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The Fullness of Midlife

“We underestimate the effect of alcohol over time.”

“We underestimate the effect of alcohol over time.”

by Dr. Barb DePree MD

Dr. Connie NewmanConnie B. Newman, MD, is an endocrinologist, physician-scientist, adjunct professor of Medicine at New York University (NYU) School of Medicine, and Academic Visitor at the University of Oxford, UK. A nationally respected leader in the field of hypercholesterolemia and other lipid disorders, she advocates for women’s rights and access to reproductive healthcare. She is the chair of an Endocrine Society clinical practice guideline on the management of high cholesterol, the writing group for the American Heart Association’s Scientific Statement on the safety of statins, and the Endocrine Society’s Special Programs Committee, as well as a consultant to the Endocrine and Metabolic Drugs Advisory Committee of the FDA.

Dedicated to helping other women pursue medical careers, Dr. Newman mentors pre-medical and medical students and young physicians through the American Medical Women’s Association (AMWA), Wellesley College, NYU, and Weill Cornell Medicine. In 2011, she founded the Wellesley Women in Medicine Group, a network of 900 women, including pre-medical and medical students and physicians of all ages, that participates in online conversations on topics such as medical training, career paths, work-life balance, and gender discrimination. Within AMWA, Dr Newman is a member of the Board of Directors, and co-chairs several committees including the Preventive Medicine Task Force, the American Women’s Hospitals Service (AWHS), and the Fellowship Committee. 

Dr. Barb: I heard a presentation at last fall's NAMS annual meeting—that's the North American Menopause Society—and it really grabbed my attention. It was about changes in women's habits and alcohol consumption, and it had included so much thought-provoking information. I reached out to the presenter to share the information with you, the listeners. Dr. Connie Newman is an endocrinologist, physician scientist, and educator with the New York University School of Medicine and the University of Oxford in the UK, and Connie joins me today from Oxford. Thank you, Connie, and welcome.

Connie: Thank you very much. It's a pleasure to talk with you today and to talk to the audience about alcohol use.

Dr. Barb: So as I said, at your presentation at NAMS this fall, I was really intrigued by the data you presented, and I'm just curious what prompted your interest in this health issue?

Connie: I've been interested in alcohol use and its health problems for 30 years or so. When I was a medical resident, I had the opportunity to do some research at the Rockefeller University, and we were looking at ways to detect alcohol in the blood of men and women because alcohol leaves the blood rapidly. So we were looking at adducts or sort of compounds of acid aldehyde and hemoglobin. Acid aldehyde is—it's complex—it's the metabolite of alcohol.

And I worked on this research for a couple of months, and that intrigued me. Later it was proven that we couldn't use the acid aldehyde adduct of hemoglobin to track alcohol use. It just wasn't present in enough quantity, so we didn't use it.

Dr. Barb: So one thing that was striking in your presentation was your data on the rate of increase in high risk drinking, especially that it had the greatest change in women 45 and over. Can you talk about that data a little bit?

Connie: Well, what's happening is, what is high-risk drinking, first of all? High-risk drinking refers to, for a woman, having more than three drinks on one occasion, so four or more drinks. For a man, it's a little larger than that. It would be more than five. It would be five or more drinks.

And so what we've learned from various surveys, comparing let's say 2002 to 2012, that there is that men are still drinking more than women, there were more men drinking, and more men drinking at risk. But for women, the percentage of women drinking is increasing at a much greater rate than it is in men.

So, and in particular, we see an increase in drinking in middle-aged women, which is of great concern. And there were some studies looking at why this is happening, which I can talk about later.

Dr. Barb: And just to review, I think the term you used in your lecture was alcohol use disorder, or AUD.

Connie: Oh yes, that is a term. Well, what I was talking about just before, it was not alcohol use disorder, although there is an increase in alcohol use disorder as well. So alcohol use disorder is the new term for saying that someone has an addiction to alcohol. So now you can, one can make a diagnosis of alcohol use disorder, and people who have this problem usually meet two of eleven criteria.

So for example, they may drink longer than they intended to. They may try to cut down on their drinking, but they can't. Their drinking may interfere with their family life, with their home or with their job, or they may drink and get involved in some activities that could be harmful. So there were eleven criteria, other than what I just mentioned. And the rate of that in women is also increasing.

Dr. Barb: So I hear you say kind of two things. Alcohol use disorder, which is really getting at the addiction side of it and understanding how it impacts behaviors and motivations. But then also this amount of drinking, which may be periodic. Occasion, may or may not impact day-to-day activities.

Connie: You mean binge drinking? At-risk or binge.

Dr. Barb: Okay.

Callout: High-risk drinking for a woman is four or more drinks.

Connie: Yes, that's absolutely correct. It may not, I mean, if you are binge drinking and you don't drive, that is a really good thing. But I think that one of the big problems—and I want to convey this to the audience—is that people don't understand what a standard drink is, and this varies by country. So in the United States, one standard drink would be five ounces of wine, and I've seen wine glass is filled much higher than five ounces. They would constitute one or one and a half or two drinks. So a standard drink is five ounces of wine or 12 ounces of beer or one and a half ounces of 80-proof spirits.

And the limit on one standard drink in women in the United States is seven standard drinks a week and three or more on one, three or less on one day. And for men, the limit per week is 14, so men can drink more than women.

Dr. Barb: And when you say the limit, that's sort of back to your definition of kind of being excessive?

Connie: Yes.

Dr. Barb: Okay.

Connie: It would be. If you drank more than that, it would be considered excess alcohol use. But it does not mean that you have alcohol use disorder or meaning you're not necessarily addicted to alcohol, but alcohol has harmful effects on the body.

Dr. Barb: And I think that was the important part of the lecture. That was my take-home, that maybe we underestimate what the impact of alcohol might be over a period of time, and having two drinks a day, for instance, which most people I don't think would identify as excessive alcohol, but can you talk a little bit more about the physical impacts, the health impacts that come from as a result of alcohol use?

Connie: Yes. Alcohol use causes liver disease, and we've known that for a very long time. It can cause end-stage cirrhosis with chronic drinking, or it can cause acute inflammation of the liver, alcoholic hepatitis, and it can lead to cancer of the liver.

Callout: Even five ounces of wine daily increases the risk of breast cancer by about 10%.

Alcohol is also known to cause cancers of the GI tract, colorectal cancer, cancers of the oral cavity of the esophagus. And also in women, alcohol increases the risk of breast cancer, which is some new findings that I found extremely interesting because even having one drink, five ounces of wine daily, increases the risk of breast cancer in a woman by about ten percent.

Dr. Barb: That's exactly the statistic I tell women. I do some high risk breast management in my practice, and we always review alcohol use. So for every one alcoholic drink there's a ten-percent increase in your baseline of breast cancer risk. I think you also outlined maybe some heart disease-related risk factors with alcohol use.

Connie: Oh yes, thank you for mentioning that. So it's been believed for a long time that having a drink a day protects the heart. And this I hear, I hear people saying, well this is good for my heart. Well, that is not necessarily the case. We have new data showing that even one drink a day could be harmful. So alcohol does increase the risk of heart disease such as angina or myocardial infarction, and there is no real level that you could say is necessarily okay for a person. Because even if there was a slight protective effect, if you had like one-half a drink a day, the adverse effects of drinking alcohol in other parts of the body would far outweigh that.

So in terms of the cardiovascular system, alcohol increases the risk of heart disease, meaning angina and MI, a blockage in your arteries. It also increases the risk of stroke, particularly hemorrhagic stroke or stroke due to bleeding.

Dr. Barb: So the broadly believed one red wine a day is good for your heart, you would say is really not accurate?

Connie: Yes, I would say it's not accurate. There's new evidence to show that it's not good for the heart.

Dr. Barb: Okay.

Connie: Some people debate that, but even if it were, there's so many negative effects of alcohol.

Dr. Barb: Yes. So can you give some insight as to why you think that rate of increase, especially in women and in midlife women, is changing? That's really, my practice is primarily women over 40, and I'm just interested to understand why that might be happening or what your understanding is.

Callout: Use other ways besides alcohol of reducing stress.

Connie: Well, that's the question that we really don't have the answer to. But there's been at least one study that I know of, and they looked at women in that age group and found that these women were drinking because of stress. They were drinking to relax themselves. And obviously, that's not the way alcohol should be used. And instead of using alcohol for stress, we should use other ways of reducing stress.

And another reason perhaps for the increased risk of drinking, increased drinking and women, is that women are now working more, have jobs, and are working and are in stressful environments. And I guess in the past 50 years or so, women have been allowed to enter bars, which was prohibited before. So there are many reasons that there is this increase in drinking in women.

Dr. Barb: And I think about the social aspect that seems in my mind to have changed over decades of including alcohol at many social outings, and which include work-related things, I think as well. So it may be women in the workplace have also resulted in more of the social activity that involve alcohol.

Connie: Yeah, you're absolutely correct, because if alcohol is present at a party that can lead to women drinking more and saying, “Oh, this feels good” and drinking later outside, you know, of these work parties.

Dr. Barb: Can you also talk just a little bit about the difference between men and women and tolerability and why that might be?

Connie: Well, it's known that women have less tolerance of alcohol compared to men, even if they drank equivalent amounts. And the reasons that I have read about are that women have lower body water which would lead to a higher concentration of alcohol in the blood. They also have higher body fat, and women have relatively low levels of an enzyme that metabolizes alcohol. This enzyme is known as alcohol dehydrogenase. So alcohol would not be metabolized, and it would have effects on your brain much more than men, so we always say that women don't tolerate alcohol, like they can't have like more than a drink, some women, at a party because they get sick, and men can drink many more drinks than women. But it's a difference in physiology that accounts for that.

Dr. Barb: And is there any difference in physiology between men and women in the health impact as you referred to liver disease or heart disease or cancer risk? Obviously breast cancer is somewhat unique to women, but other general health impacts, do we see a difference in gender based on that?

Connie: Yeah. Yes, we do. Women have a higher rate of alcoholic hepatitis, of stroke due to bleeding, of heart disease and of course, of breast cancer. A higher rate than men.

Dr. Barb: And I think your data suggested talking about mortality related to alcohol, about 2.2 percent of women's deaths can be associated with alcohol. Does that sound correct?

Connie: That sounds correct. I don't have the data right in front of me, but it sounds correct.

Dr. Barb: Okay. So when you think about it, that's not an insignificant consequence.

Connie: No, that is not. And I think that people take alcohol, their drinking, too lightly, and they don't realize its negative effects.

Dr. Barb: So is there understanding of helping an individual understand when she's crossed a line from casual to problematic alcohol use? Is it mostly about quantity really? That sounds like one of the mainstays of understanding sort of safe use versus unsafe use is really more about the quantities. Am I understanding that correctly?

Callout: We underestimate the effect of alcohol over time.

Connie: Well, it's yes and no. I think you are mostly understanding that yes, the more a person drinks or more a woman drinks, the greater their risk of adverse health effects. But also, if some women have a predisposition to being addicted to alcohol or getting alcohol use disorder so they might drink less than you than other women and present with some of the signs of alcohol use disorder that I talked about earlier.

Dr. Barb: So as a healthcare provider, what's the recommended screening we should be considering as we see women and talk about it? You know, in my office we have what we would consider a social history. Are you a smoker and what about alcohol use? How specific or how should we ask the question? How should women be providing that information to us? Is it how many alcoholic drinks per week? Is that the metric we should be recording or how would you recommend that?

Connie: Well, what you could, that's a good idea to ask about alcoholic drinks per week, but you have to make sure that the women understand what a drink is.

Dr. Barb: Yes. Back to the beginning.

Connie: Because if they're drinking like ten ounces of wine and calling it a drink, that's two drinks. And also there are two surveys that have been validated which screen for alcohol use that's risky. One is known as the audit survey, and the other one is a shorter survey called Cage. C-A-G-E. And that is not a mandatory screening in a medical practice, but I think if it were for primary care doctors, they would detect more people who have problems with drinking.

Dr. Barb: So let's move on and talk about those who may have problems. So what do you see as effective treatment options? And I think in your lecture you talked about women actually seeking different treatment options versus men. And I also wondered, are there different treatment options that might be effective for women versus men or can you talk a little bit about that next step for those who identify themselves as having a problem. You know, what's next?

Connie: Well, less women than men actually use formal alcohol treatment centers. Less than twenty, actually. Women more commonly seek care with their primary care doctor and perhaps with mental health professionals, and doctors don't refer women to treatment centers as much as they should. So women have various barriers to treatment.

First of all, it's a stigma today to be drinking alcohol excessively. It's expensive to get treatment in a treatment center. And women also have childcare responsibilities, threats to custody if they're, you know, in a live-in program. But there are ways to be treated as an outpatient.

Dr. Barb: And back to the primary care, obviously most women are going to be identified through their primary care provider as maybe having some risk. So why is it you think it's not as readily pursued, the treatment? Do you think it's not recognized that women experience this condition as much as men? 

Connie: You may be right. I think women, I think that there needs to be education of people, as well as of doctors, about what constitutes unhealthy drinking, and that many middle-aged women are drinking more than they should. So I think that's one of the reasons we need to change that. And there should be mandatory education about this.

Dr. Barb: And I wonder how much just awareness would help individuals modify?

Connie: Yes. I mean, awareness of the risks of drinking and of the amounts of drinking that are considered low risk is really important, and I think that would help women and men substantially. But you know, we have competition from the companies that produce alcohol.

Dr. Barb: Yes. It's an interesting thing because you think about how effective smoking awareness has been. Every American at least understands the impact of smoking, and the restrictions around smoking. Do you anticipate there could be any like campaigns around alcohol awareness?

Connie: Well, I would like there to be campaigns, but it would have to be funded by the government, I suppose. Campaigns take time and cost money. And I think it would be helpful if one of the national institutes that works on alcohol would have a larger campaign on the adverse effects of alcohol, and what it means to drink excessively. So if you go on the NIH website or on the government website, you can find information about what a standard drink is and what is at-risk drinking. It's there, but I don't think people look there.

Dr. Barb: Right. No, I think it just needs to be a more broader conversation—primarily between providers and their patients—and it starts with taking a good history and having some accuracy. And then again, just helping individuals understand what the health risks are, and they can make their own decisions. I think that's where it seems to be a bit of a weak link of just recognizing the impact. And I think that was one of my goals today was to help women better understand the impact of decisions around alcohol use.

Connie: Well, that's it. I'm actually happy that you're interviewing me because I think this will really help educate women.

Dr. Barb: I'd like to pivot away a little bit and just hear about your work with the American Women's Medical Association and kind of your accomplishments. Your involvements professionally are really profound, but I think one of the areas of your interest in efforts around the American Women's Medical Association would be just interesting for listeners to hear a little bit more about.

Connie: Well, thank you. I really like talking about the topic. So just to be clear, the American Medical Women's Association is an organization of women doctors that's been around for more than a hundred years, and their purpose has always been to advocate and advance women in medicine. Right now we're also advocating for equity; equity for women doctors and men doctors. And we're advocating to ensure excellence in healthcare.

So one of the areas that I work in, I work on educating doctors about burnout, the burnout syndrome. I think you know what that is.

Dr. Barb: I do know what this is. Yes.

Connie: And so because of my work in AMWA, I was able to participate in a National Academy of Medicine discussion paper about differences in women in terms of risk factors for burnout. You know, there are many differences for women doctors because women doctors have dual roles, you know, with their family and also taking care of their patients.

Women doctors often don't, they don't advance as quickly as men. If you look at academic ranks in medical centers or medical schools, you will see that only of the professors, only 25 percent are women. But half of the medical school classes are women now. And that's been the case for more than ten years. And that's, for women, that can contribute to feeling unappreciated and burnout.

And also there has been a longstanding bias against women, which is often unconscious, and that's known as implicit bias. And women are not treated the way that they should be because people, even other women, think that they're not meant to be doctors. They're meant to be at home. So there are many factors. So I work on burnout with the American Medical Women's Association.

Dr. Barb: Well, thank you for your work in that. And I know another area that's important to you is mentoring. Can you talk a little bit about your mentoring work?

Connie: Yes, thank you. I've been mentoring people who are not as educated, not as far along in their career path, for numbers of years. And within AMWA, we have several divisions, including a physician division, a resident division, a medical student division, and a pre-medical student division. So there's a lot of opportunity to interact with women who are becoming doctors, or who wish to become doctors, or who are young doctors. And I have been doing that for my entire career, always helping people who are at a lower level of the ladder than I'm at. And I find it very gratifying.

Dr. Barb: Yeah, it's interesting you say that as you're speaking, I'm thinking back to the beginning of my career in medical school and I considered general surgery, but I didn't know a single female general surgeon. So I couldn't envision it because I wasn't exposed to it. So it's interesting how that influences careers. So I don't know that it was a conscious process at the time, but I picked gynecology because it had a surgical aspect to it, and I was able to accomplish that. But I avoided general surgery, I think partly because I couldn't envision a woman doing it because I didn't see it. So it's important work.

Connie: Right. That's changed now.

Dr. Barb: It has changed now. It certainly has.

Callout: We need to make the playing field equal for women.

Connie: Yeah. Luckily, there are many more women in surgery—although they're not always treated appropriately—but there are more women, and they're getting through their programs, and they're good surgeons. But we need to make the field—the playing field—equal. And I'm a member of this organization known as Time’s Up Healthcare. I'm not sure if you've heard about it. It's an organization that's trying to achieve equity in the medical profession, and also to prevent harassment of women and also men. I'm a founding member of Time’s Up Healthcare.

Dr. Barb: Yeah. Thank you very much for your work on behalf of women in this field. So I appreciate your time today, Connie. And as we wrap up, I just would like to ask the question, where do you find fullness in your life?

Connie: That's an interesting question. I find fullness partly in my career and my work as a doctor, but also in my family. I'm very fortunate that I have two sons who are 31 and 32 years old, and I also have a daughter who is 35, and she's a doctor. I'm married and fortunately, my children have been very supportive of me during my career, and they think that women are nurturing, and they're very fitted/suited to being doctors.

Dr. Barb: Great. So I'm grateful for you again and the work you're doing, especially on behalf of women. So thanks for your time today, Connie.

Connie: Oh, thank you. It's been a pleasure talking to you.


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