Advanced Mediterranean Diet

The Million Women Study recently looked at the association between alcohol consumption and the incidence of various cancers in middle-aged women in the United Kingdom.

Here’s the conclusion from the abstract in the Journal of the National Cancer Institute:

Low to moderate alcohol consumption in women increases the risk of certain cancers. For every additional drink regularly consumed per day, the increase in incidence up to age 75 years per 1000 for women in developed countries is estimated to be about 11 for breast cancer, 1 for cancers of the oral cavity and pharynx, 1 for cancer of the rectum, and 0.7 each for cancers of the esophagus, larynx and liver, giving a total excess of about 15 cancers per 1000 women up to age 75.

Other cancers seemed to be reduced by increasing levels of alcohol consumption:  thyroid, non-Hodgkin lymphoma, renal cell carcinoma.

Comparing wine with other alcohol types, no differences in cancer risks were found.

Low to moderate alcohol consumption is associated with prolonged life, lesser risk of dementia, and lower rates of cardiovascular disease.  The article abstract doesn’t mention these issues, nor the possibility that the benefits of judicious alcohol consumption may outweigh the cancer risks.

^{Steve Parker, M.D.}

^References: 

^{Allen, Naomi, et al.  Moderate Alcohol Intake and Cancer Incidence in Women.  Journal of the National Cancer Institute, 101 (2009): 296-305.}

^{Lauer, Michael and Sorlie, Paul.  Alcohol, Cardiovascular Disease, and Cancer: Treat With Caution.  Journal of the National Cancer Institute, 101 (2009): 282-283.}

Szwarc, Sandy.  In Vino Veritas - Part Two.  Junkfood Science blog, March 1, 2009.  Accessed March 10, 2009.  A quote from Ms. Szwarc regarding the Million Women Study:

The bottom line is that scary claims that “there is no level of alcohol consumption that can be considered safe,” simply was not supported by the data. This study actually found no credible link between alcohol consumption and cancers at all. Or, if you want to split hairs and believe the small computed numbers, it found that the lowest risk for cancers was associated with women drinking up to 1-2 drinks a day.

Jesus turned water into wine at a wedding.  His mother asked him to do it.  Of all the miracles he performed and could have performed, I wonder why this is the first one recorded in the Holy Bible.

We have known for years that low or moderate alcohol consumption tends to lower the risk of cardiovascular disease such as heart attack and stroke, and prolongs life span.  Physicians have been hesitant to suggest that nondrinkers take up the habit.  We don’t want to be responsible for, or even accused of, turning someone into an alcoholic.  We don’t want to be held accountable for someone else’s drunken acts.  Every well-trained physician is quite aware of the ravages of alcohol use and abuse.  We see them up close and personal in our patients.

A scientific study earlier this year, however, lends support to a middle-aged individual’s decision to start consuming moderate amounts of alcohol on a regular basis.  It even provides a positive defense if a doctor recommends it to carefully selected patients.

This research, by the way, was supported by a grant from the National Heart, Lung, and Blood Institute, not the wine/alcohol industry.

Methodology

Researchers at the Medical University of South Carolina examined data on 15,637 participants in the Atherosclerosis Risk in Communities (ARIC) study over a 10-year period.  These men and women were 45 to 64 years old at the time of enrollment, living in four communities across the U.S.  Of the participants, 27% were black, 73% nonblack, 28% were smokers, and 80% of them had high blood pressure, high cholesterol, or diabetes.

Out of 15,637 participants at the time of enrollment, 7,359 indicated that they didn’t drink alcohol.  At baseline, these 7,359 had no cardiovascular disease except for some with high blood pressure.    Subsequent interviews with them found that six percent of the nondrinkers - 442 people - decided independently to become moderate alcohol drinkers.  Or at least they identified themselves as such.

“Moderate” intake was defined as 1-14 drinks per week for men, and 1-7 drinks a week for women.  Incidentally, 0.4% of the initial non-drinking cohort - 21 people - became self-identified heavy drinkers.

93.6% of the 7,359 non-drinkers said that they continued to be non-drinkers.  These 6,917 people are the “persistent nondrinkers.”

Type of alcohol consumed was also surveyed and broken down into 1) wine-only drinkers, or 2) mixed drinkers: beer, liquor, wine.

Researchers then monitored health outcomes for an average of 4 years, comparing the “new moderate drinkers” with the “persistent nondrinkers.”

Results

•  Over 4 years, 6.9% of the new moderate drinkers suffered a cardiovascular event, defined as a heart attack, stroke, a coronary heart disease procedure (e.g, angioplasty), or death from cardiovascular disease.
• Over 4 years, 10% of the persistent nondrinkers suffered a cardiovascular event.
• The new moderate drinkers were 38% less likely than persistent nondrinkers to suffer a new cardiovascular event (P = 0.008, which is a very strong association).  The difference persisted even after adjustment for demographic and cardiovascular risk factors.
• There was no difference in all-cause mortality (death rate) between the new moderate drinkers and the persistent nondrinkers.
• New  drinkers had modest but statistically significant improvements in HDL and LDL cholesterol and mean blood pressure compared with persistent nondrinkers.
• 133 new moderate drinkers consumed only wine
• 234 new moderate drinkers consumed mixed types of alcohol
• Wine-only drinkers were 68% less likely than nondrinkers to suffer a cardiovascular event.
• “Consumers of moderate amounts of beer/liquor/mixed (which includes some wine) tended to also be less likely to have had a subsequent cardiovascular event than nondrinkers…but the difference was not significant.”

A Few Study Limitations

• Four years is a relatively brief follow-up, especially for cancer outcomes.  Alcohol consumption is associated with certain types of cancer.
• If moderate alcohol consumption indeed lowers death rates as suggested by several other studies, this study may not have lasted long enough to see it.
• The alcohol data depended on self-reports.

Take-Home Points

The study authors cite four other studies that support a slight advantage to wine over other alcohol types.  It’s a mystery to me why they fail to stress the apparent superiority of wine in the current study.  Several other studies that found improved longevity or cardiovascular outcomes in low-to-moderate drinkers suggest that the type of alcohol does not matter.  Perhaps “the jury is still out.”  In the study at hand, however, it is clear that the reduced cardiovascular disease rate in new moderate drinkers is associated with wine.

In all fairness, other studies show no beneficial health or longevity benefit to alcohol consumption.  But at this point, the majority of published studies support a beneficial effect.

Wine is a component of the traditional healthy Mediterranean diet.  The Mediterranean diet is associated with prolonged life span and reduced cardiovascular disease.  This study strongly suggests that wine is one of the causative healthy components of the Mediterranean diet.

Starting a judicious wine habit in middle age is relatively safe for selected people and may, in fact, improve cardiovascular health, if not longevity.

Now the question is, red or white.  Or grape juice?

Steve Parker, M.D.

Reference:  King, Dana E., et al.  Adopting Moderate Alchohol Consumption in Middle Age: Subsequent Cardiovascular Events.  American Journal of Medicine, 121 (2008): 201-206.

Some of my casual readers may have misconceptions as to the definition of the traditional Mediterranean diet.  I use the word “diet” here not as a weight-loss program, but “the usual food and drink of a person or animal.”  Twenty-one countries have a coastline of the Mediterranean sea, and additional countries are in the Mediterranean region.  “Traditional” refers to the mid-20th century.  Observational studies around that time associated the Mediterranean diet with longer life spans, reduced rates of chronic disease (less cardiovascular disease and dementia), and fewer cancers of the colon, breast, prostate, and uterus.  There is no monolithic, immutable, traditional Mediterranean diet.  But there are similarities among many of the regional countries that tend to unite them, gastronomically speaking.  Greece and southern Italy are particularly influential in this context.

So here are the characteristcs of the traditional, healthy Mediterranean diet:

• It maximizes natural whole foods and minimizes highly processed ones
• Small amounts of red meat
• Less than four eggs per week
• Low to moderate amounts of poultry and fish
• Daily fresh fruit
• Seasonal locally grown foods with minimal processing
• Concentrated sugars only a few times per week
• Wine in low to moderate amounts, and usually taken at mealtimes
• Milk products (mainly cheese and yogurt) in low to moderate amounts
• Olive oil as the predominant fat
• Abundance of foods from plants: vegetables, fruits, beans, potatoes, nuts, seeds, breads and other whole grain products
• Naturally low in saturated fat, trans fats, and cholesterol
• Naturally high in fiber, phytonutrients, vitamins (e.g., folate), antioxidants, and minerals (especially when compared with concentrated, refined starches and sugars in a modern Western diet)
• Naturally high in monounsaturated and polyunsaturated fats, particularly as a replacement for saturated fats

Be aware that the documented health benefits may be related to a physically active lifestyle and other social and cultural issues.  For example, traditional Mediterranean mealtimes were leisurely family affairs, not a MacDonald’s Happy Meal eaten off your lap on your drive home from work.

Steve Parker, M.D., author of The Advanced Mediterranean Diet: Lose Weight, Feel Better, Live Longer   www.AdvancedMediterraneanDiet.com

Reference:  Oldways Preservation Trust

In my last blog post, I discussed the potential benefits of judicious alcohol consumption on longevity, coronary artery disease, and dementia.

I have no intention of overselling the benefits of alcohol. If you are considering habitual alcohol as a food, be aware that the health benefits are still somewhat debatable. Consumption of three or more alcoholic drinks per day is clearly associated with a higher risk of breast cancer in women. Even one or two drinks daily may slightly increase the risk. Folic acid supplementation might mitigate the risk. If you are a woman and breast cancer runs in your family, strongly consider abstinence. Be cautious if there are alcoholics in your family; you may have inherited the pre-disposition. If you take any medications or have chronic medical conditions, check with your personal physician first.

For those drinking above light to moderate levels, alcohol is clearly perilous. Higher dosages can cause hypertension, liver disease, heart failure, certain cancers, and other medical problems. And psychosocial problems. And legal problems. And death. Heavy drinkers have higher rates of violent and accidental death. Alcoholism is often fatal. You should not drink alcohol if you:
■  have a history of alcohol abuse
or alcoholism
■  have liver or pancreas disease
■  are pregnant or trying to become
pregnant
■  may have the need to operate
dangerous equipment or machinery,
such as an automobile, while under
the influence of alcohol
■  have a demonstrated inability to
limit yourself to acceptable
intake levels
■  have personal prohibitions due
to religious, ethical, or other
reasons.

Steve Parker, M.D., author of The Advanced Mediterranean Diet: Lose Weight, Feel Better, Live Longer   www.AdvancedMediterraneanDiet.com

References: Lieber, Charles S.  Alcohol and health: A drink a day won’t keep the doctor away.  Cleveland Clinic Journal of Medicine, 70 (2003): 945-953.

For centuries, the healthier populations in the Mediterranean region have enjoyed wine in light to moderate amounts, usually with meals. Epidemiologic studies there and in other parts of the world have associated reasonable alcohol consumption with prolonged lifespan, reduced coronary artery disease, diminished Alzheimer’s and other dementias, and possibly fewer strokes. Alcohol tends to increase HDL cholesterol, have an antiplatelet effect, and may reduce C-reactive protein, a marker of arterial inflammation. These effects would tend to reduce cardiovascular disease. Wine taken with meals provides antioxidant phytochemicals (polyphenols, procyanidins) which may protect against atherosclerosis and some cancers.

What’s a “reasonable” amount of alcohol? An old medical school joke is that a “heavy drinker” is anyone who drinks more than the doctor does. Light to moderate alcohol consumption is generally considered to be one or fewer drinks per day for a woman, two or fewer drinks per day for a man. One drink is 5 ounces of wine, 12 ounces of beer, or 1.5 ounces of 80 proof distilled spirits (e.g., vodka, whiskey, gin). The optimal health-promoting type of alcohol is unclear. I tend to favor wine, a time-honored component of the Mediterranean diet. Red wine in particular is a rich source of resveratrol, which is thought to be a major contributor to the cardioprotective benefits associated with light to moderate alcohol consumption. Grape juice may be just as good—it’s too soon to tell.

Don’t miss my next blogging topic - “Potential Adverse Effects of Alcohol.”

Steve Parker, M.D., author of The Advanced Mediterranean Diet: Lose Weight, Feel Better, Live Longer   www.AdvancedMediterraneanDiet.com

References:

Standridge, John B., et al.  Alcohol consumption: An overview of benefits and risks.  Southern Medical Journal, 97 (2004): 664-672.

Luchsinger, Jose A., et al.  Alcohol intake and risk of dementia.  Journal of the American Geriatrics Society, 52 (2004): 540-546.