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What the Doctor says
An update on Alcohol and Health by Professor Curtis Ellison M.D, Boston University

Professor Curtis Ellison is Chief of the Evans Section of Preventative Medicine and Epidemiology and is Professor of Medicine nd Public Health at Boston University School of Medicine.

We have known for many years that moderate amounts of alcohol seem to be protective against coronary heart disease (CHD). But this message was not given to the American public until Morley Safer appeared on American television in November 1991 and told the public about the French. In the weekly television programme, 60 Minutes, viewed by more than 30 million Americans, Morley said that the French do everything wrong in terms of their health: they eat a high-fat diet, they dont jog, and they smoke, yet they have much lower heart disease rates than Americans. This became known as the French Paradox.

For years, we have been seeing very large differences among countries in reported rates of death from CHD. The highest rates are now in Scotland, Northern Ireland, Finland and Eastern Europe. The lowest, with only one-fifth the number of heart disease deaths as Northern Europe, is Japan, due primarily to the very low amounts of fat in the traditional Japanese diet. We have always explained the lower rates of heart disease in Italy, Spain and Greece from the lower fat diet and other features of what is known as the Mediterranean diet. But France has even lower rates of coronary heart disease than Italy or Greece. Why do the French have such low rates of heart disease? We do not know. Their diet is higher in fat, their hypertension rates are the same, their blood cholesterol worse. Further, genes studied so far seem to be about the same as in countries with much higher rates of heart disease.

The explaination of the low rates in France include more intake of fruits and vegetables containing high levels of anti-oxidant vitamins, and a lower percentage of fat intake from red meat, as the meat in France is very low in fat and smaller portions are generally served then in the US. But the theory that has received the most scientific support is that the French consume large amounts of alcohol, on a regular basis, and particularly in the form of wine. This is not a new story, as we know from paper by St Leger et al back in 1979, that of all the lifestyle factors related to CHD in different countries, the strongest relation was with the average wine consumption in the country. Since then there have been a large number of studies on alcohol consumption among individuals and their risk of CHD, and the results have been remarkably consistent: individuals who consume alcohol moderately have fewer heart attacks.

How does alcohol produce this protective effect?

We now know many of the reasons why alcohol reduces the risk of CHD, as we have identified many of the biologic, physiologic effects of alcohol. Alcohol in any form affects the blood lipids. Alcohol will increase HDL-cholesterol, the so-called good cholesterol that lowers the risk of heart disease. Alcohol also tends to decrease slightly the LDL or bad cholesterol 'which increases the risk of CHD. But alcohol, and red wine in particular, also favourably affect the coagulation of blood within the arteries. For example, it decreases platelet aggregation, and it also has favourable effects on fibrinogen and fibrinolysis, factors related to blood clotting and the removal of clots within the arteries. The effects of alcohol on blood clotting may be just as important as the effects on the HDL-cholesterol.

The effects on coagulation are short-term effects, lasting for a day or so. The short-term beneficial effects were well-demonstrated by Jackson et al. These investigators compared the risk of heart attack and cardiac death among regular drinkers and found that if a regular drinker had had one or more drinks in the preceding 24 hours, his or her risk was reduced (to about 75% for men and 61% for women) when compared with drinkers who had not had anything to drink in the preceding 24 hours.

These results suggest that you should consume alcohol on a regular basis, perhaps daily. Unfortunately, many do not have good drinking patterns, and tend to drink nothing all week, then drink heavily at weekends, which is a very unhealthy way to consume alcohol. Many Europeans drink wine with their meals every day, it is not the amount that you drink, but when you drink it that is important in preventing CHD. In a recent study in Italy, people who drank wine with their meals were much less likely to die of any cause than those who consumed wine at other times. The best pattern is regular consumption with meals every day, but only a few drinks each day.

I am often asked, Is wine, particularly red wine, better than spirits or beer in terms of preventing heart disease? We do not have definitive data on this, and generally all types of alcoholic beverages have a protective effect against heart disease. However, we are accumulating new data suggesting that red wine may have additional benefits. A number of scientists have shown that red wine contains, in addition to alcohol, a large number of substances that are powerful anti-oxidants, tend to reduce blood clotting, and have other effects that should reduce heart disease risk. For example, we have data from the US showing that moderate amounts of red wine will prevent blood platelets from clumping together to form a blood clot which may lead to a heart attack. Such protection does not occur from white wine or alcohol, so it must be something in red wine that gives the added protection. On the other hand, in the US, wine drinkers are different in many ways from beer or spirits drinkers. They tend to be better-educated, have higher incomes, smoke less, and exercise more than beer drinkers. So it is difficult for an epidemiologist to be sure that wine drinkers are healthier because they drink wine, or whether it is just that people who have healthier lifestyles drink wine.

Should physicians prescribe alcohol to their non-drinking patients to lower their risk of heart disease? It takes only about one drink per day, or even every other day, to get most of the benefit in terms of reducing coronary heart disease (CHD). Since this is the leading cause of death throughout the developed world, why not prescribe a glass a day to everyone? Some scientists argue that we do not have to use alcohol to prevent CHD, there are other ways to prevent it: losing weight, lowering blood pressure and cholesterol, eating a healthy diet. But they do not appreciate how hard it is to lose 10kg of body weight, or to modify diet. And it is not enough to simply tell people to eat better. Several good studies show that people who get lots of vitamins, especially vitamin E and folate, may lower their risk of CHD. But recent research by Rimm et al from the Nurses Health Study found that the reduction in risk of CHD associated with folate was many times greater for those who consumed at least 15g of alcohol per day versus non-drinkers. So a little wine along with a healthy diet will be preferable to just a healthy diet.

We know that alcohol abuse is very harmful, and the question I want to consider is what we refer to as the bottom line, ie total mortality. In other words, if you are a drinker, are you likely to have a longer or shorter life than you would if you did not consume alcohol? We all realise that even moderate drinking can have adverse effects if someone quickly consumes several drinks then takes their car on the road. So I always refer to moderate and responsible drinking. But in terms of diseases, most are related to heavy drinking. The only condition that may relate to even light to moderate drinking is breast cancer in women.

A number of research reports suggest that a small increase in risk begins to appear among women who normally consume only one or two drinks per day. This is not found consistently in all studies. At our Institute at Boston University we have just completed a study of wine, beer and spirits as they relate to breast cancer, using data from the Framingham Study that has been following more than 5,000 women for 25 to 45 years. We found that women who have consumed wine or other alcoholic beverages moderately over a lifetime do not have increased rates of breast cancer in fact, they tend to have slightly lower rates.

Let's turn to the total mortality rates. In other words, are you more likely, or less likely, to die of any cause during a specified period if you drink or if you do not drink? In essentially every prospective study carried out, the net effect on total mortality of consuming one or two drinks per day is a lower death rate. As long as the alcohol intake is light to moderate, up to a couple of drinks per day, the risk of most diseases is lower, and the risk of dying of any cause is reduced.

Data from the Copenhagen Heart Study, that followed over 13,000 men and women for over 10 years, illustrate how reducing moderate drinking might increase mortality. The results from the Copenhagen Heart Study show the typical J-shaped relationship between the relative risk of death from any cause and alcohol consumption. Drinkers who stated that they averaged one to six drinks per week had about 40% lower death rates than non-drinkers; heavy drinkers had higher death rates.

When I see data such as these, I find it difficult to understand how governments justify attempts to ban alcohol, or to reduce alcohol use for the entire population through higher taxes or other steps designed to restrict alcohol availability. While such efforts are undoubtedly directed at reducing the problems of alcohol abuse, generally such efforts tend to reduce drinking more among moderate users than among alcoholics.

Whatever we do to reduce alcohol consumption among heavy drinkers, irresponsible drinkers and alcoholics, from the point of view of public health, we should be sure that we do not discourage moderate use.

How should all this information relate to alcohol policy? What should the public be advised about alcoholic beverages? What should physicians advise their patients, especially those who do not drink? Colleagues and I are preparing a report using official death rates in the US to determine the absolute risk of dying for adults 45-75 years of age, according to whether they are abstainers or consume alcohol moderately, which by our governments official definition is an average of no more than two drinks (US'drink' = 1 1/2 UK units) per day for men, and one drink per day for women. Based on an extensive review of the scientific literature, we assumed that if a non-drinking person began to consume alcohol moderately, he or she would reduce his or her risk of CHD by 33.3%, and would reduce their risk of stroke by almost as much. Other diseases related to arteriosclerosis would be reduced, but women might show a 10% increase in their risk of breast cancer.

We know that there is always the possibility that a patient will not follow his or her doctors suggestions and begin to drink very heavily. We factored into our equations that approximately 5% of patients might do this, and if so, would increase their risk of cirrhosis of the liver, death from drunk driving, and an increase in the risk for breast cancer for women.

Taking all these risks into our calculations, we found that for all women from age 55 and for all men aged 45-75, individuals who began to drink had lower mortality rates. The results indicate that a non-drinking patient would actually have a reduced risk of dying over the next 10 years if he begins to drink moderately, even if 5% of such subjects became alcohol abusers. As an example, for a 65 year old non-drinking man in the US, government statistics show that 278 will die over the next 10 years; if these men all became moderate drinkers, only 251 would die, a reduction of about 10%. Our data are based on the consumption of any type of beverage.

Physicians should no longer be so afraid of alcohol abuse that when they find middle-aged men or post-menopausal women who do not consume alcohol, or only do so rarely, that they stick to the old adage of leaving well alone. I believe that for many patients, doctors can encourage moderate alcohol consumption, especially the daily consumption of a glass of wine, without any real risk of the patient abusing wine. And in doing so, their risk of heart disease could be markedly reduced.

In summary, the scientific data are quite clear: moderate alcohol consumption, especially moderate wine consumption, should be considered a part of healthy lifestyle. We will do what we can to make sure that the public, the medical community, and our policy makers are kept up to date on the scientific findings. Those findings are now very clear, and support what St Thomas Aquinas said over 700 years ago: If a man abstains from wine to such an extent that he does serious harm to his nature, he will not be free from blame'

Wine and Health - The Current Picture by Harvey Finkel M.D.

Dr. Finkel is Clinical Professor of Medicine at the Boston University Medical Center, specializing in hematology and oncology. He writes and lectures internationally on the interrelationships of wine and health. An award-winning wine writer and educator Dr finkel is Chairman of the Committee on Health of the Society of Wine Educators, .

Our collective ancestral consciousness has long suspected that wine, in addition to enriching life, enhances health and prolongs life. In this age of sceptical and exacting science, we must have objective data to support such a contention, else we shall lose credibility.Wine has powerful enemies spreading disinformation.We must not fall into the easy trap of viewing wine as panacea or as a medicine.

It may be useful to begin with the conclusions: Moderate consumption of wine improves health and prolongs life, as scientifically demonstrated by hundreds of reported studies. Prolonged abuse of alcohol is dangerous, impairing health and shortening life. Abstention is a risk factor to health and longevity. All this is succinctly illustrated by the J-shaped curve (see figure), based on the revelation known dramatically as the French paradox*.

Epidemiologic studies all through the developed world have demonstrated repetitively that moderate drinkers live longer and healthier (and probably happier) than do those who do not drink, and that both of these groups are much better off than those who drink too much. Identical results are found in Western Europe, Canada, the United States, Japan, Australia, New Zealand, Israel, Iceland, and elsewhere, in people of various ages, in both sexes, in blacks and whites. (The benefits of wine, however, are lessened in smokers, and may be increased for those who take aspirin prophylactically.) The major benefit is the reduction of heart attacks, our most common killer.

This phenomenon was termed "the French paradox" because researchers studied middle-aged and older Frenchmen, who, because they smoked too many cigarettes, ate foie gras and other supposedly unhealthy foods, and limited their exercise to bending their elbows, were expected to have a higher-than-average risk of heart attack. They were found, instead, when they drank moderately (chiefly red wine), to be more protected than similar populations of non-drinkers. Perhaps they were protected by what their elbow flexion brought to their mouths. In fact, this protection extends to arterial blood vessels other than those of the heartvessels that supply the brain and other organs. (The common form of stroke is also reduced by moderate drinking.)

Alcohol is a two-edged sword. Excessive drinking for many years causes many life-threatening ills, among them heart disease, hemorrhagic stroke, cancers of the liver and, especially in the company of smoking, of the mouth, throat, larynx, and esophagus. It is not clear whether drinking is associated with small increases in the risks of breast and colorectal cancers. (Alcohol is the only component of wine that may be harmful, but only in excess.)

The liver is the limiting organ, the canary of drinking, in setting safe limits. It is the organ to which the first damage of too much alcohol occurs. Continued abuse may lead to cirrhosis, often fatal. What are safe limits of drinking? Figuring on the liver as the safety alarm, one may estimate that a man may very safely consume an average of fourteen ounces of wine daily all his adult life. (I am referring to the medical safety of the drinker, not necessarily to his performance abilities, which vary widely.) He should not save his weeks allotment for weekends, thereby exceeding thresholds of defense.

Sex counts. Women are safe at only half the quatity of alcohol as men, probably because they possess ony half as much of the neutralising enzyme, alcohol dehydrogenase, in their stomachs as do men. So, when my wife and I dine, I get two-thirds of the bottle. Individuals vary.

Lets look at the likely mechanisms by which wine may enhance health, particularly cardiovascular health. Alcohol is thought to contribute about half the benefits. Wine also possess special attributes, not much shared with other potables, contained in the dozens of compounds we may call polyphenolic flavonoids. Several function as antioxidants, as well see of great significance in coronary protection, and thus far mainly theoretically in offering of protection against cancer. In protecting against cardiovascular disease, the alcohol and the phenolics work together. The phenolics (resveratrol and quercetin are the two best known) are largely derived from grape skins, so are in maximum concentration in red wines, which are fermented on the skins.

Atherosclerosis, the disease of the normally smooth inner lining of arteries (the intima or endothelium), may begin at relatively early age, but usually doesnt become apparent for years. Its engenderment depends on heredity, diet, smoking, metabolic disorders (e.g., elevated cholesterol, diabetes mellitus), and other factors, possibly including arterial infection. Low-density lipoprotein (LDL), the "bad cholesterol", is deposited in the intima, leading to degeneration, inflammation, roughening and narrowing. Blood flow slows. The coup de grÔce is blood-clot formation, obstructing the artery that had contracted to supply oxygen and nutrients to heart muscle or other tissue, resulting in death of the tissue, the heart attack or stroke.

Here is what wine does to help the poor blood vessels. It (mainly its alcohol) causes the liver to produce more high-density lipoproteins (HDLs), the "good cholesterol." HDLs are like trash collectors: they cart off the LDLs from sites in the walls of arteries, where they do their evil, and carry them to the liver for disposal via the bile. Because it is the oxidized form of LDLs that does the damage, the antioxidant properties of wine (mainly the phenolics) mollify the LDL attack. Wines alcohol and phenolics, especially when drunk with dinner, inhibit damaging blood clotting by several routes. Early but growing evidence suggests that wine may also restrict abnormal growth of the muscular walls. (We certainly dont want up-tight, muscle-bound blood vessels.)

It had naturally been assumed that the damage to various organs associated with abusive drinking was due directly to the toxicity of alcohol. New data, however, suggests that at least a significant portion of the malign effects of wretched excess is exerted through alcohols direct descendant, acetaldehyde. The first step in the breakdown of alcohol, mediated by alcohol dehydrogenase, converts the alcohol to acetaldehyde, a highly toxic material that promotes damaging oxidation and other adverse effects leading to diseases of the liver, brain, heart, and other organs, and to cancer. Ordinarily, acetaldehyde is neutralized very quickly, but, due to genetic variations in a portion of certain populations (east Asians, Puerto Ricans), many people accumulate acetaldehyde, so that they may be intolerant of any alcohol or at risk for the damages listed. Here, again, is a possible beneficial role for antioxidants.

Evidence is accruing that potables, wine in particular, may help prevent and eliminate a number of infections, notably those of the gastrointestinal tract. Of great recent interest are reports that wine counters infections of the stomach with Helicobacter pylori (H pylori), a bacterium that causes much of chronic gastritis, the majority of ulcers, and a number of stomach cancers. Like so many of these implications, it is too soon for solid conclusions. A more detailed discussion has been recently publishedFinkel H: Wine for thy stomachs sake. Wine News 24:16 (Aug/Sep) 1998. Of even more stunning potential importance is the growing suspicion that the disease of blood vessels that leads to millions of deaths and an enormous range of disability via heart attacks, strokes, amputations, and other catastrophes is contributed to by the same H pylori or other bacteria.

In an arena of similarly dramatic importance, evidence continues to appear suggesting that wines polyphenolic antioxidants may help to prevent and counter cancers. It has been reported that our friendly phenolics might protect against cancer by:

~Shielding DNA from oxidative damage (perhaps the oxidation is sometimes promoted by acetaldehyde);

~Inducing enzymes that protect against malignant mutation;

~Modulating carcinogenic inflammatory reactions;

~Promoting normal cellular differentiation and maturation;

~Inhibiting growth of cancer cells;

~Enhancing the effects of chemotherapy.

We are in the early days of understanding these mechanisms.

An exciting report published by ClÚmont, et al., in the highly reliable and critical journal, Blood, on August 1, 1998 (92:996-1002), demonstrated that resveratrol triggered a death cascade of cancer cells, while not harming normal cells.

Myriad other effects of wine consumption are incompletely explored. Some seem beneficial, some adverse, some just the stuff of jokes and epigrams.

I will close with our take-home lesson. With rare exception, mounting evidence indicates that moderate, regular consumption of wine, especially with meals, is beneficial to health and longevity. Abuse of alcohol is clearly damaging to the drinker, often to others. Absention is a likely risk factor. There is no substitute for individual assessment by ones knowledgeable physician.

Do not make the mistake of using wine as therapy. We should use it to enrich life, not to medicate it

*The basic information is comprehensively reviewed and fully referenced in Finkel HE: Wine and Health: a review and perspective. Journal of Wine Research 1996; 7:157-196 and in Finkel HE: In Vino Sanitas? Savage, MD: Society of Wine Educators, 1998.Tel: (301)7768569 Fax: (301) 776 8578

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