Vol.48 - Número 3, Julio/Septiembre 2019 Imprimir sólo la columna central

Six faces of the relationship between wine consumption and cardiovascular health
RICARDO LOPEZ SANTI (1), ADRIAN BARANCHUK (2), SOHAIB HASEEB (2)
On behalf of the EVAH (Evidence in Alcohol & Heart) investigators team:
Bryce Alexander (2), Adrian D’Ovidio (1), Sergio Gimenez (1), Carlos Secotaro (1), Diego Martinez Demaria (1), Luis Maria Pupi (1), Sonia Costantini (1), Daniel Piskorz (1),
Alejandro Amarilla (1), Alberto Lorenzatti (1), Narcisa Gutierrez (1), Wilma Hopman (2).

(1) Federación Argentina de Cardiología / (2) Division of Cardiology, Kingston Health Sciences Centre, Queen’s University, Kingston, Ontario, Canada.
E-mail

Recibido 05-AGO-2019 – ACEPTADO el 17-AGOSTO-2019.
There are no conflicts of interest to disclose.

 

Cardiovascular diseases are the leading cause of death in the world, with a yearly figure of 17.5 millions of deaths by this cause [1,2]. The identification of risk factors and the main prevention tools have been crucial to the design and implementation of sanitary programs, both in the individual and population approach [3,4,5].

Excessive alcohol consumption also establishes a sanitary risk, as according to the World Health Organization, it appears as causing more than 200 diseases that determine 3.3 millions of death per year (5.9%) [6].

However, mild to moderate alcohol consumption has not been reported as a hazard for cardiovascular health, and in the particular case of wine, it has been associated to chronic diseases prevention, such as CAD, diabetes and cancer [7,8,9].

The neutral effect behavior of occasional consumption, potential benefits in mild and moderate consumption [10], and harmful effects of excessive consumption, can be perfectly matched to those of pharmacological drugs. Undoubtedly, this consideration arises in a complex scenario, as contrarily to the administration of medications, usually administered within a framework of control by the health team, alcohol consumption occurs as self-prescribed and lacks monitoring for its effects, unless the individual is willing to consult with a doctor.

For a proper assessment of the actions corresponding to individuals, by the health care agent before the patient; or in terms of the population, by the health care system before the population, it is necessary to define the actors and contingencies influencing on decision-making.

The aim of this review is to perform an analysis on wine consumption in relation to cardiovascular disease, as this is the alcoholic beverage with greater scientific background in terms of assessment of its components and evidence from clinical trials.

The scenario could be characterized as a 6-faced object (Figure 1), some of which are contrasted to each other. They are:

  • Cultural and financial connotation.
  • Analysis of components.
  • Clinical evidence.
  • Recommendations by health organizations.
  • Position by the medical community.
  • Social behavior before alcohol consumption.

Each of these is analyzed separately, to later integrate them in a final assessment for the discussion.

Figure 1. Six faces of the wine consumption and cardiovascular health relationship.

 

  • Cultural and Financial Connotation

Undoubtedly, wine consumption is linked to the history of humankind, as there is evidence of grapevine cultivation to produce wine dating from 5400 BCE, in what is Iran today [11]. Later, the great ancient cultures gave it a relevant place in the traditions of the era. Religion bestowed it with a preponderant position, to the extent of representing it in deities such as Bacchus or Dionysius. Meanwhile, Hippocrates attributed therapeutic properties to wine in relation to disinfection and sedation [12], and the Roman Empire incorporated this drink for its legions, considering it safer than water. From such perspective it makes sense that grapevine culture was promoted throughout Europe. Christianism assimilated wine as the expression of the sacred blood of Christ, and the holy scriptures attest to the unquestionable value bestowed to it by the Hebrew community. As this religion spread furthered by explorers, winemaking activity reached the new world.

As the two sides of a coin, the development of Islam through the Middle East and Asia led to a prohibition to consume it, while with the fall of the Roman Empire, catholic monasteries were in charge of preserving and developing knowledge on culture and production.

Thus, it is logical that it is the cultural legacy of the peoples which has either promoted or restrained alcohol consumption.

Also, the participation of alcohol has been given life in art, reflecting social context. Michelangelo, Titian, Velázquez, Shakespeare, Cervantes, are among the many artists along history who have immortalized wine as a social actor [13].

From a financial point of view, its background is equally consistent. From the mass plantation of grapevines promoted by Romans, wine turned into a significant resource, activating regional economies; particularly in the areas surrounding the Mediterranean basin. Currently, this activity has spread worldwide, as China is the main producer of grapes; although European countries are the main wine producers. In 2017, the balance was 7.6 millions of cultured hectares, with a commercial volume exceeding 30 billion Euros. In a study developed by John Dunham & Associates, in the US there are 50 states producing wine, which in terms of indirect revenues amount to 43 millions of tourist visits related to this activity, and 17.7 billion USD in yearly expenses from tourism, benefitting local economies and fiscal figures.

Religious influence on habits, its expression in art and the space it holds in world economy, bestow wine production and consumption with a sound present in human life undoubtedly.

  • Analysis of Components

The study of wine components has been widely developed, and maybe this is the most consistent and unquestionable piece of evidence we have today, in favor of the beneficial effects of some of them [14,15]. The proposal of the so-called “French paradox” and the greater consideration of Mediterranean diet, have allowed for the focus of investigations to shift again toward wine and its components. The hypothesis is that they could delay the evolution toward chronic pathologies as cardiovascular ones, diabetes, cancer and even neurodegenerative ones like Alzheimer’s disease and vascular dementia [16]. In the analysis of pathophysiological mechanisms that may justify wine consumers to acquire these benefits, polyphenols’ effects appear, within which the most outstanding one is a non-flavonoid called resveratrol [17,18]. Beyond the hailed anti-inflammatory and antioxidant effects, others are added such as inhibiting beta-amyloid protein aggregation, increasing cerebral circulation and modulating intracellular effects involved in survival processes and neuronal death.

The inhibitory action on pro-inflammatory molecules is proven, as in the case of cyclooxygenase 1 and 2 (COX1 and 2), as well as on tumor necrosis factor alpha [19]. The adverse effects of pharmacological products analogous to resveratrol are expected to be overcome through nanotechnology. Thus, positive effects on the lipid profile achieved by red wine consumption, are not obtained with polyphenol extracts. In this action, a flavonoid polyphenol is also present, quercetin, with less power than resveratrol.

Also, from basic investigation it was possible to determine the positive interference of polyphenol extracts from red wine with the development of colon cancer. In prostate cancer, there is an ambivalent scenario: while white wine may increase the risk, red wine reduces it.

Ethanol present in wine, may also have a positive effect on blood pressure decrease and lipid profile improvement, as long as it is consumed in moderation [20].

  • Analysis of Clinical Evidence

In this field is where there is most controversy [21]. All evidence being contributed from basic investigation does not find the expected validation in the development of clinical trials. Undoubtedly, in an age of controlled studies, everything coming from observational studies is not entirely convincing. Randomized studies made usually present a small sample, making results relative, whether positive or negative.

The first wake-up call on positive effects to prevent CAD was produced by the publication by Renaud and Logeril in Lancet, 1992 [22], known currently as the French paradox. The hypothesis on the possibility of wine being able to offset a certain amount of saturated fat ingested in French diet, strengthened the interest for the influence of the Mediterranean diet, which was the focus of the MONICA (Multinational Monitoring of Trends and Determinants in Cardiovascular Disease) and the PREDIMED study (Prevención con dieta mediterránea – Prevention with the Mediterranean Diet) [23]. The results of several clinical observations were strengthened by this positive trend, which in spite of not having unquestionable evidence from controlled trials, have shown to be solid enough not to lead to disbelief on the benefits of mild and moderate consumption.

The analysis of the PRIME study (Prospective Epidemiological Study of Myocardial Infarction) is very interesting [24], which compared a population from Belfast, Ireland, with 3 centers from France, incorporating close to 10 thousand patients free from previous cardiovascular events. In the follow-up, alcohol ingestion and the presence of events were assessed. The Irish center showed more beer consumption (75%) with an average of 22.1 g/day of alcohol; while French centers displayed a predominance of wine consumption (91.8%) with a higher average of alcohol consumption, 32 g/day. Irish patients included more compulsive drinkers, with more weekend ingestion; while between French patients, regular drinkers predominated. In the 10-year follow-up, the average of events every 1000 people per year was 5.63 in Ireland (95% confidence interval, 4.69 to 6.69) and 2.68 in France (95% CI, 2.41 to 3.20). Compulsive drinkers presented twice the risk of events than regular drinkers, and remarkably, non-drinkers presented the same percentages as the former ones. This is just an observation, but it is suggestive from the point of view of those advocating a moderate consumption of alcohol. Recently, the CARDIA study (Coronary Artery Risk Development in Young Adults) has been published [25]. There were 5115 individuals enrolled. They were apparently healthy, and coming from 4 cities in the United States, with ages ranging from 18 to 30 years of age, and on whom there was a follow-up of 20 years, establishing a profile of alcohol consumption by self-reporting, and cardiac structure modifications by echocardiography. As to remodeling echocardiographic parameters, there was a weak correlation to excessive alcohol consumption. In regard to the type of drink, wine consumers displayed an interesting behavior, by showing a decrease in left ventricle and atrium diameters, and an increase in ejection fraction.

These studies reflect the profile of the contribution made by clinical investigation in this field, which according to the perspective from which they are assessed, will be more or less consistent.

  • Health Organizations

The position of Health Organizations has been nearly exclusively related to controlling excessive alcohol consumption in the light of its morbidity and mortality implications. This has promoted guidelines attempting to establish which are the consumption limits.

The World Health Organization has proposed a measuring unit for consumption called Standard Drink (SD), equivalent to 10 g of alcohol. However, different countries have adopted different values, creating a great confusion.

This takes into account the alcohol concentration of each drink to establish which is the exact amount that could be consumed in each case.

There is a differentiation between consumption for men (2 SD/day with 2 days without drinking) and for women (1 SD/day with 2 days without drinking). There is no distinction as to the type of drink in terms of benefit/damage.

Table 1 shows a list of drinks with their alcoholic concentration.

Table 1. Faltan que envien tablas
 


To estimate alcohol grams in a given measure, the following formula should be applied:
Alcohol grams = volume (expressed in cc) x alcohol grades x 0.8/100

Maybe, one of the aspects that has led to more confusion has been the disparity in criteria with which sanitary authorities from different countries have established the advised consumption limits [26]. Table 2, shows some examples extracted from the International Alliance for Responsible Drinking (IARD) report.

Table 2. Faltan que envien tablas
 

 

  • Medical Community

In a complex scenario, given the great expectations encouraged by basic investigation, the moderate consistency of clinical observations and the great confusion generated in the communication of health care organizations, is important to assess the behavior of the medical community. In this regard, we have just published the result of a survey performed in 745 physicians, mostly cardiologists, from Argentina [27]; a country placed between the first ten producers and consumers of wine in the world. 24% of the surveyed physicians considered that any alcohol measure is harmful for health; while 71% expressed a moderate consumption is beneficial. From the latter, half attributed this effect to wine consumption.

The knowledge about guidelines manifested by the surveyed individuals was low, as shown in Figure 2.

Figure 2. Knowledge on guidelines manifested by surveyed physicians. Taken from Diseases 2018; 6: 77.

According to what has been expressed by physicians, the degree of satisfaction with the knowledge about guidelines is also low. Only 41% mentioned knowing the meaning of Standard Drink and more than 80% considered this measure confusing.

The conclusions of the study lead to considering the need of establishing standardized guidelines that could be applied universally.

  • Social behavior

This aspect presents an indirect relation to the aim of this review, but with an impact on health care decision-makers.

One of the most important problems faced by the health care system about alcoholism, is the particular impact on the age group of individuals from 20 to 39 years, as in them it is the cause of 25% of deaths. Maybe in this regard, is where lies the greatest obstacle to accept that a mild and moderate consumption may yield benefits.

In a survey developed in Japan [28] in 594 young people older than 20 years (the age when drinking is allowed in this country) with the aim of determining consumption and reasons to drink excessively, it was established that both in men and women the main reason to do it was “feeling happy or being in a good mood”. In men, “releasing stress” was an additional reason; and in women “facilitating interpersonal relations” and “forgetting something bad”.

Although control policies have been implemented about it, the results are still far from satisfactory. For instance, in the United States, the National Survey on Drug Use and Health (NSDUH) [29] in young people from 18 to 25 years of age, has shown a mild reduction of those reporting drunkenness in the 30 days before the survey over almost three decades (44.6% in 1988 to 37.7% in 2014).

The Pan American Health Organization has warned that alcohol consumption in America is 40% more than in the rest of the world, and that the most vulnerable group to its harmful effects is women, and those belonging to lower socio-economical groups. Traffic accidents, domestic violence, suicide, social disinsertion, disease are different aspects of alcoholism.

 

DISCUSSION
Wine consumption is rooted in eating habits of a large part of the world population and constitutes one of the development areas of the economy of many countries, whether as producers or consumers.

The six-faced image in relation to wine consumption and cardiovascular health seeks to shed light on a complex context characterized by confusion, in regard to evidence, knowledge and recommendations.

About excessive alcohol consumption, including wine, there is no discussion as to the health, social and financial damages caused by it. The problem of this situation in young people merits an in-depth debate, but this is not related to the essence of the proposal of this review.

Moderate wine consumption, especially the red wine variety, offers sound positive evidence in the field of basic investigation, in relation to polyphenol effects, particularly resveratrol. Clinical observations show less sound evidence, but with a clear tendency in favor, which leads to the consideration that although there are no arguments to encourage consumption as a prevention action, there is no reason to not advise a moderate consumption in those used to drinking. Consumption of wine with less alcohol content could be a future line of investigation, with the aim of reducing adverse effects, keeping the components considered more beneficial and contained in the grape’s skin.

It is important to highlight as a message to the community, that the potential beneficial contributions of consumption should occur in a context of healthy food and that this does not leave out all measures to optimize lifestyle, the cornerstone of prevention.

The unification of the recommendations emanating from health organizations and scientific institutions is considered crucial. In this regard, the first step should be to adopt universal criteria for the Standard Drink considerations. Once the measuring unit is established, consumption tables should be configured, the information of which should be included in product tags, in mobile phone apps, and made available in institutional websites. This information should be used to support legislation to protect the community, regulating the production and commercialization of these products.

Finally, it is necessary to strengthen training of health care teams in terms of the assessment of consumption of any kind of alcoholic beverage in patients, knowledge on guidelines and a proper communication to the population.

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Publication: September 2019



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