I mean, alcohol's been on a journey.
Yes.
It's been on a journey in terms of society's opinion about it.
Can you take me on that journey and tell me where we are now?
And when I'm saying that, I'm talking about society's opinion on its health benefits and what it is.
And then also what we're getting wrong now about alcohol.
Yeah, yeah.
So, I mean, the journey of alcohol is fascinating.
So first I think we think of this as a relatively modern thing, but archaeologists have discovered beer-making equipment in hunter-gatherers' cave dwellings from 13000 years ago.
That's wild.
Like 13,000 years of people figuring out how to make beer.
You know, you look at China 9,000 years ago.
It was really about like a spiritual journey or a social thing.
It was never really about health.
At some point we started talking about this as something that is good for your health.
Like drink red wine.
It's going to improve your health.
Yeah.
And that's where I think we got wrong.
And the reason why was actually from how we were looking at the data.
So first, if you look at only one health condition, there are some health conditions where a moderate amount of alcohol actually improves your health.
But it was also how people were conducting the studies.
So in most of the studies what people do is they take like a massive population, tens of thousands of people where we have some data where they're reporting how much alcohol they used.
And then we look at health risks over time.
And scientists would lump people into sort of non-drinkers versus light drinkers, moderate drinkers or heavy drinkers.
And what they're finding is that people who are drinking, even up to the moderate level, were actually doing better than the people who weren't drinking at all.
And so that was where that concept that drinking is good for your health came from.
And so people talk about this like J-shaped curve, meaning that moderate drinkers actually have lower risks of health problems.
And then it's really only when you start drinking very high levels that you start having more risk of health problems than people who don't drink at all.
What they realize is wrong with that is that in the people who don't drink at all, many of those people are not drinking because they're actually really unhealthy for another reason.
Like they might have heart failure and they like don't want to drink because they don't want it to mix with their medication.
Or they might have had a history of alcohol use disorder and they're actually in recovery.
So they've already had some damage from alcohol and they are not drinking because of that.
And so when you change the reference group, you actually make the sort of group that you compare people to, to people who very rarely drink.
So it's not that they're not drinkers at all, but they drink very, very light levels.
Then you start to see that those health benefits of alcohol go away, especially if you look across all conditions.
Are you telling me that there's no healthy level of alcohol consumption?
Yes.
I would never say drinking alcohol is good for your health.
That doesn't mean that drinking at what we call low-risk levels can't be a part of a healthy lifestyle.
So it's a slight shift that like don't fool yourself into thinking that drinking that glass of wine is like going to exercise for 30 minutes.
Like, it's not something that's going to promote your health.
I think of it more like having dessert, eating bacon, going out in the sun.
There are risks associated with all those activities.
It doesn't mean that I would say you can never do any of that, but you need to understand what the risks are and then make choices for yourself.
Say I look at this glass of wine here and this pint of beer.
If I drank one of these a day not a huge amount, I think.
What people tend to think is they think well, it's only one.
So my body will just flush it out and there'll be no adverse health consequences.
Is that true?
Well, so part of the challenge is what we think of as one drink.
So I think, much like you know, if you learn to read the serving size on a food, you realize that like a serving of ice cream is like a half scoop.
It's not like a giant ice cream sundae.
The same is true with alcohol.
So in the UK the kind of low-risk drinking limits talk about units of alcohol, which is the equivalent of eight grams of alcohol.
So how much of a drink has eight grams of alcohol?
And to be in that low-risk category, you have to be below 14 units.
The problem is that glass of wine, just eyeballing it, has several units of alcohol.
So, even though we think of it as a single drink, it's probably I mean, I have to guess, but it's probably like three units of alcohol.
So if I have a glass of wine every day, I'll be over that limit then?
You'd be right at that limit.
The problem is most people don't drink just one glass.
If you you know you have two glasses one day and then one glass one day, and then three glasses one day because you're at a social function, all of a sudden you're actually quite a lot over that limit.
So if you said that this is roughly three units roughly.
And you get 14 a week.
You get 14 a week.
So three times seven, 21.
Yep.
So yes, you're over if you're drinking that size.
Yeah.
Okay, so if I have this glass of wine every day, then I'd be over the UK limit of?
Lower risk drinking.
Lower risk drinking.
So I'd be medium risk drinking.
You'd be in what we call moderate risk, which is associated with pretty much every form of cancer which I think people don't know.
Okay.
Because I was wondering why cancer has been increasing.
Yes.
A variety of different forms of cancer are increasing.
You know, breast cancer is one of the ones we always hear about that's increasing.
Yeah.
So you're saying, what is the data in terms of low or moderate risk of drinking and cancer?
Yeah.
So the data is growing and really worrisome.
So for breast cancer, there's a few cancers that even at low risk limits you see the risk begin to increase.
So where we would say there's kind of no healthy or there's no even like low risk amount.
So breast and esophageal cancer are two examples of that.
So breast cancer if you were to drink below those low risk limits.
So in the US that would be fewer than seven drinks.
But a drink in the US is five ounces of wine which is smaller than that, or in the UK is below that, 14 units.
So it would be, you know, fewer than seven of that, that size glass of wine.
We still see a slight increase in the risk of breast cancer.
It's about a 5% increase.
So that means your risk of breast cancer would increase by about 5%.
And that's not huge.
So I think, you know, percent increase is kind of hard to do the math on.
But if you think in the US, for example, the average woman has a 13 likelihood of getting breast cancer in their lifespan.
13% likelihood of Really, yeah.
Wow.
Really high.
So 5% increase would increase that to like 13.6 or so.
So that means that if there's nine women in this room, one of them is going to get breast cancer, probabilistically.
In their life, yep.
Damn.
Yeah.
And it's increasing?
Yeah.
Yeah, and so the reasons for that are likely environmental, because your genes don't change over that time period.
So the risk factors, you know if you think about breast cancer, it's alcohol, it's obesity it's, you know age, when you have children or don't have children, because it's a really hormonally driven cancer.
Same thing if you think about colon cancer.
That's a really scary one where we're seeing more and more cases in younger people.
Some of the drivers of that, eating meat.
So processed meats increase your risk of colon cancer.
So, you know, these very sort of normal behaviors.
There's probably other environmental things honestly, that we're not yet measuring or able to measure.
Just given the rate of acceleration.
When I talk to my colleagues who are oncologists, you know things like plastics or other things that we don't yet know.
It's clearly something in the environment that is driving these increased cancer risks.
So even at this sort of level, if I'm drinking, that might be one unit, right?
Yes.
So that would be one unit.
So that would be fewer than 14 of that.
So you could see like, you know, if you had double that, it would be a decent pour of wine.
You could not have more than seven of those in a week to be in low risk.
But even drinking that amount, your risk of breast cancer would go up a little bit.
Even this amount?
There's really sort of no safe amount of alcohol when it comes to breast cancer.
Is it just breast cancer?
So that low-risk category.
So these big cancer studies categorize people as sort of low-risk or light drinkers, moderate or heavy.
And for pretty much every cancer, once you get to the moderate category, we start seeing increases.
And there's what we call a dose-response relationship.
So the more you drink, the higher your risk of cancer.
There's only a few cancers that the risk seems to increase even at that very low level, and breast cancer is one of those.
And then esophageal cancer is one of those.
So there are certain cancers where even a small amount of alcohol will increase your risk.
Does it have an impact on thinking about cancers that are prominent in men?
Yeah.
So colon cancer, we're seeing that in a lot of young men.
Liver cancer.
Yeah, prostate cancer, which is obviously a male cancer, we don't think of as much as being sort of an alcohol-sensitive cancer.
But most cancers, because the way alcohol impacts your risk of cancer is not really on a specific organ outside of the liver.
It's really about how it changes our DNA.
So it's about inflammation and what are called reactive oxygen species.
That sort of change our cells and increase the risk over time of the mutations that lead to cancer.
So yeah, can you drill down on that?
So if I'm a heavy drinker, so say that I'm drinking.
Let's say I'm drinking two glasses of wine a day consistently, which I guess would like if I was drinking two of those a day.
If you're drinking two of those glasses, yeah, you'd be in the heavy category.
So two of those a day puts me in the heavy drinker category.
Which would surprise most people, right?
Like that for many people is very normal.
Yeah.
It is very normal.
I think it's somewhat more difficult for younger people to understand, because younger people drink less.
But if I think about the generation above me, having two glasses of wine a day is quite normal.
After work, on the weekends, with every meal that you have.
So that would make me a heavy drinker.
And then what are the stats saying in terms of my cancer risk profile?
Yeah, so it varies by cancer, but roughly we're talking like a 40 increase in cancer, depending on the cancer type.
And the more you drink, the more that's going to go up.
So, you know, these are scientific studies where it's not precise to you as an individual.
They're based on large populations, but definitely the more you drink, the greater the risk.
And then if I have other sort of, do they call them comorbidities?
Yeah, exactly.
So other illnesses, other diseases in my body, my probability is going to go up further if I'm obese, if I'm overweight.
Exactly, if you smoke.
So one of the main drivers of alcohol too, and cancer is that it actually makes you more susceptible to the cancer-causing effects of tobacco.
So if you drink and smoke, your risk of cancer is going to be even higher.
How does that work?
The thought is like if you take esophageal cancer at like the cellular level, it makes you more susceptible of the carcinogens which are kind of the cancer-causing compounds in tobacco.
And so, rather than just seeing like an additive risk, you actually almost get a multiplied risk in terms of the risk of cancer.
So smoking and then obesity is the other big one.
So a lot of cancers, your risk goes up if you have an increase in your body mass.
What's going on in the body then?
If I drink alcohol, how is that leading to cancer?
You referenced it slightly there, but I want to make sure I'm super clear in my brain as to what the knock-on effects are and how that ends up as cancer.
Yeah.
I mean, there's lots of different mechanisms.
So, I mean, maybe starting just with like, what does alcohol do in your body?
So you ingest alcohol that like fancy name for that is ethanol.
It's a molecule and it basically gets absorbed pretty quickly from your stomach.
And so, you know, it hits your bloodstream usually within 10 minutes or so of having a drink.
How much it hits your bloodstream depends on how much water you have in your body.
So alcohol doesn't penetrate into your fat.
It just kind of diffuses into the water parts of your body.
So that's actually why for many women they will get more sort of drunk or more of an effect from alcohol at a lower level than men, because women have more body fat than men.
But that's going to depend on you as an individual.
If you have more body fat, you're going to have a different impact.
So alcohol gets in your bloodstream.
Alcohol can instantly cross across what we call your blood-brain barrier.
So it impacts your brain instantly and that's where you feel the initially pleasurable effects for many people of feeling a little relaxed, feeling more social, feeling a little bit you.
If you keep drinking and that level keeps going up, then you start having impaired judgment.
You might have lack of motor coordination.
So we've all seen this, and many people have probably experienced it.
You may be stumbling, not able to drive safely.
You're not going to make the same decisions you would make if you weren't drinking.
And then if you keep drinking, then you can actually lose consciousness, so pass out.
And people have experienced that.
Your body is going to try to break down alcohol as quickly as it's able to.
Like anything, we want to kind of excrete any abnormality and get back to our normal functioning.
And so that process happens mostly in your liver, which is why the liver is so sensitive to alcohol.
Because your body sees ethanol as poison.
Yes.
I mean, you know, I know you talked about this, Dr Lemke but your body always wants to restore what's called homeostasis.
Your body's always going to fight to get back to what it feels its normal is.
And so ethanol is not something that belongs in your bloodstream.
Your body's going to try to excrete it as fast as it can.
And then it converts it into something called acetate and then you can pee that out and breathe that out and get rid of it.
So to eliminate the alcohol in your body, you have to go through this process.
And part of that process includes this toxic molecule that's going to be floating around and causing damage to your cells.
So that's one way that alcohol can cause cancer.
The other is just general sort of inflammation.
People have probably heard that inflammation is just not good for the body and increases the risk of cancer.
And alcohol generates a lot of that inflammation in the process of getting eliminated.
And so it can actually change your cells that over time that can lead to cancer.
So I also found this graph which shows, for anyone that can't see, what we're describing at the moment.
It shows the acceleration in liver disease, death rates and general liver disease compared to other parts of the body, other organs in the body.
I believe it shows
What impact does alcohol have on the liver?
And we have our little mannequin here of the human body.
Where is the liver?
Yeah, great question.
So here's our little mannequin.
So just to orient people to the body.
So we're looking at the inside of the body.
So like the ribs are gone.
The outside of the skin is gone.
These two pink things are the lungs.
They kind of encase the heart.
You can see the hearts behind the lungs pumping your blood.
The liver is this brownish organ.
It's on the right side of your body, right under your ribs.
It's quite large.
It's big.
And it's an amazing organ.
It is quite big.
It processes much of what any kind of toxins that we take in things that we eat your glucose alcohol, 90 of it's metabolized by the liver.
So the liver is sort of the clearinghouse, getting rid of byproducts in your body.
The other are the kidneys, but the liver plays a huge role, especially in alcohol.
So it sits right here.
It almost looks like it's as big as the lung, as one lung.
Yeah, yeah, it is.
Really?
Yeah, it's a giant organ.
And it's an amazing organ.
So you can actually cut out 80% of the liver and it would regrow itself.
So kind of like those lizards that you cut off their tail and they regenerate a tail.
The liver is fascinating.
It's why we can do living liver transplant.
So I could take half of your liver and give it to someone who needed a liver.
You would still be able to live and they would get a second chance at life from that part of your liver.
So it's this really cool organ that can regenerate.
But it can only regenerate up to a point.
So once you get to a level where you have a lot of scar tissue in your liver we call that cirrhosis you sort of reach a point of no return where at that point the liver can't heal itself.
So I sort of think of it, like to use a baking analogy.
If you're making muffins or a cake and You're going along, you're mixing all your ingredients and you realize before you put things in the oven like oh I forgot the eggs.
You can still add the eggs in and like whisk it all together and it's going to be okay.
If the muffins are baking in the oven and you forgot the eggs you can't like, pour the eggs on top and make the batter the same.
And the liver is sort of like that, that up to a certain degree you can actually completely repair the effects of things like alcohol or obesity, other things.
But once you pass that point into scar tissue, the liver can't regenerate anymore.
Yeah.
And so, when you think about that graph, or just the rising rates of liver disease, the main drivers of liver disease are obesity and two is alcohol.
And so those are the leading causes of liver transplant.
And the thing that is so sad is I mean, I see this all the time working in the hospital is, first of all, we're seeing younger and younger people coming in and liver failure.
So people in their 20s coming in and fulminant liver failure from alcohol and then dying in the hospital.
And the terrible thing is that they often didn't even know that this was causing a problem in their health.
And by the time they get to the hospital, they're so sick it's too late.
And yet all of that could have been prevented or even repaired if it was caught sooner.
And so that's where I think this education of understanding, like what really are the health harms of alcohol.
And that we have normalized binge drinking on many occasions, especially in young people, as being totally normal.
And yet there are very serious health consequences.
So I've got a bunch of questions around the liver.
Does that mean that my liver can take a bit of a beating before there's any real problems?
Should I, you know, someone like me, I don't drink alcohol.
I'm not engaging in anything too bad.
But sometimes I do wonder if I could have like a blowout weekend and then my liver would just recover to normal again and I'd be fine.
Yeah.
I mean, so first, every person is different.
One blowout weekend, you probably would be fine.
Anyone would probably be fine.
The challenge is one blowout weekend then leads to like multiple blowout weekends.
And then over time, that can actually accelerate the damage to your liver.
You said that my liver regenerates though.
So I'm thinking this thing will just pop back to normal again.
As long as you haven't gotten to that scarring phase.
So once you get too far down that path, even if you were to stop drinking, your liver won't recover.
The hard thing is that we don't totally understand who and why that happened so young to.
So this is an active area investigation, because there are people who've been drinking for 60 years and their livers don't show signs of scarring.
And then we're seeing these young people at 25 who come in and die in the hospital.
And so there are individual factors that you don't have any way of knowing that are going to impact your risk of developing liver inflammation and scar tissue.
And so the safest way to prevent that is to not drink in these really high ways that we know are going to lead to harm.
The other way is to get medical care, because often we do detect these things through blood tests and we can do ultrasounds.
And when we see those early phases.
So what happens first is you actually get fat deposition in your liver.
That's the first step.
And then we see inflammation in fatty liver.
And if you don't stop the thing that's driving those changes, over time we see the development of what's called fibrosis, which is like scar tissue.
And then that scar tissue gets more and more advanced, to the point that your liver stops functioning and you either die or you need a liver transplant.
Wow. activities outside of alcohol cause great stress on our liver that we might not see as obvious?
Yeah.
So obesity.
Food does.
Yeah, food.
So your liver is very involved in glucose metabolism.
So our diet and our body weight impact our liver health.
And the other medications, so acetaminophen or Tylenol, which is a very common over-the-counter pain reliever above a certain threshold can cause serious liver damage.
So sometimes we'll see cases where someone didn't realize that, like their cold medicine plus the Tylenol they were taking, both had that ingredient and then they go out and drink heavily.
And that kind of combination effect can cause liver damage.
How much?
Do you think this might be a bit of a bit of an unclear question, but how much alcohol is going to cause liver damage?
So again, it varies person to person.
For liver damage, it does tend to be the moderate to higher amounts that cause damage.
One thing is that having these big surges, like these massive binge episodes, is probably more harmful than drinking at a moderate level for a long period of time.
Those big surges cause a big buildup of that toxic byproduct that your body has to clear.
And so if you have several years of binge drinking heavily, that actually probably is going to cause more damage than a longer period of time of just drinking above the risk limit.
So really trying to minimize and avoid those very heavy drinking episodes is incredibly important.
And then keeping it to those low risk guidelines which we just learned are kind of eye opening, and how low risk they are is going to reduce the risk of liver damage.
And does alcohol just impact the liver?
No, I mean, alcohol has effects across our body.
So many parts of the body can be affected by alcohol.
So kind of starting from the top, your brain.
And we can look at this with pictures like an MRI.
Oh, I've got one.
Yeah, I think.
This is, by the way, shocking.
Yes.
So when we do an MRI of someone's brain, we basically, this is like a cross slice.
So it's almost like you're facing me and I'm cutting your face off and looking at your brain onwards.
Healthy brain tissue is the gray and white matter.
And you want it to be as plump and like taking up as much space as possible, because that's where all of your brain activity is.
When people get really old or have dementia, one thing we see is more and more the black space is essentially water.
So we see the brain start shrinking and shrinking and there's more water and less active, healthy brain tissue.
That process is accelerated with heavy alcohol use.
And so you can see here this is a 43-year-old person with severe alcohol use disorder, where their brain looks the way you know a 90 year old with dementia would look because of that brain damage over time from alcohol use, and so we can.
Actually, a form of dementia is related to alcohol use, and so your brain can be hugely impacted with alcohol.
What is going on there, like what's causing the brain to deteriorate in such a way because of alcohol?
Yeah well, remember I said ethanol, which is the molecule, crosses the blood-brain barrier.
And so, especially when you're having these high levels of blood alcohol, that ethanol is sort of bathing your brain.
And if you think about what we talked about inflammation and changes to cells and to DNA and proteins, that is happening at the brain level.
The other thing that can cause – accelerate the brain damage we see with alcohol is actually nutritional deficiencies.
So people may be drinking a lot and they're actually not getting really crucial nutrients in their diet.
And that can accelerate the process of brain damage.
We can even see a very like sudden onset amnesia from heavy alcohol use in the setting of not getting enough nutrients in your diet.
Okay, so that's the brain.
That's the brain.
So the brain, for sure.
The next is the mouth and your esophagus.
So obviously you're drinking alcohol.
It's bathing your mouth, it's bathing your esophagus and your stomach.
So we do see an increase in cancer, like we talked about, and that's accelerated by smoking.
But we also see like benign but annoying and problematic health conditions, most notably acid reflux, so heartburn.
So if you notice like, oh, I'm like always having heartburn.
I'm having to pop all these like antacids and take this medicine.
You might want to think like, how much am I drinking?
Is that contributing to my heartburn?
So that's a very common thing.
The heart is affected by alcohol.
You know, the heart is an organ where at low risk levels there doesn't seem to be harm from alcohol.
But once you get into the moderate and high, we see harms.
And the harms can be a couple fold.
One is something called atrial fibrillation, which is basically where your heart starts beating really irregularly.
So in your heart, there's four chambers, the two chambers at the top.
So this is really showing the ventricles and the atrium.
So there's two chambers that blood flows through.
And in a normal heart, your electrical activity comes from the top of your heart, goes down to the bottom of your heart and tells the heart to pump.
And so you get a single impulse that goes to the bottom of the heart, says pump, and that pumps blood out to your brain and your body and your organs and your liver and In atrial fibrillation.
The top of the heart is just kind of quivering with this abnormal electrical activity and so the heart can't pump in a normal way.
We actually – there's a term in medicine called holiday heart, because we see sometimes people drink a ton over the holidays and will end up in this abnormal rhythm just from that binge drinking pattern.
Wow.
And then over time, if you're drinking at high levels, your heart actually dilates and you can end up with congestive heart failure from a cardiomyopathy, which means the heart muscle gets kind of weak and thin and floppy and can't pump the way that it needs to.
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