CME INDIA Presentation by Dr. N. K. Singh, MD, FICP, Director – Diabetes and Heart Research Centre, Dhanbad; Editor – CME INDIA.

2021 update.

Needless to say, that the modern medicine is facing novel challenges. Numerous rapid innovations keep coming but  evidence and experiences are lacking frequently.

One such scenario is cardiovascular disease prevention. Alcohol use has been linked to greater risk of death from cancer, diseases of the digestive tract, injuries and violence.

But interestingly it has been also linked to a lower risk of death from cardiovascular diseases (CVD). Recent studies have suggested that the death rate among moderate alcohol users is lower due to fewer deaths resulting from coronary heart disease (CHD).

Setting the Stage for Low-Risk Drinking for Cardio-Vascular Protection?

Lifestyle and dietary habits play an important role in the secondary prevention of cardiovascular disease (CVD).

  •  The impact of alcohol consumption on CVD patients’ prognosis is unclear.
  •  Recommendations for patients regarding upper limits of drinking vary substantially across different guidelines.
  • Light-to-moderate alcohol consumption is associated with a lower risk of developing multiple cardiovascular outcomes in general population cohorts.
  • But at present we cannot extrapolate emerging  cardio-protective effects to CVD patients and general population.

Studies which sparked ignition

  • Costanzo et al. in 2010 – The most recent meta-analysis to have explored the association between alcohol consumption and prognosis among CVD patients.
  • They analysed pooled data from eight observational studies published between 1998 and 2008.
  • Findings:
    • 22% relative risk (RR) reduction at approximately 8 g/day for cardiovascular mortality.
    • 18% at 7 g/day for all-cause mortality among patients with myocardial infarction (MI), angina, or stroke, relative to non-drinkers.
    • There was risk increasing in a dose dependent manner above these levels.

Standard drink definition in different countries

Setting the Stage for Low-Risk Drinking for Cardio-Vascular Protection?
Source: For Hazardous and Harmful Drinking a Manual for Use in Primary Care. WHO/MSD/MSB/01.6b (2001)

  • WHO suggested that a standard drink size of 10 g of pure ethanol is clearly the modal definition in use around the world.
  • But only half of countries use WHO defined standard drink
  • At the extremes, the size of a standard drink varies by 250% (from a low of 8 g to a high of 20 g).
  • Australia, Grenada, Portugal and South Africa do not provide separate low-risk drinking guidelines for men and women.
  • Health educators and researchers employ different definitions of a standard unit or drink because of differences in the typical serving sizes in that country.

1 standard drink in Canada: 13.6 grammes of pure alcohol
1 standard drink in the UK: 8 grammes
1 standard drink in the USA: 14 grammes
1 standard drink in Australia or New Zealand: 10 grammes
1 standard drink in Japan: 19.75 grammes
1 standard drink Switzerland  10–12 g /day
1 standard drink Luxembourg it is precisely 12.8 g, day
1 standard drink India 10 g/day

How to Calculate the Content of Alcohol in a Drink (WHO)

  • The alcohol content of a drink depends on the strength of the beverage and the volume of the container.
  • A WHO survey:
    • Beer contained between 2% and 5% of pure alcohol.
    • Wines contained 10.5% to 18.9%.
    • Spirits varied from 24.3% to 90%.
    • Cider from 1.1% to 17%.
  • It is essential to adapt drinking sizes to what is most common at the local level and to know roughly how much pure alcohol the person consumes per occasion and on average.
  • Another consideration in measuring the amount of alcohol contained in a standard drink is the conversion factor of ethanol.
  • Convert any volume of alcohol into grammes.
    • For each millilitre of ethanol, there are 0.79 grammes of pure ethanol.
    • 1 can beer (330 ml) at 5% (strength) x 0.79 (conversion factor) = 13 grammes of ethanol.
    • 1 glass wine (140 ml) at 12% (strength) x 0.79 = 13.3 grammes of ethanol.
    • 1 shot spirits (40 ml) at 40% (strength) x 0.79 = 12.6 grammes of ethanol.

What 2021 new meta-analysis says

Ding et al. Association of alcohol consumption with morbidity and mortality in patients with cardiovascular disease: Meta-analysis of 48,423 men and women BMC Medicine (2021)

  • Meta-analysis of the results from three major UK cohorts together with those from 12 published studies. This study was augmented with findings from 12 published studies identified through a systematic review, providing data on 31,235 patients, 5095 deaths, and 1414 subsequent events.
  • Ding et al. found J-curve relationships between alcohol consumption and mortality in those with cardiovascular disease.
  • The greatest risk reduction was  observed at 7 g/ day for all-cause mortality and 8 g/day for cardiovascular mortality relative to current non-drinkers.
  • There with a risk reduction that peaked at 7 g/day (relative risk 0.79, 95% confidence interval 0.73–0.85) for all-cause mortality, 8 g/day (0.73, 0.64–0.83) for cardiovascular mortality and 6 g/day (0.50, 0.26–0.96) for cardiovascular events,
  • No statistically significant elevated risks were found at higher levels of drinking.
  • Taken together, this  study suggested that, among CVD patients, the upper drinking limit for lower risks of mortality and cardiovascular morbidity was about 105 g/week, which was lower than those recommended in most current guidelines.
  • The American Heart Association (AHA) and American College of Cardiology Foundation 2011 guidelines on secondary prevention recommend “alcohol moderation”—up to 196 g/week (2 USA drinks/day) for male and 98 g/week (1 USA drink/day) for female according to the national dietary guidelines —for patients with atherosclerotic vascular disease.
  •  The same recommendations apply in the AHA/American Stroke Association 2014 guidelines for secondary stroke prevention.
  • UK National Institute for Health and Care Excellence 2020 guidelines recommend to keep alcohol intake within 112 g/week (14 UK units/week) for both men and women after having an MI.
  • WHO 2007 recommendations for prevention of recurrent MI and stroke were no more than about 166 g/week (3 units/ day, 1 unit contains 10 ml of pure alcohol).

What about diabetes prevention

  • We get best data from Danish nationwide database study. It showed that light to moderate vs no alcohol consumption was associated with a lower risk for diabetes, and frequent alcohol consumption was associated with the lowest risk for diabetes, after adjustment for average weekly alcohol intake.
  • Moderate to high intake of wine was associated with a lower risk for diabetes. Men who drank 7 or more glasses of wine per week had approximately a 30% lower risk for diabetes, but women who drank 7 or more spirits per week had an 83% higher risk.
  • No recommendations regarding alcohol intake or drinking patterns should be inferred from this study
  • We must remember that  alcohol is associated with the risk for at least 50 different diseases and conditions, and even low alcohol levels have been linked with breast cancer risk.
  • Healthcare providers should consider diabetes risk with alcohol intake in both men and women, especially beverage type.

What about Hypertension

  • Moderate alcohol consumption raises the odds of elevated BP, stage I hypertension, and stage II hypertension by 79%, 66%, and 62%, respectively.

CME INDIA Learning Points

  • For secondary prevention of CVD, current drinkers may not need to stop drinking but should be informed that lower levels of intake (up to 105g/week) may be associated with reduced risks.
  • Non-drinking patients should not be encouraged to take up light drinking because of well-known adverse effects on other health outcomes, such as cancers. Alcohol has been found to increase risk for cancer, and for some types of cancer, the risk increases even at low levels of alcohol consumption (less than 1 drink in a day).

References:

1. Ding et al. Association of alcohol consumption with morbidity and mortality in patients with cardiovascular disease: original data and meta-analysis of 48,423 men and women BMC Medicine (2021) 19:167 https://doi.org/10.1186/s12916-021-02040-2.

2. Addiction Debate. How should we set consumption thresholds for low risk drinking guidelines? Achieving objectivity and transparency using evidence, expert judgement and pragmatism John Holmes, Colin Angus, Petra S. Meier, Penny Buykx, Alan Brenna First published: 21 August 2018https://doi.org/10.1111/add.14381

3. Society for study of Addiction. Governmental standard drink definitions and low-risk alcohol consumption guidelines in 37 countries Agnieszka Kalinowski, Keith Humphreys First published: 13 April 2016https://doi.org/10.1111/add.13341

4. WHO_MSD_MSB_01.6b.pdf; jsessionid=994ACB496FC18E71D2D2268C1579E30C

5. The Danish Health Examination Survey 2007-2008 (DANHES 2007-2008). http://www.si-folkesundhed.dk/Forskning/Sundhedsvaner/KRAM.aspx?lang=en. Accessed July 28, 2017.

6. Holst C, Becker U, Jørgensen ME, Grønbæk M, Tolstrup JS. Alcohol drinking patterns and risk of diabetes: a cohort study of 70,551 men and women from the general Danish population. Diabetologia. Published online July 27, 2017. https://link.springer.com/article/10.1007%2Fs00125-017-4359-3. Accessed July 28, 2017.

7. Centers for Disease Control and Prevention. Alcohol Use and Your Health. Available at http://www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm.

8. Rosoff DB, Davey Smith G, Mehta N, Clarke TK, Lohoff FW. Evaluating the relationship between alcohol consumption, tobacco use, and cardiovascular disease: A multivariable Mendelian randomization studyexternal iconPLoS Med 2020;17:e1003410.



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