Remember When We All Believed In The J-Curve?

What is it in alcohol that makes people so strident, so binary? Oh, I forgot. It’s the alcohol. Which is what I thought again to myself as I read many of the reactions to the news from the UK’s leading medical journal, The Lancet, that a diet that includes a rather moderate amount of regular alcohol intake is not a very good diet if you like the quantitative aspect of life. Here is the summary of the study’s findings:

In the 599 912 current drinkers included in the analysis, we recorded 40 310 deaths and 39 018 incident cardiovascular disease events during 5·4 million person-years of follow-up. For all-cause mortality, we recorded a positive and curvilinear association with the level of alcohol consumption, with the minimum mortality risk around or below 100 g per week. Alcohol consumption was roughly linearly associated with a higher risk of stroke (HR per 100 g per week higher consumption 1·14, 95% CI, 1·10–1·17), coronary disease excluding myocardial infarction (1·06, 1·00–1·11), heart failure (1·09, 1·03–1·15), fatal hypertensive disease (1·24, 1·15–1·33); and fatal aortic aneurysm (1·15, 1·03–1·28). By contrast, increased alcohol consumption was log-linearly associated with a lower risk of myocardial infarction (HR 0·94, 0·91–0·97). In comparison to those who reported drinking >0–≤100 g per week, those who reported drinking >100–≤200 g per week, >200–≤350 g per week, or >350 g per week had lower life expectancy at age 40 years of approximately 6 months, 1–2 years, or 4–5 years, respectively.

The great thing about this study is that it is a study of all the bad stuff. In addition to using grams of alcohol instead of some useless “standard unit” measure, it does not cherry pick. From time to time you will see a beer trade consultant argue that there is a health benefit to drinking alcohol that leverages the idea up there of the log-linearly association with a lower risk of myocardial infarction. Heart disease. To dress it up, the talking head will reference “the J-Curve” to impress that this is a masonic like bit of secret information that has to be received on the basis of trust rather knowledge.* Belief over fact. Sometimes the idea actually is presented compellingly.

The most important thing to understand is that it is both true and not true at all. The J-Curve requires having a preference to not suffer from one particular set of diseases related to the heart. I know of no one who thinks that way: “I don’t mind recovering from this mid-60s bout of cancer but I will be damned if I have that mild heart attack that sets me back for a bit until I get my house in order.” But, just as craft loves to award itself first prize when it comes to harm avoidance, the booze trade loves the J-Curve.

No, it’s about overall health and the balancing of it off against overall fun. I turn 55 next week and have had my share of boozy fun, happily more and more in my further past. It’s nice to have the memories – even some of the ones that make you cringe – because the alternative to having the memories is not all that great. I had an acquaintance twenty years ago who was a regular smokey-drinky after work guy. Bob. Bob hit 50 around 1996 and would say he liked to live his live as he wanted. He’d bring that up, between phlegm sputtery coughs, most times I was out in his company. He died around age 52. No J-Curve miracle for Bob.

Max, as usual, has the more realistic view, expressed on Facebook this morning:

I don’t think having a drink every now and again is bad for you, any more than it is having a fag or a joint every now and again, but I am not convinced it is any good, either (at least physiologically) and I am equally skeptical about the conclusions of the linked article as I am about those from pieces touting the health benefits of having a pint or a glass of wine a day. And yes, I drink more than I probably should, but I do it because I like it and not because I expect any health benefit.

It’s a trade-off. Which is what the study in The Lancet is saying. If you have 200 grams of alcohol a week, well, on average that’s going to knock half a year off your life span. That’s about a 12 pack of 5% beer in 12 ounce bottles. Double that amount to about 24 bottles a week and you might be looking at a life that is shortened by four years or eight times that six months.

Now, without getting too much into the details, I have had the opportunity to work with the older and, occasionally, the dying as part of my career. I have taken a death will from someone who passed 30 minutes later. Not fun. Yet, quite important to that person and quite humbling for me. My impression is that once one gets to a certain point in years the “fun v. years” trade-off is worth it. You think “so maybe I die in October and not next April… I’ve had a good run.” My own father basically said that, even though the cause in his case was not the perils of alcohol but the perils of being freckled and living within the range of the sun’s rays. I might even go so far as to say that magic number for this sort of reflection might kick in when you get in view of your eightieth birthday – or perhaps it’s getting to 90% of your expected longevity based on your relatives. Not the Bob-span. Much more than that.

Yet note one other thing. This is from a twitter discussion amongst stats geeks reading the report in The Lancet:

Of 100 people drinking 14 units a week, 99 people will not die due to alcohol and 1 will. That 1 person loses 37 years of life. The remainder obviously lose 0 years. The average across the 100 people comes out at 0.3 years lose.

The distribution of the ill effects of too much drink is not consistent, not fairly distributed, whatever fair means. So much more important than either the J-Curve effect and even the average number of drinks is luck of the draw. You know you are shortening your life but the degree to which it is shortened is case specific. Based on you. And whatever it is you did. [What did I do? Yikes!]

Sometimes I ask myself whether at some point in my retirement I might take up smoking. Or add much more unctuously satisfying animal fat to my diet. Statistically, if I get to 73 or 76 I might as well as I won’t shift my likely outcome in terms of the quantity of my remaining years all that much. I fancy sticking a pipe in my pocket, a leather pouch of a cherry infused tobacco. Once in a while. Not Bob-like smoking. Something more sensible. No rush. That’s a couple of decades off yet. If I make it. If I haven’t already played all the strong suit cards I was dealt.

I think there is a lot of good news in this report. While the overall detrimental effect on health is steady, the line on the graph does not take off at an entirely unexpected pace. And, as the graphs do  not record longevity into the triple digits, there is a implicit reminder that we are all ending up in the same place eventually. So, it is a “fun v. years” calculation. Finding that point of balance. Unless it isn’t about fun for you. Or if you are a Bob. Or Bob. Good stuff to consider, maybe even over a beer or two this weekend.

*Trust me. I am a lapsed Mason.