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Alcohol intake in relation to non-fatal and fatal coronary heart disease and stroke: EPIC-CVD case-cohort study

BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k934 (Published 29 May 2018) Cite this as: BMJ 2018;361:k934

Re: Alcohol intake in relation to non-fatal and fatal coronary heart disease and stroke: EPIC-CVD case-cohort study

Several recent large scale studies make the case for reducing current limits of alcohol consumption. However, by making blanket statements about all sources of alcohol, these studies are disregarding their own data that suggest that the effects of wine are different to other alcoholic drinks.

The study by Ricci et al [1] has shown that whereas stroke risk is increased with increasing consumption of alcoholic drinks other than wine, moderate amounts of wine (up to at least 20 g per day) are protective for CHD and neutral for risk of stroke . However, in their drinking recommendations, Ricci et al do not dissociate wine from other sources of alcohol and recommend considering a reduction in consumption of alcohol in all its forms. The data by Wood et al recently reported in the Lancet [2] are similar, also finding that unlike other forms of alcohol, wine has a neutral effect for stroke (HR 1.01; 95% CI 0.95- 1.07) in addition to its protective effect for CHD (HR 0.93; 95% CI 0.88-0.98). However Wood et al also recommend reconsidering general alcohol guidelines, a position that was endorsed in editorials in both the Lancet and the BMJ [3, 4] and widely reported in the media.

There are several possible reasons why drinking wine may be different to drinking other types of alcoholic drinks. Wine (especially red wine) contains high levels of antioxidant phenolics not found in other alcoholic drinks as well as the stilbene resveratrol. These substances have been linked to many beneficial effects on the cardiovascular system [5].

Secondly, the common way of drinking wine - in moderate amounts and with a meal - may be important. The study by Wood et al demonstrated that drinking alcohol on more than two occasions a week was linked to a reduced risk of mortality compared to less frequent drinking (see Supplementary data in [2]). Drinking a "Mediterranean drinking pattern" - moderate alcohol intake spread out over the week, a preference for red wine drunk with meals, little intake of spirits, and an avoidance of binge drinking - was linked to lower mortality compared to other drinking patterns [6], although the benefits specifically for cardiovascular disease were less clear [7]. These issues require urgent attention and this will need detailed analysis of drinking habits. The standard EPIC food frequency questionnaire used in the study by Ricci et al did not gather information on type of wine and also the data collected makes it difficult to distinguish between someone who consumes one or two glasses a day with a meal on a daily basis compared to someone who consumes all their alcohol during a binge at the weekend.

Given the contribution of cardiovascular disease to morbidity and mortality, lumping all forms of alcohol together risks throwing the baby (wine with a meal) out with the bathwater (other alcoholic drinks), and worsening not improving public health.

1. Ricci C, Wood A, Muller D, et al. Alcohol intake in relation to non-fatal and fatal coronary heart disease and stroke: EPIC-CVD case-cohort study. Bmj 2018;361:k934.
2. Wood AM, Kaptoge S, Butterworth AS, et al. Risk thresholds for alcohol consumption: combined analysis of individual-participant data for 599 912 current drinkers in 83 prospective studies. Lancet 2018;391(10129):1513-23.
3. Connor J, Hall W. Thresholds for safer alcohol use might need lowering. Lancet 2018;391(10129):1460-61.
4. Wise J. Study backs alcohol UK limit of six glasses of wine a week. Bmj 2018;361:k1630.
5. Vidavalur R, Otani H, Singal PK, et al. Significance of wine and resveratrol in cardiovascular disease: French paradox revisited. Exp Clin Cardiol 2006;11(3):217-25.
6. Gea A, Bes-Rastrollo M, Toledo E, et al. Mediterranean alcohol-drinking pattern and mortality in the SUN (Seguimiento Universidad de Navarra) Project: a prospective cohort study. The British journal of nutrition 2014;111(10):1871-80.
7. Hernandez-Hernandez A, Gea A, Ruiz-Canela M, et al. Mediterranean Alcohol-Drinking Pattern and the Incidence of Cardiovascular Disease and Cardiovascular Mortality: The SUN Project. Nutrients 2015;7(11):9116-26.

Competing interests: No competing interests

06 June 2018
Richard M Hoffman
Retired lecturer
Royston, UK