Nutritional Diseases

CASE 10: Chronic alcohol abuse

Clinical History:

A 35-year-old man and his buddies at the biker's gathering in Sturgis, South Dakota, are extolling the virtues of the "beer diet" to which they all strongly adhere. Their physical appearance is typical: early middle-aged guys with beards whose bandanas cover balding heads and who have big guts hanging over their belts as they tool down main street. Any dietary advice to this crowd will be met with little enthusiasm.

Classic laboratory findings would include:

WBC Count6030/microliter
Hgb12.9 g/dL
MCV104 fL
Platelet count201,000/microliter
Cr1.6 mg/dL
BUN22 mg/dL
Glucose112 mg/dL
Total protein6.4 g/dL
Albumin3.5 g/dL
Bilirubin, total1.2 mg/dL
Alk Phos45 U/L
  1. What do the laboratory findings indicate?

  2. There is a mild macrocytic anemia, most likely from folate deficiency (are these guys going to eat broccoli?). Liver function abnormalities are suggested by an albumin that is at the lower limit of normal, coupled with slightly elevated liver enzymes, with AST higher than ALT. Such findings are classic for chronic alcoholism.

  3. What is the downside to increased ethanol consumption?

  4. Alcoholic beverages are the best example of a dietery source that is "empty calories" because there are 7 calories per gram of ethanol-all carbohydrate, or approximately 200 calories per ounce of absolute alcohol, or about 100 calories per "drink equivalent." Beer has about 40 to 50 calories per 100 mL, so a regular can of beer has about 150 calories (the same as a can of the average non-diet soft drink).

    Persons with a history of chronic alcoholism tend to have poor diets. The liver disease compounds this problem. Coagulopathy with diminished production of vitamin K dependent factors is typical, as evidenced by a prolonged prothrombin time.

    Persons with chronic liver disease are at increased risk for infections, particularly pneumonia, with bacterial agents such as Streptococcus pneumoniae. Or perhaps infection of that recent tattoo.

    Wernicke disease that affects the mamillary bodies and periaqueductal grey matter in brain can be due to thiamine deficiency that used to be more prevalent with alcoholism in times past. Even "fast food" nowadays is fortified with vitamins.

    Chronic alcoholism is not just a function of overall consumption, but of types of beverages consumed, patterns of consumption, and other lifestyle considerations. The effect upon the body of alcohol consumption depends upon other factors, including diet and exercise patterns. There is a good chance that our man in Sturgis is tanking more than beers.

    The type of alcohol consumed makes a difference. Beer is generally 3 to 6% alcohol, wine 8 to 14%, and hard liquor (such as whiskey) 25 to 50% alcohol. There are several ways that the amount of alcohol in a beverage can be calculated.

    The dose of alcohol in a typical 12 ounce can of beer, is approximately equal to the dose of alcohol in a 4 to 5 ounce serving of wine, or in a 1.25 ounce "large shot" of whiskey. This average-sized dose of alcohol is equal to one-half ounce of absolute alcohol, and is sometimes called a "drink equivalent."

    There is a difference in potency depending on whether the percent of alcohol is calculated by volume or by weight, because alcohol weighs less than water. A pint of water weights about one pound (16 ounces). A pint of pure alcohol weighs about 12.8 ounces. If one pint of pure alcohol is mixed with one pint of water, the result is a beverage that is 50% alcohol "by volume." If one pound of pure alcohol is mixed with one pound of pure water, the result is a beverage that is 50% alcohol "by weight." Since one pound of water is 16 fluid ounces, and one pound of alcohol is 20 fluid ounces, the 36 total fluid ounces yield a beverage that is 55.5% alcohol by volume and 50% by weight. The conversion factor for measures by weight to measures by volume is 0.79.

  5. Is the biker better off than you? (question for self-reflection)

  6. Bear in mind that you can burn your candle at both ends and, though the light is brighter for a while, it becomes darker quicker and longer.