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Liver Habits Score

You can be a drinker, or you can be overweight, but you can’t be both.

How alcohol and BMI have a synergistic interaction in negatively affecting the health of your liver.

Brooks Powell

November 28, 2020

KEY TAKEAWAYS

Everything we do in life has risk, and therefore, much of life is about deciding what risks we believe are worth it and which risks aren’t. The fact of life is that risk is unavoidable.

Some risks seem obvious: rock climbing, sky diving, doing drugs, big wave surfing, etc. However, most of the immediate risks we engage in are far more subtle: driving a car, walking through a city park at night, or sitting on the 3rd base foul ball line of a major league baseball game.

For the most part, people spend most of their time worrying about risks with immediate results. These are the things that happen in an instant, such as: someone breaking into your house, a plane crashing, being in a mass shooting, getting struck by lightning, a shark biting you, etc. However, based on statistics, worrying over the immediate should often be the least of your concerns. You should really worry about the long-term consequences of your everyday activities.

In this article, we will be discussing how your liver health should be a top concern of yours, especially if you are an overweight drinker.

Liver-related death is increasing exponentially.

The above charts show that about 1/4th of Americans die each year from heart disease. If you add up the main disease of the diet (heart disease, stroke, and diabetes), you’re looking at around 1/3rd of Americans that die primarily from the food they put into their body (along with other factors, such as lack of exercise, tobacco use, etc.).

There are many activities that can make cancer more likely, such as smoking, drinking, sun exposure, and others… but it’s unfortunately primarily influenced by age and luck of the draw (e.g., genetics). Such is life.

“Unintentional injuries” are primarily made up of motor vehicle accidents. If you’re scared of flying, but weigh 350lbs, never exercise, and smoke cigarettes like a chimney… you’re really looking in the wrong place. Or, if you’re terrified of being murdered by a robber or a break-in, and so have stocked up on guns (which isn’t necessarily a bad thing—my family owns plenty), just be aware that suicide is a far more likely outcome than being murdered.

While liver disease-related deaths are about 1.5–2% of the deaths in the United States (see pie charts above), as we discussed in the article “Why we’re launching the Liver Habits Score™”, the rate of early stage liver disease is increasing exponentially—which is the leading indicator for liver-related deaths.

Number of hospital admissions for non-alcoholic fatty liver disease, 1998-2010. Admissions to hospital defined as first finished consulted episodes. Data are from Hospital Episode Statistics. FCE=finished consultant episodes. NAFLD=non-alcoholic fatty liver disease.

As you can in the above graph, and compared to the UK trends, the trend of fatty liver disease is increasing exponentially alongside liver-related deaths.

This trend did not stop in 2010. The US Armed Forces keeps close tabs on its human resources and so has the most up to date US data that I can find. If the US Armed Forces as a group are even remotely correlated to the health trends of civilians, then you can see this trend is continuing to grow exponentially.

This then begs the question… what is causing the increase in fatty liver disease and the long-tail of liver-related death? Is it alcohol consumption, or something else?

If we look at alcohol consumption trends in the United States throughout its trackable history, we can see that alcohol consumption actually peaked through the 1970s before declining at the start of 1980. If you have watched the show Mad Men, a show about advertising firms set in the ’60s and ’70s, then you have a glimpse into the cultural alcohol consumption habits of the time.

If alcohol consumption in terms of gallons of pure ethanol consumed per capital by year hasn’t increased, and has actually decreased, then what has been driving the increases in early stage liver disease? To understand this, you first need to understand that alcohol isn’t the only thing that can affect liver health like many people false believe. We allude to this in “Why we’re launching the Liver Habits Score™” by explaining that 75% of obese people have fatty liver disease. The liver is inherently a “metabolic organ” and thus is affected significantly by diet and exercise, which of course, includes alcohol. We discuss this at length in our article titled: “Why all liver disease starts with liver fat.

As we can see in the above graph, Americans continue to be fatter than the year prior. This is a trend that has been in the works for over 60 years now, and beyond belief, appears to be to be accelerating. Currently, 1/3 American adults are obese. This may be a shocker if you live in a very health conscious city such as Venice Beach… but my weekly trips to the supermarket in Houston, the soon-to-be 3rd largest city in the United States, confirms this fact about obesity. By 2030, just 10 years from now if nothing changes, it’s projected that roughly half of all American adults will be obese.

Look at the above BMI chart. If you’re not yet obese, it’s more likely that you are “overweight” (pre-obese) than “healthy”. While BMI is not a perfect measure of health—body fat % is much better as it can account for muscle mass—BMI is one of the most efficient ways to measure population data without the use of specialize machinery such as hydrostatic water weighing.

There have been a lot of charts and graphs, so let’s quickly list everything we have discussed thus far:

So what does all of this mean?

Well, if alcohol consumption (an undisputed cause of fatty liver) hasn’t materially increased at the same rate that obesity (another undisputed cause of fatty liver) has, the massive rise in fatty liver disease correlates strongly with rising obesity.

If obesity is leading the charge in the increases in fatty liver disease nationwide, then what does this mean for the liver health of drinkers? As you will see in the next section: nothing good.

The dangers of being an overweight drinker.

In other articles we have discussed the fact that roughly 90% of “heavy drinkers”—which is typically defined as 2+ drinks a day for men (14+ a week) and 1+ drink a day for women (7+ a week)—are reported to have fatty liver disease. And in this article, we have discussed the fact that about 75% of obese people have fatty liver disease.

But what happens if you’re a heavy drinker and are overweight/obese?

For the answer to this question, we can turn to our friends across the pond: Scotland. In total they followed 10,000 men for 42 years to understand how BMI and alcohol consumption led to liver disease mortality over time. While similar studies exist, we found this one to be the best to use to show the negative interaction between BMI and alcohol.

They first broke the people into 3 weight groups based on BMI: i) under/normal weight (BMI = <25), ii) overweight (BMI = 25 to <30), and iii) obese (BMI = >29.9). The under/normal weight group served as the baseline for risk factors.


They found that:

“Overweight men had higher relative rates [for liver disease mortality] than underweight/normal weight men, and obese men had very high relative rates: fivefold increase for liver disease as the main cause and nearly fourfold increase for liver disease as any cause.”

In other words, merely being obese increased their risk for death with liver disease as a cause by 4–5x. As is clear from the above data, the greater the BMI, the greater risk of a liver disease-related death. It’s worth stating: obesity kills.

They then took population and split them up by drinks per week amounts in terms of British “units” of alcohol. These amounts were: i) 0 units, ii) 1–7 units, iii) 8–14 units, iv) 15–21 units, v) 22–34 units, and vi) >34.9 units per week. (Note, a British unit is 8g of alcohol whereas a standard American drink is 14g of alcohol. Therefore, these convert to: i) 0 drinks, ii) 0.6–4 drinks, iii) 4.6–8 drinks, iv) 8.6–12 drinks, v) 12.6–19.5 drinks, and vi) >19.9 drinks per week.) The non-drinkers served as the baseline for risk factors.


As is very clear in the data above, the more units of alcohol consumed per week the greater the chance of death cause in primary or part by liver disease. For example, a heavy drinker consuming 35+ units of alcohol a week (20+standard US drinks) had about 10x the risk of death from liver disease as a cause than a non drinker. The data shows a clear trend that the more alcohol someone consumes per week, the greater their chance from having a liver disease-related death.

To simplify the combination of both BMI and alcohol, they combined the alcohol categories into 3 groups. These were: i) 0 units, ii) 1–14 units, and iii) >14.1 units per week. (In standard US drinks, this is i) 0 drinks, ii) 0.6–8 drinks, and iii) 8+ drinks per week.) The under/normal weight non-drinkers were used as the “baseline” group.


When a Scottish male was a drinker of merely 8+ US drinks a week and was obese, their liver disease mortality risk (i.e., a death directly attributable to liver disease as the primary cause) was increased by a massive 18.7x!

Adjusting for all other risk factors (e.g., social class, smoking, diabetes, lung health, etc.), the increase of the combination of even what the US would consider well within “moderate drinking” with obesity leads to nearly a 10x increase of chance from dying of a liver disease-related cause.


In the words of the researchers:

“The effect of the combination of high BMI and alcohol was clearly greater than the additive effect of the two separately; being both overweight or obese and consuming 15 or more units per week of alcohol led to a greater risk of dying of liver disease.”

The researchers go on to highlight how their study isn’t the only one of it’s kind. Their results corroborate a similar study performed in China, Italy, and a number of ones in the United States.

The researchers gave their own implications of their study:

“Our findings have important clinical and public health implications. New perspectives on the risk of liver disease may need to be considered for people who are overweight and consume alcohol and lower, BMI specific “safe” limits of alcohol consumption may need to be defined. Liver disease is often advanced when it is diagnosed and therefore early clinical intervention and primary prevention are both important. …

From a public health perspective, strategies to jointly reduce both alcohol consumption and obesity among high risk populations with both risk factors are likely to produce much greater reductions in liver disease than through initiatives directed at each group separately. …

Health education is needed to highlight the combined risks of BMI and alcohol on liver disease.”

In our agreement with the researchers, Cheers would argue that this is one the exact purposes of the Liver Habits Score. Through the use of LHS, its results, and content surrounding it, we hope to highlight and bring awareness to the fact that there are very material combined risk of BMI and alcohol on liver disease.


Discussion about BMI & Alcohol:

In the above study, one of the things that the researchers did not do was show the upper echelons of the interaction between alcohol consumption and BMI. For example, it would have been nice to have been able to put a number to what the total risk increase would be if you were both i) obese and ii) consumed more than 20+ drinks a week. However, likely due to sample size reasons, the researchers only looked at i) obesity and ii) 8+ drinks a week so as to maintain a strong level of statistical significance.

Given that roughly 30% of Americans consume 8+ drinks a week, but around 15% of Americans consume 20+ drinks a week, it would have been helpful to understand how much the interaction risk between obesity and alcohol consumption increases at the higher levels of alcohol consumption.


While we don’t know the exact increase in risk of liver disease for both increasing BMI and alcohol consumption at various levels beyond what the researchers found… is it 15x at 20 drinks a week? 20x? 25? We won’t know from this study.

However, we do now know what to be 3 very important implications:

  1. The higher your BMI, the greater your risk for a liver disease-related death.
  2. The more alcohol you drink per week, the greater your risk for risk for a liver disease-related death.
  3. BMI and alcohol interact with each other to make the combination of both much worse than each individually. It’s a multiplicative effect, not additive.

Therefore, as the title of this article suggest… it’s really important to not be both overweight and a drinker. You need to pick one. (Or neither.)

My wife isn’t a big drinker. She often jokes that she’d rather have a dessert than two glasses of wine—I couldn’t be more opposite… when the waiter comes by I say: “I’ll skip the dessert and have another drink.” She’s made her pick: food. And I’ve made mine: alcohol.

  1. If you’re unwilling to give up a poor diet and exercise and the large BMI it usually leads to, then to reduce your risks the most, you ought to give up alcohol. (Any reduction in alcohol at all helps.)
  2. If you’re unwilling to give up alcohol, then to reduce your risks the most, you ought to adopt good exercise and dietary habits so as to reduce your BMI. (Any reduction in BMI at all helps.)
  3. If you’re unwilling to give up either, then that’s your choice. Just know that there are significant risks associated with it. (Likewise, if you want to give up both alcohol and a hefty BMI, then good for you! But many of us will never be that disciplined…)

While this article makes it seem as if it’s as simple as BMI or alcohol, as you’ll see in our other articles, there are some habits you can adopt that help the health of your liver independent of changes in BMI—such as exercise and certain dietary choices.


As we have seen with obesity trends in America above, a wave of later stage liver disease is coming due to the same alcohol consumption levels combined with increasing levels of obesity, and then the negative interaction between them both.

What I tell my friends and family is that if they want to be a “drinker” and yet also have low risk for liver disease by keeping optimal liver health, they need to earn it through other means such as staying trim, exercising, and eating right.

References

About Cheers

Cheers is the leading alcohol-related health brand focused on developing products that support your liver and help you feel great the next day. As a student at Princeton, Cheers’ founder Brooks Powell discovered the potential advantage of incorporating the natural plant extract Dihydromyricetin (DHM) into an after-alcohol consumption regimen and began working with his professors to make products that addressed the unique challenges of alcohol-related health. . Since its official launch in 2017, Cheers has sold more than 13 million doses  to over 300 thousand customers. The research-backed line of products includes three versions of supplemental pills and powders – Restore, Hydrate and Protect. Cheers is now releasing read-to-drink versions of their products—starting with Cheers Restore. Each product is equipped to meet different health needs such as rehydration, liver support, and acetaldehyde exposure. Cheers places an equal emphasis on the responsibility and health aspects of its mission and vision. The brand’s mission is bringing people together by promoting fun, responsible, and health-conscious alcohol consumption. The vision is a world where everyone can enjoy alcohol throughout a long, healthy, and happy lifetime. For more information, visit cheershealth.com or join the social conversation at @cheershealth.

These statements have not been evaluated by the Food and Drug Administration.
These products are not intended to diagnose, treat, cure or prevent any disease.