On the Liver Habits Score, there are three categories related to your present day drinking habits: i) your total amount of alcohol consumed per week, ii) your drinking days per week, and iii) amount of “alcohol break” weeks per year you have. This article will discuss the 2nd category of habits and about how everyday drinking significantly increases your risk for liver disease.

The US CDC has given the public health guidelines that women should limit their alcohol consumption to no more than 1 drink per day, and that men are “allowed” up to 2 drinks per day.² One of the main downsides of presenting the guidelines this way is that it suggests that not taking any breaks is fine as long as one stays under that threshold.

The UK recently changed their alcohol consumption public health guidelines in 2016. Rather than putting a daily limit recommendation, they instead decided to give it a weekly limit. Why? Because while they believed that i) getting drunk is bad from a public health perspective and ought to be avoided at all costs (note: they still believe getting drunk is wrong), they ii) now believe that suggesting everyday drinking can be hazardous in its own right.³

In the words of the BBC’s reporting on the subject:

“[The UK’s chief medical officers’ new guidelines] says if people drink, it should be moderately over three or more days and that some days should be alcohol-free.”³

The above is a fancy way of saying two things that the UK’s public health officials wish to hold two ideas simultaneously true: i) don’t get drunk (i.e., don’t consume all of your “allowed” units over 2 or fewer days—which would amount to binge drinking) and ii) don’t drink every day.

In a study that was conducted 2.5 years after the release of the UK’s new alcohol guidelines, it was reported that: “Overall, 71% were aware of the new alcohol guidelines, however, just 8% knew what the recommended limits were.”⁴ And that: “Even for those who were aware that there were new guidelines, only 30% knew that the guidelines had a weekly and not a daily limit.” It furthered:

“Only 7% of respondents were intending to reduce their alcohol consumption following the release of the new alcohol guidelines, whilst one-third (33%) planned to always, often or sometimes use the new guidelines to keep track of their own drinking.”

While well-intentioned, many public health guidelines fail to be able to capture the hearts and minds of people. This is often because of poor execution and/or offering guidance that people find uncompelling or too legalistic to follow. This is one of the reasons that we have created the Liver Habits Score system. This Liver Habits Score is designed to make people aware of how their habits and activities affect their liver health and how they could improve based upon the lifestyle changes they are willing to make.

One thing that is interesting is that public officials have a vested interest in preventing drunkenness as it leads to various other problems, such as accidents, quarrels, and other challenges that end up putting other citizens at risk and ties up public resources. However, as we will see, from a personal health perspective—specifically liver health—less drinking days per week can be better for you, even if it means a slightly increased BAC on those drinking days.

Would you give up a drinking day or two if it meant you could get a slightly better buzz on a Saturday evening? Everyone is different… but in my books, that would be a “hell yea!”

The concept of a weekly “liver holiday”.

Japan is famous for its drinking culture—specifically in the corporate workplace. In one article about Japanese corporate drinking culture, there is discussion about the concept “nommunication” and is described as such:

“This custom is called ‘nommunication’ — a combination of the Japanese word ‘nomu,’ meaning drink, and ‘communication.’”

The idea is quite simple: “In the workplace, alcohol serves as a lubricant to break down barriers between managers and workers. After-work drinking parties are meant to encourage bonding and allow people to let their hair down.” It’s reported that “for anyone who enjoys a drink and wants to spend time with their colleagues, these sorts of after-work events are often very helpful.”

It’s a practice held widely in Japan among corporate workers. So much so that: “One side-effect of the easy accessibility of alcohol and pressure to drink is a high level of public drunkenness. It is common to find intoxicated men and women sprawled on the floors of trains or on train platforms late at night, particularly just after six-month bonuses are handed out in the summer and shortly before the New Year holidays.”

Therefore, it should come as no surprise that when we look at studies involving alcohol consumption amounts and frequencies in Japan, the amounts consumed may seem shocking to any non-regular drinker—which in our context, is about 70% of Americans. (We have pointed out that in another article that roughly 25% of Americans are “heavy drinkers”—14+ drinks a week for men and 7+ drinks a week for women, with just about 5% of Americans being regular consumers of alcohol that fall in the range of “moderate”—weekly drinking, but under the “heavy drinking” threshold.)

In a 2007 study titled “Patterns of Alcohol Drinking and All-Cause Mortality: Results from a Large-Scale Population-based Cohort Study in Japan”, a prospective cohort of 41,702 men (aged between 40–69 years old) was followed for a period of 13 years to understand i) total alcohol consumption (“quantity”), ii) weekly alcohol consumption patterns (“frequency”), and iii) the resulting all-cause mortality rate that followed. While this study does not look at liver-specific mortality, it does give us clues into how different alcohol-related habits translate to your likelihood of death. If you protect your liver, but then die of heart disease, you’ve sort of missed the point.

(Note: We call our system the Liver Habits Score, but it’s focused on alcohol-related health in general because of this principle. It’s important to say however, that many lifestyle changes that would benefit your liver health would also be good for your overall health, such as your heart health—and vice versa—we just merely decided to focus on the liver out of drinkers’ interests and concerns.)

As can be seen in the above 3-dimensional bar chart, the study was broken into 13 groups total. These are the combination of two sets of variables: 1) alcohol consumption quantity and 2) alcohol consumption frequency.

The alcohol consumption quantities were as follows (note, as standard US drink is 14g of pure alcohol):

• i) “Occasional drinkers”, which is defined as only consuming alcohol 1–3 days per month—regardless of quantity.
• ii) <150g of alcohol. (Less than 11 drinks per week.)
• iii) 150–299g of alcohol. (Between 12–21 drinks per week.)
• iv) 300–449g of alcohol. (Between 22–32 drinks per week.)
• v) >450g of alcohol. (More than 32 drinks per week.)

The alcohol consumption frequencies were as follows:

• i) 1–2 drinking days per week.
• ii) 3–4 drinking days per week.
• iii) 5–7 drinking days per week.

If you look at the above chart, you can clearly see that all-cause mortality increases significantly with higher levels of alcohol consumption frequency. In the researchers own words:

“In the present study, quantity of alcohol consumed was clearly associated with an increased risk of all-cause mortality among regular drinkers, while frequency of alcohol intake did not appear to be related to all-cause mortality when these factors were investigated separately. When they were examined in combination, pattern of drinking emerged as an important factor in the mortality of male regular drinkers, with the highest hazard ratios observed among those consuming ≥450 g of alcohol 5–7 days per week. Interestingly, the increased risk of all-cause mortality associated with frequency of alcohol intake was seen among heavy drinkers only (≥300 g alcohol/week).”

In other words, according to this study, if you are a man and drink more than 21 drinks a week (an activity engaged in by about 15% of Americans), you are at greater risk if you consume this amount without any breaks in the week. The data here shows that drinkers in general would be better served by consuming all of their alcohol in 4 or less days per week, even if it means that those days they do drink they have a slightly higher BAC. (While this study was done in men, its results would likely translate to women, albeit at smaller alcohol consumption quantity thresholds.)

The researchers point out that their study is not without backup. They state: “[This] has been consistently observed in our previous analysis of the 7-year follow-up data from cohort 1, other Japanese prospective cohort studies, and studies conducted in other countries.”

In a study done by the British, “Drinking patterns, dependency and life-time drinking history in alcohol-related liver disease”, these findings were similar: heavy drinking done daily is the worst. Their study was focused on alcoholic liver disease (i.e., liver disease primarily stemming from alcohol).

As can be seen in the above chart, there is a huge correlation between large alcohol consumption done daily and liver disease, rather than consumed throughout less days per week.

The British researchers also noted that:

“In general, the previous studies examining human drinking patterns and the development of liver disease have similar findings. In Australia, daily drinking subjects with alcohol dependency were shown to have an eightfold increase in cirrhosis compared with subjects who drink periodically 12; Danish studies found a twofold increase in cirrhosis morbidity in daily drinkers compared with intermittent drinkers 13, 14, and a study in the United States examined drinking patterns in relation to liver deaths with similar results — 40% of decedents with alcoholic cirrhosis drank daily and a further 55% drank on 5 or more days each week 15, 16.”

This study, among others, is one of the main reasons that the UK’s chief medical officers decided to change their drinking guidelines. This warning was given within the article:

“By the time a patient presents to hospital with liver disease it is often too late. The mortality of alcohol‐related cirrhosis is around one‐quarter in the first few months, and these people never gain the chance to modify their drinking. The link between daily or near‐daily drinking and the development of liver disease is important. The (old) UK government advice gives the impression that it is perfectly safe to drink on a daily basis, and has been criticized on this basis.”

It is of course necessary to mention that this study doesn’t give someone permission to save up and binge drink over one or two days each week. These findings in particular don’t account for daily or weekly volume, and so some of the difference is likely due to a corresponding change in weekly units consumed. Binge drinking is still bad for you, and anyone that cares about their liver health should still be thinking about quantity of alcohol consumed as much as frequency.

As we have discussed in our article about our motivation behind the Liver Habits Score, one of our goals is for people to understand how their habits may be affecting their liver health before it’s too late—as the liver is an organ that externally appears to function flawlessly until one day it doesn’t… and once those problems present themselves, the damage is typically unable to be reversed. We agree with their sentiment that “we need to think about detecting subjects who are going to develop alcohol‐related illnesses at a much earlier stage” and that “the importance of 3 alcohol‐free days each week should receive more prominence.”

In the words of the Japanese researchers about their study:

“These findings support the Japanese social belief that ‘liver holidays,’ abstaining from alcohol for more than 2 days per week, are important for heavy drinkers.”

Whether it’s better to have 3 or 4 drinking days per week is less important than the fact you should do everything you can to not drink every day, and better yet, have at least 3 drink-free days.

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Putting it all together

When people think about cutting back on drinking for their health, they often just think in terms of cutting back on i) the total amount of alcohol they consume per week. However, as we have shown in this here, cutting back on ii) the amount of drinking days per week is also critical.

In another article on drinking habits, I have discussed my personal drinking habits before the creation of the Liver Habits Score. Initially, before the Liver Habits Score, I decided to cut back on alcohol by moving from 2–3 drinks a day on weekdays down to 1–2 drinks, and similarly for weekends where I often consume much more with friends. For most of my life I have been a daily drinker, and I found this counting of drinks to be extremely difficult—”one is too many, and two is not enough.”

For most of my adult life I have been a daily drinker averaging 21+ drinks a week—what I now know to be right smack dab in the high-risk zone for liver problems. I found trying to reduce this number to under 14 drinks, but still drinking most days a week very challenging—and also not very fun or sustainable. Alcohol has never been a problem for me in the sense that it hindered my work or relationships, or that I couldn’t stop completely if I needed to (such as during competition season when I swam in college)—I just wanted to cut back for health reasons. I’m not as young as I used to be and am not getting any younger.

After researching, I decided to instead cut back on my days of drinking (frequency) instead of focusing so much on the amount of drinks (quantity). I started with this goal: “Don’t drink Monday through Thursday."

What I found is very interesting: Not only have I been able to reduce my amount of drinking days by 4/7ths (frequency)… but I also reduced my total amount of drinks consumed per week with ease (quantity). For me, having 14 drinks that I can consume throughout 3 days is plenty—that’s nearly 5 drinks a day, plenty enough to get that satisfying buzz many of us are looking for.

I may be Princeton educated, make good money for age, etc., but I do everything I can to not develop expensive tastes (very Warren Buffett-esque). For me, I’m finding that picking up a 12 pack of cheap beer on Fridays and enjoying it through the weekend along with a few drinks at the bar is plenty. I’m not perfect at it—nor do I strive to be, the goal is sustainability, not perfection. If friends invite me to drinks and dinner on a Thursday, I’m not going to turn it down. For what it’s worth, I’ve also planned my healthy eating around this schedule as well—it ends up meaning that the majority of time I have liver-healthy meals, and yet don’t miss out on a margarita-fueled fajita feast with friends on weekends.

Every activity you engage in through life has risks. Obviously, not drinking at all is likely to reduce your risks the most, however, what matters is deciding what risks are worth it to you, and then working to reduce those risks. (E.g., wearing a helmet when skiing.)

My story is the perfect example of the potential benefits of the Liver Habits Score and its usefulness as a guide to better liver health. If you want to give up drinking completely, or feel that’s the only way for you to have a better relationship with alcohol, then great—we support that too! (We even have a good recommendation of where to start) However, if drinking alcohol is a beneficial part of your life and you want to continue doing it, albeit in a less risky manner so that you can enjoy it through a long, healthy, and happy life… then you will find a ton of value in our Liver Habits Score.

To see your current score and start working on better liver-related habits, visit our Liver Habits Score page!

Sláinte! (Sláinte means “health” in Irish and Scottish Gaelic and is the customary toast in Ireland, Scotland, and the Isle of Man.)

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