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http://www.nytimes.com/2002/12/31/health/31ALCO.html

The Case for Drinking (All Together Now: In Moderation!)

By ABIGAIL ZUGER

any drugs can save your life or kill you, depending on how much of them you take. Only one comes on the rocks with a twist, in a chilled mug with a foamy head, or in a goblet with lingering overtones of raspberry and oak.

Alcohol has become the sharpest double-edged sword in medicine.

Thirty years of research has convinced many experts of the health benefits of moderate drinking for some people. A drink or two a day of wine, beer or liquor is, experts say, often the single best nonprescription way to prevent heart attacks — better than a low-fat diet or weight loss, better even than vigorous exercise. Moderate drinking can help prevent strokes, amputated limbs and dementia.

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But moderate drinking also comes with some health risks, such as a slightly increased risk of breast cancer in women. And heavy drinking is accompanied by a such a fearful range of illness and catastrophe that policy makers seeking to create coherent health recommendations for the use of alcohol are stymied.

Should major diet and lifestyle recommendations actually begin to endorse moderate drinking, defined as one or two alcoholic drinks a day?

Thirty years ago, health officials were so uncomfortable with this idea that a federal agency tried to suppress early data on alcohol's beneficial effects. Now, with the data long out of the bag, policymakers say this may be one of the few areas in medicine where general recommendations are simply not possible and individual doctors and patients will have to make decisions on their own.

The cardiac benefits of low-dose alcohol are evident in study after study. All over the world, moderate drinkers have healthier hearts than teetotalers, with fewer heart attacks from fatty plaque clogging the heart's arteries and blocking blood flow.

In countries like the United States where heart disease is a major cause of death, this translates into a survival advantage: moderate drinkers live considerably longer on average than nondrinkers.

"The science supporting the protective role of alcohol is indisputable; no one questions it any more," said Dr. Curtis Ellison, a professor of medicine and public health at the Boston University School of Medicine. "There have been hundreds of studies, all consistent."

Some studies called "feeding studies" have supplemented the diets of laboratory animals with alcohol and found less narrowing of their coronary arteries, thus less chance for blockage. People fed alcohol experimentally for a few months have changes in their serum lipids that lower their risk for heart disease. But the most compelling evidence for alcohol's benefits comes from large population studies, which have had impressive results.

¶In a study of more than 80,000 American women, those who drank moderately had only half the heart attack risk of those who did not drink at all, even if they were slim, did not smoke and exercised daily. Moderate drinking was about as good for the heart as an hour of exercise a day. Not drinking at all was as bad for the heart as morbid obesity.

¶In thousands of middle-aged Danish men with high cholesterol, moderate drinkers had 50 percent less risk of developing heart disease from blocked arteries than abstainers.

¶Among more than 100,000 California adults, moderate drinking after age 40 was associated with reduced death rates during every subsequent decade of life — in some people by as much as 30 percent.

When the first alcohol studies were published, some critics objected that underlying factors might be affecting the results: perhaps the people who drank modestly were simply healthier in general, or had better access to health care. Perhaps those who abstained from alcohol knew they had heart disease and quit drinking for that reason. But many studies involving many thousands of people have swamped these objections.

"All criticisms have been shot down," Dr. Ellison said.

Still controversial, though, is the question of whether any one form of alcohol — wine, beer or hard liquor — is better for the heart than any other. Studies here give answers to suit any palate.

Red wine was the first alcoholic beverage tagged as a lifesaver when researchers reported in 1979 that the higher a country's mean per capita wine consumption, the lower its rate of coronary artery disease. France was at one end of the spectrum, while Finland, Scotland and the United States, whose citizens consumed far less wine than the French, had heart disease rates almost fourfold higher. Thus arose the famous "French paradox" of heart disease — even though the French diet is laden with butter, cheese, liver and other sources of animal fats, French hearts are relatively free of fatty blockages.

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Meanwhile, though, other studies were examining the drinking habits of individual subjects, a technique scientists usually consider more reliable than examining population averages. These studies found similar sizable benefits from a few drinks a day among Italian wine-drinkers, Japanese and German beer drinkers, and Americans who preferred hard liquor.

"If you step back, the data shows that alcohol is beneficial in all three beverages," said Dr. Eric Rimm, an associate professor of epidemiology and nutrition at the Harvard School of Public Health. "If there is any differential it is very small."

The key to maximizing the benefits from any form of alcohol may be to take small quantities regularly "like any drug," Dr. Rimm said — a glass with every evening meal, rather than half a dozen glasses only on Saturday nights.

Recent research has shown that alcohol can benefit other organs as well as the heart. Moderate drinkers seem to have fewer strokes that result when the brain's arteries become clogged with fatty deposits. They are less likely to develop fatty plaques clogging the large arteries to the legs, which can lead to incapacitating leg cramps, gangrene or, at worst, amputation.

A large study from the Netherlands reported in The Lancet medical journal early this year showed that moderate drinkers over age 55 had about a 40 percent lower risk of developing dementia than nondrinkers, possibly because they were spared the multiple small strokes that can mimic Alzheimer's disease in the elderly.

But for every one of alcohol's health benefits there is an equal and opposite risk if a single glass turns into three or four.

The hazards of drinking begin with the small but significant increased risk of breast cancer among women who are moderate drinkers.

Even among those with no family history of breast cancer or other risks, studies have repeatedly found that women who regularly have a drink a day have a 10 percent higher risk of breast cancer than nondrinkers. Heavy drinking raises the risk even higher.

Moderate drinking may also cause a small rise in strokes caused by bleeding into the brain.

And once drinking rises from moderate to heavy, health risks escalate. "You begin to see trouble at three to four to five drinks a day," said Dr. Rimm. Heavy drinking raises the risk of high blood pressure, heart failure and half a dozen forms of cancer; it may cause diabetes, pancreatic failure, liver failure and severe dementia.

Heavy drinkers have mortality rates far higher than moderate drinkers, statistics which do not even include the effects of car accidents and alcohol-fueled violence that destroy not only the drinker but others as well. These effects are especially visible in the young: in one study, young adults who reported drinking three to five drinks a day had death rates twice as high as nondrinkers.

The net health effects of alcohol are heavily influenced by its dangers. The World Health Organization estimates that over all, alcohol causes as much illness and death as measles and malaria, and more years of life lost to death and disability than tobacco or illegal drugs.

Health policy makers have been left an unwieldy balance. The benefits of moderate drinking are undeniable but, like all prevention strategies, invisible — disease simply does not happen. On the other hand the ravages of excessive alcohol use are all too visible.

"You can't see the benefits but you can see the results of heavy drinking on any highway," Dr. Rimm said. "I've had people call me up and say, what are you doing, how can you even be talking about recommending that people drink alcohol?"

Thirty years ago, policy makers just preferred to keep the whole conundrum quiet. The Framingham study, which began to examine risks for heart disease in 1948, was one of the first big studies to find heart benefits from alcohol. One of its researchers, Dr. Carl Seltzer, wrote in a short 1996 memoir that when he and his colleagues informed their government sponsors at the National Heart and Lung Institute in 1972 of these findings, they were forbidden to publish them.

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"An article which openly invites the encouragement of undertaking drinking with the implication of preventing coronary heart disease would be scientifically misleading and socially undesirable in view of the major health problem of alcoholism that already exists in the country," their contact at the government agency wrote.

Ultimately the Framingham findings were published in the company of dozens of similar ones.

Now, most policy making organizations take the lead of the American Heart Association, which suggests that moderate drinkers need not stop drinking, but that teetotalers should not aim for a few drinks a day.

"We do not specifically encourage nondrinking individuals to achieve that range — there is too much risk of habituation and disease," said Dr. Ronald M. Krauss, director of atherosclerosis research at Children's Hospital in Oakland, Calif., and national spokesman for the association.

Medical authorities who endorse moderate drinking may "open up a Pandora's box of possible risks," said Dr. David Jernigan, research director at the Center on Alcohol Marketing and Youth at Georgetown University. Acclaiming the health benefits of alcohol without emphasizing these risks "gives the product a halo effect that is confusing," he said.

Other experts feel that the key to intelligent policy is making all relevant information available so doctors and patients can make their own individual decisions.

"If I and others speak out on moderate drinking, will that lead to a country of cirrhotics?" Dr. Ellison asked. "I don't think so. The key is, how best do you present balanced information to the public? If you withhold balanced information, that's doing harm."

Drinking "is an issue that needs to be dealt with one on one," said Dr. Arthur Klatsky, a senior consultant in cardiology at Kaiser-Permanente Medical Center in Oakland, who was one of the first cardiologists to report alcohol's good effects.

For many people moderate drinking has absolutely no benefit at all, Dr. Klatsky said. This applies to all adolescents: teenagers have a negligible risk of heart disease and for them the risks of heavy drinking vastly outweigh any benefits of moderate drinking.

The same generally applies to men under 40 and women under 50, except for those with known heart disease risks. Pregnant women, people with liver disease, known drinking problems or a family history of alcoholism should never be advised to begin to drink for their health, he said.

But for others with known coronary heart disease or a risk of heart disease because of obesity, cholesterol levels, or smoking, moderate alcohol use may be a way to reduce that risk.

In fact for some people, Dr. Klatsky said, alcohol may be a lifesaver. Take a hypothetical man in his 50's who has already had a minor heart attack and has been frightened into doing everything in his power to protect his heart — losing weight, watching his fat intake, giving up cigarettes — for that man, forgoing a nightly glass of wine might actually raise his risk of recurrent heart problems, undermining all his good intentions.

"Can abstinence be hazardous to your health?" Dr. Klatsky asked. "Yes, for a person like that patient, it could be."

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