The Gut Health Podcast

Sip Smart: Alcohol and Your Gut

• Kate Scarlata and Megan Riehl • Season 2 • Episode 12

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Can drinking alcohol truly offer any health benefits, or is that just a myth we’re eager to believe? In this episode, we aim to inspire a renewed commitment to wellness in the new year with our guest, Dr. Ponni Perumalswami, a prominent hepatologist at the University of Michigan, who helps us unravel the complicated relationship between alcohol, the gut, and liver health. With her expertise, we tackle common misconceptions and explore the notion that less is more when it comes to alcohol consumption.

We dive into definitions that may surprise you, such as the different thresholds for binge drinking and heavy alcohol use among men and women. Dr. Perumalswami sheds light on the stigma associated with alcohol abuse and how it can impede access to support, urging healthcare professionals to improve patient assessments for alcohol use while providing a safe and supportive approach to care. We explore alcohol use disorder as a chronic brain condition and emphasize the essential need for comprehensive support for those affected. Additionally, we examine the interaction between alcohol use and common mental health conditions like anxiety and depression.

Whether you dabble in an occasional cocktail or perhaps have found yourself drinking more than you like, we provide tangible (and tasty) strategies for reducing alcohol intake and promoting healthier habits. Discover how simple changes such as opting for a fun mocktail and drinking less can enhance sleep, relationships, and overall well-being. Join us as we advocate for making informed choices towards a healthier, happier you.

References:
Alcohol's Impact on the Gut and Liver

Alcohol, the gut microbiome and liver disease

 Check your alcohol intake with CDC's Quiz



Learn more about Kate and Dr. Riehl:

Website: www.katescarlata.com and www.drriehl.com
Instagram: @katescarlata @drriehl and @theguthealthpodcast

Order Kate and Dr. Riehl's book, Mind Your Gut: The Science-Based, Whole-body Guide to Living Well with IBS.

The information included in this podcast is not a substitute for professional medical advice, examination, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider before starting any new treatment or making changes to existing treatment.

Kate Scarlata :

The Gut Health Podcast will empower you with a fascinating scientific connection between your brain, food and the gut. Come join us. We welcome you.

Kate Scarlata :

Hello, friends, and welcome to The Gut Health Podcast, where we talk about all things related to your gut and well-being. We are your hosts. I'm Kate Scarlata, a GI dietitian.

Dr. Megan Riehl:

And I'm Dr Megan Riehl, a GI health psychologist. We have a very exciting podcast for you today, because we are talking about alcohol, the gut and going beyond that. We are thrilled to be joined by Dr. Ponni Perumalswami, a leading hepatologist and advocate for liver health. She is the director of the Alcohol Liver Disease Program at the University of Michigan and the director of the Liver Clinic at the Ann Arbor VA. Dr Ponni Perumalswami is a renowned clinician who manages complex liver diseases, so certainly an expert for our conversation today. We are fortunate to have time with her and we are going to kick off this new year with something that a lot of people are perhaps curious about and that might be your liver function. So welcome, we are so thrilled to have you and we like to start off our podcast with a myth buster. So what's a myth about alcohol or liver function that you'd like to share with us today to kick off?

Ponni Perumalswami, MD:

That alcohol has health benefits. I'll start by saying thank you for having me. I really appreciate you guys inviting me to join you guys for this discussion today, but that is the myth. I would probably lead with.

Dr. Megan Riehl:

Wonderful.

Dr. Megan Riehl:

So, with that in mind, that specific myth, let's start with a question about is there a safe amount of alcohol that can be consumed without causing harm to the liver and the gut or any potential amount of damage to our gut, health and beyond? So let's talk about safety and alcohol.

Ponni Perumalswami, MD:

So this is a great question, I think. Kick things off. You know, our understanding of alcohol has evolved a lot, I would say, which I think has actually made it incredibly confusing for the general public. I mean, we've always known that alcohol is related and associated with many different types of harms, but what we now know is that no alcohol is best. Alcohol simply does not appear to convey any health benefits whatsoever.

Ponni Perumalswami, MD:

There used to be some belief that drinking certain types of alcohol, for example, one glass of red wine a day, might lower your risk of cardiovascular disease, but that doesn't seem to be the case with additional studies.

Ponni Perumalswami, MD:

And I think, because of this kind of confusion and knowing that alcohol is associated with so many harms and we're seeing even increases in these harms over the last 10 years, in December of 2022, the World Health Organization published a statement on this, and the statement really was focused that there's no safe amount of alcohol to consume.

Ponni Perumalswami, MD:

And then that was followed in the heels in 2023 with the WHO, the World Health Organization, declaring that the risk to drinkers' health starts with the first drop of alcohol. So when we're talking about, you know, safe, it's really hard to really now knowing what we do and having more kind of, I think, public health messaging. That's in line with what we know, that alcohol is associated with many different types of risks and known harms and, like, one classic example of that is, for example, liver disease, right, and we also know that there's been lots of observations that some people who drink alcohol versus those who don't drink the same amount might develop certain types of problems, right, organ dysfunction, for example. So we know that toxicity of alcohol is involved in generating health complications, but it may be one of many alcohol-induced changes and factors that play a role in developing some of the harms. So if it's liver disease, if it's changes in intestinal microbiota, you know composition or the function of that alcohol plays a role.

Kate Scarlata :

I don't like organ dysfunction, like that's probably not a good thing, right?!

Ponni Perumalswami, MD:

Not a good thing to hear. We don't want to ever be telling people that they're having problems like health problems, particularly right, related to alcohol. Late people do have an association right like that.

Dr. Megan Riehl:

Some amount of drinking can cause liver problems for example, what we're hearing is that there really aren't specific types of alcoholic beverages that are better or worse necessarily for your overall gut health or liver health.

Ponni Perumalswami, MD:

That's correct. I mean, I often will say the body, the liver specifically, for example, it doesn't have taste buds. When it sees alcohol, it's seeing alcohol and it's not discriminating between whether or not it's wine, it's beer, you know hard liquor spirits. So yeah, our body doesn't make any distinguishing factors, if you will, in seeing the different types of alcohol.

Dr. Megan Riehl:

So you know we're not trying to be total Debbie Downers here for the new year and I think as you listen to today's episode, if you enjoy a glass of wine or two with friends and family and this enhances your social experiences and brings joy without too many outward negative consequences, then there probably is a way that we can have a positive, balanced relationship with alcohol. Many people. We're just going to encourage you to stay mindful of the reasons for your sip selections and the role that it plays in your overall well-being. Healthy relationships with alcohol is really our goal, and for some people that's going to include moderation and tension and the absence of a reliance on alcohol. But for others, you may really be reflecting on how and when and why you drink, which can empower the choices you make, and for some that may mean that alcohol isn't a part of your life and your overall health and happiness. So just something to keep in mind as we talk about this with our expert, who is really empowering us with information today.

Kate Scarlata :

I couldn't agree more there, Megan, and I do think that there are "some social benefits to engaging in alcohol. But I do think we all have to be mindful and have sort of a reality check with ourselves. Is that one glass becoming two glasses? Is that two glass really half a bottle, three quarters of the bottle? And being very mindful of the actual amounts that we're consuming. And having that reality check. Women, you know no alcohol is great. I think moderate is one glass per day. That's seven glasses per week. And what is a glass? It's not these mondo glasses nine-ounce these pours that we can get at some restaurants.

Kate Scarlata :

So just be mindful of quantities, how frequently, and be honest with yourself, I think right. So again, it doesn't have to be none. But I think you also have to have a talk with yourself about how much you are actually consuming. I wanted to backpedal a little bit because you did talk about the microbiome and of course, being a gut health podcast, we like to talk about that. There are effects to the gut microbiome. There are some effects to the type of microbes that grow with overconsumption of alcohol and even some risk with small intestinal bacterial overgrowth. Can you just touch base a little bit on SIBO and alcohol consumption and educate our listeners on that topic a little bit.

Ponni Perumalswami, MD:

Sure.

Ponni Perumalswami, MD:

And you know, normally the gut microbiome has a healthy balance of bacteria right. The bacteria can be helpful in our bodies in many, many different ways, including supporting our immune system, supporting metabolisms or reactions that are happening or need to happen in our body. Regulating inflammation is an important kind of part of what gut microbiome is involved in, and it can also help defend certain organs against toxins, particularly things like the liver, and in that way the gut microbiome can be pretty impactful, powerful, helpful in preventing chronic and sometimes infectious diseases. So when we drink alcohol it can affect everything from the microbiome that we have in our mouth all the way down into the GI system, our digestive system, and it can involve lots of organs along the ways. And changes in the gut microbiota might be associated with potentially causation and progression of multiple different types of problems in the body, including one area, for example, that's being studied a lot is with liver disease, particularly with alcohol-related liver disease, but even non-alcohol-related liver disease. The gut microbiome is undergoing lots of study to see how that impacts risk progression outcomes with liver disease. So when we drink alcohol there can be disruption of that gut microbiome or changes in the gut microbiome, and there are probably three main ways that we think that the gut microbiome might be impacted. One is with the balance of good versus bad kind of bacteria that are kind of living together in harmony in our microbiome. I'll just start by saying that most of the work with gut microbiome and alcohol for many years has been done in animal models, although there are studies going back to the 1980s, maybe even earlier, where started to look at gut microbiome in humans and sampling in different places and trying to understand was there gut microbiome differences in people who might have alcohol use disorder, alcohol-associated liver disease, and so there were very early reported differences right in like what bacteria, how much, and what the balance looked like.

Ponni Perumalswami, MD:

So changes in the balance of the bacteria in the gut microbiome are known as dysbiosis, where you get this disruption and kind of what we think of as this happy, calm medium into where things are not balanced, the best way to do all of the important things that it needs to do.

Ponni Perumalswami, MD:

So that's one way the gut balance of bacteria can be affected.

Ponni Perumalswami, MD:

The other way is I just mentioned that gut microbiome is really important for metabolizing things in our body and reactions that need to happen, so it might create the different bacteria right as it's metabolizing and involved in the play of alcohol in the system, might create different metabolites, and this can might be involved in signaling pathways in both the liver, the blood, the intestinal kind of pathway, and this can be altered or break down when you have alcohol as a toxin in the gut.

Ponni Perumalswami, MD:

And then, finally, the last way that people think, based on what research has been done, is that it might make the gut a little bit more what we call leaky. So we have protective mucus layers in the gut that are kind of kept in check by this nice balance of bacteria in the microbiome. And when we drink alcohol and that gets disrupted, then again that protective layer between the gut and the rest of our body right, which then interacts with the blood system organs we talk about gut-liver access, gut-brain access that gut integrity can be broken down and cause the barrier protection, if you will, and how it interfaces then with blood and all the other organs to be altered. So those would be the three main ways that we know so far.

Kate Scarlata :

So interesting, and I think you know the gut and you know the intestine and the liver are connected with a particular what is it? The enterohepatic circulation, what is that? The portal vein, is that what it is that connects the two? So they're right there, they're close in proximity. So if these metabolites are being made, it makes sense that they can travel pretty readily to the liver, right, correct?

Ponni Perumalswami, MD:

Yeah, and that's why you know there are now like actually some human studies that are underway to try to understand if there are ways we can impact gut microbiome in people who are developing or have signs of, for example, liver disease, alcohol-related liver disease, particularly very advanced liver disease.

Ponni Perumalswami, MD:

There's been a couple of rigorous what we call randomized control trials trying to look at if there's ways we can administer prebiotics, probiotics, antibiotics or even something called fecal microbiota transplant to see if we can get a rebalance on gut microbiome and then thereby impact positive outcomes, right. So there's been, for example, some small studies looking at patients with very severe alcohol-associated hepatitis. You know it's an acute form of alcohol-related liver disease. So people are studying if they give them things like rifaximin, right, or other probiotics or even a fecal microbiotic transplant, can this impact outcomes positively? So there's some early, smaller randomized control data. So it's like more rigorous kind of types of study that are potentially pointing us in a direction of better understanding how we might be able to use these methods to try to improve outcomes, things like averting transplant, improving survival, decreasing inflammation because you know the pathway is also related to lots of stress, right, that alcohol can kind of create in various organs like the liver and reducing that what we call oxidative stress.

Kate Scarlata :

Wow. So I'm thinking about our friends with IBD and IBS, celiac disease, they're already at risk for this intestinal permeability and altered gut microbiome. So I would imagine might be a little bit more cautious, if you have those conditions, with your alcohol consumption and I always think about just the impact of different types of alcohol and mixers like FODMAP-containing ones that's my area of expertise and certainly if you're downing a lot of margaritas with agave syrup that's a high FODMAP food that could also sort of disrupt your symptoms and there's other factors to consider here.

Ponni Perumalswami, MD:

Right, definitely so in people who already have right, especially GI, intestinal issues, problems right such as celiac disease, even irritable bowel syndrome, to all the way more severe conditions like inflammatory bowel disease, there's already disruption and changes potentially of gut microbiome happening. So think about alcohol being another potential mediator right of either people potentially developing these problems in the first place and or, if they already have it, then mediating progression the same way we see like, for example, in the liver. I think there are very similar kind of circumstances there, yeah, and impact.

Dr. Megan Riehl:

So people are looking for ways to improve their overall health and their lifestyle, and especially to your point that if you already are living with a GI condition or really, quite honestly, any health, physical health condition or mental health condition, if we're looking for a way to live a healthy lifestyle, alcohol may be one of those controllables that by abstaining or shifting to another beverage in a beautiful coop or cup or flute, that is a mocktail or something that still allows you the opportunity to sit and be social and present with other people, but you know that what you're choosing to ingest is not going to cause you worse than diarrhea the next day or even a headache. This is your opportunity to have a little control when oftentimes, with GI conditions, it can feel like the unpredictability of your symptoms is really stressful. So you're able to mediate one of those stressors by maybe putting something else in your cup of choice.

Ponni Perumalswami, MD:

You know there's some definitions. I think you started to kind of speak on this a little bit earlier. Is it helpful to review some of like the definitions for what we consider unhealthy alcohol use? I always find that that kind of helps ground, like, because I think there's lots of confusions about like different terms we often use, like what is binge drinking, what is heavy alcohol use? Do you want me to review any of that? Yeah, that would be great. Okay, so just to add a touch of confusion, but not to get too confused, you know we have definitions by different kind of groups and so, just broadly speaking, you know binge drinking is defined in women differently than men, right, in women it's considered four or more drinks, either within two hours, one setting, or one day, depending on whose definition you're looking at, and in men as five or more in that same timeframe. Right, heavy alcohol use is typically defined as eight or more drinks in women per week and in men is 15 or more in the same time frame.

Ponni Perumalswami, MD:

And 90% of people who engage in binge drinking episodes 90%, so nine out of 10, will develop, for example, an early manifestation of alcohol related liver disease. So fatty liver, or what we call hepatic steatosis is the medical term, and that will happen within days to weeks. But this is reversible as long as the drinking is not continued in a heavy amount. But if it does, then somewhere between 10 and 35% of people will go on to develop inflammation plus fat and then close to half of those patients are at risk of developing what we call scarring or fibrosis in the liver and then over time, if that continues, somewhere between 8 and 20% are at risk for developing significant, or what we call advanced, fibrosis or cirrhosis. So, as you just said, it's helpful to know these thresholds and what we consider binge drinking or heavy alcohol use, which we now also refer to as unhealthy alcohol use. Right, because it raises even more associated harms or risks from a health standpoint.

Kate Scarlata :

And I would just say I think a lot of people go to their doctors and they say you know what's your alcohol use? It's, oh, social, you know. And really as providers we need to dig a little deeper on that, because one to two drinks might not sound terrible, but if it's seven days a week for a woman, that's heavy alcohol use. And I've only had one physician that really deep dived on that with me was like no, like what do you mean social? Tell me what that means. I just think that we have, again, as physicians, providers, we really need to deep dive a little bit on what social drinking means to that individual, because it sounds kind of moderate but it might not really be in terms of the terms you've just mentioned.

Ponni Perumalswami, MD:

Yeah, no, I think you're raising a really really good point is that we do a not great job as healthcare. No, I think you're raising a really really good point is that we do a not great job as healthcare professionals, I would say, unfortunately of quantifying the amount of alcohol. And, as you just said, there's like also what we consider one standard drink, which is, in the United States, 14 grams of alcohol in one drink. You know, one drink might be a tall pour, as you just said, or a standard kind of size drink, depending on the type of alcohol, right? So we do a pour job of asking about alcohol, getting it quantifying and, unless we quantify it, using what we call validated screening instruments. And the best validated screening instrument is something called the alcohol use disorder identification test and it comes in a mini form or a short form which is three questions and it gets at how much, how often and how much binge drinking it is to exactly try to understand who's at risk, who's having an unhealthy amount of alcohol consumption. So it's three questions. Anybody can ask them. If you actually have people self-administer it, they're more likely to report an accurate amount, because alcohol use, unfortunately, is very highly stigmatized, especially when we're talking about it in the context of health. People feel like they might get penalized or have negative consequences for not reporting accurate amounts.

Ponni Perumalswami, MD:

So using validated instruments is kind of how we can get at. Oh, is somebody binge drinking? Is somebody meeting a definition for unhealthy alcohol use? And those three items add up to a score and if that score is positive then patients should be actually evaluated for what we call alcohol use disorder. And that is the classic format of doing that is through an interview with a behavioral health provider.

Ponni Perumalswami, MD:

And we have a definition for alcohol use disorder from the Diagnostic Statistical Manual of Mental Health Disorders the fifth edition and it has a definition and it's defined also with symptoms and there are up to 11 symptoms that are assessed and if patients have two or more of those symptoms they by definition meet a diagnosis of alcohol use disorder. And people have now to try to get to more people being able to diagnose alcohol use disorder. They've actually operationalized folks at RAND have operationalized a checklist that can be used in health settings. So some parts of, for example, like the Veterans Administration, can have different types of providers, including sometimes nurses, administer that checklist to try to get more people involved in making a diagnosis. So I think like think about screening using validated instruments in healthcare settings. I think like think about screening using validated instruments in healthcare settings and then if you have positive screening, then people need to get evaluated a little further for alcohol use disorder, because then we need to work with patients to try to figure out how we can be helpful.

Dr. Megan Riehl:

Yeah, and if you've ever seen alcohol use disorder on your own medical record, I think even sometimes that gets checked and it doesn't necessarily get discussed with the patient, but based on screening measures. And so AUD, alcohol use disorder it is. It's a medical condition and it's characterized by impaired ability to control your alcohol consumption, despite the negative consequences to health, relationships and your day-to-day life. And what's really important to recognize is that you are not alone. If this is something that you are struggling with, it's chronic, it's a relapsing brain disorder. I think that's what people really, if your drinking has progressed to the level of disorder, your brain is heavily involved, and that's why working with a psychologist and good medical providers oftentimes is the necessity.

Dr. Megan Riehl:

There was a 2021 study that showed that about 11% of Americans meet criteria for alcohol use disorder, so that's over one in 10. And this is a very important statistic because it's not just a medical condition. It's one that impacts your mental health as well, and we see higher prevalence rates of co-occurring depression and anxiety often trauma as well, in patients that are living with AUD, and therefore it just makes the importance of getting help and resources and not going at this alone that much more imperative to really getting yourself into a remission state with your alcohol use. So very important, very complex and certainly one that deserves a team to support you with.

Ponni Perumalswami, MD:

Yeah, I would say the other thing, like about destigmatizing it. The more times we can think about assessing for alcohol use, I think is part of how we can get to destigmatizing it and also capturing when there is potentially unhealthy alcohol use happening. So we definitely charge primary care, like the US Preventative Services Task Force recommends it to be done, like the screening in all primary care settings. But as a field in GI, gastroenterology and hepatology, we are now really talking about how it also needs to be done at other points, and the more points that we do it where patients are intersecting with care, I think the more potential we have to normalize and to de-stigmatize this discussion and talking about alcohol with our patients and then also to appropriately identify people right, because alcohol use can change over time and it's very intertwined, as you just said, with other substances.

Ponni Perumalswami, MD:

One out of eight people with alcohol use disorder have co-occurring other substance use disorders and we have seen an increase in the number of people who are living with alcohol use disorder. We estimate, based on like the most recent data, that close to 30 million people in the United States that are adults have a diagnosis of alcohol use disorder and it's, I would say, severely undertreated. Less than 10% of people here in the United States, and then globally, are engaged in treatment for alcohol use disorder. So lots of, I think, opportunities for identification and then talking about how we can leverage tools to help people.

Kate Scarlata :

Yeah, I just think that it's. You know you go to a social event and if you're not drinking you're stigmatized. You know, like there's so much culture both ways. Where you know, over-dr, addressing over drinking is stigmatized, but on the other side, if you go to a party, there are people that are pressured to have a cocktail why aren't you drinking, you know. So there's a lot of cultural change that needs to be done.

Kate Scarlata :

I'm seeing it with the millennials, I guess, right, or is that the group Gen Z? Which group is kind of being more non-alcohol? They're probably doing more pot but less alcohol, right? So we are seeing some shifts. But I also think, in addition to screening, we all need to know that alcohol content, even in this, like craft beer movement I love a good craft beer, but some of them are 11%, they're very high, and so, again, just educating our patients on alcohol and content of things, yeah, it might be two beers, but if they're 11% each and you're having a 20-ounce pour, it's a problem. So there's lots of education and change that needs to really move forward for us to have a healthy alcohol relationship, I think.

Ponni Perumalswami, MD:

You definitely. That is so spot on. Like alcohol is a part particularly in Western countries, I would say, but even globally, it's just part of the social fabric of how we interact with other people, particularly here in the United States, and so there is a lot of work, though that is looking at how do we make some smart policy decisions so that at a population level because these things are being done in some other countries and have been shown to decrease some of the bad outcomes we're seeing. So you know, we've seen just this enormous rise in people with alcohol-related cirrhosis, for example, in the United States it's overtaken all other liver causes for cirrhosis and death as a cause. It's a leading cause for liver transplant, a rescue option when we have patients with very advanced liver disease, and these are not good things to be seeing, obviously, in our populations.

Ponni Perumalswami, MD:

These are not things anybody wants to see happening as a consequence of alcohol. So there are countries that are leading the way with some policy decisions about how we can make still allow for alcohol but try to protect populations from getting into trouble, and we are a population where we're seeing more and more harms, unfortunately. So I do think at some point thinking about some broader level changes and, as you said, like maybe even thinking about how we better make people understand, like how much alcohol is in your craft beer before you drink it. So you understand what's that the equivalent of right? Is that the equivalent of one drink? Is it equivalent of much more than that or not?

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Dr. Megan Riehl:

Can you share with us a little bit about how the liver metabolizes alcohol and how that comes to affect things like fatty liver and cirrhosis that you've mentioned and hepatitis things like fatty liver and cirrhosis that you've mentioned, and hepatitis.

Ponni Perumalswami, MD:

Yeah, so alcohol is metabolized by several processes in the body, what we call like metabolic processes or metabolism, and it most commonly involves two enzymes. One is alcohol dehydrogenase and the other enzyme is aldehyde dehydrogenase. And these enzymes help break apart alcohol as a molecule to make it possible for the body to eliminate it essentially. Alcohol or ethanol, right as the body sees it, broken down first by the alcohol dehydrogenase or ADH enzyme and that's found in the liver and that takes ethanol right into a toxic compound called acetaldehyde. And acetaldehyde is then usually not hanging out in the body very long and it's quickly broken down further to a less toxic compound called acetate. And that's done by the second enzyme I just mentioned, the aldehyde dehydrogenase, and then from there acetate gets broken down to carbon dioxide and water, mainly in the tissues outside of the liver. So it undergoes like this process to kind of break it down so that the body can eliminate it.

Ponni Perumalswami, MD:

But, as I just mentioned, you know it's a binge drinking episode right, or heavy alcohol use in nine out of 10 patients, for example in the liver, will go on to still develop hepatic steatosis. But this is largely reversible as long as like that amount isn't kept up. And when it is kept up, that's when we run into the problems with alcohol-related liver disease and then all the downstream complications that we never want to see. The other thing I'll say is, like there, so like in the liver, for example, like alcohol, it's a dose and duration dependent major risk. It's predominantly driven right. Driving the alcohol, but there are other factors, including genetic factors, environmental factors, we know women, things like history of bariatric surgery. There might be lots of other genetic factors, some of which are known, some of which are not well known, and then lots of other factors that are still being studied that we may not completely understand as being risk or putting people at risk to develop bad outcomes from like alcohol-related liver disease.

Kate Scarlata :

Keep thinking about those gut microbes. They're somehow factored in, right? Yeah, so some people get diarrhea, some people feel really bloated, some people get heartburn. What is it about alcohol that creates these symptoms for some people, and do you think it's dose-related? What's going on?

Ponni Perumalswami, MD:

Yeah, so the alcohol, like I just said, obviously can cause lots of disruptions along the entire GI tract and a lot of those disruptions can happen very high up in the GI tract. So breaking down, you know, the lining of the esophagus, for example, can then manifest as heartburn, right, and if we scope some patients who have heavy alcohol use, we might actually see something called inflammation of the esophagus or esophagitis. We also see these changes can happen in the stomach very commonly, right, the first kind of places where alcohol is the body seeing, if you will, the esophagus and the stomach, and in the stomach it can do the same thing with breaking down the lining. So, again, if we were to do an endoscopy, some patients might actually have inflammation of the stomach or what we call gastritis. Some people might actually develop ulcers, right ulcers, and that can put you at risk for things like bleeding.

Ponni Perumalswami, MD:

And so these things, like when people say like, oh, my tummy hurts or my belly hurts after I drink, it could be related to some of these changes happening and then, like as you just said, some people might get bloating. Bloating might be related sometimes to type of alcohol, person's gut microbiome, how they respond to things, and other people may not ever have these symptoms. So it's like quite a range that people can experience, but some of these might be just like manifestations of the physical changes right that are happening, particularly in the esophagus and the stomach, which is the first place the alcohol is kind of hitting in our GI system.

Kate Scarlata :

Yeah, I think at the end of the day it's a GI irritant system. Yeah, I think at the end of the day, it's a GI irritant. I think it can be really irritating to the gut and known GI irritants.

Dr. Megan Riehl:

So that was a really beautiful way to explain how it is one Well, and I'll talk with patients too about what are your behavioral choices if you've been drinking and if you've had a night of drinking. And then you get home and the next morning you wake up to the pots and pans out because you fixed yourself some mac and cheese and more snacks and maybe some ice cream and where you stopped at McDonald's in your Uber or spent $40 at Taco Bell. All of those choices on top of the alcohol consumption are going to be a bit problematic for you the next morning or, unfortunately, for a lot of people with GI conditions for several days, even after a night out.

Ponni Perumalswami, MD:

So that is exactly like that concept. It sounds like a brief intervention. So after we ask about alcohol, right, we find out about how much, and then patients come to us obviously reporting lots of symptoms in the context of whatever other things we might be seeing them for or managing them for. So brief interventions they're a behavioral treatment and it's all about having just like this focused conversation about alcohol and potentially related harms or how it's like, maybe involved in symptoms that they might be reporting and really aimed at trying to then get patients to be motivated to create a change plan around that alcohol behavior. And this is actually very effective in people with unhealthy alcohol use, so not even having a diagnosis of alcohol use disorder and then even in patients with mild alcohol use disorder or moderate to severe, to get them then engaged if needed to move towards treatment. So, yes, this brief focus conversation of the impact of alcohol is very powerful and a tool we should be leveraging a lot more when we see patients.

Dr. Megan Riehl:

Absolutely. I talk about that in terms of this bidirectional relationship with patients that have anxiety and depression, where I'll ask about what are some of the things going on in your life, what are your coping skills to manage your mood symptoms? And for the patients that say you know well, I have a drink at night and it really calms me down. It calms the anxiety. I don't feel those symptoms of depression as much anymore, there's a technique called motivational interviewing, where we start to gather information from people and not to shame them or stigmatize them about the choices that they're engaging in.

Dr. Megan Riehl:

But education can go a long way.

Dr. Megan Riehl:

So with depression specifically, I'll talk about the facts that alcohol can intensify your depressive symptoms, maybe not in the moment, but certainly because you're disrupting the brain chemistry and for some people it's also impacting your social relationships and the stability that you feel at work or at school, and so further.

Dr. Megan Riehl:

Problematic it becomes when the brain chemistry, which the neurotransmitter that specifically comes up is GABA, which promotes relaxation, and then serotonin, which affects mood, is disrupted by alcohol use, and so over time the brain then becomes less capable of managing whether it be anxiety or depression, naturally, which then leads you to more drinking, which becomes this very vicious cycle and so helping patients to understand that their alcohol choice in the short term is going to create longer term problems.

Dr. Megan Riehl:

And so let's talk about how we can create some healthier habits that will actually get at the root of why maybe you are turning to numb or to calm, and some strategies like relaxation, exercise, healthy social connection, making sure that you've got a good medical team, making sure that you're open and honest. A lot of people that are drinking alcohol are probably living with shame or guilt if their alcohol relationship is unhealthy. So again, that's not to generalize to all people drinking alcohol, but if you're somebody who wakes up the next day and kind of feels some of that emotional sensation of oh, what did I say last night, or did I do something? Or maybe you know I got behind the wheel of a car and I probably shouldn't have done that last night, if you're having any of those questioning thoughts, just make sure that you start to talk about that with somebody and know that there are available resources to help you.

Kate Scarlata :

Yeah, and I would say too, you know I've worked with some clients that come in and say, geez, you know I feel really bad on Monday, like the beginning of the week, and come to find out they're weekend warriors, you know. So they're partying hard on the weekends and it really has downstream effects to their gut and so we start seeing these patterns and then you help identify the patterns to their GI symptoms and they're more likely to go oh aha, you're right. I probably need to really focus on that if I don't want to have major diarrhea on Mondays. Connect the dots as providers and certainly our listeners. Hopefully you can also connect some dots with your own personal story and the way you're using alcohol or not using alcohol. What do you say to your patients about just ways to mitigate specific goals for them? What are some of the goals that you suggest to help them decrease their alcohol? There are certain techniques that you use in practice.

Ponni Perumalswami, MD:

So one is just like having a very open, honest conversation, like a place like where patients can feel reassured that what they're going to get from me is lots of empathy and like lots of listening and then also help if they're wanting it. But it's also helpful for them to know, like how we can be helpful, and I think a lot of people don't understand or know all the different ways maybe we might be able to be helpful. So obviously I see lots of patients who have an alcohol use disorder in the context of liver disease and so I always make sure patients are very aware of different types of treatment we have for patients. Making sure they know that there's both medications as well as behavioral treatments you were just mentioning. You know cognitive behavioral therapy, for example, is a type of more intense, focused, skill-based therapy right. To get patients to try to cope and change how they're using alcohol to cope with problems that often kind of coexist or co-occur and just occur really commonly for everybody in their everyday lives If it's stress, it's anxiety, it's depression in the context of having a bowel disorder or a liver disease. So making sure they know there are lots of tools we have in our toolbox.

Ponni Perumalswami, MD:

I find that, like a lot of patients might have a slice of the understanding of what we have to offer, even with medications. You know, the one medication I find, for example, everybody has awareness about is like Antabuse or disulfiram. It's the one medication we never give patients with liver disease because of liver toxicity and so like then talking about all the different other medications we have, if they're interested and how medication and or behavioral therapies can be helpful for somebody who, in the context we're talking about these negative maybe health consequences or harms that they're experiencing, how these treatments can be helpful and if they're not able to do it on their own right, like that's where Medicaid but they want to and really making patients feel like super centered in these discussions is, I think, very important, so that this is all about how we can be helpful to you and what do you want, how do you want us to help you, and then again asking about it, not just once, but asking about it and offering treatment early often and keeping patients engaged around this discussion, because they may not want it maybe at the start of like wait when you have this first conversation, but after they're building a relationship with you or they're seeing maybe other negative health consequences happening. You might just find the right kind of window where patient's motivation has changed, and I also really try to medicalize this in a way.

Ponni Perumalswami, MD:

I also let patients know 50% of alcohol use disorder is hereditary. So in the same way that some patients are diabetic but not overweight or have high blood pressure and are taking, you know, need medications, one person might need medications. Another person may not need medications, might be able to do with some diet and exercise. That we want to have the same approach, that you know we have treatments to offer. And how do you want us to be helpful?

Kate Scarlata :

I love that.

Kate Scarlata :

I think too, like just this is you know you're dealing with people that are in it and have a disorder, and then there's the other spectrum of people just maybe dabbling a little bit too much and you know, for that crowd I really try to get them to think about have a seltzer, then have a glass of wine, or have a spritzer instead of the glass of wine, or think about some of the non-alcoholic beers that are out there that are tasty.

Kate Scarlata :

If you want to participate in you know last call, but you really don't want to have an alcoholic beverage, consider a non-alcoholic option. There's so many cool mocktails, as Dr Riehl mentioned earlier, that can feel festive and that you're part of the crowd. Having seltzer with a little splash of cranberry and a lime looks like a cocktail and you don't have to deal with the commentary. So there are little strategies for those that are on the well I really want to cut down, but I don't have a liver disorder, but I don't want to get one and addressing those patients which I see frequently they just need to dial it back and need some tools to do so.

Ponni Perumalswami, MD:

Yeah, yeah. So I think, yeah, we need to address people much earlier, right before they develop. And, yeah, making sure people know that they have these other options to have non-alcoholic choices and to still feel like they fit in in social settings, because that is a big part of how alcohol is consumed. It's really part of the social fabric in a lot of different cultures. I also think, like highlighting what patients tell us right after they cut back or they stop, even in those settings, that they tend to sleep better, they tend to feel better, they tend to have better personal relationships. So making sure we're highlighting all of the potential positive things that can come right with making some small changes, like, as you said, this summer I started kind of exploring mocktails and my favorite seems to be transitioning well from summer to winter.

Dr. Megan Riehl:

I love a little ginger beer with a squeeze of lime and then I just add to it. So whatever else I want, if I want it a little spicy, I'll do a slice of jalapeno. If I want it more festive, I can throw in some rosemary. So maybe our listeners can share their favorite mocktail recipes with us too. And I also then feel really comfortable with my kids seeing me make this. So they're observing, mom, that's putting something together to drink. That's not just water or coffee or tea, but if they have a sip of it, whereas if you have a glass of wine or something and inevitably your child comes over and they pick it up and it's like no, no, no, no, that's for mommy, that's mommy's drink. It's like if they want to try a sip of it, sure you can have a sip of this.

Dr. Megan Riehl:

So certainly our relationships with alcohol are individualized and personal, and if you need somebody to talk to about it, I encourage you to do that. Hepatologists like Dr Perumalswami are like you know. You're right. The empathy just exudes out of you and you create a safe space for people that really allow them to embrace their health journey, and that's really what everybody certainly deserves. So with that, I just want to thank you so much for your expertise. Today we're all kind of looking at this brand new year and maybe rethinking relationships, whether it be with alcohol or broader health and wellness goals, and we are here. The Gut Health Podcast, Kate and I are going to be with you all year long talking about our gut health and really hoping to inspire everyone along the way. As we wrap up at this episode, we like to ask all of our guests the following questions. So, for the first time in 2025, Dr. Perumalswami, what is something that you prioritize when it comes to your own health and wellness?

Ponni Perumalswami, MD:

I'm hoping to like be working out more. I would say, you know I'm always like challenged with trying to figure out, you know, the balance. I think I hear this a lot from patients. I'm also, you know, we're all patients also too right In some capacity, and so like I feel like eating healthier and being more active is something I'm always trying to, particularly not just in the new year but throughout the year. But recommitting in the new year to trying to do so. I just signed up for a workout class at our community center. They're continuing it. Yeah, so that's my commitment for the new year.

Dr. Megan Riehl:

You deserve it, good.

Kate Scarlata :

It's perfect. It's so perfect. Well, thank you so much for coming on today. Really informative. I love your patient-centered care model. Really today, really informative. I love your patient-centered care model. Really important to The the patient be the center of their universe and their healthcare. So thanks for all the work that you do and sharing your level of expertise with our listeners today as we kick off our 2025 season. So please make sure you subscribe, follow and like The Gut Health Podcast. Your support means the world friends.

Dr. Megan Riehl:

Thank you for joining us as we grow this gut health community. We hope you enjoyed this episode and don't forget to subscribe, rate and leave us a comment. You can also follow us on social media at The Gut Health Podcast, where we'd love for you to share your thoughts, questions and experiences. Thanks for tuning in, friends.

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Kate Scarlata

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Megan Riehl

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