Alcohol: how bad is it?

The news media have been filled with reactions to the U.S. Surgeon General’s recent pronouncement that alcohol was a major cancer risk, and that alcoholic beverages should carry a cancer warning label like that on cigarette packages. (Ireland currently requires such warning labels.)

The World Health Organizations estimates that about 4% of cancers worldwide are alcohol-related.

The long-touted heart protective effects of alcohol have been questioned.

What should you believe?

First, some definitions. A “standard” drink is defined as 5 ounces of wine, 12 of beer and 1.5 ounces of liquor.

Women metabolize alcohol differently than men, and so have higher blood levels than men from the same amount consumed.

Almost all studies of the effects of alcohol on health are flawed.

First, they depend on self-reported consumption. Since many, if not most, people know that heavy drinking is not good, there is a strong tendency to under-report what you drink.

Second, they are observational: groups are followed and their health outcomes studied. We know that this type of study is prone to bias. People who drink alcohol may have many other habits that non-drinkers do not share, such as smoking.

Alcohol consumption has been linked to higher incidences of head and neck cancer, liver cancer, colorectal cancer, esophageal cancer and breast cancer.

Even the most toxic of substances only cause harm at threshold doses, and for most toxins, the more, the worse. Consistent with this, the National Academy of Medicine estimated that 2 drinks/week would shorten your life by less than a week, 7 drinks/week would shorten your life by 2.5 months while 5 drinks/day would shorten it by over two years.

A recent study from Spain shed fascinating light on wine and the heart. Rather than ask subjects how much they drank, they took urine samples and measured metabolites of wine to objectively estimate how much they drank. They found that light-to-moderate drinkers (from ½ to 1 glass/day) had 50% fewer cardiac events over 6 years of follow-up. This protective effect disappeared in those who drank more than 1 glass/day.

My take-aways:

If you do not drink, there is no reason to start. There are no net health benefits to drinking.

If you drink heavily (more than 2 drinks/day for men, 1/day for women), please cut down. You are harming yourself.

If you enjoy a glass of wine a few times a week, relax. The slight increased cancer risk is probably balanced by less heart disease.

The Greeks had it right: all things in moderation.



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Norovirus - what you need to know

There are many gastrointestinal infections that spread person-to-person, including E. coli, salmonella and listeria, but by far the most common is the norovirus.

Norovirus typically infects some 20 million people in the U.S. every year, and this winter has seen an increase in reported outbreaks.

The virus is highly transmissible, resistant to alcohol (the active ingredient in most hand sanitizers) and heat, and persists for many days on surfaces such as counters.

Places where people are in close quarters and sharing food preparation are particularly prone to outbreaks: cruise ships, nursing homes, schools and day care centers.

The symptoms: nausea, vomiting, cramps and diarrhea, usually begin very abruptly – you feel fine one minute and then all the symptoms hit you. If there is a fever, it is usually low-grade. The symptoms generally only last 2-3 days and most people recover uneventfully.

There is no specific treatment; antibiotics are of no use. The most important therapy is fluids to prevent dehydration. Adults can drink plain water, tea, sports drinks or light fruit juices. Children will benefit from pediatric-tailored electrolyte solutions.

While most healthy people will do fine at home taking frequent small amounts of fluid, an ER visit or even hospitalization may be needed if you cannot keep down liquids.

A persistent fever of 101 or more is unusual and warrants at least a call to your doctor. Blood in the stool is also not expected and should prompt medical attention.

The best way to avoid catching norovirus is good hand-washing before you eat or prepare food, and cleaning surfaces with bleach if they may have been exposed to virus particles.

Note that virus may be shed in the stool for up to two weeks, long after you have recovered, so be careful if you have had such symptoms to wash well after using the toilet and you had best not handle food.

Norovirus has also spread via shellfish and other food. Cook shellfish to an internal temperature of over 145 F and wash all fresh fruits and vegetables.

If you do catch it, remember that “this too shall pass.”



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The Annual Physical: Time Well-spent or a Waste of Time?

About 78% of U.S. adults, including 68% of adults under 45, reported seeing a doctor in the last year for a wellness check.

Is this a good use of your and your doctor’s time?

Academic studies of the value of the annual physical exam (APE) have focused on whether doing this saves lives. Here the evidence is mixed. An analysis of many large observational studies reported an impressive 45% reduction in mortality comparing those who had vs. those who did not have an APE.

As regular readers know, this type of study is often misleading. People who have an APE are likely to be more health-conscious and have better health habits than those who do not. Smaller randomized trials of APE/no APE found very little mortality benefit.

Why might an APE help you live longer? It is an opportunity for your doctor to review your overall health rather than focusing on a specific problem. It is the ideal time to discuss and perform (immunizations, pap smears) or schedule (colonoscopy, cholesterol blood tests) important preventive health measures.

In a young healthy person, the traditional head-to-toe physical is unlikely to find new conditions, but focused exams may. It is a great time for a skin check looking for cancer and to measure BMI and discuss weight if it is a problem. High blood pressure is generally a symptomless condition until far advanced and blood pressure should be checked annually.

An APE is also a good time to discuss sleep, diet and exercise and mental health. Smoking and alcohol use should also be discussed. Older adults may want to bring up hearing issues.

So, if you are a young adult who feels fine, and you are aware of the importance of good habits, you can probably skip the “routine physical.” If you do, be sure to get your blood pressure checked when you go in for a problem-focused visit and that you have had your cholesterol checked within memory.

If you are at risk for such chronic conditions as hypertension, diabetes or heart disease because of your weight or family history, schedule that visit.

If you are 50+ it is worth doing even if you feel fine; the biggest risk factor for many conditions is simply aging.

An APE is also a good time to be sure you and your doctor get along and review how their office works, including off-hour availability.

For many, a normal physical can also be reassuring.



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Fluoride - Friend or Foe?

Among the controversies around public health, fluoridation of the public water supply ranks second behind vaccination. The nominee for Secretary for Health and Human Services wants to remove it. Is that a good idea?

The major benefit of fluoride is that it dramatically reduces dental cavities in children and to a lesser extent in adults also. In 1945 Grand Rapids, MI, became the first city in the world to add fluoride to its water. Dental cavities in children living there have dropped by more than 60% since that was done. Calgary, Alberta, stopped fluoridation and the rate of cavities in children doubled.

Canadian, Australian and U.S. dental societies support fluoridation, though most European countries have stopped mandating fluoridation. Most dentists also recommend topical fluoride, including fluoride in toothpaste, which fights plaque but does not reduce cavities.

What are the hazards? Very high levels of fluoride can lead to bone disease and staining of teeth.

(I must note that very high levels of almost anything can be harmful. Marathon runners and others have died from drinking too much water.)

The biggest concern is that studies have suggested that when mothers drink fluoridated water, their children have lower IQs. These studies were done in regions of Asia and Mexico where naturally occurring levels of fluoride in water are very high. None were done in U.S. communities that had fluoridation programs.

Good studies show that there is no harm to animals or humans from levels up to 10 times the usual consumption of fluoride.

The FDA has recommended a very conservative level of 0.7 mg/liter in the public water supply, a level that maximizes benefit while minimizing risk. In the U.S., about 85% of communities fell in that range.

How can you know? In most of the U.S. and Canada, fluoridation is a local decision. Call your town’s Department of Public Works. If your town adds fluoride they should know, and indeed should publish that data annually. Not every state requires fluoride be added, and if it is not added testing will probably not be done.

If you use well water, you can arrange for private testing.

What about fluoride in toothpaste? If it is not swallowed, very little gets into the body. If you have children too young to follow the advice not to swallow, put a very small amount (less than 1/8 inch) on the toothbrush yourself.

If you are pregnant and worried, you can buy deionized water to drink during your pregnancy.

So, proven benefit for children’s teeth or very unlikely effect on their IQ? You decide.



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What shots does an adult need?

Much of the discussion around vaccines focuses on children, who get a large number in their early years, but adults also benefit from appropriate vaccination.

Which shots should you be discussing with your doctor?

People of any age should get an annual flu shot. Influenza is a serious illness, not just a bad cold, and older adults may be hospitalized or die from influenza. The efficacy of the shot varies year to year, as the CDC must make an educated guess as to which strains will circulate, but even partial immunity is better than none.

A bonus is that those who get their flu shot are less likely to suffer heart attacks.

COVID – yes, that old virus is still around. It has mutated enough that the vaccine you got a year or two ago is no longer that protective. The only vaccine available is the newer one, and you should get it.

Shingles is a very unpleasant illness that you do not catch from others; it is the virus that caused your chicken pox when you were a child and remained dormant in your body ever since. As we age and our immune system weakens, the virus can flare up. It causes a very painful rash which can go on to a persisting nerve pain for months or years after the rash clears. The 2-shot series is highly protective and is given once if you are 50 or over.

The shingles vaccine is associated with a decreased risk of dementia, an added inducement to get it.

The pneumococcus is a bacterium that causes pneumonia in many and meningitis in some. There have been many different vaccines and the subject of which vaccine(s) to get deserves its own column – discuss it with your doctor. Bring the record of any you have received.

RSV causes severe disease in infants. In adults it is usually just a cold, but if you have weak lungs or heart failure or are elderly, it can cause more severe illness. The new vaccine seems to be a one-time only shot that is worth considering.

Tetanus boosters are recommended every 10 years and are usually combined with either diphtheria or diphtheria and whooping cough. If you have new grandchildren, getting the DPT will protect them as well if you will be close to them.

A stitch in time saves nine, and the right shots can save you from serious illness.



If you enjoy these posts, you might want to also receive those done by my medical school classmate, Dr. Steven Kanner. Check out https://drkanner.com



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Killing Brian Thompson will not solve America's health care problems

The fatal shooting of UnitedHealthcare CEO Brian Thompson as he headed to a shareholder meeting should not have come as a surprise. The U.S. is a gun-obsessed culture and leads the world in gun fatalities. What was more shocking was the outpouring of “he had it coming” posts on social media.

Whether or not the killer was motivated by a personal experience with United, the numerous posts referenced people’s rage at the health insurance industry.

Should we be surprised?

Recent years have seen health insurance rates soar and out-of-pocket costs skyrocket. Even those with employer-provided health insurance are often unable to pay for needed care as deductibles and copays keep rising.

At the same time, the industry has had one black eye after another, with multiple insurers in the news.

Private health insurance companies offering Medicare Advantage plans routinely overstate the health problems of their enrollees to get unjustified extra payments from the government.

A former Aetna medical director admitted under oath that he never looked at patients’ records when deciding whether to approve or deny care but simply rubber-stamped the nurse reviewers’ decisions.

United was castigated by a Senate committee for using algorithms to deny care and it was noted that the denial rate for rehab care after hospitalization rose from 10.9% in 2020 to 22.7% in 2022.

Denying care is good for insurers’ profits, and these profits flow into executive salaries. The CEOs of America’s six largest health insurers took home a total of $122,970,614 in total compensation in 2023.

Taking money from employers and individuals and paying medical bills is not rocket science and does not warrant sky-high profits. Medicare operates with an overhead of about 3% while private insurers charge 15% or more.

As I document in my book, some 25% of U.S. “health care” expenditure does not go to health care but to administrative overhead.

We need to get the excess profits out of health insurance companies and put that money towards patient care.

Shooting one CEO will not change the culture. We must hold our legislators’ feet to the fire and get the excess profits out of health insurance, whether at the state or the federal level.



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When is it time to take away the car keys?

Our ability to safely drive varies enormously. Even though 75% of surveyed drivers felt that their skill behind the wheel was in the top 25%, statistics do apply, and 25% of us are in the bottom 25%.

Many factors determine whether someone should still be driving a car. Teens and young adults tend to take more risks than older drivers while older drivers have poorer vision, slower reaction time, are likely to be taking medication that may compromise driving safety and are at greater risk of cognitive decline.

The latest survey available showed that in 2020, 59% of people 85 and older in the U.S. still had their driving license.

Older drivers are not necessarily bad drivers; that distinction clearly goes to teenage drivers, who have by far the greatest number of accidents and fatalities. Accidents are relatively low for drivers 30 to 69 and then start going up.

What is of concern is that fatal accidents rise dramatically in drivers 80 and older.

So, what do you do if your parent or spouse should not be driving? Many states require older drivers to have their vision checked at license renewal, but none require a driving test.

You cannot rely on your doctor to be proactive; only six U.S. states require doctors to report people whose medical condition makes it unsafe to drive.

If you have witnessed unsafe practices such as running lights or stop signs, drifting across lanes or driving way below the speed limit on highways, you should bring the subject up. If this is met with denial, you could contact their doctor and ask the doctor to broach the subject.

If someone is clearly a risk to themselves and others, you may need to contact the registry of motor vehicles or local police department in a smaller community. In the extreme, you can make the car undriveable by disconnecting the battery.

The corollary is figuring out how to let them get places without a car – often a major issue for those who do not live in a densely populated area with shops and services within walking distance.

Sign them up for Uber or Lyft, contact the local Council on Aging about community resources and/or offer to drive them to medical appointments and shopping or arrange for others to do so. In much of the country, to be unable to drive dramatically shrinks a person’s world.

Just maybe, if you make good alternatives available, they will give up driving and save a life.



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