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For this doctor who has dedicated his career to treating the ravages of alcohol, the everlasting debate about whether there is an acceptable amount of drink from the point of view of health does not have a Manichean answer. Ramón Bataller, head of Hepatology at the Clinic in Barcelona, prefers to move in the gray scales, in the nuance and in the individual assessment. He recalls that "alcohol-associated liver disease is the leading cause, by far, of cirrhosis mortality in the world", but also states that it would be "cynical" to promote a dry law. After emphasizing the risks of alcohol, he provides some coordinates: "Moderation, occasional consumption and avoid binge drinking."

Bataller believes that although it is "biologically plausible" that a glass of wine with food is healthy – depending on age, genetics, comorbidities and type of diet, among other factors – the really difficult thing is to stay alone in one. "And I say that because I've done the study with me as a research subject," he jokes about one of his recent tweets: "I tried to drink just one drink at a dinner party, but in the end I drank two." On the other hand, he is blunt with the consumption in minors: "The law of minors has to be complied with. Behind every child who consumes alcohol is an adult who has made it possible."

This specialist has forged an international reputation with his care and research work in centers such as the University of Pittsburgh -pioneers in liver transplantation-, from where he has just returned after 12 years. He gives this interview during the congress of the Spanish Association for the Study of the Liver (AEEH) that was held in Madrid until Friday, with the assistance of more than 800 specialists in liver pathologies. He peppers his speech with clear and forceful messages – "I would like to influence society, help in health education," he says with a spirit of dissemination – and with fresh data after having published an extensive review on alcohol-associated hepatitis this December in The New England Journal of Medicine.

93% of Spaniards have consumed alcohol at some time in their lives, 77.2% during the last year, 63% during the last month and more than 8.8% consume it daily. These data, provided by the Ministry of Health, indicate that alcohol is part of our culture. Is there any amount of consumption that is safe for health? It's a complex issue, and my perspective is conditioned by my work, in which I see people dying from binge drinking. It is clear that alcohol is part of our culture, especially in southern Europe with wine. It would be cynical to promote a dry law, which, moreover, has already been seen not to work. However, it must be said that alcohol is an inherently addictive substance; more so than cannabis. If you take it excessively, there is a risk of losing control and falling into dependence, which is not just anything. Quitting smoking can make you nervous, but I've seen sufferers go to the ICU for alcohol withdrawal.

On the other hand, there are people genetically predisposed to that addiction. Although moderate and occasional consumption is not necessarily harmful to health, we must not forget that it is the leading cause of mortality from cirrhosis in the world; regardless of its relationship with different types of cancer. And also that alcoholic beverages do a lot of damage to society because of their association with violence, sexual abuse and traffic accidents. With all this in mind, this debate cannot be approached with a yes or no, zero or nothing. One message may be that if taken, it should be done in moderation, occasionally and avoid binge eating. Precisely, drinking during the weekend, and sometimes in excess, is a common mode of consumption now. If you add metabolic syndrome or diabetes to those weekend binges, they can favor the development of cirrhosis. It is not true that you can drink as much as you want one day and leave three without trying gout to 'recover' the liver; On the contrary, such practices worsen an underlying disease. Binge eating, coupled with obesity and other risk factors, promotes cirrhosis. A pending study of an American cohort of thousands of people treated with bariatric surgery finds an impact of binge eating on life expectancy. And other work has shown us that a day of excessive consumption alters the intestinal microbiota. In fact, hangover comes from neuroinflammation that occurs when alcohol alters intestinal permeability and certain products of microorganisms, such as lipopolysaccharides, pass into the blood. Wine is being studied as part of the Mediterranean diet, a mainstay in healthy eating. Can differences be made according to the type of alcohol? About wine there is a biological plausibility of being different, because it presents more antioxidants than other types of drink; There are even meta-analyses that suggest that a cup could have protective effects due to its polyphenol content, although this is debated. But when you look at the design of these studies, we see that they are made to analyze other aspects and the alcohol data has been collected in an aggregated way. The fact is that it is not easy to do alcohol surveys: we do not always remember well what we have drunk, or eaten, in the last month, so thatThe collection of data is always imprecise. On the other hand, there are biases that can contaminate jobs. In a study of 200,000 people in a French supermarket on shopping carts, classified according to the presence of alcohol, it was found that those who had wine in the cart the type of food was healthier than the one that compared beer or no alcohol. Therefore, it is possible for the exclusive wine drinker to take a healthier diet.Does it make sense to talk about the amount of alcohol limit, if different factors influence each person? The amount will depend on the age, on the other diseases of the person, and of course you can not apply the same to everyone. And the type of alcohol also influences. I would say a very simple message: if you drink a single glass of wine a day, perhaps the beneficial effects of antioxidants can equal or exceed the harmful effects of alcohol; But if you take two, the alcohol wins and if you drink three, it does it by a landslide. The glass of wine is not easy to achieve in real life and requires a self-control that you do not always have. Who is able to really have just one drink, probably shows a self-discipline that may make him do more sport, take care of himself more, lead a more regular life in every way. That would be a selection bias in the studies.How to address the problem of alcohol consumption in adolescents? Here I am categorical. After living almost 12 years in the US, when I returned to Spain I had a culture shock when I saw children buying whiskey with impunity in supermarkets. It caught my attention. In the United States, a country that is not exactly a model of public health, at 57 years old they still ask me for my card to sell me alcohol. And stores know, whatever it is, that since they find a person under 21 with a drink, they close it forever. An effort is made to comply with the law that goes far beyond putting up a prohibition sign. Behind every child who consumes alcohol is an adult who has made it possible.

The latest data from Madrid says that more than 50% of children between 14 and 18 years old have consumed alcohol in the last month of their lives. We are not talking about a third or a quarter, but half, and in a month, not a year. It's a generalized thing. We are creating a new generation of addicts. Not to mention that children are more vulnerable to the harmful effects of alcohol, not only in the liver, but also in the brain, as shown by some studies that associate it with an increased risk of developing Alzheimer's disease. To the damage to the liver by alcohol, we must also add that of non-alcoholic causes, such as the current diet. What is known about the sum of these two liver diseases? Medicine tends to isolate the causes of diseases, but in real life they go together. A person who overeats, smokes and drinks, because he already has a hat trick for the liver. We are doing studies that show that people with metabolic syndrome and obesity are much more susceptible to alcohol, and vice versa. Both of these factors help create liver disease additively at the very least, and perhaps even synergistically. It is what is known as fatty liver of dual etiology, where obesity, diabetes and dyslipidemia are combined, to name a few factors, with alcohol consumption.and alcohol-associated hepatitis? As a first step, we must work on primary prevention, aimed at avoiding the consumption of alcohol risk. Here would enter measures such as a warning labeling about the risks. It is also very important to ensure compliance with the law and educational measures. On taxes and price surcharges, I think that in the long term they do not change society, and it is always a bit sad to have to resort to punitive strategies.

The second important measure is early detection. We have a study that we did globally with countries on five continents that shows that alcohol-associated liver disease is, by far, the one that is detected later. By not having a treatment as with the C virus, there is no rush to detect it. Of every 10 seriously ill patients you detect with alcohol-associated liver disease, only one receives an early diagnosis. As for transplantation, which is the option in the most advanced phase of the disease, it should be noted that now in Spain in a hepatitis associated with severe alcohol can already be offered to selected cases early transplantation (without the need for sobriety of months); This is vital because the risk of mortality in these patients is 80%.

In any case, one message I would give is that in medicine what works best is to treat the cause: it is never too late to stop drinking alcohol. I have had patients with cirrhosis who were in palliative care and by going a while without drinking, you saw a remarkable improvement. The liver is an organ that forgives more than others, and it can give you a second chance.

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