Health for life

As a class, people who dont drink at all have a higher mortality risk than light drinkers. But nondrinkers are a diverse bunch, and the reasons people have for abstaining affects their individual mortality risk, in some cases lowering it on par with the risk for light drinkers, according to a University of Colorado study.

Multiple studies have shown that the likelihood of dying for people who drink increases as they consume more alcohol. Those same studies have shown that a persons mortality risk also increases at the other end of the spectrum — among people who choose not to drink at all — though the risk is still much less than for heavy drinkers.

Some researchers have hypothesized that the increased mortality among nondrinkers could be related to the fact that light alcohol consumption — drinking, on average, less than one drink a day — might actually protect people from disease and reduce their stress levels.

But researchers at the University of Colorado Boulder, working with colleagues at the University of Colorado Denver, decided to examine whether characteristics of different subgroups of nondrinkers could explain the increased mortality risk.

"Among nondrinkers, people have all sorts of background reasons for why they dont drink," said sociology Professor Richard Rogers, director of CU-Boulders Population Program in the Institute of Behavioral Science. "We wanted to tease that out because its not really informative to just assume that nondrinkers are a unified group."

For the new study, published in last months issue of the journal Population Research and Policy Review, Rogers and his colleagues relied on data collected in 1988 by the National Health Interview Survey about the drinking habits of more than 41,000 people from across the United States. The researchers also had access to information about which respondents died between taking the survey and 2006.

During the survey, nondrinkers were asked to provide their reasons for not drinking. Possible answers ranged from "dont socialize very much" to "am an alcoholic" to "religious or moral reasons."

The research team divided nondrinkers into three general categories: "abstainers," or people who have never had more than 12 drinks in their lives; "infrequent drinkers," or people who have fewer than 12 drinks a year; and "former drinkers." Each category was further divided using a statistical technique that grouped people together who gave similar clusters of reasons for not drinking.

The team then calculated the mortality risk for each subgroup compared with the mortality risk for light drinkers, and they found that the risks varied markedly.

Abstainers who chose not to drink for a cluster of reasons that included religious or moral motivations, being brought up not to drink, responsibilities to their family, as well as not liking the taste, had similar mortality risks over the follow-up period to light drinkers.

"So this idea that nondrinkers always have higher mortality than light drinkers isnt true," Rogers said. "You can find some groups of nondrinkers who have similar mortality risks to light drinkers."

The other subgroup of abstainers — whose largest reason for not drinking appeared to be a dislike of the taste and to a lesser degree family responsibilities, religious or moral motivations or upbringing — had a 17 percent higher mortality risk over the follow-up period compared with light drinkers.

The scientists also found that infrequent drinkers generally had a slightly higher mortality risk than light drinkers. Former drinkers, however, had the highest mortality risk of all nondrinkers. Former drinkers whose cluster of reasons for not drinking now included being an alcoholic and problems with drinking, for example, had a 38 percent higher mortality risk than light drinkers over the follow-up period.

By comparison, people who drink between one and two drinks per day, on average, have a 9 percent higher mortality rate than light drinkers, while people who drink between two and three drinks per day have a 49 percent higher mortality. People who consume more than three drinks per day had a 58 percent higher mortality risk over the follow-up period compared with light drinkers.

Despite confirming that some subgroups of nondrinkers have a higher mortality rate than light drinkers, it doesnt necessarily follow that those peoples mortality rates would fall if they began drinking, Rogers said. For example, people who were problem drinkers in the past might increase their mortality risk further by starting to drink again.

Also, people who dont drink at all, as a group, have lower socioeconomic characteristics than light drinkers, which could be one of the underlying causes for the mortality differences, Rogers said. In that case, starting to drink without changing a persons socioeconomic status also would not likely lower mortality rates.

"I think the idea that drinking could be somewhat beneficial seems like its overstated," Rogers said. "There may be other factors that lower mortality for light drinkers. Its not just the act of drinking."

The Disease Management Care Blog recently attended a physician meeting that keynoted a U.S. Senator.  In his prepared comments, he admitted that he knew little about controlling health care costs.  Unfortunately, that didnt stop him from humbly paraphrasing the testimony of a famous economist:

"Find out what works," said the expert, "and do that."

Maybe some of the physicians silence that followed was an "aha!" reaction to the Senators insightful nostrum.  Some of it may have also been out of respect. 

The DMCB is sure, however, that most of the docs in the room were quietly thinking "You must be kidding me."

Such is the approach of the mandarins leading our federal health care institutions.  "Science and existing literature" says HHS Secretary Sebelius.  "Effectiveness" is the mantra of the Center for Medicare and Medicaid Innovation.  "Improving health care" is now part and parcel of CMS. 

Unfortunately, applying scientific evidence to the economics of health care delivery sounds easy enough until you get down into the weeds.  For a perfect example of that, consider the common condition of painful spinal stenosis among Medicare beneficiaries. According to this JAMA article, there were over 37,000 operations in this population at a national cost of $1.65 billion. 

Which begs the question: does spinal surgery "work," is "effective" and "improves health care?" Can the "science and existing literature" help us decide?

To get an idea of just how complicated the answer is, check out this Agency for Healthcare Research and Quality (AHRQ) research review on Spinal Fusion for Treating Painful Lumbar Degenerated Discs or Joints.  The conclusions from the abstract are:

Overall, limited evidence suggests that spinal fusion compared with physical therapy improves pain and function for adults undergoing fusion for low back pain due to disc degeneration. Because of insufficient reporting and variation in surgical methods used in the different studies, the incidence of adverse events (serious and minor) associated with fusion could not be determined conclusively. The evidence was insufficient to draw evidence-based conclusions for the benefits and harms of spinal fusion for patients with degenerative stenosis or degenerative spondylolisthesis of the lumbar spine. The evidence was also largely insufficient to draw conclusions about the benefits and harms of fusion compared with other invasive treatments or different fusion approaches or techniques.

In other words, there is some evidence that, compared to conservative treatment, surgery helps.  After that, its the stuff of caveats, statistics, evolving technique and myriad study limitations.

In fact, its so complicated that the only way it can be applied is by helping patients understand how the science applies to their unique circumstances and values.  Once the patient understands things, its a matter of letting that patient and doctor jointly decide on the best course of action.

That approach - in contrast to U.S. Senators musing on how we need a one-size-fits-all approach to what works - is called shared decision making and it can be applied to back surgery with considerable cost savings.

"What works?" asks the Senator?  The answer is for you to consider staying out of the way.

We’ve been told that a diet high in fiber is good for our health as it improves digestion and lowers biomarkers associated with chronic disease. Researchers publishing in the Archives of Internal Medicine provide important evidence to show that a high daily intake of fiber can lower the incidence of cardiovascular, infectious and respiratory diseases as well as reduce the risk of death from all-causes.

Contrary to earlier studies, new research suggests that omega-3 fatty acids may not benefit thinking skills. The study is published in the September 25, 2013, online issue of Neurology®, the medical journal of the American Academy of Neurology. Omega-3s are found in fatty fish such as salmon and in nuts.

"There has been a lot of interest in omega-3s as a way to prevent or delay cognitive decline, but unfortunately our study did not find a protective effect in older women. In addition, most randomized trials of omega-3 supplements have not found an effect," said study author Eric Ammann, MS, of the University of Iowa in Iowa City. "However, we do not recommend that people change their diet based on these results. Researchers continue to study the relationship between omega-3s and the health of the heart, blood vessels, and brain. We know that fish and nuts can be healthy alternatives to red meat and full-fat dairy products, which are high in saturated fats."

The study involved 2,157 women age 65 to 80 who were enrolled in the Womens Health Initiative clinical trials of hormone therapy. The women were given annual tests of thinking and memory skills for an average of six years. Blood tests were taken to measure the amount of omega-3s in the participants blood before the start of the study.

The researchers found no difference between the women with high and low levels of omega-3s in the blood at the time of the first memory tests. There was also no difference between the two groups in how fast their thinking skills declined over time.