What's the deal with alcohol?

9:50Emily Oster:Now's the time.

9:51Perry Wilson:But health wise guys still avoid iceberg lettuce for the moment, unless you know where it was grown and it was like your backyard. All right. Next up, aging research is setting upper bounds on our human lifespan. Disappointing news for Brian Johnson and for the rest of us. But what does this say? How old could I live to be?

10:15Emily Oster:These studies are entirely theoretical and are always so interesting to me. People have asked the question, this isn't what this study is about, but people have asked the question, what if the only thing that could kill you was accidents? You're basically a immortal, right? You're an elf or something, but like you can get killed if you fall out of a tree or something like that, but you'll never get sick. You'll never get old. And you can model this mathematically because you know what like the rate of accidents, fatal accidents are. And it turns out, I'm not going to get exactly right, but it turns out like on average people would live to be 700 or 800 years old if the only thing that could kill you was getting in an accident.

10:50Emily Oster:Okay, cool. This study looked at DNA mutations. So as you age your DNA, you know, little gamma rays come from outer space and they mutate DNA. And they asked the question, if this is the only thing that can kill you, are these like random gamma rays? Like we fix everything else, right? There's no heart disease. There's no cancer. But we can't fix the random gamma rays mutating your DNA. What's the maximum you can live? And the overall answer was 146 to 194 years. This was limited mostly by problems in your heart, which the DNA mutation accumulation would cause fatal heart dysfunction at about 150 years, similar levels in the brain.

11:35Emily Oster:And interestingly, the liver, which is always just like down to party, could go for thousands of years before it would kill you from just DNA mutations alone. And so the researchers are saying like, okay, this is like longevity people, you know, this is the upper limit here. Like you fix all the other stuff, you know, this is what's going to get you. But of course, like if you fix all the other stuff, I don't know, can we fix DNA? Right, totally.

11:59Perry Wilson:I mean, this seems ridiculous. I don't know if these people have not watched Futurama where you just put your heads in the container. did you watch Futurama? That was so great. People just live forever and their heads were like in these, like it was just their head in like a little tube or whatever. I don't totally know how it worked, but it's - Yeah, a little glass bowl. Yeah, licking a little glass bowl. So get with it, aging researchers. But I think mathematically, this is a super interesting approach. I like it. I like it a lot. Yeah, it's kind of fun.

12:26Emily Oster:Let's move on to talk about Secretary of Defense Pete Hegseth's plan.

12:32Perry Wilson:Get it right.

12:34Emily Oster:I mean, I think legally it's still the Secretary of Defense. But whoever he is has a plan to test all, I guess, male.

12:45Perry Wilson:Sorry there. It's to test all people in the military for testosterone, including ladies. Spoiler, they don't have very much.

12:54Emily Oster:Oh, geez. Okay. I love when stories are even stupider than I assumed.

12:59Perry Wilson:You went more logic than he was going with this.

13:02Emily Oster:So I think the overall, at least the overall idea here is that they want to identify people with low testosterone and presumably to supplement it in order to increase the efficacy of the armed forces. If you want to go back in time to our testosterone replacement therapy episode, you can get all the science about why this is a bad idea, including the fact that testosterone supplementation doesn't end up doing much for men except increasing libido and testing testosterone levels is not really recommended unless you're having libido or rectile dysfunction problems. And I don't think that's what the secretary of war is worried about.

13:46Emily Oster:God, I hope it's not, but now maybe it is.

13:48Perry Wilson:Yeah. I mean, I think he's sort of pitching an idea here that's like, I mean, we've seen this, this is Captain America. But I think FDA approved level of testosterone supplementation will not produce Captain America. So I'm not really sure where we're going with this issue.

14:07Emily Oster:I mean, yeah, you could like juice up all the army people. You give them real steroids, like anabolic steroids and have them go into roid rage in the battlefield. I'm not really sure that's what we want. I don't know. This feels, I don't exactly know how to put this, But this obsession with testosterone and sperm count and stuff feels like this is what my kids would say. It's like small dick energy. Totally. That's what this is. Totally. It's what it is. Like just – you don't have to prove your manliness constantly by like announcing it to the world and performing it. Just like be a good dude.

14:48Emily Oster:Jesus.

14:48Perry Wilson:Be a good dude, but consider getting your sperm count and testosterone levels in a small tattoo in a place that just people might see on your cheek.

14:58Emily Oster:Consider the lower back. That's what I want. I want all our army officers to have lower back tattoos just to mess with people. That's it. That's what I'm talking about. It's amazing.

15:08Perry Wilson:Okay. That's what I want. That's your proposal.

15:09Emily Oster:Let's make that manly. All right. I think with those news items under our belt, let's take a dive into alcohol. And, you know, I think we can actually skip this entire episode because someone has summed it up more perfectly than you and I ever could. Emily, let me play the clip.

15:30Perry Wilson:To alcohol, the cause of and solution to all of life's problems. Homer is very wise. He's wise.

15:41Emily Oster:This is the best episode. If you're a Simpsons fan, the Prohibition episode is so great when he becomes the beer baron and Marge is actually proud of him for doing something clever as he's filling bowling balls with hooch. And like there's a whole system of pipes that take sit from the bowling alley to Moe's bar. Such a classic. Alcohol, Emily, has been around for quite some time.

16:06Perry Wilson:Yeah. People have been fermenting things for a very long time. I think the first confirmed fermentation is 7 ,000 BCE. So that's what, 9 ,000 years ago?

16:19Emily Oster:That's a long time.

16:21Perry Wilson:I mean, fermentation is not hard. You leave stuff. You can imagine how this happens, right? You make some stuff with rice. You leave it out for a little while. You're thirsty. You taste it. You realize, man, it doesn't taste that great. But boy, is this fun. And then we're kind of off to the races.

16:36Emily Oster:Yeah, absolutely. And it's not just humans who do this amazingly. So a brief list of animals who have been documented to actively seek out fermented fruits. So these are animals basically that like there'll be a, you know, fruit rotting essentially becomes alcoholic over time. Here's some animals that like to play around with these chimpanzees, black-handed spider monkeys, African elephants, tree shrews, and even fruit flies. Although apparently fruit flies aren't getting drunk. they're laying their eggs in fermented fruit because the antiseptic properties of alcohol prevent some egg diseases on fruit fly eggs.

17:15Emily Oster:That's nice.

17:17Perry Wilson:So people have been consuming alcohol either for fun or, you know, in some periods, beer was a sort of much safer way to consume liquids than water because it was much less likely to be full of cholera and so on. So we really, alcohol is one of our oldest customs. The Romans loved wine. Everybody loves alcohol.

17:41Emily Oster:Everybody loves alcohol. Why are they telling us it's so bad for us then?

17:45Perry Wilson:I don't know. I guess we're going to get into that, but it has been popular for many millennia. Let's put it that way.

17:50Emily Oster:On the medical side, a bit of fun history of prohibition, not that prohibition was that fun. So US prohibition was from 1920 to 1933, the 18th amendment banned the sale of alcohol at that time, but it did carve out an exception for medicine. And so you could get a prescription for medicinal whiskey. And apparently in that period, doctors wrote an estimated 11 million prescriptions for medicinal whiskey, treating ailments ranging from indigestion to depression, usually charging a hefty fee for those prescriptions. What else is new?

18:25Perry Wilson:That sounds right. I mean, Prohibition is a very interesting historical episode, obviously, because there were a lot of social problems. are a lot of social problems caused by alcohol. You can see the instinct and yet you seem to really backfire in a lot of ways. It was certainly unpopular in addition to generating a lot of mob related crime and apparently fake prescriptions.

18:47Emily Oster:You ban stuff that is really easy to make in your own home and people are going to make it in their own home.

18:52Perry Wilson:Totally. Have you ever made your own alcohol?

18:54Emily Oster:I have. I brewed my own beer. That's all I've done. I've never distilled anything, but I had fun brewing my own beer. I made this very delicious tasting IPA that was not very high in alcohol content, which is now a popular thing.

19:10Perry Wilson:One time in college, one of my roommates brought back raisin-based homemade liquor from Christmas break. It was bad, actually. I wouldn't recommend making hard liquor out of raisins.

19:23Emily Oster:One thing I used to see in Pennsylvania are people who would come in with chronic lead toxicity, which can present doctors as the triad of kidney disease, gout, and hypertension. And what we would occasionally trace it back to are people making moonshine because in Appalachia, people will often distill the liquor, the moonshine liquor in old car radiators, which used to be lead lined. And so the lead would leach out into the moonshine. Then they drink moonshine. They'd come and see us with gout and kidney disease.

20:02Perry Wilson:Yikes. Okay. All right. So don't make your moonshine in your car radiator. The more you know. How does alcohol work? Dr. Perry, let's do it. What are the reasons the alcohol is fun, basically? I think that's the first question.

20:18Emily Oster:Yeah, it works in your brain. It actually works like a lot. We have drugs that kind of work in similar ways and alcohol sort of touches on all of these. So the primary one that you'll read about is that it stimulates the GABA receptor in the brain. This is the same receptor that benzodiazepines like Ativan, Valium, those types of drugs bind to. So it gives that sort of tired, sleepy, funky feeling that comes with stimulation of that receptor. But it also blocks the NMDA receptor. That is what ketamine does. So it has a little bit of the depressant effect or the dissociative effect that you see with ketamine.

20:58Emily Oster:It causes dopamine release in the brain, which is why it feels pleasant and happy and good, at least for most people. And it releases endogenous opioids. So it has even an opioid effect in the brain. So it kind of, it's like an amazing cocktail, no pun intended, of drugs that people like to abuse because it makes their brain feel nice. And it also makes you pee a lot. Okay.

21:26Perry Wilson:So we talked about prohibition and post-prohibition Americans have been drinking a lot, but actually in the U S the amount that people drink has been going down very precipitously over time. Uh, there was a sort of bump up over the last short period. There was a bump up during COVID when everyone was at home drinking, uh, but it has continued a downward slide. And we are now seeing both the sort of the lowest levels of drinking the most number of people who are and totally sober, and also a lot of discussion in, I would say, the wellness and health space about how much alcohol is okay, and more and more a message that none is okay.

22:09Perry Wilson:I would say there's a piece of health messaging that comes, some of it from the government, some of it from official sources, some of it from online, that's in the space of the appropriate amount is really done. And that even a small amount is bad for your health and how bad is not so clear. And that's the piece of the messaging I'm most interested in looking at the data on today, because I think it's the piece that's most relevant for a lot of people. But before that, I actually do want to touch just briefly on the question of problematic drinking, because these are fundamentally somewhat different questions.

22:44Perry Wilson:And the question of, you know, is it okay three times a week to have a glass of wine with dinner is pretty different from, you know, how do we think about someone for whom alcohol is getting in the way of their life or their family's life or other things. But that is an issue for many people. Alcohol is something a lot of people have a problem with and abuse. And it's also very clear in the data that heavy drinking is associated with quite a lot of bad outcomes. There are large estimates of amount of excess death from heavy drinking. So I'm not even sure how to separate these. And I think it gets complicated because there's a continuum.

23:20Perry Wilson:It's not just two groups of people. But I do want to try hard in the discussion to sort of separate those two things out.

23:27Emily Oster:Yeah. I couldn't agree more. I think most people, you know, if you have alcohol use disorder, if your alcohol use is affecting your daily life, if you feel guilty about drinking, if a loved one has brought it up to you that perhaps you're drinking too much, if you need to drink after you wake up in the morning. There are plenty of signals of problematic drinking, and that is a group of people who need to seek some help because it definitely is associated with many bad health outcomes and, of course, life outcomes. That's not really what we're talking about today. We're talking to the majority of people who may drink a bit, may drink moderately, who are hearing all these statements that, oh, every single glass of wine you have, every single drink is poison and want to know if that's true or not.

24:13Emily Oster:And that's where we have to break down the data.

24:15Perry Wilson:Yeah. Before we leave the question of problematic drinking, this is actually a space where, if we could do another episode on it, but there's a space where there is an increasingly interesting discussion about different possible treatments. There's been some evidence that GLP-1s have improved alcohol use disorder. There's a drug called naltroxone, which people have used and actually a variety of interesting ways to try to limit alcohol use. So that's for another day, But let me just leave here by saying if you are struggling with alcohol use disorder, if you feel like alcohol is getting in the way of your life, that really is something to seek treatment for.

24:49Perry Wilson:And it is there are an increasing number of possible solutions that might be helpful.

24:57Emily Oster:Sounds good. For the rest of you, we are going to dig into the data about light to moderate drinking and its health effects, if any, after the break.

25:10Perry Wilson:I thought I looked so cute. I pieced together a cute outfit. And this girl comes up to me, just sits next to me, telling me, oh, hey, girl, I see your skin. I know what you're suffering with. I just remember feeling so just, like, distraught and, like, robbed of my time. When I finally freed myself of that conversation, the lights were coming on and the party was over. It felt like I had a sticker on my forehead that said, She has eczema.

25:39Emily Oster:We've all been there, wanting to go out, feeling cute, forgetting about all your problems, and just existing in the present with joy. But when you live with a visible skin condition, that can be a lot harder than it needs to be. This is Skin Queries. Listen on the iHeartRadio app, Apple Podcasts, or wherever you get the stories that make you feel understood.

26:04Perry Wilson:Shortly after I enrolled at Rasmussen, I was diagnosed with breast cancer. It was like a bomb had just been dropped in my life. I reached out to Rasmussen. They immediately were like, Rosa, take what time you need. You can come back when you're ready. We are cancer-free today, and I'm just so grateful for Rasmussen, for all of their support throughout my journey, and for my own village.

26:27Emily Oster:Rasmussen University. Find your seat and start now at rasmussen.edu.

26:57Emily Oster:your trusted travel advisor.

27:07Perry Wilson:Okay, Perry, we are back and we're going to talk about what the data says on light to moderate drinking. And I want to play you a clip of somebody's feeling about this.

27:19Emily Oster:It's one of those areas where you don't understand the hidden cost until you really give it up for a while and and I think about my own relationship with drinking and I stopped drinking at 30 years old I'm now 33 and I had just drank because I just drank I'd never ran the experiment of just giving it up for a while and I and then like I don't know maybe I was at 31 I thought you know I'll have a drink again because now I could really a b test it I had a year of not drinking decided to have a drink again it ruined three days of my life I had a couple of glasses of wine didn't get drunk it ruined three days of my life because of the domino effect it caused so it meant that I I got worse sleep that night.

27:51Emily Oster:And then because I got worse sleep that night, I ate more poorly the next day because my dopamine system or whatever, the cortisol system was all messed up. And then I podcasted worse. I didn't go to the gym the day after, that day or the day after because of that, because I felt really bad. I then slept worse. And I could track all of this on my week, hashtag ad, hashtag sponsor, hashtag investor, whatever. Yeah. And I was like, oh my God, those three glasses of wine had this hidden domino effect that I must have been living with for my whole life. I like how one of his metrics was like, oh, I'm not as good at podcasting after I drink, which definitely I was like, oh, no.

28:28Emily Oster:Did you drink last night? I had a glass of wine last night or maybe slightly more than that.

28:32Perry Wilson:I don't drink, actually.

28:35Emily Oster:You don't drink alcohol ever? What?

28:38Perry Wilson:Not ever. I very occasionally drink and I used to drink more. But at this point, maybe once every couple of months.

28:46Emily Oster:I feel like this should have come out earlier in the episode, but that's OK.

28:50Perry Wilson:I will tell you, I more or less quit drinking because it really affects my whoop recovery score. It's the same reason as every other thing I do, Perry, actually. It's like 12 % on my whoop and that's it.

29:02Emily Oster:I'm out. So amazing. I mean, how do you forget your troubles at the end of the day? How do you while your person?

29:12Perry Wilson:I just like look at my whoop recovery score. I'm like, okay. Oh, it's so high. I'm the best. It's not something I miss. I really like non-alcoholic beer. Yeah.

29:22Emily Oster:I don't mind some non-alcoholic beer. But yeah.

29:24Perry Wilson:Anyway, I don't drink. So that's why I'm so much better at podcasting than you.

29:28Emily Oster:I guess that does explain quite a bit. Everyone – Emily is a teetotaler and I – there's this old joke which is if you ask a doctor what the definition of an alcoholic is, the answer is, well, anyone who drinks more than I do.

29:44Perry Wilson:So. So if you ask not a doctor, but the U.S. dietary guidelines, we actually have some, I would say they're fluid guidelines, but we have some U.S. dietary guidelines about how much alcohol is considered recommended. And again, these things are always like, what do you mean recommended? Like that's a good amount, that's too lit. But those numbers in the U.S. dietary guidelines from 2020 to 2025 were less than or equal to one drink a day, for women, two drinks a day for men. In the 2026 guidelines, they just went with less. So I don't know. That's not a number. The 26 guidelines are a bit different.

30:26Perry Wilson:So just not so much is where they went.

30:29Emily Oster:They should have said fewer, I feel like, but that's okay.

30:31Perry Wilson:Fewer. The American Heart Association is in the range of two drinks a day, probably limited risk. The World Health Organization says none. So everyone kind of agrees that you should keep it low, but people differ on what that means or how bad it is. And the reason for that is that the data is mostly trash, actually, when we are talking about light drinking. Yeah.

31:01Emily Oster:I think before we dig in, we're going to dig into some of the risks, cancer, cardiovascular disease and so on in a minute. But to set the stage, there is a problem in the literature. There's the standard problem of observational data, which we'll get to. We talk about this a lot. But there's another problem which is called, or one way we can call it, is linear extrapolation. And that's when you have an exposure that has a dose. So it's not just like, yes, no, you take a medication, but it has a dose associated with it. And you have a wide range of those doses. and you're looking at a large data set where some people have very high doses of the thing like alcohol and some people have very low and some people have none.

31:43Emily Oster:And you look at the rates of some outcome and you draw a line, you fit a line of best fit to all of these data points. And one of the risks of doing that is that if the risk actually clusters at the high end, fitting a line can be inappropriate. There can be threshold effects, for example. We see this not only with alcohol, but for example, with radiation dosages. So a lot of the sort of quote unquote risk of like getting a chest x-ray, for example, which is a vanishingly small amount of radiation, they'll be like, oh, it increases your risk of cancer by, you know, 0.0003 % every chest x-ray. Well, actually, that data is coming from the cancer rate of people who were like in Hiroshima, Nagasaki and surrounding areas who got, you know, thousands of times the doses and then a linear extrapolation down to getting one one thousandth of the dose.

32:37Emily Oster:And that's just not always accurate in biology. So that's a big meta problem we're going to have to face with all this stuff. And I think that's why the WHO comes out and says like no level is safe because they're extrapolating. They're extrapolating.

32:49Perry Wilson:And then, of course, we have our standard observational data problem. There's a little, you know, we'll talk, I think, maybe a couple of places where you've got a little bit of randomized data on sort of small things. But for the most part, this is going to come from data that compares people who drink different amounts and looks at their outcomes and tries to adjust for some differences across them, but is not going to be able to do that in a complete way. And I actually think sometimes we talk about this. I think it can be quite opaque to people. Like, what do you mean they couldn't adjust for the things?

33:27Perry Wilson:Like, what do you mean they couldn't see enough details about about people? But in these studies, you will see things about people like, did they go to college? How much income do they have, you know, kind of in some broad buckets? But you won't see all of the little details. And like, to go back to our conversation about our behaviors, you and I actually in these studies to this researchers would look very similar other than our gender, right? We both, we actually went to the same college. Forget it. They'd never see that. But we went to, you know, we both went to college. we probably are in similar income brackets.

34:01Perry Wilson:We have, you know, similar other kinds of risk factors. But let's say you were running a study where the outcome was like, you know, some kind of like VO2 max or some like sort of cardiovascular performance. When we run that study, you drink more than I do. And we're going to see like, that's going to, if you and I are like representative, it's going to look like, boy, not drinking is really good for your VO2 max. But actually the reason I don't drink is because I'm doing every possible thing in my whole life to invest in the VO2 max, which the researchers will never see. And that's the kind of example of where there's so much in the data and it's all causing itself that it's really hard to draw conclusions, especially when you're talking about what's the impact of one drink or two drinks, where those impacts are very, very small relative to the size of these biases.

34:53Yeah.

34:54Emily Oster:And this is one of the reasons. I think red wine in particular for like 20 years was a health food to some extent, because there was observational research that said, oh, drinking a glass or two of red wine a day is associated with a lower risk of cardiovascular disease and so on and so forth. And that is true associationally, like there's a correlation there. But who's the type of person who drinks red wine, especially versus other types of alcohol, right? Yeah, it's rich people. It's people who eat a very different diet than people who are drinking even beer or hard alcohol or things like that.

35:28Emily Oster:And we sort of know this is BS because the explanation outside of confounding was, oh no, red wine has these stuff in it like recevitrol, which is this special thing. And that's actually what's protecting your heart. And then they did a randomized trial. They're like, well, you don't need to the red wine. Let's just synthesize recevitrol and we'll give half the people that and half placebo and we'll see what their heart attack rate is and bupkis, nothing whatsoever.

35:53Perry Wilson:But I actually think that's a particularly good example of yet another problem here, which is we started telling people in the 1970s, red wine is good for you. And then who are the people who start drinking red wine? It's the people who are like, oh, I'm really interested in investing in my health. I'm doing all this other stuff. I'm going to add some red wine. Then you come back to look at them later. It looks like red wine is even better because now it's like even more selected. So anyway, you know how I feel about selection by.

36:19Emily Oster:I know, but don't worry because I have a Mendelian randomization study for you. Oh, I saw in the notes that I am. Coming up deep cut for podcast listeners. We know how much Emily loves these studies.

36:27Perry Wilson:Bringing up my ex-boyfriends in the notes here.

36:30Emily Oster:All right, let's talk about cancer. That's the elephant in the room, I think, these days when we're talking about alcohol. And I will say from the doctor perspective that there's biologic plausibility here. Alcohol is metabolized primarily in the liver, but also in the gut to acetaldehyde. acid aldehyde damages DNA. It does. It is a DNA toxin. We know that that happens if you put acid aldehyde on cells in a Petri dish. Therefore, if you have that floating around your body for too long, maybe it can damage DNA. Damaged DNA leads to cancer. Ipso facto, alcohol causes cancer.

37:08Perry Wilson:And in the observational data, if you look at like you fit a trend to the entire higher distribution of drinking, you definitely see higher cancer rates with heavier drinking. But when you try to limit down to the smaller amounts of drinking, even in these data, which again have these other biases, the effects are either zero or really, really very tiny. And for example, a lot of these find kind of almost no increased risk for people who are say not smokers. And that suggests that maybe some behaviors like smoking are also driving some of what we're seeing in the relationship because those seem to move together.

37:51Perry Wilson:So, yep.

37:53Emily Oster:Absolutely. There's the confounding of smoking, which is that when people who drink are more likely to smoke and even when people drink, they might be more likely to smoke, even if they're not sort of chronic smokers. That's an issue. There is also likely some synergy here where the cancer-promoting effects of smoke and the potential cancer-promoting effects of alcohol sort of work together to increase the risk more dramatically. I think, Emily, you're referring to this big study of 200 ,000 health professionals in the US and the BMJ in 2015, which basically showed that across kind of reasonable amounts of consumption that there is no increased cancer risk among non-smokers.

38:33Emily Oster:There's an exception to this, which is breast cancer in women, and this is one that keeps coming up. So it's very clear that alcohol doesn't increase the risk of all cancers. Even in the bad observational data, the cancers that are associated with alcohol intake mostly kind of lie in the GI tract, like the area of your body that gets exposed to the alcohol. So mouth and oral cancers, stomach cancer, colon cancer. But then breast cancer always stands out as a signal that we continue to see. So I am a little bit more worried about that. But you've heard that my wife is a breast cancer surgeon. So that one always is the monkey on my back.

39:11Perry Wilson:And I will say even in those, the kind of size of the impact at small levels of drinking is very small. And I guess this gets to another piece of this, which we can sort of talk about it maybe more at the end because I think it's a broader picture. But even the places where people would say, you know, maybe there's some hint of an increase in breast cancer, it's really, really, really small.

39:34Emily Oster:Yeah.

39:35Perry Wilson:And -

39:35Emily Oster:It is not the major risk factor for breast cancer.

39:38Perry Wilson:It's not the major risk factor for breast cancer. And I think we want to think about, you know, like that trades off against, say, the fact that you might enjoy this. And this surrounds all of this conversation that we're kind of looking for evidence that alcohol is like somehow good for you, as opposed to saying, you know, there are a lot of things we do that are not health investments and that maybe even have some small negative impacts that we like. And that's, you know, there's other reasons that people engage in these activities other than that they're a health food.

40:06Emily Oster:Yeah. And I did, I worked pretty hard. We'll get there to try to find actual hard data that alcohol is good for you. We'll get there in a minute. But I will

40:14Perry Wilson:say like another place that like in this BMJ study, one of the things you see, for example, is people who drink a little bit relative to not at all, which is kind of the comparison we're looking at are actually quite a bit more likely to have had a mammogram. So that one interpretation of some of this is maybe some of the cancer that we're seeing is actually like screening and not actual diagnosis, which again gets into the whole, like, it's just really, really hard to interpret observational data when you're seeing such small effects because a billion different things in the data, a billion different differences might drive them.

40:47Emily Oster:Absolutely. Let's try to get away from observational data. So I'm going to talk to you about a Mendelian randomization study. I hate you. Okay. Let's do the one that appeared in cancer in 2022. So for those of you who weren't here the last time, when Emily, let's just say where it got heated about this study design. The idea of Mendelian randomization is that in this case, some people are genetically predisposed to drink more alcohol than others. We know that there are certain gene variants that just that mean all else being equal, you're going to drink a little bit more. Maybe it hits you in the right way.

41:24Emily Oster:It's more pleasurable. You all might know some people who actually genetically almost can't drink alcohol. Many people of Asian ancestry lack the aldehyde dehydrogenase activity to appropriately process alcohol, and it becomes very unpleasant to drink even small amounts of alcohol. So there are genetic determinants of how much alcohol you take in. This study in cancer in 2022 looked at breast cancer risk, again, something I'm concerned about when it comes to alcohol intake. And the model that predicted alcohol intake full stop showed that people genetically predisposed to drink more alcohol over their lives had no higher risk of breast cancer.

42:03Emily Oster:But another model which looked at the genetic risk of problematic drinking, which is a separate genetic risk model, did show an increased risk of breast cancer. And so one possible interpretation of that could be that low to moderate amounts of alcohol intake don't increase your risk of breast cancer, all else being equal, but problematic intake does.

42:27Perry Wilson:Okay. I guess. I mean, sure. I guess that could be an interpretation. Okay.

42:31Emily Oster:Let's move on before Emily says anything else?

42:33Perry Wilson:I hate this method. Please just, I can't do it again. But I think that there are a lot of other things that these genetic variants might be linked to. And I don't really think this is any better than anything else. But I will say that it is not inconsistent with this broader picture that maybe at high levels, problematic drinking could be linked with a higher risk of cancer. I'm not sure we learned anything particular from this particular stupid technology. All right. I'm just going to leave it there.

43:04Emily Oster:Bottom line, cancer. If you drink, don't smoke.

43:07Perry Wilson:My husband told me after last week it was like too much complaining about medallionization, so I'm just going to stop.

43:14Emily Oster:Okay. Please see prior episode for Emily's rant. All right. Alcohol may be modest effects on cancer. We're not too worried about low to moderate intake. Don't smoke while you are drinking. Don't smoke.

43:26Perry Wilson:Don't smoke. Oh, yeah.

43:27Emily Oster:Don't smoke at all. Smoking is associated with cancer.

43:28Perry Wilson:Don't smoke.

43:29Emily Oster:Right, right, right. Sorry. Don't smoke at all. Okay. But also don't smoke while you're drinking. Even just the one. Let's talk about heart disease. I think actually back in the day, that was the bigger sort of both concern. First of all, is it cardioprotective? Is it good for your heart? And then is it bad for your heart? One slam dunk effect I will give you for alcohol on the heart is blood pressure. We know from randomized trials, you take people in the lab, you give them alcohol or you give them placebo alcohol and their blood pressure goes up. But this effect is small. So one meta-analysis I was looking at that integrated these results from randomized trials in the journal Hypertension.

44:15Emily Oster:This is sort of an older study, but I mean, this has been studied for a long time. one drink less per day led to about a one millimeter of mercury lower systolic blood pressure. That's the top number. So I believe this is true, but the effect is not huge. That being said, if you're struggling with high blood pressure, alcohol ain't helping. Yeah.

44:37Perry Wilson:I mean, I will say when I look, when you dig into sort of some of the studies that make this up, they are mostly randomized trials that start with a population that's drinking quite a lot and then have to sort of encourage them to drink less. So like in one of these studies, you know, average consumption at the start is like 36 drinks a week. That's a lot. I mean, that's more than five drinks a day. That's more than me. Just barely. And so I think there again is a little bit of this interpolation issue, which is it's less clear if you are drinking one drink every day, if going down to zero would actually have an impact on your blood pressure that would be measurable.

45:17Perry Wilson:But it is worth saying, again, if you are struggling with this, it's something to try based on that data.

45:23Emily Oster:And it is as nephrologists like me, kidney doctors deal with complex hypertension. That's one of our sub-subspecialties. And it's always on our checklist for like, oh, drink less alcohol.

45:34Perry Wilson:Heart disease in general has the J-shaped curve, drinking a little bit.

45:39Emily Oster:Oh, I know you love J-shaped curves.

45:41Perry Wilson:I love it because there's so much. Okay. J-shaped curve, which means that the people with the lowest risk of heart disease are people who drink some, but not very much or very little. Now, of course, people who drink a little bit are kind of different from both the people who don't drink and all the people who drink a lot in ways that are observable and ways that are not observable. And so it has been very difficult to figure out whether this J-shaped relationship is a real thing or just an artifact of observational bias. It's the second thing.

46:17Emily Oster:Yeah. And it's the J-shaped curve that led to a lot of that one to two drinks a day is heart healthy. There's just another Simpsons quote where – oh, my God, another great episode where Homer gets hired by Hank Scorpio. and their life is just perfect there, but the perfection of their life sort of gives them annui. And Marge, you see her drinking and eventually they tell Homer that they can't live in this beautiful place anymore. And Marge is like, I'm drinking a half a glass of wine a day. I know the doctors say you're supposed to drink a glass, but I just can't drink that much. So anyway, sorry.

46:54Emily Oster:That's what the doctors say. And it's this J-shaped curve that led to that belief. But one thing that sounds simple, but people really didn't account for in the early observational studies were that people with chronic health conditions might be avoiding alcohol because they make their chronic health conditions worse. People with cancer undergoing therapy are going to drink less than people who aren't. And so you get this tale where non-drinkers have a higher risk of a lot of different things.

47:24Perry Wilson:Yeah. That is called reverse causality. We have a different name for that. And yeah, so that shows up there. And I think over time, people have kind of moved. Interesting aspect for me of this whole discussion is we had this J-shaped curve. And over time, we've kind of moved away from the J-shaped curve into sort of arguing that this positive effect is gone. And so it's really just only the increase. But somehow, many people who are making that argument are making it like, well, the people who are not drinking at all are totally different from the people who drink a little bit. But those people are then unable to understand the argument that the people who drink a lot are also different.

48:01Perry Wilson:It's like we're only interested in understanding bias in support of a view that we are hoping to hold.

48:07Emily Oster:Right, right, right. For what it's worth, I did pull a Mendelian randomization article, Circulation Genomic and Precision Medicine 2020, which looked at cardiovascular disease based on genetic predisposition to alcohol intake and basically found more or less bupkis. They did find higher risk of stroke in people who were genetically predisposed to alcohol intake and higher risk of peripheral arterial disease. But most of the other signals were pretty weak in that analysis. But no protection, certainly no heart health signal.

48:42Perry Wilson:Yeah, I don't think it's reasonable to say, based on the data, that alcohol protects you from heart disease. I think there's also pretty limited evidence that at moderate levels, it is bad for you, bad for your heart. Okay. Let's talk about a couple of things where I think we maybe have better evidence that there are some impacts. So one is anxiety and depression, which alcohol use disorder in particular really makes quite a lot worse. And we have a lot of evidence on that.

49:13Emily Oster:Yeah. This is not a treatment for anxiety. I know people think it is. And there's a lot of self-medication going on with alcohol and anxiety and depression, but there's no evidence that for people with those clinical diagnoses that alcohol has any benefit. In fact, there's quite a lot of evidence that it makes it worse. That ain't the solution. Now, this is different than alcohol acting as a social lubricant. We're not talking about just kind of, I get a little anxious when I meet new people. We're talking about actual anxiety and depression, but I just want to put it out there that this is not, we're not going to see any benefit.

49:45Emily Oster:We're only going to see harm with alcohol in those conditions.

49:47Perry Wilson:The other place I think is we're talking about is sleep. So I think There's actually very little question that alcohol, even at relatively low levels, makes people sleep worse.

49:59Emily Oster:Yeah, no question.

50:00Perry Wilson:So people have, you know, like it increases your resting heart rate. It lowers the quality of your sleep. And this is true for healthy people, even with, again, sort of relatively mild amounts of alcohol consumption. So, you know, I think this is the kind of thing that you can get into with the wellness. like, you know, it made my resting heart rate three units higher and here's all the problems with that. It's not really clear why, again, sort of from a longevity or clinical meaningful health perspective that matters. I will say if you are looking to optimize tomorrow's performance in some, you know, podcast or sporting event, you know, it is perhaps not the best active.

50:42Perry Wilson:Most people do not drink before a race. I will say that.

50:46Emily Oster:Yeah. So give me some feedback. everyone after this episode, how my performance was. I think it's worth mentioning that, yes, alcohol clearly disrupts sleep. It also has an effect of suppressing REM sleep, which is dreaming sleep. That's through that GABA receptor antagonism. So benzodiazepines have the same effect. In fact, psychiatrists will use benzodiazepines to treat people who have chronic nightmares like PTSD-induced nightmares and things like that to suppress the dreams. But in general, you don't want to suppress your REM sleep. That's where a lot of memory consolidation happens and learning happens.

51:27Emily Oster:And so that's yet another reason to limit alcohol, especially right before bed.

51:33Perry Wilson:I think a lot of people, in the case of alcohol use disorder, it is common for people to use alcohol to fall asleep. And then they're often up in the middle of the night because alcohol will help you fall asleep at the beginning of the night to some extent, but then - Yeah, you withdraw essentially. Exactly. Withdrawal disrupts your sleep later.

51:50Emily Oster:Right. And alcohol is constantly getting metabolized. And especially if you are a frequent user of alcohol, then that withdrawal that happens at 2, 3 a.m. I mean, we've all been there. Maybe not you, Emily, but in college, if you remember.

52:05Perry Wilson:I have been there.

52:06Emily Oster:You've been there. 2 to 3 a.m., you wake up, you feel hyper, you feel uncomfortable. It's fall back asleep.

52:12Perry Wilson:Not great.

52:12Emily Oster:Not great, folks.

52:14Perry Wilson:Okay. But let's talk about where alcohol is great, which is making parties more fun. That's right. Basically.

52:21Emily Oster:It's like everything in medicine is risk benefit and we've given you a lot of risks and we don't have much benefits to share except that it is fun and it makes social interactions a little bit better. Which is a real benefit.

52:34Perry Wilson:I mean, I think that is like, you know, an aspect of this conversation that's very frustrating again is this piece of it where it's like we're looking for evidence that alcohol is like broccoli and it's not it's not like broccoli okay broccoli like you can have as much of it as you want it's super energy dense a lot of fiber nature's brew broccoli's great for you a lot of vitamins whatever alcohol's not broccoli but we're talking about it like if it's not broccoli it's basically cocaine and it's like at low levels it's also not cocaine. And I think we got to kind of like find the middle here.

53:07Emily Oster:Yeah. What is, is it bacon?

53:10Perry Wilson:I think it's like Doritos. It's like Doritos or bacon or something. It's like a sometimes food, you know? Yeah.

53:18Emily Oster:All right. I like that. The studies of alcohol and its social effects are really fascinating. And whenever I read these, I get sad that I study kidney disease and I don't actually get to run these trials. So these are studies, these alcohol researchers bring people into the lab. Some of them have their lab set up like a bar to like have the full experience. So they have a bar in their lab and then they're measuring out all these precise amounts of alcohol. There's a fun study in psychological science in 2012. They took 720 people, strangers in groups of three, and they put them in a room and they randomized them to drink alcohol versus placebo.

53:59Emily Oster:And then they saw how they felt. They just interacted and how they felt about each other. And those who got the alcohol reported a significantly enhanced positive affect, so good feelings about the other people, a reduced negative affect, and increased self-reported bonding. In short, they had a good time and they made some friends.

54:19Perry Wilson:Yeah. Which is really, that's what it's for, man. That's what it's for. I don't know. I mean, I think that's – I'm curious here. What is the placebo? Like does it taste like alcohol?

54:29Emily Oster:Yeah, they do. They have stuff that tastes alcohol-ish like medicinal. I think maybe quinine or things. In some studies now, they are using alcohol-free beer and alcohol-free wine, de-alcoholized wine, which now doesn't taste as crappy as it did 10 years ago. Still pretty bad. A lot of advances. I think – I don't know. The athletic I think is pretty good.

54:49Perry Wilson:No, the beer is great. The alcohol-free wine is no good. I still haven't made any progress on that. Yeah.

54:54Emily Oster:So yeah. And there are some other studies as well that show, for example, in social interactions with alcohol compared to without alcohol, alcohol consumption moderated seven of 10 associations between state social anxiety and indicators of healthy social interactions. What this means is that you measure someone's general social anxiety, how nervous they are, and how well they interact with new people. And across seven of 10 of those metrics, alcohol improved the social interaction. So you don't want to go too crazy when you're meeting new people, but it smoothed things over. It does.

55:35Perry Wilson:It does. And I think that's worth noting. I mean, interacting with other people who you haven't met before is one of my nightmares. And so I actually really appreciate this.

55:47Emily Oster:I'm trying to imagine how you even do it. I assume you just say, hi, I'm Emily. Here is my whoop score for recovery score for today. What's yours?

55:55Perry Wilson:I don't like it. I don't. For someone whose life is spent so aggressively in the public eye, I am surprisingly shy and weird at parties. So.

56:05Emily Oster:I'm not entirely surprised, Emily. Well, you've known me for a long time. I mean that in the nicest way.

56:11Perry Wilson:We've known each other a long time. I'm sure you were at college parties with me when I was probably also super weird.

56:17Emily Oster:No, you were always. Even though I was drinking. Okay, let's move on. Always wonderful and charming. I threw in a study for you about, I always have to find something about endurance athletes. So do you buy the idea, as told in Sports Medicine 2026, a journal we like, that the observational links between alcohol and death, overall mortality, were restricted to only the 20 % of people who got the least amount of exercise. So if you're in the top 80 % of exercisers, the alcohol effect goes away. Is that nice? No, I don't.

56:51Perry Wilson:I don't. I don't believe in this because it is the the set of people who are exercising are very different from the set of people who are not. And the people who are exercising with alcohol like those differences are smaller. This just feels to me like it is entirely driven by different kinds of complicated biases. And so it's good to exercise, but it doesn't mean that you can just, you shouldn't drink while you exercise. Don't put vodka in your water bottle, my friends. It's not good.

57:26Emily Oster:at the same birthday party I was telling you about that where the Taco Bell incident happened back in the news portion of the show. What we did is one of these group bikes where there's 12 people on a bike. I don't know if you have one out in Rhode Island and you bike around the city from bar to bar, but it's really hard. Like you get a real workout. I was sweating and I loved it. I was drinking, I was exercising and I was like, this is a great combo. I feel good in so many ways.

57:55Perry Wilson:I feel like you're on the bike with 12 other people on the same bike.

57:59Emily Oster:It's a big oval of pedals. And so there's a driver and everyone's pedaling together. And the driver is steering it around the streets of New Haven. It's fun, but it's a workout. Then you're at a hill and everyone's like, oh no, it's a hill. And then at the red lights, he makes you drink.

58:17Perry Wilson:Wow. I mean, I grew up in New Haven and I never knew about this amazing bike. Okay.

58:23Emily Oster:Option.

58:23Perry Wilson:I'm totally doing that.

58:25Emily Oster:All right. People are going to ask us. And so I'm going to ask you, Emily, who doesn't drink and you can ask me who does. How much is okay to drink?

58:36Perry Wilson:I think in my view is in in moderation, which is defined by yourself. So I would generally tell people I wouldn't have more than two drinks a day because I think as you get up above there, you start seeing some of these impacts on more meaningful impacts on things like sleep. But I certainly would not tell people not to drink at all. I don't think that the data supports that. I agree.

59:05Emily Oster:My party line is I tell people they can drink just enough. And it's their job to figure out what just enough is and to try to draw the line there. This is also something you can experiment with. I told you on a prior episode that I did dry January this year. So I didn't drink for a month. And I was waiting to feel as amazing as everyone says you're going to feel. And it's like, oh, my sleep is so good, my energy and my focus. And I really just didn't feel any different. And that was a valuable experiment for me, but you can do that too.

59:34Perry Wilson:And I will say, I also experimented with this and had more or less the opposite experience, which is it totally changes how I feel in the morning. And I think that's why self-experimentation is helpful.

59:48Emily Oster:All right, Emily, smash or pass? Alcohol.

59:53Perry Wilson:Smash in moderation.

59:56Emily Oster:Yep. I am a smash. Alcohol is proof that God loves us. I believe it. So that's it. That's it for alcohol. Your mailbag question of the week after the break.

1:00:11Perry Wilson:I thought I looked so cute. I pieced together a cute outfit. And this girl comes up to me, just sits next to me telling me, oh, hey, girl, I see your skin. I know what you're suffering with. I just remember feeling so just like distraught and like robbed of my time. When I finally freed myself of that conversation, the lights were coming on and the party was over. It felt like I had a sticker on my forehead that said, she has eczema.

1:00:40Emily Oster:We've all been there, wanting to go out, feeling cute, forgetting about all your problems and just existing in the present with joy. But when you live with a visible skin condition, that can be a lot harder than it needs to be. This is Skin Queries. Listen on the iHeartRadio app, Apple Podcasts, or wherever you get the stories that make you feel understood.

1:01:05Perry Wilson:16 years ago, I started working as a CNA in the hospital. I loved it. On the day I decided to enroll in the nursing program at Rasmussen University, it was afternoon, my 35th birthday. I was hanging out with a friend, and they had just questioned me what I was going to do with this next chapter of my life. I immediately had said, I want to go to nursing school. So I actually had contact information from an advisor at Rasmussen, contacted her, and actually ended up starting like three weeks later. My name is Cherish Adams, and I'm a Rasmussen University graduate.

1:01:32Emily Oster:Learn more at rasmussen.edu. Apple Vacations, where your story starts. The July Savings Event from Apple Vacations is here. Book by July 23rd and save up to$400 off your flight and hotel package to Mexico, the Caribbean, Central America, Hawaii, or Europe. From all-inclusive escapes to bucket list adventures, Apple Vacations makes it easy to create memories with the people who matter most. Start today at AppleVacations.com or contact your trusted travel advisor. Apple Vacations, where your story starts.

1:02:08Emily Oster:Hi, Emily and Perry. This is Kristen in Minneapolis. My question for you is about sleep apnea. Perry, you mentioned you had it in an earlier episode. And I was wondering if you would talk a little bit more about how to recognize it in someone, someone who snores, like, say, my husband. Thanks so much.

1:02:33Perry Wilson:Okay, Perry, I'm going to pass this one to you as someone who has been through this testing. Yeah.

1:02:40Emily Oster:So for those of you who haven't gone through all the episodes, I have sleep apnea. I use a CPAP. And that is something, an intervention actually, that has made, I think, my life a little better. I do think I have more energy using CPAP, but more importantly, my wife still sleeps in the same bed with me, which is nice because snoring is the primary symptom of obstructive sleep apnea. Virtually everyone with obstructive sleep apnea is going to snore. Not everyone who snores has obstructive sleep apnea. That's how to think about this. The diagnosis of OSA requires a sleep study. That's the standard.

1:03:18Emily Oster:This can be done in a sleep clinic where you actually go somewhere and you're in a bed and they have all sorts of monitors on you. But actually, they've gotten really good now about doing this in your own home using portable devices. And what they're measuring for obstructive sleep apnea is not snoring, but what are called apneas. So the cessation of breathing and hypopneas, which are periods of low levels of breathing. So they're measuring how your chest is moving up and down and their criteria for how many of those and how long they last to make the diagnosis.

1:03:49Perry Wilson:Is there a way to tell if you are just a person who's a very loud snorer, whether you are not breathing based on the noise? Is there a noise diagnostic?

1:04:02Emily Oster:I mean, spouses, bed partners can usually tell. The person who is awake listening to you snore will hear periods of apnea or can hear periods of apnea and get nervous about it. You would think that someone would invent an app that records your snoring or something and gives you a risk and maybe one exists, but certainly none are FDA approved for diagnostic purposes. Tamar, our producer, just came up with the idea that it should be called apnea, which is genius. Patent pending wellness, actually. That's ours now. It'll be on the App Store next week.

1:04:39Perry Wilson:My last question on this, and I'm just going to – this is just a personal question, is what's the – let's say your partner is a loud snorer but doesn't have sleep apnea. What are some ways other than kicking to get them to stop snoring?

1:04:57Emily Oster:Yeah.

1:04:58Perry Wilson:Do you know?

1:04:59Emily Oster:I do. Yeah. So, yes, waking them up, not ideal because it'll come right back. Sleep position is the main one. So snoring happens usually for most people when they're sleeping on their back. People will tend to roll back onto their back once they fall asleep, if that's their comfortable sleep position. I have had some patients who have sewn a tennis ball into a pajama shirt so that if they lie on their back, it sort of digs into them princess and the pea style. So they have to turn over so you're sort of retraining. There are oral appliances that advance the jaw a little bit. I actually used one of these before I got my CPAP machine, and that opens up the oropharynx so that snoring doesn't happen.

1:05:42Emily Oster:They can be kind of uncomfortable. It's uncomfortable for me, but there are dentists who specialize in this. There are surgeries that can eliminate snoring, soft palate surgeries. And then for people with an elevated BMI, weight loss is a primary method to reduce snoring.

1:05:59Perry Wilson:So I'm hearing kicking. Or tennis ball in the back of the shirt. Kicking or tennis ball. Yeah. Okay. I'm going to try it out.

1:06:05Emily Oster:Both are fun. All right.

1:06:09Perry Wilson:That is it for us today. Stick with us next week when we'll ask, what's the deal with the sun? What's the deal with the sun?

1:06:18Emily Oster:What the hell is it?

1:06:19Perry Wilson:We'll get into it. Is it a star? We need that anyway.

1:06:23Emily Oster:Is it a god?

1:06:25Perry Wilson:Come back next week. You'll find out. Wellness Actually is produced in association with iHeart Media. Our senior producer is Tamar Avishai. Our executive producer at iHeart is Jennifer Bassett. Our theme music is by Eric Deutsch. And our content is for educational purposes only.

1:06:43Emily Oster:If you like the show, help other people find us. Leave a rating and review on Apple Podcasts or your podcatcher of choice. And help us spread the word about the show. You can follow us on Instagram at wellnessactuallypod. And don't forget, we want to hear from you. Head over to wellnessactually.fm and leave us a question for our mailbag. or suggest a topic for a future show.

1:07:04Perry Wilson:We'll let the influencers have the last word. I don't want to alarm anyone, but I think there's a little outgy call in this point. Well, I do have a warm sense of well-being and I seem to be sorry in my speech. You're right. Give me another.

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1:08:36Perry Wilson:Sixteen years ago, I started working as a CNA in the hospital. I loved it. On the day I decided to enroll in the nursing program at Rasmussen University, it was afternoon, my 35th birthday. I was hanging out with a friend, and they had just questioned me what I was going to do with this next chapter of my life. I immediately had said, I want to go to nursing school. So I actually had contact information from an advisor at Rasmussen, contacted her and actually ended up starting like three weeks later. My name is Cherish Adams and I'm a Rasmussen University graduate.

1:09:03Emily Oster:Learn more at rasmussen.edu.

1:09:06Perry Wilson:This is an iHeart Podcast. Guaranteed Human.