Announcer:
0:00
Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts Hosted by cardiologist and top medical researcher, Dr. Michael Koren.
Dr. Michael Koren:
0:11
Hello, I'm Dr Michael Koren and we have a STAT episode of MedEvidence! and, as the executive editor of MedEvidence!
Dr. Michael Koren:
0:25
Every once in a while, a public health issue will come out and I want to get a quick read on it and I'm very fortunate to have a fabulous key opinion leader, Dr. Bharat Misra, joining me today, who's a gastroenterologist and a colleague in research, and we're going to comment today on the Surgeon General's recommendation that there be warning labels put on alcohol because of epidemiological data showing an increase in certain types of cancer, particularly GI cancers, related to alcohol use at any level.
Dr. Michael Koren:
0:54
The argument is that it starts at a low level of use of alcohol and increases as the amount of alcohol use is increased per patient, and Bharat and I have already had a little bit of an offline conversation about this. I come at this question as a cardiologist and a researcher and Bharat comes at it from the point of a researcher and a gastroenterologist, and we want to have a little discussion around this issue because it's created a little bit of a stir, I would say, and I'm not sure that rank and file physicians are all that comfortable saying that we should have warning labels on alcohol. So, Bharat, just quickly introduce yourself to our population, who have seen you on other podcasts, but just remind them and then we'll jump into the discussion.
Dr. Bharat Misra:
1:42
Hello Mike. It's a pleasure to join you today. My name is Bharat Misra. I'm a practicing gastroenterologist with the Borland-Grover Clinic. I also do some clinical research. We have an organization, ENCORE Borland-Grover Clinical Research, where we do phase one to phase four clinical trials. But at heart I'm a practicing gastroenterologist, so I'm very excited to join Mike and discuss this, new guidelines and alcohol in general.
Dr. Michael Koren:
2:15
Yeah Well, Bharat is a fabulous and brilliant clinical researcher, so I don't want to fool you with his modesty, so I just want to put that out there. So okay, Bharat, so let's just jump right in. So the Surgeon General, Dr. Murthy, came up with his recommendations based on years of epidemiological research, with the concern that any level of alcohol use is associated with an increase in cancers, particularly GI cancers and breast cancer, in fairness and so give us your immediate reaction to that, and then we'll dive in a little bit more.
Dr. Bharat Misra:
2:50
So this guideline came out, I believe last week, and I think it caused most people by surprise, including myself.
Dr. Bharat Misra:
3:01
I treat a fair number of patients with liver disease and pancreatic disease with alcohol and when I was in training I ran the alcohol rehab program at a hospital, so I'm really familiar with the extreme effects of alcohol. But this guideline caught us by surprise because what the Surgeon General said and there is some data to support that that even what we consider moderate intake of alcohol is associated with an increased risk of seven cancers. Most of them are upper airway and gastrointestinal. They include larynx, which is the voice box, pharynx, which is the part at the mouth right behind the tongue. It includes the esophagus. It includes the colon and rectum and, surprisingly, it also includes breast cancer. So the new guideline suggests that we should be warning our patients and the general population that what they consider as very modest social levels of alcohol is actually associated with an increased risk of seven cancers. And that is the sum of the guideline and we're going to tease it out a little bit today as we talk.
Dr. Michael Koren:
4:27
Right and historically we've been taught, as cardiologists and people who are interested in cardiac epidemiology is that moderate or less alcohol use actually has a net cardiovascular benefit. This is based on some epidemiological studies and Bharat will talk a little bit about some people who are questioning that information and I think we both agree that there's a potential trade-off between cardiovascular benefits and other problems. I think we all acknowledge that heavy alcohol use is associated with lots of problems, obviously liver disease being a huge part of what you do day-to-day and in other problems. But is there a subtlety here that we need to tease out? And is a public advisory about alcohol really in the best interest, when maybe some patients are more prone to GI cancers and others may be more prone to coronary disease? But before we get into some of those details, just define for everybody what an alcoholic beverage is, so that we're all talking about the same page, because I think part of the controversy is how you define alcohol use to begin with.
Dr. Bharat Misra:
5:43
Yeah. So for most people, one drink, you know. For men, for example, the current guidelines recommend that up to two drinks a day or 14 drinks a week is considered moderate and acceptable. For women. That's half the number. For women, that's half the number. One drink a day or seven drinks a week is considered an acceptable limit.
Dr. Bharat Misra:
6:09
The problem we run into, Mike and we were talking about this before is how we define this. This varies from country to country, place to place. For example, one glass of wine, which is considered a single drink, is only five ounces, and Mike just mentioned that his bartender at the club is usually much more generous than that. So what has crept up as to? So when we say one drink, we may be doing one and a half or two drinks, but that is what is considered normal.
Dr. Bharat Misra:
6:46
And here's the striking thing about the Surgeon General's warning we know that excessive alcohol is a definite risk factor for many cancers. The Surgeon General is saying even moderate amounts of alcohol increases your risk. And I just wanted to throw out some numbers because I have the report in front of me. So, for example, in the United States, according to the Surgeon General's report, 100,000 cancers are associated with alcohol and 20,000 cancer deaths are related to alcohol. And this is just alcohol. So, for example, if you take traffic fatalities, 14,000 traffic fatalities are associated with alcohol. So the numbers are somewhat striking to me as a practicing physician, and so this is why this guideline is very interesting and I'm glad to be discussing this. This is what most of us do. I like my Chardonnay on the weekend, and now I may be a little worried about, you know, having a couple of glasses We'll have to get you drinking some red wine.
Dr. Michael Koren:
8:01
That's right.
Dr. Bharat Misra:
8:05
So there is a lot of nuance to this and we're going to talk about it. But, in summary, the Surgeon General's report indicates that moderate amounts of alcohol is associated with seven different cancers and the surprising thing to me is the association with breast cancer. So, for example, women who drink one drink a day, their increased risk they're about 11% increased risk of breast cancer. For two drinks a day, that's like 15% increased risk. So, in fact, of all the cancers, breast cancer has the closest association to moderate alcohol intake. So women especially need to be listening to this podcast and taking it, you know, and looking at the data along with their doctors.
Dr. Michael Koren:
8:48
Yeah. So, and just to repeat what Dr. Mishra said, one alcoholic beverage is currently defined as 12 ounces of beer, 5 ounces of wine and 1.5 ounces of a spirit, and there's other alcohol that falls in the middle of those ranges. So the type of alcohol you use, of course, is important. Alcohol, remember, is actually a chemical ethanol, it's a two-carbon chemical. It has hydroxyl group on it going back to my old chemistry days and like anything, it should be considered a substance, a drug, something that may have different effects at different doses. And that's one of the important take-home lessons in medicine in general is the dose matters, the devil is in the dose. So I think that's important.
Dr. Michael Koren:
9:36
And the last fact we'll just bore you with is that one of those equivalents of an alcoholic beverage is equal to 14 grams of pure alcohol, of pure ethanol. So just get those statistics out there. So let's jump into the controversy now. So, from a cardiovascular standpoint, we believe that there are benefits to using alcohol at moderate or less levels, and some of the data that have come out have actually suggested that people live longer if they drink a little bit, compared to people who don't drink at all. And there's also this notion that maybe when some of these studies were done, that they were looking at people who were abstaining from alcohol in a different way than they should have, because some of these people who abstain from alcohol have had problems with alcohol in the past. So I know, if you want to jump into that concept a little bit in terms of how difficult it is to do epidemiological studies, given those concerns.
Dr. Bharat Misra:
10:38
Yeah, Mike makes a very good point. So my reading for this podcast showed that there are actually only two randomized prospective. That means looking at patients going forward for alcohol that are more than one year in duration, and that's the best way to get data. So most of the studies are retrospective. In other words, they call patients, they collect information from charts and then they see what kind of diseases they got. So we know that retrospective studies, that is, looking back there are so many other possible explanations that have not been included that the data is less reliable.
Dr. Bharat Misra:
11:23
Having said that, that's all we have today. In other words, the vast majority of data on alcohol is retrospective. So, for example, and then they looked at all these retrospective studies and they did put them together and analyze them together something called a meta-analysis and the largest meta-analysis included about 110 studies and that showed the same thing that even modest amounts of alcohol is associated with an increased risk of these seven and a few more cancers. And so by putting all these together, you make the study more powerful, in other words, more likely to be an approximation of truth. So the bottom line is that we don't have great studies, but what studies we do have. Confirm this association.
Dr. Michael Koren:
12:25
Right, so let's help people with the numbers a little bit, because in some sense epidemiology is a numbers game. So we know, in the United States, for example, that heart disease is the number one cause of mortality. People die of heart disease and stroke more than anything else. We know that cancer is number two. Actually, stroke is considered number four. They separate heart disease and stroke. And we know that, for example, probably between 700,000 and 800,000 Americans die of cardiovascular disease each year, and you mentioned some numbers that maybe alcohol is associated with another 100,000 deaths in the US related to cancer, if I heard your statistics correct.
Dr. Bharat Misra:
13:13
100,000 Cases and 20,000 deaths per year.
Dr. Michael Koren:
13:14
Okay, so we'll take a 20,000 death number. So just from the pure standpoint of the mathematics, if alcohol was associated with a 10% reduction in heart attacks and heart disease deaths, that would be a net positive of 70,000. And so this whole concept of trade-offs in different populations becomes really super interesting. And, to your point, we don't know these numbers exactly. It's all guesswork. And the other piece that's really difficult is to sort out what the fundamental problem is. So I read some of the studies that you mentioned brought in terms of the increased risk and it's a little bit hard to sort out the independence of alcohol versus cigarette smoking, versus depression, versus other things that are contributing factors family history, et cetera and the research just makes some effort. But we all know that when you're looking at retrospective analyses that it's a model, it's a bit of guesswork. So I don't know if you agree with that point, but I think it's an important point to help people understand.
Dr. Bharat Misra:
14:21
Yeah, I agree with it. In other words, all retrospective studies, even prospective studies, are not the whole truth. They have their limitations and you know Mike's point about the cardiovascular benefits are very, very important. So the point I would like to make there is that I have a strong family history of heart disease and I have an uncle who when I go to his house he serves like one fourth of a glass of wine every night and it's red wine typically, and nobody enjoys having dinner at his house for that reason. Well, it turns out he's right. The ideal amount of red wine that has been shown to be beneficial for heart disease is six grams, and remember, a glass of wine five ounces is about 14 grams, so it's actually less than a glass of half a glass of wine every day.
Dr. Michael Koren:
15:23
So he serves his wine like a pharmacist!
Dr. Bharat Misra:
15:29
Exactly. By the way, if you want the cardiovascular benefit, I think you should be doing it like that. In other words, once you exceed about 10 to 14 grams, then the actual benefit declines. So there is a lot of nuance in this, and I think our job is to help our listeners and for me, eventually, to help my patients do the right thing. So the picture is not as clear as we'd like it to be, but there are some concerns coming up.
Dr. Michael Koren:
16:02
What are you recommending to your patients? Have you seen patients that have brought this up to you in the past week?
Dr. Bharat Misra:
16:08
Not in the last week, but remember. I'm a gastroenterologist and the second most common cause of cirrhosis in the United States is alcohol. So I see that very common. The most common cause of damage to the pancreas is alcohol. So I see a lot of patients who are heavy users of alcohol, but I haven't brought up the risks of cancer with moderate users.
Dr. Bharat Misra:
16:37
One of the things I'm learning is that I may have to now I may have to bring this up. To me after I've spent the last three evenings for a few hours every day looking at the data, and the thing that it has done is this guideline has taken away the halo effect of alcohol.
Dr. Bharat Misra:
17:01
So, in other words, I'm still going to drink alcohol occasionally because I enjoy it, but I will not delude myself that its benefits are more than the risks, and I'll talk about it a little bit later. You know, one of the problems with being a specialist is we know more and more about less and less. So Mike is a cardiologist he happens to be my cardiologist and his points are very clear. There are clear cardiovascular benefits to alcohol. If they're real or not, we don't know, but the data points in that direction. I look at more GI cancers liver and pancreas but sometimes we have to step back and look at alcohol as a whole, and when you do that then the picture becomes, I think, a little more clearer, and I'll make that point a little later in the podcast.
Dr. Michael Koren:
17:55
Sure. So do you have any specific recommendations to patients as of now, based on what you've read?
Dr. Bharat Misra:
18:02
So again, pre-podcast this podcast and post. Probably my recommendations will be different. The first recommendation I'm going to tell patients, including my 23-year-old in college, is that if you don't drink alcohol, don't start drinking it, thinking that it may be more beneficial than harmful. I think that, including American, you know, the cardiology societies are also on board with that. In other words, the net effects of alcohol may be negative. So if you're not drinking, you don't enjoy it, don't start it.
Dr. Bharat Misra:
18:43
The second thing I'm going to recommend to my patients going forward is, I think what we call moderate alcohol has to be decreased from one a day for women and two a day for men to one a day on the weekends or two a day on the weekends, and give yourself alcohol free days. So, for example and I follow this for myself: don't drink alcohol on the weekdays. It makes the weekends more pleasurable and I think you're likely to prevent some of the downsides by doing it. So for heavy alcohol, of course, we tell patients not to do that ever, but even for moderate alcohol, I'm going to start recommending to my patients that on weekdays they abstain. Your thoughts on that, Mike?
Dr. Michael Koren:
19:38
Yeah, I think you made an interesting point that when we talk about alcohol use, we almost always talk about it in terms of weekly use, and I'm with you. I don't use alcohol every day, but I do enjoy my wine. More of a red guy than a white guy compared to you but I do enjoy my wine with dinner periodically when we go out, but I certainly don't even come close to drinking every day. And I think there's something to be said about using alcohol periodically rather than as a daily "medication or a daily stress reliever. The old concept of coming home and having your martini to relax may have some social connections with your partners and maybe a nice way of doing of separating yourself from the stresses of the workday, and I get that, but don't do it for health reasons. So I don't disagree with you on that concept, oh yeah. But I'd also say is that there's a lot of stuff that we just don't know, so we're making guesses here. We really don't know if there is a difference between taking one drink seven days a week versus taking seven drinks every other day in total. So we just don't understand enough about the doses to make strong recommendations.
Dr. Michael Koren:
20:56
But I don't disagree with the concept that you don't need to drink every day for health reasons. So I would agree with you on that. So let me answer the big question. Just jump right into it. The Surgeon General has asked Congress to put warning labels on alcohol. How do you feel about that?
Dr. Bharat Misra:
21:14
Again. If you had asked me that question last week I would have said that's overkill. But now that I'm actually looking at the data and the numbers, I am not opposed to it now. And, as you all know, our next president is a famous teetotaler. His brother died from alcoholic liver disease or he suffered a lot from alcoholism independence. So I kind of at least. So the way I would put it is how does the average Joe know about this? They don't. Most of them don't listen to our podcast. They should. They learn a lot, but they don't. So most of them are getting limited information. So I suppose it would be reasonable to put a modest warning on labels. I don't know if they make a difference, but at least you've given them a chance to know about it and then educate them a little bit that way, okay.
Dr. Michael Koren:
22:17
Yeah, I might disagree with you a little bit on that. So in the MedE vidence! world, in our educational environment, we like to talk about net health benefits and I think anybody that listens to our discussion would hopefully agree that, while there are some risks of the use of alcohol that I won't argue with, it's really hard to know whether or not there's a net health benefit. And then you know we're not even talking about some of the psychological benefits, the social benefits and the other thing. So do you really want to put a "warning label, quote unquote, on something where you don't know the net benefit? Obviously, when it comes to cigarette smoking, for example, there's no question that the net effect is negative, no one can argue with that but alcohol is just definitely much more subtle.
Dr. Michael Koren:
23:09
So I would support something that says please speak with your physician about the use of alcohol to see whether or not you're at higher risk for some of the complications associated with it.
Dr. Michael Koren:
23:21
But to put a general warning on it to me just feels wrong and it also, I think, takes away from the doctor-patient experience where individual physicians who have the best interest of their patients at heart can say hey, you know what, you're at much higher risk for a heart disease than you are for esophageal cancer or breast cancer.
Dr. Michael Koren:
23:41
So I don't really have a problem with you using 7 to 14 equivalents of alcoholic beverages over the course of a week, whether you're female or male. I'd be okay with that concept. The flip side is somebody that may have a really strong family history of esophageal cancer and other risk factors for esophageal cancer, say varicose esophagus or severe reflux etc. That person probably needs to hear. I think the alcohol is going to be the best thing for you and I think the net health benefit is probably going to be negative in your case. So I'd like more to encourage that discussion between physicians and their patients rather than some blanket statement that puts out a warning on a product that has an unclear net benefit or risk when you look at it in totality.
Dr. Bharat Misra:
24:32
Got it, I agree with that. I'd like to clarify my stance and tell you why I'm now as I said. Alcohol has lost its halo effect for me. So when you? We just talked about the increased risk of cancers, but alcohol is the second or third most common cause of liver disease in the United States. It's the most common cause of pancreatitis in the United States. It can cause kidney dysfunction. My younger brother every time he has a glass of wine he gets gout, so that forces him to be, so, "Alcohol is a risk factor for gout. It also causes bone thinning a little bit.
Dr. Bharat Misra:
25:11
But more important than that are the social effects of alcohol. So if you look at motor vehicle accidents, as I mentioned, there are 14,000 fatalities associated with alcohol, for example. If you look at domestic violence, at least half of all domestic violence includes alcohol. A quarter of all rapes include alcohol and maybe about half of all suicides are associated with alcohol. I make this point because we live in a higher socioeconomic strata and you don't see this a lot in Ponte Vedra Beach, where I live, but amongst the population that is not as wealthy, more middle class, more working class people, these effects are very prevalent and I had not thought about it until I read for this podcast.
Dr. Bharat Misra:
26:13
To me as a physician, I think the data is very strong on the social negative effects of alcohol and I think, similar to guns, we need to educate our patients and then the average public about this. Now I'm not saying we need to bring back prohibition about this. Now I'm not saying we need to bring back prohibition but what I am saying is that many patients who consume alcohol are not aware of the total picture of the damage that alcohol does to your health, to your relationships and to the society as a large. Now it has that terrific social lubricating function. It is very enjoyable, so there are benefits and I think most people are aware of the benefits. Because you have a glass of wine, you're immediately aware of the benefits of alcohol, but most people are not aware of the downsides of alcohol. So, again, we need to educate and have adults make their own decisions about what they should do.
Dr. Michael Koren:
27:40
By and large I agree education is good, but you have to be careful about associations, and that's important.
Dr. Michael Koren:
27:42
I think there's been a lot of awareness in recent years about drinking and driving, and I think we've made some progress with that. But here I'll give you an association that you probably never thought of that every major peace treaty that has been signed has been celebrated with a champagne toast. So I argue that all the great peace deals are associated with alcohol use, and so that's an association as well. So you always have to be a little bit careful about cause and effect in associations.
Dr. Bharat Misra:
28:12
Absolutely, and you're right. I think again, as physicians, we may be focusing on alcohol too narrowly, we're focusing just on the health benefits, but there are social benefits to alcohol. I'm more of an introvert, so when I have to go to the gut club or a research meeting, there is nothing like a glass of wine to make me more comfortable, and I tell you, I'd go to very few meetings if it was not for that. So I agree with you, I think the jury is still out and, as I said, each person has to make their own decision. And you know those of you who know Hegel knows that you know, everything goes in pendulums. You have an idea and then it swings to the other extreme and then it comes to the middle. There is thesis, there is antithesis and then there is synthesis. So I think with alcohol, at least recently, the pendulum is swinging in the other direction, and how far it will go we don't know. But it's an important discussion because it's an important part of our lives and we need to know these facts.
Dr. Michael Koren:
29:33
Yeah, and I like what you're saying and, again, I love the concept that people should be talking to their physicians about their individual risk and how they use it. I think that those are great conversations, but I also don't want to get into political correctness, which I think is really important. So I'm worried that somebody's going to come up with the idea that we have to change the name of happy hour to cardiovascular prevention hour or GI risk hour, and I don't think we want to go down that road. We still want to be able to function as human beings and enjoy some special times together. So, Bharat, this has been a really wonderful conversation and I want to end it with one last concept that I think you'll agree with.
Dr. Michael Koren:
30:20
You started the conversation by saying there weren't a lot of good randomized studies that look at these issues, and that's what we do every day.
Dr. Michael Koren:
30:29
You and I are part of these randomized studies and we can do these longitudinal studies in a randomized fashion. That would be much more rigorous than the epidemiological studies that we're relying on for these kind of recommendations. So, for example, what would you think about a study where we took 50,000 people who either had lower or upper endoscopy that looked basically clean and then track their alcohol use over the next five years and then determine what the risk would be of alcohol use in a group that was clearly defined as not having a cancer at some starting point, and in five years we can have a lot of information. And we could do the same thing for women and breast cancer with mammograms, or the same thing for people that had clean hard caths or something where we're starting from a baseline that's knowable and see what the risk is over time, based on more careful reporting of actual alcohol use. What would be your thoughts around something like that?
Dr. Bharat Misra:
31:32
I find that very exciting. I think that's a great idea and that's why I think you're such a good researcher.
Dr. Michael Koren:
31:38
Any final comments for the MedEvidence! audience?
Dr. Bharat Misra:
31:42
No, I think the bottom line is that, again, I've made this point many times. Even though I'm a practicing gastroenterologist, I've actually, until the last three days, I've not sat down and read about the data on alcohol, and there is a considerable amount of data. I was not aware of that, and I think it just makes you a little more cautious. That's all and that's a good thing. The knowledge should drive us in the right direction. In the right direction, and I'm hoping our listeners will now go to good websites and look at the data and make their own decisions.
Dr. Michael Koren:
32:26
I love it. Cheers to that, my friends. Thank you for participating. This is 100% water, just to make it clear. Same here, tap water, by the way, absolutely. Again, thank you for being part of the MedEvidence! family and we'll do another podcast soon.
Dr. Bharat Misra:
32:40
Thank you, Mike.
Announcer:
32:41
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