love a glass of wine maybe two. Thank you for your skepticism. A correction the name Murthy is changed to Murphy in a few places probably AI. The province of India Murthy comes from Alcohol is totally banned not because of religion but the poor people spend the earnings on alcohol. The negative side is moonshine has gone up & regularly scores of people die in villages. In India the politicians who ban alcohol in specific states get elected. No science behind it but populism. There is nothing in Hinduism against intoxicants except a large part of the population in India is Muslim & there religion does not approve.
This is very similar to Salt & Hypertension debate (By the way I am a Cardiologist& I do enjoy your skepticism most of the time).
My apologies. I should have said “Predictive text” AI was the wrong term.
No AI was used in the creation of this post. I claim complete responsibility for Murphy. I corrected it the last time but failed to correct earlier misspellings.
I appreciate your clarification of Hindu and alcohol. I had actually asked a urologist colleague who comes from a Hindu background about this and he confirmed that it was not a teaching of Hindu but was widely practiced (?like vegetarianism).
And yes, too much and too little salt, like alcohol can be harmful
Thanks for this clearly written refutation of the nonsense that's been breathlessly reported in the media recently. While my consumption of 2 glasses of wine a day is considered above moderation for a woman, I am unapologetic about our 3 oz of Cava at the end of the day, when together we reflect on our day and 6 oz of red wine with dinner. I'm not making any changes. I'm in my 70s, and I see no upside to abandoning a ritual that gives us pleasure, an opportunity to sit together in contemplation each evening and enjoy a good glass of wine with our meal. We exercise daily, cycling and walking rather than using a car (I'm guessing that's an overall reduction in risk) and eat food I prepare from real ingredients. We can afford to purchase lots of fruits and vegetables and do so, sometimes without moderation. Oh - and as a Canadian, I will live 3 years longer than an American. Thanks to your cogent post, I will enjoy my glass of wine tonight just that much more.
Another aspect of nuance in alcohol messaging is that the manner in which it is consumed (with meals, with friends, versus alone or binge) is significantly associated with health outcomes. These data are not captured by most studies. Responsible drinkers like you are lumped in with reprobates who get wildly drunk on the weekend.