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The Sick-Quitter Effect: How Alcohol Can Seem Cardioprotective When It Isn't

Christopher Labos, MD, CM, MSc

Disclosures

June 29, 2021

People ask me if they should drink more red wine. They ask me this repeatedly. Ever since 60 Minutes ran their story on the French Paradox, people are fixated on the idea that red wine can lower your risk of having a heart attack even if everything else in your life is going wrong. You can smoke and eat unhealthy food, but somehow red wine will fix all that. It won't, of course, and for one very simple reason: The French Paradox, like most medical paradoxes, is a statistical anomaly and is most certainly not true.

The most fascinating thing about the French Paradox is that it has persisted for this long. For years, physicians and health groups have talked about the negative health impacts of alcohol. Notwithstanding the problem of drinking and driving, we need to remember that alcohol itself is inherently unhealthy.

First, wine and most alcoholic drinks are high in sugar. So drinking regularly results in excess calorie consumption and weight gain. It is not by accident that we refer to it as beer belly and not celery belly. In fact, anyone looking to lose weight can probably make a good start by cutting out alcohol and other sugary drinks from their diet.

In large amounts over the long term, alcohol will cause liver damage and cirrhosis. It increases the risk for cancer, particularly breast cancer, and large amounts of alcohol can also be toxic to cardiac myocytes and cause a form of heart failure known as alcohol cardiomyopathy. Excessive drinking has also given rise to the "holiday heart" syndrome, a condition where people decide to overindulge during the holidays or while on vacation and then develop sudden arrhythmias. Alcohol's ability to induce palpitations or more severe arrhythmias has been fairly well established. A recent Australian study published in The New England Journal of Medicine took subjects with established atrial fibrillation (AF) and randomized them to either maintaining their current drinking habits or to abstinence. While the abstinence group were not perfect teetotalers, they did substantially reduce their average alcohol consumption from 16 to two drinks per week and saw a large reduction in their AF burden and risk for AF recurrence when they did so. There is substantial evidence that alcohol negatively impacts your health and that cutting back is good for you. And yet, the myth of alcohol's health properties survives.

The issue stems from the observation that people who drink no alcohol tend to be at higher risk than people who drink moderate amounts of alcohol on a regular basis. There are a number of issues here, not the least of which is the fact people often overestimate what moderate alcohol consumption actually means. The idea that a standard bottle of wine should contain five servings of wine seems ridiculous to anyone that has hosted a dinner party.

Another issue is the terms we use. When you compare drinkers to non-drinkers, you always have to make a key distinction. There might be many reasons why someone doesn't drink alcohol. There may be religious or cultural reasons why someone doesn't drink, and in some circumstances there may be medical reasons why someone abstains from alcohol. For example, someone who develops liver disease or atrial fibrillation, or has found themselves inching toward early-stage diabetes because of gradual weight gain, might be advised by their doctor to quit. Herein lays the issue. There is a difference between people who have never drunk alcohol and people who used to drink alcohol and now quit. There is essentially a distinction to make between never drinkers and former drinkers.

The key here is that former drinkers are fundamentally at higher risk than the general population. In essence, they have already developed a chronic disease which puts them at higher risk for adverse outcomes. Someone who has already developed some form of heart disease is obviously more likely to have a complication than someone from the general population. By mixing former drinkers with never drinkers, a study will make those who abstain from alcohol seem to be at higher risk than the general population that drinks just a small amount on a regular basis. There is a name for this phenomenon and it is called the sick-quitter effect. It basically implies that people don't get sick because they abstain from alcohol; they abstain from alcohol because they got sick.

There are ways to correct for this statistical phenomenon. In 2019, researchers used a research technique called Mendelian randomization to look at genetic factors that can predict a person's alcohol consumption. They found no protective effect to alcohol and indeed found that the risk goes up the more you drink. Recently researchers also found that increasing alcohol consumption accelerates age-related changes in the brain.

Although it has been stated before, it is time to acknowledge that alcohol is not a health food. It has numerous negative health effects, and the safest amount of alcohol to consume is none. People will naturally bristle at this suggestion, but the point is not to resurrect the idea of prohibition but rather to acknowledge that alcohol is an indulgence and should be treated as such. If you enjoy drinking it and aren't planning to drive anywhere, you can drink alcohol in the same way that you can eat potato chips or have some ice cream. It tastes good but you aren't doing yourself any favors in the long term, even if you are French.

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About Dr Christopher Labos
Christopher Labos is a cardiologist with a degree in epidemiology. He spends most of his time doing things that he doesn't get paid for, like research, teaching, and podcasting. Occasionally he finds time to practice cardiology to pay the rent. He realizes that half of his research findings will be disproved in 5 years; he just doesn't know which half. He is a regular contributor to the Montreal Gazette, CJAD radio, CBC Morning Live and CTV television in Montreal.

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