Saturday, May 28, 2011

Cholesterol drug Niaspan disappoints; better to just have a glass of wine?

This week it was announced that a clinical trial on the use of Niaspan (a sustained release formulation of the vitamin niacin) to raise levels of HDL or “good” cholesterol, was suspended because of disappointing results. While it is well-established that higher levels of HDL (high-density lipoprotein) relative to LDL (its low-density counterpart) are associated with reduced risk of heart attack and stroke, the addition of Niaspan to the cholesterol-lowering statin drugs (for example Lipitor) has failed to deliver the same benefit seen in people who naturally have a high HDL/LDL ratio. In this recent trial, there was even a trend to an increased stroke incidence. Sales of Abbott’s Niaspan totaled nearly $1 billion last year, but development of several cholesterol drugs has been suspended recently due to lack of efficacy in preclinical trials.

It seems appropriate then to take a few steps back and see what we know about what does work. Not smoking, along with exercise and a healthy diet are unquestionably the first steps in reducing the risk of cardiovascular disease. But how is a healthy diet defined? Regular consumption of red wine has long been identified as a significant element in a heart-healthy diet, though randomized prospective clinical trials such as those used in drug development are few. Nevertheless, a positive pattern emerges for wine consumption especially with meals.

Wine consumption is known to affect cardiovascular disease risk factors in several ways: First, alcohol in moderate amounts also raises the HDL/LDL ratio, though in light of the Niaspan study the benefit of this effect seems debatable. Alcohol also helps prevent thrombosis, or clotting in the arteries which is the critical event in heart attack. A 2008 prospective clinical trial from the Netherlands pointed to additional benefits from alcohol, observing that the addition of white wine but not grape juice to the diet of postmenopausal women improved insulin sensitivity—a good thing for cardiovascular risk—while raising HDL and lowering LDL along with triglycerides, another bad actor. At a more fundamental level, tissue levels of a substance called adiponectin were increased, providing a possible explanation for less weight gain observed among middle-aged wine drinkers. A similar trial in men, looking a a broader range of alcoholic beverages, found positive effects on blood pressure and various markers of inflammation in the blood after red wine or beer consumption but not whiskey or white wine.

As anti-alcohol activists point out, alcohol also has deleterious effects on blood pressure, but intervention studies find that the threshold for this is at about 4 drinks per day. So alcohol seems to be at least acceptable if not beneficial in moderate amounts, and when combined with the long list of properties associated with the antioxidant polyphenols in wine, it seems clear that a glass or two of wine with dinner should be a central part of a heart-healthy diet.

Sunday, May 15, 2011

The French Paradox at 20

This year will mark twenty years since the CBS television show 60 Minutes christened the 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, and it still has its naysayers; at the other extreme, 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?

As with many questions in the realm of lifestyle and health, the answers are often nuanced and conditional. Though challenged by government authorities in both America and Europe, the authors of the idea РSerge Renaud in Bordeaux and Curt Ellison in Boston Рprovided a rigorous defense of the notion. The French paradox is invoked regularly as an excuse for having a few, to the point that it has become a clich̩ and its real lessons 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 daily 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 though. Antioxidant polyphenols from the skins of wine grapes (not so much from juice or table 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, whereas there a more than 2 every day now. Resveratrol and other wine polyphenols provide a handy explanation for why wine drinkers have lower odds of developing Alzheimer’s, diabetes, osteoporosis, and pretty much all of the disease of aging. They help break up the protein plaques in the brain associated with Alzheimer’s, prevent cholesterol from aggregating into concretions in the arteries, kill cancer cells (while protecting normal ones), even improve insulin sensitivity. Resveratrol appears at first glance to be a miracle molecule, as I dubbed it in my book Age Gets Better with Wine.

But there remains a problem with giving resveratrol all the credit: there isn’t very much of it in wine. Data clearly supports 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. It is the synergies of these various things that unleash the true benefits of wine.

Monday, May 2, 2011

New Heart Association Survey on wine: Why are Americans confused about healthy drinking?

The American Heart Association recently released the results of a survey of Americans on their knowledge of healthy drinking and consumption of sea salt. No surprise, they concluded that we have it all wrong. On the plus side, two thirds agreed with the statement that wine is good for the heart, but less than one third know the AHA’s recommended limits of a daily glass or two for men and no more than one for women. The survey showed that “we need to do a better job of educating people about the heart-health risks of overconsumption of wine” according to a spokesperson.

I say bless their hearts but their paternalistic message only adds to the confusion. For starters, they don’t even have their definitions right, which is a 5-ounce pour as the standard on which research and policymakers have long agreed, but the AHA cuts it back to 4. Granted, they have come a long way since the mid 1990’s when the official policy grudgingly acknowledged that a glass or two a day “might be considered safe” while hastening to add a disclaimer about all of the social ills attributed to alcohol consumption. But these problems are associated with excess and problem drinking, not a glass or two or even three with a leisurely dinner. What statistics consistently show is that wine with dinner is among the most powerful contributors to health.

Part of the problem is the narrow focus on heart health, which we can forgive to some degree for the AHA but it leads to an incomplete picture of the broader benefits of healthy drinking. When consumed with meals, up to 3 glasses for a man and about half that for a woman is associated with the greatest reduction in health problems across the board leading to longer lifespan and a higher quality of life, especially in old age.

Just as interesting to me is the comments that follow the various news postings about the study. It would seem that we are even more confused about wine and health now as ever, judging from remarks suggesting that red grape juice has the same benefits as wine without the alcohol.