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.

Studies produce consistent results

The theories to explain 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-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. For example, after consuming alcohol, the platelets are less sticky for 24-48 hours, then they go back to their usual state or they may even become abnormally sticky and more likely to cause a blood clot. 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. And the risk of dying from a heart attack was reduced even further for drinkers who had had something to drink in the previous 24 hours.

What counts is when you drink it

These results suggest that you should consume alcohol on a regular basis, perhaps daily. Unfortunately, most Americans 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, so their platelets and endothelium never show the rebound effect that may relate to increased risk of CHD. It is not the amount that you drink, but when you drink it that is important in preventing CHD. Further, it may be especially important when wine is drunk with meals rather than on an empty stomach. 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 wine consumption with meals every day, but only a few drinks each day.

Abstinence is an important risk factor

There are a number of other ways in which alcohol favourably affects risk of CHD. They include beneficial effects on glucose and insulin levels, which may reduce the risk of diabetes. Also, part of the protection that post-menopausal women get from moderate drinking may relate to an increase in oestrogen levels, which tends to lower their risk of osteoporosis and fractures as well as CHD. From all the available research data, we have to conclude that abstinence from alcohol is an important risk factor for CHD.

Wine, beer or spirits?

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, improve endothelial function, and have other effects that should reduce heart disease risk. For example, we have considerable data 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. In some studies, 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. Luckily, we have a number of studies from the animal laboratory supporting an added protection for wine.

This article is based on Dr Curtis Ellison's paper, An Update on Wine, Alcohol and Health? presented to the 1st World Congress of Young Wine Lovers in Lisbon, Portugal in June 1998.

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 breast cancer 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. Also, we know that women in Italy, France and Spain consume up to ten times as much wine as women in the UK, Ireland and the US, yet their rates of breast cancer are actually somewhat lower. I appreciate that there may be many confounding lifestyle habits in these comparisons, but real questions still remain about the relation between alcohol and breast cancer. A large number of studies are now underway, and I hope we will soon have a better understanding of this important concern.

But if we have something that reduces the risk of dying from one condition but increases the risk of another, we 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. We recently had a report from a very large survey by the American Cancer Society in the US of the effects on the risk of dying according to alcohol consumption. There was a significant reduction of more than 20% in mortality rates for men and women who reported consuming an average of one or two drinks per day, when compared with non-drinkers. 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.

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. And what I have described here suggests that from the point of view of public health, we should not decrease moderate use.

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.

During follow up, there were 2,229 deaths. Gronbaek et al looked at the excess deaths that could be attributed to alcohol. They used death rates for individuals with alcohol consumption of one to six drinks per week as the referent group, the group with the lowest death rates in this study, and calculated the number of excess deaths (from any cause) that could be attributed to alcohol consumption that was either more or less than this amount. For men, the excess deaths attributed to alcohol include a number of deaths in heavy drinkers, 16, 30 and 37 for men reporting that they consumed on average 28-41 drinks per week, 42-69 drinks per week, or what is the equivalent of 10 or more drinks per day; but 53 deaths in men were attributed to not drinking alcohol. For women, almost all of the deaths related to alcohol were due to abstinence from alcohol, due primarily to excess heart disease deaths among abstainers. These investigators estimated the total number of deaths they would expect given theoretical distributions of death in their cohort: if all consumers of seven or more drinks per week decreased their consumption to one to six per week, their data suggested that there would have been 117 fewer deaths. On the other hand, if the entire population had been warned about the evils of alcohol so much that they all stopped drinking entirely, they estimated that there would have been 447 additional deaths. The reduction in deaths from alcohol abuse would have been much less than the increase in deaths from CHD that would be expected if all moderate drinkers stopped drinking entirely. Whatever we do to reduce alcohol consumption among heavy drinkers, irresponsible drinkers and alcoholics, 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 have carried out preliminary analyses Showing that even if up to 5% of patients being encouraged to consume a little alcohol on a regular basis (an unrealistically high estimate), we stil found that for all women from age 55 (regardless of breast cancer risk) 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%. 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 alcohol. 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.