US deaths from alcohol related liver disease is at its highest rate since 1999, according to Reuters (11/29, Mathias). The incidence has steadily increased since 2006 and is seen across all ethnicities. A rise has been in seen in patients aged 25-34 years old. I have noticed this trend in my own experience in treating inpatients with alcohol related liver disease. My concern, is that alcohol may be the next epidemic…following in the footsteps of the obesity epidemic. Unfortunately, alcohol and obesity together cause accelerated liver disease.
So, how much can you drink?
The American Society for the study of Liver Disease (last update published in 7/2019) suggests a threshold of no more than 2 standard drinks per 24 hr in men and no more than 1 standard drink per 24 hr in women, in those without known liver disease. This guideline is in conjunction with the US Department of Health and Human Services and US Department of Agriculture. This equates to 14 drinks in a week for men and 7 drinks in a week for women. Binge drinking is also advised against by the National Institute of Alcohol Abuse and Alcoholism, and this is defined by 5 or more drinks over 2 hr in men and 4 or more drinks over 2 hr in women. There is no known safe drinking amount if you have underlying liver disease from any cause.
Now for the obesity/metabolic syndrome adjunct. If you are obese, have insulin resistance/diabetes, hypertension, dyslipidemia or any combination qualifying as the metabolic syndrome, you could be at risk for non-alcoholic fatty liver disease (NAFLD). Even if you don’t drink alcohol, fat can deposit in the liver and start an inflammatory process. Over time, this can lead to scarring in the liver and cirrhosis.
If you have risk factors for NAFLD, I would discuss this with your primary care physician who may refer you to a gastroenterologist. It may be wise to limit alcohol intake to below the levels listed above...or abstain from it altogether.
What is a standard drink?
12 oz beer: (5% alcohol)
8-9 oz malt liquor: (7% alcohol)
5 oz table wine: (12% alcohol)
3-4 oz of fortified wine (sherry or port): (17% alcohol)
2-3 oz of cordial liqueur or aperitif: (24% alcohol)
1.5 oz distilled spirits or brandy: (40% alcohol)
How to know if your drinking is excessive and possibly harmful?
Take the test: The AUDIT-C and AUDIT 10 question calculators can be found online.
Putting it into practice
So, all of this is informational at best, but putting it into practice to cut back on drinking seems unattainable for many. Alcohol has become such a mainstream part of our culture. It’s acceptable to drink at any time of day: bloody Mary at breakfast, beer with your burger at lunch, and wine to complement dinner. We drink to socialize and to celebrate. We also drink when we are sad, anxious, or stressed. I first advise being aware of the amount you’re drinking. Write it down, because it’s easy to lose track, for obvious reasons. Recognize what a standard drink is (this does vary based on country) and use a measuring device with ounces to have an accurate assessment of your intake. Of note, my husband uses a Medela baby bottle for this purpose! There are also wine glasses with a line indentation, or my favorite is the solo cup:
Then be deliberate in your drinking. Know ahead of time if you plan on drinking and how much. Be able to say no even when you are offered a drink. Know your reasons why you want to cut back, and have a STRONG why.
I will never forget when I was out with my husband on a date night, and I felt a burning pain in my chest. I didn’t want to finish my meal, or even talk. I wanted to go home and curl up in the fetal position. Hello heartburn at 38 years old! That just added to the headaches and hangovers, even with just 2 glasses of wine. I went on to test out different types of alcohol and amounts, but most of the time, it affected me in negative ways. There came a point when I no longer desired alcohol. What I did desire was a good night sleep and waking up, feeling fresh in the morning.
Although it took me several months, mostly because I felt like a social outcast for not drinking alcohol in company, I now easily refuse it. Now, when I’m offered a drink, I say no thank you without explanation. This is not out of some crazy will power. It’s actually easy for me because I truly don’t want it!
Ok let’s go to the other side...drinking to escape or buffer negative emotions. Here’s something to think about: what if we felt our emotions in the raw? I dare you to try and feel your emotions, rather than drink them or eat them away. Let’s try to be adults! I promise that those problems and feelings don’t go away, but are just postponed. An emotion is just a vibration or sensation in your body. Some people feel a tightening in their stomach, a racing heart, or a restlessness. I would first take a few slow deep breaths. Ask yourself what thoughts have led to the emotion or feeling. Are those thoughts true? Often, the exact opposite thought can have validity. Asking yourself questions, will help you come up with answers. Remember, you can choose your thoughts on purpose and be sure to sprinkle in some positive ones!
There is a podcast by Rachel Hart who you may want to subscribe to if you have a hard time cutting back on alcohol on your own. You should also seek the help of a mental health provider or primary care physician if you use alcohol to treat possible underlying anxiety, depression, pain or insomnia.
Those with addiction or alcohol related liver disease should seek the help of medical professionals. A multi-disciplinary approach is often most successful to help this patient population. There are 3 FDA approved medications (Acamprosate, Naltrexone, and Disulfiram) and a non-FDA approved medication (Baclofen) that can aid in achieving alcohol abstinence and in preventing relapse. Behavioral therapists/mental health providers, hepatologists/gastroenterologists and primary care physicians should all be involved in the treatment of this group of patients.
However, the first step has to come from you. It’s within your decision-making capacity to do what’s right for you and to make that change. Know that there is a myriad of resources and help to support you along the way!
References
American Association for The Study of Liver Diseases. (2019). Diagnosis and Treatment of Alcohol-Related Liver Disease: 2019 Practice Guidance from the American Association for the Study of Liver Diseases. Retrieved from https://aasldpubs.onlinelibrary.wiley.com/doi/abs/10.1002/hep.30866
Mathias, T. (2019, November 29). Drinking-related liver disease and deaths on the rise in U.S. Reuters. Retrieved from https://www.reuters.com/article/us-health-alcohol-liver-mortality/drinking-related-liver-disease-and-deaths-on-the-rise-in-u-s-idUSKBN1Y32AL
Mukamal, K.J. (2019). Overview of the risks and benefits of alcohol consumption. In L. Kunins, (Ed.), UpToDate. Available from https://www.uptodate.com/contents/overview-of-the-risks-and-benefits-of-alcohol-consumption?search=standard%20drink%20alcohol&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2.