A perspective on liquor

“I drink just the same amount of alcohol as the average Canadian,” he said in the telephone interview. I stopped my line of questioning, and thought for a moment. “And how much is that?” I asked, genuinely unsure of what the true answer would be these days. “Five or six beers a day.” I told him that someone of his weight, with hypertension and five drugs, including Xarelto, should be drinking considerably less, if at all. “Oh, no, all my friends drink that much.” I suggested that his friends were just trying to keep up with his excesses. Read: When listening to your patient pays off The next 10 minutes were used up listing the toxic effects of alcohol, its effect on drug metabolism, and its propensity to cause abdominal obesity. He wasn’t interested in getting to a root cause of metabolic disarray or avoiding the pickling effects. Effects that cause cirrhosis, pancreatitis, alcoholic cardiomyopathy, hypertension, glucose dysregulation and obesity. Two weeks later, Abraham Scott comes through the door. I had seen him two years ago, and given him a similar exhortation to cut back on the demon drink. So, I was ready to jump when he answered the question, “Hey, how much are you drinking these days?” Abraham is a well-rounded seaman, 84-years-old, and not long retired. His BP at home is 144/95 and his A1c is 8.4. He has had a coronary stent seven years ago, as well as an aortic valve replacement. Needless to say, he is on medication—his favourite now being Ozempic. Weight loss needs to be a long-term project. His reply—“two rums a day”—came with the assumption that most alcoholics usually report half their actual intake. I was starting in on his alcohol excess when I remembered he was (a) 84 and (b) a mariner. Who was I to say this single chap couldn’t enjoy his liquor? He could drop down dead tomorrow. Read: Blood pressure: an important target I explained my thoughts on liquor, the new salve for COVID times. An anxiolytic that doesn’t begin with the letter A. “So,” I said, “one rum a day, unless you are celebrating something.” I went over his labs, and found his GGT was mildly elevated. His EKG showed LVH. I suggested his aspiration to reach age 95 might be optimistic. Usually I tell patients about the myths surrounding booze: ‘Alcohol is a tonic’ (no, it is a fixative, like formalin, but different). ‘Alcohol is nutrition’ (maybe, as it is broken down to sugar and water. Of course sugar is full of calories). ‘Binge drinking is OK, my friends encourage me’ (well, if you have very active alcohol dehydrogenase, it will try to keep up. If not, it just pickles you). ‘Red wine is good for you’ (wine might contain antioxidants and procyanidins, but who needs liver cirrhosis and cancer added in? Sure, it causes vasodilatation and maybe hypotension in the short-term, but causes hypertension, cardiomyopathy, stroke and arrhythmia long-term). ‘In these stressful times, I need a sedative’ (agreed, but a toxic one?). I used to accept 14 units a week for men, nine for women (women have a lighter build and are more susceptible to adverse effects). The new guidelines from the Canadian Centre on Substance Use and Addiction—that there is no amount of alcohol that is safe, and low risk is two drinks per week (2)—have garnered a lot of interest. Now that we know the cancer risks of alcohol intake (3) we need to educate the public. What’s my interest in alcohol? My father was a whiskey distillery manager (Bowmore, Islay), so I guess I was baptised with the stuff. Although he had unlimited access, he never drank whiskey. As a blender, he sniffed whiskey, but if he sipped it, it was soon to be ceremoniously spat out. From my reading, the history of brewing goes back a long way. Residue found in Haifa, Israel (13,000 years ago) and traces of beer in jars from Jiahu, China (7,000 years ago) suggest it is a long-established tradition. Ziggurat builders in Mesopotamia were paid in ‘bread and beer.’ Their goddess of beer and brewing, Ninkasi, has given her name to a US brewery. (1) Beer is also mentioned in the Epic of Gilgamesh and relates how Enkidu suffered alcoholic euphoria after consuming seven jugs. The saying, “He who does not know beer, does not know what is good” is not a Scottish truth, as I assumed, but originates as a Sumerian proverb. The proof of this is that the Babylonians knew of 70 varieties of beer, almost as many as I do. When the King of Assyria, Ashurnasipal II, threw a party, it was a doosie:(4) 2,200 oxen and 16,000 sheep were washed down with 10,000 skins of wine and 10,000 barrels of beer. He knew the value of beer as a ‘social lubricant.’ What is our responsibility as educators? Well, if you need a sedative, we have better. If you want to avoid cancer and obesity and stroke, think twice. Yes, education starts in school, but our adult patients could use some tips (e.g., labelling the product, debunking myths, and supporting those in transition - especially women).(5) Don’t get me wrong, I like the look of wine, the taste and aroma, and the social ambience. A clear, pale, sparkling refreshment. Funny, diet-ginger-ale seems to have similar benefits. But less advertising. Hmmm. References: 1. Beer in Ancient Mesopotamia. Shivaprasad P. Quora. https://theeducationalblog.quora.com/Beer-in-Ancient-Mesopotamia 2. A ‘drink’ is 5oz of 12% wine, 1.5oz 40% spirits, 12oz of 5% beer 3. 3.5 drinks a day increases risk of cancer (mouth, pharynx, esophagus) 200-300%, and colon and breast cancer by 50% https://cancer.ca/en/cancer-information/reduce-your-risk/limit-alcohol/some-sobering-facts-about-alcohol-and-cancer-risk 4. The Greatest Party Ever Thrown. World History Encyclopedia. https://www.worldhistory.org/article/729/the-greatest-party-ever-thrown-ashurnasirpal-iis-k/ 5. New alcohol guidelines highlight unique challenges women face. Camille Bains. The Times Colonist. Feb 9, 2023 https://www.timescolonist.com/health/how-women-face-unique-alcohol-use-challenges-from-physiology-to-stigma-and-child-care-6493483

Casebook of a Community Internist

A perspective on liquor

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Hector Baillie

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