(Circulation. 2001;104:e73.)
© 2001 American Heart Association, Inc.
Correspondence |
American Heart Association Advisory, "Wine and Your Heart," Is Not Science-Based
Fellow, The Lindesmith Center–Drug Policy Foundation, 27 W Lake Blvd, Morristown, NJ 07960, speele@earthlink.net
To the Editor:
The American Heart Association (AHA) Advisory on "Wine and Your Heart"1 functions more as a propaganda document than a scientific one. It discounts the null hypothesis, that wine has measurable beneficial effects for coronary heart disease (CHD), on 2 contradictory grounds: that wine is indistinguishable from other types of alcoholic beverages that produce similar beneficial effects, and that alcohol in general does not produce such beneficial effects. Thus, the following statement, "Statistical modeling that includes potential cofounders [such as social and health behavior advantages in favor of wine drinkers] does not mitigate the beneficial effect of alcohol consumption on CHD," is somehow used as evidence against the reliability of the overall alcohol-CHD connection.
The fact that well-controlled studies find an alcohol-CHD benefit instead reinforces the advantages of moderate alcohol consumption. Although the advisory accepts that "higher [alcohol] intakes are associated with increased total mortality,"1 it nowhere states the converse, true statement—that moderate alcohol drinkers, particularly in higher risk categories, experience lower mortality rates than do lifetime abstainers. This result is obtained in prestigious, massive, prospective studies, such as the study administered by the American Cancer Society2 and the Physicians’ Health Study.3 So many studies showing mortality advantages for moderate drinkers have accumulated that reliable meta-analyses have been constructed from these individual studies.4 A part of this mortality advantage is the result of a similar U-shaped ischemic stroke function in relation to alcohol consumption, which the AHA advisory discounts without reviewing recent research.
The logic underlying this and similar attempts to undercut possible advantages of alcohol consumption is that alcohol is a dangerous substance to be avoided at virtually all costs—an aversion in most cases not displayed by the well-educated, middle-class health professionals who author these opinions. Indeed, a strong case can be made that the inability to accept the complex conclusion that some levels of drinking are healthy and others unhealthy (a realization that is centuries old, at least) is a sign of our society’s inability to articulate a sensible policy in regard to alcohol,5 even as alcohol remains the most commonly consumed psychoactive substance in the United States and the world.
References
1.
Goldberg IJ, Mosca L, Piano MR, et al. AHA Science Advisory: wine and your heart. Circulation. 2001; 103: 472–475.
2.
Thun MJ, Peto R, Lopez AD, et al. Alcohol consumption and mortality among middle-aged and elderly U.S. adults. N Engl J Med. 1997; 337: 1705–1714.
3. Gaziano JM, Gaziano TA, Glynn RJ, et al. Light-to-moderate alcohol consumption and mortality in the Physicians’ Health Study enrollment cohort. J Am Coll Cardiol. 1999; 35: 96–105.
4. White IR. The level of alcohol consumption at which all-cause mortality is least. J Clin Epidemiol. 1999; 52: 967–975.[Medline] [Order article via Infotrieve]
5.
Peele S. The conflict between public health goals and the temperance mentality. Am J Public Health. 1993; 83: 805–810.
Response
Columbia University College of Physicians and Surgeons New York, NY
University of Illinois Medical Center Chicago, Ill
Mt Sinai School of Medicine New York, NY
The purpose of the advisory entitled "Wine and Your Health"1 was to review the current literature and to generate a reasonable message based on the strongest studies that could direct health care providers to methods for improving both the cardiovascular and general health of their patients. Although there are scientific correlates that add to the plausibility of wine and other alcoholic beverages as cardioprotective agents, there are also data that do not show atheroprotective actions.2 We advocate the use of alternative approaches for several reasons.
First, data for alcohol or wine consumption do not reach the usual standards to recommend this as a primary or secondary prevention approach. Most data are correlative and suffer from a number of confounders (reviewed by Corrao et al3). In this context, observational and biological plausibility data in the area of cardiovascular disease are not always supported by the results of randomized clinical trials, as has been exemplified by the recent findings in studies using hormone replacement therapy or vitamin E. The use of such incomplete data on alcoholic beverage consumption to make a broad clinical recommendation is especially inappropriate when alternative approaches to the same problem, such as blood pressure control and cholesterol lowering, have been proven to reduce cardiovascular disease in randomized trials. The alcohol data are not as strong.
Second, as noted by Dr Peele, alcohol is the "most commonly consumed psychoactive substance in the United States and the world." Moreover, this substance is addictive in a subgroup of people and is responsible for a large degree of mortality (much more than that found with other cardioprotective medications). If alcohol were a conventional "drug," these side effects would prohibit its use as a cardioprotective agent.
Therefore, we do not believe that physicians and other health care providers should advocate the use of wine or other alcoholic beverages as health-promoting substances but rather should continue to advocate and address the importance of other lifestyle behaviors. This view is separate from any limited use of alcohol as a beverage.
Most importantly, providing the public with a rationale to increase a behavior that is one of the leading causes of disease is not reasonable. Perhaps if we could ensure that all patients limit their alcohol intake to prescribed amounts, alcohol-related illnesses would not occur. If the authors of these letters have a method to do this, it would be a major boon for the health of the nation. Even if this were achieved, however, the evidence to support the benefits of alcohol consumption at a safe level is, at present, still below the standard required for other drugs. If evidence from randomized trials in which alcohol reduced cardiovascular disease without leading to liver, neurological, or psychosocial illness were to become available, we would be happy to include it in a revised advisory in the future.
Footnotes
*The author, in addition to writing frequently about alcohol problems and their treatment and about the healthy use of alcohol, has consulted with alcohol manufacturers on social and cultural issues relating to alcohol consumption and on the benefits of moderate drinking. This letter was not reviewed, approved, or funded by any organization, and it represents the views of only the author. 
References
1. Goldberg IJ, Mosca L, Piano MR, et al. AHA Science Advisory: wine and your heart. Circulation. 2001; 103: 472–475.
2.
Bentzon JF, Skovenborg E, Hansen C, et al. Red wine does not reduce mature atherosclerosis in apolipoprotein E–deficient mice. Circulation. 2001; 103: 1681–1687.
3. Corrao G, Rubbiati L, Bagnardi V, et al. Alcohol and coronary artery disease: a meta-analysis. Addiction. 2000; 95: 1501–1523.[Medline] [Order article via Infotrieve]
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