Should doctors prescribe wine?

Epidemiologists have known for many years the inverse association between ethanol consumption and heart disease. Only recently, however, have most physicians and the general public become aware of the degree of protection that moderate consumption provides for a variety of cardiovascular diseases, especially for two of the leading causes of death throughout the developed world: coronary heart disease (CHD) and stroke. Of the mechanisms of such effect, an increase in the protective HDL-cholesterol from ethanol is probably most important. In addition to its effects on lipids, increasingly we are finding that the moderate consumption of wine or other alcoholic beverages favorably affects many factors in the clotting and thrombolytic processes, effects that are transitory, implying that regular drinking is most important.

Interactions of Alcohol and Other Dietary Factors

Some data indicates that many of the antioxidants and other phenolic compounds in alcoholic beverages (especially red wine) are better absorbed or become more biologically active in the presence of ethanol. Of particular interest is the recent report from the Nurses' Health Study that while higher levels of folate were associated with less CHD, the protection was much greater among drinkers than among abstainers. The risk of CHD was reduced by only about 15% among non-drinkers but by almost 80% among women consuming 15 g/day or more of ethanol. In the Lyon Diet Heart Study, wine consumption predicted blood levels of vitamin E better than vitamin E intake. These and other studies suggest that moderate consumption may enhance dietary components of a healthy life-style.

Adverse Effects of Alcohol

We are all aware of the adverse effects of excessive or irresponsible consumption. Alcoholics are at increased risk of certain upper digestive cancers and liver cancer, but these are not diseases that occur in light-to-moderate drinkers. The only cancer that may relate to even moderate drinking is breast cancer in women, and some analyses suggest that there may be a 10% increase in risk for each drink per day a woman consumes. However, we recently reported results among the 5,000 women who have been followed in the Framingham Study for 25-45 years. With repeated assessments of the women's drinking habits and complete detection of breast cancers, we found no increased risk of breast cancer for total ethanol or for beer, wine, or spirits consumption among these generally light-to-moderate drinking women. If there is an increase in risk with drinking, it is probably very slight (and may not be present for wine consumption). Further, even in studies such as the Nurses' Health Study that have shown an increase in risk of breast cancer with ethanol consumption, recent research has shown that adequate dietary folate intake protects against this increase in risk.

The Bottom Line: Alcohol Consumption and Total Mortality

Regardless of increases or decreases in the risk of specific diseases, what is the bottom line? Is someone more likely or less likely to die of any cause during a specified period of time if he or she drinks? We recently had a report by Thun, et al from an American Cancer Society study of almost 500,000 people in the U.S. For both men and women, the lowest death rates were among the individuals reporting 1-2 drinks per day; in these groups, death rates were 21% lower than those of nondrinkers.

In the Copenhagen Heart Study, that followed over 13,000 men and women for more than ten years, it was shown that reducing moderate drinking in a population might actually increase mortality. In that study, drinkers who stated that they averaged 1-6 drinks/week had about 35% lower death rates than non-drinkers; heavy drinkers had higher death rates. During follow up in this study, there were 2,229 deaths. The investigators looked at the excess deaths in each category of consumption that could be attributed to ethanol abuse. They used death rates for individuals with consumption of 1-6 drinks per week as the referent group, the group with the lowest death rates in this study, and calculated the number of excess deaths (of any cause) that could be attributed to consumption that was either more or less than this amount. For both men and women, the excess deaths that were attributed to excess were less than those attributed to no intake (leading to much greater risks of cardiovascular diseases in such people). Th e investigators estimated that if all consumers of 7 or more drinks per week decreased their consumption to 1-6/week, there would have been 117 fewer deaths. On the other hand, if the entire population had stopped drinking, they estimated that there would have been 447 additional deaths. This suggests that our efforts to reduce consumption among heavy drinkers, irresponsible drinkers, and alcoholics should focus on abuse, and should not discourage moderate use.

Applications to the U.S. Population

My colleagues and I are currently carrying out analyses using U.S. Government death rates to estimate what would be the net health effects for non-drinking Americans at ages 45-75 if they should begin to consume alcoholic beverages at a level of up to 1 drink per day for women and up to 2 drinks per day for men. We realized that, even if encouragement to consume alcoholic beverages would not be given to former abusers or those with health or religious reasons not to drink, some such individuals who began to drink moderately might become abusers, thereby increasing their risk of death from cirrhosis, alcohol-related cancers, or accidents or violence related to excessive abuse. While we do not know what percentage of new drinkers might become abusers, data from the Framingham Study suggest that it would be less than 3%. However, among men, even if we estimate that 5% of non-drinkers who start drinking became abusers, we still see a lower risk of dying over the next 10 years if a non-drinker begins to consume th an if he remains an abstainer! For men at high risk of heart disease on the basis of increased blood pressure or cholesterol, or from cigarette smoking, the potential benefits from moderate consumption are much greater.

In general, women are at lower risk for heart disease at each age than men; further, there is the possibility that even moderate drinking might increase slightly their risk of breast cancer (we estimated a 10% increase in breast cancer risk for one drink/day and 30% increase for becoming an abuser). Our results indicate that at ages 45 and 55 for women, consumption is estimated to have only minimal effects on survival (if 5% of such women become abusers). At ages 65 and 75, we see reductions in risk of death to be associated with drinking, even for those women who are at high risk for breast cancer. And for women who still smoke cigarettes or have elevated cholesterol or blood pressure, the protective effects on survival from beginning to consume alcohol are greater.

Should Physicians Prescribe Moderate Alcohol for Non-Drinking Patients?

Are we at the point when physicians should start encouraging certain non-drinking adults to begin to consume small amounts for the health benefits? The most-recent version of the "Report on Sensible Drinking" from the Department of Health in the United Kingdom stated regarding adults who are non-drinkers, "While some people do no wish to take up drinking, for religious or other reasons, or there may be medical grounds for them not to do so (and such individuals should make other life-style changes to improve health and lower the risk of CHD), middle aged or elderly men and post-menopausal women who consume infrequently (less than one unit per day) or not at all may wish to consider the possibility that light usage might benefit their health."

Obviously, physicians would not advise moderate drinking to a former abuser, to pregnant women, or to others who should not drink or do not wish to drink for any reason. And physicians must always be sensitive to the problems of abuse. But I believe that physicians should discuss consumption with every patient. For those who are drinking in excess or in an unhealthy manner, advise them of the current evidence that small amounts on a regular basis may be better for their health. And for appropriate patients who drink only occasionally or not at all, encouraging a glass of wine with dinner every evening may be the best advice you can give them. By failing to give such patients scientifically sound, balanced advice about the potential health benefits of moderate use, as well as the adverse effects of excessive or inappropriate use, physicians may be doing their patients a disservice. (Italics ours-Ed.)

(Dr. Ellison is affiliated with the Boston University School of Medicine. His remarks were presented at the 207th quarterly dinner of The Society of Medical Friends of Wine. His remarks also were printed in The Society's Bulletin.)

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