Critique 189: Importance of drinking pattern on the effects of wine on health — 26 July 2016
Boban M, Stockley C, Teissedre P-L, Restani P, Fradera U, Stein-Hammer C, Ruf J-C. Drinking pattern of wine and effects on human health: why should we drink moderately and with meals? Food Funct 2016;7:2937–2942. DOI:10.1039/c6fo00218h
Conclusions of epidemiological studies examining the effects of alcoholic beverages on human health may be unclear and limited if they do not take into account drinking pattern parameters such as beverage type, regular moderate versus binge drinking and drinking with or without meals. This review considers different aspects of drinking patterns and effects on human health with special attention to wine. We particularly discuss the potential underlying mechanisms for epidemiological evidence that the beneficial effects of wine are more evident if consumed with food.
In this context, we address the effects of food on blood alcohol concentration and acetaldehyde production in the gastrointestinal tract, the role of wine components and uric acid in counteracting the detrimental effects of postprandial oxidative stress, as well as wine’s antimicrobial properties and its potential to act as a digestive aid. In addition to its biological correlates, drinking patterns with regard to different socio-cultural circumstances in different populations are also considered. In order to avoid confusion and misconceptions in the general population because of the hormetic associations of wine with human health, it is important that all medical and scientific information concerning the effect of wine consumption on human health are evidence-based and communicated in a competent, credible and unbiased manner.
In conclusion, we propose several practical recommendations concerning wine consumption and consumer information to minimize the risks of alcohol-related harm and to encourage individual responsibility and a healthy lifestyle.
Note on Potential Conflict of Interest: While several of the authors of this paper are members of our Forum, they have had no input into the review of the article.
While this brief review article does not report new data, it presents a very well-thought-out appraisal of how the pattern of alcohol (especially wine) consumption may affect its risks and benefits regarding health. The pattern includes the type of beverage, consumption with meals, regular moderate versus binge drinking, cultural effects, etc. It is recognized that some of the authors of this publication work primarily with wine; however, the article covers key behaviors that affect the relation of all types of alcohol consumption to health. Members of the Forum consider that these aspects of alcohol consumption are especially important when one is considering individual or population-based guidelines regarding drinking.
There are considerable data showing that heavy drinking and binge drinking are associated with a large number of adverse health effects, both for the individual and for society. However, it is now clear from observational epidemiologic studies, animal experiments, and limited human clinical trials that moderate amounts of wine and other types of alcohol may have beneficial health effects, especially in lowering the risk of cardiovascular disease and total mortality. The type of beverage that one drinks, and especially how it is consumed, help determine whether alcohol consumption has net positive or negative heath effects.
The health effects of phenolic substances, in addition to alcohol, that are present in wine: The authors of this review propose that the non-alcoholic components of wine, especially phenols, decrease oxidation and increase the beneficial effects of alcohol in protecting against disease. Numerous studies by Renaud and colleagues have demonstrated the beneficial effects of wine on coagulation and on cardiovascular disease (e.g., Renaud & de Lorgeril 1992; Renaud & Gueguen 1998; Renaud et al 1999). Indeed, many epidemiologic studies have shown that regular wine drinkers tend to have better health outcomes than consumers of other beverages. Some of these benefits may come from socio-economic and behavioral factors (especially the pattern of drinking), but experimental data also indicate that some of these benefits relate to the non-alcoholic components of wine.
In addition to the immediate protective effects of the polyphenols in wine, the unabsorbed phenolic compounds that remain in the gastrointestinal system following wine consumption may also contribute anti-oxidant effects. There they can scavenge free radicals locally, preventing lipid peroxidation as well as the absorption of cytotoxic lipid peroxidation products. Wine also favorable affects urate levels; thus, the antioxidant activity is apparently influenced by two separate mechanisms: wine-derived phenolic compounds and plasma urate.
A further important biological property of wine is its potent antimicrobial activity that tends to decrease adverse effects of food-borne and oral pathogens. In addition to the improvement of microbial food safety, wine consumed with a meal may also be protective against alimentary infections. On the other hand, high blood alcohol concentration (BAC) levels tend to force the liver to metabolize alcohol through a different system, which generates oxidative free radicals that have adverse health effects, and can damage liver tissue in the long-term.
Lanzmann-Petithory noted: “Wine is a fermented grape juice naturally enriched in polyphenols. A glass of wine can bring about half of the average polyphenol intake of people in western countries. That may explain why the specific effects of wine, compared to other alcoholic beverages, may actually be less important when the diet is already full of polyphenols; when the diet is poor, wine can be a major source of polyphenols, with perceptible beneficial effects.”
Consuming wine with meals: The consumption of wine or other alcoholic beverage with meals lowers the BAC levels that result from the ingestion of a given amount of alcohol. The net effect of food plus wine is a lowering of oxidants and an increase in anti-oxidants in the blood; these effects are particularly important in correcting for the oxidative stress that accompanies the post-prandial period. Further, consuming food with wine may also act as a mechanical ‘wash-out’ of alcohol from the oral mucosa, thereby decreasing the risk of ethanol-associated carcinogenesis in the oral cavity and upper gastrointestinal tract.
Forum member Lanzmann-Petithory: “Yes, to drink alcohol with food slows gastric emptying that lowers BAC. But wine does not need the Mediterranean diet to be effective as the authors conclude themselves. It should be noted, however, that protective effects of wine against oxidative damage are influenced by the type of food and may be less pronounced in individuals consuming a well-balanced diet.” She added: “The authors do not discuss the ‘French Paradox,’ which suggests that the habit of drinking moderate amounts of wine with meals could be one of the explanations for the lower rates of cardiovascular disease in France despite similar or worse risk factors than in the USA. Renaud proposed the hypothesis of a hemostatic mechanism, rather than an interaction with the atherosclerosis process, as a key factor for this paradox (Renaud & de Lorgeril). A ‘French Paradox’ is still observable today in recent WHO data, with France having the second lowest mortality rates in the world from cardiovascular disease after Japan; this occurs despite higher cholesterol levels, greater rates of smoking, and higher saturated fat consumption (33.4 g/day versus 25.9 g/day) among the French than in the United States. It is noteworthy that in comparisons by country, the French remain first for wine drinkers but 20th in the ranking of alcohol drinkers.”
Varying drinking patterns in different cultures: Cultures vary dramatically in how people consume alcohol. In some cultures the typical pattern is the regular consumption (often on a daily basis) of moderate amounts of alcohol, while in others the typical pattern is for episodic heavy drinking, especially on weekends. While the average weekly consumption may be the same for both cultures, the drinking pattern of the former tends to be associated with beneficial health effects, while the latter pattern tends to have mainly adverse effects (Ruidivets et al). These differences emphasize why evaluating only the total amount of alcohol consumed, and not how it is consumed, is inadequate when evaluating its effects on health and disease.
Reviewer Lanzmann-Petithory noted: “Wine is an alcoholic beverage that in many cultures is generally consumed with meals. More recently, wine has become a ‘snack’ in the USA, consumed alone before dinner, as described in a French-US comparison study (Mathe et al). Two ways of drinking 7 to 14 drinks/week were imported into the United States: the French/Latin way of a glass or two of wine at mealtimes, and the Scandinavian/Northern-European way of 7 to 14 servings of spirits at one time (Lanzmann-Petithory).”
Implications of current study: Forum member Skovenborg commented: “Boban et al present a fair review of the many aspects of the issue of beverage choice and drinking patterns. In a review of observational epidemiological data it is difficult to separate specific effects of e.g., wine polyphenols, from the influence of many confounding factors. For example, in Denmark wine drinkers seem to have a healthier eating pattern than beer drinkers do (Johansen et al). It has also been difficult to translate positive results of wine intake from laboratory studies to hard endpoints in large population studies. Even so, it is difficult to argue against the sympathetic advice from the authors: a regular and moderate intake of wine with your meal.”
Skovenborg continued: “It is important that all medical and scientific information concerning the effect of wine consumption on human health is evidence-based and communicated in a competent, credible and unbiased manner. In doing so, the authors may have taken the ‘precautionary principle’ too far regarding breastfeeding. According to a recent review on alcohol and breastfeeding, special recommendations aimed at lactating women are not warranted; instead, lactating women should simply follow standard recommendations on alcohol consumption (Haastrup et al).
Forum member Ursini commented: “This paper does not present new data, but an educated review of evidence gleaned, over many years, after the news broke about the “French Paradox”; it is more than welcome. Paradoxes are generated when there is an epistemological bias and one of the two truths generating the conflict is not true, sometimes both. We know now that alcohol in moderation is protective and that wine does it better. This is everything but a paradox. It’s never too late to support and communicate this concept.”
References from Forum review
Haastrup MB, Potteg A. Damkier P. Alcohol and Breastfeeding. Basic & Clinical Pharmacology & Toxicology 2014;114:168–173.
Johansen D, Friis K, Skovenborg E, Grønbæk M. Food buying habits of people who buy wine or beer: cross sectional study. BMJ 2006;332(7540):519-522. doi:10.1136/bmj.38694.568981.80.
Lanzmann-Petithory D. Commentary on Kerr et al. The ‘French Paradox’ versus binge drinking. Addiction 2013;108:1049-1050.
Mathe T, Francou A, Colin J, Hebel P. Comparaison des modèles alimentaires français et états-uniens [French eating habits compared to Americans]. CREDOC, Research Center for the Study and Observation of Living Conditions. Consommation et modes de vie, n°255, 2012, ISSN 0295-9976.
Renaud S, de Lorgeril M. Wine, alcohol, platelets, and the French Paradox for coronary heart disease. Lancet 1992;339:1523–1526.
Renaud S, Gueguen R. The French paradox and wine drinking. Novartis Found Symp. 1998;216:208-217.
Renaud S, Guéguen R, Siest G, Salamon R. Wine, beer and mortality in middle-aged men from Eastern France. Arch Intern Med 1999;159:1865-1870.
Ruidavets J B, Ducimetière 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.
A review article appearing in Food & Function, a publication of the Royal Society of Chemistry in the United Kingdom, presents a summary of evidence-based scientific data relating the moderate consumption of wine and other alcoholic beverages to health. Forum members considered the paper to be a well-thought-out appraisal of the effects that the pattern of consumption (e.g., the type of beverage, regular versus binge drinking, consumption with meals, etc.) affects its risks and benefits. (It is recognized that some of the authors of this publication work primarily with wine, but the review article covers key behaviors that affect the relation of the consumption of all types of alcohol to health.)
The authors describe how the polyphenols and other non-alcoholic components of wine provide anti-oxidants and decrease post-prandial oxidative stress. These phenols can also scavenge free radicals in the mouth and throughout the gastro-intestinal tract, preventing lipid peroxidation as well as the absorption of cytotoxic lipid peroxidation products. Wine also favorably affects urate levels; thus, the antioxidant activity is apparently influenced by two separate mechanisms: wine-derived phenolic compounds and plasma urate. A further important biological property of wine is its potent antimicrobial activity that tends to decrease adverse effects of food-borne and oral pathogens.
The article summarizes the key differences in health effects when alcohol (especially wine) is consumed moderately, with food, and on a regular basis rather than in binges. These differences emphasize why evaluating only the total amount of alcohol consumed, and not how it is consumed, is inadequate when evaluating its effects on health and disease. Further, the authors emphasize how all medical and scientific information concerning the effects of wine and alcohol consumption on human health should be evidence-based and communicated in a competent, credible and unbiased manner.
* * * * * * * *
Comments for this critique by the International Scientific Forum on Alcohol Research have been provided by the following members of the Forum:
Dag S. Thelle, MD, PhD, Department of Biostatistics, Institute of Basic Medical Sciences, University of Oslo, Norway; Section for Epidemiology and Social Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
Elizabeth Barrett-Connor, MD, Distinguished Professor, Division of Epidemiology, Department of Family Medicine and Public Health and Department of Medicine, University of California, San Diego, La Jolla, CA USA
R. Curtis Ellison, MD, Professor of Medicine & Public Health, Boston University School of Medicine, Boston, MA, USA
Diewertje Sluik, DrPH, Division of Human Nutrition, Wageningen University, NL
Erik Skovenborg, MD, specialized in family medicine, member of the Scandinavian Medical Alcohol Board, Aarhus, Denmark
Harvey Finkel, MD, Hematology/Oncology, Boston University Medical Center, Boston, MA, USA
Fulvio Ursini, MD, Dept. of Biological Chemistry, University of Padova, Padova, Italy
Dominique Lanzmann-Petithory, MD, PhD, Nutrition Geriatrics, Hôpital Emile Roux, APHP Paris, Limeil-Brévannes, France
David Van Velden, MD, Dept. of Pathology, Stellenbosch University, Stellenbosch, South Africa
Andrew L. Waterhouse, PhD, Department of Viticulture and Enology, University of California, Davis, USA
Arne Svilaas, MD, PhD, general practice and lipidology, Oslo University Hospital, Oslo, Norway
Ramon Estruch, MD, PhD, Hospital Clinic, IDIBAPS, Associate Professor of Medicine, University of Barcelona, Spain