Alcohol and longevity: can we all be winners in the race of life?
In April, an article in the Lancet regarding safe limits for alcohol levels reignited the long-held debate regarding safe levels of alcohol consumption...1
The study looked at the life expectancy at 40 years for drinkers according to the amount of alcohol that they consumed. It concluded that higher alcohol consumption was linearly related to lower life expectancy. Put simply, the more you drink, the shorter your lifespan. This was hysterically reported in the media with headlines in the Guardian claiming that a single glass of wine can rob you of 30 minutes of precious life, and “drinking more than five glasses of wine a week could knock years off life,” frothed The Daily Telegraph. Gone from this study was the strong body of research over decades that notes a lower risk of death for those drinking in moderation compared with non-drinkers.
Collectively, this bulletin must have had the drinking classes choking over their prosecco. However, as always, the reality is less sensational. On closer inspection, the Lancet study did not include non-drinkers in their published results, only those drinking ‘some alcohol’. If one flicks back to the appendix, one can see the extended graph that shows the data on non-drinkers. And unsurprisingly, given what numerous large studies have shown, it demonstrated what we already know: drinking small amounts of alcohol is associated with lower risks of cardiovascular disease and overall mortality compared with being teetotal, whilst heavier drinking increases the risk and lowers life expectancy. Prosecco drinkers: heave a sigh of relief and pop that cork.
A slight note of caution needs to be inserted at this point, however – one theory behind the higher death rates in non-drinkers is that the group includes reformed heavy drinkers who have nonetheless been exposed to higher risk levels for many years and therefore may have higher mortality. The protective effects of moderate alcohol consumption were supported by one epidemiological study published in 2005, where the group separated their study cohort of 12 000 male doctors into ex-drinkers and never drinkers.2 Compared with never-drinkers, the light drinkers (less than two units per day) still had an overall mortality 12% lower and cardiovascular mortality 28% lower.
However, eschewing alcohol appears to be drifting into the national psyche. Young people are less likely to drink and smoke than at any time during the past. Repeated health scares about the perils of drinking, combined with movements on ‘clean eating’ and avoiding exposure to ‘toxins’ appear to risk consigning hangovers and imprudent couplings to the past – or at least to the socially unacceptable. Drinking is now most common in older adults: the baby boomer generation. Perhaps this also relates to its cost. The widely publicised squeeze on living standards has hit the younger generation disproportionately, meaning that high rents and food costs leave little room for nights on the sauce. For those sitting comfortably in their owner-occupied homes with no mortgage to pay, however, the gentle tinkle of wine hitting crystal can be a nightly treat. Has alcohol, therefore, become the preserve of the middle classes? But now we reach a paradox: middle class citizens of this country have the longest life expectancy and yet according to the figures they are drinking more. Is alcohol so very dangerous?
Several studies have examined the effects of socioeconomic status and risk of alcohol-related harm and have concluded that more affluent, higher socioeconomic class individuals have lower mortality than individuals in lower social classes who drink the same amount.3-6 This caused consternation at first, but it was subsequently concluded, particularly in an article by a team from Bangor University in 2016, that this is due to multiple additive risk factors that are more prevalent in the lower social classes.7 Obesity, smoking, drug misuse and poor diet are more likely to affect those in manual jobs or who are unemployed than those in higher socioeconomic groups. This theory seems to make perfect sense, and therefore, despite the government’s continued warnings about the risks posed by alcohol, many in the middle classes take this as carte blanche to continue cracking through a bottle a night in a fishbowl-sized glass.
However, could there be another effect at play? A study published in Health Psychology in 2017 has found that those who perceive that they do less exercise than their peers die earlier.8 The researchers involved looked at data from three large longitudinal studies in America in the 1990s and 2000s and discovered that, even when activity levels were the same, those who believed that they were doing less than others were a whopping 71% more likely to die prematurely than their peers who enjoyed greater self-belief. The size of the effect was evident despite controlling for chronic illness, lifestyle habits, demographic differences and socioeconomic status.
Studies in cancer patients have had mixed results, but there is some evidence that a positive attitude improves survival from cancer.9 One group looked at 578 breast cancer patients and found that survival was strongly associated with depression scores, and risk of relapse or death was increased by high hopelessness scores.10 It is suggested that negative feelings and depression induce a damaging inflammatory response that can affect the body’s ability to mount an attack on the malignant cells.
Stress is a physiological adaptation to situations of potential danger. However, modern life has meant that we take on stress much more readily than our cave-dwelling ancestors, and stress is widely believed to be damaging to health. One study of highly stressed people found that those who felt that stress was negative and damaging were 43% more likely to die prematurely than unstressed individuals. However, those who did not believe that stress was harmful were no more likely to die than their peers.11 Furthermore, responses to the stress hormone cortisol when under stressful situations are more adaptive in those people who believe that stress is enhancing. Researchers took students and put them in stressful situations, measuring their cortisol response and comparing it with a non-stressful situation. Those people who believed that stress was beneficial tended towards more moderate cortisol levels than those who avoided stress. The team suggest that mid-range levels are optimal for performance, whereas perhaps high levels are distracting, and low levels reduce the performance ‘edge’.12
Primate populations offer another tantalising view of the possible mechanisms underpinning differing health outcomes in a society. In female macaques, subordinates receive higher aggression, lower affiliation and are consequently more likely to exhibit depressive behaviours than higher status animals. They experience lower levels of progesterone during egg-maturing phase of their hormonal cycle, the luteal phase, which reduces their overall fertility. They display elevated stress-related biomarkers such as heart rate and cortisol. Although mean body weight is similar, the subordinate animals have lower bone density and higher levels of visceral fat, that is to say fat around their vital organs, which has been linked to higher cardiovascular risk in humans. These changes leave the lower status macaques at increased risk of inflammatory conditions compared with their higher social status peers.13
Could knowledge of one’s comfortable situation and relative social position therefore be protective? Jeanne Calment died at 122 years old, still the oldest verified person ever to have lived. She had given up smoking at the age of 119 as she had thought it unhealthy. When asked the secret to her longevity, she proclaimed “If you can’t do anything about it, don’t worry about it”. We all know of people who have indulged in unhealthy lifestyles, but lived to a ripe old age, as well as those who have lived blameless, healthy lives and dropped dead in their fifties and sixties. This can be ascribed to many things according to your personal beliefs, but ‘luck’ and ‘genetics’ often come into it. However, the evidence suggests that a positive attitude may have an impact as well.
Since time immemorial, the human race has been obsessed with finding the secret to immortality, the elixir of life, how to live longer – from alchemists in dank castles to the current trend for ‘wellness’ with its preened and glowing proponents, to the sensational tabloid headlines cyclically praising and vilifying different foodstuffs and lifestyle factors, we’re all convinced that there must be a simple solution for living longer and better. Perhaps there is. Extrapolating this evidence to its natural conclusion suggests that you’re more likely to live a long and healthy life if you think that you’re winning at life.
So how does one use this information to improve health outcomes nationally? The sticky issue here is that if there are winners in life, there are, by definition, losers. It’s hard to perceive that you’re doing well without a comparator. It’s human nature to compare oneself to one’s neighbour. Much of the commercial economy is built on selling the notion of being better than one’s peers - having a better car, a more glamorous outfit, clearer skin, the latest technology. How do we vanquish health inequality when society’s structure is built on the very foundations of striving to be better than one’s associates?
Perhaps one step we could take is to stop classifying some careers as ‘better’ than others. Earlier, I referred to studies stratified by socioeconomic class. This is perhaps a useful research tool, but it only serves to reinforce the winner-loser mentality. What is so despicable about performing a manual job? In an era where increasing numbers of roles are likely to be taken by machines, many of us in future may instead be able to find employment in careers of enjoyment or societal benefit. Perhaps this will allow the stigma of manual labour to be reduced. Much like people in poorer nations who survive on a subsistence diet cannot understand why westerners voluntarily go for a run, once manual work becomes the luxury of time, it may become something to be proud of, something to feel a sense of achievement over – the physical pleasure of a ton of earth shifted, of a house well cleaned, or a wall built. With more time for voluntary work, perhaps we’ll all find value in doing care work for the elderly, rather than offering minimum wage to desperate people on society’s bottom rung.
Another intriguing possibility comes from an earlier piece of work by Alia Crum, who was involved in the study on exercise perceptions paper mentioned above.14 Crum and her colleague looked at female hotel attendants, many of whom perceived themselves as inactive. They took two groups of these women and to one gave a 20-minute interview where they pointed out that their working habits met government targets for recommended daily exercise. The other group had no interview. They found that those attendants who were told that their activity levels were adequate experienced reductions in their weight, blood pressure and body fat, despite not making conscious changes to their lifestyle.
Between Jeanne Calment and the hotel attendants, it appears that the government might see tangible benefits from launching a campaign slogan along the lines of "Hakuna Matata": Don’t worry, don’t stress, you’re doing ok! Stop reading newspapers that trade in sensationalism, health anxiety and concern. Try to eat well and get some exercise, but don’t sweat it if you can’t. Learn to find value in the small things in life. But real inequality starts early – even before birth. Studies in rats show that your health can be determined to some degree by what your grandmother ate.15 Studies in children and adolescents who have experienced neglect and abuse demonstrate altered brain functioning that never recovers,16 going some way to explaining why crime begets crime, abuse begets abuse. A positive mindset requires nurturing from the very beginning of life. As always, this is a hard area to tackle, but needs to be a priority for the government in ensuring the health of its people.
Let’s return to alcohol: explanations for its protective effects in low doses range from effects on lowering blood pressure, increasing high density ‘good’ cholesterol and changes in clotting and platelet activity. The ‘French Paradox’ describes that nation’s favourable life expectancy in spite of its fondness for wine and saturated fat that goes against the received wisdom on a healthy lifestyle. What wine may also offer, however, is a moment to savour with friends and family; an experience of the good life. Typical meals in the Mediterranean take longer to prepare and to eat than in the rushed office culture of the United Kingdom and processed foods have traditionally been almost unheard of. One possibility for the favourable lifespan is that it relates to outlook, and that wine plays an important social function that improves wellbeing in its own right.
The author Susan Ertz said, “millions long for immortality who don't know what to do with themselves on a rainy Sunday afternoon.” But better than immortality, we could instead have the expectation of health and of a life well-lived, of contentment and no worries. This is what our society has been striving for but has somehow allowed to slip further from its sweaty grasp...