Tuesday, November 14, 2017
Because physical fitness and good health go hand in hand, muscle mass and strength are markers of resistance to frailty with aging. There are important behavioral associations such as regular exercise (no surprise there) and moderate regular consumption of alcohol, especially wine (only a surprise if you haven’t been reading this blog!)
Studies on the subject are numerous and from many countries, suggesting that more than cultural factors are involved. A great example is this study from Spain, which prospectively evaluated more than 2000 community-dwelling adults aged 60 and older at enrolment. The researchers were specifically interested in the Mediterranean drinking pattern, defined as moderate alcohol intake, with ≥80% of alcohol intake from wine, and drinking only with meals. The subjects were followed regularly, with measures of muscle mass, walking speed, and endurance, and other factors. Using validated criteria, the subjects were classified as “frail” if they had low functional scores.
If you are considering a retirement facility, you might want to check out the wine list before you make a decision: After only 3 ½ years, the moderate drinker group was 10% less likely to become frail, but if they were in the clique that preferred wine, the benefit increased to 25%. Those who had their wine with meals were almost 50% less likely to develop frailty.
These results are not unique. A recent meta-analysis combining the results of studies from around the world evaluated the role of alcohol consumption and muscle wasting (sarcopenia) in more than 13,000 subjects. Those who consumed alcohol regularly were about 25% less likely to develop sarcopenia compared to nondrinkers. Though this type of review was not able to parse out the wine drinker subset as in the Spanish study above, the role of alcohol in general was consistently found in high quality studies.
It is also important to note that the amount of alcohol consumed is as important as the pattern of drinking. Heavy alcohol consumption is more likely to promote frailty with advancing age than to forestall it. But get regular exercise, practice lifting a glass with dinner, and things will work out.
 Ortolá R, García-Esquinas E, León-Muñoz LM, Guallar-Castillón P, Valencia-Martín JL, Galán I, Rodríguez-Artalejo F. Patterns of Alcohol Consumption and Risk of Frailty in Community-dwelling Older Adults. J Gerontol A Biol Sci Med Sci. 2016 Feb;71(2):251-8.
 Steffl M, Bohannon RW, Petr M, Kohlikova E, Holmerova I. Alcohol consumption as a risk factor for sarcopenia - a meta-analysis. BMC Geriatr. 2016 May 11;16:99.
Friday, October 20, 2017
With breast cancer awareness month upon us again, it’s fair to ask what we have learned about prevention and treatment, and for wine drinkers, it remains a confusing picture. It’s clear that heavy alcohol consumption increases risk, not so certain whether moderation – especially wine – is all that bad; it might even be good. On one hand, the message from the medical community is unambiguous: any level of drinking increases the odds of developing breast cancer. On the other hand, at moderate levels of drinking, cancer risk is extremely difficult to measure with confidence, even more so with wine. Here’s why I think a daily glass or two of red wine with dinner is still a healthy choice:
- A recent study from the University of California San Diego looked at survival and recurrence after breast cancer treatment, finding that light drinking had no correlation. Moderate alcohol intake was “protective against all-cause mortality” in non-obese women.
- There appears to be no breast cancer risk of drinking in premenopausal women, according to a very large European study involving more than 66,000 women followed for 15 years. In postmenopausal women, the risk became clear at more than 2 drinks per day, but as with other studies this was seen mostly in overweight subjects.
- In order to confirm a possible correlation between alcohol and breast cancer, a plausible cause-effect relationship needs to be demonstrated. The prevailing idea is that alcohol elevates estrogen levels via enzymes called aromatases. Aromatase inhibitors (AIs) are commonly prescribed for prevention of cancer recurrence, and interestingly red wine contains natural AIs. A clever study from the Women’s Heart Center at Cedars Sinai in Los Angeles tested the idea that wine could be an anti-cancer agent by assigning women to have an 8-oz glass of either red or white wine daily for a month, while monitoring hormone levels. The two groups then switched from red to white or vice-versa. The researchers concluded that red wine is a natural AI in premenopausal women, providing an explanation for its possible protective effect. The strength of this particular study is that drinking was carefully measured and consistent, rather than reliance on self-reported questionnaires.
- This pattern of regular, moderate, exclusive consumption of red wine is unfortunately not typical in modern society, making it increasingly difficult to suss out from population studies whether their risk profile is distinct. The best evidence is still from a 2008 study in southern France, with a population of consistent wine drinkers. There was a clear J-shaped curve, with an unequivocal benefit to moderate drinking. It was the nondrinkers most likely to get breast cancer.
Why we should make the pink ribbons red
We would do well to remember that despite all the fear and publicity around breast cancer, heart disease remains far and away the biggest threat to women’s health. Even if there was a risk of breast cancer from wine – a debatable supposition – it is almost certainly cancelled out from the benefits to heart health. Let’s make the pink ribbons red.
Low to moderate alcohol intake is not associated with increased mortality after breast cancer.
Flatt SW1, Thomson CA, Gold EB, Natarajan L, Rock CL, Al-Delaimy WK, Patterson RE, Saquib N, Caan BJ, Pierce JP. Cancer Epidemiol Biomarkers Prev. 2010 Mar;19(3):681-8.
 Alcohol consumption and breast cancer risk subtypes in the E3N-EPIC cohort.
Fagherazzi G1, Vilier A, Boutron-Ruault MC, Mesrine S, Clavel-Chapelon F. Eur J Cancer Prev. 2015 May;24(3):209-14.
 Red versus white wine as a nutritional aromatase inhibitor in premenopausal women: a pilot study.
Shufelt C1, Merz CN, Yang Y, Kirschner J, Polk D, Stanczyk F, Paul-Labrador M, Braunstein GD. J Womens Health (Larchmt). 2012 Mar;21(3):281-4.
 Patterns of alcohol (especially wine) consumption and breast cancer risk: a case-control study among a population in Southern France.
Bessaoud F1, Daurès JP. Ann Epidemiol. 2008 Jun;18(6):467-75.
Friday, September 1, 2017
That “gut feeling” you sometimes get may be more literal than you think: research continues to reveal the importance of the bacteria in our digestive tract, called the “gut microbiome.” This symbiotic population of microbes affects health and well-being in often unexpected ways. The microbiome sends signals to the central nervous system, regulates inflammation, even influences cardiovascular health. Wine’s impact on health appears to depend significantly on the microbiome, and we are now learning that it may not actually be the constituents of wine that make it healthy for us; it is the things that the microbiome transforms them into.
How wine promotes a healthy microbiome
Wine’s relationship with the microbiome is a two-way street: Recent studies demonstrate how wine consumption influences the composition of the various bacteria, while other research demonstrates how the microbiome metabolizes wine into components that boost the immune system. The idea that wine’s health benefits may not derive directly from what’s in it is revolutionary, and it is re-jiggering the field of nutrition and aging. For nearly 200 years we have gone by the words of the famous 19th century gastronome Anthelme Brillat-Savarin, who wrote "Tell me what you eat, and I will tell you what you are,” but that is turning out to be only half right, at least in the physiologic sense.
How the microbiome enhances the health effects of wine
Here’s how it works: wine encourages a healthy microbiome, which returns the favor by enhancing what is called bioavailability, the absorption and transport to the tissue where the active ingredient or nutrient in a food or drug is to have an effect. Wine’s effects are attributed to its antioxidant polyphenols, but their poor absorption gives them low bioavailability. This is one reason why effects in tissue cultures and lab studies don’t predict what happens in people: you can’t get the same levels in the target organ as you can in cells in a Petri dish. But think of a healthy microbiome as a sort of Amazon Prime for wine: it metabolizes wine polyphenols into compounds that are taken up and delivered, rapidly and often in a more potent form.
An elegant example of this was published by researchers from Washington University School of Medicine, who detailed how this phenomenon helps wine fight influenza. They showed how flavonoids, a class of immune-boosting polyphenols present in red wine, are altered by a specific type of bacterium in the colon into a molecule called DAT. This in turn signals the production of the immune modulator interferon, which then enhanced the survival of mice inoculated with the flu virus. Inflammation in the lungs was correspondingly lessened as well.
Similar examples abound for a variety of diseases. One study demonstrated wine’s influence on gut bacteria in obese subjects with a condition called metabolic syndrome. After a period of regular wine consumption, strains of bacteria known as “intestinal barrier protectors” proliferated, while those producing markers of inflammation diminished. So if “you are what you eat,” in the updated interpretation of Brillat-Savarin’s maxim, you are equally what you drink, and with wine all the better for it.
 Carolina Cueva , Irene Gil-Sánchez , Begoña Ayuda-Durán , Susana González-Manzano , Ana María González-Paramás , Celestino Santos-Buelga , Begoña Bartolomé and M. Victoria Moreno-Arribas . An Integrated View of the Effects of Wine Polyphenols and Their Relevant Metabolites on Gut and Host Health. Molecules. 2017 Jan 6;22(1).
 The microbial metabolite desaminotyrosine protects from influenza through type I interferon. Steed AL,, Christophi G, Kaiko GE, Sun L, Goodwin VM, Jain U, Esaulova E, Artyomov MN, Morales DJ, Holtzman MJ, Boon ACM, Lenschow DJ, Stappenbeck TS. Science. 2017 Aug 4;357(6350):498-502.
 Red wine polyphenols modulate fecal microbiota and reduce markers of the metabolic syndrome in obese patients. Moreno-Indias I, Sánchez-Alcoholado L, Pérez-Martínez P, Andrés-Lacueva C, Cardona F, Tinahones F, Queipo-Ortuño MI. Food Funct. 2016 Apr;7(4):1775-87.
Wednesday, August 9, 2017
Summer has me thinking about skin cancer (I am a plastic surgeon after all) and recent reports that drinking alcohol increases the risk of skin cancer are not helping to ease my mind. "Drinking just one glass of beer or wine a day could give you skin cancer, scientists have warned," reports Britain’s Mail Online. Researchers reached this conclusion by analyzing pooled results from previous studies (the notorious meta-analysis; see last month’s post.) It seems that every drink increases your odds of developing non-melanoma skin cancer by around 10 percent. But just as blending random wines together may produce something drinkable but lacking nuance, pooling results of different types of studies may obscure crucial details. With the specific question of wine consumption and skin cancer risk, the details are especially important.
Is skin cancer risk the same with all types of alcohol?
Granted, some of the studies are very well done and should not be dismissed out of hand. These results were widely characterized as applying to all types of drinking. But here’s the first important detail: only white wine and liquor consumption were associated with basal cell skin cancer (BCC), the most prevalent type. BCC being strongly associated with UV exposure from sunlight, it is possible that white wine and cocktail drinkers simply spent more time outdoors. It is also possible that red wine has completely different effects.Results from the Nurses Health Study, involving nearly 168,000 women whose health and lifestyle were tracked for decades, align with findings from the more than 43,000 men in the Health Professionals Follow-Up Study: when analyzed for non-melanoma skin cancer: alcohol consumption had a clear correlation.[i]
But not all studies conclude that alcohol is associated with skin cancer. In fact most do not; a review from the UK’s University of Nottingham looked at 22 publications on lifestyle and skin cancer risk, and found no relationship to drinking of any type.[ii]
How red wine might protect against skin cancer
There’s actually good evidence for red wine having a protective effect against skin cancer. A very large study from Australia – where skin cancer is particularly prevalent – looked at diet and lifestyle factors associated with pre-cancerous lesions known as Actinic Keratoses.[iii] The lowest rate of AK’s was in the group that drank the most wine, specifically red. Other studies point to a reason for this, according to another Australian report.[iv] Consumption of foods rich in polyphenol antioxidants – wine, tea, fruits and vegetables – confers protection against UV damage to the skin. This was documented in an interesting study from Germany, in which they found that consumption of red wine diminished redness of the skin from standardized doses of UV light.[v] (This is the same method used to test sunscreens, which measures the time to produce redness, known as the Minimal Erythema Dose or MED.) Interestingly, this group also studied topical application of red wine, finding minimal benefit; you have to drink it.
So slather on the sunscreen, have a glass of (red) wine and enjoy the sunshine.
[i] Wu S, Li WQ, Qureshi AA, Cho E. Alcohol consumption and risk of cutaneous basal cell carcinoma in women and men: 3 prospective cohort studies. Am J Clin Nutr. 2015 Nov;102(5):1158-66.
[ii] Leonardi-Bee J, Ellison T, Bath-Hextall F. Lifestyle factors of smoking, BMI and alcohol on the risk of Non-Melanoma Skin Cancer in adults: a systematic review. JBI Libr Syst Rev. 2012;10(6):352-398.
[iii] Hughes MC, Williams GM, Fourtanier A, Green AC. Food intake, dietary patterns, and actinic keratoses of the skin: a longitudinal study. Am J Clin Nutr. 2009 Apr;89(4):1246-55.
[iv] Chen AC, Damian DL, Halliday GM. Oral and systemic photoprotection. Photodermatol Photoimmunol Photomed. 2014 Apr-Jun;30(2-3):102-11.
[v] Moehrle M, Dietrich H, Patz CD, Häfner HM. Sun protection by red wine? J Dtsch Dermatol Ges. 2009 Jan;7(1):29-32, 29-33.
Thursday, July 6, 2017
What used to be accepted as gospel – that moderate drinkers are healthier than nondrinkers or heavy drinkers – has been challenged in recent years, and a new study to be conducted by the National Institutes of Health aims to settle the question once and for all. The study plans to enroll about 8,000 volunteers aged 50 or older from around the world, who will be assigned to avoid drinking or have one drink per day for 6 years. The lack of such large scale prospective studies is one reason why the question of alcohol’s influence on health and longevity remains subject to debate. However I am not sure the study will yield the answers it seeks to, but not for the reasons others are already finding to criticize the project.
It’s an ambitious undertaking, with an equally ambitious price tag of US$100 million. The plan is for most of the money to come from the alcoholic beverage industry through grants, and $68 million has reportedly already been pledged. Skeptics point out that many of the study’s investigators have accepted money from alcohol industry groups in the past, and raise the issue of scientific influence peddling. But the study’s principal investigator, Dr. Kenneth Mukamal of Harvard, has no such ties and has authored numerous research articles on alcohol and health. As someone who has been a clinical investigator myself, I can vouch for the many levels of independent oversight that prevent any influence by investigators on the results. There's just no way to slip things through, and no reason to risk one's reputation by attempting to.
The challenges to the long held view that alcohol in moderation has a net positive benefit come largely from different types of studies, such as the one I critiqued in last month’s blog. These studies aggregate previously done observational studies (as opposed to interventional studies, like the NIH trial). The example I used last month essentially “cherry picked” the studies that met the criteria that would yield the desired findings. It's not new research, just old research repackaged to imply a different interpretation - one that fit the goals of an alcoholism treatment center.
But conflicts of interest are not the problem with the NIH trial, it is the complexities of human behavior. Volunteers willing to give up drinking will come from a specific subset of individuals that may not be representative of the average consumer. Allowing people to choose their beverage or to vary which one they drink could make it difficult to see if wine drinkers, for example, are different (evidence suggests that wine drinking is not the same as other types of drinking.) It may be that more than one drink per day is the optimal dose, and the effect too small to be statistically significant with only one. Another issue is the pattern of drinking; with wine, it is the relationship with meals. And how will the one drink per day rule be enforced? What of people who for whatever reason choose not to have a drink, or make up for it by skipping a couple of days then having several?
I do applaud the effort required to do this study, but I expect that whatever the results they will be challenged by those with an opposing ax to grind.
Tuesday, June 20, 2017
For this post I decided to address what I see as a neo-prohibitionist and paternalistic trend in medical advice about drinking, with a point-counterpoint on a blog that appeared recently on self.com. I believe the author made a sincere attempt to get the story right but was misinformed by the physicians she quotes. What was not disclosed is that the meta-analysis that this story references was done under the auspices of the Centre for Addictions Research of British Columbia, University of Victoria, an institution with a presumed anti-alcohol bias. An invited commentary with the original publication came from the Alcohol Research Group in Emeryville, CA, whose mission “seeks to reduce alcohol-related harms.” They lauded the findings, saying that it could help fight back against “renewed calls from certain medical commentators to prescribe moderate drinking.” Disclosure: I count myself among those medical commentators.
By Korin Miller
The Truth About Whether Red Wine Actually Helps Your Heart Health
This isn't the most delightful news ever.
People love to talk about how red wine is good for your heart—and they usually do it while they’re drinking red wine, which is only natural. But research on the subject has been mixed, and even most positive findings have stopped short of actually recommending that people go out of their way to have a glass to prevent heart disease. Now, a large new meta-analysis is adding to the conversation, concluding that there's not much to support the idea that you should be drinking red wine to benefit your heart health.
For the analysis, which was published in the Journal of Studies on Alcohol and Drugs on May 21, scientists examined 45 studies on alcohol and heart health and found the conclusion that alcohol—especially red wine—is good for your heart are misleading.
Previous individual studies have suggested that moderate drinkers, defined as having at most one drink a day for women and two drinks for men, have lower heart disease rates than people who don’t drink. But researchers in this meta-analysis point out that a good portion of the people who don’t drink are teetotalers either because they have a problematic history with alcohol or have health problems that prevent them from drinking—not just because they choose not to drink for no reason. So, although healthiness and moderate drinking have been linked in past research, these studies have usually compared drinkers with people who already had health issues of some sort. When the researchers behind this new meta-analysis addressed this by controlling for heart health, they found no significant evidence that drinking moderate amounts of alcohol protects your heart.
RAB: This is known as the “abstainer bias” or the “sick quitter” hypothesis. In order to determine the validity of a hypothesis, it needs to be tested; additional observational data does not answer the question. The way to do this is to ask “What happens to lifelong abstainers who start drinking, and what happens to healthy moderate drinkers who quit?” This was addressed in a largestudy from Australia that followed 13,000 female subjects for 12 years. They found that when healthy moderate drinkers either increased or quit drinking, their health status declined. They further found that the health of recent abstainers and lifelong abstainers was the same, disproving the sick quitter hypothesis.
There's historically been a lot of confusion around the idea of red wine being healthy for your heart.
As you can see, it’s complicated, and somewhere along the line, the message got muddled. "The American Heart Association and other organizers have never recommended that a person has a daily allotment of alcohol," Richard Becker, M.D., director and physician-in-chief of the University of Cincinnati Heart, Lung and Vascular Institute, tells SELF. "If a person [stays within the moderate-drinking recommendations], that may be acceptable, but there's never been a recommendation to consume alcohol for heart health."
While the American Heart Association acknowledges that some research has shown that there may be a benefit to drinking wine due to components like flavonoids and other antioxidants that can help lower your heart disease risk, they also point out that these can be found in other foods, like grapes, and that the wine is likely not the key component here. “The [health and drinking] linkage reported in many of these studies may be due to other lifestyle factors rather than alcohol,” the organization states. “Such factors may include increased physical activity, and a diet high in fruits and vegetables and lower in saturated fats.” And, the American Heart Association notes, there have been no direct comparison trials to determine the specific effect of wine or other forms of alcohol on the risk of developing heart disease or stroke.
RAB: There should be no confusion. It would be more accurate to say that a substantial body of research supports a connection between moderate wine drinking and overall good health and longevity. Additional research documents an independent association of moderate alcohol consumption and heart health specifically. What is important to recognize is that the relationship is nonlinear, but follows a J-shaped curve: lower risk with moderate consumption, increased risk with heavy drinking compared to nondrinking. Moderate regular wine consumption is associated with other healthy lifestyle factors but these do not fully account for the observed benefits.
George S. Abela, M.D., chief of the division of cardiology at Michigan State University, tells SELF that alcohol and heart health can be a “double-edged sword.” On the one hand, moderate alcohol intake can raise your levels of HDL ("good") cholesterol, which is great for your heart health, he says. It also may help you de-stress here and there, and stress is a risk factor for heart disease.
On the other, when you drink in extreme excess or if you have a genetic condition, alcohol can damage your heart muscle and cause an abnormal heartbeat. It can also increase your blood pressure. “I’ve had patients that I’ve had to get off of alcohol completely to control their blood pressure,” Abela says. And, if you have a strong family history of high blood pressure, stroke, or weakening of the heart, Becker points out that you should talk to your doctor—they may advise that you shouldn't be drinking alcohol at all.
RAB: Again, the relationship is a J-shaped curve. Stating that heavy drinking is bad does not discredit the benefits of moderate drinking.
There's also the nutritional aspect to think about. “I’m not a big supporter of alcohol being cardio-protective,” Nicole Weinberg, M.D., a cardiologist at Providence Saint John's Health Center in Santa Monica, California, tells SELF. “When I look at wine, I think it’s just a big glass of sugar." While indulging is a huge part of what makes life great, overdoing it on alcohol can lead to inflammation, weight gain, and an increased risk of diabetes—all of which are risk factors for heart disease, she says.
RAB: The statement that wine is the same as a “big glass of sugar” is nonsense. In wine, the sugar has fermented into alcohol, which is metabolized in a way that avoids the spike in blood sugar levels that sugary drinks such as grape juice have. The high sugar content and lower antioxidant polyphenols levels are among the reasons that grapes and grape juice do not have the same benefits as wine. Sugar is a notorious pro-inflammatory substance and responsible for much more cardiovascular disease than alcohol. Wine drinkers have lower markers of inflammation, are less likely to be overweight, and have a lower incidence of diabetes.
It's understandable that this "double-edged sword" concept can be frustrating, Malissa Wood, M.D., co-director of the Corrigan Women's Heart Health Program at Massachusetts General Hospital, tells SELF. But one of the main problems with alcohol, she says, is that people often drink more than they say they do—and drinking more than a moderate amount clearly isn’t great for your heart.
RAB: This points out a primary weakness in the studies on which the meta-analysis was done and a fault in how they are interpreted. Since people tend to under-report their actual drinking, what this actually means is that the benefits of moderate drinking apply to higher levels of consumption.
Luckily, this doesn’t mean you have to choose between pinot noir and your heart if you're healthy.
You can still drink alcohol and live a healthy life. “It’s a complicated situation, and I don’t think there’s a clear message that small amounts of alcohol are bad for your heart,” Wood says. Instead, experts recommend keeping your drinking in check. “A glass of wine here and there is perfectly reasonable, and so is going out on the weekend and having a few drinks with dinner,” Weinberg says. “But when it starts to become regular or heavy use, I tell people to dial back.”
Also, know this: If you prefer beer or cocktails, you don’t have to become a wine person to be “healthier.” “At the end of the day, the body only sees alcohol,” Abela says.
RAB: This is demonstrably false. Multiple studies document an association of regular, moderate wine consumption with improved health and longevity that are not observed with other drinks. The pattern of drinking is important; wine with dinner on a regular basis has the strongest benefit, limiting drinking to weekends or drinking different forms of alcohol and in varying amounts is associated with increased risk.
Thursday, May 25, 2017
Whether we are talking about driving a car, drinking wine, or any other routine activity, most of us are not very good at calculating risk. Life insurance company actuaries devote careers to these sorts of calculations, but even they will tell you it gets really muddled when assessing small risks of prematurely dying from everyday endeavors. With nutrition and lifestyle choices it’s practically impossible. That doesn’t stop us from trying though, and one approach is unit of measurement called the micromort. A micromort is a one in a million chance of dying (mort from mortality.) If nothing else, it is useful in placing things in perspective; there’s even an app for tracking your micromorts as you consider lifestyle choices.
Take scuba diving, for example: 5 micromorts. It is said that 3 glasses of wine equals eating 100 char-broiled steaks or spending an hour in a coal mine, for a micromort each. Really? That sounds bad, and frankly didn’t make sense to me when I heard the term recently. So I decided to look into it.
The term dates to the 1970’s and is attributed to physics professor Richard Wilson, then at Harvard. I tracked down the original reference, or at least the earliest I could find, in the journal Technology Review. Interestingly, the article contains no references but does have a detailed list. For example add a micromort for traveling 6 minutes by canoe, 10 miles by bicycle, or 300 miles by car. Smoke 1-1/2 cigarettes or live with a smoker for a month. Spend 2 months in Denver (more cosmic radiation at higher altitude.) Oh and there is wine – right alongside the risk of living near a nuclear power plant.
If these are all small risks, what is the problem? It’s this: describing risk this way assumes that it is a linear relationship, meaning a little is not so bad, a lot really bad. This is true for many of the choices we make, but we now know that the risk with wine is a J-shaped curve. Unlike smoking, moderate consumption is less risky compared to teetotaling. We forgive the professor because we could not have expected this more nuanced perception in the era before the French Paradox and all the research that occurred in its wake. But the thinking pattern persists, and references to wine and its micromort factor continue to be bandied about. It’s this kind of thinking that underscores policy recommendations, for example Britain’s chief health officer’s recent admonition that any amount of drinking is unsafe. Or breast cancer researchers, seeing only risk and raising alarm without looking at overall health and longevity.
Celebrate National Wine Day
What we need is macro-life, a way of seeing the big picture. We need to consider quality of living as much as quantity. Today, May 25, has been designated National Wine Day, and I say cheers to that. And subtract a micromort if you care – spend it on a plane flight (1000 miles).
Nothing is more useful than wine for strengthening the body, and also more detrimental to our pleasure if moderation is lacking.
- Pliny the Elder