Alcohol over time: Still under control?

For women, there's not much leeway between healthful and harmful drinking, especially as we get older.

Currently, the word is that moderate drinking can be good for you. Various studies suggest that it promotes longevity, helps prevent cardiovascular disease, and lowers the risk for dementia and other ills. What hasn't made as many headlines are the downsides for women, especially drinking that starts at a moderate level but eventually becomes a problem. Why this happens and to whom isn't fully understood. Most people who drink in moderation do so with little or no risk. But 1 in 13 adults in the United States has developed a serious alcohol problem, and at least six million of them are women. According to the National Center on Addiction and Substance Abuse (CASA) at Columbia University (www.casacolumbia.org), published figures are probably an underestimate of alcohol problems in women, in part because they don't take into account drinking patterns that are not serious enough to be called abuse or addiction but still have damaging physical and psychosocial consequences.

At every age, women develop drinking problems at lower levels of alcohol consumption and over shorter periods of time than men do. Women are also less likely to get medical attention for the problem, often because physicians don't recognize the signs in women. Older women are especially susceptible to alcohol's harmful effects and may be at particular risk. According to CASA's analysis of substance abuse in women, Women Under the Influence (Johns Hopkins University Press, 2006), about half the cases of alcoholism in older women begin after age 59.

You don't need to be addicted to alcohol to have a problem. For women, there's a fine line between healthful and harmful drinking. Moderate drinking means no more than seven drinks per week and no more than three in a single day. But even these levels don't guarantee safety. What constitutes moderation varies with many factors, including age, genetic makeup, and health. What's okay in your 30s or 40s can be risky after age 60. And if you have liver problems or a history of alcohol addiction, no amount of alcohol is moderate or safe.

No one should feel obliged to start drinking for the health benefits. There are plenty of other ways to safeguard your health, including exercise, a nutritious diet, weight control, and not smoking. But if you enjoy alcoholic beverages, it's important to know when and where to draw the line — and to be prepared to redraw it as you get older. Fortunately, there are ways to determine how much is too much and limit your intake.

A special concern for women

Women are more sensitive to alcohol than men are. That's because our bodies contain proportionately less water and more fatty tissue than men's bodies. Water dilutes alcohol in the bloodstream; fat retains it. So our brains and other organs are exposed to higher concentrations of alcohol for longer periods of time. At any given dose, even after accounting for differences in body weight, our blood levels will be higher, and we'll be more intoxicated (and more likely to suffer a hangover). Moreover, men's stomachs secrete more alcohol dehydrogenase, a digestive enzyme that breaks down alcohol before it reaches the bloodstream. As a result, one drink for a woman, on average, is the equivalent of two for a man.

Age and alcohol use

Our bodies contain even less water and more fatty tissue as we age, so blood alcohol concentration rises faster. We also metabolize and eliminate alcohol more slowly and less effectively. And older women are more likely to take multiple medications that may interact with alcohol, further raising the risk of accidents and health problems.

Women often turn to alcohol when faced with later-life changes, such as the loss of a spouse or friends, health problems, financial insecurity, or empty-nest syndrome. After retirement, some women engage more in social activities that involve alcohol, or drink more in order to relieve boredom. A woman may conceal her drinking problem or seek help for its symptoms — insomnia, depression, or anxiety — without mentioning the underlying reason. Moreover, physicians may fail to recognize the problem because of cultural bias. "A woman just can't be an alcoholic," elaborates Nancy Waite-O'Brien, a psychologist at the Betty Ford Center in Rancho Mirage, Calif., and a speaker at a recent CASA conference on substance abuse in women. "She doesn't look like it. She comes from a nice family. Or she has an education. So she just can't be."

If the symptoms of alcohol abuse are mistaken for depression or anxiety, a woman may be given a psychoactive drug that raises the risk of multiple addictions or drug-alcohol interactions.

Weighing the benefits

There's solid evidence for benefits from moderate drinking. For example, the Nurses' Health Study (NHS), a large-scale, 30-year study of women's health, found that one drink per day, compared to no drinking at all, reduced women's risk for heart disease and stroke by 50%; beer, wine, or spirits provided the same benefit. A Swedish study of women with heart disease found that wine (but not beer or spirits) improved a measure of heart risk called heart rate variability.

Not everyone is swayed by such findings. An international team of researchers, analyzing 54 studies on the relationship between alcohol consumption and mortality, reported in the May 2006 issue of Addiction Research and Theory that most of the studies were flawed — because they included among the "abstainers" former drinkers who quit for health reasons. Thus, the higher death rate in this group (compared to the alcohol-imbibing group) may have had little to do with lack of alcohol consumption. When moderate drinkers were compared with long-term nondrinkers, there was no difference in mortality.

Some studies suggest that older women who drink moderately have improved cognitive skills, compared with women who don't drink at all, but it's not clear whether other factors might be at work, such as education or overall health habits. The NHS found that women who consumed an average of one drink per day had higher bone density than nondrinking women, but this benefit was outweighed by the increased risk of falling and resultant hip fractures.

The risks

Alcohol — as little as one-half drink per day — is an established risk factor for breast cancer. One explanation: It raises estrogen levels in the blood, which can promote the growth of breast tumors. It may also stimulate a particular type of breast cancer. A study of women ages 65–79 found that those who consumed about two drinks per day were more likely than nondrinkers to develop hormone-sensitive breast cancer (especially lobular cancer). Taking folate may lower this risk. Among women in the NHS who had one drink or more per day, the risk of breast cancer was higher in those with low folate intake. Some studies suggest that low folate also plays a role in the slight increase in colon cancer risk that's been linked to moderate alcohol consumption.

Moderate drinking for men — two drinks per day — is the threshold of heavy drinking for women. Women are quicker to become alcohol-dependent and to suffer the consequences, which include brain damage; psychiatric problems; damage to the cardiovascular, musculoskeletal, and gastrointestinal systems; anemia; and fatal accidents. Even if you drink fewer than seven drinks per week, you're at risk if you occasionally have four or more on a given day.

Thus far, few studies have focused exclusively on women or included enough older women to provide conclusive evidence on the particular health risks that drinking has for them. But in the absence of more information — and given their increased susceptibility to alcohol-related problems — women 65 and over should be especially careful to limit themselves to one standard drink per day (see "What's a drink?"). They may want to consider drinking even less, especially if they're taking medications that could interact with alcohol.

Do I have a problem?

There are many ways to tell, including several simple questionnaires:

CAGE test. This test asks: Have you ever felt you should Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt Guilty or bad about your drinking? Have you ever taken an Eye-opener (a drink first thing in the morning)? One "yes" suggests that you might have a drinking problem. Two or more mean you probably do. But you could have a problem even if you answer "no" to every question.

AUDIT. Another screening tool is the 10-question AUDIT (Alcohol Use Disorders Identification Test) developed by the World Health Organization. An online version is available at www.alcoholscreening.org.

Number of drinks. Some research suggests that it's possible to screen for risky alcohol use with a single question: "On a typical day when you're drinking, how many drinks do you have?" If you answer "three or more," you probably have an alcohol problem.

Drinking patterns. Binge drinking (four or more drinks on a given day or occasion) is a sign of an alcohol problem, even if you rarely drink that much and even if you abstain most days. For a woman, taking more than one drink every day also indicates an alcohol problem.

What to do

If you think you might have a problem with alcohol — especially if you feel depressed or irritable — speak with a trusted clinician or pastoral counselor, or make an appointment with a mental health professional. Having an alcohol problem doesn't mean that you're an alcoholic or that abstinence is the only solution — assuming you tackle the problem early enough, can learn to drink in moderation, and don't have a genetic vulnerability to alcoholism.

One strategy for people who aren't alcohol-dependent but are drinking too much is the "brief intervention." This typically involves one to four visits with a health professional such as a physician, nurse, or social worker who evaluates an individual's drinking pattern, discusses the possible health risks, and offers nonjudgmental advice on cutting back. You can find out more on the Web site of the National Institute on Alcohol Abuse and Alcoholism (NIAAA): www.niaaa.nih.gov.

Here are some other suggestions for cutting back — or stopping altogether:

Set a goal. Decide on a drinking limit. Write it down. Tell a friend. Track your progress in a drinking diary — a sample diary can be found on the NIAAA Web site.

Change your pattern. Decide not to drink for several days each week. Or try abstaining for two or three weeks to see how you feel. Taking a break can be a good way to start drinking less. You may be pleasantly surprised by how much more productive you are with less alcohol in your life. If you're used to a drink before dinner, pour yourself a glass of water, seltzer, or diet soda instead. You may find that your desire for a drink fades.

Drink carefully. Sip your drink slowly. Savor it. Set it down often. Make it last for more than an hour. After one drink, have a glass of water.

Find other ways to relax. Fatigue, loneliness, and stress sometimes trigger the desire for a drink. Instead, take a walk, put on a record and dance, or go out to a movie. Take a class. Pick up a new hobby, or revisit an old one. Plan games or other activities after a meal to reduce the temptation to stay at the table and drink.

Take a measure. Know what a standard drink looks like. Measure out 5 ounces of water, for example, and pour it into various wine glasses. When you're dining out or socializing, you'll have a better sense of what you're getting — and when to draw the line.