Deciphering Mixed Messages On Drinking And Health
NEAL CONAN, HOST:
This is TALK OF THE NATION. I'm Neal Conan in Washington. Everybody knows too much alcohol is not good for you, and scientists continue to study behavior, the brain, genetics and psychology to learn more. Last week alone, the Centers for Disease Control and Prevention released a study on binge drinking and adults, and the British government issued a recommendation that everybody should abstain at least two days every week.
That's against the background that alcohol can be blamed for at least 80,000 deaths in this country every year. That two-days-a-week suggestion made us curious. What rules do you impose on yourself to regulate your drinking? 800-989-8255. Email us, email@example.com. You can also join the conversation on our website. That's at npr.org. Click on TALK OF THE NATION.
Later in the program, we'll listen back to Martin Luther King, Jr.'s speech "I Have A Dream." But first what we're learning about alcohol. We begin with Dr. Robert Brewer, who leads the Alcohol Program at the CDC and joins us from a studio in Atlanta. Nice to have you with us today.
DR. ROBERT BREWER: Thank you very much, Neal, it's a pleasure to join us.
CONAN: And looking at the outlines of your study, I was surprised to learn that the binge-drinking problem is indeed a problem for people over 65.
BREWER: Yes, it is, and I think one of the key points that we wanted to make in our study is that while binge drinking is certainly a problem for young people, it continues to be a problem throughout the lifespan, and as you noted, among seniors, as well.
Overall, we estimate that about one in six adults 18 and older, about 38 million adults in total, report binge drinking one or more times within the past 30 days. And when we're talking about binge drinking here, we're talking about consuming, for a woman, four or more drinks within a short period of time, within an occasion; and for a man five or more drinks within a short period of time or within an occasion.
What was a little different about this study, though, is that in addition to looking at the proportion of the population, or what we would call the prevalence of binge drinking, which, as I mentioned, was about one in six adults, we also looked at how frequently people report binge drinking and how much they consume when they binge.
And I think that's perhaps where you were particularly going with your comment about seniors, because, in fact, seniors had - seniors who reported binge drinking did so more frequently, even than younger people, which I think is a surprise to a lot of us.
CONAN: And what else in that study surprised you?
BREWER: I think the thing that was most shocking to many of us was the amount that people report consuming when they binge drink. And we had another question in this survey that we were looking at that allowed us to estimate what's referred to as the average largest number of drinks consumed by various drinkers.
And when we focused in on binge drinkers, we found that, on average, they reported consuming eight or more drinks on average during at least the largest episodes of binge drinking within the past 30 days. So that's obviously well above the cut point that we use for defining this behavior and certainly a level of consumption that puts the individual, as well as others that they're with, at substantially increased risk for a whole host of problems.
CONAN: So frequency and intensity, how many drinks in what period of time?
BREWER: Exactly, and I think that's - a key take-home message here is that binge drinkers do tend to do so frequently. If you look across all binge drinkers, it's on average about four times a month or roughly once a week, and consume as I mentioned, about eight drinks per binge.
What's also interesting here, I think, though, is that some of the groups that have the highest prevalence - where binge drinking is most common - are not necessarily the groups that are drinking the most when they do. So, for example, if you look at this by income, one thing that surprises a lot of people is that the prevalence of binge drinking is actually higher among people with higher household incomes, whereas the amount consumed per binge episode, was actually higher among those with lower household incomes.
And I think the finding in particular of high prevalence of binge drinking in higher household income populations, also more highly educated populations, is in stark contrast to what we see with smoking, for example, which has become increasingly a problem, still, across the entire population, but much more common among those with lower household incomes, often lower educational levels.
So I think it says we have a lot more to do as a society to address this problem.
CONAN: There also were some interesting findings regarding different ethnic groups.
BREWER: Yes, that's true. Overall, again, binge drinking tends to be most common among white non-Hispanics, which is again very different than what we see with some other risk behaviors. But when you look at who is binge drinking most frequently and who is consuming the most when they binge drink, it was actually other racial and ethnic groups, which could include, for example, American Indians and Alaska natives, Asian-Pacific Islanders. We sort of looked at those groups together. We didn't separate them out in this particular study.
But there are certainly some interesting variations across race ethnicity, as well.
CONAN: I wonder, what did you make of the - I don't know if you saw it - but the British government recommendation just don't drink at all at least two days a week.
BREWER: Well, I think it's an interesting idea. The big concern we have, though, is with excessive drinking, which we would define as binge drinking, certainly, which is drinking, as I've mentioned, a large amount on a particular occasion - or heavy drinking, which we would define as drinking, for a woman, more than one drink on average per week, or per day, rather, and for a man more than two drinks on average per day.
So it's really, from my standpoint and from CDC's standpoint, much more a question of how much people are drinking when they're drinking and not necessarily the frequency of their drinking in particular. In the U.S., you know, we have dietary guidelines for drinking, which recommend that a woman drink up to or no more than one drink per day and a man drink no more than two drinks per day.
So I think it's the amount that people are consuming when they're drinking that's most important.
CONAN: We're talking about what we're learning about alcohol. Dr. Robert Brewer is with us from the CDC. What rules do you set for yourself to control your drinking? 800-989-8255. Email firstname.lastname@example.org. We'll start with Peter(ph), Peter with us from San Ramon in California.
PETER: Hi, yes, good afternoon. Real simply, what I have done, about 10 years ago, I was drinking all the time, we had two little infants, and my wife looked at me one time when we were fighting, and she just simply said, have another drink. It embarrassed me, and I realized I had two children to raise, and I was going to lose my family, and I just stopped drinking.
And how I control it, whenever I have that urge, is I just simply, for me, I just look at my family and what I have to lose.
CONAN: And how old are your kids now?
PETER: Josh(ph), he's 11, and Isabel(ph) is 10.
CONAN: So have you had the chance to talk with them about drinking? It's probably not too early.
PETER: Yes, we starting talking, matter of fact, Joshua and I had a conversation yesterday when we were driving. We saw - there was a movie that was on, and there was a lot of drugs involved, and I just happened to stop the movie, and then we - I ended the movie, and then we just discussed that issue. And then what happened to my brother Greg(ph), he died on the result of drinking too much. That's basically what killed him.
CONAN: I'm sorry to hear that, Peter.
PETER: It ended his life.
CONAN: Yeah, thanks very much, appreciate it.
PETER: Thank you.
CONAN: The finding of the CDC study, by the way, that is of the 80,000 deaths that alcohol is responsible for, at least in this country every year, half of them the result of binge drinking. Dr. Bankole Johnson is a professor and chair of the Department of Psychiatry and Neurobehavioral Sciences at the University of Virginia and joins us today from a studio in Charlottesville. Good of you to be with us today.
DR. BANKOLE JOHNSON: Thank you for inviting me, Neal, it's great to be on your program.
CONAN: And you've been studying addiction and treatment for more than two decades and how alcohol, and the idea of alcohol, affects our brains. What are we learning now that surprises you?
JOHNSON: One of the most important things to know about alcohol is that alcohol has important effects on the brain in that it releases brain chemicals. Basically when somebody becomes addicted to alcohol, is using alcohol very frequently, the pathways in the brain or the circuits in the brain that basically give the brain the ability to make good decisions, go-no-go decisions about whether to drink more become hijacked.
And therefore the person starts off in a spiral of drinking a little bit, then drinking a little bit more, and then they eventually get into this spiral in which their brains basically tell them they need to drink more.
CONAN: Their brains tell them, that's an odd way to put it.
JOHNSON: Well, what happens to these pathways in the brain, is they become more plastic; therefore, they become sensitive to the effects of alcohol. And therefore when the person withdraws alcohol from the brain, the brain basically is looking for those chemicals that are released when the person is drinking.
So this is really a corruption of the way the brain truly works, but because it's using pathways that already exist in the brain, the effects of drinking excessively are very powerful, and it's very difficult for people to stop.
CONAN: And Dr. Brewer, does that kind of information factor into your studies, too?
BREWER: Well, it does. I think what Dr. Johnson is particularly talking about are people who have more severe drinking problems, alcohol dependence, for example, and I think that is a huge public health problem, and I certainly agree with him that it's an important one that we need to address.
The reality, however, is that most people who are drinking to the point of intoxication, which is really what binge drinking is, actually don't meet diagnostic criteria for dependence. And if you wanted to put a number on this, it varies across different studies, but on the order of 80 percent of people who report binge drinking would not meet diagnostic criteria for alcohol dependence.
So I think the kind of feedback loops that he's describing in the brain are certainly very important, particularly for those who meet dependence criteria, but for the large bulk of people who are binge drinkers, I think we have to look at some of the other stimuli that exist within the environment, that actually encourage people to binge drink and to continue to drink at high levels over time.
CONAN: Other stimuli such as?
BREWER: Well, frankly, I think we have to look at social norms around drinking. And I would say that at a minimum, they are often rather confusing for people. I think a lot of people get the message that drinking to the point of intoxication, which again is what binge drinking really is, is not only something that is socially acceptable but actually is encouraged.
I mean, we've just finished the holiday season here, and I think a lot of people tend to associate binge drinking with having a good time over the holidays, and New Year's Eve in particular. And I think they do so often not recognizing the tremendous dangers associated with this behavior, which you've described before.
I think it's also reflected that those social norms are also reflected in the policies that we have around alcohol. Alcohol tends to be relatively inexpensive, it tends to be readily available in many communities and quite heavily advertised.
And we're particularly concerned in terms of advertising about youth exposure to alcohol marketing, which we know to be a significant risk factor for initiation of drinking by young people and that young people who are exposed to more advertising tend to drink more, as well.
So I think many of the factors that influence people's drinking behavior actually relate to the environment in which they're making their drinking decisions. And in that way, the situation with alcohol is really very similar to what we know to be true for tobacco and what we also recognize to be true in terms of people's eating behavior, as well.
CONAN: Interesting, you were talking about the comparison with tobacco, yet we're seeing an expansion of alcohol advertising, rather than a retraction. It's going the other way. We'll talk more with Dr. Brewer from the CDC and Dr. Bankole Johnson from the University of Virginia when we come back from a short break. We'd like to hear what rules you devised to control your drinking. 800-989-8255. Email us, email@example.com. Stay with us. I'm Neal Conan. It's the TALK OF THE NATION from NPR News.
This is TALK OF THE NATION from NPR News. I'm Neal Conan. For two years running, the Daily Beast has weighed market research with the CDC's data on heavy and binge drinkers by metro area to list the drunkest cities in America: Boston, Milwaukee and Austin, Texas, all make the top 10, and whether that's a sports bar culture, a brewing history or, well, the weather we can only guess.
But many of those cities' denizens drink to excess, and even outside the top 10, of course, drinking is a significant part of many of our rituals and celebrations. We want to know: How do you regulate your own drinking? Give us a call, 800-989-8255. Email is firstname.lastname@example.org. You can also join the conversation at our website. Go to npr.org, and click on TALK OF THE NATION.
A couple of emails that we have, this from Samuel in South Korea: Although more expensive, I tend to buy just one or two beers from my nearest convenience store than buy a cheaper six-pack at the supermarket. I drink more responsibly when I have no more than two alcoholic drinks in my apartment at any one time.
Then we have this from J.J.(ph) in Cincinnati: As an occasional drinker, mostly when I'm out at the club, I've learned from hard experience that when I become drunker than I intended to by drinking too fast or drinking beers when I'm thirsty. In order to slow myself down, my rule is to drink a large glass of water for every beer or shot or glass of wine. Each is a drink I consume. Also, the best remedy for a hangover is to avoid one. Water and aspirin after a night on the town before bed can help.
And we've gotten a lot of questions along these lines, this from John(ph) in Oakland: What do you define as one drink exactly? Dr. Brewer, is that the shot of hard liquor, the eight ounce of beer or wine?
Yeah, that's - yes, there is a standard definition for a standard drink, and it is a 12-ounce beer, five ounces of wine or, as you said, Neal, one shot of hard liquor, an ounce and a half of hard liquor. And those would all include the same amount of alcohol, which would be about 0.6 ounces or 14 grams of alcohol.
And Dr. Bankole, as you listen to this conversation, is it right that your research is more with people who are abusive drinkers rather than the kinds of drinkers that Dr. Brewer is talking about?
JOHNSON: Actually, the research of our group encompasses a wide variety of individuals, including those who actually binge drink. For example, we're looking - we're currently doing a study in which we are looking at individuals around the college years who are drinking excessively, and they are also binge drinking.
One of the things that Dr. Brewer mentioned that I think is very important to reinforce is quite a number of people who - and I think it's about half - who actually binge drink don't meet diagnostic criteria for alcohol dependence and alcohol abuse.
Now, you have to think what this means. What this means it that these people tend to slip through the cracks. So the family practitioner doesn't recognize who these folk are because they're not presenting as having a problem. This is not being presented to an addiction specialist.
Yet the problem with society and the problem of the health consequences are there. So this is really an under-recognized group and an under-recognized problem that is very important to address in managing the etiology of drink behavior and drink-related consequences of behavior.
CONAN: When you say - so you say they should be diagnosed as being alcohol abusers or people with an addiction problem?
JOHNSON: I think that they need to be recognized, and they need to have either some kind of intervention or treatment. The most important intervention, I think, for most people who are drinking and not meeting our dependence criteria is education. A lot of people are not told whether their drinking is hazardous, they don't have clear guidelines as to how much they can drink. So education is very important, very powerful.
The second is simple behavioral methods in order to identify how one's drinking is progressing. So just like the idea given for dieting and overeating, being able to measure and take account of your drinking in this high-risk population is very important to modulate drinking.
And I would say the third most important is when you think about where these risk populations are - Dr. Brewer talked about the elderly, but certainly with college students, it's very important to understand that binge drinking is associated with all sorts of horrible things like date rape and sexually inappropriate behavior and drunk driving. And therefore colleges also need - also have a very important part to play in monitoring drinking on campus and setting appropriate rules.
CONAN: Let's go next to Janet, Janet with us from Santa Rosa, California.
CONAN: Hi, go ahead, please.
JANET: Yes, actually my question is not about binge drinking specifically but more broader about drinking. I work in weight management, and I'm very curious as to what kind of statistical evidence there is regarding obesity and excessive drinking.
CONAN: Dr. Brewer, can you help us out?
BREWER: Well, I think the evidence about the relationship between excessive drinking and obesity is somewhat mixed. But I think the overall point is that you're not getting beneficial or nutritious calories from alcoholic beverages. They're excess calories. And alcohol also is quite energy dense, so you're getting a number of calories per ounce of alcoholic beverage you're consuming.
So whether or not strictly speaking you can tag obesity to the amount of alcohol that people are drinking on average in the population, I think it is certainly safe to say that you're adding a lot of excess calories that don't really have nutritional benefits.
Now, in extreme amounts, there's no question you're adding a lot of excess calories that can't help but contribute to problems with weight management. So I think once again it's all the more reason why we would recommend that people comply with the dietary guidelines, which as I mentioned before; recommend that a woman consume no more than one drink per day and a man consume no more than two.
JANET: I have a little bit more of a question here. Something that I have heard, and I don't know is true, is that alcohol slows your metabolism down.
BREWER: I'm certainly not aware of any research that has said that alcohol consumption slows your metabolism down. There is some variation in metabolism in the population, but I'm not aware that alcohol in particular affects your metabolic rate.
CONAN: If it did, it would then reduce the number of calories you would consume just sitting around. But Dr. Johnson, do you have any information on that?
JOHNSON: There is no known effect on alcohol in terms of metabolomics or basically energy production. What she might be referring to is that individuals who drink tend to get tired, but that's due to a lot of other effects, mainly neuronal effects or effects in the brain due to various neurochemicals and endorphins being released, which can make the person feel sleepy. But there's no obvious, direct effect in terms of metabolism in the body.
CONAN: Thanks very much for the call, Janet.
JANET: Thank you.
CONAN: Here's an email from Tristan in Apple Valley, Minnesota: I only allow myself to drink on Friday or Saturday. Then if I drink on Friday, I shall not drink on Saturday. And this from Ron in Berlin, Maryland, and this - he writes: My cardiologist prescribes one small glass of red wine or an occasional dark beer per day. Who's to argue with the good doctor? I rarely go over that for health reasons and because I know it would be unwise.
But having a new craft brewer a short walk away sure tests my commitment. And Dr. Brewer, I wonder, given the advice that we do hear from time to time, a glass of wine helps your heart, is that right? And does that also counterintuitively lead people to drink more than they might - maybe should?
BREWER: Well, it certainly is a question that comes up quite frequently, Neal. I think in doctor-patient encounters, and we encounter this question in our interactions with the public, as well. First of all, just to put this in appropriate context, I want to emphasize what we were looking at in our study was specifically binge drinking, drinking to the point of intoxication and not what would often be referred to as moderate drinking, which is defined at the level that I described before.
Now, as far as the scientific evidence on the - I'm going to call them alleged health benefits of moderate drinking. I would say the jury is still out. And the reason I say that is that the studies that have found beneficial effects from moderate drinking, particularly related to heart disease, are all observational studies and therefore are really subject to a lot of what we would call confounding, that is where they might be other factors in addition to the alcohol or instead of the alcohol that are really resulting in the health benefits that people are attributing to alcohol.
And the reality is that people who drink moderately, again, up to say one drink a day for a woman, up to two drinks a day for a man, tend to be very different in a lot of ways than people who don't drink at all. They tend to have better health habits, more likely to exercise, tend to have healthier body weight, tend, if they have high blood pressure, for the blood pressure to be controlled.
So there are a lot of known and suspected risk factors for heart disease that tend to be less common in people who are drinking moderately. So I think one has to be very cautious about ascribing the health benefits, and particularly lower risk of heart disease, among moderate drinkers to the alcohol consumption itself.
CONAN: Dr. Johnson, I wondered if you wanted to weigh in on that.
JOHNSON: I think, actually, the data is fairly complex. I think that one of it is to do with the attribution of groups. But I think it is reasonable to say that individuals who don't drink at all tend to actually seem - or seem to have higher risk factors for cardiovascular disease.
Now, the exact mechanism by which these metabolic changes due to alcohol produce an effect that could lower blood pressure or reduce cholesterol are not well-known or established, and they really need further study. But I think it is an area that is very important to look, especially vis-a-vis a comparison with nicotine.
JOHNSON: So one of the good analogies that I always say we always teach is that there are not obvious good benefits of smoking. But if to the extend that there might be some benefit - or let us put it this way, some amount of alcohol consumption that is not associated with a negative health benefit, then I think it's possible to manage alcohol consumption in a slightly different way than smoking. And therefore, moderation of drinking might actually be an important target rather than absolutely banning people from drinking.
CONAN: Well, we're asking callers today about how they moderate their drinking; what rules do they set for themselves. 800-989-8255. Herb is on the line from Oswego in New York.
HERB: How we doing today, gentlemen?
CONAN: Good. Thanks.
HERB: All right. Well, I neglected to let your screener know, I started drinking when I was, you know, my teens. I was 16 years old. And some people say it was from my divorce. My parents were divorcing, but I was just drinking because it was cool. And by the time Michigan's age was - they lowered their age to 18, and then they raised it back up to 21. By the time it was up to 21, I was in the Navy, and I was drinking about $100 worth of alcohol on a Friday or Saturday.
CONAN: That can vary from place to place. But anywhere you are, that's too much.
HERB: That's a lot, yeah. And - but when I got out of the military, I roamed around for a little while. I got my CDL. I'm now a truck driver. And the public limit is .08, so the private sector people just driving their cars, but our limit is .04. If I'm even going to drive anywhere, I limit myself actually to one beer if I'm drinking anywhere. If I drink any more than that, my wife gets the car keys. I can't afford to lose my livelihood.
CONAN: I can understand that. And so oddly enough, government regulation seems to have done the trick for you.
HERB: Yeah, unfortunately. I mean, I like to have fun now. I'm 53 years old, and it's not - your body begins to throw it out. It just doesn't take the abuse anymore, so I just, like I said, I limit myself now because of my CDL. I want to keep my career. I want to keep my family and earning money, and I just don't imbibe any - past a certain limit. It's on my own control.
CONAN: All right. CDL, the commercial driving license. Herb, thanks very much for the time and stay steady on the road.
HERB: All right, sir. Take care. I'll see you out there.
CONAN: We're talking with Dr. Robert Brewer, who's the lead of the alcohol program at the CDC in Atlanta, and Dr. Bankole Johnson, who's the professor and chair of the Department of Psychiatry and Neurobehavioral Sciences at the University of Virginia about what we're learning about alcohol. You're listening to TALK OF THE NATION from NPR News.
Dr. Brewer, I wanted to ask you one question about - you're talking about numbers of drinks per event. If that's a drink per hour over the course of four or five or six hours, that, to a lot of people, is not going to be binge drinking.
BREWER: That's a very good point, Neal. I think one of the key points about binge drinking is that it's not only drinking a large number of drinks, again, four or more drinks for a woman and five or more drinks for a man, but it's doing so within a short period of time. And the strict definition from the National Institute on Alcohol Abuse and Alcoholism about binge drinking actually would state that that level of consumption needs to occur within a two-hour period.
When we do survey work on binge drinking, we are not quite as specific about the time period, in that most people are not timing their drinking occasion. So the kind of terminology we would use would be asking people if they've had four or more drinks again for a woman, five or more drinks for a man within an occasion, which is defined as a short period of time, two to three hours. So it does matter, certainly, the length of time that people are consuming this alcohol.
I think it's important to recognize, though, that in other studies they have looked at the relationship between binge drinking and drinking to get drunk, asking people about drinking to get drunk. The two are very strongly related. And some of what we're finding in our public health surveillance work - the results of these surveys - I think reflects the fact that people are, to a large degree and to a medical terminology, titrating their dose of alcohol in order to experience acute intoxication or impairment. So that's why, again, we tend to talk about binge drinking as more or less equivalent to drinking to get drunk. And the levels of consumption here, I - we were talking about, Neal, I think it's important to recognize are way above the levels of consumption that we would use to define moderate drinking.
So the message here is not about prevention of moderate drinking. It's about the prevention of people drinking too much, and with binge drinking being by far the most common pattern of excessive drinking in the U.S.
CONAN: And let me ask you a question. You talked about our culture and, indeed, you're right. But how do you change that?
BREWER: Well, you know, again, I think we can learn a lot of lessons from our experience with tobacco control. And I don't think - to get to Dr. Johnson's point - that the endgame here is necessarily to say that people shouldn't drink at all. There are certainly some people who should not drink at all. And I'm sure Dr. Johnson would agree that people who are in recovery, for example, from alcohol dependence would be among those who may - for whom it may be important if they don't drink at all; underage youth, pregnant women.
But by and large for the population, what we're talking about, again, is trying to prevent people from drinking too much. So how do we do that? Well, there are a number of strategies that have been shown to be effective, and I'm talking about, based on scientific evidence here. One of the key ones is looking at the price of alcoholic beverages. And we know that people's alcohol consumption is very sensitive to price. If the price goes up, consumption tends to go down, just as it's true with many different products. The availability of alcohol, again, is a key thing. If you're in an area that has a very high concentration of alcohol establishments - retail alcohol establishments, bars, liquor stores within a small geographic area - that tends to be associated with higher rates of alcohol consumption and with more problems related to it. The age 21, minimum legal drinking age, that one of your callers talked about is also another very effective strategy to reduce access to alcohol, particularly among young people. So there are actually a number of different things that we can do as a society for which science has told us, and really make a very significant difference on reducing excessive drinking.
CONAN: And if it seems fantasy land to change those things, go back and look at an episode of "Mad Men" or the new film "Tinker, Tailor, Soldier, Spy" and look how much smoking has changed in our culture over a few decades and realize these things are possible to do. Dr. Brewer, thanks very much for your time today.
BREWER: Thank you so much. I really appreciate being on your program, Neal.
CONAN: Dr. Robert Brewer is the lead of the alcohol program of the CDC in Atlanta. And our thanks as well to Dr. Bankole Johnson, professor and chair at the Department of Psychiatry and Neurobehavioral Sciences at the University of Virginia. Thanks very much for coming in.
JOHNSON: Thank you so much, Neal.
CONAN: When we come back, we'll turn back the clock to August 1963, when Martin Luther King Jr. stepped up to the podium on the steps of the Lincoln Memorial and delivered one of the most important speeches of the 20th century. Stay with us. I'm Neal Conan. It's the TALK OF THE NATION from NPR News.
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