Tomorrow We Die

In Defense of Coffee and Chocolate but mostly Alcohol

© Photo by Bertie

In the course of taking a social history for a new-patient physical the other day, I asked about alcohol intake. 

“Oh, I quit,” the patient said. 

“Really?” I said. “Was it becoming a problem?” 

“Not at all,” she said. “I never used to drink more than one or two, but haven’t you heard? They just discovered that no amount of alcohol is safe.”

I hadn’t heard, actually, but I was not surprised. A new study is published every few weeks on the health risks or benefits of society’s favorite vices: coffee, chocolate, and alcohol. 

Or, as some like to think of it, breakfast, lunch, and dinner.

After a bit of probing, I discovered the culprit. On April 4th, The New York Times published a widely read article entitled: Moderate Drinking Has No Health Benefits, based on a meta-analysis, published in the Journal of the American Medical Association. The article garnered over a thousand comments.

I jotted a note on an index card where I write down stuff I come across that I might want to look into later. That night, I dug a little deeper and found the meta-analysis itself. 

The report analyzed over a hundred studies of almost five million adults. The authors found that while many of those studies support what we think of as common wisdom - that heavy drinking is bad, no drinking is good, but light drinking is best - many of these studies shared a fatal flaw. 

Heavy drinking still came out bad. No drinking still came out good. But the supposed benefits of light drinking disappeared when you corrected for the fact that light drinkers tended to be healthier overall than abstainers, who often had health problems that prevented them from being able to drink.

In other words, the article undermined one common wisdom - moderate drinking is healthy - by pointing out that the data was being skewed by another common wisdom - why abstain if you don’t have to?

So is it true? Should we put down our glasses for good? I don’t think so - for (at least) the following five reasons.

Reason one: read the study.

Lo and behold, while the authors do conclude that moderate drinking is not a benefit, they do not conclude that it’s a risk. In fact, the study found no increase in all-cause mortality in drinkers of up to 25g a day, which is about two drinks, and a non-significant increase in risk in male drinkers of up to 44g a day, or about three drinks. 

The significant increase in all-cause mortality only began to appear in female drinkers after more than two drinks a day, and in male drinkers after more than three drinks a day, which you probably didn’t need a large-scale meta-analysis to tell you. 

Reason two: do the math.

Granted that light drinking does not increase all-cause mortality, but what about other negative health outcomes, like cardiovascular disease or cancer? 

The JAMA article doesn’t address that question, but In 2017, the American Society of Clinical Oncology published a similar warning, based on an even wider review of the literature, that even moderate consumption of alcohol could increase the risk of certain cancers (specifically breast, oropharyngeal, larynx, esophageal, colon, and liver).

Permit me a brief detour into statistics here.

One of the most useful concepts in medicine is the number needed to harm, or NNH (closely related to the number needed to treat, or NNT). The NNH can answer the following question: how many people would have to start light drinking (i.e. 1-2 drinks a day) in order to produce one additional negative outcome?

While it’s very hard to find this number, it’s likely to be very, very small. Let’s take breast cancer, for example, which is a prominent concern. 

The relative risk of breast cancer in moderate drinkers, according to the American Society of Clinical Oncology report, is 1.04, which means they are 4% more likely to get breast cancer than abstainers. 

Now, an average 40-year-old woman has a 1.45% absolute risk of developing breast cancer over the next 10 years. Add 4% to that and you get 1.51% or an increase in absolute risk of 0.06%.

Calculate the NNH from those numbers and you get 1,667 - which means that 1,667 women would have to start drinking lightly to cause one additional case of breast cancer. Put another way, you could drink alcohol moderately for more than a thousand years before blaming it for giving you breast cancer - and by then you may have other concerns. 

Reason three: everything in moderation.

Most things are fine when done in moderation. What’s more, moderation gives you the bandwidth to do a lot more things.

Moderation is one of my mantras. And while I can’t take credit for the idea, I’m in good company: Aristotle, Confucius, Maimonides - the list goes on and on. They all advocated moderation - the golden mean - as a cornerstone of healthy living. 

Even Epicurus, the ancient Greek philosopher who founded Epicureanism, better known for his focus on the pursuit of pleasure, advocated moderation. He believed that true pleasure lay in simple things - friendship, physical safety, and intellectual contemplation - as opposed to the more extreme pursuits of power, wealth, or physical indulgence.

How would I define moderation when it comes to alcohol? I use the 7/2 rule: no more than 7 drinks a week with a maximum of 2 drinks a day. After that (or before it), switch to something non-alcoholic, like a seltzer with bitters.

Where did I get that from? I feel like I made it up but I probably stole it from somewhere. In any case, it's a conservative mix of evidence and common sense. 

A word of caution. Sometimes moderation is not an option. There’s abuse. There’s addiction. Individual psychology also plays a role. Some people are all or nothing. Some people fool themselves - a rule of thumb you learn in medical school is to double the amount of alcohol a patient says they drink.

Some environments set you up for failure - whether through peer pressure, temptation, or by default. Happy hour. Open bars. Client dinners. College. One of my pet peeves is that a bottle of wine contains more alcohol than two people should split.

Be honest with yourself. If you have a hard time following the 7/2 rule - either in general or in specific situations - it may be better to abstain. But that in itself is also an argument - whereby the inability to steer a middle way (for whatever reason) narrows down your options.

Reason four: cost-benefit.

Getting up in the morning. Crossing the street. Driving to work or taking the train. Holding your tongue or hitting send. Even sleeping in. Everything has costs and benefits.

We’ve spoken about the risks of moderate drinking, but what about the benefits? 

Rather than wax poetic about drinking, which might sound weird coming from a doctor, let me sketch out a few scenarios that a poet could write about.

A drink with friends after work. A glass of champagne at a graduation party. A scotch with your spouse after a long day, sitting on the couch with the kids all tucked in bed. A glass of wine on a first date; or at a wine tasting; or at a vineyard, while sitting at a small round table overlooking a field. A cold beer on the beach in Tel Aviv at dusk, leaning back in a flimsy red plastic chair, toes curling in the sand, warm on the surface, cool underneath…

You get my point.

Reason five: it’s not medicine.

When I was in college, my mentor was a remarkable woman, writer, and journalist named Gloria Emerson (my everlasting claim to fame, at least in my own mind, is that a minor character in her novel, Remembering Graham Greene, is named Bertie). One day, while walking on campus, we passed a group of students exercising on the lawn.

She gazed at them and said, in her inimitable way, “You do realize that all this obsession with working out and going to the gym is crypto-fascist, right?”

Actually, no. Not only did I not realize that, but I wasn’t even sure what crypto-fascist meant (great word, though).

At the time, I thought she was kidding, or at least being melodramatic. Nevertheless, I never forgot what she said. It stuck with me. Until I came to think she wasn’t joking after all.

I think she meant that there is something intrinsically fascistic about the adulation of strength and force. Think of Nietzsche’s concept of the Uber-mensch; Leni Riefenstahl’s footage of young Aryans playing sports; Goebbels’ famous line: “When I hear the word culture, I reach for my gun.”

By extension, Gloria looked at the world of sports and fitness and saw glimmers of the fascist preoccupation with materialism, power, and physical domination lurking beneath a veneer of campus innocence. Hence crypto-fascism.

So, in memory of Gloria, let me say that our obsession with dissecting and parsing all the health risks and benefits of enjoyments like coffee, chocolate, and alcohol is also just a little crypto-fascist.

The pleasures of the world are not the same as medicine. And by subjecting and reducing them to a calculus of pros and cons based on clinical trials and meta-analyses - by medicalizing them - we are both depriving ourselves and flattening our lives.

No one should consume alcohol because it’s healthy, nor necessarily avoid it because it’s unhealthy. In moderation, it’s essentially neither. Furthermore, way to miss the point.

We add up to more than the sum total of our material selves. Coffee, chocolate, and alcohol are gifts of nature, substances that possess a spiritual dimension. They have the potential - when used correctly - to enhance the quality and texture of our lives, to help elevate us in work, play, and love.

And so, to paraphrase Epicurus (and Isaiah, and Ecclesiastes, not to mention the Book of Mormon), eat, drink, and be merry - not just for tomorrow we may die but for today that we may live.