To Drink or Not to Drink

Most people drink for reasons other than alcohol’s health benefits, and many of them are already using alcohol in amounts that appear to promote cardiovascular health. But the accumulated research on alcohol’s positive effects presents a challenge to physicians. On the one hand, mild to moderate drinking seems better for heart health than abstinence for select people. On the other hand, heavy drinking is clearly dangerous. It can contribute to noncardiovascular conditions such as liver cirrhosis, pancreatitis, certain cancers and degenerative neurological disorders, and it plays a part in great numbers of accidents, homicides and suicides, as well as in fetal alcohol syndrome. (No conclusive evidence links light to moderate drinking to any of these problems.)

Heavy drinking also contributes to cardiovascular disorders. Too much alcohol raises the risk of alcoholic cardiomyopathy, in which the heart muscle becomes too weak to pump efficiently; high blood pressure (itself a risk factor for CHD, stroke, heart failure and kidney failure); and hemorrhagic stroke, in which blood vessels rupture in or on the surface of the brain. Alcohol overindulgence is also related to “holiday heart syndrome,” an electrical signal disturbance that disrupts the heart rhythm. The name refers to its increased frequency around particular holidays during which people engage in binge drinking.

Given the potential dangers of alcohol, how can individuals and their physicians make the decision as to whether to include alcoholic beverages in their lives and, if so, in what amounts? The ability to predict accurately an individual’s risk of a drinking problem would be a great boon; the least disputed possible consequence of moderate drinking is problem drinking. Individual risk can be approximated using family and personal histories of alcohol-related problems or conditions, such as liver disease or, of course, alcoholism. Even when known factors are taken into account, however, unpredictable events late in life may result in deleterious drinking changes.

Exactly because of these dangers, public health concerns about alcohol until recently have been appropriately focused solely on the reduction of the terrible social and medical consequences of heavy drinking. And the correlation between total alcohol consumption in society and alcohol-related problems has been used to justify pushes for abstinence. Ultimately, however, a more complex message is necessary. Merely recommending abstinence is inappropriate health advice to people such as established light drinkers at high risk of CHD and at low risk of alcohol-related problems—which describes a large proportion of the population. Of course, the most important steps for this group are proper diet and exercise; effective treatment of obesity, diabetes, high blood pressure and high cholesterol; and avoidance of tobacco. But there is a place on that list of beneficial activities for light drinking. Most light to moderate drinkers are already imbibing the optimal amount of alcohol for cardiovascular benefit, and they should continue doing what they are doing.

Abstainers should never be indiscriminately advised to drink for health; most have excellent reasons for not drinking. Yet there are exceptions. One case is the person with CHD who “goes clean”—quits smoking, switches to a spartan diet, starts exercising and, with good intentions, gives up the habit of a nightly bottle of beer or glass of wine. This self-imposed prohibition should be repealed. In addition, a number of infrequent drinkers might think about increasing their alcohol intake to one standard drink daily, especially men older than 40 and women older than 50 at high risk of CHD and low risk of alcohol-related problems.

But women also have to consider one possible drawback of alcohol: several studies link heavy drinking—and a few even link light drinking—to an increased risk of breast cancer, a less common condition than heart disease in postmenopausal women but certainly quite a serious one. For young women, who are generally at low short-term risk of CHD and therefore may not benefit greatly from alcohol’s positive cardiovascular effects, this possible breast cancer link looms larger in estimating the overall risks and benefits of alcohol. And for all women, the upper limit on moderate drinking should be considered one drink a day.

The only clear-cut message regarding alcohol and health, then, is that all heavy drinkers should reduce or abstain, as should anyone with a special risk related to alcohol, such as a family or personal history of alcoholism or preexisting liver disease. Beyond that, however, the potential risks and benefits of alcohol are best evaluated on a case-by-case basis. I believe that it is possible to define a clear, safe limit for alcohol consumption that would offer a probable benefit to a select segment of the population. The ancient Greeks urged “moderation in all things.” Three decades of research shows that this adage is particularly appropriate when it comes to alcohol. (Feature article, abridged. From Scientific American, February, 2003)

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