Alcohol

Prof Mike Kirby Centre for Research in Primary &

Community Care University of Hertfordshire

Confused about alcohol?

• In 1992, the Lancet published a paper that showed moderate alcohol consumption resulted in a 40% reduction in heart attacks

• In 2001, The AHA came out with the slogan ‘A drink a day takes some arterial stiffness away’

McCrea W. Telegraph (online). 27th June 2014. Lancet. 1992 Jun 20;339(8808):1523-6. Wine, alcohol, platelets, and the French paradox for coronary heart disease. Renaud S1, de Lorgeril M.

Unit = 10ml or 8g absolute alcohol • Present in - ½ pt ordinary beer - 1 glass average strength wine

- 1 glass sherry - 1 single measure spirit

Can of premium/super strong beer – 3.5/5 units Designer drinks, eg, Alcopops – 2 units Fruit flavoured spirits, eg, Bacardi Breezers – 1.5 units Fortified wines – 4/7 units

Alcohol The good the bad & the ugly!!

• Did you know a standard glass of wine can contain as many calories as a piece of chocolate, and a pint

of lager has about the same calorie count as a packet of crisps?

• The average wine drinker in England takes in around

2,000kcal from alcohol every month.

• Drinking five pints of lager a week adds up to 44,200kcal over a year, equivalent to eating 221 doughnuts.

• Many drinkers add to their calorie count by having snacks, such as crisps, nuts or pork scratchings, to accompany their tipple.

Alcohol - related physical harm • GETTING DRUNK

Death from arrhythmia, respiratory depression, inhalation of vomit

• CHRONIC ABUSE Accidents, suicides, criminal

behaviour, marriage, work problems Organ damage:– liver, pancreas, CVS

(hypertension, cardiomyopathy), CNS (dementia, neuropathy), bones, cancers, foetal damage

Data WHO HFA, re-analysed N Sheron 2009

Alcohol induced liver damage

Hepatic inflammation → acute liver failure

Compensated or decompensated with portal hypertension/jaundice encephalopathy/ascites

Common, usually asymptomatic

Fatty Liver

Alcoholic Hepatitis

Cirrhosis

Hepatocellular Ca.

100%

10-35%

15%

2% annually

Liver failure from acute alcoholic hepatitis

Male 21 yrs, drinking since 13, 60 u/day 21st MAY ‘09 local hospital after 2 wks illness Treated nutritional support, Terlipressin & albumin, antibiotics, in

trial of steroids 11th JUNE ‘09 UCLH, TJ biopsy confirmed AAH with cirrhosis

ITU care 17th JULY ’09 - Stable: Encephalopathy Grade I – II, Bil 400

Referred to UK LT Advisory Group

(Courtesy of The Times Newspapers Ltd)

Excess weight risk factor for Alcoholic Liver Disease

1604 alcoholic patients

(Naveau S, et al. Hepatology 1997; 1: 108-111)

402 Steatosis

281 Fibrosis

with/ without

steatosis

119 Acute

alcoholic hepatitis

232 Cirrhosis without

AAH

179 Cirrhosis and AAH

Excess weight risk factor for Alcoholic Liver Disease

Cirrhosis Alc. Hep Steatosis

Age

Being overweight > 10 yrs

Female sex

Total duration alcohol use

= independent positive risk factor (Naveau S, et al. Hepatology 1997; 1: 108-111)

(Stickel F, et al. Gut. 2012; 61(1): 150-9)

Genetic determents of liver disease

Variants (polymorphisms) in 1. Neurotransmitter genes eg, GABA 2. Alcohol metabolism genes eg,

ADH & ALDH, GST’s 3. The PNPLA3 adiponutrin gene rs738409

(Stickel F, et al. Gut. 2012; 61(1): 150-9)

Increased preference for alcohol & dependency

Increased risk of liver damage & progression to cirrhosis

Association of water softness & heavy alcohol

consumption with higher hospital admission rates

KNOWN: Marked regional variations of ALD admissions in

England -13% to +32.7% of mean

STUDY FINDINGS: Annual rates per 100,000 population in

28 SHA’s (2003 – 2006) significantly higher in soft water

areas; associated also with levels of alcohol consumption

HYPOTHESIS: Low Mg. conc. in soft water an additional

factor to alcohol consumption in liver damage

Avoiding liver damage from alcohol – take home messages

Know what you are drinking in units & test yourself by keeping an honest weekly diary

Make sure other risk factors, particularly obesity are not creeping up on you

Take serious notice of abnormal liver blood tests, fibroScan readings, etc

Burden of disease attributable to 20 leading risk factors for both sexes in 2010, expressed as a

percentage of UK disability-adjusted life-years

]

18 PCCS NHS Health Check 9.11.13

*

Hypertension

Psychological Factors

INTERHEART: abdominal obesity more than doubles the risk of AMI

16.0 8.0 4.0 2.0 1.0 0.5 0,25

Smoking

Diabetes

Visceral obesity

Fruits / vegetables

Physical exercise

Alcohol

ApoB/APoA1

F M F M F M F M F M F M F M F M F M

Yusuf et al,The Lancet, 2004; 364: 937-52

No. The new recommendations are at pains to point out that these guidelines are not for "safe" drinking, but rather just at minimising risk of illness. All alcohol consumption carries some risk, the guidance says. "The vast majority of the population can reduce health risks further if they reduce drinking below the guideline levels, or do not drink at all," Drinking above the new recommended 14 units a week is the point at which a person's risk of an early death increases by 1% - the equivalent amount of risk as driving a car.

Is there a safe drinking level?

It's an issue which has caused great debate. But the new guidelines for pregnant women have now been updated in England, Wales and Northern Ireland to be clear that no level of alcohol is safe to drink in pregnancy. Previously it was recommended that for women who had opted to drink, consuming no more than one or two units of alcohol - equivalent to one or two small glasses of wine - would "minimise the risk to your baby". The new guidance says that for women who do drink that amount the risk to their baby is likely to be low, but "nevertheless, we cannot rule out the risks altogether".

What about drinking while pregnant?

The new recommendations appear to be moving away from this long-held belief. The review found that the benefits of alcohol for heart health only apply for women aged 55 and over - and even then it's in very small amounts, around five units a week. The guidelines say: "There is no justification for recommending drinking on health grounds - nor for starting drinking for health reasons.“ It also says that evidence in support for drinking alcohol in small amounts to maintain good health was "weaker than it was at the time of 1995".

I thought a small amount of alcohol was good for you?

Why may it be beneficial?

• May be due to the antioxidants (e.g. flaavonoids or resveratrol) & polyphenols found in the skin of the red grape – particularly when grown at high altitudes

• These substances have been found to prevent damage to the inside of blood vessels and inhibit blood clotting

- but this only applies to moderate intake (<125mls/2 small glasses/day) McCrea W. Telegraph (online). 27th June 2014.

Which wine is best for preventing clots?

• Chilean Cabernet Sauvignon (grown at high altitude) shown to contain highest levels of antioxidants (Glasgow University 1993)

• Other beneficial wines include those made with the Pinot Noir & Petite Syrah (Shiraz) grapes

• Italian wines have medium levels of antioxidants • Red Zinfandel from California has some of the

lowest levels

McCrea W. Telegraph (online). 27th June 2014.

The new changes affect men more than women. Previously, women were advised to drink no more than 2-3 units a day and men no more than 3-4. This technically meant men could consume around 28 units a week, although the Royal College of Physicians (RCP) recommended no more than 21 units should be drunk over seven days. The old guidance said that by sticking within recommended limits, there was "only a low risk of causing harm in most circumstances". However, the new rules now state that both men and women should drink no more than 14 units over the course of three days or more. This is the equivalent of a bottle and a half of wine over the course of a week. The rules also say that it's best not to "save up units" and drink them all in one go and to make sure you have alcohol-free days.

Summary

Heavy vs moderate drinking • In 2001, a study compared drinkers in Northern

Ireland (mainly weekend binge-drinking) with those in France (regular smaller daily quantities)

• Found adverse effects on BP in the Irish drinkers vs no fluctuations in BP in the French drinkers

• Concluded that fluctuations in BP levels due to the binge-drinking pattern may also partly explain the higher incidence of MI on Mondays in countries characterised by a high alcohol intake on weekends

Marques-Vidal P et al. Hypertension. 2001 Dec 1;38(6):1361-6.

“These guidelines define ‘low-risk’ drinking as giving you less than a 1% chance of dying from an alcohol-related condition. So should we feel OK

about risks of this level? “An hour of TV watching a day, or a bacon sandwich a couple of times a week, is more dangerous to your long-term health. In contrast, an average driver faces much less than this lifetime risk from a car accident.

It all seems to come down to what pleasure you get from moderate drinking.”

The alcohol industry lobby group cautioned that the UK was “breaking with established international precedent by recommending the same guidelines for men and women”. The rationale for having a lower limit for women than men has been based on women weighing less than men on average and having less water in their bodies, pound for pound. The latest Health Survey for England says that 85% of women and 68% of men drank 14 units or fewer a week in 2014, including those who did not drink at all. By comparison, 78% of men drank 21 units a week or fewer.

PLACEBO

• Portion control • Lose the booze • Axe the snacks • Cut the carbs • Exercise regularly • Bottle of Cabernet Sauvignon from Chile