Critique 009 25 June 2010
Clinical Crossroads: Conferences with patients and doctors
A 42-year-old man considering whether to drink alcohol for his health. Kenneth J. Mukamal, MD, MPH, Discussant. JAMA 2010;303:2065-2073. (doi:10.1001/jama.2010.550)
This report is from a conference that took place at the Medicine Grand Rounds at Beth Israel Deaconess Medical Center, Boston, Massachusetts, on January 15, 2009; it has recently been published in JAMA. It provides a discussion by an epidemiologist with a broad knowledge in the field in response to a theoretical question, as from a middle-aged patient, as to the advisability of consuming some alcohol “for his health.”
Alcohol consumption is widespread and, in excess, a leading cause of morbidity and mortality worldwide. At the same time, a consistent body of observational evidence has found that individuals who consume alcohol within recommended limits have a lower risk of coronary heart disease than do abstainers. These observations have led many to consider small amounts of alcohol as a cardioprotective strategy. Mr Q, a 42-year-old man who has consistently sought ways to preserve his health, is at a crossroads in his discussions with his physicians about the health effects of his regular, limited alcohol intake.
The discussion reviews the epidemiology of drinking in the United States, the established effects of moderate alcohol intake on key pathophysiological biomarkers and pathways, the strengths and limitations of observational evidence linking alcohol intake to lower risk of coronary heart disease, other chronic diseases linked to moderate alcohol intake, and a framework in which Mr. Q can discuss the potential risks and benefits of alcohol consumption with his physicians.
The full article is available at http://jama.ama-assn.org/cgi/content/full/303/20/2065
Most members of the International Scientific Forum on Alcohol Research were pleased with Mukamal’s discussion of the topic. It was noted how uncommon it is that such knowledgeable, detailed, and mostly objective data appear in the mainstream medical literature. It was thought to be “readable, informative and thoughtful.”
Mixing moderate drinking and alcohol misuse: There was some criticism that the discussion repeatedly switched to statements about the dangers of drinking excessively instead of focusing on the effects of a level of alcohol intake that was being questioned by the patient: regular moderate drinking. It would have been preferable to present first the known and serious health effects of excessive or binge drinking, and then present a balanced discussion of the risks and benefits of moderate drinking.
Potential dangers of inadequate information: According to the premise presented in the paper, the reason the patient questioned his moderate use of alcohol was based on an encounter with a “specialist” who advised him to consider stopping drinking because alcohol could “accelerate brain shrinkage.” While “brain shrinkage” is a radiological term with little known relation with clinical outcomes, an extensive epidemiologic literature suggests less decline in cognitive functioning over time, and lower risk of dementia, among moderate drinkers in comparison with non-drinkers. Such findings are supported by much data from basic science experiments. This illustrates the danger of incomplete information (“a little knowledge”) by a member of the medical profession. Mr. Q seems to be very careful (perhaps even a little too careful) in following a healthy lifestyle, including consuming small amounts of alcohol in a reasonable pattern. His new concern might be considered an iatrogenic condition.
Importance of pattern of drinking: In comparing the effects of alcohol consumption in France and Northern Ireland, the discussant missed an opportunity to enlighten physicians about the effects of different drinking patterns on health outcomes. As described by Evans et al,1 the per-capita consumption of total alcohol is almost identical for France and Northern Ireland, but the net effects on health are quite different between the two countries. This has been attributed partly to the fact that all of the alcohol in Northern Ireland is consumed by about one-half of the population (whereas in France the large majority consume alcohol) and especially by the differing patterns of consumption in the two countries (tendencies to regular moderate drinking in France versus week-end binge drinking in Northern Ireland).
Effects of polyphenols: There was concern by several members of the Forum that the discussant did not present an adequate statement about the effects on cardiovascular risk from polyphenols and other non-alcoholic substances present in wine and in certain other beverages. Statements such as, “However, the concentrations of such constituents even in red wine are much lower than the concentration of ethanol and, given their limited bioavailability, are unlikely to have substantial physiological effects at the modest doses consumed by most Americans.” This statement ignores a huge amount of experimental data indicating strong beneficial effects on endothelial function, oxidative processes, and blood coagulation from such substances.
It is also unfortunate that this aspect of the discussion focused on resveratrol. A number of recent reports have suggested that very large doses of resveratrol may relate to greater longevity, and pharmaceutical companies are rushing to develop and sell products based on resveratrol. These companies tend to relate the health benefits of red wine only to resveratrol. However, the scientific literature (including extensive experimental data in animals) have demonstrated that there are many active substances in wine which show protection against atherosclerosis, intravascular clotting, and abnormal functioning of the endothelium. Some of these substances may well be more important than resveratrol, and could be playing an important role in preventing myocardial infarction and other types of cardiovascular disease.
Reference from critique
1. Evans A, Marques-Vidal P, Ducimetiere P, et al. Patterns of alcohol consumption and cardiovascular risk in Northern Ireland and France. Ann Epidemiol 2007;17(Suppl):S75–S80.
This paper, based on a presentation at a medicine grand rounds, gives an excellent discussion of a theoretical question about drinking and health. It focuses on the potential risks and benefits associated with moderate drinking for a middle-aged male patient. Most members of the International Scientific Forum on Alcohol Research (ISFAR) were pleased with Mukamal’s discussion of the topic. It was noted how uncommon it is that such knowledgeable, detailed, and mostly objective data appear in the mainstream medical literature. It was thought to be “readable, informative and thoughtful.”
The ISFAR critique points out a number of topics that were covered incompletely in the paper, including inadequate information on the importance of the pattern of drinking: moderate regular consumption versus binge drinking. Further, there was a notable lack of information on the beneficial effects on many pathophysiologic processes of polyphenols and other non-alcohol substances present in wine and certain other foods and beverages. Overall, it was believed that the paper provided important information for physicians who may be discussing alcohol consumption with their patients.
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Contributions to this critique by the International Scientific Forum on Alcohol Research were from the following:
Roger Corder, PhD, MRPharmS, William Harvey Research Institute, Queen Mary University of London, UK
R. Curtis Ellison, MD, Section of Preventive Medicine & Epidemiology, Boston University School of Medicine, Boston, MA, USA
Harvey Finkel, MD, Hematology/Oncology, Boston University Medical Center, Boston, MA, USA
Dominique Lanzmann-Petithory,MD, PhD, Nutrition/Cardiology, Praticien Hospitalier Hôpital Emile Roux, Paris, France
Ross McCormick PhD, MSC, MBChB, Associate Dean, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
Francesco Orlandi, MD, Dept. of Gastroenterology, Università degli Studi di Ancona. Italy