Tuesday, January 12, 2016

Why the UK's new guidelines on alcohol consumption are misguided

   Dismissing decades of research on alcohol and health, the UK’s new stringent guidelines on drinking bring to mind a quote from champagne lover Sir Winston Churchill: “Statistics are like a lamppost to a drunk; used more for support than illumination.” In announcing the new policy, England’s chief medical officer and neo-prohibitionist Sally Davies scorned the idea that a daily glass of wine could be healthy, proclaiming it an “old wives’ tale” and suggesting a cup of tea instead. The policy is said to be based on the latest statistics, but do these truly shed any new light? We are hardly in the dark about the effects of wine on health, with many thousands of research papers on record.
   Davies’ fundamental mistake is to judge all types of drinking the same while focusing the outcome narrowly on cancer, failing to consider the opposite: that an equally narrow focus on wine drinkers might have different outcomes when overall health is concerned. Nothing in the “latest data” counters the fact that on average, people who drink wine with meals on a daily basis outlive nondrinkers, are healthier, and enjoy a higher quality of life by objective measures. Davies’ advice to avoid any drinking at all several days a week is similarly imprudent as it can only serve to encourage bingeing instead of healthy drinking. All types of drink are not the same, and all types of drinking are also varied in their effect on health.
   The policy shines a spotlight on alcohol and cancer where broad daylight is needed in order to see the whole picture. But even here the statements in the new policy take liberties with the facts, with assertions such as “no level of alcohol consumption is safe” while acknowledging in the same document that drinking within the guidelines carries the same cancer risk as not drinking. But even that self-contradictory statement oversimplifies the question, because the relationship is nonlinear; for wine, many disease conditions including most types of cancer plot out on a J-shaped curve. In other words the risk is lower for moderate drinkers, then about the same, and increasing rapidly with heavy drinking.  Unfortunately for the Brits and their pub culture, the J curve is shallower for beer. Unfortunately for the new policy, it similary fails when alternating drinking and teetotaling.

   Perhaps the UK would do well to heed Churchill’s view on drinking: “I have taken more out of alcohol than alcohol has taken out of me.”

Thursday, January 7, 2016

Increasing alcohol levels in wine spurs debate on health effects

     Much ado has been made about a recent article documenting that the alcohol content in wines is often higher than stated on the label, and increasing. It’s been an open secret among winemakers for some time, but if the trend continues it threatens the whole concept of healthy drinking. Policymakers in the UK and elsewhere are already using it to bolster anti-drinking campaigns.
     The analysis, from the University of California Davis and others, was comprehensive and included several factors.  Over the past 2 decades, Old World wines have seen a greater increase in alcohol levels, but New World wines started out higher. Using heat index climate data, the authors found that part of the increase correlated to warmer growing conditions (resulting in higher sugar content translating into more alcohol), and part driven by consumer preference for riper wines with more concentrated flavors. Several factors contribute to the trend and confusion about what it means.
     In the U.S., federal law allows for a tolerance of plus or minus 1.5% of stated alcohol content for wines with less than 14%, which means that a label can say for example 13.5% but actually contain almost 15. Studies on wine and health typically presume an alcohol content of 13% or less, consistent with how wines have traditionally been made. Because people tend to like higher alcohol wines, the regulation is essentially a health benefit loop-hole; it’s sort of like telling us we can get credit for eating our vegetables even though they are deep-fried.
     Alcohol is a part of the healthy drinking equation, but only up to a point. Wine is not just sugar-free grape juice, and there is evidence that de-alcoholized wine does not provide the same level of health benefits. The problem is not that wine has alcohol, it’s a matter of how much is ideal.

     The concept of healthy drinking goes back thousands of years. Philosophers in ancient Greece gathered around wine drinking parties (called symposia) and developed the very ideas upon which civilization is grounded. What is worth noting however is that the wine was always diluted with water, and it was considered unsophisticated to drink it undiluted; even a 50:50 mixture was deemed quite strong. The average wine from recent vintages today would have been judged barbaric by ancient standards.

     There’s a lot at stake for the future of the wine industry and the well-established relationship with healthy living. How will winegrowers adapt to climate change and the shift in consumer preferences without erasing our excuse to enjoy wine? Let’s have a glass or two and philosophize about it – maybe we can figure something out.

Tuesday, December 8, 2015

Resveratrol in your coffee? It’s already a healthy drink

resveratrol coffee glassWhen they come out with a coffee infused with resveratrol, that’s how you know it’s just gone too far. Vera Roasting Company just announced their “CoffVee” blend, intended to bring “the heart-healthy benefits of red wine” to coffee. Like makers of resveratrol supplements, the idea is based on the claim that it is possible for consumers “to enjoy the heart-healthy benefits of a glass of red wine” with every cup, “minus the alcohol.” If only it were so simple.
Here’s why infusing coffee with resveratrol is a bad idea:
Coffee is already a heart-healthy drink. Coffee contains some very potent natural antioxidants and anti-inflammatory compounds, so the addition of resveratrol is unnecessary. A study just out last month evaluated overall causes of mortality in a large population found that coffee consumption was related to lower chances of dying from heart disease, as well as respiratory diseases, diabetes, and pneumonia. The researchers attributed this to improved insulin sensitivity and other benefits. A study last year looking at heart disease specifically found a J-shaped curve for coffee consumption similar to that for wine drinkers: Moderate consumption (3-5 cups per day) had a lower risk than non-consumption or high consumption.
Part of the heart health benefits of red wine are attributable to the alcohol. The only thing that has all the heart health benefits of a glass of red wine is a glass of red wine. Alcohol in the right amounts improves the HDL/LDL cholesterol ratio, which translates to lower risk of cardiovascular disease. Although the effect is more pronounced for wine, drinkers outlive abstainers on average. (Similarly, in coffee, some of the health benefits are attributable to caffeine.)
There isn’t enough resveratrol in a glass of wine to explain all of the benefits of wine consumption. Although there are more than 8,000 articles on resveratrol published in the biomedical literature, it is not clear that it plays as big a role in wine’s health benefits as was thought. It does provide a mechanistic explanation for many of the specific benefits associated with wine such as lowered Alzheimer’s risk, diabetes, and cancer, but in general the doses required to demonstrate the effect experimentally far exceed what you get in a glass (or a few dozen glasses) of wine. Ergo, it can’t be resveratrol alone that explains the French Paradox.

There are some interesting parallels with wine and coffee. Both contain potent antioxidants and demonstrate a J-shaped curve. Sugar in coffee largely negates the health benefit, and that is also a reason why wine consumption is not the same as drinking grape juice. Processing the sugars into alcohol produces a healthier drink. For me, I’ll stick to regular coffee in the morning and wine with dinner.

Tuesday, September 22, 2015

Seeing red over breast cancer-wine reports: Why studies still get it wrong

A recent headline announcing the results of another study examining the role of alcohol and risk of breast cancer proclaimed that even a glass of wine a day “can significantly increase a woman’s cancer risk.” The connection between drinking and breast cancer has been a troublesome one, the thorn among the rosés, if you’ll pardon the metaphor. It’s not that I mean to make light of all this well-intentioned alarm bell ringing, but the way I see it research on wine and breast cancer just keeps repeating the same mistakes. When it comes to the question of wine and breast cancer, most studies still get it wrong.
That’s one reason why I can’t help but be a little bit cynical every October, when pink ribbons start sprouting everywhere, from lapels to football jerseys to cereal boxes. Increased awareness is laudable, but I wonder if these efforts do more to make us feel good than they do to actually make a difference for women with breast cancer. Case in point: the Komen Foundation, with its trademarked “for the cure” campaigns, reportedly spends less than a fifth of funds on research support to find a cure.
Advocates for breast cancer victims can’t be blamed for the misunderstandings about wine and cancer, and it’s hard to criticize the researchers - whose intentions are noble – but perspective is lacking. The Komen foundation wouldn’t even accept funds from a charitable wine auction I was involved in a few years ago when we approached the local chapter with the idea of making them a beneficiary. So we have this crazy situation where a breast cancer foundation won’t accept wine money, which may be a good thing because they don’t allocate much of it for research anyway.
Here’s the fundamental problem: When you do a study to identify which lifestyle factors are related to breast cancer (or anything else), of necessity you rely on self-reported questionnaires. With the question of drinking, there is a well-known under-reporting tendency so what subjects say they drink and what they actually drink are often not the same. This results in heavy drinking being mis-categorized as moderate drinking, with the implication that moderate drinking is riskier than it is.
When it comes to type of drinking, for example wine vs. beer or spirits, it becomes even murkier. What is well known about wine drinking and other disease conditions is that a pattern of a glass or two of wine with dinner on a daily basis is associated with lower risk than for nondrinkers. But very few people in a given North American population actually drink this way. What the studies do is ask about drinking preferences; if someone says they prefer wine with dinner, they may only do it occasionally, and sometimes have no alcoholic beverage, sometimes other types of drinks, and in varying amounts depending on circumstances. This makes it virtually impossible to know what the actual role of wine might be, even accounting for the under-reporting bias. No matter how large the study, or how long-term, it’s the same problem only amplified.
It’s clear that heavy drinking of any type is associated with higher risk, but what’s not as clear is how this extrapolates to low or moderate drinking. Generally, studies infer that a drink a day increases breast cancer risk by 10%, 2 drinks 20%, and on up. What this means (often misunderstood) is this is a percentage of baseline risk; so if you are at average lifetime risk of about 8 or 9 percent, a 10% increase is not 18 or 19%, but somewhere around 10 percent overall. (10% of 9% is 0.9%, so a 10% increase = 9.9%)
To put this in perspective it is helpful to consider that heart disease dwarfs breast cancer as a cause of death in women, and there is no question that moderate drinking (especially wine) associates with a lower risk. The same is true for diabetes, osteoporosis, and Alzheimer’s. For most women, stopping drinking to reduce breast cancer risk would result in an increased overall risk of premature death and disability.
But even that doesn’t tell the whole story. I am not convinced that moderate wine drinking contributes to even a low risk of breast cancer for the average woman. The definitive way to answer the question would be to study a population of women who only drink red wine, and in moderation as an integral part of their lifestyle. There are not very many of these studies because there are not many such populations anymore, but there is some good data. The best of these studies was done in Bordeaux a few years ago (1), and the conclusion was that wine drinkers had a substantially lower rate of breast cancer than nondrinkers.
Why should this be the case? For alcohol and breast cancer, it took years for a plausible cause-effect relationship to be put forth, and the best hypothesis is that it changes estrogen metabolism. Higher estrogen translates to greater risk of certain types of breast cancers. These types, known as estrogen-receptor positive (ER+), are often treated with drugs called aromatase inhibitors, which ramp down estrogen production. Red wine, as it turns out, is a natural aromatase inhibitor.
So forgive me if I don’t sport a pink ribbon, but I wish we had more efforts like the former Cleavage Creek Winery, which used profits to directly fund research at institutions like the Fred Hutchinson Cancer Research Center and Bastyr Naturopathic University in Seattle, bypassing “Big Pink.”  Founded by the late California winemaker Budge Brown after losing his wife of 48 years to breast cancer, Cleavage Creek donated more than $90,000 before the winery closed. So I say please do have a glass of red wine and toast to all those who are doing so much to save and improve women’s lives.

1.  Bessaoud F, Daurès JP. Patterns of alcohol (especially wine) consumption and breast cancer risk: a case-control study among a population in Southern France. Ann Epidemiol. 2008 Jun;18(6):467-75.

Monday, August 3, 2015

Feeling blue? Drink some red

Drinking and depression have problematic relationship, so the consensus from recent studies that moderate red wine consumption correlates to lower odds of depression may seem hard to swallow. But it is clear that daily wine drinkers show a J-shaped curve for clinical depression: lower in moderation, higher in excess. Some very good data comes from a long term study called PREDIMED (“Prevención con Dieta Mediterránea” (Prevention with Mediterranean Diet)), which is a randomized, multicenter, controlled, clinical trial conducted in Spain involving more than 5500 subjects. At up to 7 years of follow-up, wine intake within the range of 2-7 drinks per week was significantly associated with lower risk of incident depression.
Resveratrol, wine’s miracle molecule, offers a potential explanation though it is likely the whole story. There is an experimental model of depression in rats, allowing for measurement of depressive symptoms in response to various drug treatments (no model yet for the effects of counseling or group therapy.) A recent study found that rats given resveratrol for one week exhibited a dose-dependent decrease in activities correlated to depression. More significantly, this effect was associated with an increase in hippocampal and frontal cortical brain-derived neurotrophic factor (BDNF), a protein implicated in chronic effects of many antidepressants.
While it is tempting to unite these findings into and conclude that wine drinkers have lower rates of depression because of the resveratrol, there is an obvious in that logic: Only moderate consumption of wine has a clinical correlation, and it is likely that much higher doses of resveratrol are needed to raise BDNF levels in the brain than what you get in a glass of wine. Both studies are true, but unrelated.

There are many other factors to consider, such as the role of alcohol, but it may be that moderate wine drinking is a marker for other lifestyle factors that relate to lower incidence of depression or elevation of BDNF in the brain. Maybe I will have a glass of wine and think about it.

Wednesday, June 24, 2015

Can red wine can help you lose weight? – Yes but not how you think

There’s nothing like a good study on red wine as a weight loss aid to get attention, but in the case of a recent study from Washington State University it’s not quite so simple. Gilliam Fuller, writing for Elite Daily, led with “Drink Up: Science Says Red Wine Can Actually Help You LoseWeight” while the Sentinel Republic headlined simply “Red wine can help you lose weight.” Meanwhile Chris Mercer reported in Decanter.com on the United Kingdom’s National Health Service weighing in with “Red wine weight loss theory is ‘nonsense’.” They’re all partly right, but mostly wrong.
The study analyzed fat metabolism in mice given resveratrol, finding that it promoted conversion of normal white fat cells into brown fat, which is associated with higher metabolism and less weight retention. It was a well done study, but findings in mice given resveratrol cannot be directly extrapolated to humans consuming wine. So UK health officials were correct in stating that “‘based on mice studies only, we don’t know whether resveratrol will have the same effect in people.” Many reports on the paper emphasized the high calorie content of wine, and suggested that we might be better off getting our antioxidants from berries and fruits.
I have so many issues with this it’s hard to know where to begin. For starters, wine is unique in the diet as a source of resveratrol, though even the most robust wines don’t have a lot. Berries and other fruits generally do not have meaningful amounts, but they do have large amounts of natural sugars. Because wine has fermented the sugars into alcohol, it wreaks less havoc with blood sugar levels. That is one reason why wine drinkers have lower rates of obesity and remains an important aspect of the Mediterranean diet. Resveratrol, at least in doses attainable from a couple of glasses of wine, probably has little if anything to do with it.

Lost in all this is the scientifically most interesting aspect of the study: brown fat. Until only a couple of years ago it was thought to exist only in babies and hibernating animals. If resveratrol can be proven to promote the formation of brown fat and hence weight loss in human clinical trials, it would be another facet to this miracle molecule. But not a reason to drink – or not drink – red wine.

Wednesday, April 29, 2015

Do larger wine glasses contribute to overdrinking and obesity? Alcohol nutrition labeling debated

The UK’s Royal Society for Public Health recently issued a warning that “the insidious increase in the size of wine glasses in bars and restaurants in the past decade” has led many of us to have “unwittingly increased the number of invisible calories we consume in alcohol.” They called for food labeling laws to include calorie content in alcoholic beverages, which are exempt. Writing in the British Medical Journal, RSPH chair Professor Fiona Sim cites a survey which found that 80% of adults did not know the calorie content of their drinks, and speculates that in addition to gargantuan glasses, this may be contributing to the obesity epidemic in the UK. According to the Professor, the average portion served is a whopping 250 ml. (8 ½ ounces!) If that’s true I can’t wait for my trip to the UK this October.
 While public health officials are right to be concerned with rising obesity rates and abuse of alcohol, in this case they have missed the mark. For one thing, if larger glasses have become fashionable it is likely because they are believed to enhance the flavors and aesthetic appreciation of the wine, in part because of the space above the pour within the glass. It seems to me that would have the effect of slowing the pace of drinking, not increasing overall drinking. I would further venture that wines ordered by the bottle are typically shared between two diners regardless of glass size, and by-the-glass pours are unlikely to be a third of a bottle – the unit economics of that don’t pencil out. On this side of the pond, I am more likely to get too small of a pour in too small of a glass.
Professor Sim goes on to compare two glasses of wine to the caloric content of a McDonald’s order of fries, and notes that it exceeds recommended daily alcohol allowance for women.  She points out that most women “do not realise that two large glasses of wine, containing 370 calories, comprise almost a fifth of their daily recommended energy intake.” But 17 ounces is a lot of wine under most circumstances, and two of the more typical 5 ounce pour of red wine contains around 250 calories, close to half of the number cited in the article.
The article justifies inclusion of alcohol calories in food labeling because “there is no reason why calories in alcohol should be treated any differently from those in food.” It does not provide evidence that labeling laws have had any influence for other foods however. Indeed, the increasing rates of obesity despite nutritional labeling mandates suggest otherwise. It would be interesting to know if the survey subjects could accurately estimate the calories in their fries any better than in their vino (I doubt it.)

On the question, of labeling, we may have an answer soon. As of this year, in the U.S. all restaurant chains with more than 20 outlets will have to provide calorie counts for alcoholic beverages in addition to food items.  So if McDonald’s decides to offer wine to augment their fine dining experience (happy meal for mom and dad?), you will be able to make an informed decision. I expect you will find wine a more nutritional choice than a 17-ounce cola.