Review
Moderate alcohol use and health: A consensus document

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Abstract

Aims

The aim of this consensus paper is to review the available evidence on the association between moderate alcohol use, health and disease and to provide a working document to the scientific and health professional communities.

Data synthesis

In healthy adults and in the elderly, spontaneous consumption of alcoholic beverages within 30 g ethanol/d for men and 15 g/d for women is to be considered acceptable and do not deserve intervention by the primary care physician or the health professional in charge. Patients with increased risk for specific diseases, for example, women with familiar history of breast cancer, or subjects with familiar history of early cardiovascular disease, or cardiovascular patients should discuss with their physician their drinking habits. No abstainer should be advised to drink for health reasons. Alcohol use must be discouraged in specific physiological or personal situations or in selected age classes (children and adolescents, pregnant and lactating women and recovering alcoholics). Moreover, the possible interactions between alcohol and acute or chronic drug use must be discussed with the primary care physician.

Conclusions

The choice to consume alcohol should be based on individual considerations, taking into account the influence on health and diet, the risk of alcoholism and abuse, the effect on behaviour and other factors that may vary with age and lifestyle. Moderation in drinking and development of an associated lifestyle culture should be fostered.

Section snippets

Methodology

The Nutrition Foundation of Italy coordinated a team of Italian experts, as follows: selected Italian scientific societies were contacted and required to provide topic-specific reviews of the alcohol–health relation. Twenty societies out of 23 agreed (see Appendix 1), although one finally chose not to contribute to this document. All contributions were merged, discussed and agreed upon by the entire Panel, which approved the final paper in September 2012.

Methodological limitations in the assessment of alcohol–health associations

All studies on the associations between alcohol and health are methodologically complex. This is due to the methods used to assess alcohol consumption, to the choice of control groups and to the correct definition of confounding factors. Assessment of alcohol consumption is usually done by specific questionnaires, where frequency and amount of consumption are collected. This procedure often underestimates the true rate of consumption, especially in heavy drinkers, who tend to report

Coronary heart disease and fatal arrhythmia

Data derived from epidemiological studies and obtained in primary care individuals consistently show the existence of a significant inverse association between moderate alcohol use and cardiovascular risk (mainly, myocardial infarction and stroke). Conversely, excessive intake does increase cardiovascular risk. Several meta-analyses reported a ‘J’-shaped curve that describes the association between alcohol consumption and cardiovascular risk, namely a higher risk associated to both abstention

Lipid profile

An early review, published in 1999 [44], suggested that moderate alcohol use is associated with increased plasma concentrations of high-density lipoprotein (HDL) cholesterol (HDL-c), with a clear dose–response relationship, namely, an increase of 0.133 mg/dl for every gram of alcohol ingested daily. Likewise, every gram of alcohol was associated with a 0.294 mg/dl increase in plasma apolipoprotein A-I levels (Apo-AI; the foremost component of HDL) and of 0.190 mg/dl in triacylglycerol (TG)

Metabolic syndrome

The metabolic syndrome (MS) is a multifactorial disorder that, according to the recent International Diabetes Federation definition, requires the presence of central obesity and at least two of the four following abnormalities: high TGs, low HDL-c, high blood pressure or raised fasting plasma glucose level. According to the Adult Treatment Panel-III (ATP-III) definition (with which the general practitioner is more familiar), the presence of any three of the five risk factors mentioned above

Moderate alcohol use and liver disease

Alcoholic liver disease (ALD) is the most prevalent cause of advanced liver disease in the Western world. It comprises a large spectrum of liver injuries, ranging from fatty liver or simple steatosis (alcoholic fatty liver disease, AFLD) to acute alcoholic hepatitis, alcoholic steatohepatitis (ASH), chronic hepatitis with hepatic fibrosis and cirrhosis [100], [101]. Non-alcoholic fatty liver disease (NAFLD), on the other hand, is the most common liver disorder in Western countries and affects

Alcohol, cognitive impairment and dementia

Five epidemiological studies have been published on the association between alcohol use and incidence of dementia and Alzheimer's disease [111], [112], [113], [114], [115]. In addition, two meta-analyses examined 26 and 15 studies, respectively [116], [117].

The available evidence comes mostly from longitudinal cohort studies, in which non-dement or mild cognitive impairment (MCI) elderly have been followed to monitor their cognitive performance. The results are summarised in Table 3.

All studies

Alcohol, skeletal frailty and osteoporosis

Several observational studies indicate that alcohol consumption might influence bone density, depending on intake levels. In general, moderate alcohol use has no significant influence on bone density (or it has even positive effects), whereas data on heavy intake are conflicting, mainly pointing to negative effects on bone structure.

The effects of two or three drinks/d depend on age, sex and hormonal profile; for example positive effects are described for menopausal, but not for fertile women.

Alcohol and cancer

Most cancers are reportedly not associated with moderate alcohol intake. Only the association between light alcohol consumption and cancer risk for sites for which sufficient or limited evidence for carcinogenicity of alcohol is available [128], [129], that is, cancers of the upper digestive and respiratory tract (oral and pharyngeal cancer, oesophageal squamous cell carcinoma and laryngeal cancer), colorectum, pancreas and breast will be examined in this paper. Adenocarcinoma of the oesophagus

Alcohol and all-cause mortality

The most objective way to evaluate the role of alcohol in health is to assess total mortality (i.e., for all causes) associated with its use. Infarction, risks and benefits are, in this manner, compared with the same epidemiological hard ‘end’ point.

The association between total mortality and alcohol consumption not only depends on quantities and drinking behaviour, but also on the distribution of causes of death in the population at study. Further to the first study that showed a ‘J’-shaped

Differential health effects of the various alcoholic beverages

Alcoholic beverages contain both ethanol and other components. The quality and quantity of the latter differs greatly between wine, beer and spirits, as well as within these categories (red vs. white wine, different beers, etc.). While the role of ethanol in human health has been elucidated to a great extent, that of the non-alcoholic components is less clear. Several experimental studies (in vitro and in animals) suggest that these components (in particular, polyphenols) might play important

Conclusions

Dozens of epidemiological studies and the meta-analyses that analysed their results clearly show a statistically significant association between moderate alcohol consumption, that is two or three drinks/d or 24–36 g of ethanol/d for men and one to two drinks/d or 12–24 g of ethanol/d for women and risk reduction of specific clinical events, namely those involving the cardio-circulatory system such as atherosclerosis, myocardial infarction or ischaemic (though not haemorrhagic) stroke. This

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