Alcohol-how much should we drink?

17 Apr 2018 Lifestyle

For many years there has been this ongoing debate in society regarding the potential health detriments, along with the possible health benefits, of consuming alcohol. Much of the evidence points to a J shaped curve suggesting 1-2 standard drinks per day may even confer some health benefit, compared with those people who are teetotallers.

The argument given by those people opposed to any alcohol consumption is that often the non-drinkers in society were previous heavy drinkers or even alcoholics and the prior damage caused to their body from alcohol made the non-drinking group look sicker than they otherwise would have been because of the prior drinkers being included.

There is no dispute that consuming consistently more than 3 standard alcoholic drinks on a daily basis is associated with a number of health detriments and in particular alcohol-related liver disease, varying forms of cerebral degeneration, along with atrial fibrillation and even dilated cardiomyopathy. There is also a strong link to peripheral neuropathy and many cancers.

A recent extensive trial published in the Lancet looked at just under 600,000 people from 19 developed countries around the world with records often dating back to 1964. There were 11,000 Australians in this trial.

The key findings here related to the consumption of standard drinks over a week. So we can be clear about what is a standard drink, 375 mls of full strength beer (4.8% alcohol) is equivalent to 1.4 standard drinks. 150 mls of wine (13.5% alcohol) is equivalent to 1.5 standard drinks. 30 mls of spirits (40% alcohol) is the equivalent of 0.95 standard drinks.

The lowest death rates in the study were in people who consumed less than 10 standard drinks per week. 10–20 standard drinks per week reduced life expectancy by 6 months. Greater than 35 standard drinks per week reduced life expectancy by 4–5 years. It was found that having 14 cans of beer per week (1–2 per day, not all on the same day!) increased death risk by around 5%, whereas greater than 21 cans of beer per week (3 per day) increased death risk by 20%.

Although I believe it is highly irresponsible for any doctor to encourage people to drink, I also believe it is important to have a more global view of the science. The vast majority of studies looking at alcohol consumption come from non-Mediterranean Europe, America and Australia. The problem here is that there is no separation between alcohol consumption and, often, poor dietary habits. For example, if you examine the standard American diet and add alcohol there are certainly no benefits and now with this new information probably significant detriments. But, studies performed in the more affluent Boston area known as the Male Physicians’ trial showed that one standard glass of red wine per day reduced sudden cardiac death by 80%. Probably even more compelling is all of the data from Mediterranean countries showing the low-dose consumption of alcohol (on average 2 standard drinks typically of red wine per day) is associated with a 50% reduction in heart disease and cancer.

Data, again from Boston, this time from the Nurses’ Health study, a 30 year study from Harvard University has shown that women who consume 1-2 glasses of wine per day may increase their breast cancer risk but taking a daily Multivitamin negates this risk if the vitamin is consumed for 15 years or more.

Thus, although I am not suggesting alcohol is a health tonic, low-dose consumption may offer some health benefits only if combined with healthy eating. This new data, although compelling and should not be ignored, should be put into perspective. As with most suggestions, moderation in all things.

Obesity Paradox

3 Apr 2018 Lifestyle

A number of studies over the past decade have suggested better mortality rates in people over the age of 50 carrying a bit of extra weight. For most of us in the health industry and the general public, this appears counterintuitive.

Let’s examine some of the evidence. There have been a variety of studies, mainly meta-analyses, which have suggested an inverse link between body weight and health. 40 cohort studies of just over 250,000 participants demonstrated a 13% reduction in all cause death & a 12% reduction in cardiovascular death in overweight patients i.e. BMI between 25 to 30. There were no differences in the death rates between normal weight people (BMI 20 to 25) and Grade 1 obese people (BMI 30 to 35). In this particular study, however, once the BMI rose above 35, there was an 88% increase in death risk.

A very large meta-analysis of 2.9 million people from 97 trials showed a 6% reduction in death in overweight people when compared with normal weight and Grade 1 obesity.

The benefits are even more striking in hypertensive patients, with a reduction in death, heart attack, stroke of 23% in overweight patients and strangely a 32% reduction in those with Grade 1 obesity and a 24% reduction in those with higher grades of obesity compared with people who are normal weight.

Another study from Holland followed patients for seven years after coronary stenting and demonstrated those who had a BMI between 27.5 up to 30 had a 41% reduction in death.

The benefits of being overweight are also demonstrated for people with heart failure, peripheral arterial disease, stroke, previous history of thrombo-embolism, post coronary bypass grafting, atrial fibrillation, death rates in intensive care, general surgery, type II diabetes, chronic obstructive pulmonary disease, haemodialysis, critically ill patients and those with osteoporosis.

Doctors are always encouraging their patients to lose weight and the reality is that most people are spectacularly unsuccessful in doing so. Although it is my strong belief that it is important for us to keep our weight down to healthy levels, it certainly appears that there is a significant difference between a healthy weight before the age of 50 and over the age of 50.

As anyone over the age 50 reading this article will fully appreciate that once your hormones go south, whether you’re male or female, it is much more difficult to keep the fat down, especially off your belly. It may well be that obese patients with more severe abdominal obesity and visceral fat died earlier and therefore skewed the data compared with those with less risky lower body obesity. Interestingly, the accumulation of visceral fat is much greater in age group 35 to 45 with an average 52% increase, compared with 55 to 65 with only 7% and for those older than 65, 11%.

So, are there any adequate explanations for this so-called obesity paradox? The first and rather obvious explanation is what we call reverse causality. It is a well-established fact that the sicker patients tend to lose more weight than those who have mild disease. Thus, it is not the obesity that is protecting people rather the loss of weight occurring as a consequence of a more severe illness. Secondly, those people who are carrying less weight with established illnesses such as cardiovascular disease, cancer, osteoporosis and type II diabetes, tend to have a stronger genetic predisposition to the disease. Could it be, therefore, the more genetic an illness, the more seriously it affects the body compared with lifestyle associated disease, which tends to be associated with obesity?

Another explanation is that smokers tend to be thinner than non-smokers but also suffer more serious diseases.

In the specific case of chronic kidney disease this is a chronic inflammatory state and also associated with protein energy wasting. There is a paradoxical association between traditional risk factors & cardiovascular disease in this setting and the weight loss itself may be a marker of more severe disease.

Also, BMI is not as good a marker for abdominal fat as waist circumference and it may be that those with the higher BMI have a larger muscle mass, which is felt to be protective. Also, there is the consideration of being fat but fit which may include better cardiovascular and muscle strength.

It is my strong belief that we should all try and maintain a healthy body weight but over the age of 50, I would suggest you should be aiming for a BMI between 25 to 30 with the waist circumference around 90 to 95 for a male and 75 to 80 for a female. I advise all my patients beyond the age of 50 to focus more on healthy eating which is basically to eat less and eat more naturally, along with maintaining 3 to 5 hours of testing exercise per week which should include two thirds cardio and a third resistance training. This is much better for your health than obsessing about weight.