Can binge drinking be safer than moderation? Not likely.

Is binge drinking safer than regular moderate drinking? The simple answer is definitely not, but a large recent study from Korea suggested otherwise, and it’s been getting some traction. I don’t usually devote an entire post to analysis of one single paper but because this one seems to fly in the face of what we thought we knew about wine and health, I feel that it merits a closer look.

“Frequent drinking is a more important risk factor for new-onset atrial fibrillation than binge drinking: a nationwide population-based study,” published in the journal Europace in October 2019, is an impressive project, based on a review of the medical records of almost ten million people in the Korean healthcare system.[1] In a nutshell, the findings were that for the same amount of overall alcohol consumption, binging was safer than spreading out your drinking through the week! This was for a specific condition called atrial fibrillation, an irregular heartbeat from failure of the heart’s natural pacemaker. There are many causes of “a-fib,” including high blood pressure and heart attack, but it can occur independently. The correlation in this study held for all types of drink.

It has become well-accepted that binge drinking is much more harmful overall than the moderate daily consumption that defines the J-curve of the French Paradox, especially as it applies to wine. This study did in fact find a J-curve, with moderate drinkers doing better than either abstainers or heavy imbibers, but what was surprising is that frequency of drinking also had a J-curve. The less often the better, even at excessive total levels. So what’s going on here, and can we really refute such a massive study? Well, yes and no. First, let’s not forget that any single study, no matter how large, has to be interpreted in context, especially when its findings are contrary. As far as I can tell, this study is the only one that suggests a benefit to bingeing, and it only applies to one condition.

A possible explanation for a French paradox of bingeing

Secondly, the authors offer no convincing explanation for the finding. That being the case, I will offer one: I recently wrote about efforts to reduce the toxicity of alcohol by enhancing the activity of an enzyme called ALDH. By itself, alcohol is not among the most toxic things that we consume, but the product of alcohol metabolism–called acetaldehyde–is nasty indeed.  I think it’s more than a coincidence that much of the published research on ALDH is also from Korea, because almost half of Asians have a genetic variant which impairs the enzyme that breaks down acetaldehyde.[2] They get an unpleasant facial flushing syndrome, among other things. (See an interesting idea on reducing the effect of ALDH dysfunction here.) So my hypothesis is this: People with this condition experience more exposure to acetaldehyde, and therefore more toxicity when they drink regularly, even at low amounts. Unlike alcohol, peak levels followed by a washout period may be less harmful than low but chronic exposure. If so, the findings in this study could be accurate but apply only to this particular population. A study on alcohol and a-fib from Australia supports this conclusion, as no relationship to frequency of drinking was found in that populace.[3]

The other issue with all studies of this type is reliance on self-reported drinking. It is a universal truth that people under-report by as much as 40-50%, and researchers account for this. If you saw my post from last year on how under-reporting confounds these types of studies, you may recall how Nicole Tran MD, PhD, at Kaiser was able to determine that a significant number of very heavy drinkers get misclassified as moderate drinkers, skewing results even after applying the usual adjustments for under-reporting. So whether the subject pool is ten people or ten million, you can never be confident that you are tabulating true levels of consumption if you just ask people what they drink. In fact, you will almost certainly be wrong.

[1] Kim YG, Han KD, Choi JI, Boo KY, Kim DY, Lee KN, Shim J, Kim JS, Kim YH. Frequent drinking is a more important risk factor for new-onset atrial fibrillation than binge drinking: a nationwide population-based study. Europace. 2019 Oct 17. pii: euz256.

[2] Wall TL, Peterson CM, Peterson KP, Johnson ML, Thomasson HR, Cole M, Ehlers CL. Alcohol metabolism in Asian-American men with genetic polymorphisms of aldehyde dehydrogenase. Ann Intern Med. 1997 Sep 1;127(5):376-9.

[3]Voskoboinik A, Costello BT, Kalman E, Prabhu S, Sugumar H, Wong G, Nalliah C, Ling LH, McLellan A, Hettige T, Springer F, La Gerche A, Kalman JM, Taylor AJ, Kistler PM. Regular Alcohol Consumption Is Associated With Impaired Atrial Mechanical Function in the Atrial Fibrillation Population: A Cross-Sectional MRI-Based Study. JACC Clin Electrophysiol. 2018 Nov;4(11):1451-1459.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s