Alcohol and mortality in British men: explaining the U-shaped curve

Alcohol consumption and the risk of nosocomial infection in general surgery

BACKGROUND

Alcohol consumption increases community-acquired infections and affects the immune system. The aim of this report was to analyse whether drinking increases the risk of nosocomial infection.

METHODS

This was a prospective study of 1505 patients admitted consecutively to a general surgical department. Alcohol consumption was assessed by a structured questionnaire. Postoperative infection was classified using the Centers for Disease Control criteria. Confounding was controlled for by logistic regression analysis, and the results were stratified by gender and drinking pattern.

RESULTS

Most women were light drinkers and no increased risk of postoperative infection was noted. In men, drinking was associated with a lower American Society of Anesthesiologists grade and fewer co-morbidities. Heavy alcohol consumption (more than 108 g/day) in men increased the rate of all-site nosocomial infection (adjusted odds ratio (OR) 2.51, 95 per cent confidence interval (c.i.) 1.06 to 5.96) and the rate of in-hospital surgical-site infection (SSI) (adjusted OR 2.16, 95 per cent c.i. 0.84 to 5.58). An intake of above 72 g/day increased the rate of lower respiratory tract infection (adjusted OR 5.22, 95 per cent c.i. 1.04 to 26.2). Alcohol consumption was not related to the rate of SSI after hospital discharge. When drinking was limited to weekends, there was no relationship with nosocomial infection.

CONCLUSION

Heavy alcohol consumption increased the risk of nosocomial infection in men who underwent general surgical procedures.

Diagnosis and treatment of alcohol dependence in older alcoholics

Treatment of alcohol dependence among older alcoholic patients should be multidimensional to address as many potential relapse factors as possible. As the literature suggests, alcohol-related disorders often are under diagnosed and under treated. More efforts are needed to identify and improve diagnosis of these disorders in older alcoholic patients. For better outcomes, age-specific programs should be implemented. Furthermore, when treating elderly patients, basic therapeutic principles like respect for privacy and a respectful attitude should be adopted. Adequate medical, pharmacologic, and psychiatric treatment should be provided when appropriate. Medication to reduce cravings should be considered in patients without contraindications to its use. Participation in individual, group, and family therapy and attendance at self-help group meetings such as AA should be encouraged (Table 8). Despite the lack of empiric testing to validate these recommendations in an elderly population, clinical experience suggests that adherence to these recommendations will benefit elderly patients just as it has the general adult population. Research is necessary to explore the benefits of alcohol treatments in elderly patients. Until then, adherence to these recommendations should be the best available approach.

Alcohol drinking as a predictor of intensive care and hospital mortality in general surgery: a prospective study

AIMS

To analyse whether alcohol drinking increases admission to intensive care and in-hospital mortality in general surgery.

DESIGN AND PARTICIPANTS

A prospective cohort study on a consecutive series of 1505 hospitalized patients in a Service of General Surgery of a tertiary hospital.

MEASUREMENTS

Drinking pattern was defined by quantity, frequency and volume of drinking. Information on relevant confounders was obtained: smoking, body mass index, nutritional status (measured by serum albumin), cholesterol and its fractions, severity of the underlying disease and all therapeutic measures. Multivariate logistic regression was applied to assess the relationship between drinking and both admission to intensive care and in-hospital death.

RESULTS

Twenty-nine (1.9%) patients died and 33 (2.1%) were admitted to the intensive care unit (ICU). Drinking was heavier in men, patients without antecedents of cancer, with lower preoperative risk assessment scores, number of co-morbidities and age and higher serum albumin levels. After adjusting for age, severity of underlying disease, smoking and serum albumin, male drinkers of 72+ g/day had an increased risk of being admitted to ICU, the effect being stronger for week-day drinking (odds ratio, OR = 8.48; 95% confidence interval, CI = 1.68-42.8). A significant association was also seen between week-day drinking (72+ g/day) and death in men (OR = 7.19, 95% CI = 1.43-36.1). Numbers for women were too small to evaluate.

CONCLUSION

Heavy drinking increases admission to intensive care and in-hospital mortality in hospitalized male patients undergoing general surgery procedures.

Alcohol consumption and risk of stroke: a meta-analysis

CONTEXT

Observational studies suggest that heavy alcohol consumption may increase the risk of stroke while moderate consumption may decrease the risk.

OBJECTIVE

To examine the association between alcohol consumption and relative risk of stroke.

DATA SOURCES

Studies published in English-language journals were retrieved by searching MEDLINE (1966-April 2002) using Medical Subject Headings alcohol drinking, ethanol, cerebrovascular accident, cerebrovascular disorders, and intracranial embolism and thrombosis and the key word stroke; Dissertation Abstracts Online using the keywords stroke and alcohol; and bibliographies of retrieved articles.

STUDY SELECTION

From 122 relevant retrieved reports, 35 observational studies (cohort or case control) in which total stroke, ischemic stroke, or hemorrhagic (intracerebral or total) stroke was an end point; the relative risk or relative odds and their variance (or data to calculate them) of stroke associated with alcohol consumption were reported; alcohol consumption was quantified; and abstainers served as the reference group.

DATA EXTRACTION

Information on study design, participant characteristics, level of alcohol consumption, stroke outcome, control for potential confounding factors, and risk estimates was abstracted independently by 3 investigators using a standardized protocol.

DATA SYNTHESIS

A random-effects model and meta-regression analysis were used to pool data from individual studies. Compared with abstainers, consumption of more than 60 g of alcohol per day was associated with an increased relative risk of total stroke, 1.64 (95% confidence interval [CI], 1.39-1.93); ischemic stroke, 1.69 (95% CI, 1.34-2.15); and hemorrhagic stroke, 2.18 (95% CI, 1.48-3.20), while consumption of less than 12 g/d was associated with a reduced relative risk of total stroke, 0.83 (95%, CI, 0.75-0.91) and ischemic stroke, 0.80 (95% CI, 0.67-0.96), and consumption of 12 to 24 g/d was associated with a reduced relative risk of ischemic stroke, 0.72 (95%, CI, 0.57-0.91). The meta-regression analysis revealed a significant nonlinear relationship between alcohol consumption and total and ischemic stroke and a linear relationship between alcohol consumption and hemorrhagic stroke.

CONCLUSIONS

These results indicate that heavy alcohol consumption increases the relative risk of stroke while light or moderate alcohol consumption may be protective against total and ischemic stroke.

Low prevalence of the metabolic syndrome in wine drinkers--is it the alcohol beverage or the lifestyle?

OBJECTIVE

To study how the intake of alcohol and the choice of wine, beer, and spirits is related to lifestyle factors and the metabolic syndrome in 60-y-old men and women.

DESIGN

Cross-sectional population based study.

SETTING

Stockholm County, Sweden.

SUBJECTS

Sixty-year-old men and women (n=4232).

RESULTS

Moderate intake of wine (10-30 g/day) was associated with a lifestyle characterized by being married, having a university education, being employed, being Swedish-born, having a good quality of life according to economy, leisure time and health, compared with a group with low alcohol intake. The opposite characteristics were seen among the non-drinkers. Drinkers of spirits were more often smokers and also reported higher intake of sausage and fried potatoes compared with a group with low alcohol intake. In women, the metabolic syndrome was significantly more common in non-drinkers (20%), P<0.05, and less common among wine drinkers (8%), P<0.01, compared with a group with low alcohol intake. After adjustments, a significant lower odds ratio for the metabolic syndrome were seen in wine drinkers in women (OR=0.60, P<0.05).

CONCLUSIONS

Compared with low alcohol drinkers, moderate wine drinkers exhibited a more favorable pattern according to both lifestyle factors and metabolic parameters. The close link between alcohol drinking behaviour and lifestyle habits illustrate the complex relationship between alcohol and health.

Roles of drinking pattern and type of alcohol consumed in coronary heart disease in men

BACKGROUND

Although moderate drinking confers a decreased risk of myocardial infarction, the roles of the drinking pattern and type of beverage remain unclear.

METHODS

We studied the association of alcohol consumption with the risk of myocardial infarction among 38,077 male health professionals who were free of cardiovascular disease and cancer at base line. We assessed the consumption of beer, red wine, white wine, and liquor individually every four years using validated food-frequency questionnaires. We documented cases of nonfatal myocardial infarction and fatal coronary heart disease from 1986 to 1998.

RESULTS

During 12 years of follow-up, there were 1418 cases of myocardial infarction. As compared with men who consumed alcohol less than once per week, men who consumed alcohol three to four or five to seven days per week had decreased risks of myocardial infarction (multivariate relative risk, 0.68 [95 percent confidence interval, 0.55 to 0.84] and 0.63 [95 percent confidence interval, 0.54 to 0.74], respectively). The risk was similar among men who consumed less than 10 g of alcohol per drinking day and those who consumed 30 g or more. No single type of beverage conferred additional benefit, nor did consumption with meals. A 12.5-g increase in daily alcohol consumption over a four-year follow-up period was associated with a relative risk of myocardial infarction of 0.78 (95 percent confidence interval, 0.62 to 0.99).

CONCLUSIONS

Among men, consumption of alcohol at least three to four days per week was inversely associated with the risk of myocardial infarction. Neither the type of beverage nor the proportion consumed with meals substantially altered this association. Men who increased their alcohol consumption by a moderate amount during follow-up had a decreased risk of myocardial infarction.

Migration within Great Britain and cardiovascular disease: early life and adult environmental factors

AIM

To examine the relative contributions of early life and adult life factors to risk of cardiovascular disease (CVD) in middle-aged men using migration within Great Britain (GB).

METHODS

Prospective study of 7,735 men (40-59 years) drawn from one group practice in each of 24 British towns. Zones of birth and/or examination: South of England and rest of GB (Midlands and Wales, North of England, and Scotland).

RESULTS

There were 1,392 coronary heart disease (CHD) events and 1154 cardiovascular deaths during 21.8 years mean follow-up. Regardless of birth zone, men examined in the South showed lower risk of CHD events and CVD mortality than those examined in the rest of GB. Migrants from South to rest of GB showed a small increase in cardiovascular risk. Men born and examined in the rest of GB showed the highest adjusted risk of CHD events (RR = 1.15, 95% CI: 0.96-1.38) and CVD mortality (RR = 1.28, 95% CI: 1.04-1.57). Men born in the rest of GB who moved to the South showed adjusted risks of CHD events and CVD mortality similar to those born and examined in the South. Zone of examination was more strongly associated with CHD events and CVD mortality than zone of birth (RR = 1.23 versus 0.95 for CHD; RR = 1.26 versus 1.04 for CVD mortality). Smokers, irrespective of zone of birth or examination, showed higher risk than non-smokers.

CONCLUSION

Factors in adult life appear to be dominant in determining cardiovascular risk in middle and older age although this does not exclude early life effects on cardiovascular risk.

Cross-sectional association between total level and type of alcohol consumption and glycosylated haemoglobin level: the EPIC-Norfolk Study

OBJECTIVE

To investigate the association between total level and type of alcohol consumed and glycaemia.

DESIGN

Cross-sectional study.

SETTING

The EPIC-Norfolk Study, a population-based cohort study of diet and chronic disease.

SUBJECTS AND METHODS

Non-diabetic men (n=2842) and women (n=3572), aged 40-78 y. Alcohol intake was assessed by self-reported questionnaire, and glycaemia measured by glycosylated haemoglobin (HbA(1c)).

RESULTS

Ten percent of men and 18% of women reported drinking no alcohol. Among drinkers, median alcohol intake was 8 units/week for men and 3 units/week for women. In analyses stratified by sex and adjusted for age, total energy intake, education, fruit and vegetable intake, smoking, family history of diabetes, physical activity, body mass index and waist:hip ratio, alcohol intake was inversely associated with HbA(1c) in men and women, although the association was stronger in women. A 1 unit/week increase in alcohol intake was associated with 0.0049% (s.e.=0.00223; P-value=0.028) and 0.017% (s.e.=0.00343; P-value <0.001) reduction in HbA(1c) in men and women respectively. In similar multivariate analyses, wine intake was inversely associated with HbA(1c) in men, and wine, spirits and beer intake were inversely associated with HbA(1c) in women. When also adjusted for total alcohol intake, only the association between wine intake and HbA(1c) in men remained significant.

CONCLUSION

Alcohol intake was associated with lower HbA(1c) level, an association not explained by confounding. The distinction between type of alcohol consumed was particularly important in men.

Alcoholic beverage preference, diet, and health habits in the UNC Alumni Heart Study

BACKGROUND

Moderate alcohol intake is related to better health, and additional benefits may be associated with wine. However, beverage preference may be confounded by lifestyle factors related to health.

OBJECTIVE

The goal was to describe the associations between alcoholic-beverage preferences and indicators of a healthy diet and other health habits.

DESIGN

This cross-sectional study included data from 2864 men and 1571 women enrolled in the UNC Alumni Heart Study. Self-reports of drinking habits were used as predictors of health behaviors and of intakes of nutrients and food groups.

RESULTS

Subjects who preferred wine had healthier diets than did those who preferred beer or spirits or had no preference. Wine drinkers reported eating more servings of fruit and vegetables and fewer servings of red or fried meats. The diets of wine drinkers contained less cholesterol, saturated fat, and alcohol and more fiber. Wine drinkers were less likely to smoke. Compared with all drinkers, those who drank no alcohol consumed fewer vegetables but more fiber. Nondrinkers were less likely to exercise regularly and had a higher mean body mass index. Controlling for income and education had little effect on these associations.

CONCLUSIONS

The apparent health benefits of wine compared with other alcoholic beverages, as described by others, may be a result of confounding by dietary habits and other lifestyle factors. Confounding by lifestyle variables could also be a factor in the previously observed health differences between drinkers and nondrinkers, although the evidence for this association is not as strong.

[Evolution of the mortality attributable to alcohol consumption in Catalonia, 1988-1997]

OBJECTIVE

To analyse the evolution of mortality attributable to alcohol (MAA) and the potential years of life lost (PYLL) due to alcohol consumption in Catalonia between 1988 and 1997.

DESIGN

Retrospective, descriptive study of mortality.

SETTING

Catalonia 1988-1997.

PARTICIPANTS

Residents in Catalonia. Main measurements. Deaths occurring in Catalonia for the 36 causes of MAA between 1988 and 1997 were studied. The MAA, proportional mortality and the PYLL for each year were calculated on the basis of the population fractions attributable to alcohol (FPAA). Evolution of proportional mortality was studied with the chi2 test for linear trends. Evolution of the MAA and the PYLL were studied through regression straights and Pearson s correlation coefficient.

RESULTS

5.5% of deaths in Catalonia between 1988 and 1997 were attributable to alcohol. Men contributed most deaths (65.8%) and PYLL (80%). Traffic accidents were the most common form of death in men (15.3%), and cerebro-vascular diseases (25.9%) in women. Traffic accidents caused most PYLL (43.3%). Both a steady reduction in proportional mortality, dropping from 6.2% in 1988 to 4.8% in 1997 (chi2=213.4; P<.00001), and a fall in the total MAA (P<.05) and PYLL (P<.05) were found.

CONCLUSIONS

There are gender differences in the numbers and most common causes of MAA. There was a steady drop in the number of MAA and PYLL during the period studied, basically due to the drop in deaths caused by traffic accidents. Similarly, proportional mortality dropped, drawing close to the 4% proposed in the Health Plan for Catalonia.

Alcohol consumption and nearly lethal suicide attempts

We conducted a case-control study of the association between nearly lethal suicide attempts and facets of alcohol consumption; namely, drinking frequency, drinking quantity, binge drinking, alcoholism, drinking within 3 hours of suicide attempt, and age began drinking. Subjects were 13-34 years of age. In bivariable analyses, all measures were associated with nearly lethal suicide attempts. Odds ratios ranged from 2.4 for alcoholism to 7.0 for drinking within 3 hours of attempt. All exposure variables except age began drinking exhibited a J-shaped relationship between alcohol exposure and nearly lethal suicide attempt. After controlling for potential confounders and other measures of alcohol exposure, drinking within 3 hours of attempt remained most strongly (odds ratios > 6) associated. Alcoholism remained significantly associated in most models, but at lower strength.

Lower risk for alcohol-induced cirrhosis in wine drinkers

Although there is a well-known relationship between total alcohol intake and future risk for cirrhosis, other factors such as the type of alcohol consumed are sparsely studied. The aim of this study was to assess the effects of wine compared with other types of alcoholic beverages on risk for alcohol-induced cirrhosis. In 3 prospective studies, 30,630 participants from the Copenhagen area were followed-up for a total observation time of 417,325 person-years. Information on weekly intake of beer, wine, and spirits, and sex, age, body mass index, smoking habits, and education was obtained from questionnaires. The primary outcome measures were first admission or death, with alcohol-induced cirrhosis obtained from death certificates and from the National Hospital Discharge Register. Data were analyzed by means of multiplicative Poisson regression models. We confirmed the increasing risk for cirrhosis with increasing alcohol intake. Individuals who drank more than 5 drinks per day had a relative risk of 14 to 20 for developing cirrhosis compared with non- or light drinkers. However, compared with individuals who drank no wine (relative risk set at 1.0), individuals drinking 16% to 30% wine of their total intake had a relative risk of 0.4 (95% confidence limits, 0.3-0.6) and those drinking 51% or more of wine had a relative risk of 0.3 (95% confidence limits, 0.2-0.5) for developing cirrhosis. In conclusion, the results suggest that a high intake of all 3 types of alcohol conveys an increased risk for cirrhosis, but wine drinkers are at a lower risk than beer and spirits drinkers.

Alcohol volume, drinking pattern, and cardiovascular disease morbidity and mortality: is there a U-shaped function?

The health effects of a binge pattern of alcohol consumption have not been widely investigated. The objective of this study was to evaluate the cardiovascular consequences of binge drinking (consumption of eight or more drinks at one sitting) and usual (nonbinge) drinking in a longitudinal, population-based study. Data obtained from 1,154 men and women aged 18-64 years interviewed in Winnipeg, Manitoba, Canada, in 1990 and 1991 were linked to health care utilization and mortality records. Using an 8-year follow-up period, the authors performed separate Cox proportional hazards regression analyses for men and women on time to first event for physician visits, hospitalizations, and deaths due to coronary heart disease, hypertension, and other cardiovascular disease. Binge drinking increased the risk of coronary heart disease in both men (hazard ratio (HR) = 2.26, 95% confidence interval (CI): 1.22, 4.20) and women (HR = 1.10, 95% CI: 1.02, 1.18). It increased the risk of hypertension in men (HR = 1.57, 95% CI: 1.04, 2.35) but not in women. Binge drinking had no effect on the risk of other cardiovascular disease. In contrast, usual drinking had significant cardioprotective effects in both men and women. Thus, the harmful effects of binge drinking on cardiovascular disease morbidity and mortality can be disaggregated from the protective effects of usual drinking at various levels of consumption.

Taking up regular drinking in middle age: effect on major coronary heart disease events and mortality

AIM

To examine effects of taking up regular drinking by middle aged non-drinkers and occasional drinkers on major coronary heart disease events and total mortality.

METHODS

A prospective study of 7735 men from general practices in 24 British towns screened in 1978-80 at age 40-59 years (Q1). Five years after screening, 7157 men then aged 45-64 completed postal questionnaires (Q5) on changes in alcohol intake.

RESULTS

In 6503 men without diagnosed coronary heart disease, there were 874 major coronary heart disease events and 1613 total deaths during 16.8 years of follow up after Q5. With stable occasional drinkers as baseline, men who continued to drink regularly had a significantly lower risk of major coronary heart disease events, coronary heart disease mortality, and overall cardiovascular mortality, but a slightly increased risk of non-cardiovascular mortality. New regular drinkers (89% light), even after adjustment for their many advantageous characteristics, showed a lower risk of major coronary heart disease events than stable occasional drinkers (relative risk (RR) = 0.70; 95% confidence interval (CI) 0.48 to 1.03; p = 0.07). New drinkers showed no reduction in coronary heart disease or cardiovascular mortality and experienced an increase in risk of non-cardiovascular mortality (RR = 1.40; 95% CI 0.99 to 1.97; p = 0.06). In 654 men with diagnosed coronary heart disease, new drinkers experienced no mortality benefit compared with stable occasional drinkers.

CONCLUSIONS

Middle aged new regular drinkers experienced lower risk of major coronary heart disease events than stable occasional drinkers or non-drinkers, but had increased risk of non-cardiovascular mortality and total mortality. These findings provide little support for encouraging older men who do not drink or who only drink occasionally to take up regular drinking, whether or not they have coronary heart disease.

Effects of depression and social integration on the relationship between alcohol consumption and all-cause mortality

AIMS

This study was designed to assess the potentially confounding influences of social integration and depression on the form of the relationship between alcohol consumption and all-cause mortality. DESIGN, PARTICIPANTS AND MEASUREMENT: Respondents from the 1984 US National Alcohol Survey (N = 5177) were followed by searching the National Death Index (NDI) through 1995; 540 were identified as deceased. Predictor variables in a Cox proportional hazards model included gender, ethnicity, marital status, income, smoking, age and alcohol consumption (volume and patterns). Two social variables and their interactions with alcohol consumption were added, the Center for Epidemiological Studies Depression (CES-D) scale and an eight-item social isolation scale.

FINDINGS

The J-shaped risk curve for all-cause mortality by volume was approximated for men but not significantly for women. In addition heavy drinking occasions independently contributed to mortality in men. Low social integration (bottom 12%) had no significant effects on mortality or on the relationship between alcohol consumption and mortality curve. Inclusion of the interaction between alcohol consumption and depression proved significant for heavy male drinkers (> six drinks on average per day) and for female former drinkers with heavy drinking occasions. In both cases, the respective subgroup, which additionally was depressed, had about four times the risk of a life-time abstainer.

CONCLUSIONS

The relationship of alcohol consumption to 11-year all-cause mortality in a general population indicated little confounding effect of social isolation, but revealed important interactions with depression for heavy male drinkers and heavy female ex-drinkers.

Physical activity and risk of cancer in middle-aged men

A prospective study was carried out to examine the relationship between physical activity and incidence of cancers in 7588 men aged 40-59 years with full data on physical activity and without cancer at screening. Physical activity at screening was classified as none/occasional, light, moderate, moderately-vigorous or vigorous. Cancer incidence data were obtained from death certificates, the national Cancer Registration Scheme and self-reporting on follow-up questionnaires of doctor-diagnosed cancer. Cancer (excluding skin cancers) developed in 969 men during mean follow-up of 18.8 years. After adjustment for age, smoking, body mass index, alcohol intake and social class, the risk of total cancers was significantly reduced only in men reporting moderately-vigorous or vigorous activity; no benefit seen at lesser levels. Sporting activity was essential to achieve significant benefit and was associated with a significant dose-response reduction in risk of prostate cancer and upper digestive and stomach cancer. Sporting (vigorous) activity was associated with a significant increase in bladder cancer. No association was seen with colo-rectal cancer. Non-sporting recreational activity showed no association with cancer. Physical activity in middle-aged men is associated with reduced risk of total cancers, prostate cancer, upper digestive and stomach cancer. Moderately-vigorous or vigorous levels involving sporting activities are required to achieve such benefit.

Effects of alcohol reduction on blood pressure: a meta-analysis of randomized controlled trials

Alcohol drinking has been associated with increased blood pressure in epidemiological studies. We conducted a meta-analysis of randomized controlled trials to assess the effects of alcohol reduction on blood pressure. We included 15 randomized control trials (total of 2234 participants) published before June 1999 in which alcohol reduction was the only intervention difference between active and control treatment groups. Using a standard protocol, information on sample size, participant characteristics, study design, intervention methods, duration, and treatment results was abstracted independently by 3 investigators. By means of a fixed-effects model, findings from individual trials were pooled after results for each trial were weighted by the inverse of its variance. Overall, alcohol reduction was associated with a significant reduction in mean (95% confidence interval) systolic and diastolic blood pressures of -3.31 mm Hg (-2.52 to -4.10 mm Hg) and -2.04 mm Hg (-1.49 to -2.58 mm Hg), respectively. A dose-response relationship was observed between mean percentage of alcohol reduction and mean blood pressure reduction. Effects of intervention were enhanced in those with higher baseline blood pressure. Our study suggests that alcohol reduction should be recommended as an important component of lifestyle modification for the prevention and treatment of hypertension among heavy drinkers.

Factors influencing the relation between alcohol and mortality--with focus on wine

The impact of alcohol intake on mortality has been described in a large number of prospective population studies from many countries. Most have shown a J-shaped relation between alcohol intake and subsequent mortality, indicating that there are both beneficial and harmful effects of ethanol on health. In exploring the French paradox, it has been suggested that wine may have beneficial effects additional to that of ethanol. Recently, several prospective population studies have supported this idea. However, it is also likely that the apparent additional beneficial effect of wine on health is confounding.

Alcohol consumption and hemostatic factors: analysis of the Framingham Offspring cohort

BACKGROUND

Moderate alcohol consumers have lower rates of cardiovascular disease than abstainers. One proposed mechanism is a beneficial effect on hemostatic parameters, but previous studies have provided conflicting results.

METHODS AND RESULTS

We measured levels of fibrinogen, plasma viscosity, von Willebrand factor, factor VII, plasminogen activator inhibitor antigen-1, and tissue plasminogen activator antigen in a cross-sectional analysis of 3223 adults free of cardiovascular disease enrolled in the Framingham Offspring Study. We assessed their alcohol consumption with a standardized questionnaire. Light-to-moderate alcohol consumption was associated with lower levels of fibrinogen, plasma viscosity, von Willebrand factor, and factor VII. This association was most pronounced for consumers of 3 to 7 drinks weekly for viscosity and 7 to 21 drinks weekly for the other hemostatic measures. Alcohol intake of 7 to 21 drinks weekly or more was associated with impaired fibrinolytic potential, reflected by higher levels of plasminogen activator inhibitor antigen-1 and tissue plasminogen activator antigen. Wine drinkers had lower plasminogen activator inhibitor antigen-1 levels than other drinkers, particularly at 3 to 21 drinks weekly, but beverage type did not otherwise consistently affect the results.

CONCLUSIONS

Light-to-moderate alcohol consumption is associated with lower levels of coagulatory factors, but higher intake is associated with impaired fibrinolytic potential. These findings are consistent with the hypothesis that a balance between hemostatic and fibrinolytic activity may contribute to the complex relation of alcohol use with coronary heart disease.

Alcohol and mortality: if you drink, do not forget fruits and vegetables

Moderate amounts of alcohol may have cardioprotective effects. Several studies reported a higher protection by the consumption of wine. The favorable effects of wine have been attributed to different polyphenolic compounds, among others. However, these biochemical compounds are also found in other beverages. In view of the present evidence, there is no "right" or "wrong" drink, only a "right" and "wrong" drinking behavior regarding absolute amounts, drinking frequency, and accompanying lifestyle and eating pattern.

Weight change, body weight and mortality: the impact of smoking and ill health

OBJECTIVES

This paper examines the influence of cigarette smoking and ill health on the relationship between weight change, body weight and subsequent mortality to determine whether weight loss and leanness in middle to older age is deleterious to health.

METHODS

Men aged 40-59 years at screening drawn from one general practice in each of 24 British towns, who completed a questionnaire 5 years after screening (Q5) and provided full information on changes in weight and smoking status (n = 7065) were then followed up for an average of 13.8 years.

RESULTS

In all men a shallow U-shaped relationship was seen between body mass index (BMI) at Q5 and all-cause mortality rates. Weight loss and substantial weight gain (> or =10%) were associated with increased mortality rates compared to the stable weight group. The increased risk associated with weight loss was seen in long- term non-smokers (n = 4101) and recent ex-smokers (n = 722) but not in current smokers (n = 2242) after adjustment for a wide range of potential confounders. However, the increased risk was markedly attenuated after exclusion of those with ill health (relative risk [RR] = 1.16, 95% CI : 0.84-1.59 and RR = 0.79, 95% CI : 0.29-2.20 for long-term non-smokers and recent ex-smokers, respectively). Moderate weight gain (4-10%) was associated with lower risk of mortality than observed in those with stable weight but only in recent ex-smokers and in current smokers, not in long-term non-smokers. A positive association was seen between BMI at Q5 and all-cause mortality in non-smokers and this was strengthened by exclusion of men with weight loss.

CONCLUSION

The increased risk of mortality associated with weight loss or low body weight in middle-aged and older men appears to be a direct consequence of ill health leading to weight loss and leanness. In healthy non-smoking men weight loss and leanness are not associated with increased mortality and moderate weight gain (4-10%) was neither deleterious nor beneficial.

Mortality in England and Wales attributable to current alcohol consumption

STUDY OBJECTIVE

To estimate the number of deaths attributable to current alcohol consumption levels in England and Wales by age and sex.

DESIGN

Epidemiological approach using published relative risks and population data.

SETTING

England and Wales.

MAIN OUTCOME MEASURES

Numbers of deaths by age and sex and years of life lost for alcohol related conditions.

RESULTS

Because of the cardioprotective properties of alcohol, it is estimated that there are approximately 2% fewer deaths annually in England and Wales than would be expected in a non-drinking population. This proportion varies greatly by age and sex and only among men aged over 55 years and women aged over 65 years is there likely to be found a net favourable mortality balance. It is also estimated that there were approximately 75 000 premature years of life lost in England and Wales in 1996 attributable to alcohol consumption. The main causes of alcohol attributable mortality among the young include road traffic fatalities, suicide and alcoholic liver disease.

CONCLUSIONS

At a population level, current alcohol consumption in England and Wales may marginally reduce mortality. However, the benefit is disproportionately found among the elderly. Estimating alcohol attributable mortality by age and sex may be a useful indicator for developing alcohol strategies. More research into the possible effect modifications of pattern of consumption, beverage type, age and gender will enable these estimates to be improved.

Alcohol, aging, and cognitive performance in a cohort of Japanese Americans aged 65 and older: the Kame project

OBJECTIVE

To investigate the effects of light to moderate alcohol consumption on cognitive performance.

DESIGN AND SETTING

A cross-sectional analysis including older Japanese Americans in King County, WA, enrolled in the Kame Project, a population-based study of cognition, dementia, and aging.

PARTICIPANTS

1,836 cognitively intact participants aged 65 and older who participated in the baseline (1992-1994) examination.

MEASUREMENT

Cognitive performance was measured using the Cognitive Abilities Screening Instrument, reaction time (simple and choice), and a measure of vocabulary (North American Adult Reading Test).

RESULTS

Multivariate analyses were used to examine the relationship between cognitive performance and alcohol consumption at baseline with men and women together and then separately controlling for age, education, smoking, history of stroke, angina, hypertension, diabetes, and coronary heart disease. Findings showed lower cognitive test scores were observed for men who were either abstainers or in the heavy drinking group. For women, a linear relationship between alcohol consumption and cognitive performance was seen on two of the four measures of cognitive functioning. No significant difference in the association of drinking and cognitive function was identified within the different Japanese American subgroups.

CONCLUSION

RESULTS suggest a possible positive relationship between light to moderate drinking and cognitive performance in an aging Japanese American population. Additional long-term prospective and cross-cultural studies are needed to determine the generalizability of these findings to other aging cohorts.

Effect of alcohol consumption on systemic markers of inflammation

BACKGROUND

Epidemiological studies suggest that light to moderate alcohol intake is associated with lower all-cause mortality than abstention or heavy alcohol intake, primarily through reduced risk of coronary heart disease. The underlying mechanisms are incompletely understood.

METHODS

We investigated the association between alcohol consumption (assessed by a 7-day food record) and concentrations of C-reactive protein (CRP), alpha1-globulins, alpha2-globulins, albumin, and transferrin, and leucocyte count in a sample of 2006 men and women aged 18-88 years participating in a national health survey carried out in former West Germany in 1987-88. Analyses were based on 781 men and 995 women with complete data.

FINDINGS

Among men, alcohol consumption showed a U-shaped association with mean values of CRP (p for linear term 0.65, for quadratic term 0.048), alpha1-globulins (p=0.20, 0.0006), alpha2-globulins (p=0.82, 0.31), and leucocyte count (p=0.51, 0.26) even after adjustment for age, smoking, body-mass index, HDL and LDL cholesterol, history of hypertension, education, and income. There were inverted U-shaped associations between the negative acute-phase reactants albumin (p=0.41, 0.006) and transferrin (p=0.14, 0.28) and alcohol intake. In women, the associations were less strong for CRP (p=0.35, 0.31), leucocyte count (p=0.28, 0.15), and transferrin (p=0.86, 0.83). Concentrations of alpha1-globulins and alpha2-globulins were inversely related to alcohol consumption, and albumin showed a positive association with increasing alcohol intake in women.

INTERPRETATION

Non-drinkers and heavy drinkers had higher CRP concentrations than moderate drinkers. In view of the robust association between markers of inflammation, especially CRP, and risk of coronary heart disease, an anti-inflammatory action of alcohol could contribute to the link between moderate consumption and lower cardiovascular mortality.

Average volume of alcohol consumption, patterns of drinking, and all-cause mortality: results from the US National Alcohol Survey

The objective of this study was to investigate the effects of an average volume of alcohol consumption and drinking patterns on all-cause mortality. The sample (n = 5,072) was drawn from the 1984 National Alcohol Survey, representative of the US population living in households. Follow-up time was until the end of 1995, with 532 people deceased during this period. The authors found a significant influence of drinking alcohol on mortality with a J-shaped association for males and an insignificant relation of the same shape for females. When the largest categories of equivalent average volume of consumption were divided into people with and without heavy drinking occasions, serving as an indicator of drinking pattern, this differentiation proved important in predicting mortality. Light to moderate drinkers had higher mortality risks when they reported heavy drinking occasions (defined by either eight drinks per occasion or getting drunk at least monthly). Similarly, when the category of exdrinkers was divided into people who did or did not report heavy drinking occasions in the past, people with heavy drinking occasions had a higher mortality risk. Finally, indicating alcohol problems in the past was related to higher mortality risk. Results emphasized the importance of routinely including measures of drinking patterns into future epidemiologic studies on alcohol-related mortality.

Nutritional and health benefits of beer

Physicians should be aware of the growing evidence supporting the nutritional and health benefits of moderate consumption of alcohol as part of a healthy lifestyle. The recently approved voluntary label on wine ("the proud people who made this wine encourage you to consult your family doctor about the health effects of wine consumption") implies that physicians should promote wine as the preferred source of dietary alcohol. However, studies evaluating the relative benefits of wine versus beer versus spirits suggest that moderate consumption of any alcoholic beverage is associated with lower rates of cardiovascular disease. From a nutritional standpoint, beer contains more protein and B vitamins than wine. The antioxidant content of beer is equivalent to that of wine, but the specific antioxidants are different because the barley and hops used in the production of beer contain flavonoids different from those in the grapes used in the production of wine. The benefits of moderate alcohol consumption have not been generally endorsed by physicians for fear that heavy consumers may consider any message as a permissive license to drink in excess. Discussions with patients regarding alcohol consumption should be made in the context of a general medical examination. There is no evidence to support endorsement of one type of alcoholic beverage over another. The physician should define moderate drinking (1 drink per day for women and 2 drinks per day for men) for the patient and should review consumption patterns associated with high risk.

Alcohol consumption, Type 2 diabetes mellitus and impaired glucose tolerance in middle-aged Swedish men

AIMS

To investigate the association between alcohol consumption and impaired glucose tolerance and Type 2 diabetes mellitus.

METHODS

A population-based cross-sectional study consisting of 3,128 Swedish men, aged 35-56 years. Oral glucose tolerance testing identified 55 cases of Type 2 diabetes and 172 cases of impaired glucose tolerance. Information on alcohol consumption, family history of diabetes, smoking and physical activity was obtained by questionnaire.

RESULTS

After adjustment for family history, smoking, physical activity and body mass index, the odds ratio of diabetes was 2.1 (95% confidence interval (CI) 1.0-4.5) in men with high consumption of alcohol (corresponding to over 12 drinks per week) and 0.7 (0.3-1.8) in moderate consumers (7-12 drinks), compared to occasional drinkers. For impaired glucose tolerance, the corresponding odds ratios were 0.7 (0.5-1.1) and 0.6 (0.4-1.0), respectively. Separate analyses for type of beverage indicated that high consumers of beer, spirits and wine had an odds ratio for diabetes of 2.9 (1.2-6.9), 3.3 (1.4-7.8) and 1.2 (0.5-2.7), respectively.

CONCLUSIONS

The results indicated that high consumption of alcohol increases the occurrence of Type 2 diabetes and that this may primarily concern consumption of beer and spirits. For impaired glucose tolerance, regular alcohol consumption was associated with a reduced prevalence, particularly at moderate levels.

Alcohol consumption and risk of coronary heart disease by diabetes status

BACKGROUND

An inverse association between moderate alcohol consumption and coronary heart disease (CHD) has been observed in several epidemiological studies. To assess whether a similar association exists among diabetics, we examined the relation between light to moderate alcohol consumption and CHD in men with and without diabetes mellitus in a prospective cohort study.

METHODS AND RESULTS

A total of 87 938 US physicians (2790 with diagnosed diabetes mellitus) who were invited to participate in the Physicians' Health Study and were free of myocardial infarction, stroke, cancer, or liver disease at baseline were followed for an average of 5.5 years for death with CHD as the underlying cause. During 480 876 person-years of follow-up, 850 deaths caused by CHD were documented: 717 deaths among nondiabetic men and 133 deaths among diabetic men. Among men without diabetes at baseline, the relative risk estimates for those reporting rarely/never, monthly, weekly, and daily alcohol consumption were 1.00 (referent), 1.02, 0. 82, and 0.61 (95% CI 0.49 to 0.78; P for trend <0.0001) after adjustment for age, aspirin use, smoking, physical activity, body mass index, and history of angina, hypertension, and high cholesterol. Among men with diabetes at baseline, the relative risk estimates were 1.00 (referent), 1.11, 0.67, and 0.42 (95% CI 0.23 to 0.77; P for trend=0.0019).

CONCLUSIONS

These results suggest that light to moderate alcohol consumption is associated with similar risk reductions in CHD among diabetic and nondiabetic men.

Health-associated changes in drinking: a period prevalence study of the Atherosclerosis Risk In Communities (ARIC) cohort (1987-1995)

BACKGROUND

Several investigators have suggested that drinking cessation occurs because of poor health which may bias studies on the benefit or risk of alcohol consumption.

METHODS

Drinking status, level of alcohol consumption, and two measures of health (perceived health and physician diagnosed chronic disease status) were determined from exams 1 (1987-1989) and 3 (1993-1995) on 12,562 African- and European-American participants, who were aged 45-64 years at exam 1 in the ARIC Study. For those in good health at exam 1, logistic regression analyses were used to model the association between health decline and drinking change at exam 3.

RESULTS

Among the total population, drinking cessation was significantly more common among those who reported poor health at exam 3, and nondrinkers were unlikely to begin drinking regardless of exam 3 health. Using different measures of health status resulted in associations whose strength and significance varied with ethnicity and, in some cases, by gender.

CONCLUSION

While the current data do not prove that the health decline occurred prior to drinking cessation, our findings support the hypothesis that poor health results in drinking changes which could potentially bias studies of alcohol's benefit and risk even when lifetime abstainers are used as the reference group.

The relation between alcohol and cardiovascular disease in Eastern Europe: explaining the paradox

BACKGROUND

Recent evidence from Eastern Europe of a positive association between alcohol and cardiovascular disease has challenged the prevailing view that drinking is cardioprotective. Consuming amounts of alcohol comparable to those consumed in France has been linked to detrimental cardiovascular effects. One possibility is that this could be related to the particular consequences of binge drinking, which is common in Russia.

METHODS

A systematic review of literature on the relation between cardiovascular disease and heavy drinking and irregular (binge) drinking.

RESULTS

Most existing reviews of the relation between alcohol and cardiovascular disease have examined the amount drunk per week or month and have not looked at the pattern of drinking. These have consistently shown that alcohol has a cardioprotective effect, even at high levels of consumption. In contrast, studies that have looked at pattern of drinking, either directly, or indirectly, using indicators such as frequency of hangovers or reports of the consequences of drunkenness, have consistently found an increased risk of cardiovascular death, particularly sudden death. A separate review of the physiological basis for a difference between regular heavy drinking and heavy binge drinking demonstrates that the two types of drinking have quite different effects.

CONCLUSION

An association between binge drinking and cardiovascular death meets the standard criteria for causality. It is important that future studies of alcohol related harm examine the pattern of drinking as well as the amount drunk.

Beneficial effect of moderate alcohol consumption on vascular disease: myth or reality?

Moderate ethanol consumption (1-3 drinks/day on 5-6 days/week) has a favourable effect on vascular disease-related mortality and morbidity [especially ischaemic heart disease (IHD)]. This cardioprotective effect may be due to significant effects on cardiovascular risk factors such as high density cholesterol (HDL) concentration (HDL protects from IHD) and an inhibition of platelet aggregation (increased platelet aggregability predicts coronary events). In contrast, alcoholics and problem drinkers have an excess of IHD-related, and possibly stroke-related, mortality. Excessive alcohol intake may raise the blood pressure. Prolonged alcohol abuse can also result in alcoholic heart muscle disease. Alcohol is the major cause of non-ischaemic cardiomyopathy in Western society. Although there is a widespread belief that red wine protects more than other alcoholic beverages, several studies do not support this interpretation.

Light-to-moderate alcohol consumption and the risk of stroke among U.S. male physicians

BACKGROUND

Several studies have shown U- or J-shaped relations between alcohol consumption and the risk of stroke. We evaluated the effect of light-to-moderate alcohol intake on the risk of stroke, with separate analyses of ischemic stroke and hemorrhagic stroke.

METHODS

Our analyses were based on a prospective cohort study of 22,071 male physicians, 40 to 84 years old, who were participating in the Physicians' Health Study. At base line, the participants reported that they had no history of stroke, transient ischemic attack, or myocardial infarction and were free of cancer. Alcohol intake, reported by 21,870 participants at base line, ranged from none or almost none to two or more drinks per day.

RESULTS

During an average of 12.2 years of follow-up, 679 strokes were reported. As compared with participants who had less than one drink per week, those who drank more had a reduced overall risk of stroke (relative risk, 0.79; 95 percent confidence interval, 0.66 to 0.94) and a reduced risk of ischemic stroke (relative risk, 0.77; 95 percent confidence interval, 0.63 to 0.94). There was no statistically significant association between alcohol consumption and hemorrhagic stroke. The overall relative risks of stroke for the men who had one drink per week, two to four drinks per week, five or six drinks per week, or one or more drinks per day were 0.78 (95 percent confidence interval, 0.59 to 1.04), 0.75 (95 percent confidence interval, 0.58 to 0.96), 0.83 (95 percent confidence interval, 0.62 to 1.11), and 0.80 (95 percent confidence interval, 0.64 to 0.99), respectively, in an analysis in which we controlled for major risk factors for stroke.

CONCLUSIONS

Light-to-moderate alcohol consumption reduced the overall risk of stroke and the risk of ischemic stroke in men. The benefit is apparent with as little as one drink per week. Greater consumption, up to one drink per day, does not increase the observed benefit.

Moderate alcohol consumption: the gentle face of Janus

OBJECTIVES

The regular consumption of alcohol in moderate amounts (defined in North America as up to 2 drinks per day for men and 1 drink per day for females) has been recognized in the last decade as a negative risk factor for atherosclerosis and its clinical sequelae: coronary heart disease (CHD), ischemic stroke, and peripheral vascular disease. Mortality and morbidity attributable to CHD are 40-60% lower in moderate drinkers than among abstainers. Among the mechanisms accounting for these reductions, increased circulating concentrations of HDL-cholesterol and inhibition of blood coagulation appear to be paramount. Additional benefits are, in certain beverages, conferred by the presence of constituents other than alcohol (e.g., flavonoids and hydroxystilbenes), which prevent oxidative damage, free radical formation, and elements of the inflammatory response.

CONCLUSIONS

A number of other diseases appear to be beneficially modulated by moderate alcohol consumption based on epidemiologic surveys and, in some instances, experimental evidence. These include duodenal ulcer, gallstones, enteric infections, rheumatoid arthritis, osteoporosis, and diabetes mellitus (type II). Compared with abstainers, moderate drinkers exhibit improved mental status characterized by decreased stress and depression, lower absenteeism from work, and decreased incidence of dementia (including Alzheimer's disease). Although limits of safe drinking have been conservatively defined, it is regrettable that political considerations are hampering the clinical application of this knowledge and its dissemination to the lay public.

Type of alcohol and mortality from cardiovascular disease

Many epidemiological studies have described a U-shaped relation between alcohol intake and all-cause mortality (Boffetta and Garfinkel, 1990; Fuchs et al., 1995; Gronbaek et al., 1994; Marmot et al., 1981). Most researchers attribute the 'U' to a combination of beneficial and harmful effects of ethanol itself. It has, on the other hand, been explained as an artefact due to misclassification or confounding (Shaper et al., 1998). Most of the studies of the effect of total alcohol intake have found that the descending leg of the curve mainly is attributable to death from cardiovascular disease (Rimm et al., 1991; Stampfer et al., 1988). Until recently, most studies addressed the effect of the three beverages taken together as ethanol. Studies of the correlation between wine intake per capita in different countries and incidence of ischaemic heart disease gave rise to the hypothesis that there is a a more beneficial effect of wine than of beer and spirits. Leger et al., Renaud and de Lorgeril and later Criqui and Rigel found an inverse relation between incidence rates of ischemic heart disease and wine consumption in different countries, but no such relation for the other types of beverages (Criqui and Rigel, 1994; Leger et al., 1979; Renaud and de Logeril, 1992).

Alcohol consumption and disability pension among middle-aged men

PURPOSE

To analyze the relation between alcohol consumption and the risk of disability pension among middle-aged men.

METHODS

In the mid-seventies, complete birth-year cohorts of middle-aged male residents in Malmö, Sweden, were invited to participate in a general health survey. The 3751 men with complete data who constituted the cohort in this study were followed for 11 years. Alcohol consumption was estimated from the scores obtained from a test designed to identify subjects with alcohol related problems.

RESULTS

Of the 498 men granted disability pension during follow-up, 48 stated to be teetotalers. The cumulative incidence of disability pension among teetotalers was 19%, whereas, it was 12% and 16%, respectively, among men with low and high alcohol consumption. The adjusted relative risk (RR) for acquiring a disability pension (using the group with low alcohol consumption as reference) was 1.8 among abstainers and 1.3 among men with high alcohol consumption.

CONCLUSIONS

Alcohol overconsumption, as well as teetotalism, showed a positive relation to disability pension, and a moderate alcohol intake was found to be beneficial with respect to the risk of future disability pension.

Alcohol consumption and non-Hodgkin lymphoma in a cohort of older women

We investigated the relation of alcohol consumption to risk of non-Hodgkin's lymphoma (NHL) in a cohort of 35 156 Iowa women aged 55-69 years who participated in the Iowa Women's Health Study in 1986. Alcohol consumption at baseline was obtained using a mailed questionnaire. During the 9-year follow-up period, 143 incident cases of NHL were identified. Higher alcohol consumption was significantly associated with a decreased risk of NHL (P-trend = 0.03). Compared to non-drinkers, multivariate-adjusted relative risks (RRs) were decreased for women with intake of < or = 3.4 g day(-1) (RR = 0.78; 95% confidence interval (CI) 0.51-1.21) and > 3.4 g day(-1) (RR = 0.59; 0.36-0.97). The inverse association could not be attributed to one particular type of alcoholic beverage, although red wine (RR = 0.21 for > 2 glasses per month vs non-drinker; 0.05-0.86; P-trend = 0.02) has the most distinct effect. The apparent protective effect was universal regardless of specific NHL grade or Working Formulation subtype, but was most pronounced for nodal NHL (RR = 0.48; 0.26-0.90; P-trend = 0.01) and low-grade NHL (RR = 0.52; 0.21-1.26; P-trend = 0.05). These data suggest that moderate alcohol consumption is inversely associated with the risk of NHL in older women and the amount of alcohol consumed, rather than the type of alcoholic beverages, appears to be the main effect determinant.

Type of alcoholic drink and risk of major coronary heart disease events and all-cause mortality

OBJECTIVES

This study examined the effects of beer, spirits, and wine drinking on coronary heart disease (CHD) events (fatal and nonfatal) and all-cause mortality.

METHODS

Men aged 40 to 59 years (n = 7735) were drawn at random from one general practice in each of 24 British towns and followed up for an average of 16.8 years.

RESULTS

Regular drinkers showed a significantly lower relative risk of CHD, but no all-cause mortality, than occasional drinkers, even after adjustment for potential confounders. The benefit for CHD of regular drinking was seen within both beer drinkers and spirit drinkers but not among men who reported wine drinking. However, all men who reported wine drinking (both occasional and regular) showed significantly lower age-adjusted risks of CHD and all-cause mortality than men drinking beer or spirits; beer and spirit drinkers showed similar risks.

CONCLUSIONS

The findings suggest that regular intake of all alcoholic drinks is associated with a lower risk of CHD, but not all-cause mortality, than occasional drinking. A large part, but not all, of the greater benefit seen in wine drinkers relative to other drinkers can be attributed to advantageous lifestyle characteristics (e.g., low rates of smoking and obesity).

Alcohol intake and cardiovascular morbidity and mortality

Recent studies reinforce the consistent finding of a J-shaped inverse association between alcohol and cardiovascular disease morbidity and mortality, primarily as a result of the underlying association between alcohol and coronary heart disease. The most plausible mechanism behind this effect is through increases in high-density lipoprotein cholesterol. All types of alcoholic beverage reduce the risk of cardiovascular disease, suggesting that ethanol is responsible for the protective effect.

Fibrinogen: a possible link between alcohol consumption and cardiovascular disease? DESIR Study Group

The relation between alcohol consumption and fibrinogen concentration was evaluated in a French population to investigate whether fibrinogen could explain part of the relation between alcohol consumption and cardiovascular disease. Cross-sectional data on self-reported alcohol consumption and fibrinogen, measured by the immunonephelometric method, of 4967 men and women aged 30 to 64 years were used. These subjects were volunteers for a free health checkup in the western central part of France from 1994 to 1996 and participated in the DESIR Study (Data from an Epidemiological Study on the Insulin Resistance syndrome). Alcohol consumption was strongly associated with fibrinogen concentration, with higher concentrations in those who were nondrinkers or who drank >60 g of alcohol per day. This U-shaped association was stronger among men than women. Consumption of wine and spirits was associated with fibrinogen, whereas consumption of beer or cider was not. Furthermore, smoking was positively associated with fibrinogen concentration, and in men the difference between nondrinkers and drinkers with the lowest fibrinogen level was higher in nonsmokers and ex-smokers than in current smokers. We conclude that moderate drinking may lower fibrinogen concentration. If fibrinogen is a causal risk factor for cardiovascular disease, it may be 1 of the variables that explain the protective effect of moderate alcohol consumption on cardiovascular disease.

Confounded by confounding: separating association from causation

Health-care professionals need to be able to distinguish causal relationships from simple associations in two main areas: when unravelling the aetiology of diseases, and when assessing the effects of therapies. In each of these the presence of confounding can seriously mislead. This short report explains the nature of confounding and outlines criteria that can be applied to help distinguish causality from mere statistical associations.

The J-shaped curve and changes in drinking habit

The accepted interpretation of the J-shaped curve relating alcohol intake to mortality or coronary heart disease is that the lowest point on the curve (light/moderate drinking) represents optimum exposure to alcohol and that the increased risk in non-drinkers reflects the consequence of sub-optimum exposure. However, non-drinkers, both ex-drinkers and lifelong teetotallers, consistently show an increased prevalence of conditions likely to increase morbidity and mortality compared with occasional or light drinkers. In addition, regular light drinkers tend to have characteristics extremely advantageous to health. Changes take place in alcohol intake in individuals over time, with a strong downward drift from heavy or moderate drinking towards non-drinking, affected to a considerable extent by the accumulation of ill health. Reduction in alcohol intake or giving up drinking is associated with higher rates of new diagnoses than remaining stable in alcohol intake and also with higher rates of both cardiovascular and non-cardiovascular mortality. The use of non-drinkers as a baseline, and failure or inability to adequately take into account the characteristics of subjects in the different alcohol intake categories, exaggerates the risk of coronary heart disease events and all cause mortality in non-drinkers and the benefits of light/moderate alcohol intake.