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Association of alcohol consumption with selected cardiovascular disease outcomes: a systematic review and meta-analysis

BMJ 2011; 342 doi: (Published 22 February 2011) Cite this as: BMJ 2011;342:d671

Lower CVD mortality and alcohol: is it what's in the drinks? Or something else?

With their exhaustive meta-analysis appearing in BMJ, Ronksley and
colleagues make an important contribution to our understanding of the
links between alcohol and cardiovascular disease (CVD) outcomes.(1) The
investigators show that drinkers of alcohol have significantly lower risks
of CVD-related mortality than nondrinkers. The implication is that
alcoholic beverages may provide CVD benefits. But is it the alcohol,
something else in the drinks, something else about drinking, or something
else entirely that matters?

Certainly the Ronskley team provides biological plausibility for an
alcohol effect in their second article from the same BMJ issue.(2)
According to that report, alcohol itself seems to favorably affect HDL, as
well levels of apoliprotein A1, fibrinogen, and adiponectin, irrespective
of whether that alcohol comes from beer, wine, or spirits.(2) And while
the Ronskley et al meta-analysis on CVD outcomes had insufficient data to
provide separate risk estimates for beer, wine, and spirits, it is likely
that all of these beverages confer some benefits due to their alcohol

To presume that the benefits of beer, wine, and spirits can be
reduced simply to alcohol content, though, probably does disservice to
these complicated beverages. Just as whole foods from plants provide
benefits with respect to CVD,(3, 4) one might expect that the juices and
fermentation products of grains, fruits, vegetables, and flowers (e.g.,
beer, wine, and spirits) would have vascular benefits. Indeed, past
research has demonstrated vascular benefits from the non-alcohol
components of alcoholic beverages;(5) constituents such as the
antioxidants and other phytochemicals may be particularly important.(6)

But perhaps the benefits of beer, wine, and spirits have less to do
with what is in the drinks themselves than how people incorporate these
drinks into their overall diets. For instance, perhaps sipping an
alcoholic beverage with a meal encourages a drinker to eat more slowly and
to eat less. Evidence suggests drinkers consume fewer carbohydrates and
fewer calories than non-drinkers.(7) And drinkers also have greater diet-
induced thermogenesis(8) and better glucose control(9) (which could lead
to better CVD outcomes downstream). Other beneficial effects of alcohol's
inclusion in the diet may include myriad food-alcohol interactions, the
likes of which are only beginning to be appreciated. (10) In fact, while
drinking with food may be a good thing, drinking without food may be
undesirable for CVD risk.(11)

There is also the possibility that the benefits of drinking alcoholic
beverages relate more to "the act of drinking" than to anything about the
alcohol-containing drinks themselves. For instance, alcohol often
accompanies social interaction. Could some of the measured benefits of
drinking be the benefits of interpersonal engagement or social support
(associated with better CVD outcomes in their own right)?(12, 13) Or
might moderate drinking indicate an individual's conscious attempts at
stress reduction? Certainly, people often drink to relax, and the
ceremony of drinking might bring on relaxation independent of alcohol's
sedating effects. (We know, for example, that heroin addicts can feel
better simply by injecting themselves with a needle--irrespective of
weather that needle contains water or actual heroin(14). Is it possible
drinkers might achieve a similar psychological benefit from performing the
act of drinking, irrespective of the drink?)

Regardless, what seems clear is that "how" you drink may be just as
important or more important than "what" you drink (or how much). For
instance, evidence suggests that regular moderate drinkers have better CVD
outcomes (despite higher overall consumption) than binge-drinkers (having
higher episodic consumption).(15) Is this the effect of merrily enjoying
regular meal-time glasses of wine with loved ones versus sullenly downing
pints on an empty stomach in some lonely pub? Hard to say. Perhaps
these issues relate to why the dose-response benefit for CVD outcomes that
Ronksley and colleague report peaks at 1-2 drinks daily?(1)

In the absence of evidence that accounts for many possible
confounders, I think we can probably say that taking time to relax and
regularly enjoy good food, moderate drink, and the company of loved ones
is a heart healthy activity. I'll certainly drink to that.

Nutrition enthusiast with no conflicts to disclose.

Sean C. Lucan, MD, MPH, MS

Department of Family and Social Medicine,
Montefiore Medical Center,
Albert Einstein College of Medicine,
1300 Morris Park Ave,
Mazer Building, Room 410,
Bronx, NY 10461,
Tel: (718) 430-3667,
Fax: (718) 430-8645,


1. Ronksley PE, Brien SE, Turner BJ, Mukamal KJ, Ghali WA.
Association of alcohol consumption with selected cardiovascular disease
outcomes: a systematic review and meta-analysis. BMJ 2011;342:d671.

2. Brien SE, Ronksley PE, Turner BJ, Mukamal KJ, Ghali WA. Effect of
alcohol consumption on biological markers associated with risk of coronary
heart disease: systematic review and meta-analysis of interventional
studies. BMJ 2011;342:d636.

3. Bazzano LA, He J, Ogden LG, Loria CM, Vupputuri S, Myers L, et al.
Fruit and vegetable intake and risk of cardiovascular disease in US
adults: the first National Health and Nutrition Examination Survey
Epidemiologic Follow-up Study. The American journal of clinical nutrition
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Fruit and vegetable intake and mortality from ischaemic heart disease:
results from the European Prospective Investigation into Cancer and
Nutrition (EPIC)-Heart study. European heart journal 2011.

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Effect of acute intake of red wine on flow-mediated vasodilatation of the
brachial artery. The American journal of cardiology 2001;88(12):1457-60,

6. Corder R, Douthwaite JA, Lees DM, Khan NQ, Viseu Dos Santos AC,
Wood EG, et al. Endothelin-1 synthesis reduced by red wine. Nature

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9. Shai I, Wainstein J, Harman-Boehm I, Raz I, Fraser D, Rudich A, et
al. Glycemic effects of moderate alcohol intake among patients with type 2
diabetes: a multicenter, randomized, clinical intervention trial. Diabetes
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10. Lands WE. Alcohol, calories, and appetite. Vitamins and hormones

11. Stranges S, Wu T, Dorn JM, Freudenheim JL, Muti P, Farinaro E, et
al. Relationship of alcohol drinking pattern to risk of hypertension: a
population-based study. Hypertension 2004;44(6):813-9.

12. Christenfeld N, Gerin W, Linden W, Sanders M, Mathur J, Deich JD,
et al. Social support effects on cardiovascular reactivity: is a stranger
as effective as a friend? Psychosomatic medicine 1997;59(4):388-98.

13. Greenwood DC, Muir KR, Packham CJ, Madeley RJ. Coronary heart
disease: a review of the role of psychosocial stress and social support.
Journal of public health medicine 1996;18(2):221-31.

14. Bourgois PI, Schonberg J. Righteous dopefiend. Berkeley:
University of California Press; 2009.

15. Ruidavets JB, Ducimetiere P, Evans A, Montaye M, Haas B, Bingham
A, et al. Patterns of alcohol consumption and ischaemic heart disease in
culturally divergent countries: the Prospective Epidemiological Study of
Myocardial Infarction (PRIME). BMJ 2010;341:c6077.

Competing interests: No competing interests

28 May 2011
Sean C. Lucan, MD, MPH, MS
Family Physician & Public Health Researcher
Albert Einstein College of Medicine / Montefiore Medical Center