Hi {{first_name | Phoenix friend}},

I used to love wine. A good Pinot noir with a cheese board, a celebratory champagne toast, the ritual of unwinding after a long day. Then I got my APOE4 test results back: 4/4 homozygous. Two copies. The highest genetic risk category for Alzheimer's disease.

So I did what I always do: I went deep into the research. And what I found changed everything.

Here is the uncomfortable truth that nobody wants to hear: the rules about alcohol are different for us. That "moderate drinking might be protective" message you have heard? It does not apply to APOE4 carriers. The studies are clear, and once you see the data, you cannot unsee it.

I am not here to lecture you or tell you what to do with your own body. But I am going to share exactly what the science shows, what it means for your brain, and what I personally do now. Because you deserve to make this decision with full information.

About this: I have another post that I am writing for next week about how to “still enjoy life” while optimizing against Alzheimer’s risk. I realize that many of us are overwhelmed by the amount of interventions to do and getting “robbed of life’s joy” when you need to fix your diet, remove alcohol, follow so many interventions and everything else.
I hear you.
I am in the same shoes.
I want you to know: its okay to be kind to yourself and divert from always optimizing against Alzheimer’s risk to just enjoy life.
More about this in my next post.

Now going back to alcohol..

The Honolulu-Asia Aging Study followed 2,416 men from midlife (average age 52) to late life (average age 87). What they found was striking: APOE4 carriers showed increased cognitive impairment risk at ALL consumption levels [Chosy et al., 2022].

Let me repeat that: not just heavy drinking. ALL levels.

For non-carriers, light-to-moderate drinking showed neutral or even slightly protective effects. But for APOE4 carriers? Moderate drinking came with a hazard ratio of 2.039, meaning roughly double the risk compared to abstainers.

The Vietnam Era Twin Study of Aging found the same pattern in 1,266 middle-aged men (mean age 56, so directly relevant to our community). The never-drinking APOE4 carriers had the BEST cognitive performance. The heavy-drinking APOE4 carriers had the WORST. Meanwhile, among non-carriers? No significant differences between drinking groups [Slayday et al., 2020].

Perhaps most concerning: the Framingham Heart Study Offspring Cohort discovered that the exact same alcohol consumption had opposite effects based on APOE4 status. Non-carriers who drank moderately showed improved learning and memory. APOE4 carriers who drank the same amount showed accelerated decline [Downer et al., 2013].

If you have been telling yourself that your evening glass of wine is "fine because it is moderate," the data suggests otherwise. The protective J-curve that gets so much attention in popular health media? It was built on studies that did not stratify by APOE genotype.

For non-carriers, light drinking might genuinely be neutral or beneficial. For us, there appears to be no safe harbor.

Action Steps:

Here is something most APOE4 carriers do not know: your blood-brain barrier (BBB) is likely already leakier than non-carriers, even if you are cognitively healthy right now.

A landmark 2020 study published in Nature found that APOE4 carriers have significantly greater BBB permeability in the hippocampus and medial temporal lobe, the exact brain regions hit hardest by Alzheimer's. This breakdown was present even in cognitively unimpaired carriers and was independent of amyloid-beta and tau pathology [Montagne et al., 2020].

Now add alcohol to the equation: binge-level ethanol compromises BBB integrity through multiple mechanisms, degrading tight junction proteins essential for barrier function [Vore & Deak, 2021].

KEY INSIGHT: You are starting with a compromised defensive barrier. Alcohol further degrades it. The combined effect is accelerated entry of toxins, inflammatory molecules, and pathogens directly into brain tissue.

Think of your BBB like the walls of a fortress protecting your brain. APOE4 carriers already have cracks in those walls. Every drink you take is like removing more bricks. Non-carriers can afford some wear and tear. We cannot.

The inflammatory markers tell the story: one study found that alcohol use was positively associated with the inflammatory cytokine IL-6 in APOE4 carriers, but not in non-carriers [Monnig & Shah, 2024]. Same exposure, completely different inflammatory response.

Action Steps:

Your brain has a waste-clearing system called the glymphatic system. It is essentially the janitorial crew that removes toxic proteins, including amyloid-beta, the hallmark protein of Alzheimer's disease. Here is the critical detail: 80-90% of this waste clearance happens during deep sleep [Reddy & van der Werf, 2020].

A 2020 study in Brain, Behavior, and Immunity showed what alcohol does to this system:

That is not a typo. Chronic moderate consumption causes irreversible structural damage to your brain's cleaning system.

IMPORTANT CAVEAT: These findings are from mouse studies. But given the mechanistic plausibility and the human epidemiological data showing worse outcomes for APOE4 carriers who drink, the precautionary principle applies.

And about that sleep you think alcohol helps with? Yes, alcohol shortens sleep onset and may increase initial slow-wave sleep. But it suppresses REM sleep and causes fragmented, poor-quality sleep in the second half of the night [Colrain et al., 2014]. Exactly the opposite of what your glymphatic system needs.

APOE4 carriers already have impaired amyloid-beta clearance because the ApoE4 protein is less efficient at this job than ApoE3. When you add alcohol-induced glymphatic impairment on top of genetic impairment, you are double-handicapping your brain's ability to clear the proteins that drive Alzheimer's pathology.

One night of sleep deprivation causes a measurable 5% increase in amyloid-beta in the hippocampus [Shokri-Kojori et al., 2018]. Now imagine what repeated alcohol-disrupted sleep does over years.

Action Steps:

Here is where the research gets personal. A 2018 cell study directly tested what happens when you combine ApoE4 protein with ethanol exposure. The findings were stark:

ApoE4 and high-concentration ethanol synergistically enhance neurotoxicity through elevating cellular oxidative stress [Li & Cheng, 2018].

The mechanism: ApoE4 significantly amplifies alcohol-induced cellular damage compared to ApoE3 through two pathways: elevated reactive oxygen species (ROS) production and increased programmed cell death (apoptosis). When researchers blocked oxidative damage with the antioxidant NAC (N-acetyl cysteine), the heightened toxicity was eliminated.

This is not additive damage. It is multiplicative. The ApoE4 protein itself makes alcohol more toxic to neurons.

THE DATA: Chronic alcohol metabolism generates reactive oxygen species through CYP2E1 activity, depletes protective antioxidants like glutathione, triggers immune activation, and creates a hyperglutamatergic state causing calcium overload [Kamal et al., 2020].

This is the piece that finally convinced me to quit entirely. It is not just that APOE4 carriers clear amyloid-beta less efficiently, or that our BBB is leakier, or that our glymphatic systems are already working harder.

It is that the ApoE4 protein itself turns alcohol into a more potent neurotoxin for our specific brains. Same drink, same blood alcohol level, more neuronal death.

Action Steps:

After reviewing this research, I made the decision to eliminate alcohol completely. That was almost two years ago. Here is what I have learned:

This was my biggest concern. So much of adult socializing revolves around alcohol. What I discovered: nobody cares nearly as much as you think they will.

What works:

If you were using alcohol to unwind, you need replacement rituals.

What works:

But what about the resveratrol and polyphenols in wine?

The math does not work. A glass of wine contains roughly 1mg of resveratrol swimming in three-quarters of an ounce of alcohol, which is a pro-oxidant. You would need to drink 100+ glasses to get a therapeutic dose of resveratrol, and you would destroy your brain in the process.

Better polyphenol sources:

KEY TAKEAWAYS - Your Quick-Start Protocol:

ACTION STEP: Whatever you decide, track it in Phoenix alongside your cognitive metrics, sleep data, and bloodwork. Your data will tell you what is true for your body.

I will not pretend this is easy. Alcohol is woven into our culture, our celebrations, our stress relief. Making a change requires replacing rituals, navigating social situations differently, and sometimes explaining yourself when you would rather not.

But here is what I know: you are the kind of person who looks at hard data and makes hard decisions. 96% of all Phoenix members are already taking action on their APOE4 status. You are not looking for easy answers. You are looking for the truth.

The truth is that our brains process alcohol differently. The protective effects that non-carriers might experience do not apply to us. The risks compound through multiple mechanisms. And the research is only getting clearer.

The good news? Cognitive improvement is possible with abstinence. Studies show that APOE4 carriers who stop drinking can recover function, even if it takes longer than non-carriers [Escudero et al., 2023].

Your future self, the one who is sharp and present for your grandchildren, for your legacy, for whatever matters most to you, that person will thank you for the decision you make today.

Want support making this change? Phoenix members track interventions like this alongside their bloodwork, sleep data, and cognitive assessments. Our pods provide accountability and community from others walking this same path. Join Phoenix to connect with APOE4 carriers who are doing the hard work together.

Most Newsletters? One-way street.
How boring…
This is the Phoenix Community. So let's make it a two-way street.
Got a question? Feedback?
Hit reply. I read every single one.