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Drink to Your Health? Author(s): Arthur L

Nursing

Drink to Your Health?

Author(s): Arthur L. Klatsky

Source: Scientific American , Vol. 288, No. 2 (FEBRUARY 2003), pp. 74-81

Published by: Scientific American, a division of Nature America, Inc.

Stable URL: https://www.jstor.org/stable/10.2307/26060167

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Drink to Your? said something about “intoxicating liquor” that probably got a frosty reception. “It is true that . . . many were greatly injured by it,” the future president noted. “But none seemed to think the injury arose from the use of a bad thing but from the abuse of a very good thing.”

America has always had trouble deciding whether alcohol is a bad thing or a good thing. Millions who remember Prohi- bition, when all alcoholic beverages were illegal, now witness a constant stream of advertisements from producers of alco- holic beverages encouraging people to drink. Despite alcohol’s popularity today, however, many still consider abstinence a virtue. Certainly, heavy drinking and alcoholism deserve deep concern for the terrible toll they take on alcohol abusers and

society in general. But worry about the dangers of abuse often leads to emotional denials that alcohol could have any med- ical benefits. Such denials ignore a growing body of evidence indicating that moderate alcohol intake wards off certain car- diovascular (circulatory system) conditions, most notably heart attacks and ischemic strokes (those caused by blocked blood ves- sels). A few studies even show protection against dementia, which can be related to cardiovascular problems.

The Alcohol Effect A DISCUSSION OF moderate drinking requires a working de- finition of “moderate.” Simple definitions of light, moderate or heavy are somewhat arbitrary, but a consensus in the medical

w w w . s c i a m . c o m S C I E N T I F I C A M E R I C A N 75

Three decades of research shows that

drinking small to moderate amounts

of alcohol has cardiovascular benefits.

A thorny issue for physicians is whether to

recommend drinking to some patients

Health By Arthur L. Klatsky

Photographs by Tina West

Addressing an Illinois temperance society in 1842, Abraham Lincoln

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literature puts the upper limit for moder- ate drinking at two standard-size drinks a day [see illustration on opposite page]. Studies show that drinking above that level can be harmful to overall health, al- though sex, age and other factors lower and raise the boundary for individuals.

The main medical benefit of reason- able alcohol use seems to be a lowering of the risk for coronary heart disease (CHD), which results from the buildup of atherosclerosis (fatty plaque) in the arter- ies that feed blood to the heart. (The word “atherosclerosis” is in fact a descriptive union of two Greek words: athera, for “gruel” or “porridge,” referring to the fat- ty deposits, and sclera, for “hard,” per- taining to the loss of vessel flexibility.)

Atherosclerosis restricts blood flow to the heart and can promote the formation of vessel-blocking clots. It can thereby cause angina (chest discomfort resulting from low oxygen levels in the heart mus- cles), heart attack (the death of heart tis- sue that occurs when a blood clot or nar- rowing of the arteries prevents blood from reaching the heart) and death, often with- out warning. The condition usually starts at a young age but takes decades to blos- som into overt CHD. The most common form of heart disease in developed coun- tries, CHD causes about 60 percent of deaths from cardiovascular ills and about

25 percent of all deaths in those nations. Pathologists uncovered the first clues

to the value of alcohol in the early 1900s, noting that the large arteries of people who died of alcoholic liver cirrhosis seemed remarkably “clean”—that is, free of atherosclerosis. One explanatory hy- pothesis assumed that alcohol was a neb- ulous solvent, essentially dissolving the buildup in the arteries; another explana- tion held that heavier drinkers died be- fore their atherosclerosis had a chance to develop. Neither idea truly explained drinkers’ unblocked arteries, however.

A more telling hint emerged in the late 1960s, when Gary D. Friedman of the Kaiser Permanente Medical Center in Oakland, Calif., came up with a novel idea: use computers to unearth unknown predictors of heart attacks. The power of computing could first identify healthy people who had risk factors similar to heart attack victims. Such factors include cigarette smoking, high blood pressure, diabetes, elevated levels of low-density- lipoprotein (LDL, or “bad”) cholesterol, low levels of high-density-lipoprotein (HDL, or “good”) cholesterol, male gen- der, and a family history of CHD. Fried- man then searched for predictors of heart attacks by comparing the patients and the newly found controls in hundreds of ways—for example, their exercise and di-

etary habits and their respective levels of various blood compounds. The comput- ers spit out a surprising discovery: absti- nence from alcohol was associated with a higher risk of heart attack.

Various studies had missed the con- nection because they neglected to exam- ine alcohol use as a behavior separate from smoking. We now know that be- cause drinkers often also use cigarettes, the negative impact of smoking was masking the beneficial effect of alcohol. In 1974 my Kaiser Permanente colleagues Friedman and Abraham B. Siegelaub and I were the first, to our knowledge, to pub- lish an examination of moderate drinking in the absence of smoking. We saw a clear connection between alcohol consumption and a decreased risk of heart attack.

Since then, dozens of investigations in men and women of several racial groups in various countries have correlated pre- vious alcohol use with current health. These studies have firmly established that nondrinkers develop both fatal and non- fatal CHD more often than do light to moderate drinkers. In addition, in 2000 Giovanni Corrao of the University of Mi- lan-Bicocca in Italy, Kari Poikolainen of the Järvenpää Addiction Hospital in Fin- land and their colleagues combined the results of 28 previously published inves- tigations on the relation between alcohol intake and CHD. In this meta-analysis, they found that the risk of developing CHD went down as the amount of alco- hol consumed daily went up from zero to 25 grams. At 25 grams—the amount of alcohol in about two standard drinks— an individual’s risk of a major CHD event, either heart attack or death—was 20 percent lower than it was for someone who did not drink at all.

New data about alcohol protecting against death from CHD are even more impressive. At a meeting of the American

76 S C I E N T I F I C A M E R I C A N F E B R U A R Y 2 0 0 3

? An assortment of studies from around the world indicates that drinking in small to moderate amounts decreases the risk of dying from coronary heart disease by almost one third.

? Some research points to red wine as being particularly protective against coronary heart disease. Other healthful habits of red wine drinkers, however, may be partly responsible for the apparent effect.

? A select group of people—those with CHD or at risk for CHD and without risks associated with alcohol itself—may wish to consult their physicians about moderate drinking as part of a heart-healthy diet.

Overview/Alcohol and Heart Health

The large ARTERIES OF PEOPLE who died of alcoholic liver cirrhosis were remarkably

free of atherosclerosis.

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Heart Association last November, my Kaiser Permanente colleagues Friedman, Mary Anne Armstrong and Harald Kipp and I discussed an updated analysis of 128,934 patients who had checkups be- tween 1978 and 1985, with 16,539 of them dying between 1978 and 1998. CHD was responsible for 3,001 of those deaths. We discovered that those who had one or two alcoholic drinks a day had a 32 percent lower risk of dying from CHD than abstainers did.

The possible mechanisms by which alcohol has such an apparently profound effect on cardiovascular health primarily involve cholesterol levels and blood clot- ting. Blood lipids, or fats, play a central role in CHD. Numerous studies show that moderate drinkers have 10 to 20 percent higher levels of heart-protecting HDL cholesterol. And people with high- er HDL levels, also known to be in- creased by exercise and some medica- tions, have a lower risk of CHD.

That lower risk stems from HDL’s ability to usher LDL cholesterol back to the liver for recycling or elimination, among other effects. Less cholesterol then

builds up in the walls of blood vessels, and so less atherosclerotic plaque forms. Al- cohol seems to have a greater influence on a different HDL subspecies (HDL3) than on the type increased by exercise (HDL2), although both types are protective. (The biochemical pathways in the liver that could account for alcohol’s ability to raise HDL levels remain incompletely known; it is thought that alcohol probably affects liver enzymes involved in the production of HDL.) Three separate analyses aimed at determining specific contributions of alcohol all suggest that the higher HDL levels of drinkers are responsible for about half of the lowered CHD risk.

Alcohol may also disrupt the com- plex biochemical cascade behind blood clotting, which can cause heart attacks when it occurs inappropriately, such as over atherosclerotic regions in coronary arteries. Blood platelets, cellular compo- nents of clots, may become less “sticky” in the presence of alcohol and therefore less prone to clumping, although data on this question remain ambiguous. A 1984 study by Raffaele Landolfi and Manfred Steiner of Brown University’s Memorial

Hospital revealed that alcohol intake in- creases the level of prostacyclin, which in- terferes with clotting, relative to the level of thromboxane, which promotes clot- ting. Walter E. Laug of the University of Southern California Keck School of Med- icine showed that alcohol raises levels of plasminogen activator, a clot-dissolving enzyme. Finally, several studies suggest that alcohol lowers levels of another pro- moter of blood clots, fibrinogen.

Overall, alcohol’s anticlotting capac- ity is not as well established as its HDL effect, and some effects, such as platelet clumping, may be reversed by heavy or binge drinking. Nevertheless, anticlotting appears to have a role in the lower risk for heart attacks enjoyed by moderate drinkers. In addition, studies have shown a beneficial effect on CHD risk in people who have far fewer than two drinks a day—say, three or four drinks a week. Anticlotting could be a major factor in the protection accorded by alcohol in these small amounts, which seem insuffi- cient to affect HDL levels greatly.

Although alcohol reduces heart dis- ease risk mainly by raising HDL levels

w w w . s c i a m . c o m S C I E N T I F I C A M E R I C A N 77

ALTHOUGH THERE IS NO formal definition of a standard-size drink, something of a consensus does exist. Beer is often sold in a 12-ounce bottle or can, which is a useful reference point as one standard drink. The amount of alcohol, about 0.6 ounce, in

12 ounces of beer is virtually the same as is found in a 5-ounce glass of wine or a 1.5-ounce glass of distilled spirits, such as vodka, gin, bourbon or scotch. Wine and distilled spirits in these amounts are thus also considered standard drinks.

“STANDARD” SERVINGS OF ALCOHOLIC BEVERAGES

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and reducing clotting, it acts in other ways that could lower the risk more sub- tly. Moderate drinking may lessen CHD risk indirectly by decreasing the risk of type 2 (adult-onset) diabetes, which is a powerful predictor of CHD. This bene-

fit appears to be related to enhanced in- sulin sensitivity, which promotes proper glucose usage. (Heavy drinking, howev- er, has been connected to higher blood glucose levels, a marker for future dia- betes.) Evidence is also growing that in-

flammation contributes to CHD, and al- cohol’s anti-CHD power may be related to an anti-inflammatory action on the en- dothelial tissue that lines blood vessels.

Before accepting alcohol’s benefits, an epidemiologist attempts to locate hidden

78 S C I E N T I F I C A M E R I C A N F E B R U A R Y 2 0 0 3

No CHD risk factor other than current age

Has diabetes or CHD or has 2 or more

CHD risk factors

0 or 1 CHD risk factor

No change for health reasons Should consider

1 to 3 standard drinks a week

NONDRINKERS

Has diabetes or CHD or has 1 or more CHD risk factors other

than current age

No CHD risk factor other than current age

No change for health reasons

Should consider 1 to 3 standard drinks a week

LIGHT/MODERATE DRINKERS

Has diabetes or CHD or has 2 or more

CHD risk factors

0 or 1 CHD risk factor

No change for health reasons

No change for health reasons

LIGHT/MODERATE

Has diabetes or CHD or has 2 or more CHD risk factors other

than current age

0 or 1 CHD risk factor other than current age

No change for health reasons If drinking less than 1

standard drink a day, increase to 1;

otherwise, no change

Has diabetes or CHD or has 2 or more CHD risk factors

0 or 1 CHD risk factor

Should abstain Should reduce to no more than 1 standard drink a day or abstain

Has diabetes or CHD or has 1 or more

CHD risk factors other than current age

Should abstain Men should reduce to no

more than 2 standard drinks a day or abstain;

women should reduce to no more than 1 standard drink

a day or abstain

NONDRINKERS

HEAVY DRINKERS HEAVY DRINKERS

LIGHT/MODERATE DRINKERS

MEN AGE 21 to 39 / WOMEN AGE 21 to 49 MEN AGE 40 AND OLDER / WOMEN AGE 50 AND OLDER

MAKING THE DRINKING DECISION

Coronary heart disease (CHD) risk factors, according to National Cholesterol Education Program guidelines: 1. Family history of CHD (father or brother younger than 55 with CHD,

mother or sister younger than 65 with CHD) 2. Smoking 3. High blood pressure

4. Total cholesterol higher than 200 5. HDL cholesterol lower than 35

(if HDL is higher than 60, subtract one risk factor) 6. Age 40 and older for men, 50 and older for women

Roger R. Ecker, a cardiovascular surgeon at Summit MedicalCenter in Oakland, Calif., and I developed these charts to help individuals determine whether to include alcoholic beverages, and in what amounts, in their diets. The charts are designed to be used by physicians in consultation with patients. Coronary heart disease (CHD) risk factors are listed at the bottom. “Light/ Moderate” is defined as up to one standard drink a day for women and up to two standard drinks a day for men. “Heavy” is three or

more drinks a day for men and two or more drinks a day for women. These charts do not apply to the following people, who should

abstain from alcoholic beverages: anyone under the age of 21; pregnant women; nondrinkers with a family history of alcoholism, with moral or religious beliefs that preclude alcohol, with a personal history of alcohol abuse, with known organ damage from alcohol, with any chronic liver disease, or with a genetic risk of breast or ovarian cancer. —A.L.K.

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factors possibly at work. For instance, could lifelong abstainers differ from drinkers in psychological traits, dietary habits, physical exercise habits or other ways that might account for their higher CHD risk without the need to invoke the absence of alcohol? Were such traits to explain away alcohol’s apparent protec- tion, they would need to be present in both sexes, various countries and several racial groups. Considering that no such traits have been identified, the simpler and more plausible explanation is that light to moderate alcohol drinking does indeed enhance cardiovascular health.

In fact, the available evidence satisfies most standard epidemiological criteria for establishing a causal relation. The nu- merous studies examining light and mod- erate alcohol intake and health reach con- sistent conclusions. The prospective stud- ies that exist have the correct temporal sequence—that is, individuals’ habits of interest are identified, after which their health is monitored over the long term, and alcohol users have different health profiles than nondrinkers do. The posi- tives associated with alcohol can be at- tributed to biologically plausible mecha- nisms. Alcohol offers specific enhance- ment of cardiovascular health, not general protection against all illness. And alco- hol’s effect can be identified independent of known “confounders,” other alcohol- related factors that could be responsible for a subject’s cardiovascular condition.

The 30 percent reduction in risk is, perhaps surprisingly to some, less con- vincing evidence than the arguments above, because a strong unknown con- founder could still account for the con- nection. To take an extreme example, consider a hypothetical set of genes that confers on the possessor 60 percent less CHD risk and causes a strong predisposi- tion toward liking moderate amounts of alcohol. The independent consequences of the genes could appear causally linked.

(In fact, however, no such confounder is known or likely, and the 30 percent risk reduction appears to be a probable mea- sure of alcohol’s beneficial effect.)

Because heavy drinking is not more protective than lighter drinking, this ab- sence of a clear dose-response relation is also a weakness. Nevertheless, the col- lected data make a strong case for the cardiac benefits of controlled drinking. I should note, however, that the kind of study considered to be the gold standard in human research—a prospective ran- domized blinded clinical trial—has not yet been done. Such a study might, for example, engage a large pool of non-

drinkers, half of whom, chosen at ran- dom and without the knowledge of the researchers, would commence a moder- ate drinking regimen, while the other half remained abstainers. The two groups would be followed for years in a search for eventual differences in cardiovascular disease and heart-related deaths.

To Drink or Not to Drink MOST PEOPLE DRINK for reasons oth- er than alcohol’s health benefits, and many of them are already using alcohol in amounts that appear to promote cardio- vascular health. But the accumulated re- search on alcohol’s positive effects pre-

w w w . s c i a m . c o m S C I E N T I F I C A M E R I C A N 79

The collected data make a strong case for the CARDIAC BENEFITS of controlled drinking.

HOW ALCOHOL MIGHT PROTECT AGAINST CHD Alcohol Effect Probable Action Evidence Raises blood HDL Removes and transports Solid supporting evidence; cholesterol LDL cholesterol from effect explains at least

vessel wall half of alcohol’s benefit

Lowers blood LDL Reduces level of one Evidence weak; effect cholesterol major CHD risk factor probably not independent

of diet

Lowers the oxidation Prevents the plaque Largely hypothetical, of LDL formation associated although antioxidants are

with LDL oxidation plentiful in red wine

Lowers levels Lessens the risk of clot Moderate supporting data of fibrinogen in blood formation on

atherosclerotic plaques

Exerts other anticlotting Lessens the risk of clot Inconsistent data; actions: lessens platelet formation on possible reversal of effect stickiness; raises levels atherosclerotic plaques with heavy or binge of prostacylin; lowers drinking levels of thromboxane

Lessens insulin Lessens key risk factor Evidence comes from resistance for adult-onset diabetes a small number of studies

and atherosclerosis

Lessens psychosocial Unclear No supporting data stress or likely mechanism

Improves conditioning Imparts better resistance Preliminary supporting of heart muscle to damage from oxygen evidence

deprivation

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sents a challenge to physicians. On one hand, mild to moderate drinking seems better for heart health than abstinence for select people. On the other hand, heavy drinking is clearly dangerous. It can con- tribute to noncardiovascular conditions such as liver cirrhosis, pancreatitis, certain cancers and degenerative neurological dis- orders, and it plays a part in great num-

bers of accidents, homicides and suicides, as well as in fetal alcohol syndrome. (No conclusive evidence links light to moder- ate drinking to any of these problems.)

Heavy drinking also contributes to cardiovascular disorders. Too much al- cohol raises the risk of alcoholic car- diomyopathy, in which the heart muscle becomes too weak to pump efficiently;

high blood pressure (itself a risk factor for CHD, stroke, heart failure and kidney failure); and hemorrhagic stroke, in which blood vessels rupture in or on the surface of the brain. Alcohol overindul- gence is also related to “holiday heart syn- drome,” an electrical signal disturbance that disrupts the heart rhythm. The name refers to its increased frequency around particular holidays during which people engage in binge drinking.

Given the potential dangers of alco- hol, how can individuals and their physi- cians make the decision as to whether to include alcoholic beverages in their lives and, if so, in what amounts? The ability to predict accurately an individual’s risk of a drinking problem would be a great boon; the least disputed possible conse- quence of moderate drinking is problem drinking. Individual risk can be approxi-

80 S C I E N T I F I C A M E R I C A N F E B R U A R Y 2 0 0 3

Beer, wine and liquor all seem to be related to a lower risk ofcoronary heart disease (CHD). A tantalizing question, however, is whether one kind of drink—wine, for example—is better than the others. The short answer: the jury is still out.

The death rate from CHD in France, where red wine consumption is common, is only about half that in the U.S., despite similar fat intake and sedentary lifestyles. That observation led to the catchphrase “the French paradox” and the idea that red wine is the beneficial alcoholic beverage. This belief has a hypothetical basis—red wine especially contains a number of ingredients with potential antioxidant and other atherosclerosis-fighting benefits.

An excellent 1995 Danish study, in which almost 13,000 people were followed during a 12-year period, suggested that wine drinkers have lower death rates from CHD than do other alcohol imbibers. My Kaiser Permanente colleagues Mary Anne Armstrong and Gary D. Friedman and I published on the risk of CHD death (in 1990) and the risk of CHD hospitalization (in 1997); in these investigations, which included almost 130,000 Californians, wine and beer drinkers had a lower CHD risk than did hard-liquor drinkers. At a meeting of the American Heart Association in November 2002, I presented new data that updated the 1990

study. We were surprised to find that those drinking wine daily had about a 25 percent lower risk of CHD death than did those who drank beer and wound up taking in the same amount of alcohol. And the wine drinkers had about a 35 percent lessened

CHD death risk compared with the light to moderate hard-liquor drinkers. Significantly, there was no difference in apparent benefit between red wine and white wine.

A vexing complication of all these studies, however, is that the overall habits of wine drinkers, beer drinkers and hard- liquor drinkers tend to differ greatly. In Denmark, for example, wine drinking goes hand in hand with a healthful diet (high in fruits, vegetables, fish, salads and olive oil) and two other markers for better health in general: higher socioeconomic status and higher IQ. In our California studies, those who preferred wine also smoked less, had more education and had more temperate drinking habits than those who preferred beer or hard liquor.

Lifestyle differences among those who prefer one type of alcoholic beverage over another thus make it exceedingly difficult to determine whether the differences in apparent health effects are actually related to the beverage type itself (and therefore to wine constituents besides alcohol), to drinking pattern (imbibed slowly and with food, for wine) or to other factors. —A.L.K.

ARTHUR L. KLATSKY is a senior consultant in cardiology and an adjunct investigator at the division of research at the Kaiser Permanente Medical Center in Oakland, Calif. A graduate of Harvard Medical School, he headed the medical center’s division of cardiology from 1978 to 1994 and directed its coronary care unit from 1968 to 1990. Since 1977 he has been prin- cipal investigator of a series of studies of the link between drinking alcoholic beverages and health. His 1974 Annals of Internal Medicine article [see More to Explore, on opposite page] was the first published epidemiological report of an inverse relation between alcohol drink- ing and coronary disease; it was cited in 1995 by the National Institute on Alcohol Abuse and Alcoholism as one of 16 seminal articles in alcohol research. His most recent honor was a Health Forum Cardiovascular Health Fellowship for 2000–2001. Klatsky has completed six marathons and in 1990 climbed Mount Kilimanjaro.

TH E

A U

TH O

R

WINE, BEER OR SPIRITS?

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mated using family and personal histories of alcohol-related problems or condi- tions, such as liver disease or, of course, alcoholism. Even when known factors are taken into account, however, unpre- dictable events late in life may result in deleterious drinking changes.

Exactly because of these dangers, public health concerns about alcohol un- til recently have been appropriately fo- cused solely on the reduction of the terri- ble social and medical consequences of heavy drinking. And the correlation be- tween total alcohol consumption in soci- ety and alcohol-related problems has been used to justify pushes for abstinence. Ultimately, however, a more complex message is necessary. Merely recom- mending abstinence is inappropriate health advice to people such as estab- lished light drinkers at high risk of CHD and at low risk of alcohol-related prob- lems—which describes a large proportion of the population. Of course, the most im- portant steps for this group are proper diet and exercise; effective treatment of obesity, diabetes, high blood pressure and high cholesterol; and avoidance of tobac- co. But there is a place on that list of ben- eficial activities for light drinking. Most light to moderate drinkers are already im-

bibing the optimal amount of alcohol for cardiovascular benefit, and they should continue doing what they are doing.

Abstainers should never be indiscrim- inately advised to drink for health; most have excellent reasons for not drinking. Yet there are exceptions. One case is the person with CHD who “goes clean”— quits smoking, switches to a spartan diet, starts exercising and, with good inten- tions, gives up the habit of a nightly bot- tle of beer or glass of wine. This self-im- posed prohibition should be repealed. In addition, a number of infrequent drinkers might think about increasing their alco- hol intake to one standard drink daily, es- pecially men older than 40 and women older than 50 at high risk of CHD and low risk of alcohol-related problems. But

women also have to consider one possi- ble drawback of alcohol: several studies link heavy drinking—and a few even link light drinking—to an increased risk of breast cancer, a less common condition than heart disease in postmenopausal women but certainly quite a serious one. For young women, who are generally at low short-term risk of CHD and there- fore may not benefit greatly from alco- hol’s positive cardiovascular effects, this possible breast cancer link looms larger in estimating the overall risks and bene- fits of alcohol. And for all women, the upper limit on moderate drinking should be considered one drink a day.

The only clear-cut message regarding alcohol and health, then, is that all heavy drinkers should reduce or abstain, as should anyone with a special risk related to alcohol, such as a family or personal history of alcoholism or preexisting liver disease. Beyond that, however, the po- tential risks and benefits of alcohol are best evaluated on a case-by-case basis. Cardiovascular surgeon Roger R. Ecker and I constructed an algorithm that can help health practitioners and their pa- tients decide how much—if any—alcohol is right for a given individual [see box on page 78].

In short, health professionals should provide balanced, objective guidelines re- garding their patients’ use of alcohol, and such advice needs to be tailored to each person. I believe that it is possible to define a clear, safe limit for alcohol consumption that would offer a probable benefit to a select segment of the population. The an- cient Greeks urged “moderation in all things.” Three decades of research shows that this adage is particularly appropriate when it comes to alcohol.

w w w . s c i a m . c o m S C I E N T I F I C A M E R I C A N 81

Alcohol Consumption before Myocardial Infarction: Results from the Kaiser-Permanente Epidemiologic Study of Myocardial Infarction. Arthur L. Klatsky, Gary D. Friedman and Abraham B. Seigelaub in Annals of Internal Medicine, Vol. 81, No. 3, pages 294–301; September 1974.

Epidemiology of Coronary Heart Disease—Influence of Alcohol. Arthur L. Klatsky in Alcoholism: Clinical and Experimental Research, Vol. 18, No. 1, pages 88–96; January 1994.

Alcohol in the Western World. Bert L. Vallee in Scientific American, Vol. 278, No. 6, pages 80–85; June 1998.

Alcohol and Coronary Heart Disease. Giovanni Corrao, Luca Rubbiati, Vincenzo Bagnardi, Antonella Zambon and Kari Poikolainen in Addiction, Vol. 95, No. 10, pages 1505–1523; October 2000.

Alcohol in Health and Disease. Edited by Dharam P. Agarwal and Helmut K. Seitz. Marcel Dekker, 2001.

M O R E T O E X P L O R E

RISKS

Established Heavy drinking

Unresolved Breast cancer Fetal damage

Unlikely Bowel cancer Hemorrhagic

stroke High blood

pressure

RISKS

Noncardiovascular Liver cirrhosis Pancreatitis Certain cancers Accidents Homicides Suicides Fetal damage Degenerative

disorders of the central nervous system

Cardiovascular High blood pressure Arrhythmia Hemorrhagic stroke Cardiomyopathy

(damaged heart muscle)

BENEFITS

Probable Decreased risk of CHD Decreased risk

of ischemic stroke Decreased risk

of gallstones

Possible Decreased risk

of diabetes Decreased risk

of peripheral vascular disease (narrowing or clogging of the arteries carrying blood to the arms and legs)

BENEFITS

None

DRINKING: RISKS AND BENEFITS Light/Moderate Drinking Heavy Drinking

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