another study on alcohol and lower risk of death

[Guest guest]

A study on Medscape illustrates lower risk of death and protection

from various diseases (coronary heart disease, diabetes, hypertension,

congestive heart failure, stroke, dementia, Raynaud's phenomenon) from

moderate alcohol consumption, but most interesting to me was:

" The biologic mechanism whereby alcohol improves insulin sensitivity

appears to involve suppression of fatty acid release from adipose

tissue. "

Full text is copied below, but click the link to see some handy

graphs. Registration is free.

Dave

+++++++++++++++++++++++++

link:

http://www.medscape.com/viewarticle/562474

text:

Alcohol and Cardiovascular Health

H. O'Keefe MD, FACC; A. Bybee MD; Carl J. Lavie MD, FACC

J Am Coll Cardiol. 2007;50(11) ©2007 Elsevier Science, Inc.

Posted 09/10/2007

Abstract and Introduction

Abstract

An extensive body of data shows concordant J-shaped associations

between alcohol intake and a variety of adverse health outcomes,

including coronary heart disease, diabetes, hypertension, congestive

heart failure, stroke, dementia, Raynaud's phenomenon, and all-cause

mortality. Light to moderate alcohol consumption (up to 1 drink daily

for women and 1 or 2 drinks daily for men) is associated with

cardioprotective benefits, whereas increasingly excessive consumption

results in proportional worsening of outcomes. Alcohol consumption

confers cardiovascular protection predominately through improvements

in insulin sensitivity and high-density lipoprotein cholesterol. The

ethanol itself, rather than specific components of various alcoholic

beverages, appears to be the major factor in conferring health

benefits. Low-dose daily alcohol is associated with better health than

less frequent consumption. Binge drinking, even among otherwise light

drinkers, increases cardiovascular events and mortality. Alcohol

should not be universally prescribed for health enhancement to

nondrinking individuals owing to the lack of randomized outcome data

and the potential for problem drinking.

Introduction

It has long been recognized that the problems with alcohol relate not

to the use of a bad thing, but to the abuse of a good thing.

Abraham Lincoln[1]

Alcohol (ethanol) consumption is analogous to the proverbial

double-edged sword, and perhaps no other factor in cardiovascular (CV)

health is capable of cutting so deeply in either direction depending

on how it is used. Accumulating scientific evidence indicates that

light to moderate drinking done on a daily basis may significantly

reduce the risks of coronary heart disease (CHD) and all-cause

mortality. In contrast, excessive alcohol intake and binge drinking

are toxic to both the heart and overall health and are the third

leading cause of premature death among Americans.

The purpose of the present review is to: 1) outline the specific

benefits and risks of alcohol, and the threshold of intake at which

drinking becomes a health danger rather than an advantage; 2) detail

the mechanisms whereby alcohol confers cardioprotection; and 3)

discuss the ideal quantities, drinking patterns, and beverages, and

which individuals are most likely to benefit.

Alcohol and Health: The J-Shaped Curve

The health effects of ethanol are dependent on the amount of alcohol

consumed and the pattern of drinking. Most studies report J-shaped

curves, whereby light to moderate drinkers have less risk than

abstainers, and heavy drinkers are at the highest risk. A recent

meta-analysis of over 1 million individuals showed that consumption of

1 drink daily by women and 1 or 2 drinks daily by men was associated

with a reduction in total mortality of 18%.[2] On the other hand,

intakes of >2 drinks daily in women and 3 drinks daily in men were

associated with increased mortality in a dose-dependent fashion (Fig. 1).

Figure 1.

The possible CV benefits appear to be the most important health

effects of light to moderate drinking, with most studies showing CHD

risk reductions of approximately 30% to 35%.[3,4] In the INTER-HEART

study,[5] involving 27,000 patients from 52 countries, regular alcohol

consumption was associated with a reduced incidence of myocardial

infarction (MI) in both genders, and in all adult age groups. Light to

moderate drinking is associated with improved CV health in higher-risk

individuals, such as those with known CHD and/or diabetes, but it also

may reduce CV risk even in lower-risk individuals. A subgroup study

taken from the total cohort of 51,000 men in the Health Professionals

Follow-Up Study focused on the effects of alcohol in the 8,867 men

(mean age 57 years) who followed all 4 of the major healthy lifestyle

behaviors (abstention from smoking, maintaining a body mass index <25

kg/m2, exercising at least 30 min daily, and eating a healthy diet).

That study found that even in men who were already following a very

healthy lifestyle, the consumption of 1 or 2 drinks per day was

associated with a 40% to 50% decreased risk of MI (Fig. 2).[6]

Patients with hypertension also appear to benefit from moderate

alcohol consumption. In a recent 16-year longitudinal study of 11,711

hypertensive men, 1 drink per day reduced the risk of acute MI by

approximately 30%.[7] In contrast, alcohol increases blood pressure in

a dose-dependent fashion at intakes above 2 drinks daily, and

excessive ethanol intake is one of the most common reversible causes

of hypertension.[8] Acute ethanol exposure causes a negative inotropic

effect on the myocardium, and heavy alcohol use has been associated

with both declining ejection fraction and progressive left ventricular

hypertrophy.[9,10] Yet, light to moderate drinking has been associated

with a substantially reduced risk of congestive heart failure,

especially for those with CHD.[11] Light to moderate alcohol intake is

also associated with lower risks of both ischemic stroke (Fig.

3)[12,13] and dementia.[14] Consistent J-shaped curves demonstrate

increased risks for stroke, especially hemorrhagic stroke,[15] and

dementia at heavier levels of alcohol consumption.[12-15]

Figure 2.

Figure 3.

Studies indicate that alcohol, when used in moderation, has an

antiatherosclerotic effect. Investigators have reported that moderate

alcohol use is associated with a decreased atherosclerotic burden as

assessed by coronary angiography,[16] computerized tomography-detected

coronary calcium (Fig. 4),[17] and carotid ultrasound.[18] Moderate

alcohol intake has also been associated with a decreased incidence of

peripheral arterial disease.[10] Recent Data from the Framingham study

indicate that a J-shaped relationship even exists between alcohol

intake and Raynaud's phenomenon, whereby light to moderate drinkers

have a lower incidence of Raynaud's compared with abstainers or

heavier drinkers.[19]

Figure 4.

How Alcohol Confers Cardioprotection

Existing data suggest that light to moderate alcohol consumption

confers CV protection predominantly through enhancement of insulin

sensitivity, and elevation of high-density lipoprotein (HDL)

cholesterol; however, improvements in inflammation and abdominal

obesity may also be playing lesser roles in the apparent

alcohol-related cardioprotection.[20] Because these parameters are

interrelated via complex metabolic pathways, the exact contribution of

each is difficult to tease out statistically.[4,21] Alcohol intake

increases HDL levels in a dose-dependent fashion. For example, HDL

will rise about 5% with 1 drink per day and 10% with 2 to 3 drinks per

day.[4,22-24] The dose-dependent effect of alcohol on HDL contrasts

with the J-shaped relationship between alcohol and adverse health

outcomes. A recent cross-sectional study of 3,700 Russian individuals

between the ages of 18 and 75 years reported that 75% of male and 47%

of female Russians chronically consume excessive amounts of

alcohol.[25] Consequently, adults in Russia have significantly higher

mean levels of HDL cholesterol compared with other countries.[26]

Despite higher HDL levels, Russia has higher age-adjusted rates of CV

disease and all-cause mortality than Western Europe or the U.S..[25,26]

The 2007 American Diabetic Association guidelines state, " In

individuals with diabetes, light to moderate alcohol intake (1 or 2

drinks per day; 15 to 30 g alcohol) is associated with a decreased

risk of CV disease, which does not appear to be due to an increase in

HDL cholesterol " .[27] Consuming a moderate amount of alcohol, like

exercising aerobically, will increase insulin sensitivity and glucose

metabolism for the ensuing 12 to 24 h.[22,28] Randomized

placebo-controlled trials in nondiabetic individuals showed that 2

drinks per day will significantly lower fasting insulin and

postprandial insulin levels and increase insulin sensitivity.[23,24]

Ethanol, when consumed by diabetic patients in small to moderate

quantities with or immediately before the evening meal, has been shown

to substantially reduce the glucose excursion following the meal (Fig.

5).[22,28] The biologic mechanism whereby alcohol improves insulin

sensitivity appears to involve suppression of fatty acid release from

adipose tissue.[29] This reduction in fatty acids decreases substrate

competition in the Krebs cycle of skeletal muscles, thereby

facilitating glucose metabolism.[29]

Figure 5.

One or 2 drinks per day lowers triglycerides modestly (7% to 10%), but

alcohol consumption above 2 drinks per day increases triglycerides in

a dose-dependent fashion.[23,24] Individuals who consume light to

moderate amounts of alcohol on a daily basis have less abdominal

obesity than do nondrinkers, but those who consume more than 2 drinks

per day have increased abdominal obesity that rises in proportion to

the amount of alcohol consumed.[29,30] Intra-abdominal fat is strongly

linked with low HDL levels, insulin resistance, and inflammation,

suggesting that alcohol's health effects may in part be mediated by

its influence on abdominal obesity.[29]

The anti-inflammatory effects of light to moderate alcohol intake were

documented by reductions in C-reactive protein in a small randomized

controlled trial and a large observational study,[31,32] and in tumor

necrosis factor alpha, interleukin-6, and fibrinogen in other studies

(Fig. 6).[10,33]

Figure 6.

Consumption of wine, more so than beer or spirits, has been

independently associated with improvements in heart rate variability,

a marker of autonomic balance.[34] This augmentation of the vagal tone

could be a factor in improving CHD prognosis.[35]

Favorable Effects on Diabetes and Metabolic Syndrome

Alcohol, with its favorable effects on HDL, insulin action, and

inflammation, may be particularly beneficial for individuals with

abnormal glucose metabolism and/or insulin resistance. Recent studies

indicate that diabetes, prediabetes, or the metabolic syndrome is

present in approximately 1 of every 3 American adults[36] and 2 of 3

patients who present with symptomatic CHD.[37] Light to moderate

alcohol intake is associated with reductions in both the prevalence

and incidence of diabetes. A large meta-analysis of 370,000

individuals followed for 12 years showed a 30% reduction in new

diabetes in people who consumed 1 to 2 drinks per day (Fig. 7).[38]

Figure 7.

Moderate alcohol consumption is also associated with lower rates of

the metabolic syndrome. In a recent study of 1,966 men followed for 13

years, alcohol intake of approximately 1 drink daily was associated

with a 40% decreased risk of having the metabolic syndrome.[39] That

same study demonstrated a 39% risk-adjusted decrease in risk of CHD

events that was more apparent in those with the metabolic syndrome

than in those without it. Moderate alcohol intake is associated with

similar reductions in relative risk of CHD in diabetic and nondiabetic

cohorts; although superior reductions in absolute risk of CHD are seen

in diabetic patients owing to their higher overall event rates.[40]

Drinking Patterns, Beverage Choices

The ethanol itself, rather than a specific component of wine, beer, or

spirits, appears to be the major factor in conferring the health

benefits,[4,21] and most studies show equal protection from all types

of alcohol. Red wine, however, has been shown to have higher levels of

bioflavonoids (with antioxidant, antiplatelet, and antiendothelin-1

effects) compared with white wine and other forms of alcohol.[41]

Nevertheless, the developing consensus suggests that the specific

alcoholic beverage is less important than the quantity and pattern of

the alcohol intake.[42]

Studies of both men and women have shown that daily alcohol intake

provides superior health benefits compared with less frequent

consumption.[4,21,43-45] In one large study, a 37% decrease in CHD

risk was present for those who drank 5 to 7 days per week compared

with those who drank less than once per week.[4] This may be due to

the fact that the alcohol-induced favorable changes in insulin

sensitivity, HDL cholesterol, and inflammation are transient,

reverting back to baseline within 24 h.[43] Some studies show that

alcohol is most cardioprotective when consumed before or during a

meal;[44] the improvements in postprandial glucose metabolism noted

with light to moderate drinking lend biologic plausibility to this

finding.[22]

Although Mark Twain once quipped, " Everything in moderation, including

moderation, " studies indicate that even occasional immoderate drinking

presents a health risk. Binge drinking increases risk of MI, all-cause

mortality, and other adverse outcomes even among otherwise light

drinkers.[4,44-46] In the MONICA (Monitoring of Trends and

Determinants in Cardiovascular Disease) project, men who consumed & #8805;5

drinks per drinking day had a 2-fold increased risk for acute MI and

all-cause mortality compared with those who did not drink at all.[47]

In that same study, men who consumed 1 or 2 drinks daily had a 50%

reduction in risk of acute MI compared with abstainers.

Cardioprotective alcohol intake is generally defined as 1 or 2 drinks

per day for men and 1 drink per day for women.[2,4,27] A drink is

considered to be 12 oz beer, 5 oz wine, 1.5 oz 80-proof spirits, or 1

oz 100-proof spirits, all of which contain approximately 13 g to 15 g

ethanol.

Summary and Recommendations

The cumulative scientific evidence demonstrates concordant J-shaped

associations between alcohol intake and a variety of adverse health

outcomes. These data suggest that alcohol consumption, like exercise,

is most cardioprotective when done daily and in moderation.[29] It is

tempting, based on the current wealth of evidence, to recommend small

daily doses of alcohol (e.g., 1 drink per day) to nondrinkers with or

at high risk for CV disease. Guidelines for sensible drinking

developed in the United Kingdom state, " Middle-aged or elderly men and

postmenopausal women who drink infrequently or not at all may wish to

consider the possibility that light drinking may benefit their

health " .[42] We occasionally make this recommendation to patients well

known to us who have no personal or family history of substance abuse,

have no history of depression or bipolar disorder, and are nonsmokers.

However, light to moderate drinking cannot be universally recommended

to the general public or even patients with CV disease.

Despite convincing observational data and randomized trials using

surrogate end points suggesting that hormone replacement therapy in

women and antioxidant vitamins improved cardiovascular outcomes,

subsequent large randomized outcomes trials showed the opposite.[48]

Randomized trials of alcohol for improving clinical outcomes have not

been done, and residual unmeasured confounding factors could be

playing a role in the benefits associated with light to moderate

drinking in observational studies.[49-51]

Sobering statistics warn that moderate daily drinking is a slippery

slope that many individuals cannot safely navigate. Heavy drinking is

the source of much individual and societal suffering and morbidity;

and some studies suggest that alcohol abuse and binge drinking have

been on the rise over the past 15 years.[52] Alcohol abuse, the third

largest preventable cause of death, is responsible for killing more

than 100,000 Americans annually.[52] Excessive alcohol intake

increases the risks of motor vehicle accidents, stroke,

cardiomyopathy, cardiac dysrhythmia, sudden cardiac arrest, suicide,

cancer (most notably of the breast and gastrointestinal tract),

cirrhosis, fetal alcohol syndrome, sleep apnea, and all-cause

mortality.[44-46,52] The latest American Heart Association guidelines

caution people not to start drinking if they do not already drink

alcohol, because it is not possible to predict in which people alcohol

abuse will become a problem.[10] Until we have more randomized outcome

data, and tools for predicting susceptibility to problem drinking, it

would seem prudent to encourage physicians and patients to focus on

more innocuous interventions to prevent CHD.

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Acknowledgements

The authors thank Lori J. for her assistance in the preparation

of this manuscript and Neil Gheewala for assistance with data research.

Abbreviation Notes

CHD = coronary heart disease; CV = cardiovascular; HDL = high-density

lipoprotein; MI = myocardial infarction

Reprint Address

Dr. O'Keefe, 4330 Wornall Road, Suite 2000, Kansas City,

Missouri 64111. Email: jhokeefe@...

H. O'Keefe MD, FACC,* A. Bybee MD,* Carl J. Lavie MD, FACC†

*Mid America Heart Institute, University of Missouri, Kansas City,

Missouri; and the †Ochsner Medical Center, New Orleans, Louisiana.