Wine Information Council

BACKGROUND AND AIMS: Epidemiological evidence on the impact of different alcohol drinking patterns on health-care systems or hospitalizations is sparse. We investigated how the different average volumes of alcohol consumed relate to all-cause and cause-specific hospitalizations.

DESIGN: Prospective cohort study (baseline 2005-10) linked to a registry of hospital discharge records to identify hospitalizations at follow-up (December 2013).

SETTING: Molise region, Italy.

PARTICIPANTS: A total of 20 682 individuals (48% men, age >/= 35 years) who participated in the Moli-sani Study and were free from cardiovascular disease or cancer at baseline.

MEASUREMENTS: The alcohol volume consumed in the year before enrolment was classified as: life-time abstainers, former drinkers, occasional drinkers and current drinkers who drank 1-12 (referent), 12.1-24, 24.1-48 and > 48 g/day of alcohol. Cause-specific hospitalizations were assigned by Italian Diagnosis Related Groups classification or by ICD-9 code of main admission diagnoses. Incidence rate ratios (IRR) of hospitalization were estimated by Poisson regression, taking into account the total number of admissions that occurred during the follow-up per person.

FINDINGS: During a median follow-up of 6.3 years, 12 996 multiple hospital admissions occurred. In multivariable analyses, life-time abstainers and former drinkers had higher rates of all-cause [IRR = 1.11, 95% confidence interval (CI) = 1.05-1.17 and IRR = 1.19, 95% CI = 1.02-1.31, respectively] and vascular (IRR = 1.14, 95% CI = 1.02-1.27 and IRR = 1.48, 95% CI = 1.24-1.76, respectively) hospitalizations compared with light alcohol consumers. Alcohol consumption > 48 g/day was associated with a higher rate of hospitalization for both alcohol-related diseases (IRR = 1.74, 95% CI = 1.32-2.29) and cancer (IRR = 1.36, 95% CI = 1.12-1.65). The magnitude of the association between heavier alcohol intake and hospitalization tended to be greater in smokers than non-smokers. No associations were observed with hospitalization for trauma or neurodegenerative diseases.

CONCLUSIONS: Moderate alcohol consumption appears to have a modest but complex impact on global hospitalization burden. Heavier drinkers have a higher rate of hospitalization for all causes, including alcohol-related diseases and cancer, a risk that appears to be further magnified by concurrent smoking.

BACKGROUND: Adherence to the Mediterranean diet is associated with lower mortality in a general population but limited evidence exists on the effect of a Mediterranean diet on mortality in subjects with diabetes. We aim to examine the association between the Mediterranean diet and mortality in diabetic individuals.

DESIGN: Prospective cohort study on 1995 type 2 diabetic subjects recruited within the MOLI-SANI study. Methods: Food intake was recorded by the European Project Investigation into Cancer and Nutrition food frequency questionnaire. Adherence to the Mediterranean diet was appraised by the Greek Mediterranean diet score. Hazard ratios were calculated using multivariable Cox-proportional hazard models.

RESULTS: During follow-up (median 4.0 years), 109 all-cause including 51 cardiovascular deaths occurred. A 2-unit increase in Mediterranean diet score was associated with 37% (19%-51%) lower overall mortality. Data remained unchanged when restricted to those being on a hypoglycaemic diet or on antidiabetic drug treatment. A similar reduction was observed when cardiovascular mortality only was considered (hazard ratio = 0.66; 0.46-0.95). A Mediterranean diet-like pattern, originated from principal factor analysis, indicated a reduced risk of overall death (hazard ratio = 0.81; 0.62-1.07). The effect of Mediterranean diet score was mainly contributed by moderate alcohol drinking (14.7% in the reduction of the effect), high intake of cereals (12.2%), vegetables (5.8%) and reduced consumption of dairy and meat products (13.4% and 3.4% respectively).

CONCLUSIONS: The traditional Mediterranean diet was associated with reduced risk of both total and cardiovascular mortality in diabetic subjects, independently of the severity of the disease. Major contributions were offered by moderate alcohol intake, high consumption of cereals, fruits and nuts and reduced intake of dairy and meat products.

The Mediterranean diet (MD) has been associated with prolonged survival in the general population, but no meta-analysis has apparently investigated the potential health benefits in relation to mortality in the elderly. We performed a longitudinal analysis on 5200 individuals aged >/=65 years identified within the general population recruited in the Moli-sani study cohort (2005-2010). Adherence to the MD was appraised by the a priori Mediterranean diet score (MDS; range 0-9). Survival estimates were derived using Cox regression and competing risk models. For the meta-analysis, PubMed and Scopus databases were searched from inception until April 2018 to identify prospective studies on the MD and death risk in the elderly. Over a median follow-up of 8.1 years, a total of 900 deaths were ascertained in the elderly sub-sample of the Moli-sani cohort. A one-point increase in the MDS was associated with lower risk of all-cause, coronary artery disease/cerebrovascular and non-cardiovascular/non-cancer mortality (multi-variable hazard ratio (HR)=0.94; 95 % CI 0.90, 0.98; HR=0.91; 95 % CI 0.83, 0.99 and HR=0.89; 95 % CI 0.81, 0.96, respectively). In a meta-analysis of seven prospective studies, including our results, for a total of 11 738 participants and 3874 deaths, one-point increment in MDS was associated with 5 % (4-7 %) lower risk of all-cause death. An inverse linear dose-response relationship was found from a meta-analysis including three studies. In conclusion, a prospective cohort study and a meta-analysis showed that closer adherence to the MD was associated with prolonged survival in elderly individuals, suggesting the appropriateness for older persons to adopt/preserve the MD to maximise their prospects for survival.

BACKGROUND & AIMS: Biological age (BA) is the hypothetical underlying age of an organism and has been proposed as a more powerful predictor of health than chronological age (CA). The difference between BA and CA (Deltaage) reflects the rate of biological aging, with lower values indicating slowed-down aging. We sought to compare the relationship of four a priori-defined dietary patterns, including a traditional Mediterranean diet (MD) and three non-Mediterranean diets, with biological aging (Deltaage) among Italian adults. We also examined distinctive nutritional traits of these diets as potential mediators of such associations.

METHODS: Cross-sectional analysis on a sub-cohort of 4510 subjects (aged >/=35 y; 52.0% women) from the Moli-sani Study (enrolment, 2005-2010). Food intake was recorded by a 188-item semi-quantitative food-frequency questionnaire. A Mediterranean diet score (MDS) was used as exposure and compared with non-Mediterranean dietary patterns, i.e. DASH (Dietary Approaches to Stop Hypertension), Palaeolithic and the Nordic diets. A Deep Neural Network based on 36 blood biomarkers was used to compute BA and the resulting Deltaage (BA-CA), which was tested as outcome in multivariable linear regressions adjusted for clinical factors, lifestyles and sociodemographic factors.

RESULTS: In a multivariable-adjusted model, 1 standard deviation increase in the MDS was inversely associated with Deltaage (beta = -0.23; 95%CI -0.40, -0.07), and similar findings were observed with the DASH diet (beta = -0.17; 95%CI -0.33, -0.01). High dietary polyphenol content explained 29.8% (p = 0.04) and 65.8% (p = 0.02) of these associations, respectively, while other nutritional factors analysed (e.g. dietary fibre) were unlikely to be on the pathway. No significant associations were found with either the Palaeolithic or the Nordic diets.

CONCLUSIONS: Increasing adherence to either the traditional MD or the DASH diet was associated with delayed biological aging, possibly through their high polyphenol content.

Low grade inflammation is characterized by raised concentrations of inflammatory markers in the absence of any overt symptoms and is recognized as a risk factor for a number of chronic diseases including cancer, cardiovascular, cerebrovascular and neurodegenerative diseases. Many studies suggest that low grade inflammation is mitigated by health promoting behaviours such as healthy eating patterns, physical activity, body weight maintenance and tobacco cessation. To date, large scale studies were mainly focused on circulating markers and little evidence is available on cellular biomarkers.

The MOLI-SANI study is a prospective cohort study that has recruited 24 325 men and women aged >/=35 years from the general population of the Molise Region, a Southern Italian area, with the purpose of investigating genetic and environmental risk/protection factors for cardiovascular and cerebrovascular disease and cancer. Within this cohort, a composite score of low grade inflammation based on the use of plasmatic (C-reactive protein) and cellular (leukocyte and platelet counts and granulocyte : lymphocyte ratio) biomarkers has been proposed and validated. This score accounts for all possible synergistic effects of such inflammatory markers, thus overcoming any potential bias linked to the multi-collinearity of these variables.

Of notice, the MOLI-SANI study was the first to address the relationship between the traditional Mediterranean diet and platelet and leucocyte counts as emerging cellular biomarkers of low grade inflammation. The present review paper will discuss the main findings derived from the MOLI-SANI study on the association of low grade inflammation with a Mediterranean eating pattern, with a particular emphasis on the associated dietary polyphenols.

An Italian study investigating the contribution of a Mediterranean-type diet and its components adds more evidence that such an eating pattern can reduce the mortality risk among diabetics. Among various components such as a high consumption of cereals, fruits and nuts, the moderate intake of alcoholic beverages/wine was a major protective factor.

The “Mediterranean Diet” (MD) is reputed for its beneficial health effects in the nutrition field. This dietary pattern refers to the traditional way of eating by Mediterranean populations in the early 1960s. It is characterized by abundant use of olive oil, high consumption of plant foods (fruits, vegetables, legumes, cereals, nuts, and seeds), frequent but moderate intake of wine with meals, moderate consumption of fish, seafood, fermented dairy products (yogurt and cheese), poultry, and eggs and low consumption of red and processed meat and sweets.

In numerous studies, adherence to the Mediterranean diet was associated with lower mortality in the general population. The epidemiological evidence is particularly strong for the preventive effects of the MD on cardiovascular disease (CVD). In fact, some experts consider the MD the most likely dietary model to provide causal CVD-protection as there is high biological plausibility for this effect. In addition, the MD has been associated with a reduced incidence of diabetes. But so far, only limited evidence exists on the effect of a Mediterranean diet on mortality in diabetic individuals.

Recently, several Italian researchers examined whether greater adherence to the traditional MD in a Mediterranean region such as Southern Italy, could reduce overall and/or cardiovascular mortality in individuals with type-2-diabetes. In addition, they investigated the contribution of single dietary components to the overall effect of the MD in relation to mortality.  A prospective cohort study with 1995 type-2 diabetic subjects recruited within the MOLI-SANI study to examine these associations was carried out. The food intake of the participants was recorded by a validated food frequency questionnaire and adherence to the traditional MD was estimated by using the Mediterranean Diet Score developed by the famous Greek scientist Antonia Trichopoulou.

During an average follow-up of 4 years, 109 deaths due to miscellaneous causes occurred, including 51 cardiovascular deaths. The researchers observed that a 2-unit increase in the Mediterranean diet score was associated with 37% lower overall mortality. A reduction of 34 % was observed when cardiovascular mortality only was considered.

When the scientists calculated the relative contribution of the MD to the effect for each dietary component, the results showed that the greatest protective effect derived from moderate drinking of alcoholic beverages (14.7 %) followed by a high intake of cereals, monounsaturated fatty acids, vegetables and fruits and nuts (12.2 %, 5.8 %, 5.8 % and 5.2 %, respectively).

Thus, based on the results of this study, the traditional Mediterranean diet was associated with reduced risk of both total and cardiovascular mortality in diabetic subjects, independently of the severity of the disease. The major contributions of this protective effect were offered by moderate intake of alcoholic beverages, followed by the broadly accepted “healthy foods” like cereals, fruits and nuts.

Bonaccio M, Di Castelnuovo A, Costanzo S, et al; on behalf of the MOLI-SANI study Investigators. Adherence to the traditional Mediterranean diet and mortality in subjects with diabetes. Prospective results from the MOLI-SANI study. Eur J Prev Cardiol. 2015 Feb 3. [Epub ahead of print]

For more information about this article, read the scientific abstract here.

In this prospective study of a Mediterranean population (more than 22,800 men and women), moderate drinkers compared to abstainer, had a lower risk of heart failure. Wine was the preferred alcoholic beverage.

Heart failure (HF), often referred to as congestive heart failure, occurs when the heart is unable to pump sufficiently to maintain the blood flow in order to meet the body's needs. The problem can originate from damage or overloading. 

Common causes of HF include high blood pressure, atrial fibrillation (*), valvular heart disease, infection, and cardiomyopathy (**) or a previous heart attack. Another common cause is excess use of alcoholic beverages. HF causes shortness of breath which usually becomes worse with exercise, and while lying down, and may wake the person at night. Typical symptoms of HF also include excessive tiredness, a limited ability to exercise, and leg swelling. Chest pain, as in angina, does not typically occur due to heart failure.

Initially, the heart tries to make up for the failure by enlarging: it stretches to contract more strongly and keep up with the demand to pump more blood. Because the contracting cells of the heart get bigger, an increase in muscle mass occurs, which initially allows the heart to pump more strongly. At the same time, the heart will be pumping faster to increase its output. In addition, the body compensates for HF by narrowing the blood vessels to increase the blood pressure, trying to make up for the heart's loss of power. Also, the body diverts blood away from less important tissues and organs to the heart and brain. While these temporary measures initially mask the problem, HF untreated usually continues and worsens until these substitute processes fail and becomes a life-threatening condition.

Studies have shown that excessive consumption of alcoholic beverages increases the risk of HF and atrial fibrillation (AF), however, the effect of light-moderate alcohol intake is less certain. Di Castelnuovo and colleagues (Italy) aimed to assess among participants of the MOLI-Sani study, if and what amounts of alcohol consumption are associated with the onset of HF and/or AF. They followed 22,824 AF- or HF-free subjects (48% men, age ≥35 years) for approx. 8.2 years. During the follow-up period, a total of 943 cases of HF and 554 of AF were identified. In comparison to never drinkers, ingesting 1 to 4 alcoholic drinks/day (wine was the prevailing alcoholic beverage in this population) was associated with a lower risk of HF, with a 22% maximum risk reduction at 20 g/day, independent of common confounding variables. They also found that both former and occasional drinkers showed a comparable risk of developing HF as never drinkers.

The authors, however, observed no association with the consumption of alcoholic beverages and the onset of AF.

Another group of scientists recently looked at this relationship in a Norwegian population-based HUNT study. They investigated the association between alcohol consumption within recommended limits and AF risk in a light-drinking population. During the 8-year follow-up period, 1697 out of the 47,002 participants were diagnosed with AF. The risk increased in a curvilinear manner, with a threshold at which AF risk clearly increased above that of nondrinkers at about 4 to 5 drinks per week. The risk for AF increased significantly by 38 % in participants consuming more than 7 drinks per week compared to abstainers. The scientists concluded that the attributable risk of moderate alcohol consumption within recommended limits among participants without binge or problem drinking was negligible in this population.

(*) Atrial fibrillation (AF) is an irregular, often very fast heartbeat (arrhythmia) that can lead to blood clots, stroke, heart failure and other heart-related complications. Normally, the heart contracts and relaxes to a regular beat. In atrial fibrillation, the upper chambers of the heart beat irregularly instead of beating effectively to move blood into the ventricles.

(**) Cardiomyopathy is a diseased heart muscle that cannot contract adequately.

When the heart fails to contract properly, oxygenated blood is not pumped adequately to the tissues and organs of the body. This inability to deliver oxygen to body tissues can lead to a general weakness and fatigue. Other symptoms may include shortness of breath on exertion or chest pain.

Di Castelnuovo A, Costanzo S, Bonaccio M et al. Moderate Alcohol Consumption Is Associated With Lower Risk for Heart Failure But Not Atrial Fibrillation. JACC Heart Fail. 2017 Oct 4. [Epub ahead of print]

For more information about this article, read the scientific abstract here.

Usually, a standard drink contains 10 g of ethanol, which is the equivalent of approx. 100 ml of wine. However, the definitions of a standard drink and of moderate drinking are not the same in every study. At the end of every study, the respective definitions are specified.

12 g/day of ethanol = 1 alcoholic drink

Drinking categories were defined as:

Former drinkers, abstainers, occasional drinkers: up to 1g/day or equivalently 2.5 alcoholic drinks/month

>1 g to 12g of ethanol/day

>12g to 24g of ethanol/day

>24g to 48g of ethanol/d

> 48 g of ethanol /d

Irregular drinkers: > 48g of ethanol/d (4 alcoholic drinks) for women and > 5 alcoholic drinks/d for men

Gémes K, Malmo V, Laugsand LE, et al. Does Moderate Drinking Increase the Risk of Atrial Fibrillation? The Norwegian HUNT (Nord-Trøndelag Health) Study.
Drinking within recommended limits:

1 Standard drink = 12 g of ethanol

Non-risky drinking: Up to 1 drink/day for women and up to 2 drinks/d for men

The results of a recent publication indicate that the Mediterranean diet can significantly reduce the mortality in elderly individuals.

During a follow up of eight years, Italian researchers of the Moli Sani Study analysed the relationship between the traditional Mediterranean diet and mortality among 5000 participants above 65 years old. In addition, they also carried out a meta-analysis of other epidemiological studies published in several countries with a total of 12,000 participants.

The results clearly show that a traditional Mediterranean diet (rich in fruit, vegetables, fish, legumes, olive oil and moderate consumption of wine with the meals) decreases by 25% the risk of mortality in elderly people.

Previous studies have already shown that the Mediterranean diet can reduce the mortality risk among the general population. What is new about this research is the focus on the population aged 65 and over. The subsequent meta-analysis confirmed that the more individuals followed a Mediterranean diet, the lower their overall mortality risk is; this risk decreasing in a dose-response manner.

The foods that contribute to a greater protection within the Med Diet are those with high levels of monounsaturated fats (i.e. olive oil and fish) but also moderate wine consumption almost exclusively during meals. On the other hand, binge drinking and preference for beer instead of wine are not part of the traditional Mediterranean Diet.

The findings confirm - what has already been observed in numerous studies – that the moderate consumption of wine in combination with a Mediterranean food context can be protective for health.

The authors conclude that it is important to identify modifiable lifestyle factors that cannot only guarantee an increased life expectancy but also whether these additional life years are spent in good or poor health.

Bonaccio M et al 2018, Mediterranean diet and mortality in the elderly: a prospective cohort study and meta-analysis, Br J Nutr, p. 1-14, doi:10.1017/S0007114518002179

WHAT IS THE MOLI-SANI STUDY?

The Moli-sani study (www.moli-sani.org) is a cohort study carried out in central/southern Italy aiming at evaluating the risk factors (environmental, genetics, bio-molecular) linked to chronic-degenerative disease with particular regard to cancer, cardiovascular, cerebrovascular and neurodegenerative disease.

WHAT ARE THE LATEST FINDINGS OF THE MOLI-SANI STUDY?

In this prospective study of 21.000 participants from a Mediterranean population, life-time abstainers and heavier consumers (>48g/day)* had higher rates of hospitalization for all causes compared to moderate drinkers, especially among current smokers.

WHAT DOES IT MEAN?

It shows that moderate intake of alcoholic beverages had a modest but complex impact on global hospitalization burden. The authors thus suggest that efforts to reduce both the heavy drinking and smoking are likely to have meaningful impacts on health-care systems.

Definitions:

* Heavy drinking: >48g of alcohol/day

Reference group: 1-12g of alcohol/day

12.1-24 g of alcohol: light drinkers

24.1 -48 g of alcohol: moderate drinkers

Occasional drinkers: less than 2.5 alcoholic units/month

Binge drinkers: >4 alcohol units (48g/d) for women and >5alcoholic units (60g/d) for men on a single occasion

1 alcoholic unit: 120 ml of wine, 330ml of beer or 40 ml of spirits (containing 12 g of alcohol)

Costanzo S and all the Moli sani study investigators, Alcohol consumption and hospitalization burden in an adult Italian population: prospective results from the Moli-sani study, Addiction 2018, https://doi.10.1111/add.14490 

For more information about this article, read the scientific abstract here.

 Index

1. Are alcoholic beverages and wine a risk factor for cancers? An ambivalent topic

2. Excessive consumption of alcoholic beverages and cancer risk

Regular heavy excessive consumption of alcoholic beverages and binge drinking patterns are risk factors for certain types of cancer, and the risk generally increases with increasing levels of consumption.  

3. Moderate consumption of alcoholic beverages and cancer risk

In this context, we should remember that the risk of developing cancer involves various risk factors and all cancers that have been associated with alcohol also occur in the absence of drinking.

The overall effect of light to moderate consumption of alcoholic beverages on cancer incidence is less clear and findings are inconsistent. The exception is breast cancer, which also depends on a number of other, more salient factors.

4. Cancer as a multifactorial disease and the importance of context

Since cancer is a multi-factorial disease, the cancer risk cannot be evaluated in isolation,  and studies suggest that lifestyle factors are important risk factors for cancer. Accordingly, the consumption of alcoholic beverages cannot be accurately evaluated in insolation from the other risk factors.

5. Wine consumption as part of the Mediterranean Diet - risk in context

The Mediterranean Diet (Med Diet), which includes moderate consumption of wine, is considered as one of the healthiest dietary pattern in the world by the WHO, noting that it is directly associated with a lower rate of mortality due to its effects on chronic disease prevention.  The Med Diet has been linked with a lower prevalence of several cancers, including breast and colorectal cancer.

6. Moderate wine consumption and cancer risk in context (“umbrella”) of a healthy lifestyle

Several studies confirm that moderate wine drinking is compatible with a healthy lifestyle (non-smoking, physical activity, normal body weight, balanced diet).

1. Are alcoholic beverages and wine a risk factor for cancers? An ambivalent topic

Cancers are a multifactorial disease and it is increasingly accepted that certain lifestyle choices can affect the risk of developing a cancer. Besides several unmodifiable risk factors (such as age, sex, ethnicity and genetic disposition) which may contribute to an increased risk for most cancers, improvement of lifestyle habits may contribute to a reduced risk of cancer.

According to World Health Organisation (WHO) and the World Cancer Research Fund (WCRF 2018), one third of the cancers could be prevented by adopting a healthy lifestyle (such as avoiding smoking, maintaining a normal body weight, being physically active, avoiding excessive consumption of alcoholic beverages and keeping a healthy dietary pattern)  (WHO 2017, WCRF 2018).

In addition, a study performed by the Harvard University further suggested that moderate consumption of alcoholic beverages is one of the five healthy lifestyle factors that reduce the risk of death from all causes, including cancer (Li et al 2018), where the number of low-risk behaviours adopted was inversely related to the risk for mortality.

Furthermore, the Mediterranean Diet (Med Diet) is considered as one of the healthiest diets in the world by the WHO, that notes that it is directly associated with a lower rate of mortality thanks to its effects on disease prevention (WHO Europe 2018).The moderate consumption of alcoholic beverages, particularly wine, is an important component of that diet.

So, recommendations for a “healthy” lifestyle which include a healthy diet and avoidance of alcohol, may be confusing, at least from the Med Diet perspective.

Both, the International Agency for Research on Cancer (IARC) and the World Cancer Research Foundation (WCRF) report that alcohol consumption is associated with an increased risk for certain cancers (WCRF 2018, IARC 2012).  Risk is elevated with heavier drinking for all alcohol-associated cancers, with the exception of breast cancer that merits a special consideration (see later). In this context, we should remember that the risk of developing cancer involves various risk factors and all cancers that have been associated with alcohol also occur in the absence of drinking.

Some population studies suggested that ANY consumption of an alcoholic beverage is harmful to health, because of increased cancer risk, regardless of the amount consumed and without assessing the pattern of consumption, the type of alcoholic beverage and other lifestyle factors (Gakidou et GBD collaborators 2018, Wood et al 2018).

These authors concluded that it would be best for our overall health to avoid drinking at all, despite the fact that a reduced risk of myocardial infarction and of all-cause mortality was found, and that cardiovascular diseases are the number one cause of death globally (WHO 2017)[1]. 

Can we still enjoy a glass of wine with the meal without jeopardizing our health? What does the scientific evidence say regarding a possible cancer risk when wine is consumed moderately within the context (“umbrella”) of a healthy lifestyle and a Mediterranean-style diet?

What do we know – scientific evidence

The chemical substance ethanol/alcohol

The chemical substance ethanol, also referred to as ethyl-alcohol or alcohol per se has been classified as a Group 1 carcinogen by the International Agency for Research on Cancer (IARC 1988). This classification is given to agents or exposures where the agency considers there to be sufficient evidence of its carcinogenic effects in humans (IARC 1988).  

Alcohol metabolism

Two enzymes primarily in the liver (alcohol dehydrogenase (ADH) and aldehyde dehydrogenase (ALDH)) are involved in breaking down alcohol to enable the body to eliminate it. In the first step, ADH metabolises alcohol into acetaldehyde, which is a highly toxic chemical substance and known carcinogen[2]. Then in a second step, acetaldehyde is further metabolised by ALDH to another, less active metabolite called acetate, which is then further broken down into water and carbon dioxide for elimination from the body. The damage that acetaldehyde can cause to the cells in the body depends on how quickly it is broken down in the first step into acetate (Stockley et al 2010). Therefore, the faster an individual consumes an alcoholic beverage, the higher the BAC will rise with the respective negative health consequences.

For more information on how alcohol is metabolised by the body and the influencing factors, please click here. 

What is cancer?

Cancer is a term used for a certain group of diseases in which abnormal cells divide without control and invade other body tissues and organs. Tumours form when unimpeded abnormal cell growth occurs over a period of time. Cancer cells can subsequently spread to other parts of the body through the blood and lymph systems forming secondary malignant tumours or metastases.

There are more than 100 different types of cancers and most cancers are named after the organ or type of cell in which they start.

Benign tumours do not spread, and eventually stop growing.

Several observational studies and meta-analyses, however, have also found a reduced incidence for certain cancers associated with light to moderate alcohol consumption. The mechanism by which this alcohol consumption may decrease the risks of some cancers is not completely understood and may be indirect and/or alcoholic beverage specific through anti-oxidant and anti-inflammatory effects.

For more information on the mechanism of alcohol in the development of cancer, click here. 

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2. Excessive consumption of alcoholic beverages and cancer risk

Alcoholic beverages do not cause or contribute to the cause of all cancers.

The association between the consumption of alcoholic beverages and the risk of certain cancers has been studied for several decades. These studies have found that the extent to which alcoholic beverages are a risk factor of a cancer depends significantly on the amount of alcohol consumed, the type of alcoholic beverage and how it is consumed, that is the pattern of consumption, and probably also the dietary pattern in which alcohol is consumed.

Consumption levels and drinking patterns vary greatly between cultures and societies, however, and large amounts of an alcoholic beverage as well as regular heavy and binge drinking patterns generally impact on an individual’s general health and welfare.

Excessive consumption of alcoholic beverages is a risk factor for certain types of cancer and the risk generally increases with increasing levels of consumption.

For example, there is evidence that regular heavy excessive consumption of alcoholic beverages and binge drinking patterns (Roerecke et al 2014) are associated with increased morbidity and mortality from certain cancers (Bagnardi et al 2015), and particularly cancers of the upper aero-digestive tract (such as the mouth, tongue, larynx, pharynx and oesophagus) (Pelucchi et al 2011).

This increased risk is especially seen among individuals who also smoke tobacco (Anantharaman et al 2011, Szymariska et al 2011). Alcohol and tobacco enhance each other’s effects (i.e. act synergistically) on the risk of cancers of the upper digestive and respiratory tract. Cancer of the liver can result from alcoholic liver cirrhosis, which  is related to long-term heavy drinking (Parry et al 2011, White et al 2017; Jin et al 2013, Xi et al 2017) in conjunction with an unhealthy diet and/or hepatitis C and B virus infection. Besides those cancers listed above, other malignancies shown to be associated with heavy drinking include colorectum cancer as well as female pre- and post-menopausal breast cancer (IARC Working Group 2018). These cancers are referred to as alcohol-attributable cancers, and there is sufficient or convincing evidence of the attributions (World Cancer Research Fund International 2018).

One of many meta-analyses relating the consumption of alcoholic beverages to all cancer mortality suggested, however, that for heavy drinkers (>50 g alcohol/d), the relative risk of dying from any cancer was increased by 32% (Jin et al 2013).

→ There is no doubt that excessive drinkers have a high risk to develop cancer.  

For more information about binge drinking, click here.

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3. Moderate consumption of alcoholic beverages and cancer risk

While existing research is largely consistent as to the harms of heavy/excessive drinking in term of both cancer risk and overall mortality, there are disparate messages regarding the safety of light to moderate consumption of alcoholic beverages. Some argue that there is ‘no safe limit of alcohol’, mainly on the basis of an increased cancer risk (Wood et al 2018), and others emphasize the potential benefits for reducing cardiovascular mortality (Xi et al 2017).

Although excessive consumption has been linked to increased risk of several types of cancer, the overall effect of light to moderate consumption of alcoholic beverages on cancer incidence is less clear and findings are inconsistent (Zhou et al 2016). Whereas some studies have found a minimally increased or no increased risk of overall cancer (Xi et al 2017), others have found that even light and moderate drinking significantly contributes to an increased overall cancer risk (Bagnardi et al 2013, Bagnardi et al 2015, Cao et al 2015).

The overall cancer risk is difficult to evaluate since cancer consists of various diseases, each having specific characteristics. Furthermore, some of the meta-analyses investigating the association between the consumption of alcoholic beverages and cancer risk have limitations that need to be considered when evaluating the cancer risk: they did not assess the different drinking patterns and types of alcoholic beverages in modifying the effect of the total amount of alcohol (Bagnardi et al 2015); in addition, underreporting of alcohol consumption may partly or largely explain the cancer risk with light drinking (Klatsky et al  2014).

A large prospective study found a J-shaped association between alcohol and mortality when examining the lifetime alcohol consumption in older adults, which remained after adjusting for the cancer risk. The lowest combined risk of death and cancer was observed for light alcohol intakes (between 1 and 5 drinks/week [3]) in both men and women (Kunzmann et al 2018).

An assessment of risk for all cancer types by pooling the results of several epidemiological studies in a meta-analysis found a J-shaped curve between light to moderate drinking and overall cancer risk. This translated into a 9% lower risk of developing cancer for light drinkers (<12.5 g alcohol /d) compared to abstainers but an increased risk for excessive drinkers. No increased risk of dying from cancer for moderate drinkers (1-3 drinks/day) compared to abstainers (Jin et al 2013) was also reported.

A large meta-analysis reached similar conclusions that the consumption of alcoholic beverages (up to 1 drink/day) was not associated with the risk of most of the common cancers, except for the relatively small increase in the incidence of breast cancer in women and colorectal cancer in men (Choi et al 2018).

For more information about the link between moderate drinking and overall cancer risk, click here. 

3.1 Breast cancer 
Even though an increased overall cancer risk for women who drink moderately, was not shown by Hendriks et al (2018), it did indicate that women appear more sensitive to the pro-cancerous effects of alcohol.

Most observational, epidemiological studies have accordingly shown a small increase in the risk of breast cancer for women who consume any alcoholic beverages compared to non-drinkers. The degree of increase is usually small for light-to-moderate drinkers of between 5% and 10% increase in the relative risk for consumers of no more than one drink/day, but the risk may be higher for women consuming greater amounts  (Bagnardi et al 2015, Fagherazzi et al 2015, Choi et al 2018).

Since breast cancer is the most common cancer among women in Western countries (Bray et al 2018), even a small increased breast cancer risk from light drinking women may be relevant.

3.2 Salient confounding factors 

It has also been shown that the risk of breast cancer among obese women is higher than among non-obese women, but there are limited data on how obesity interacts with alcohol influencing the risk of breast cancer (Seiler et al 2018, Xiao et al 2019, van den Brandt et al 2000). 

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4. Cancer as a multifactorial disease and the importance of context

Since cancer is a multi-factorial disease, the cancer risk cannot be evaluated in isolation, and studies suggest that lifestyle factors are important risk factors for cancer (Kerr et al 2017). Accordingly, the consumption of alcoholic beverages cannot be accurately evaluated in insolation from the other risk factors.

For example, when the risk from alcohol is assessed within the context of a balanced diet and a healthy lifestyle, the results seem to be very different (see below).

Indeed, the balance between genetic predisposition and environmental factors, including nutritional components and lifestyle behaviours, determines individual susceptibility to develop cancer (Khan 2010). For example, click here. 

Smoking (30%), obesity (20%) and infections (15%) appear to account for a large proportion, while physical inactivity, an unhealthy diet and occupational hazards contribute 5% each, where the excessive consumption of alcoholic beverages contributes 3% to the overall cancer incidence (Fig. 1) (Arteaga et al 2014).

Figure 1. Besides various other risk factors, alcohol’s contribution to overall cancer incidence is estimated at approximately 3% (Arteaga et al. 2014)

Thus, it is important to assess the cancer risk in context with its cultural, drinking and eating patterns and lifestyle influences, and also to remember that epidemiological studies cannot adequately control for all possible confounding factors such as social background, education, physical activity, eating and drinking pattern, and other unknown factors.

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5. Wine consumption as part of the Mediterranean Diet - risk in context

Long-term observational studies have also found differences between the alcoholic beverages. At low to moderate wine consumption, often no association with alcohol-related cancer types was observed. Especially when the risk was assessed in the context of other lifestyle factors, light to moderate wine consumption does not seem to be related to any increased cancer (and other disease) risk (Schwingshackl et al 2017, Li et al 2020).

The Mediterranean Diet (Med Diet), which includes moderate consumption of wine, is considered as one of the healthiest dietary pattern in the world by the WHO, noting that it is directly associated with a lower rate of mortality due to its effects on chronic disease prevention (WHO Europe 2018).

Taken together, this results in a dietary pattern with a low content of saturated fatty acids (7–8% of daily total energy consumption) and a total percentage of fat of 30–40% or greater per day (Schwingshackl et al 2019; Schwingshackl et al 2017, Sofi et al 2014, Willett et al 1995; Fidanza et al 2005).

5.1 Mediterranean drinking pattern
The Mediterranean drinking pattern is not only about the amount of alcoholic beverage consumed but also the type of alcoholic beverage predominantly consumed – wine - and how it is consumed.

Drinking patterns in terms of frequency and the amount of wine consumed as well as drinking with or without a meal are important influencing factors for the biological effects of this alcoholic beverage. Risky and harmful drinking patterns including the regular consumption of heavy amounts of wine, as well as consuming heavy and excessive amounts on a single occasion (binge drinking), should be discouraged. It is thus recommended that individuals drink wine as an accompaniment to food and alternate it with a non-alcoholic beverage such as water (Boban et al 2016).

Spanish researchers examined the drinking patterns and concluded that the traditional Mediterranean drinking habits (such as moderate intake of alcoholic beverages, alcohol intake spread over the week, low spirit consumption, a preference for wine, wine consumed during meals, and avoidance of binge drinking) were also associated with a lower risk of all-cause mortality (Gea et al 2014).

5.2 Low to moderate wine consumption as part of a balanced diet such as the Med Diet
Intake of individual foods has been extensively studied in relation to cancer risk and for the chemical substance ethanol, a convincing evidence has been established, particularly for breast cancer (IARC 2012, WCRF 2018). However, individuals do not consume isolated foods or nutrients and examining dietary patterns in relation to cancer risk is consequently more meaningful.

Thus, it should be emphasized that the effect of alcohol on the tumour development depends on the context. Diet has been identified as a modifiable lifestyle component that influences the cancer development. The Med Diet is considered one of the healthiest diets because of its abundance of plant-based foods and the lack of processed foods (Willett et al 1995). Numerous epidemio­logical studies (Pellucchi et al 2009, Eleftheriou et al 2018, Soltani et al 2019) have focused on the health effects of the Med Diet, where studies that have examined the role of wine in the Mediterranean diet have identified a decreased risk of multiple health outcomes.

5.3 Med diet and all-cause mortality
More adherence to a Mediterranean dietary pattern resulted in: a reduced risk of all-cause mortality, cardiovascular diseases, coronary heart disease, stroke, overall cancer, diabetes and neuro-degenerative incidence (Dinu et al 2018, Soltani et al 2019).

An updated meta-analysis quantified the association of adherence to the Med Diet and all of its components with all-cause mortality (Eleftheriou et al 2018). When looking at the Med Diet components, a statistically significant inverse association was highlighted for a moderate consumption of alcoholic beverages compared to abstinence or excessive consumption[4].

5.4 Med Diet and cancer risk
The extent to which different drinking and dietary patterns, lifestyle habits and/or beverage specific ingredients are responsible for the observed reduced risk of certain cancers continues to be discussed, and may provide an explanation as to why no increased breast cancer risk has generally been observed within the context of a Med Diet (Trichopoulou et al 2010, Cade et al 2011, Couto et al 2011, Toledo et al 2015).

When examining moderate wine consumption in the context of the Mediterranean diet and typically with the meals, no increased cancer risk, even for breast cancer and colorectal cancer (Schwingshackl et al 2017, Toledo et al 2015) was observed. Furthermore, a better adherence to the Med Diet was also associated with a lower risk total mortality, that is dying from any cause (Soltani et al 2019).

Furthermore, a better adherence to the Med Diet was associated with a lower risk of total mortality, that is dying from any cause (Soltani et al 2019).

The above results were confirmed by large meta-analyses, where a greater adherence to the Med Diet was associated with a lower cancer risk (Schwingshackl et al 2017, Galbete et al 2018). When focusing specifically on prospective trials, this meta-analysis highlighted significant decreases in the risk of suffering colorectal and breast malignancies and in cancer mortality among subjects with high Med Diet adherence.  In line with these findings, a randomized controlled trial has studied the effect of this dietary pattern on cancer incidence. Adherence to the traditional Med Diet in the context of the PREDIMED Study demonstrated a decrease in the development of all sub-types of breast cancer and a decrease in its recurrence (Toledo et al 2015). It should be emphasized however that such findings need to be confirmed in further long-term trials. 

Regarding the alcohol, as stated by Schwingshackl et al. (2017), the attribution of anti-cancer effects to its consumption seems controversial, considering that it is categorized by the IARC as a Group 1 carcinogen for humans (IARC 2012) and by the World Cancer Research Fund as a convincing carcinogen for mouth, pharynx, larynx, esophagus, stomach, liver, colorectal, and breast malignancies (WRCF 2018). Low-to-moderate wine consumption contributes, however, to a higher Med Diet adherence (linked to the previously described benefits) and no dose-response effect of the toxicity of alcohol or wine consumption can be inferred from their conclusions.

5.5 Wine – a protective component of the Med Diet
The inclusion of alcohol in the Med Diet usually means moderate wine consumption as part of a meal (Gea et al 2014). When analysing the components of the Med Diet that contributed most to such a decreased cancer risk, researchers have specifically identified the moderate, but not excessive consumption of alcoholic beverages and predominantly wine, fruits, vegetables and whole grains as protective components (Schwingshackl et al 2017, Eleftheriou et al 2018).

There is sufficient clinical evidence to point out that moderate wine drinkers have a lower risk for cancer compared to drinkers of other alcoholic beverages. So far, the anti-cancer effects of wine-specific polyphenols have only been observed in animal and laboratory studies. In some epidemiological studies, however, the risk of cancer has been shown to be lower in wine drinkers than in those who consumed other alcoholic beverages (Xu et al 2019, Groenbaek M et al 2000).

5.6 Possible mechanisms
Wine provides large amounts of several bioactive compounds such as polyphenols that may be potentially responsible for some of the wine’s anti-cancer effects (Fernandes et al 2017) and the possible counter effects of the entire dietary composition of a Med Diet against the toxicity of alcohol on cancer has not been explored (Hernaez A et al 2019). Thus, the observed positive health effects of light to moderate wine consumption may be - at least in part - linked to the protective effects of specific bioactive ingredients in the wine (polyphenols) as well as in the foods consumed with higher abundance in the Mediterra­nean diet (Eleftheriou et al 2018).

For more information about wine polyphenols, click here.

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6. Moderate wine consumption and cancer risk in context (“umbrella”) of a healthy lifestyle

Several studies confirm that adopting a healthy lifestyle and a balanced diet, including a moderate consumption of wine/alcoholic beverages, has a number of positive and protective health effects. 

6.1 More years without chronic diseases

A large study from Harvard University examined comprehensively how multiple lifestyle factors relate to life expectancy without major diseases and confirmed these recommendations: following a healthy lifestyle at mid-life is associated with a longer life expectancy and a lower risk of major diseases such as cancer, cardiovascular and diabetes. The study highlights five specific lifestyle factors, one of them is the moderate consumption of alcoholic beverages (Li et al 2020):

The researchers found that women (at age 50) who ate a healthy diet, exercised 30 minutes each day, had a normal body weight and consumed alcoholic beverages in moderation lived to an average of 84.4 years old without developing diabetes, cardiovascular disease and cancer. Those women who did not practice these healthy habits were more likely to develop those diseases in their 70s. Middle-aged men practising these habits lived to an average of 81.1 years old without chronic diseases compared to 73.5 years old for men who did not.

Thus, in the context of a healthy lifestyle, moderate wine/alcohol consumption is one lifestyle factor that contributes to a longer life expectancy free of major diseases (Li et al 2020).

6.2 Longer life expectancy 

The same Harvard researchers (Li et al 2018) (Fig. 3) had already shown earlier that those five lifestyle factors could increase the life expectancy. They were surprised how immense the benefits of all these five lifestyle factors would be:

• 50 year old women who would practice ALL these healthy lifestyle factors could enjoy 14 additional years (93 instead of 79 years) and
• 50 year old men would benefit with 12 additional years (87 instead of 75 years).
• The reference group consisted of individuals with none of these lifestyle factors.
• Compared to this group, the mortality risk was 74% lower when all 5 factors would be followed, the cancer risk was 65% lower and the CVD risk was 82% lower. 

One of the five lifestyle factors - a moderate amount of alcoholic beverages - was defined for women 5-15 g of alcohol/day or the equivalent of 50 to 150 ml of wine and for men, 5-30 g of alcohol/day or the equivalent of 50 to 300 ml of wine.

Figure 3: Impact of healthy lifestyle factors on life expectancies in the US population (Li et al 2018)

A recent large European study reported similar results (Nyberg et al 2020), where the higher the number of healthy lifestyle habits, the longer the lifespan without major chronic diseases (type 2 diabetes, coronary heart disease, stroke, cancer, asthma, chronic obstructive pulmonary disease, heart failure, dementia*). The longest life span free of disease was observed among those participants with a normal weight (BMI < 25) and two of the following lifestyle factors: never smoking, physical activity and moderate consumption of alcoholic beverages (1-14 drinks per week for women and 1-21 drinks per week for men[5]). 

Even the World Cancer Research Fund recently stated five lifestyle factors that contribute to a lower cancer risk (WCRF 2018), among them a healthy diet, including moderate wine/alcoholic beverage consumption.

(*)These specific diseases were selected because they are the most common major non-communicable diseases in developed countries and targets prioritised for global disease prevention by WHO (Gakidou et al 2018)

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[1] https://www.who.int/en/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds) [back to reading]

[2] A chemical that promotes carcinogenesis or the promotion and progression of cancer. [back to reading]

[3]  One glass of wine = approx. 147 ml = approx. 14 g of alcohol [back to reading]

[4] Med diet score for alcoholic beverages = value of 1 for men who consumed quantities from 10 g /day to less than 50 g/day and a value of 0 otherwise; the corresponding cut-offs for women were 5 g/ day and 25 g/ day (Trichopoulou et al 2009) [back to reading]

[5] One drink being equivalent to 10 g of alcohol [back to reading]