March 30, 2008

Alcohol Treatment — i on NIH — episode #0011, segment 2

A key question when it comes to alcohol abuse is How Much is Too Much. To learn more, we talked to Dr. Mark Willenbring, the Director of the Treatment and Recovery Research Division in the National Institute on Alcohol Abuse and Alcohol.


Welcome to “i on NIH”!

Featured in this month’s episode is a feature about the 2008 Red Dress Fashion Show, an update on alcohol abuse and alcoholism, and an i-to-Eye interview with the National Library of Medicine's Julia Royall about an innovative African malaria tutorial.

Narrator: From the national institutes of health in Bethesda, Maryland – America’s premiere medical research agency – this is “i on NIH”!

Covering health-research topics important to you and the nation, this public service vodcast is your information source from inside all 27 institutes and centers at NIH.

Half an hour, once a month, we’ll show you the excitement of advances and the important information that comes from medical research.

And now, here’s your host, Joe Balintfy.

Joe: Welcome to the eleventh episode of I on NIH! Thanks for joining us. This month, we’ll take you back-stage to the 2008 Red Dress Collection Fashion Show. We talk to an expert about how much is too much when it comes to drinking. And for our Eye-to-eye interview, we hear how efforts at the National Library of Medicine, reach all the way to Africa. But first, we have a news update. Here’s Harrison Wein from the NIH news-desk.

Harrison: Thank you, Joe. In this NIH Research Update, the role of diet in metabolic syndrome, supplement use in cancer patients and survivors, and a cholesterol drug to fight staph. * Last month I talked about metabolic syndrome, which means you have a higher risk of cardiovascular diseases like heart attack and stroke. Diet has been linked to metabolic syndrome, but exactly how isn't really well understood. NIH-funded researchers looked at the eating habits of almost 10,000 middle-aged adults. By 9 years later, nearly 40% of the people had developed metabolic syndrome. A Western diet—that is, lots of refined grains, processed meat, fried foods and red meat—was associated with a greater risk of developing metabolic syndrome. In particular, hamburgers, hot dogs, processed meats and fried foods were each linked to higher rates. The researchers didn't find any associations with whole grains, refined grains, nuts, coffee or fruits and vegetables. On the other hand, those who ate more dairy were less likely to develop metabolic syndrome. Strikingly, diet soda was strongly associated with an increased risk for metabolic syndrome, although sweetened drinks like juices and regular soda weren’t. Now, the findings aren’t conclusive. These foods may not play a role in causing metabolic syndrome themselves, but rather might serve as markers for other behaviors that do lead to metabolic syndrome. Future research will hopefully clear up the confusion. * Many cancer patients and survivors think that vitamin supplements can reduce treatment side effects, decrease the chance of their cancer coming back or prolong their lives. But studies addressing these topics have been inconsistent or inconclusive—and many doctors worry that supplements can interact with cancer treatments or have other unintended consequences. NIH-funded researchers analyzed 32 studies that had looked at vitamin and mineral supplement use. They found that between 64 and 81% of U.S. adult cancer patients and survivors used some kind of vitamin or mineral supplements. That’s compared to half of all adults who take them. Strikingly, 31 to 68% of cancer patients and survivors may not discuss their supplement use with their doctors. The finding highlights the need for doctors and cancer patients to discuss supplement. * In another new study, an international research team pieced together a new approach to reduce the virulence of staph bacteria by preventing production of its gold-colored pigment. Scientists already knew that the gold pigment helps to protect the bacteria. It protects them by deactivating the lethal chemicals released by immune cells. The researchers found a cholesterol-lowering drug that could block the pigment’s production. It weakened the bacteria’s defenses and made them more vulnerable to the immune systems of mice. Their next step will be to explore if the strategy can work in humans * You can read about these and many other research studies in “NIH Research Matters.” Go to the NIH home page and look for the link on the right-hand side, under “In the News” that says, “eColumn: NIH Research Matters” * And in this month’s health newsletter, “NIH News in Health”… The idea of eating more protein has gained popularity in the past few years. You might think the way to build body muscle is to eat a high-protein diet or use protein powders, supplements and shakes. But there’s no solid scientific evidence that most Americans need more protein. Most of us already get all we need. Some of us may even be eating much more than we need. Read about this and more in the March NIH News in Health. You can find it at news-in-health-dot-nih-gov. * This is Harrison Wein at the NIH Science Desk.

Joe: Thanks Harrison. Now for our first feature report. Here are the sights and sounds from the 2008 Red Dress Collection Fashion Show.

Voice Over : In New York City, the Heart Truth – the National Heart, Lung, and Blood Institute’s landmark heart health awareness campaign for women – rolled out the red carpet for its 2008 Red Dress Collection Fashion Show. Walking in this year’s fashion show, presented by Diet Coke with national sponsors Johnson and Johnson, Swarovski, and partner Bobbi Brown Cosmetics, 15 celebrated women united with America’s top designers at the Mercedes Benz fashion week to showcase the annual collection of one-of-a-kind red dresses and raise awareness of heart disease in women.

The good news is that awareness among women about heart disease is rising. Only one-third of women recognize that heart disease was the number one killer in 2000. But awareness has now grown to about 50 percent of women now in 2008, whch is fablous, fablous progress.

For women out there who have such a busy life and schedule and they’re juggling always ten things at the same time – as we women do – to kind of think about ourselves sometimes and check out our hearts – make sure the most important thing is working. And when i found out that heart disease is actually the number one killer in America for women – more than all the cancers out there put together – I was like wow – that is huge. I had no idea.

It’s an amazing, amazing event to be a part of. It’s such a wonderful cause. I actually lost a few people to heart disease, so anytime that i can do anything positive for this organization, i’m glad to be a part of it.



The red dress as a symbol of heart disease I think is so unique because it’s so sexy and feminine – and it’s just all about women and femininity and protecting your heart. And i think the little red dress is perfect.



It’s very prevalent, almost to epidemic proportions in the Hispanic and black communities. Sometime due to hereditary reasons and more often than not having to do with lack of exercise and the way we eat.






Unfortunately many women still do not take heart disease seriously and personally. Millions of women still have one or more risk factors for heart disease, dramatically increasing their risk for developing the condition. For more information about the heart truth campaign visit

Joe: For our next report, a key question when it comes to alcohol abuse is How Much is Too Much. To learn more, we talked to Dr. Mark Willenbring, the Director of the Treatment and Recovery Research Division in the National Institute on Alcohol Abuse and Alcohol. His first point stresses the importance of understanding what a drink is…

Willenbring: And a drink is defined for all purposes as the amount of alcohol in one 12-ounce beer, or one and a half ounces of 80-proof spirits like vodka or brandy, or five ounces of table wine, like Burgundy or Chablis.

And it's very important to understand that these all contain about the same amount of alcohol. Like a lot of people think that beer is better than other beverages and it's just a matter of how much you drink. So if you drink 12-ounces of beer it's the same as a shot of whisky. Also mixed drinks can often contain more than one shot. And shots sometimes aren't measured very precisely.

So it's really important, if people want to understand how much they're drinking, to be aware of what a drink is and to count. You could prevent a lot of problems in this country if people would just learn to count, to keep track of their drinking. And that in and of itself would have a major affect on people's drinking habits. Because most people who drink more than occasionally, drink more than they actually believe they do.

Joe: Dr. Willenbring points to the NIAAA website,, and the Clinician’s Guide to help understand, What’s a Standard Drink? Again, that’s 12 ounces of beer, 8 or 9 ounces of malt liquor, 5 ounces of table wine, or one-and-a-half ounces of hard liquor. Using those measurements, then we can ask How Much is Too Much?

Willenbring: The Institute recommends that a daily maximum be no more than three drinks for women and no more than four drinks for men in any one day, and no more than seven drinks a week for women and no more than 14 drinks a week for men.

Now it's not like if you go to eight or 15 drinks in a week something terrible will happen. What it is is that it increases your risk of something bad happening. And the more you drink in a day and the more often you have a heavy drinking day, the more the daily risk is that something bad will happen. Well what kind of things could happen? Well, you could fall and hurt yourself. People also get aggressive. They get into fights or suffer from assaults. So they become vulnerable. And they may be vulnerable to sexual assault, for example, because they're intoxicated.

We all know about drinking and driving. That's one of the major killers of young people in this country. And it's down from where it was, but it's still a really big problem. And people should also be aware that they shouldn't get in the car with a driver who's been drinking because a lot of times the victim of a drinking driver are other people in the car with that driver, or people in the other car.

So these are the bad things that can happen and if it goes on long enough, then people can develop symptoms of alcohol dependence, which is known as alcoholism.

Joe: At-risk drinking and alcohol problems are common. About 3 in 10 U.S. adults drink at levels that elevate their risk for physical, mental health, and social problems. NIAAA’s Dr. Willenbring explains that there's a progression of problems associated with drinking.

Willenbring: There's a progression of problems associated with drinking. The first part of it is drinking too much. And too much is drinking in excess of the daily NIAAA guidelines, which is no more than three in a day for women, no more than four in a day for men. So drinking more than that in a day we call a heavy drinking day. And the more you exceed those limits, the more likely a problem will occur.

So there's a difference between drinking six drinks and drinking 10, for example, pretty obvious, but it deserves to be said. So the first step is drinking heavily and then, so that's drinking too much too fast and then doing that too often is where people's risk really starts to increase. So doing it once a week or more, your chances of having alcohol symptoms or problems associated with drinking really rises. And when you get up to daily or near daily heavy drinking, then the risk of developing an alcohol use disorder is enormous compared to people who drink less than that.

So what's an alcohol use disorder? Well so the first thing you have is you have heavy drinking. Heavy drinking by itself is not necessarily a problem, but it puts you at risk. It's sort of like having high cholesterol before you have a heart attack, or having high blood pressure that doesn't get treated. That's kind of what heavy drinking is. It may not be symptomatic, necessarily, but it increases your risk for problems later downstream. And you may not be able to predict when those problems occur. And that's what makes it risky and dangerous.

So there's heavy drinking. We call that at-risk drinking. And then when people start to develop symptoms we call it an alcohol use disorder.

Joe: So what are symptoms? Well the very first symptoms are difficulty controlling how much you drink or how long you drink, having trouble setting limits, trying to quit or cut down and having trouble doing so. Those are the very first kind of symptoms. Another very common symptom is drinking and driving. Those are the very early symptoms that occur.

Willenbring: Now alcohol dependence, which is, you know, typically known as alcoholism, is something a little bit different, because that refers to the loss of control. It's not actually complete loss of control, it's diminished control over a person's drinking. And this is usually something people are quite aware of, that they are — they're aware that they'll set a limit. They'll say, “Well, I'm only going to drink two drinks tonight,” or, “I'm not going to get drunk tonight; I'm just going to have a few drinks.” But most of the time when they start drinking they'll get intoxicated, and they'll drink eight or 10 drinks. And this happens over and over. Or they'll say, “Well, I'm just going to stop off at the bar for a quick drink after dinner,” — I mean — I was going to start over. Or they'll say, “I'm just going to stop off at the bar after work for a quick drink before I go home for dinner.” And there they are still at the bar at nine o' clock. And their family is unhappy about that.

Those are the kinds of things — and then also that other activities start to drop away, the non-drinking activities. Friends who don't drink, they’ll — you'll stop spending time with them or hobbies or interests that people once had that were quite important to them kind of drop away because you're spending more and more of your time drinking or thinking about drinking or recovering from drinking. And so those are the main symptoms of alcohol dependence.

Joe: So then the question is who is at risk. Dr. Willenbring says the number one thing that increases a person's risk for alcohol use disorder is a positive family history and a close relative.

Willenbring: So if you have a brother or sister or a parent who has alcohol dependence, your risk of developing alcohol dependence is four times greater, about, than someone who does not have a family history. And in particular, if it's multi-generational, if your father and grandfather were both alcoholic, then your risk is really quite high. That's the number one risk.

The second risk is certain kinds of psychiatric disorders during childhood, particularly what we call externalizing disorders. These are things like conduct problems, having problems with authority, truancy, crime, that kind of thing. So kids who manifest those kinds of behaviors are much more likely to involve alcohol dependence, even as a teenager, let alone as an adult. Those are two of the biggest risk factors for developing alcohol dependence.

But the important thing is that most people who develop alcohol dependence don't have either one of those risk factors. So there's increase of risk, but not having those doesn't mean you can't get it.

Joe: Another factor that Dr. Willebring points out is that most heavy drinking occurs in young people.

Willenbring: And in fact, the portion of the population that has alcohol dependence at any point in time is greatest between the ages of 18 and 25. That's not something most people think of. Most people think of an alcoholic as somebody who's 40 or 50 years old, that has been ill for 20 or 30 years. And that does occur in a more chronic relapsing form, but the most common form of alcohol dependence occurs earlier in life. And a lot of people today who are within a few years that they may suffer a lot of consequences in the meantime.

So, I'm thinking here of spring break, for example. There's an increasing number of young adults and adolescents who are dying of alcohol poisoning. And some of the most dangerous things are things like drinking games. And so, what I would really encourage people to do is really think carefully before getting involved, before going out for a night. And even if you, you know, you're going to drink and you're going to drink more than the guidelines say, decide how much you're going to drink in advance. Decide how you want to drink. Don't drink too much too fast. That's really the dangerous thing, drinking too much too fast. And we really would like to see fewer people getting hurt due to their drinking during spring break.

Joe: Drinking too much too fast is often called binge drinking.

Willenbring: A binge is about five drinks in a two-hour period. Five drinks in a two-hour period brings you to, the average adult, up to the level of being legally drunk. So that's too much too fast, five drinks in two hours. And if you think how much can be in martini or in margarita or other mixed drink or cocktail particularly, it could have three or four drinks. I've seen bars, for example, advertise 12-ounce martinis. Now, if a drink is an ounce and a half, and even at a bar, you know, it's going to be at least half pure booze and maybe more. I mean, you can figure it out. That's probably, that's at least four drinks or five drinks right there. So — and that stuff can go down pretty easily and I think that's what I'm saying, is just trying to raise people's awareness that a drink is, not a drink is a drink, I mean, in the sense of how it comes to you.

And so if people want to protect themselves, they’ll do things like space their drinks. They'll drink, you know, some water or plain tonic or ginger ale or diet coke or something like that, you know between drinks. They'll pace them so they're not drinking more than one or two drinks an hour, for example. They'll, and they'll make sure that they don't drink these highly concentrated drinks rapidly. That's how people really get into trouble. And, of course, drinking games where you're actually drinking shots, that's really, that's really dangerous because you can black out and get into a real problem without intending to and that's really what we're trying to prevent.

Joe: For more information, Dr. Willebring recommends the publication” Helping Patients Who Drink Too Much: A Clinician’s Guide” as well as the pocket guide for Alcohol Screening and Brief Intervention. And coming in the next couple months on the NIAAA website, a self-help manual for people who want to quit or cut down, that's called "Rethinking Drinking." Visit

Joe: Now for our Eye-to-Eye interview, Calvin Jackson sat down with Julia Royall of the National Library of Medicine. We learn how efforts here at NIH, reach all the way to Africa…

What is the Medline Plus African tutorial and why did the national library of medicine decide to undertake this ambitious project?

For a while, NLM has been interested in consumers - end users - how they get their information. If they use it, do they use it to really make behavior change and have better health as a result?

So the thought was, since we do a lot of outreach work in Africa, why don’t we make a tutorial that would work there? But rather they make something here for Africa, the idea was to make something in Africa collaborating with folks there. So, we worked with the medical school at Makerere University in Kampala, Uganda, and also Ugandan artists who were in Kampala, and made a version of a Medline Plus tutorial about malaria, which is quite different from the Medline Plus malaria tutorial that you see on the web site that’s geared for American audiences going abroad, about how not to catch malaria and how to treat it. Well this one, in Africa, had to be geared for people in villages being able to understand that the mosquito is the vector, and take precautions against getting malaria so they can prevent it, as well as when they do get treated for it, following the treatment properly.

So, it was a big challenge for everyone, and the medical students deserve huge amounts of credit for going into villages, talking with people, finding out what their concerns about malaria were, thinking, for example, that mangoes caused malaria, or maize – corn - causes malaria. Well, mangoes come during the rainy season and so that’s — and when it rains there’s a lot of water that’s not absorbed that stays around in puddles, and that’s where mosquitoes can breed. So, it does make sense as part of the process, but it’s not like if you eat a mango you get malaria.

So, it was a long process and a very iteratative kind of process of going back and forth with the team here at NLM that makes Medline Plus and the team in Africa and Uganda that was working on the ground. So we’d go back and forth with various versions, various questions, and then the one in Uganda was also translated into Luanda, Rukiga, and Luo, as well as English. So, there are several versions that can be used, played on radios, played in clinics. We’re finding a lot of uses for it because we’re looking at a proactive kind of outreach approach.

Can you describe the tutorial in greater detail?

The tutorial exists in several forms. It exists as an online interactive tutorial that you access via the internet. It exists as a booklet, a hardcopy version, sort of laminated version that a health worker could use to go through with clients and explain to them how malaria works and how you prevent it, how you get it, how you treat it. There are also posters that can be used in health clinics. When i visit health clinics like the smallest ones at the end of the line, the health officer always tells me, “what we really need are visual aids.” Because people come, hundreds of them might come in the morning to wait around, and they wait around, you know, much of the day, waiting to see a doctor. And while they’re waiting around, you have all that time to have an educational moment. So we hope they’ll be used that way.

The illustrations and the text were — and they’re very simple — were actually agonized over so that everything in an illustration communicated the message. So, even if you couldn’t read the text, you could still look at the picture and get the message.

Can you describe the collaboration you started with librarians in Uganda to help students obtaining their master’s degrees learn how to search the NLM databases?

As you know, NLM has fabulous resources. We have wonderful databases. We have access to full text articles, not everything, but certainly a lot of access to full text. There’s Medline, you know, the largest biomedical database in the world, all peer-reviewed. Medline Plus, it’s great information, it’s always being reviewed by people here. So not only is there a lot of information and it’s free, but it’s good, it’s been looked at, it’s been reviewed. So, unfortunately a lot of people even here don’t know about these riches and wonders. Oh, and then there are databases like, which has clinical trials from all over the world in it. Wonderful. Of surgery, videos of surgery. A whole database on surgeries.

So there’s just a lot of stuff. So you’ve got all of that, this kind of gold mine, and then you’ve got students who have come to get master’s degrees. And then you’ve got a library, which is a building. And the library might have a workshop where people come into the library or people are invited to come in and learn. But we found that that’s a very kind of passive way to train people or to show people what’s available.

So we, the librarians and i, went directly to one of these master’s students classes and there are 70 people in it. And we said, “how many of you have used Medline?” Well, not many. “how many of you know about Medline Plus? Or” And so on. And very low numbers. And we said, “well, we’re here to tell you that we are happy to help you find out about these resources. When could you come to a workshop? And they said, “we could come on the weekend.” So we said, “okay, we’ll organize one this weekend and one next weekend. How many are coming this weekend? How many are coming next weekend?” And they came.

And then we would show them databases, but we would also say, okay, say one of them might be interested in sickle cell, really help them work through what we were showing them using sickle cell, so that they’re working on something they are really interested in and that they will use.

And then after that, we went back to the class and said, “how are you all doing?” And they said, “we’re doing okay.” And we said, “would you like to come back for more one-on-one instruction?” And some of them definitely wanted to do that. So, they started coming back at lunchtime, and the librarians would help them one-on-one.

This is the midpoint of your term as a Fulbright scholar and you’re heading back to Uganda in a few days. What has this experience meant to you personally?

I think it’s fabulous to be immersed in the field. Granted, i have a round-trip ticket, so i can never experience exactly what my colleagues in Uganda experience. But, i can get some of the experience. I am now very used to blackouts, power outages, internet fluctuations, internet that’s not very good, and those things make getting things done difficult from time to time. And i wanted to learn — i wanted to experience that firsthand, so i could walk in their shoes if you will. That’s been a real privilege to do that.

And at the same time, the students, the doctors, the folks i work with have energy, they have creativity, they have hope, that’s inspiring.

For more information on the tutorials, visit for more information about the National Library of Medicine visit

Joe: That’s it for another episode of I on NIH – thanks for watching. Please tune in again next month – we’re working on stories about Fibroids, bipolar disorder and much more. For i on NIH, I’m Joe Balintfy.


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