Alcohol-related liver disease (ARLD): How many units are in your drink?

Alcohol is a normal and pleasurable part of life. As long as you monitor your intake and follow recommended guidelines, you can keep your body in good health. After reading this article by Dr Jeremy Cobbold, you’ll know how much alcohol is bad for you, how many units are in your average wine, beer and spirits, have tips to reduce alcohol consumption and more.

How much alcohol is bad for me?

When consumed in moderation, alcohol is generally not associated with significant health impacts. But when people increase their alcohol intake beyond recommended guidelines, the risks of developing liver damage increases.

• The recommended weekly maximum alcohol intake is currently no more than 14 units a week (for men and women). This is within safe limits and will not have significant health impacts.
• The risks of liver disease increase the more you drink beyond the safe limits. For women, this is 15 to 35 units and for men, 15 to 50 units. This range is considered hazardous and poses some risk of liver damage.
• Exceeding the weekly limit of 35 units for women and 50 units for men results in a high risk that the liver is being damaged.

Everyone is different. The amount of alcohol required to damage one person’s liver may be very different from the amount required to damage someone else’s.

Binge drinking

Occasional binge drinking is unlikely to cause long-lasting liver damage because the liver can to regenerate. However, repeated and/or regular binge drinking is associated with the gradual increase of the weekly consumption of alcohol units. People who binge drink on average drink more than people who don’t. Consequently, they’re at a higher risk of exceeding the 14-unit limit, or eventually reaching and exceeding the 35 or 50 limits.

But binge drinking itself is dangerous for other reasons. This includes, but it not limited to:

• Accidents (such as car accidents and accidents in the street while walking)
• Violence
• Trauma (head injuries)
• Chocking on vomit
• Mental health issues

How does alcohol cause liver disease?

There are two main ways in which alcohol can damage the liver:

1. Alcohol itself and the sugars from alcoholic drink mixers contain lots of calories. All of these calories can lead to increased fat levels in the body, specifically in the liver.
2. In addition, as alcohol is metabolised it produces breakdown products (substances). Breakdown products cause the production of toxins which damage the liver cells directly.

Over time, the combination of excess fat from calories, sugars and breakdown products can lead to inflammation in the liver, as well as the production of scar tissue (also known as fibrosis). In some people, over a longer period of time, this can lead to cirrhosis, which is advanced and permanent scarring in the liver. Cirrhosis can lead to complications including liver failure and liver cancer.

What are the symptoms?

Most people with mild or moderate alcoholic related liver disease are asymptomatic, meaning they don’t know they have it because it doesn’t cause symptoms. Usually, people don’t notice anything until they already have irreversible damage. Blood tests may be helpful to look for evidence of inflammation. Alternatively, many specialists will look for evidence of scarring via other tests such as a FibroScan ® to look at the liver’s stiffness.

Occasionally, when the liver is damaged by alcohol, you can get a condition called alcoholic hepatitis. This can occur before or alongside cirrhosis. Alcoholic hepatitis can be associated with

• Jaundice
• Dark urine
• Pale stools
• Fatigue
• Nausea

Sometimes, if you have cirrhosis, the liver starts to fail. Cirrhosis can be associated with:

• Jaundice
• Swollen abdomen with fluid
• Swollen ankles
• Loss of muscle bulk
• Occasional complications like vomiting blood, drowsiness or confusion

It’s important to remember that cirrhosis and hepatitis in ARLD are the results of long-term excessive alcohol consumption and that moderate consumption won’t cause these.

Is ARLD curable?

The good news is that most of these damages can be reversed simply by reducing or stopping alcohol intake.

Conditions of mild ARLD, such as fatty liver and inflammation, will often reverse completely after a period of abstinence from alcohol. If non-permanent scarring has developed (fibrosis), it can take years for it to reverse. Alcoholic hepatitis will often reverse with alcohol abstinence. Cirrhosis, meanwhile, is typically irreversible.

The key thing in treatment for liver disease is to prevent additional complications. This means alcohol abstinence. As the liver can regenerate itself, there isn’t much that specialists or a person with ARLD can do other than supporting the liver’s self-healing capability.

What happens if someone with ARLD continues to drink alcohol?

If someone with evidence of ARLD continues to drink alcohol, then it is likely that the scarring will get worse. They will have a higher chance of cirrhosis and if they do, they will have a higher risk of liver failure and the complications that come with it.

Whether you do or don’t have evidence of ARLD, you may experience other problems. Long-term heavy drinking in general can cause an increased risk of:

• High blood pressure (hypertension)
• Stroke
• Various cancers
• Nerve problems
• Dementia

In short, there are many reasons to look after yourself by drinking in moderation.

Tips to reduce alcohol consumption

If you struggle to cut down on alcohol, you can try the following measures:

• Have two alcohol-free days a week.
• Consider dry January (or any month). This can reset your alcohol intake.
• If you’re a wine drinker, consider getting a vacuum pump to keep the wine fresh. This will keep it fresher for longer so you don’t need to drink a whole bottle at once.
• Use smaller wine glasses.
• If you’re a social drinker, alternate wine with soft drinks or water.
• If you like the odd spirit, you may consider buying a measuring cup to measure the unit.
• Learn what a unit of alcohol looks like, and pay attention to how many you’re consuming.

Know your units

Knowing what a unit looks like can help greatly when monitoring how much alcohol you drink. When it comes to drinking spirits, many people end up serving themselves a double or triple while intending to pour a single.

Wine is commonly misunderstood when it comes to drinking units:

• A bottle of wine is usually 10 units. If you have a bottle and a half, you’ve exceeded your weekly limit.
• A large glass of wine is often 250ml and 3.3 units (but some large glasses can be more than this).
• A standard glass is often 175ml and 2.3 units.
• A small glass if often 125ml and 1.5 units.

Beer

• A standard pint of lager is often 2.3 units.
• A standard pint of strong lager (around 5% alcohol) is around 2.8 units.

Spirits

• The rule of thumb is that a standard bar measurement is 1 unit. However, as we tend to serve ourselves more at home, a measuring cup is useful for not exceeding the general measurement.

If you feel your drinking is problematic, you may wish to seek help. Your GP will certainly be able to provide you with resources and local services. Otherwise, you can contact nationwide charities and organisations such as Alcoholics Anonymous, or search for help and information online.

What lifestyle factors can help with ARLD?

While the reduction of alcohol is central, there are other things you can do to help your liver regenerate.

• Have a healthy balanced diet with plenty of good quality proteins from fish, chicken, legumes, soya and vegetables. Monitor your intake of sweet and fatty foods.
• Exercise regularly. Being overweight or obese can accelerate the progression of liver disease.

Am I at risk?

If you think you might have a problem with alcohol, you can take the audit C questionnaire. It can indicate if you are at risk of ARLD. These questions are routinely used in many hospitals, including Dr Cobbold’s, and depending on the answers, it can trigger further medical investigation.

Click here to see how Dr Cobbold can assist you in looking after your liver, as well as all your other hepatology and gastroenterology needs.