Tuesday, January 3, 2017

The J Curve explained

In order to make sense of the seemingly conflicting reports about wine and health there’s one essential thing to understand: the J-shaped curve. It’s a simple concept, universal, in plain sight, and often ignored. It goes like this: Take “nondrinking” as the baseline and plot increased or decreased relative risk of a health issue with increasing levels of daily consumption. Nondrinkers have a certain risk of, say heart attacks, moderate drinkers a lower risk, heavy drinkers a relatively higher risk. Not too complicated. The tricky parts are separating wine drinkers from drinkers in general, and daily moderate drinkers from occasional drinkers.

The J-curve is not just about wine

The J-shaped curve is too universal to ignore once you see it. Even dietary salt intake has a J-curve; consuming too little in your diet can be as harmful as too much. For years, the American Heart Association has endorsed a 1.5 gram per day limit on sodium intake (salt is about 40% sodium), about what you get in a 6-inch sub sandwich or a bowl of vegetable soup. However, a massive multi-country review a couple of years ago found that the lowest incidence of heart disease correlated to about 4-5 grams per day, the bottom of a J-curve. Similar patterns plot out for coffee, vitamins, even water.
Wait - water? Obviously not drinking enough water is unhealthy, and questioning the benefits of hydration seems a fool’s errand. But it is possible to take it too far; in 2007 a woman participating in a water drinking contest called “Hold Your Wee for a Wii” was found dead of water intoxication. Superhydration throws electrolyte balances out of whack, with toxic and even fatal levels of water intake surprisingly easy to achieve. A  J-shaped curve.
Even lifetime happiness reportedly follows the curve. Young people generally enjoy a sense of well-being and optimism, career and family stress creates a dip through the 20’s and 30’s, then later in life happiness rises above the baseline, at least for most.

Why the J-curve is sometimes overlooked

Why is this simple model so often overlooked? One reason is that good data points are hard to come by, when it is drinking and eating habits that are being tabulated. People are unreliable self-reporters. Or researchers may have hidden agendas based on the need to publish, so that they focus on only the findings that support their hypothesis. Research on breast cancer and alcohol is particularly fraught with this problem; heavy drinking is unquestionably bad, but difficult in parsing out the subset of women who drink red wine (for example) with regularity and in moderation leads to extrapolation errors. If you simply draw a line from the heavy drinking/high risk corner of the graph down to the no drinking corner, you miss the bottom of the J. And you don’t want to miss the bottom of the J curve.

Thursday, December 15, 2016

Wine is a food group

Why are wine’s maximal health benefits related to consuming it with meals? It’s well known that wine with dinner on a regular basis is best, and understanding the role of wine as a food can help illuminate wine’s larger role in health. A central puzzle about wine and health is how much is due to biochemical substances such as resveratrol.  On the other hand, to what degree wine drinkers do other healthy things that can either compensate for the detrimental effects or amplify the good ones? People who regularly have a glass of wine with dinner more often eat in moderation, prefer healthier foods, and deal better with stress.

Wine with meals is associated with other healthy habits

A few recent studies bring clarification to the issue. One from the University of Helsinki in Finland reported the results of a long term population study evaluating drinking patterns and subjective well-being. Although a comparatively small percent of Finns have wine with dinner on a regular basis, those who did recorded better health, less psychological stress, and tended to be of higher socioeconomic status. Those who drank only wine also had fewer episodes of risky drinking behaviors such as bingeing. This type of study, while affirming the role of moderate wine drinking as a healthy thing, also suggests that lifestyle patterns are important.
It also illustrates why there are sometimes contradictory recommendations about wine and health; the pattern of drinking matters more than the amount, up to a point, but not all studies make this distinction. Another recent study, this one from the University of Split School of Medicine in Croatia, looked more deeply into the question. After reviewing available data from other studies, they found a clear correlation of wine with meals to maximal health benefits. The authors speculated that several factors such as the effect of food on alcohol absorption could be involved.

Why wine with meals makes food more healthy

The most telling evidence comes from a clinical trial conducted by the University of Rome Tor Vergata in 2014. This study measured the effects of red wine on post-meal oxidized cholesterol levels and expression of genes involved in inflammation. In order to see what the independent effects of wine were, they compared a McDonald’s meal to a Mediterranean diet meal, each with and without red wine. There was a clear benefit of wine with each meal type. So having a glass or 2 of wine makes even junk food better for you, pointing to biochemical properties of wine as the mediator of its health benefits. In other words, wine is more than a marker for a healthy lifestyle. Wine is a food.
1.       Oksanen A, Kokkonen H. Consumption of Wine with Meals and Subjective Well-being: A Finnish Population-Based Study. Alcohol Alcohol.  2016 Nov;51(6):716-722.
2.       Boban M, Stockley C, Teissedre PL, Restani P, Fradera U, Stein-Hammer C, Ruf JC. Drinking pattern of wine and effects on human health: why should we drink moderately and with meals? Food Funct. 2016 Jul 13;7(7):2937-42.

3.       Di Renzo L, Carraro A, Valente R, Iacopino L, Colica C, De Lorenzo A. Intake of red wine in different meals modulates oxidized LDL level, oxidative and inflammatory gene expression in healthy people: a randomized crossover trial. Oxid Med Cell Longev. 2014;2014:681318.

Monday, November 7, 2016

The French paradox at 25

 November 17 2016 will mark twenty-five years since the CBS television show 60 Minutes christenedthe term “French paradox” and ushered in the modern era of research on wine and health. It was a provocative idea at the time, attributing the French custom of regular imbibing to health and well-being. It still has its naysayers; as recently as 2015, England’s chief medical officer Sally Davies scorned the idea and proclaimed it an “old wives’ tale.” (She suggested a cup of tea instead, presumably with pinky finger raised.) Then there are those who reduce the idea to a simple question of nutritional biochemistry and proclaim that all of wine’s health benefits can be put into a pill, conveniently and properly skipping the alcohol. Is there still a useful truth underlying the paradox?

Why the French Paradox is still true

As with many questions in the realm of lifestyle and health, the answers are often nuanced and conditional. Government authorities in both America and Europe challenged the authors of the French Paradox –Curt Ellison in Boston and the late Serge Renaud in Bordeaux – who were challenged to defend the idea. Their work drew from both epidemiology and basic science, laying the groundwork for a legion of researchers who followed. The French paradox is now so well ingrained that it risks becoming a cliché and its true meaning lost. Despite all of the advances in understanding the components of wine and how they contribute to health, at its heart the paradox is a reflection of a lifestyle. Wine is a food, squarely affixed in the quotidian rituals of the Mediterranean diet.
The science that grew from the seed planted by the French paradox idea has grown far beyond what any of the early researchers could have predicted. Polyphenols from the skins of wine grapes have emerged as vitally important elements of an anti-aging diet. Among the best known is resveratrol, about which there were 2 articles in the scientific literature in the year of the original broadcast of the story; there a more than 2 every day now. Resveratrol provides a handy explanation for why wine drinkers have lower odds of developing Alzheimer’s, diabetes, osteoporosis, and pretty much all of the diseases of aging. It helps break up the protein plaques in the brain associated with Alzheimer’s, prevents cholesterol from aggregating into concretions in the arteries, kills cancer cells (while protecting normal ones), even improves insulin sensitivity in diabetics. Resveratrol certainly appears to be a miracle molecule, as I dubbed it in my book Age Gets Better with Wine. There are huge international conferences on resveratrol, and tomes on resveratrol market conditions.

It's not just resveratrol

But there remains a problem with giving resveratrol all the credit: there isn’t very much of it in wine, and less in anything else we might consume. Resveratrol has little if anything to do with the French paradox. Data still support the benefits of regular wine consumption, but is lacking when it comes to the use of resveratrol in supplement form. This brings us back to the role of wine as a lifestyle factor. Wine drinkers tend to do a lot of health things besides having a daily tipple with dinner, and wine contains a lot more than the pittance of resveratrol, including alcohol. It is the synergies of these various things that release the power of the paradox. 
In 1979 a paper was published in the famous medical journal The Lancet.(1) The article found a clear correlation of average wine consumption by country to lowered rates of heart disease, and it became an iconic reference. No one knew at the time why this should be so, but the authors concluded the article by observing that if the ingredient in wine should ever be identified, “we consider it almost a sacrilege that this constituent be isolated. The medicine is already in a highly palatable form (as every connoisseur will confirm.)”
1    1. St Leger AS, Cochrane AL, Moore F. Factors associated with cardiac mortality in developed countries with particular reference to the consumption of wine.  Lancet. 1979 May 12;1(8124):1017-20.

Friday, September 9, 2016

Should colleges teach drinking 101?

A quick glance at statistics on alcohol abuse in American colleges and universities reveals a huge problem, and I believe that tackling the issue will require a new and perhaps controversial strategy. Various approaches have failed, so in this “back to school” edition I take a look at the question and offer a sensible, if counterintuitive, alternative. The majority of young people who choose to drink need to be taught that there is such a thing as healthy drinking. The drinking 101 curriculum has to include “how drinking can be healthy” and not just “don’t drink.”
First the numbers: According to the National Institute on Alcohol Abuse and Alcoholism, as many as 1800 students die each year from alcohol-related causes. More than a half million more are injured while drunk, and tens of thousands become victims of sexual assault attributable to alcohol.  Tellingly, more than half of the 80% of students who consume alcohol engage in binge drinking, and this lies at the heart of most of the problems.

Party Culture Reinforces the Role of Alcohol as a Drug

Cultural factors make the problem of college drinking intractable to the usual approaches based primarily on enforcement of drinking restrictions. As the song goes, students are willing to fight for their right to party, and it’s the party culture that reinforces the role of alcohol as a drug. According to a 2014 New York Times article, the nation’s #1 party school Syracuse University faced a revolt over efforts to curtail drinking on campus. Students labeled the school a police state, and officials backed off. On many campuses, problem drinking is endemic to the Greek system, not directly under university control.
One clue hidden in plain sight is that the abuse is almost entirely in the form of beer and liquor. This reflects a trend in how we view beer and liquor consumption as a society. A 2015 study analyzing content of beer and liquor TV commercials revealed that “partying” has become the primary theme, while not identified in ads from 20 years ago. (1) Even Dos Equis, the last holdout of a mature approach to beer marketing with their “most interesting man in the world," just replaced  him with a younger jock in order to appeal to more youthful consumers.
There is evidence-based guidance on reducing problem drinking on college campuses, but the efforts are still narrowly focused on overall reduction rather than type of alcohol. The NIAAA’s “College Alcohol Intervention Matrix” rates 60 strategies on their effectiveness, with skills training in the top tier. None of this training appears to include a discussion of wine as healthy part of a meal. Alcohol is alcohol, be aware of how much, and drink less or none. Other recommendations include higher taxes on alcohol, banning Sunday sales, and limiting happy hour promotions.

Wine Offers a Positive Alternative Model

Aside from political campaigns, negative messages generally don’t move the needle on human behavior as much as positive ones. Offering a positive healthy way to consume (at the appropriate age) seems likely to work better than stronger enforcement of prohibitions. Perhaps I was lucky in this regard; my wine “epiphany” came during a summer when I was doing a research project at UCLA, when someone brought a bottle of Chambolle-Musigny to a pre-concert picnic at the Hollywood Bowl. It enlightened me to the aesthetic virtues of drink over the anesthetic properties of alcohol. It would be years before I had the budget for good wine on a regular basis, but I saw immediately that there could be a positive and healthy approach to drinking. Obviously we can't expect to create an entire student body of wine snobs, but it is also obvious that we need a different approach. We need to promote a culture of healthy drinking.

"The dipsomaniac and the abstainer make the same mistake: They both regard wine as a drug and not as a drink."
G.K. Chesterton (1874-1936)

1. Content Themes of Alcohol Advertising in U.S. Television-Latent Class Analysis.
Morgenstern M, Schoeppe F, Campbell J, Braam MW, Stoolmiller M, Sargent JD.
Alcohol Clin Exp Res. 2015 Sep;39(9):1766-74.

Monday, August 1, 2016

This is your brain on wine: an update on cognition, Alzheimer’s, and wine

Even as the silent epidemic of Alzheimer’s disease grows, wine’s positive if seemingly unlikely effects on brain health continue to offer a map toward a solution. It’s long been known from lifestyle surveys that wine drinking is a defining characteristic of the lowest risk group for Alzheimer’s (AD).* In fact, without exception regular wine consumption is the only factor that features in every study across the board. But given that alcohol is neurotoxic, it just didn’t seem to make sense.

The resveratrol promise tested

Resveratrol, the anti-aging miracle molecule in wine, offered a plausible explanation. Laboratory and animal studies showed that resveratrol works in several specific ways to counteract the noxious effects on brain cells of protein plaques called ß-amyloid, a marker for AD. While the role of ß-amyloid in the pathogenesis of AD is still not completely clear, it is evident that with enough resveratrol the formation of the plaques can be suppressed, and health of the neurons enhanced, at least in lab studies. No other product, whether a drug, vitamin, or nutraceutical, has shown such promise.
These findings led to several clinical trials of resveratrol as a supplement. Most are still are underway, with only one having published results (1); however this study produced more questions than answers. For example, after one year levels of one type of ß-amyloid in the fluid around the brain (CSF) declined more in the placebo group, and brain volume shrunk more in the resveratrol cohort. The authors pointed out that the “etiology and interpretation of brain volume loss observed here and in other studies are unclear, but they are not associated with cognitive or functional decline.” One take-away message was that only tiny levels of resveratrol in the brain were required to have an effect.

More to wine’s benefits than just resveratrol

So there must be something more to wine’s unique association with brain health than resveratrol and AD. It is likely that there is synergy between resveratrol and other polyphenols in red wine, for example, and alcohol may help absorption of these compounds making them more bioavailable. And we cannot discount the fact that moderate daily consumption of wine is a lifestyle marker for other healthy behaviors. Maybe wine drinkers are just smarter to begin with!
*Studies on lifestyle factors and cognition/dementia

  • Canadian Study on Health and Aging: Cohort study of >6000 subjects; wine, coffee, NSAID use, regular exercise (Am J Epidemiol 2002)
  • Copenhagen City Heart Study: 15-year case-control study of >1700 subjects; wine consumption but not beer or spirits correlated with lowest risk (Am Acad Neurol 2002)
  • Bordeaux Study: Cohort of ~4000 subjects age >65; 80% lower incidence in wine drinkers (European J Epidemiol 2000)
  • Catholic University of Rome multicenter study: cognitive testing of >15,000 subjects; highest scores in men drinking up to 1 liter/day, women 0.5 liters/day (Alcoholism Clin Exp Res 2001)

Thursday, June 30, 2016

Of reds, whites, and bluebloods: revolution and wine in America and France


Liberty and wine (apologies to Delacroix and Bartholdi for taking a few liberties  . . .)

How diminished access to affordable wine factored in to both the American and French revolutions

There are more than a few parallels between the French and American revolutions: Both are commemorated by holidays in July, (Independence Day on the 4th and Bastille Day the 14th), the same national colors, and similarly spurred by corrupt royal rule and unfair taxation. In both countries, access to affordable everyday wine played a significant role. Though not widely recognized, the liberation of the Bastille was not the first major act of the insurrection in France, but rather the storming of the customs offices at the gates of Paris where increased taxes on wine had been imposed. And while the Boston Tea party marked a significant escalation of protests against taxation without representation on British subjects in the colonies, it was wine they really relied upon for their day-to day existence. Tea was a luxury, wine a necessity.
Colonists were desperate to figure out how to make wine in the New World. Wine made trans-Atlantic seafaring possible, by decontaminating drinking water; the pilgrim ships carried more wine than fresh water. It was well understood that survival in the colonies depended on winemaking for the same reason.  A 1623 law in colonial Virginia underscored this urgency, mandating that “Every householder doe yearly plante and maintaine10 vines, untill they have attained to the arte and experience of dressing a vineyard, either by their owne industry, or by the instruction of some vigneron.” Winemaking was never successful in the colonies despite consultants being brought over from France, so the colonies remained dependent on imports. The British blockade during the Revolutionary War cut off access to imported wine, furthering discontent.


Is a tax on wine a tax on health?

In France wine was increasingly taxed toward the end of the Ancien Régime, under an elaborate system known as tax farming.  An important collection point was at the gates of Paris, where the taxes effectively tripled the price. Ordinary Parisians would circumvent this by going to taverns just outside the city for their daily quaff after a day’s labor, but as Paris expanded and the walls moved farther out this became impractical. The result was a lack of affordable wine for the average man, a situation that undoubtedly contributed to increasing unrest. On July 11, 1789, a series of dramatic attacks on the customs barriers began, continuing for the next 3 days; according to one historian, Paris was “encircled by a wall of flames.”
Addressing the wine tax issue was one of the first orders of business for the National Assembly after the revolution. Étienne Chevalier, a deputy from Argenteuil (and a winemaker) argued for abolishing the tax: “Wine is the basis of the survival of the poor citizens of Paris. When bread, meat, and other foods are too expensive, he turns to wine; he nourishes and consoles himself with it.” He held that the taxes were “unjust in their principles and unproductive, immoral and disastrous in their consequences.”
This same sentiment would be argued in the United States by Jefferson: “I rejoice as a moralist at the prospect of a reduction of the duties on wine by our national legislature… Its extended use will carryhealth and comfort to a much enlarged circle. And later: I think it is a great error to consider a heavy tax on wines as a tax on luxury.  On the contrary, it is a tax on the health of our citizens.”

A toast to freedom!

Tuesday, May 31, 2016

Which came first: Beer or wine? (or something else?)

Actually neither beer nor wine was the first fermented beverage, and wine arguably has a closer connection to health, but recent evidence indicates that humans developed the ability to metabolize alcohol long before we were even human. The uniquely human ability to handle alcohol comes from the digestive enzyme alcohol dehydrogenase, or ADH4. A new science called paleogenetics identifies the emergence of the modern version of the ADH4 gene in our ape ancestors some 10 million years ago. Interestingly, this corresponds to the time when our arboreal forebears transitioned to a nomadic lifestyle on the ground. We went from swinging from tree limbs to walking upright, and the rest is history. Understanding the circumstances that led to perpetuation of the ADH4 mutation may contain clues to what made us human in the first place.

How the ability to metabolize alcohol made us human

Paleogenetecist Matthew Carrigan has an idea about how this happened. Arboreal species rely on fruit that is in the tree, but if you can digest fruit that has fallen, and partially rotted – meaning fermented and therefore alcoholic – then you could get by just fine with less effort or when other sources of food were scarce. One simple mutation was all that was needed to impart this enhanced ability to metabolize alcohol, and this characteristic remains a defining difference between humans and other primates.

Why I think wine was first

One argument in favor of the wine first theory is that wild grapes, which grew on vines climbing trees (not the neatly trellised rows in modern vineyards), simply had to be gathered. Since wine could easily come from fermented fallen fruit, it could possibly go back millions of years, requiring only the ability to collect and store liquids. Fermentation happened automatically, so winemaking was more of a discovery than an invention. Physical evidence for early winemaking includes pottery fragments with wine residue that have been carbon dated to around 7400 years ago.
There is no direct evidence for beer making until at least 1000 years later. However, it has been theorized that a taste for fermented grain products may have prompted humans to begin farming around 10,000 years ago, because harvesting wild grains in sufficient quantities for brewing would be much less efficient than gathering fruit.  No hard evidence to support that idea has appeared, so the debate remains an open question.

About the only thing that we can be certain of is that the gathering of minds around shared drinks would lead to spirited discussions for millennia.