Really appreciate the review. The J-shaped response curve tells a lot. Unfortunate that some will game the statistics to create a pre-conceived outcome. Not scientific. Too many journals, too many papers, too many pages and not enough rigorous peer-review vs. 40 years ago. Observational/epidemiology studies are a mine field. Clearly these can be very useful but very susceptible to poor quality data and confounding effects.
"Guiness is Good for You" is the title of my powerpoint on this for my residents. And that was written about 5 years ago. The Academy of Medicine agrees with me in 2025. Alcohol, in moderation is helpful in preventing CAD. It's even linearly helpful but higher doses do other harm than we encourage moderation. The sweet spot is around half a drink a day but one a day is fine. Never get your information from MSM or the Wuhan Health Organization.
The idea that it improves health or specifically CVD risk is used to justify drinking...possibly more than helpful. I've always debunked this with asking if doctors are really prescribing alcohol to reduce your risk? My experience is no. Not everything we enjoy is good for us but let's not pretend it is.
2 drinks daily would make it hard to sleep unless I had them hours before bed which would interfere with getting anything else done.
I think it's worth considering how much you need it. If as you get a prescription that interferes with alcohol, my recent antibiotic perhaps, you should be able to go to zero alcohol until the issue is resolved without creating stress for yourself.
Attia recognizes the weakness of the data in this area (as he does in nutritional epidemiology) and continues to imbibe alcohol.
The Attia article you cite is about a Mendelian Randomization (MR) study with significant limitations because the connection between SNPs and alcohol consumption is not strong in European and American populations.
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.
Thanks for your comments! I see a great future for you in medicine unless your critical thinking gets you in trouble with the powers that be.
Kudos on pointing out that "no evidence that minimal amounts of alcohol in pregnancy harmed the foetus... (eg drinking at recommended nonpregnant levels of drinking) "
No reason to stigmatize those moms to be!
Perhaps it was the pescatarianism that led to the dementia of your brother-in-law? (JK)
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.
Really appreciate the review. The J-shaped response curve tells a lot. Unfortunate that some will game the statistics to create a pre-conceived outcome. Not scientific. Too many journals, too many papers, too many pages and not enough rigorous peer-review vs. 40 years ago. Observational/epidemiology studies are a mine field. Clearly these can be very useful but very susceptible to poor quality data and confounding effects.
"Guiness is Good for You" is the title of my powerpoint on this for my residents. And that was written about 5 years ago. The Academy of Medicine agrees with me in 2025. Alcohol, in moderation is helpful in preventing CAD. It's even linearly helpful but higher doses do other harm than we encourage moderation. The sweet spot is around half a drink a day but one a day is fine. Never get your information from MSM or the Wuhan Health Organization.
The idea that it improves health or specifically CVD risk is used to justify drinking...possibly more than helpful. I've always debunked this with asking if doctors are really prescribing alcohol to reduce your risk? My experience is no. Not everything we enjoy is good for us but let's not pretend it is.
2 drinks daily would make it hard to sleep unless I had them hours before bed which would interfere with getting anything else done.
I think it's worth considering how much you need it. If as you get a prescription that interferes with alcohol, my recent antibiotic perhaps, you should be able to go to zero alcohol until the issue is resolved without creating stress for yourself.
I’m a physician in allergy pulmonary and critical care( where I work now) with a MPH in epidemiology, and I would like to buy you a drink.
sorry, but for a more comprehensive discourse on the toxicity of alcohol see Huberman https://www.youtube.com/watch?v=DkS1pkKpILY.
Alcohol is a neurotoxic, liver toxic, cancer promoting substance. No amount is safe. I am a non teetotaler, but have dramtcially reduced consumption.
also see Peter Attia md https://peterattiamd.com/alchohol-intake-and-cardiovascular-disease-risk/
Huberman is not a reliable source to cite.
Attia recognizes the weakness of the data in this area (as he does in nutritional epidemiology) and continues to imbibe alcohol.
The Attia article you cite is about a Mendelian Randomization (MR) study with significant limitations because the connection between SNPs and alcohol consumption is not strong in European and American populations.
Of note, MR studies don't show any increased risk of the 7 cancers the Surgeon General said were caused by alcohol. Do you still believe alcohol is a "cancer promoting substance." https://pmc.ncbi.nlm.nih.gov/articles/PMC7377370/#:~:text=In%20a%20mendelian%20randomization%20study,genome%2Dwide%20association%20studies%20consortia.
https://xkcd.com/323/
(And plenty of commentary if you search for "Ballmer Peak")
Thank you - a very good take on this matter, and I appreciate the balance and nuance. I tend to agree with you in my personal choices, too!
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.
Heather,
Thanks for your comments! I see a great future for you in medicine unless your critical thinking gets you in trouble with the powers that be.
Kudos on pointing out that "no evidence that minimal amounts of alcohol in pregnancy harmed the foetus... (eg drinking at recommended nonpregnant levels of drinking) "
No reason to stigmatize those moms to be!
Perhaps it was the pescatarianism that led to the dementia of your brother-in-law? (JK)
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