UK alcohol guidance January 2016
When it comes to alcohol, it could be said that there's a definite case of Nanny State or Big Brother, following the UK Chief Medical Officer's new official guidelines on drinking. Last week the number of units that UK citizens are recommended to drink dropped from 21 to 14 units for Men and remained at 14 units for women. Yet the basis for this new prohibition on scientific grounds seems dubious at best.
Note that FermentedGrape.com has no links to the drinks industry and as a lover of wine the only vested interest is to explore the facts and communicate the truth. Wine, as an antidote to civilisation, is a pleasure that cannot be killed by public health bureaucrats.
The new guidance is the first full review of alcohol guidelines since 1995, although updated advice on drinking in pregnancy and for young people was published in 2007 and 2009, respectively. The advice is now that any amount of alcohol can increase the risk of cancer and pregnant women should not drink at all. But are the new guidelines too simplistic and based on the full range of clinical evidence?
See Alcohol Guidelines Review – Report from the Guidelines development group to the UK Chief Medical Officers.
Differences in Blood Alcohol Concentration (BAC)
Despite differences in Body Mass Index (BMI), age and the ratio of fat/muscle and hence BAC (Blood Alcohol Concentration) males and females have been given the same maximum weekly limit in the new UK alcohol guidelines.
Many experts around the world argue that applying a "one size fits all" alcohol limit is impossible as the way alcohol is metabolised varies significantly from person to person. Yet public health "experts" have attempted to apply a simplistic message to ease communication to the population.
The more your body can metabolise the alcohol, the less gets into the blood and the lower the Blood Alcohol Concentration. Those who metabolise the best are least affected and age as well as sex has a big impact. An 85kg male who drinks two glasses of wine during a meal will have a much lower BAC than a women who drinks the equivalent amount with food, almost half as much, and as well as Body Mass Index effects there are also differences in certain enzyme levels between genders.
Drinking with food dramatically lowers blood alcohol levels as there is an enzyme in your stomach called alcohol dehydrogenase which helps break it down to acetaldehyde. The enzyme is also mainly found in the liver where it works to oxidise alcohol via the portal vein. Higher concentrations of alcohol depress the gastrointestinal (GI) tract to slow absorption and also mucus secretion is increased due to alcohol's irritant effect which further reduces its impact on the body.
The metabolite of alcohol, acetaldehyde, has been blamed by some for the rise in some cancers since it can alter DNA at higher concentrations but it is normally swiftly converted to safer molecules by an enzyme called acetaldehyde dehydrogenase and there are different versions including ALDH1 and ALDH2.
Some races have faulty versions of these enzymes e.g. about half of people from Han Chinese, Taiwanese and Japanese descent. This means that they become intoxicated even after drinking very small quantities of alcohol and get "Asian Flush", a characteristic reddening of the face. Alcohol dehydrogenase levels are also lower in women than men and since alcohol is only distributed in the body in parts made of water not fat it it means that the BAC is also reduced as men have a higher water/fat ratio. As we age, levels of alcohol dehydrogenase also fall so a 65 year old will be intoxicated by alcohol by than a 21 year old.
Eating a high protein or fat meal will delay the release of alcohol from the stomach into the small intestine (where absorption is greatest). This has the effect of reducing BAC as the enzymes have a chance to break down more of the alcohol as the food/drink mixture is parked in the stomach for longer. So drinking wine with a meal or after it is the best way to keep blood steam levels low but eating after drinking has no effect as the alcohol has already reached the blood steam and therefore cannot sober you up.
Risks of alcohol consumption
The new guidelines highlight the increased risk of various cancers caused by alcohol, particularly breast cancer and bowel cancer at greater than 14 units. For example the risk of breast cancer in women is nearly 50% higher in drinkers consuming 14-35 units per week. The clinical evidence is strong that certain cancers and alcohol have a causal link. But alcohol confers significant positive benefits in reducing heart attack and stroke at moderate levels which which more than offset these negative effects in terms of total risk of dying and these were dismissed. Strange?
A counter view
The committee which developed the new guidelines seemed to be determined to focus on clinical research which supported their case but were dismissive of very large studies which showed the positive impact of moderate consumption of alcohol. The discarded data involved very large numbers grouping many individual studies. The message of the UK government is now that any level of drinking is unsafe. But having reviewed the evidence without a drink industry or public health committee agenda convinces me that this is not true.
The positive effects of alcohol were dismissed by Dame Sally Davies and the committee as they concluded that drinking only had a protective effect for a small number of sub-groups. This may be because many of the members of the expert panel had a direct financial interest in painting a negative picture as they are involved in various anti-alcohol activities funded by academic research or other grants. Great emphasis has been placed on work done by the Sheffield group's statistical analyses, but very large population based studies which paint a much more positive picture have been dismissed.
Alcohol guidelines extracts
They state that:
"Meta-analyses have identified that for some conditions, notably ischaemic heart disease (IHD), drinking alcohol at low levels may have a protective effect (compared to not drinking), particularly for all-cause mortality.
However, the group noted that: any potential protective effect seems mainly relevant to older age groups; • unresolved confounding and health selection (for instance, the health of people who can afford to drink more in older age may be better than those who do not) may explain a substantial part of the protection observed; • mortality from IHD is continuing to decrease substantially; and • the peak of any protective effect is achieved at very low levels of consumption (around one unit a day).
"The group therefore concluded that the evidence supporting protective effects today is now weaker than it was at the time of the 1995 report and that there are substantial uncertainties around direct attribution to alcohol of the level of protection still observed. Taking this into account alongside all the known acute and chronic risks to health from drinking even at low levels, supports the conclusion of the group that there is no justification for recommending drinking on health grounds, nor for starting drinking for health reasons."
"Evidence for a net protective effect of alcohol from risk of death (which has been linked to possible reduced risks of heart disease late in life) is considered less strong than it was. A reduced risk still exists, but, in the UK, it now appears to matter overall in a significant way only for women aged 55 or older.13 The 1995 report for the current guidelines found this protective effect applied at that time to men over 40 and postmenopausal women. This change in understanding is consistent with changes in the profile of heart disease in the UK and a changing population. "
"The evidence about any protective effect of drinking small amounts (1 unit or less a day) of alcohol in reducing risks of death, mainly from ischaemic vascular disease such as heart disease, has been taken account of in framing the regular drinking guideline and was part of the research used to inform that.
The expert group concluded that people who do not drink any alcohol at all should not be recommended to start drinking in the interests of their health because such advice cannot be justified for a number of reasons:
- (a) the evidence for a direct, protective, effect of alcohol on mortality is a subject of continuing scientific discussion;
- (b) methodological limitations in the evidence base mean there is uncertainty on the extent of the effect;
- (c) ischaemic vascular disease including heart disease, which is the key condition in the evidence of reduced risk, mainly affects older adults and particularly deaths in older age. Deaths from this type of disease have been falling in the UK population for some years, which means there is less risk for which low alcohol consumption might give protection;
- (d) lifestyle changes, such as stopping smoking, increasing levels of physical activity, and eating a healthy diet, can help protect against heart disease, so any potential protective effects from alcohol could be achieved in other ways, which avoid the other health risks which come with any drinking of alcohol.
After accounting for these limitations in the evidence used within the Sheffield model, the best specific evidence available on protective effects suggests that the maximum net reductions in deaths are present in those regularly drinking only 1 unit or less a day.
Previous analyses suggested the protective effect was only likely to be relevant to men from age 40 onwards and for post-menopausal women. The Sheffield report commissioned for the expert group included a UK analysis, which has found that the net protective effect that may be attributable to drinking regularly at low levels appears now to be significant only for women aged 55+ (with men aged over 55+ showing such a protective effect only of negligible size).
The Sheffield report estimates that for females aged 55 and over, the greatest risk reductions occur in those drinking approximately five units per week (mean weekly consumption). 53. The impact of any such apparent protective effect would be expected to vary, for example, with differences in the risk of heart disease in the population over time, and so this recent finding is not necessarily inconsistent with previous evidence."
Disputing the official view
Christopher Snowdon (writer and researcher at the Institute of Economic Affairs) points out on his personal blog "Velvet Glove, Iron Fist" that, "The authors used a simple statistical trick. They gathered data which clearly showed health benefits from moderate drinking and then divided it into so many subgroups that it was almost impossible for them to produce statistically significant results. By the time the authors had sliced and diced the data, the only people who appeared to benefit from drinking were post-menopausal women. I wrote about it at the time, as did David Spiegelhalter. It was absolute junk."
See the full blog post at:
The J-shaped curve
Many studies have found a J-shaped relationship between drinking and heart disease & stroke/mortality. In other words, moderate drinkers have a reduced risk of cardiovascular disease and total mortality than total abstainers from alcohol. At higher levels of drinking these positive effects disappear. There have been numerous other clinical studies which have shown positive benefits of alcohol in Alzheimer's disease, diabetes and other conditions - all dismissed as irrelevant!
In 2006 Di Castelnuovo et al used a meta analysis technique where the results of 34 studies were collated and reviewed and published in the Archives of Internal Medicine (Arch Intern Med. 2006;166(22):2437-2445). The study looked at the link between the amount of alcohol drunk and death rates in men & women in clinical trials conducted before the end of 2005 with over 1 million subjects (1 015 835 subjects and 94 533 deaths). Yes over 1 million people!
A J-shaped relationship between alcohol and total mortality was confirmed in both men and women. Consumption of alcohol, up to 4 drinks per day in men and 2 drinks per day in women, was inversely associated with total mortality or the chance of dying, maximum protection being 18% in women and 17% in men. Higher consumption of alcohol was detrimental.
The J-curved relationship between alcohol consumption and coronary heart disease is particularly strong. It was summarised in a meta-analysis of 84 studies and can be illustrated with this graph from Corrao et al. (2000).
There is a lower rate of mortality until drinkers consume 40 units of alcohol per week. Beyond this, risk increases above that of the teetotaller. A unit of alcohol is 8 grams so this works out at five standard drinks or more.
Yet this evidence is dismissed by the latest guidelines as apparently "The evidence for a direct, protective, effect of alcohol on mortality is a subject of continuing scientific discussion. The committee says that "Evidence for a net protective effect of alcohol from risk of death (which has been linked to possible reduced risks of heart disease late in life) is considered less strong than it was. A reduced risk still exists, but, in the UK, it now appears to matter overall in a significant way only for women aged 55 or older.", "Previous analyses suggested the protective effect was only likely to be relevant to men from age 40 onwards and for post-menopausal women. "
There is a very large body of evidence that J-curve is real when it comes to alcohol and this clinical data is in fact larger and more consistent than the data linking alcohol with cancer. The committee even dismiss protection for heart disease saying "Deaths from this type of disease have been falling in the UK population for some years, which means there is less risk for which low alcohol consumption might give protection.", even though Ischaemic heart disease was the leading cause of death for males in 2013, which accounted for 15.4% of male deaths. The second leading cause of death in 2013 was lung cancer (malignant neoplasm of trachea, bronchus and lung) for males and ischaemic heart disease for females.
The committee state that "Lifestyle changes, such as stopping smoking, increasing levels of physical activity, and eating a healthy diet, can help protect against heart disease, so any potential protective effects from alcohol could be achieved in other ways, which avoid the other health risks which come with any drinking of alcohol."
Christopher Snowdon points out the following, "Imagine them saying this about anything else! Imagine them saying that people don't need to bother about eating too much salt because they can always reduce the risk of having a heart attack by losing weight. In any case, it's not true. A non-smoking teetotaller is as greater risk than a non-smoking moderate drinker.
This whataboutery is a blatant attempt to downplay the significance of alcohol's protective effect on heart disease to such an extent that they are even happy to downplay the significance of heart disease as a cause of death. The lengths these people will go to is extraordinary."
Should we worried that drinking a glass of wine is going the same way as smoking a cigarette? Some commentators are now saying that the tide is turning against alcohol in public health circles with an excuse ultimately for governments to tax alcoholic drinks even more. In England and Wales, a bottle of wine is already taxed at £2 per 750ml plus 20% VAT ( tax on a packet of 20 cigarettes is £3.52 plus VAT). In Scotland, the minimum price per unit of alcohol has been set at 50p and despite resistance from the EU the public health zealots are pushing for this in the rest of the UK.
But unlike smoking tobacco which is proven without doubt to be very bad for your health, I do not agree with the conclusions of the "Report from the Guidelines development group to the UK Chief Medical Officers".
Much is made of the evidence that alcohol causes cancer, but the positive effect of alcohol on stroke and heart attack risk as well as overall mortality for moderate drinkers has been erroneously dismissed out of hand. Ishaemic heart disease is the leading cause of premature death in England and Wales (38,000 male deaths, 25 female deaths in 2013).
Dame Sally Davies has been influenced by anti-alcohol zealots and let bad science get in the way of a good story. I continue to believe that drinking 2-3 glasses of wine a day has a negligible risk compared with many everyday activities such as travelling in a car, living in a city with any pollution, not eating healthily or doing no exercise. Everything in moderation......
Further articles and blog posts to read
The Sheffield study (Mortality and morbidity risks from alcohol consumption in the UK: Analyses using the Sheffield Alcohol Policy Model (v.2.7) to inform the UK Chief Medical Officers’ review of the UK lower risk drinking guidelines).
Very good post from the blogger, the Stats Guy (Adam Jacobs, a medical statistician) called "New Alcohol Guidelines" and in it he says "Does any of this matter? After all, the guidelines are not compulsory. If my own reading of the evidence tells me I can quite safely drink 2 glasses of wine with my dinner most nights, I am completely free to do so.
Well, I think this does matter. If the government are going to publish guidelines on healthy behaviours, I think it is important that they be as accurate and evidence-based as possible. Otherwise the whole system of public health guidelines will fall into disrepute, and then it is far less likely that even sensible guidelines will be followed."
Telegraph: Don’t let the public health zealots demonise us innocent drinkers, Charles Moore.
The Guardian: The state needs to butt out of Britain’s drinking habits, Simon Jenkins.
The Mail Online: Why those killjoy new alcohol rules are just plain wrong: A devastating critique by an award-winning writer on how alcohol affects our health, Tony Edwards. Some interesting extracts from the article:
- Re. Dame Sally Davies "Her warning received huge publicity - but, having looked in detail at the research into alcohol and health, I'm afraid to say she's simply wrong. Her motivation may be admirable, but her knowledge of the scientific and medical evidence is decidedly not.
- The irony is that if people who already drink within the old guidelines do follow her advice and completely stop drinking, their risk of disease and premature death will increase. Medical studies now running into many hundreds and published in the world's top journals say that, providing you don't go overboard on the booze, drinking will help you live a longer and healthier life."
- "Yes, drinkers are at extra risk of liver disease - but the dangers are often exaggerated. For example, a recent official survey showed that, in the heavy-drinking South-East of England, only 6.7 in every 200,000 people die from alcohol-related liver diseases per year, not much more than the death rate from playing sport or doing exercise. And even that low figure is misleadingly high, with official figures for 'alcohol-related' deaths not quite what they might seem.
- In detailed email exchanges with the UK Office for National Statistics last year, they told me that under the heading of 'alcohol-related' deaths, 'we include all deaths from liver cirrhosis except for (the rare) biliary cirrhosis . . . we are aware that liver cirrhosis can also be caused by drugs, exposure to chemicals, bile duct obstruction, diabetes, malnutrition, hepatitis C, other infective agents, and several other conditions.'"
- "Another indication that the alcohol/liver problem is overblown is what happens to alcoholics. In 2003, researchers at Canada's prestigious Centre for Addiction and Mental Health surveyed the entire international evidence and found that only one in seven of the heaviest drinkers has any liver problems at all. 'Alcoholics drink an average of 160 grams of alcohol [i.e 20 units - more than half a bottle of scotch] per day,' they observed, but found only 'about 14 per cent of alcoholics will develop cirrhosis if they drink this quantity for a period of eight years'.
- But what about sensible drinkers? Take a look at Finland, the country with Europe's highest rates of liver disease. Post-mortem studies by pathologists at Helsinki University show that 'in males, daily ingestion of alcohol below 40 grams for a period of 25 years does not increase the risk of alcohol-related liver disease'. What's 40g? Five units ie. half a bottle of wine, two to three pints of beer, or four measures of spirits.
- But as you drink more, the liver does start to be affected and 'the incidence of liver cirrhosis increases significantly when daily alcohol intake exceeds 80 grams (ten units/day) - (but this occurs) in only 20 per cent of heavy consumers', the Finns reported in the journal Alcoholism: Clinical And Experimental Research."
- "Utterly surprisingly, alcohol has been found to reduce the risk of about half a dozen cancers: kidney, thyroid and many of the blood cancers. That might explain the findings of a 2013 survey of the health of nearly half a million Europeans (part of the European Prospective Investigation into Cancer and Nutrition, one of the largest-ever studies) which showed a 21 per cent reduction in men's death rates from cancer after 'life-time alcohol consumption' of up to two-and-a-half units per day."