Critique 282 – Is coffee, tea, and red wine consumption beneficial for individuals with hypertension?

Authors

Zhang S; Xiang B; Su X; Zhou Y; Zhao Y; Zhou X

Citation

PMJ 2024 100(1186): 603–610. doi.org/10.1093/postmj/qgae039

Author’s Abstract

Objective To investigate the associations of tea, coffee, and red wine intakes with health risks among individuals with hypertension.

Methods This prospective cohort study included participants with hypertension from the UK Biobank cohort. Study exposures included self-reported intakes of coffee, tea, and red wine. The primary outcome was all-cause mortality, and the secondary outcomes were cardiovascular mortality and cardiovascular disease. The associations of beverage intake with outcomes were analyzed using Cox regression models. The hazard ratios and 95% confidence intervals were estimated.

Results A total of 187 708 participants with hypertension were included. The median follow-up period was 13.8 years. In individuals with hypertension, drinking one to two cups/day of coffee or three to four cups/day of tea was significantly associated with the lowest risk of all-cause mortality compared with less than one cup/day [hazard ratio for coffee, 0.943 (95% confidence interval, 0.908-0.979); hazard ratio for tea, 0.882 (95% confidence interval, 0.841-0.924)]. Red wine intake was inversely associated with all-cause mortality risk. Dose-response analysis revealed that high coffee intake (approximately greater than or equal to six cups/day) was significantly associated with increased risks of cardiovascular mortality and cardiovascular disease, but high tea and red wine intakes were not. Furthermore, replacing plain water with tea, but not coffee, significantly reduced the risks of all-cause mortality and cardiovascular disease. Replacing other alcoholic beverages with red wine also significantly reduced the risks of all three outcomes.

Conclusions These findings suggest that tea and red wine, but not coffee, can be part of a healthy diet for the hypertensive population.

Forum Summary

Because hypertension is the leading risk factor for cardiovascular diseases and all-cause mortality, the relationship of alcohol consumption with blood pressure (BP) has been the subject of extensive investigation. Zhang et al. (2024) support that drinking moderate amounts of red wine as part of a healthy diet and lifestyle reduces the risk of cardiovascular disease and death from all causes for hypertensive individuals, an effect most likely due to the biological activity of wine-derived phenolic compounds.

Forum Comments

Background

Hypertension is a prevalent condition (Stanaway et al., 2018, Chobufo et al., 2020; GBD 2021 Risk Factors Collaborators, 2024) and a well-documented risk factor for all-cause mortality, cardiovascular disease, chronic kidney disease, and vascular dementia. (Kannel, 1993, Fuchs and Whelton, 2020). Systolic blood pressure (SBP), the top number in a blood pressure reading, measures the force against the artery walls when the heart contracts. It rises steadily with age and is a strong predictor of cardiovascular disease risk. Diastolic blood pressure (DBP) measures the force against artery walls between heartbeats and is not as strong a predictor of heart disease risk in comparison to systolic. More than one-third of the global population currently has hypertension with an estimated 46% of adults being unaware of that condition according to the WHO (WHO, 2023). Effective blood pressure management is vital to reduce, prevent or delay the development of high blood pressure, and thereon cardiovascular disease, where one of the WHO’s global targets for non-communicable diseases is to reduce the prevalence of hypertension by 33% between 2010 and 2030.

The prevalence of hypertension in the USA during the years 2017–2018, for example, was approximately 50%. Increasing age, male gender, obese individuals, diabetics and chronic kidney disease were independent determinants of having hypertension. Only about 40% of hypertensive patients on medications had well-controlled blood pressure (Chobufo et al., 2020).

Non-pharmacological measures and lifestyle interventions may contribute significantly to the prevention of hypertension, with a healthy diet and physical activity being the most effective combination of lifestyle modifications for prehypertensive and hypertensive patients (Krishnamoorthy et al., 2023). A recent umbrella review supported recommended dietary guidelines involving the DASH (Dietary Approaches to Stop Hypertension (Guo et al., 2021)) and Mediterranean dietary patterns, restricting sodium, with moderate alcohol consumption, as indicated by mostly moderate-quality randomised controlled trials (Aljuraiban et al., 2024).

Apart from restricting sodium and moderation of alcohol consumption, numerous other dietary components have been investigated in their effect on blood pressure. An analysis of the available evidence reported in meta-analyses showed a wide variation in the quality of the research methodology with high confidence in results obtained in randomized controlled trials rather than for results obtained from observational studies on specific dietary components. High confidence in effect was obtained for dietary components such as flaxseed, nitrates, multivitamins and multi-minerals, and grape and its products (Aljuraiban et al., 2024).

For beverages, moderate-quality evidence from randomized controlled trials showed significant reductions in systolic blood pressure and diastolic blood pressure with intakes of black tea (Ma et al., 2021), green tea (Xu et al., 2020), and alcohol consumption in moderation (Roerecke et al., 2017). There was moderate-quality evidence showing a nonsignificant reduction in both systolic and diastolic blood pressure with coffee intake (Steffen et al., 2012). The evidence was rated as low quality for tea (Liu et al., 2014) and decaffeinated coffee (Ramli et al., 2021).

The current paper is interesting since there is already extensive literature on the benefits of tea, coffee and red wine consumption on all-cause and cardiovascular (CVD) mortality and morbidity as well as extensive literature on the role of diet and dietary components in hypertension prevention, but minimal information on these dietary effects in hypertensives. This study reports on the associations of the beverages ­— tea, coffee and red wine, on cardiovascular disease and mortality and total mortality in a hypertensive population group.

Critique

This report by Zhang et al., (2024) from the Department of Cardiology at Soochow University in China used data from the large-scale, long-term prospective cohort study, the UK Biobank. A total of 187,708 participants with hypertension were included in the analysis. The median follow-up time was about 14 years, those with an adverse event in the first year were excluded.

The authors conclude that tea and red wine consumption were inversely associated with all-cause mortality and CVD risk and mortality in individuals with hypertension. The authors also conclude that these effects were not attributable to the water and alcohol content of the beverages. The basis for this conclusion is their substitution analysis which shows that replacing one glass of water/day with one cup of tea/day was associated with a 1.3% lower risk of all-cause mortality and a 0.7% lower risk of CVD. Also, replacing one glass/week of other alcoholic beverages with one glass/week of red wine was associated with a 1.8% reduced risk of all-cause mortality and a 2% reduced risk of CVD mortality.  

These results are consistent with an earlier study also using the UK Biobank data (Schaefer et al. 2023) examined how alcohol intake from wine and non-wine alcoholic beverages in g alcohol/d, as well as cups of coffee and tea, were associated with all-cause, cancer, non-cancer and CVD mortality. Consumption was assessed in 354,386 participants who drank alcohol at least occasionally. Similarly, the median follow-up time was about 12 years. A significant U-shaped association was detected between wine consumption and all-cause, non-cancer and CVD mortality. Wine consumption with the lowest risk of death (nadir) ranged from 19 to 23 g alcohol/d in all participants and both sexes separately. Tea consumption, however, was significantly and negatively associated with all mortality types in both sexes.

In general, tea (Chung et al., 2020, Chen et al. 2022) and wine consumption (Lucerón-Lucas-Torres et al., 2023) have been reported to be inversely associated with all-cause and CVD mortality. Risk reductions in non-hypertensives were estimated to be in the range of 2-4% (Chung et al., 2020) for tea consumption and 20-25% for wine consumption (Lucerón-Lucas-Torres et al., 2023).

Indeed, although both tea and red wine contribute to the beneficial CVD and total mortality effects in hypertensives, red wine has a larger protective effect. The red wine polyphenolic effect on CVD has been referred to in the discussion text by the authors. An earlier intervention study demonstrated that de-alcoholised red wine decreased SBP and DBP (Chiva-Blanch et al., 2012), although the reduction in blood pressure after the consumption of de-alcoholised and polyphenol-rich red wine was modest (5.8 and 2.3 mm Hg of SBP and DBP, respectively), decreases of 4 or 2 mm Hg in SBP or DBP respectively, have been associated with a 14% and 20% reduction in coronary heart disease and stroke risk, respectively, conferring clinical significance to the results (Lewington et al. 2002).

This smaller effect with de-alcoholised wine compared to that observed in Zhang et al. (2024) and Lucerón-Lucas-Torres et al. (2023) suggests that polyphenolics are not the only bioactive compounds responsible for the reduction in risk, specifically in the case of red wine. There has been a longstanding discussion in the literature on alcohol consumption and CVD and all-cause mortality as to whether the alcohol component or the polyphenol component is relevant for the described effects. It has been subsequently established, that both components play complementary roles, in addition to other (behavioural) factors (Gronbaek, 2001, Lamuela-Raventos and Estruch, 2016). Indeed, Okubo et al (2001) had previously observed such an inverse association between alcohol consumption and SBP and DBP changes in a normotensive population, with a threshold effect at 18 mL of daily alcohol consumption.

Alcoholic beverage-specific effects with all their different components are hard to study in longitudinal studies. Comparing countries with one main specific alcoholic beverage being consumed has major drawbacks; the beverage may not be the only difference between the countries studied. Comparing alcoholic beverage-specific effects within countries is also complicated because most people do not drink one alcoholic beverage exclusively. Attempts to still disentangle the health effects of the three main alcoholic beverages are controversial. A recent meta-analysis, however, did not find major differences in health outcomes of low to moderate consumers of all three alcoholic beverage types (Estruch & Hendriks, 2021).

Directly comparing the effects of alcoholic beverages is possible in randomized controlled trials. Most of these trials do show that the biomarkers for cardiovascular disease risk change similarly for all three alcoholic beverages (Van Der Gaag et al., 2001)(Van Der Gaag et al., 1999). These observations, however, only concern specific aspects of the complex association between alcohol consumption and health outcomes. So, it seems that alcohol is at least a major contributor to the beneficial CVD and all-cause mortality effects.

Also, numerous processes are involved in the aetiology of CVD and all-cause mortality. So, compounds in beverages like tea consisting of water and polyphenols and red wine consisting of water, polyphenols and alcohol may all have differential effects. Possibly, polyphenols will beneficially affect processes that are antioxidant-sensitive and related to the restoration of endothelial function via nitric oxide production. Alcohol, however, may beneficially affect the atherogenic process. This may have been the case in another study on hypertensives (Beulens et al., 2007) that showed moderate alcohol consumption was associated with a decreased risk for myocardial infarction, but not for CVD and total mortality.

Although the authors stress the importance of moderation, this notion is not reflected in their conclusion, viz. these findings suggest that tea and red wine, but not coffee, can be part of a healthy diet for the hypertensive population.

Specific Comments from Forum Members

Forum member Ellison suggests that “this paper is impressive from a number of factors.  First, the authors carried out several approaches to test the associations found from their initial unadjusted analyses, and all provided firm support for the protective effects noted for tea and red wine.  Further, it is interesting that the effects of red wine were much greater than those for tea, with striking reductions in all-cause mortality of up to 15 – 20% from red wine consumption.  There was no evidence of an increased risk of all-cause mortality even for subjects reporting more than 15 drinks per week.  This finding supports the very early and well-done report from Gronbaek et al. (2000) that showed moderate wine consumption does not increase the risk of premature death. Considering that the authors were unable to adjust for the pattern of drinking or whether or not it was with food, these results are impressive support for the potential health benefits of red wine consumption.  Based on previous research (Morales et al., 2020, Jani et al., 2021), one would expect even greater health effects if analyses were done for subjects who consumed wine only with meals.  Also, the authors included HDL-cholesterol, diabetes, and other potential variables that are mechanisms of alcohol’s effects as confounding factors, which may have reduced their estimate of health effects.

These results should (but probably will not) put to rest the claims of a few authors (Stockwell et al., 2024) who have stated that moderate wine or alcohol consumption does not reduce the risk of total mortality.  Overall, sound and unbiased scientific research continues to indicate that moderate alcohol consumption has important and clinically meaningful protective health effects.  Current knowledge does not suggest that, for middle-aged or elderly adults without contraindications to drinking, zero alcohol is healthier than moderate drinking; this is not the correct message to give to the public.”

Forum member Harding muses that he “agrees that the findings are consistent with the conclusion that moderate (red) wine consumption does not increase the risk of premature death.  That said, I identified a number of difficulties with this paper, and the rationale for the conclusions is unclear. The most important is a common feature of epidemiological studies of this nature, namely that observed associations merge into assumed causations throughout the text, with little or no mechanistic justification.  Consequently, the main conclusion, “these findings suggest that tea and red wine, but not coffee, can be part of a healthy diet for the hypertensive population”, is not justified by the data.

The opening paragraph states that “More than one-third of the global population currently has office hypertension”.  I assume that ‘office hypertension’ is the same as ‘white coat hypertension’, i.e. the blood pressure readings are significantly affected by the way blood pressure is measured.  I assume that is a mistake.  The studies cited (Reference 1 and 2, Global Burden of Disease studies) make no mention of office hypertension, just hypertension.

The Discussion section is confusing.  The researchers state, ‘The current study found that participants with higher tea or coffee intake had water intakes far below the daily requirement.’  And then go on to assert, ‘The health benefits of tea or coffee intake are probably due to the supplement of water.’

The next paragraph says, “Early evidence (what is that?) suggested that alcohol intake was a double-edged sword.  Light-moderate alcohol intake was associated with a lower cardiovascular risk, but heavy alcohol intake had the opposite effect”. And then they say, “however, increasing evidence consistently showed that light to moderate alcohol intake among the general population was associated with higher risks of other severe diseases”, citing Reference #26. Reference #26 is not a study at all, but a comment published in The Lancet that draws on other work.  It does not distinguish in weight of evidence between epidemiology (e.g. Wood et al., 2018, Reference # 6, which actually did not show that moderate consumption carried additional risks, quite the reverse) and studies on the actual effect of alcohol on metabolism (e.g. Ronksley et al., 2011, Schrieks et al., 2014, References #7 and #8).  This conclusion is also not supported by Figure 1 and is simply wrong. Those consumers of red wine kept on getting healthier, up to 15 glasses/week.

Then at the end, the researchers suggest a mechanism to explain their observations, namely that the polyphenols in red wine are responsible for the association between red wine consumption and the fall in all-cause and cardiovascular mortality.  But there is no mention of the effect of polyphenols in tea, or indeed in coffee, both beverages high in polyphenols and which are cited as possible mechanisms for the benefit of tea and coffee consumption in the references the authors cite (References #6 and #7).”

Forum member Mattivi considers that “the work is interesting but suffers from some inaccuracies. I agree with the critical points reported by other forum members. I also suggest that it should be highlighted in the commentary that the geographical reference is specific to the population of England, Scotland and Wales where the diet is very different, for the intake of polyphenols, compared to other countries (such as Poland), and can be extremely variable between different subgroups, as highlighted by a recent review (Luana Alberti Noronha et al., 2024).

The potential effect due to the possible protective action (not only antioxidant) of polyphenols and their circulating metabolites and catabolites could be very different for the intake of beverages such as red wine and tea, rich in polyphenols, on populations with starting dietary intakes much lower than average, compared to individuals who adhere to nutritional guidelines and have increased intakes (Castro-Acosta et al., 2019). This aspect should be explored further (if the UK biobank data permits) to support the hypotheses on the putative protective mechanisms linked to polyphenols mentioned in the study.

They conclude, “this study revealed that approximately five glasses/week of red wine was associated with remarkable health benefits, but higher intake had few additional benefits”, but the hazard ratios in Figure 1 do not show that, as they show a steady improvement with increased consumption.  The final sentence (on page 608) again assumes association is the same as causation, as do the conclusions.”

So in summary, my comments are

•   association is assumed to be causation throughout;

•   the statement, “moderate alcohol consumption among the general population was associated with higher risks of other severe diseases” is simply wrong; and

•   the biological mechanisms proposed to explain the results are unconvincing.”

Concluding comments

This investigation of the large UK Biobank Cohort supports previous studies showing that particularly red wine, in moderation, is a legitimate component of a healthy diet and lifestyle in individuals with hypertension. This is in addition to normotensive individuals as previously demonstrated. This study, however, can not necessarily be extended directly to hypertensive individuals in other countries due to dietary differences between countries.

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Zhang, S., Xiang, B., Su, X., Zhou, Y., Zhao, Y., & Zhou, X. (2024). Is coffee, tea, and red wine consumption beneficial for individuals with hypertension? Postgraduate Medical Journal, 100(1186), 603–610. https://doi.org/10.1093/postmj/qgae039

Comments on this critique by the International Scientific Forum on Alcohol Research were provided by the following members:

Henk Hendriks, PhD, Netherlands

Creina Stockley, PhD, MBA, Independent consultant and Adjunct Senior Lecturer in the School of Agriculture, Food and Wine at the University of Adelaide, Australia

R Curtis Ellison, MD, Section of Preventive Medicine/Epidemiology, Boston University School of Medicine, Boston, MA, USA

Fulvio Ursini, MD, Dept. of Biological Chemistry, University of Padova, Padova, Italy

Giovanni Gaetano, MD, PhD, Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo NEUROMED, Pozzilli, Italy

Richard Harding, PhD, Formerly Head of Consumer Choice, Food Standards and Special Projects Division, Food Standards Agency, UK

Fulvio Mattivi, MSc, Scientific Advisor, Research and Innovation Centre, Fondazione Edmund Mach, in San Michele all’Adige, Italy