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Clinical Crossroads
Clinician's Corner
May 26, 2010

A 42-Year-Old Man Considering Whether to Drink Alcohol for His Health

Author Affiliations

Author Affiliation: Dr Mukamal is Associate Professor of Medicine, Harvard Medical School, and Associate Physician, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

JAMA. 2010;303(20):2065-2073. doi:10.1001/jama.2010.550
Abstract

Alcohol consumption is widespread and, in excess, a leading cause of morbidity and mortality worldwide. At the same time, a consistent body of observational evidence has found that individuals who consume alcohol within recommended limits have a lower risk of coronary heart disease than do abstainers. These observations have led many to consider small amounts of alcohol as a cardioprotective strategy. Mr Q, a 42-year-old man who has consistently sought ways to preserve his health, is at a crossroads in his discussions with his physicians about the health effects of his regular, limited alcohol intake. The discussion reviews the epidemiology of drinking in the United States, the established effects of moderate alcohol intake on key pathophysiological biomarkers and pathways, the strengths and limitations of observational evidence linking alcohol intake to lower risk of coronary heart disease, other chronic diseases linked to moderate alcohol intake, and a framework in which Mr Q can discuss the potential risks and benefits of alcohol consumption with his physicians.

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    2 Comments for this article
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    For Enjoyment, But Not for Health
    Timothy S Naimi, MD, MPH | Boston Medical Center
    If Mr. Q is enjoying alcohol, is providing reliable information about his drinking, does not currently binge drink, and had no alcohol-related problems in college, then his drinking is not of clinical concern. However, we agree with the U.S. Dietary Guidelines that it is "not recommended that anyone begin drinking or drink more frequently on the basis of health considerations."(1) We support this recommendation based on the limitations of the evidence surrounding moderate drinking and based on practical considerations. These concerns supersede the particulars of Mr. Q's situation. Preventive interventions require the highest levels of evidence before adoption, and pharmaceuticals require randomized trials before FDA approval. Moreover, alcohol is a leading preventable cause of death and even low-dose alcohol can cause harm, including cancer. To date, there has been no randomized trial of low-dose alcohol and any mortality outcome, and reams of consistent observational studies can be consistently wrong. Observational data relating beta carotene, Chlamydia infection, vitamin E, hormone replacement therapy (HRT) to several health outcomes have been contradicted by randomized trials. HRT offers a particularly striking example since multiple well-done observational studies by the world's leading epidemiologists suggested 40% reductions in coronary heart disease (CHD).
    Confounding is more than a theoretical problem in observational alcohol studies in Western countries. Most traditional CHD risk factors are more prevalent among non-drinkers.(2,3) Moreover, moderate average alcohol consumption is also a marker of affluence, education, social advantage and good mental health,(2,4) none of which is plausibly caused by alcohol consumption itself. These psycho-socio-economic markers are, in turn, important determinants of CHD and death. Furthermore, in terms of the selection of observational study subjects, established moderate drinkers are likely different than non-drinkers who might be advised to drink by a provider or randomized to drink in a study: they chose to drink alcohol; tolerated or enjoyed its effects; did not die or stop drinking due to health or social problems (alcohol-related or otherwise); and continued to drink moderately until they were assessed. Finally, rates of binge drinking may be considerably lower among study participants than the general population,(5,6) and approximately one-quarter of U.S. adults who consume moderately based on average consumption also binge drink.(7) Since binge drinking is associated with a loss of any protective association with moderate average alcohol consumption (8,9) (average consumption is the exposure variable related to health outcomes in most studies), the associations observed in studies may not be generalizeable to the population.
    From a practical perspective, many people don't routinely visit health providers, and many who do are not screened adequately (or at all) for unhealthy alcohol use. Furthermore, most people overestimate the amount of alcohol that constitutes "moderate" consumption, and approximately half of current drinkers in the U.S. consume alcohol in excess of U.S. Dietary Guidelines levels.(10) Therefore, absent evidence from randomized trials and weighing the real-world implications of messages promoting alcohol consumption, we would best be served by implementing effective practices to reduce risky alcohol consumption among those who already drink.
    References:
    1. US Department of Agriculture and US Department of Health and Human Services. Dietary Guidelines for Americans, 2005 (chapter 9, alcoholic beverages). http://www.health.gov/dietaryguidelines/dga2005/document/html/chapter9.htm Accessed May 19, 2010.
    2. Naimi TS, Brown DW, Brewer RD, et al. Cardiovascular risk factors and confounders among nondrinking and moderate-drinking U.S. adults. Am J Prev Med. 2005;28:369-373.
    3. Wannamethee G, Shaper AG. Men who do not drink: a report from the British Regional Heart Study. Intl J Epidemiol. 1988;17:307-316.
    4. Hansel B, Thomas F, Pannier B, et al. European Journal of Clinical Nutrition; 2010: doi:10.1038/ejcn.2010.61.
    5. Jousilahti P, Veikko S, Kuulasmaa K, et al. Total and cause-specific mortality among participants and non-participants of population-based health surveys: a comprehensive followup of 54,372 Finnish men and women. J Epidemiol and Community Health. 2005;59:310-315.
    6. Rosengren A, Wilhelmsen L, Berglund G, et al. Non-participants in a general population study of men, with special reference to social and alcoholic problems. Acta Med Scand. 1987;221:243-51.
    7. Naimi TS, Brewer RD, Mokdad AH, et al. Binge drinking among U.S. adults. JAMA. 2003;289:70-75.
    8. McElduff P, Dobson AJ. How much alcohol and how often? Population based case-control study of alcohol consumption and risk of a major coronary event. BMJ. 1997;314:1159-1164.
    9. Roerecke M, Rehm J. Irregular heavy drinking occasions and risk of ishcemic heart disease: a systematic review and meta-analysis. Am J Epidemiol. 2010:DO1: 10.1093/aje/kwp1451.
    10. Fan AZ, Russell M, Naimi TS, al e. Patterns of alcohol consumption and the metabolic syndrome. J Clin Endocrinol Metab. 2008;93:3833-3838.
    AUTHORSHIP: Richard Saitz MD, MPH is co-author, affiliation is also Boston Medical Center; rsaitz@bu.edu
    DISCLOSURES: none for Drs. Naimi or Saitz
    CONFLICT OF INTEREST: None Reported
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    Alcohol and Cognitive function
    Peter M Clifton, MD, PhD | Baker IDI Heart and Diabetes Institute
    There have been several recent systematic reviews and meta analyses examining alcohol intake and cognitive function. A recent one from Anstey et al (2009) looked at 15 prospective studies and concluded that light to moderate drinkers compared with non drinkers had a 25-28% reduction in Alzheimers and vascular dementia. Peters et al (2008) did not find that alcohol protected against vascular dementia or cognitive decline although they did find a 37-43% reduction in the incidence of Alzheimers or any dementia in drinkers. The optimal dose of alcohol required for benefit was very unclear and ranged from one drink per month to more than 3 drinks per day. Solfrizzi et al (2007) found that light alcohol consumption (<15g of alcohol per day) slowed the rate of progression of mild cognitive impairment to dementia compared with abstaining while heavier alcohol consumption was not associated with an increased rate of progression. Alcohol intake did not appear to be related to the appearance of cognitive impairment in initially normal subjects. A population based study in Bordeaux found that consumption of 250-500ml of wine per day dramatically reduced the risks of Alzheimers disease and vascular dementia by 72-81% while light drinking (1-2 glasses/day) was less impressive (Letenneur 2004). In the Rotterdam study drinking 1-3 drinks/day significantly reduced the risks of any dementia and vascular dementia We can thus reassure the patient that his current level of alcohol intake will not harm his cognitive function in any way and may lower his risk of dementia in the future.
    Dr Clifton reports no potential conflicts of interest.
    Anstey KJ, Mack HA, Cherbuin N.Alcohol consumption as a risk factor for dementia and cognitive decline: meta-analysis of prospective studies.Am J Geriatr Psychiatry. 2009 Jul;17(7):542-55.
    Letenneur L. Risk of dementia and alcohol and wine consumption: a review of recent results.Biol Res. 2004;37(2):189-93.
    Peters R, Peters J, Warner J, Beckett N, Bulpitt C.Alcohol, dementia and cognitive decline in the elderly: a systematic review.Age Ageing. 2008 Sep;37(5):505-12. Epub 2008 May 16
    Solfrizzi V, D'Introno A, Colacicco AM, Capurso C, Del Parigi A, Baldassarre G, Scapicchio P, Scafato E, Amodio M, Capurso A, Panza F; Italian Longitudinal Study on Aging Working Group.Alcohol consumption, mild cognitive impairment, and progression to dementia. Neurology. 2007 May 22;68(21):1790-9.
    CONFLICT OF INTEREST: None Reported
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