Epidemiologists 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 don't 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.
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
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
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
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.