Ruth C. Engs. Women, Alcohol and Health: A drink a day keeps the heart attack away. Current Opinion in Psychiatry 9(3):217-220, 1996.
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WOMEN, ALCOHOL, AND HEALTH : A DRINK A DAY KEEPS THE HEART ATTACK AWAY
Ruth C. Engs Professor, Department Applied Health Science
Indiana University, Bloomington, IN 47405
This review examines the effects of alcohol on women's health. It discusses studies examining the association of lower mortality with moderate drinking, explores reports relating alcohol consumption to health problems among women, and alludes to the ancient Mediterranean moderate drinking norm in light of this current research.
Until the past few years, most research examining the health effects of alcohol consumption used male subjects. However, it is not always possible to extrapolate information concerning women from these data as women have different biological functions. A few recent studies have included, or focused upon, the effect of alcohol on women in terms of health and illness, other than fetal alcohol research. Most studies appear to show that moderate alcohol consumption, and in particular wine, is associated with lowered mortality among women. Southern European drinking patterns have their origins in antiquity. Could moderate drinking have been associated with health and longevity by the populace thus reinforcing this pattern as a cultural norm?
HEALTH IMPLICATIONS OF MODERATE ALCOHOL CONSUMPTION BY MEN AND WOMEN
Over the past decade, most studies which focused upon alcohol consumption among women investigated the fetal alcohol syndrome. Several reports discussing this subject were found during the past year[1,2,3]. However, few studies in the past have examined other health aspects of alcohol consumption. Therefore, this review will explore health issues of women and alcohol other than the fetal alcohol syndrome.
Prospective cohort studies, conducted primarily with men, have found that light to moderate drinkers - one or two drinks per day -have lower mortality rates compared to either non drinkers or heavier drinkers. This 'U or J shape curve' in mortality has been largely due to a decreased risk of coronary heart disease and, to a smaller extent, ischemic stroke[4,5,6*,7].
Besides decreased mortality, there appears to be other health implications related to moderate drinking in studies which examined both women and men. Among Italians, La Vecchia et al.  found that individuals who consumed any alcohol were at less risk for gallbladder disease compared to abstainers. Randin et al.  in a Swiss study, suggests that low levels of alcohol acts to dilate blood vessels thus reducing blood pressure. On the other hand, above two to three drinks per day increased blood pressure. A study from the National Heart, Lung and Blood Institute , showed an association with lower body weight and alcohol consumption among non-smokers. Women who consumed under two drinks per week had the lowest body mass index. This could have implications for a lowered risk of heart disease.
Studies examining the effect of drinking on general health among college students and on bone density in older individuals were accomplished. Among a sample of American university students, Engs and Aldo-Benson [11*] found no difference between non-drinkers and those who consumed up to twenty one drinks per week in the incidence of upper respiratory infections and other acute health problems for both females and males. Above this level there was increased illness. Among elderly women, age related loss of bone mineral density is a chief factor in osteoporosis, a leading cause of death and disability. A report from the Framingham cohort study found that consuming alcohol was associated with a high bone density in post menopausal women and also in elderly men[12*]. These reports, which include both women and men, appear to suggest that more than two or three drinks per day are associated with health problems.
THE HEALTH IMPLICATIONS OF MODERATE ALCOHOL CONSUMPTION BY WOMEN ONLY
In the early 1990's a few publications began to focus exclusively on women and alcohol . As a whole, women in the United States, and other cultures, are more likely to abstain, drink less, and drink less frequently compared to men . Only a few studies, over the time period for this review, found a positive association with moderate alcohol consumption and health. Fuchs et al. [15**] reported on 86,000 American women from the prospective Nurses Health Study. Over a 12 year period, they found the Relative Risks of death in drinkers, as compare with non drinkers were .83 for women who consumed from one to three drinks per week. Light-to-moderate drinking(1.5 to 29.9 g per day) was associated with a decreased risk of death from cardiovascular disease. Risks for breast cancer and hepatic cirrhosis increased at three drinks a day(> 30 G/day) or more(See figure 1). The authors concluded that the benefits were greatest for women over 50 and those reporting one or more risk factors for coronary heart disease which accounted for almost 75 percent of the study population. The results of this study are similar to other reports which suggest that small amounts of alcohol decrease the risk of heart disease in women.
A few studies suggested a lack of association between moderate alcohol consumption and breast cancer. Freudenheim et al. [16*], in a case control study of pre- and post menopausal women in western New York, found little evidence of increased risk of breast cancer for lifetime low levels of alcohol consumption. The Relative Risk of about two drinks per day was .86.
The Netherlands Cohort Study on diet and cancer found moderate consumption led to a non-significant risk for breast cancer. However, increased risk, particularly among post menopausal women, who consumed 30 grams(3 or more drinks) or more of wine and spirits, was found. The Relative Risk of drinkers vs. nondrinkers was 1.31. [17*].
In one gynecological study, no significant physiological change in the responsiveness of women to alcohol during the menstrual cycle due to changes in levels of sex steroid hormones was found. Among Italian women, no significant difference for spontaneous abortion rates between those who abstained and those who consumed different levels of alcohol was ascertained. The results of these reports appear to support a lack of association of health problems with moderate consumption among women.
THE HEALTH CONSEQUENCES OF ALCOHOL CONSUMPTION AMONG WOMEN
In contrast to the above results, there have been several reports suggesting increased cancer risks for women associated with alcohol consumption. Parazzini, et al., in a study of Italian women, found an increase in endometrial cancer associated with increased alcohol consumption. The Relative Risk for drinkers compared to abstainers was 1.3. The estimated risk was 1.3, 1.1, 1.4, and 1.6 for women drinking under one, from 1 to 2, and over 2 drinks/day.
Longnecker et al. [21**] studied women from the North Eastern and North Central sections of the United States. This case control study found the risk for breast cancer increased with increasing doses of alcohol. Women whose lifetime average daily alcohol consumption was greater than or equal to 33g/d (about three drinks or more) experience a Relative Risk of 2.3 compared to that of 1.0 for lifelong abstainers. However, the authors found that alcohol
consumption before age 30 or by post menopausal women receiving estrogen replacement therapy did not increase the risk of breast cancer.
Very heavy drinking has been found to be associates with cardiac damage. In a study among Spanish alcoholic patients, despite the fact that the mean lifetime dose of alcohol among the females was only 60% that of males, the prevalence of cardiomyopathy was the same. The authors concluded that women were at greater risk for alcohol induced cardiac damage compared to men. In a sample of American alcoholic women, Smith et al.  found an association of higher mortality with bender drinking among the older women. They suggested that women might be more sensitive to short periods of high concentrations of alcohol compared to men. One study suggested that small amounts of alcohol could cause potential cardiac problems. Wang et al., with a sample of American women, reported that even one drink increased blood pressure and heart rate in an exercise situation. Most, but not all, of the studies showing an association of alcohol with health problems, suggested the relationship occurred with heavier drinking.
WINE, HEALTH AND THE ORIGINS OF DRINKING CULTURES
Some studies have implied that moderate wine consumption is more associated with longevity compared to moderate drinking of spirits. Grnbaek et al.[26**], over a 12 year study period in Copenhagen, found that the risk of dying steadily decreased with an increasing intake of wine for both women and men for all causes of mortality. The Relative Risk was 1.00 for the subjects who never drank wine compared to 0.5 for those who drank three to five glasses a day. Intake of neither beer nor spirits, however, was associated with reduced risk.
Longnecker et al., in contrast to the negative effects of total alcohol consumption as discussed above, in the same study found that moderate wine consumption did not increase the risk of breast cancer in women. They suggested the reason for these results could be that somewine contains phenolic compounds, that have antioxidant activity, while beer and spirits may contain substances that have estrogenic activity.
In view of these reports it, is interesting to note that the mortality rate for women from cardio vascular disease is 256/100,000 in Glasgow, Scotland compared to 30/100,00 in Catalonia, Spain where wine is the most commonly consumed beverage among older women compared to beer and spirits in Scotland[[27,28,29]. A review by Rimm and Ellison[30*] suggest that a Mediterranean diet high in fruits, vegetables and grains along with wine may be an important factor in preventing heart disease and ischemic stroke for both women and men. La Vecchia also discusses the same subject. In addition, La Vecchia et al.  found that Italians who abstained from alcohol(primarily wine) were at increased risk of diabetes, hypertension, heart attacks, ulcers, and other health problems. They concluded that one to two drinks a day is an important component of a healthy lifestyle and is conducive to good health and longevity.
These studies suggest that moderate drinking, and in particular wine, is associated with longevity and better health among women, and also men. Alcohol based beverages have been drunk in moderation with meals by Italian, and other Southern Europeans for centuries. Folk wisdom, through proverbs, has suggested that 'wine builds the blood' and 'wine is the milk of the elderly' .
The observation that a small amount of alcohol had beneficial, while large amounts had harmful, health effects, may have been a factor in shaping cultural norms. It has been suggested that in antiquity divergent climates, political processes, and agricultural eco-systems led to different drinking norms and beverage preferences in the Northern and in the Southern regions of Western Europe[34*]. The Mediterranean regions, well suited to viticulture, developed a drinking pattern of consuming small amounts of wine with meals. Alcohol was widely acceptable and available to most members of the culture, however, intoxication was frowned upon. In contrast, episodic 'feast drinking' to intoxication developed among the Northern tribes due to the scarcety of alcohol. Their grain based beverages, without preservatives, led people to consume it immediately. The resulting health and social problems from this pattern led to ambivalence about alcohol.
It is interesting to speculate if these drinking styles, and their relationship to health, were a reinforcing factor to the shaping of cultural norms. Could women, and also men, who drank small amounts of alcohol with meals have been seen by the populace to live longer and have better health than those who abstained or drank to intoxication? Some of the data based research discussed in this review, which appears to imply health benefits from small amounts of alcohol, may, in fact, support ancient folk wisdom.
In conclusion, with a few exceptions, moderate alcohol intake among women(1 to 2 drinks per day), is associated with a reduction in overall mortality. This reduction is due primarily to a reduced risk of coronary heart disease. Increased alcohol consumption may increase the risk of breast and endometrial cancer. However, wine consumption may not to be related to the risk of breast cancer. The norm of moderate drinking with meals, in Southern Europe, may have partially developed in antiquity based upon 'folk' observations that this moderate drinking was associated with longevity and health among women and men.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as: * of special interest ** of outstanding interest
1. Hannigan JH, Martier SS, Baber JM: Independent associations among maternal alcohol consumption and infant thyroxine levels and pregnancy outcome. Alcohol Clin Exp Res 1995, 19(3):557--581.
2. Sampson PD, Bookstein FL, Barr HM, Streissguth AP: Prenatal alcohol exposure, birthweight, and measures of child size from birth to age 14 years. Am J Public Health 1994, 84(9):1407--1413.
3. Streissguth AP, Sampson PD, Olson HC, Bookstein FL, Barr HM, Scott M, Feldman J, Mirsky AF: Maternal drinking during pregnancy:attention and short-term memory in 14-year old off-spring: a longitudinal prospective. Alcohol Clin Exp Res 1994, 18(1):220.
4. Doll R, Peto R: Mortality and alcohol consumption [letter]. BMJ 1995, 310(6977): 470
5. Doll R, Peto R, Hall E, Wheatley, K, Gray, R: Mortality in relation to consumption of alcohol: 13 years' observations on male British doctors. BMJ 1994, 309(6959): 911--8.
*6.Klatsky AL: Annotation: Alcohol and longevity. Am J Public Health 1995, 85(1):16--17.
This brief review discusses and cites many studies which show an association of moderate drinking with health. It includes several reports which focus on women.
7. Carmelli D, Swan GE, Page WF, Christian JC: World War II-veteran male twins who are discordant for alcohol consumption:24-year mortality. Am J Public Health 1995, 85:99--101.
8. La Vecchia C, Decarli A, Ferraroni M, Negri E: Alcohol drinking and prevalence of self reported gallstone disease in the 1983 Italian National Health Survey. Epidemiol 1994, 5(5): 533--6.
9. Randin D, Vollenweider P, Tappy, L, Jequier E, Nicod, P. and Scherrer U: Suppression of alcohol-induced hypertension by dexamethasone. N Engl J Med 1995, 332(26): 1734--1737.
10. Istvan J, Murray R, Voelker H: The relationship between patterns of alcohol consumption and body weight. Int J Epidemiol 1995, 24(3):543--546.
*11. Engs RC, Aldo-Benson M: The Association of Alcohol Consumption With Self-reported Illness in University Students. Psychol Rep 1995, 76:727--736.
Healthy female and male university students who consume up to a mean of 3 drinks per day have no more acute health problems compared to abstainers. Above this level an increase in upper respiratory and other health problems are found.
*12. Felson DT, Zhang Y, Kiel DP : Alcohol intake and bone mineral density in elderly men and women. The Framingham Study. Am J Epidemiol 1995, 142(5):485--492.
Age-related loss of bone mineral density is the chief factor in osteoporosis, a major health problem of elderly women. This new report from the Framingham study suggests that consuming at least 7 oz. of alcohol per week is associated with high bone density in post menopausal women.
13. Engs, RC: [Editor] Women: Alcohol and Other Drugs. Dubuque, Iowa: Kendall Hunt; 1990.
14. Wilsnack SC, Wisnack RW, Hiller-Sturmhfel S: How women drink: Epidemiology of women's drinking and problem drinking. Alc Health and Res World 1994, 18(3):173--184.
**15. Fuch CS, Stampfer MJ, Colditz GA, Giovannucci EL, Manson JE, Kawachi I, Hunter DJ, Hankinson SE, Hennekens CH, Rosner B, Speizer FE, Willett WC: Alcohol consumption and mortality among women. N Engl J Med 1995, 332(19):1245--1250.
This report is from the Nurses Health Study(USA) established in 1976 to study risk factors for cancer and heart disease among women. Over a 12 year span, it was found that light to moderate drinking was associated with a decreased risk of death from cardiovascular disease; heavier drinking was associated with an increased risk of death from breast cancer and cirrhosis.
*16. Freudenheim JL, Marshall JR, Graham S, Laughlin R, Vena JE, Swanson M, Ambrosone C, Nemoto T: Lifetime alcohol consumption and risk of breast cancer. Nutr Cancer 1995, 23(1): 1--11.
This case control study examines the relation of lifetime alcohol use to risk of breast cancer in pre-and post menopausal women. The results found little evidence of increased risk of breast cancer with intake of alcohol at any of the time periods studied or with an index of total lifetime intake.
*17. Van den Brandt PA, Goldbohm RA, Van 't Veer P : Alcohol and breast cancer results from the Netherlands cohort study. Am J Epidemiol 1995, 141(10):907--915.
The association of diet and cancer was explored in this Cohort study. They found low risk under three drinks per day for breast cancer.
18. Lammers SM, Mainzer DE, Breteler MH: Do alcohol pharmacokinetics in women vary due to the menstrual cycle? Addiction 1995, 90(1): 23--30.
19. Parazzini F, Tozzi L, Chatenoud L, Restelli S, Luchini L, La Vecchia C: Alcohol and risk of spontaneous abortion. Hum Reprod 1994, 9(10): 1950--3.
20. Parazzini F, La Vecchia C, D'Avanzo B, Moroni S, Chatenoud L, Ricci E: Alcohol and endometrial cancer risk: findings from an Italian case control study. Nutr Cancer 1995, 23(1): 55--62.
**21. Longnecker MP, Newcomb PA, Mittendorf R, Greenberg ER, Clapp RW, Bogdan GF, Baron J, MacMahon B, Willett WC: Risk of breast cancer in relation to lifetime alcohol consumption. J Nat Can Inst 1995, 87(12): 923--929.
This population based Case Control study(USA) suggested that increases in lifetime average alcohol consumption, particularly over three drinks per day, was associated with breast cancer. Wine consumption was not related to risk of breast cancer, however.
22. Urbano-Mrquez A, Estruch R, Fernndez-Sol J, Nicols JM, Par JC, Rubin E: The greater risk of alcoholic cardiomyopathy and myopathy in women compared with men. JAMA 1995, 274(2):149--154.
23. Smith EM, Lewis CE, Kercher C, Spitznagel E: Predictors of mortality in alcoholic women:A 20-year follow-up study. Alcohol Clin Exp Res 1994, 18(5):1177--1186.
24. Wang MQ, Nicholson ME, Richardson MT, Fitzhugh EC, Reneau P, Westerfield CR: The acute effect of moderate alcohol consumption on cardiovascular response in women. J Stud Alcohol 1995, 56(1):16--20.
25. Klatsky AL, Armstrong MA: Alcoholic beverage choice and risk of coronary artery disease mortality: Do red wine drinkers fare best ? Am J Cardiol 1993, 71:467--469.
26. Grnbaek M, Deis A , Srensen T, Becker U, Schnohr P, Jensen G: Mortality associated with moderate intakes of wine, beer, or spirits. BMJ 1995, 310:1165--1169.
27. Tunstall-Pedo H, Kuulasmaa K, Amouyel P, Arveiler D, Rajakangas AM, Pajak A: Myocardial infarction and coronary deaths in the World Health Organization MONICA Project: Registration procedures, event rates, and case-fatality rates in 38 populations from 21 countries in four continents. Circulation 1994, 90(1):583--612.
28. Woodward M, Tunstall-Pedoe, M: Alcohol consumption, diet, coronary risk factors, and prevalence of coronary heart disease in men and women in the Scottish Health Study. J Epidemiol Comm Health 1995, 49(4):354--362.
29. Alvarez FJ, Carmen del Rio M: Gender differences in patterns of alcohol consumption in Spain. Alc Clin Exp Res 1994, 18(6):1342--1347.
*30. Rimm EB, Ellison RC: Alcohol in the Mediterranean diet. Am J Clin Nutr 1995, 61(6 Supplement):1378S--1382S. A review of the literature which suggests that a diet of fruits, vegetables, grains and moderate alcohol consumption is associated with longevity and health.
31. La Vecchia C: Alcohol in the Mediterranean diet: assessing risks and benefits [editorial]. Eur J Cancer Prev 1995, 4(1): 3--5.
32. La Vecchia C, Decarli A, Franceschi, S, Ferraroni SFM, Pagano, R: Prevalence of chronic disease in alcohol abstainers. Epidemiol 1995, 6:436--438.
33. Cotino A: Wine is the blood of the earth. Addiction Research 1995, 2(3):251--258.
*34. Engs RC: Do Traditional western European drinking practices have origins in antiquity? Addiction Research 1995, 2(3):227--239.
This report explores the probable origins of Western European drinking patterns including the Mediterranean practice of moderate drinking. Implications for alcohol consumption among women, and men, in modern western societies are discussed.
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