"Do Any Benefits of Alcohol Outweigh the Risks?"
Once you remove from studies on alcohol and mortality
the systematic error of misclassifying former drinkers as if they were lifelong abstainers,
moderate alcohol consumption, like a glass of wine a day,
does not appear to be protective after all.
The immediate implication from this new research
is that clinicians need to be highly skeptical about the hypothesized
health benefits of alcohol consumption
and should not advise their patients to drink to improve their life expectancy.
This is especially important given increasing awareness of cancer risks
from even moderate alcohol use.
Given the cancer risk, if there's just harms and no benefits,
then the ideal alcohol intake on a routine day-to-day basis should really be zero,
potentially making it a red-light beverage.
The problem was that many of these population studies
classified those that quit drinking in response to ill-health as nondrinkers.
This is the problem of reverse causation:
instead of abstaining leading to poor health,
poor health may have lead to abstaining.
It's like when studies show those who sit around and watch TV have worse health.
Is more TV leading to illness,
or is illness leading to more TV on the couch?
That's one of the reasons why if you look at the hierarchy of evidence,
where higher on the pyramid means stronger evidence,
interventional trials, like randomized controlled trials,
tend to offer better evidence than observational studies of populations,
which can suffer from both reverse causation and confounding factors.
For example, light drinkers as a group may be more likely to drink their glass of wine
with a salad than a cheeseburger, and that's why the wine appeared protective.
But sometimes it's hard to do randomized controlled trials,
like you can't randomize people to smoke a pack a day for a few decades.
So sometimes you have to base your decisions on observational studies.
But now we have a new tool, Mendelian randomization.
In cases where randomized controlled trials are not feasible or practical,
this new tool can provide reliable evidence on the cause and effect relationship
between exposures and risks of disease.
It's like the HDL story.
Alcohol does raise your HDL 'good' cholesterol levels.
But unfortunately, it seems
good cholesterol isn't any good
at lowering heart disease risk after all,
based in part on Mendelian randomization studies,
where people who were randomly assigned
higher HDL levels genetically from birth don't appear to be protected.
Is there any way to study people
who are randomly assigned since conception
to not drink as much?
Remarkably, yes.
Alcohol is detoxified in the liver to carbon dioxide and water by two enzymes.
But in the process, a toxic intermediate metabolite is produced
called acetaldehyde, which can cause unpleasant nausea and flushing sensations.
So if people are born with a slow variant of this enzyme,
or a superfast variant of this enzyme, acetaldehyde can build up,
making alcohol drinking in these people a relatively unpleasant experience
throughout their lives.
So they're just born less likely to drink as much.
So do they have an increased risk of heart disease,
like the original observational studies would suggest?
No, they have reduced risk of heart disease.
This suggests that reduction of alcohol consumption,
even for light to moderate drinkers, is beneficial for cardiovascular health.
So this just sheds further doubt on the protective association
between 'moderate' alcohol consumption and heart disease,
which was already plagued with the confounding and bias.
And now the scientific pillars on which it's based appear increasingly shaky,
leading some to suggest the leaning tower of presumed health benefits
from 'moderate' alcohol use has finally collapsed.
Given the harms attributed to alcohol use,
it is not surprising that reports suggesting benefits attracted enthusiasm
among consumers, the media, and, of course, the alcohol industry,
but these apparent benefits are now evaporating.
What conclusions should we draw from this emerging evidence?
First, in health as elsewhere, if something looks too good to be true
—like butter is back—
it should be treated with great caution.
Secondly, health professionals should discourage drinking.
Thirdly, health advice should come from health authorities,
not from the alcohol industry, which should remove all misleading references
to purported health benefits, which are increasingly looking more
like a triumph of spin doctoring than good science,
as contrived as the alleged split among scientists over climate change,
advanced by the petroleum industry.
As an intoxicating, addictive, toxic, carcinogenic drug,
alcohol is not a great choice as a therapeutic agent, even if it did help.
There are better ways to prevent heart attacks,
namely diet and exercise, and drugs when necessary.
In contrast to that of alcohol,
effectiveness of lifestyle interventions has been demonstrated,
and as a bonus has no abuse potential.
There's a reason there's no Appleholics Anonymous.