14 ACPINTERNIST PATIENT COMMUNICATION

Alcohol continued from page 1 Cancer Society, the American Society of About 30% of the U.S. population misuses Clinical Oncology, and the American Heart Standard drink equivalents alcohol, according to a report from the U.S. Association all recommend no more than Preventive Services Task Force (USPSTF) one drink per day for women and one to published in the Sept. 25, 2012, Annals of two for men. Beer or cooler 12 oz = 1 Internal Medicine . The USPSTF reported that The definition of a drink in all of the 12 oz, 16 oz = 1.3 21.3% of patients in primary care are risky recommendations is 12 oz of regular beer ~5% alcohol 22 oz = 2 drinkers who consume on average more than (which contains about 5% alcohol), 5 oz of 40 oz = 3.3 four drinks per day if they are men or more red or white table wine (about 12% alco - than two drinks per day if they are women. hol), or 1.5 oz of 80-proof spirits (about 40% “The topic of alcohol habits should be alcohol). Those standard-size drinks each Malt liquor 12 oz = 1.5 asked by every health practitioner of every contain about 12.5 to 15 mL of pure ethyl 8-9 oz, 16 oz = 2 patient who comes for care,” said Arthur alcohol (see chart at right). ~7% alcohol 22 oz = 2.5 Klatsky, MD, FACP, adjunct investigator at Understanding the difference between 40 oz = 4.5 the Kaiser Permanente Northern California serving size and alcohol content is impor - Division of Research and senior consultant tant. Anyone tempted to drink a glass of the in cardiology at Kaiser Permanente. “These new Scottish beer Armageddon, with a Table wine A 750-mL (25-oz) questions about alcohol consumption reported 65% alcohol content, should 5 oz, bottle = 5 should be asked routinely, objectively, non - understand that just one 330-mL (11.6-oz) ~12% alcohol judgmentally, just like questions are asked bottle of that beer far exceeds the total about smoking and family history.” weekly limit for women and is close to the total weekly limit for men. 80-proof spirits A mixed drink = 1 or more* Recommended guidelines Although the effects of alcohol are some - (hard liquor), A pint (16 oz) = 11 The messages about alcohol consump - what tied to body mass, the daily/weekly 1.5 oz, A fifth (25 oz) = 17 tion continue to be confusing, but alcohol recommendations are gender- ~40% alcohol 1.75 L (59 oz) = 39 internists can help patients sift through based for a reason. Women have less water that information. They should start by: in their bodies than men and also have * Depending on factors such as the type of spirits and the recipe, one mixed drink can contain I explaining what is currently known lower levels of the enzyme that metabolizes from one to three or more standard drinks. Source: National Institute on Alcohol Abuse and Alcoholism. about the benefits and risks, alcohol. They therefore experience higher http://pubs.niaaa.nih.gov/publications/Practitioner/pocketguide/pocket_guide2.htm I providing information about the blood alcohol concentrations than men who recommended daily and weekly limits, and consume similar amounts of ethanol/kg of I educating patients about how age, body weight, according to Dr. O’Connor’s drinking are high-risk behaviors for car - A report in Heart Rhythm in 2011 about gender, medical and family history, and the chapter on alcohol abuse and dependence diovascular mortality and cancer, light to the risk of sudden cardiac death (SCD) in effect of alcohol when combined with cer - in Goldman’s Cecil Medicine, 24th edition . moderate drinking has been found to be women reported that the lowest risk tain medications should be considered in The recommendations make no dis - cardioprotective for certain people at cer - occurred among those who consumed their decision making. tinction between red and white wine and tain ages, said Dr. Klatsky. approximately one-half to one drink per The National Institute on Alcohol other types of alcohol because they all In a 2010 article in Physiology & day. Their risk was 36% lower when com - Abuse and Alcoholism (NIAAA) recom - con tain ethanol, and it’s the ethanol that Behavior , he noted that nearly all epidemi - pared with abstainers. mends three or fewer standard drinks per makes the difference. A common miscon - ologic studies have found a reduced risk of The authors said that the results sup - day ( ≤seven per week) for women and any - ception is that red wine’s resveratrol or acute myocardial infarction and coronary port evidence that consumption by women one older than age 65, and four or fewer phe nolic content makes it the more artery disease death in moderate drinkers of up to one drink per day is related to lower standard drinks per day ( ≤14 per week) for health ful choice, but that argument is compared with abstainers. This reduced risk risk of not only SCD but also coronary heart men younger than age 65. In other words, over stated, Dr. Klatsky said: “The longevity is attributed to an increased level of high- disease (CHD), stroke and congestive heart it recommends no more than seven drinks studies in animal models require huge doses density lipoprotein cholesterol conferred failure. Higher intake, they said, may be per week for women, without exceeding that you cannot possibly do.” by alcohol, thus limiting plaque buildup in associated with lower risk of overall CHD three drinks on any day, and no more than blood vessel walls. Alcohol also seems to but also a greater risk of atrial fibrillation, 14 per week for men, without exceeding Cardiovascular benefit inhibit several promoters of clotting, stroke and cancer. four drinks on any day. The American Although heavy drinking and binge including platelet stickiness and fibrinogen levels, according to Dr. Klatsky. Cancer risk “If you study a young population, you There’s a clear link between alcohol Additional reading are not going to see any benefit because consumption and cancer risk, and no data they don’t die of coronary disease or get suggest that alcohol would be helpful for Allen NE, Beral V, Casabonne D, Kan SW, causality, bias, or a bit of both? Vasc Health heart attacks very often, particularly young cancer prevention, according to Wendy Y. Reeves GK, Brown A, et al; Million Risk Manag. 2006;2:239-49. [PMID: 17326330] women. But if you study middle-aged and Chen, MD, MPH, a medical oncologist at Women Study C ollaborators. Moderate Jonas DE, Garbutt JC, Amick HR, Brown older men, then the benefit [of light to Dana-Farber Cancer Institute in Boston and alcohol intake and cancer incidence in JM, Brownley KA, Council CL, et al. moderate alco hol consumption] will be first author of a paper about moderate alco - women. J Natl Cancer Inst. 2009;101:296- Behavioral counseling after screening more apparent,” he said. hol consumption and breast cancer risk 305. [PMID: 19244173] for alcohol misuse in primary care: A The increased risk of breast cancer in published in Journal of the American Medical Breslow RA, Chen CM, Graubard BI, sys tematic review and meta-analysis for moderate female drinkers outweighs any of Association in 2011 . Mukamal KJ. Prospective study of alcohol the U.S. Preventive Services Task Force. the cardiovascular benefit of alcohol in “There is clearly a dose-response rela - consumption quantity and frequency and Ann Intern Med. 2012. [PMID: 23007881] women younger than age 50, but in post - tionship between people developing breast cancer-specific mortality in the US popula - Klatsky AL. Alcohol and cardiovascular menopausal women the cardiovascular cancer for the first time and alcohol con - tion. Am J Epidemiol. 2011;174:1044-53. health. Physiol Behav. 2010;100:76-81. benefit for total mortality outweighs the sumption, regardless of whether it’s wine, [PMID: 21965184] [PMID: 20045009] breast cancer risk, Dr. Klatsky said. beer or liquor,” she said. Drinking patterns also have been The research by Dr. Chen and col - Chen WY, Rosner B, Hankinson SE, Klatsky AL. Alcohol and cardiovascular linked with cardiovascular benefit and risk. leagues was based on long-term data from Colditz GA, Willett WC. Moderate alcohol mortality: common sense and scientific A 2006 article in Vascular Health and Risk the Nurses’ Health Study. They found that consumption during adult life, drinking truth [Editorial]. J Am Coll Cardiol. Management reported that drinking with consumption of three to six drinks per week patterns, and breast cancer risk. JAMA. 2010;55:1336-8. [PMID: 20338494] 2011;306:1884-90. [PMID: 22045766] meals seems to have a beneficial effect on was modestly but significantly associated National Institute on Alcohol Abuse and cardiovascular risk, possibly due to the with a 15% increased risk of breast cancer. Chiuve SE, Rimm EB, Mukamal KJ, Rexrode Alcoholism. Harmful Interactions: Mixing effect on blood pressure, thrombotic factors Women who consumed at least two drinks KM, Stampfer MJ, Manson JE, et al. Light- Alcohol with Medicines . http://pubs.niaaa.nih. or lipids. The article noted that light to per day had a 51% increased risk compared to-moderate alcohol consumption and risk gov/publications/Medicine/medicine.htm moderate drinking seems to reduce major with women who never consumed alcohol. of sudden cardiac death in women. Heart O’Connor PG. Alcohol abuse and depend - vascular risk in middle-aged people by Drinking in both early and later life was Rhythm. 2010;7:1374-80. [PMID: 20638933] ence. In: Goldman L, Schafer AI. Goldman’s about 20%, which includes a reduction in independently associated with breast can - Emberson JR, Bennett DA. Effect of alcohol Cecil Medicine. 24th ed. Philadelphia: risk of ischemic stroke. Binge drinking, cer risk, and there was a modest association on risk of coronary heart disease and stroke : Saunders; 2012:146-53. however, is linked with increased cardio - vascular risk. See Alcohol , page 15