The Alcohol Paradox

THE ALCOHOL PARADOX

Tony Edwards

Published by Third Eye Media, UK

FISBN 978-1-907797-xx-x

Copyright © 2017 Tony Edwards

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying or otherwise without the prior permission of the author.

Library of Congress Cataloging-in-Publication Data

Edwards, Tony

The Alcohol Paradox

Includes journal references & index

1. Medicine 2. Public Health 3. Alcohol

Cover design: Robert Norman-Reade

Printed in the United States of America

For Debs,

my rock and pal through thick and thin.

Cheers, darling!

Contents

Acknowledgements

Author’s Note

The Author

Foreword by Professor Karol Sikora

Preface

Preface to this Edition

Chapter 1 Introduction

Chapter 2 The Cancer Paradox

Chapter 3 Heart Disease

Chapter 4 Diabetes

Chapter 5 The Body: Joints

Bones

Kidneys

Naughty Bits

Naughtyish Bits (men only)

Noses (and the Common Cold)

Multiple Sclerosis

Chapter 6 The Brain Paradox

Chapter 7 The Weight Paradox

Chapter 8 Beer Belly

Chapter 9 Lifespan

Chapter 10 Gender and Genes

Chapter 11 Alcoholism

Chapter 12 Wine

Chapter 13 Beer

Chapter 14 No Paradox: The Fuzzy End of the J-curve

Chapter 15 The Societal Paradox

Chapter 16 Reflections In, On and With a Glass

Appendix 1 Breast Cancer: Truths, Half-Truths and Statistics

Appendix 2 What should John Q Public be told?

Appendix 3 National Guidelines

Appendix 4 Pleasure and Pain

Appendix 5 Alcohol Antidotes

References

Index

Acknowledgements

As with most modern in-depth writing about medicine, this book would not have been possible without the generosity of 1. the US taxpayer for PubMed, the online medical database, and 2. Larry Page and Sergey Brin for Google Scholar. Vital extra research facilities came from the librarians at London’s Royal Society of Medicine who provided liberal access to the full texts of published papers. My son Joe Edwards used a tiny fraction of his BSc (Econ) skills to construct the graphs. My thanks are also due to the staff of NIAAA, and to Drs Richard Harding, Zoe Harcombe, Peter Kalivas, Tony Harrison, Kristian Rett and Tom den Heijer.

I am particularly grateful to Professor Byron Sharp of the University of South Australia for his generous and tireless support, and of course to Professor Karol Sikora for so kindly offering to write the Foreword. However, it goes without saying that I am solely responsible for the book’s contents and the views expressed.

Author’s Note

This book attempts to distil the medical evidence from many thousands of scientific studies about alcohol and health. In reporting the evidence, it occasionally draws inferences about their practical import for the individual. However, the book is essentially a reportage, and is not intended as health advice. The information and opinions provided here are believed to be accurate and sound, and are based on the best judgments of the author. However, readers should make their own enquiries and/or consult knowledgeable health professionals before acting upon anything they read in this book.

The author and the publisher cannot be held responsible nor liable for any loss or claim arising from the use, or misuse, of the information in this book.

The Author

Tony Edwards is a former BBC television producer / director / writer, specializing in science and medicine. He has made over 80 full-length documentary films, some of which have aired on PBS Nova; six of them received international awards, including the British Medical Association’s Medicine in the Media – the BMA’s top prize for medical journalism. He now writes on medicine for a variety of publications. He is married to Debbie Rix, broadcaster, communications consultant and writer (of fiction). They have two young adult children and live in rural Kent, UK.

Foreword

by Professor Karol Sikora

Consultant Oncologist

Dean of the Medical School, University of Buckingham, UK.

Alcohol kills. Alcohol ruins lives, destroys families, ends successful careers, causes untold physical and mental illness and has a huge adverse impact on society. If you have the misfortune to be in a hospital Emergency Room late on a Saturday night you will see unbelievable scenes of social degradation caused by alcohol. The cost in human, monetary and societal terms is just staggering. So why is a doctor who specialises in cancer treatment writing a Foreword for a book like this? After all, the whole healthcare system continuously bombards us with the evils of drink.

There’s a paradox lurking in this whole area, however, where a naturally occurring molecule with the formula C²H⁵OH – what chemists call ethanol and the rest of us know as alcohol – is both beneficial and harmful to health.

Science is all about evidence. Observational and experimental data are collected, assessed, dissected, re-examined and conclusions drawn in a fair and unbiased way. Often the end results do not fit our preconceived notions. That’s the excitement of science – it can change our perception of the world around us. Science has discovered that the world is not flat, matter and energy are inter-convertible, the atom can be split and cells divide by intricate chemical processes within their DNA. It’s all based on good evidence…. which sometimes can surprise us.

That’s what science writer Tony Edwards has done with the research data on alcohol. He has gathered up the evidence on alcohol’s effects on our health in one place, often unearthing some genuinely surprising findings. He’s painstakingly gone through reams of extremely dull text published in impenetrable medical journals. He’s taken the data and processed it in a very understandable way, mixed with a great, if a little quirky, sense of humour. Whether you’re teetotal, an occasional pint person or an avid wine buff, the book will be of considerable interest.

Health education systems globally tend to simplify their messages. There is no room for doubt. They have to get through clearly to as many people as possible of different educational backgrounds. Unknowns get taken over by evangelical half-truths. The complex becomes simple. Were you aware that even the safe number of units of alcohol we can drink was originally based on a back of an envelope calculation by a committee of the great and the good back in the late 1980s? Each country has its own views – and that’s precisely why there is no internationally agreed maximum safe daily intake. Bias confounds all the messages.

When I was a young house physician (the lowest rank of junior doctor) in a famous London teaching hospital as recently as the 1970s, it was standard practice to prescribe sherry, beer, and even whisky and brandy to patients as a tonic with their evening meal.* We wrote it on the prescription sheet at the end of the bed alongside the antibiotics, immuno-suppressants, heart drugs and painkillers. At first I didn’t know the dose, so I would write 15 ml sherry…until one nice elderly lady very politely told me she usually got a much larger glass. It was my first example of what would now be called ‘a fully engaged patient’ giving 360 degree feedback. However, before you book yourself into the local hospital, I am sorry to tell you that those days are long gone, because alcohol is now thought to be dangerous and even evil. But how can it be such bad thing if we were encouraged to prescribe it in hospitals not so very long ago? What we knew then – that alcohol is a double-edged sword with both good and bad effects – we appear to have forgotten.

That’s surprising, as the data gathered since the 1980s has shown increasing evidence of, if anything, the benefits of alcohol. On the other hand, what’s also now clear is the importance of what’s called the J-curve. If you don’t drink at all, you have a defined risk of developing all sorts of medical problems in your heart, joints, brain, blood sugar levels, and kidneys - indeed all round your body. As you begin to drink there seems to be evidence of benefit. As you drink more, that gradually disappears and the damaging effects kick in... and eventually go above the non-drinking baseline. This creates a health graph resembling the letter J. And most surprisingly of all, how long you will live – your longevity – follows the same J-shaped curve if you drink.

Interestingly, different sources of alcohol have different good effects. I am glad to say that there seems reasonable evidence that my own favourite tipple – red wine – seems to have a powerful beneficial effect at the sort of doses I imbibe.

Clearly much more research is needed in this fascinating area. From pharmacology to sociology there is a dearth of meaningful research. New protective mechanisms need to be discovered and new medicines developed to mimic alcohol’s beneficial effects on the body. Understanding why alcohol leads to addiction in certain people is absolutely critical to the prevention of alcoholism and the downward spiral that it can cause. But suppressing the truth about the beneficial side of the alcohol paradox is not the way forward.

Of course this book will be labelled as ‘controversial’. But its contents are based on the scientific and medical evidence from published studies. Its value is that it could lead to a much better understanding of all the complex issues involved.

So, here you have the data you need to help you make your own decision about how much, what and when to drink. Yes, alcohol kills, but it can also have a positive effect on our physical, mental and spiritual well-being. You have to come to your own conclusion. My advice is to stay as low as you can on the letter J.

Professor Karol Sikora MA, MB. BChir, PhD, FRCR, FRCP, FFPM

* Wine was also considered a ‘medicine’ by Britain’s free National Health Service. There’s a story of two British family physicians who regularly prescribed each other a case of wine every month!

Preface

Imagine this.

John Doe goes to his physician. My hands hurt, I get a bit of a pain in my chest sometimes, and I’m beginning to forget things, he complains. The doctor examines him and says: You’ve got a touch of arthritis, possibly mild heart disease, and you may be in the first stages of dementia. How much are you drinking? Never touch a drop, doc, says John proudly. Ah, that explains it, says the physician, wagging an admonishing finger. Here’s a prescription for red wine – a quarter of a liter a day. Don’t like red wine, splutters the astonished patient. White wine, Mr Doe? Don’t like wine at all doc, or really any alcohol. Pity, says the doctor. In which case, I’ll have to give you a prescription for vodka. Drink a double measure every day before or after your evening meal; take the taste away with fruit juice if you like, but make sure you drink it.

Ridiculous? Absurd? A story in the Bumper Book of Jokes for Alcoholics?

Absolutely not.

Let me tell you this: if primary care physicians fail to recommend alcohol to at least some of their patients, they should be struck off for medical negligence. That’s the startling (albeit tongue-in-cheek) conclusion from a mass of scientific research data, the salient bits of which are in this book.

On the other hand, what’s also medical negligence would be for the same physicians to be confronted by a patient with trembling hands, jaundiced eyes, white nails, high blood pressure and a fluttering heart, and not warn him to lay off the booze.

That’s the Alcohol Paradox in a nutshell. Unlike smoking, which is clearly an injurious indulgence at any intake, alcohol has contrary health effects: at very high intakes, it’s potentially as harmful as smoking, but at everyday ‘social’ intakes there’s growing evidence it’s very beneficial – indeed, far more health-promoting than the official ‘5-a day’ diet.

The problem is that there’s not much of a gap between harmful high and beneficial low doses. Apart from prescription medications, there are vanishingly few substances we ingest that are on such a health knife-edge. So while for some people alcohol is life-destroying, for most of us it is not only life-enhancing but life-extending.

Making sense of alcohol’s almost unique health paradox is what this book’s about.

But the task is not easy. Unlike most areas of medicine and health, alcohol seems to trigger an emotional response – even among ‘experts’ – which can color the interpretation of scientific data. As you will see, some medical authorities take the view that alcohol is nothing but evil, with the result that they may be disinclined to look dispassionately at any health evidence that suggests otherwise. On the other hand, drinkers and the drinks industry may be tempted to downplay alcohol’s risks and talk up its benefits.*

So it’s a complex picture, brimming with counter-intuitive and paradoxical data. But to show only the downsides of alcohol, as the medical authorities overwhelmingly do, is not good medicine because it infantilizes the general public and prevents them making informed decisions about how much and what to drink for optimum health.

This book may help.

It’s been written as a kind of medical reference book for the layman – and perhaps even for physicians. So you’ll find no colorful stories about dysfunctional drunken families, beaming German brewmasters or the personal lives of the world’s top alcohol experts – just their scientific research. In fact, it’s a bit of a slog through a litany of medical studies*, leavened by occasional light-hearted asides, personal anecdotes and common-sense comments.

In summary, this book is what its title implies: a sober synthesis of the medical evidence that alcohol is both good and bad for your health.

Tony Edwards, November 2017

* The alcohol industry never does so in practice, however, because both self-censorship and the law forbid it. For example, in Europe advertising which claims that alcohol has therapeutic qualities is forbidden.

* Although the book refers to data derived from animals, this does not imply endorsement of such research methods – in this field particularly.

Preface to this edition

This is a fully revised and updated version of The Good News About Booze, originally published in Europe in 2013. Its less frivolous new title more appropriately reflects its purpose: to provide a fully referenced review of the medical data about the pros and cons of alcohol’s health effects. The word Paradox in the title is key: while it is a truism that some people’s lives and health are destroyed by alcohol, it is equally clear that alcohol can offer lifelong health benefits to sensible drinkers. The surprise is that the medical evidence for both of these effects is equally strong – although you’d be forgiven for being skeptical about that statement, given what you hear from the medical authorities.

In fact, one of the common reactions to the original version of this book, whose title emphasized alcohol’s health benefits, was straight disbelief. Despite the fact that almost every statement in the book was backed up by references to published research papers, some readers – even those with a science background – found the book’s overall message difficult to accept. You must have cherry-picked the data, I was told.

That’s an understandable criticism. After all, no book for the layman can reference every single piece of research on a particular topic, so the author has to make a selection. That’s where potential bias can creep in. But that problem isn’t only confined to health writers such as myself.

Doctors and medical researchers are also prone to cherry-pick data, particularly in contentious areas where opinions are divided and individual stances hotly defended. Alcohol is a classic instance. For example, many of the supposedly objective ‘reviews’ of the health evidence about alcohol routinely ignore studies whose findings conflict with the reviewers’ opinions. That’s why I have generally avoided citing such papers. Almost all the evidence in this book comes from individual studies and non-selective meta-analyses. I have also rejected studies funded by the pharmaceutical and alcohol industries (of which there are in practice very few).

My first book received other criticisms. A bizarre one was that drawing attention to alcohol’s health benefits was an insult to alcoholics, for whom booze is a curse. But that’s rather like saying: no book should be written about the pleasures of swimming because some people drown.

A more common criticism was that I am neither a doctor nor have a biomedical qualification, so how can I be trusted to report on the evidence? Two answers. First, the studies I cite come from highly reputable research institutions and some of the world’s leading academics, and I often quote their conclusions verbatim. Second, one doesn’t need a medical education to assess medical research – indeed, paradoxically it could be a handicap. How come? Because the process of becoming a doctor and obtaining a medical degree requires a conformist attitude and blind acceptance of the dictats of authority figures – fertile ground for biased opinions. By contrast, a journalist’s training is to be independent-minded, seeking objective evidence from impartial sources, and having a healthy skepticism for received opinions.

So it’s no accident that many of the recent revolutions in health thinking have been spearheaded not by medics but by ‘mere’ medical journalists: Nina Heicholz and Gary Taubes* are shining examples. Both drew attention to semi-suppressed medical evidence challenging prevailing medical dogmas.

It would be an honor if the readers of this book were to put me in the same category as those two luminaries.

* Respectively, the authors of The Big Fat Surprise and Good Calories, Bad Calories (and many others)

1

Introduction

Doctors used to berate us about smoking, but now that we’ve all got the health message about tobacco, it’s alcohol that’s been put in the naughty corner. And doctors can get quite moralistic about it. A few decades ago, Britain’s eminent Royal College of Physicians produced a report on alcohol with the bizarre title: Alcohol – a great and growing Evil.¹ Why bizarre? Is evil really a medical adjective? A great and growing problem maybe, but only the religious professions are licensed to talk of evil, surely – not medics.

The last time ‘evil’ was officially used in the alcohol context was during the failed Temperance and Prohibition movements of the 19th and 20th centuries, so it’s a word the US authorities are loath to utter in these more enlightened times.

Nevertheless, the language currently used by US medics still echoes the militancy of Prohibition. For example, here’s the American Medical Association’s current take on alcohol:

The alcohol industry is a complex, international industry with great economic and political power, and impacts at all levels of society and around the globe…. [it] has ample political muscle and can be a formidable foe…. victories can be won when a broad coalition of grassroots community people speak up.²

Just like the prohibitionists of the past, the AMA seems to think that alcohol and the people who produce it are foes – an enemy to be defeated, with the goal of ultimate victory against them.

But what’s so wrong with doctors using the warfare metaphor? After all, alcohol is really bad for our health – or so we’re led to believe. For example, here’s what the World Health Organization says about alcohol’s devastating effects across the Americas, North and South (my italics):

Alcohol [is] the most important risk to health in low and middle income countries (including Brazil, Mexico and most Latin American countries) and the second [most important] in developed countries, such as the USA and Canada.³,*

The WHO’s message is the same in Europe, where the French are told that:

L’alcool (est un) problème majeur de santé publique.

which almost exactly translates into:

Drinking too much is a major public health issue

a claim made by Britain’s socialized health system, the NHS.

How much is too much?

Perhaps surprisingly, it wasn’t until as late as 1987 that medics decided they ought to figure out how dangerous drinking actually was. It was the Brits who paved the way with a report from its Royal College of Physicians, which set up a committee of experts chaired by the then Editor of the British Medical Journal, Dr Richard Smith, in order to recommend maximum drinking limits.

However, the whole exercise was somewhat haphazard, as Dr Smith admitted 25 years later I remember the debate when the epidemiologist said it was impossible to set limits because the evidence was poor…. But we agreed that it was better to offer some advice rather than none, and that it needed to be simple.⁴

The figures they arrived at were 21 units a week for men and 14 for women, with one unit being 8 grams of alcohol – roughly equal to a measure of liquor, half a pint of beer or a tenth of a bottle of wine. Interviewed about five years later, Dr Smith confessed that the figures were plucked out of the air. They were not based on any firm evidence at all. It was a sort of intelligent guess by a committee.⁵

Dr Smith is aware his frankness hasn’t exactly endeared him to his fellow medics, but he was right. The limits were indeed pretty arbitrary, and based on precious little scientific evidence.

An indication of just how plucked out of the air the world’s first official alcohol guidelines really were comes from the fact that when other countries’ health authorities followed Britain’s lead, most of them disagreed on the maximum safe limit. While the UK decreed men’s daily limit to be 32 grams of alcohol, Italy stipulated 40 grams, Canada and Portugal 37 grams, New Zealand 30 grams, and Sweden and Australia 20.⁶

More absurdly, the same country’s medical authorities disagreed with each other. Predictably, in France there were vehement arguments between their bureaucracies, but even in the USA there was conflict. NIH originally claimed the safe male maximum was 56 grams a day, while the DHHS insisted it was 28 grams.

Latterly, international guidelines have become more convergent, but there are still some significant disparities: Britain’s male limit is currently 16 grams a day, Australia’s is 20, while it’s 28 in the USA and Canada.

A further complication is that countries’ official bodies don’t use understandable measures like ounces or grams of alcohol, but what they call ‘units’, ‘drinks’ or ‘servings’. That might be OK if everyone agreed on what these terms actually mean. But they can’t. For example, while in the USA one ‘unit’ contains 14 grams of alcohol, in the UK a unit is 8 grams, in Denmark 12, and in Japan 19.5. Helpfully, there is an ‘international unit’ which is 10 grams, but unhelpfully many countries ignore it.

There’s a body called ICAP (International Center for Alcohol Policies) which sounds as though it ought to oversee international alcohol standards, but it’s in fact toothless. All it can do is bleat about the current shambles:

The way in which the concept of a standard drink is currently implemented within an international setting is less than optimal. The manner in which standard drinks are applied can be confusing. International comparisons are made difficult by a wide range of definitions. This disparity is often not taken into consideration when information on drinking guidelines from different countries, often given in terms of standard drinks or units, is interpreted and compared.⁷

ICAP wrote that in 1998, but since then nothing’s happened. Alcohol units and guidelines are still as disparate and confusing as ever.

One consequence of this ‘drinks/units’ muddle is that it can be difficult for medical researchers to compare data across national boundaries – a problem which it’s been suggested accounts for some of the discrepancies in the research findings. It also makes it a pain for science writers such as myself, because many researchers report their findings only in terms of units or ‘drinks’, rather than grams of alcohol.

So, when assessing and reporting the medical findings in this book, I have followed the procedure used by all the professional research analysts: to convert the ‘drink/units’ measures into grams according to the national figures of the particular research team.

Inside the back cover, you’ll find two ways of showing the gram quantities of alcohol in standard drinks, so you can refer to them as you read.

Now, let’s take a long look at the evidence.

* These statements are questionable, however. According to the WHO itself, the Number 1 killer in the world is not alcohol but heart disease [WHO Fact sheet N°310; July 2013] . Ironically, the medical evidence says alcohol may actually prevent heart disease (see Chapter 3 )

2

The Cancer Paradox

Cancer, the most feared of diseases, whose incidence is rising inexorably. The first inklings that alcohol might be partly to blame came in the 1970s, when doctors began to notice a worrying trend of mouth, throat and gullet cancers occurring among drinkers – particularly drinkers who also smoked.

Since then, more cancers have been added to that trio, but none are quite as clear-cut as the original three. Indeed the whole cancer/alcohol connection is actually rather opaque – not least because there is surprising evidence that alcohol may actually prevent some cancers.

So that’s Paradox No.1: alcohol appears both to cause and prevent cancer.

Read on.

The Bad News

By 2007, researchers had done more than 500 clinical studies on the connection between alcohol and cancers of all types, and that year the World Cancer Research Fund and the American Institute for Cancer Research collaborated in a joint project they claimed to be the most comprehensive report ever produced on the links between lifestyle and cancer risk. It was a massive undertaking, in which over 200 researchers round the world ploughed their way through billions of bits of data. At the time of writing, that WRCF/AICR Report remains the supreme source of data on alcohol and cancer.⁸

Its overall message is unequivocal, stark and scary: From the point of view of cancer prevention, the best level of alcohol consumption is zero, the Report concludes. However, if you examine its fine print, a much more nuanced picture emerges.

Mouth, Throat and Gullet Cancers

Of all the cancers, these are far and away the most obviously caused by alcohol. That’s hardly surprising, as they’re the parts of the body booze hits first. You may remember the almost unrecognizable pictures of Anglo-American journalist Christopher Hitchens as he underwent chemotherapy – ultimately futilely – for esophageal (gullet) cancer in 2011. He had been a heavy drinker and smoker.

However, although the cancer evidence is strong, it’s not nearly as clear-cut as that linking smoking and lung cancer, for example, as there’s quite a lot of inconsistency between the various studies. But what’s impressive is that there’s a fairly consistent dose-response effect. Also, of all the claimed alcohol-related cancers, these three seem to have the most likely cause: localized damage to the tissues – possibly to do with DNA (see later in this chapter).

However, the WCRF Report says that the actual risk of these cancers is not huge. Averaging out the data, the Report says that if you imbibe 3 US ‘drinks’ per day (42 grams of alcohol) you’ll only double the risk – pretty insignificant, especially as the diseases themselves are so rare. However, a more recent survey of the evidence has found that, although the risks are small for moderate alcohol consumption, people who drink 100 grams a day have four times the cancer risk.⁹ A very detailed US study found that the risk is highest in liquor drinkers, although the killer factor is the combination with tobacco. For example, although wine drinkers may have a modestly reduced cancer risk, if they also smoke (or even are ex-smokers) the cancer risk can zoom up 7-fold.¹⁰

However, buried in the data is an apparent paradox. Two separate research teams in the USA and Australia have investigated a condition called Barrett’s Esophagus, and found that both wine and beer drinkers have less risk of the disease than non-drinkers.¹¹,¹² Why is this so paradoxical? Because Barrett’s Esophagus is the main precursor of esophageal cancer, of which alcohol is a major cause.

So, how can drinking both prevent and cause the same condition?

The answer is that there are two types of esophageal cancer: the ‘squamous cell cancer’ type which is clearly caused by alcohol¹³, and the ‘adenocarcinoma’ type which equally clearly isn’t¹⁴….and that’s the one which is becoming a growing problem, possibly because of increasing obesity.¹⁵

Bowel Cancer

This cancer of the colon and rectum (hence, ‘colorectal’ in medical jargon) is the third most common cancer, accounting for about 10% of all cancers worldwide, and whose incidence has been rising dramatically especially in the last 50 years¹⁶

What does the WCRF Report say about alcohol’s role in all this?

The evidence that consumption of more than 30 g/day of ethanol from alcoholic drinks is a cause of colorectal cancer in men is convincing, and probably also in women.

In plain language: men can drink up to 30 grams of alcohol* (i.e. about a third of a bottle of wine, or 1½ pints of beer) a day with no risk of bowel cancer; however, it’s less clear that women are affected, even