Straight Up

You thought you were a lightweight; look how incoherent health officials can get over a drink or two.

For more than a decade now, researchers have been reporting that adults who drink moderate amounts of alcohol--a drink or two a day, on average--are 20% to 30% less likely to develop heart disease than those who drink rarely or never.

Yet just last year, a team of health officials in France challenged the so-called French paradox, the theory that the French custom of drinking with meals explains the country’s low rate of heart disease, despite rich food. And earlier this year, the American Heart Assn. published a strong caution against drinking, urging doctors to downplay the “popular but unproven supposition that drinking red wine can ward off heart attacks” and denying there is good evidence that alcohol improves cholesterol readings.

Was it all hype? Or another story of false promise, like vitamin E or beta carotene, in which early enthusiasm over possible protection against heart disease cooled after further research?

Neither, say those who study the relation between alcohol and heart disease. For one thing, alcohol is not a supplement or a drug administered for health reasons; it is part of the human diet that, for better or worse, predates the fields of nutrition and cardiology by thousands of years.

For another, the evidence that moderate drinking protects against heart disease has not suddenly become murky, as happened with beta carotene and vitamin E. If anything, researchers say, the case for moderate drinking has only gotten stronger in the last year. “Any epidemiologist worth anything who looks at the 60 or so studies on this would conclude that moderate drinking reduces the risk of heart disease and overall mortality,” says Eric Rimm, who studies the interaction of diet and disease at the Harvard School of Public Health. “You get the benefit by drinking beer in Germany, or wine in France, or distilled spirits in Asia. You name a country, they’ve done studies showing this effect.”

The recent double talk about alcohol is more political than scientific, researchers say, and reflects officials’ reluctance to trust the public with good news about a substance that causes so much harm when abused. The assault on the French paradox, for example, came at a time when the French government was waging a campaign against alcohol consumption, according to critics of the recent research.

The concern is easy to understand: About 15% of regular drinkers have serious alcohol problems, according to government data. And any statement from a group such as the American Heart Assn. is bound to have a strong influence on recommendations across the country, according to Dr. Edward Fisher, a heart disease researcher at the Mount Sinai School of Medicine in New York, who co-authored the AHA report. Fisher says that the AHA chose to “err on the conservative side, because the benefits of light drinking aren’t absolutely proven for everybody, and we wanted to avoid any hint of endorsing it.”

Yet the resulting message blurs the crucial distinction between heavy and moderate drinking, researchers say, and confounds the understanding of both. “Any discussion of alcohol should start with a clear statement of the risks of heavy drinking: car accidents, suicide, alcoholism and so on,” says Dr. Arthur Klatsky, a cardiologist at Kaiser Permanente Medical Center in Oakland, who in 1974 authored one of the first papers linking alcohol to reduced heart disease risk. “But 70% of adults in this country drink, and the vast majority do so moderately, not heavily. There is a difference.”

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That difference is fairly well defined, in fact, for a substance whose effect varies so much from person to person. Studies find that “problem” drinking usually begins after people start downing three or more drinks a day, on average. That’s when the DUIs turn up; that’s when it becomes harder to get to work on time (or at all); that’s when the family arguments flare and relationships suffer.

Not coincidentally, that third beer or glass of wine also marks the difference, for many people, between drinking and drunk, when alcohol noticeably turns on the body. Having three pops or more in an evening quickly raises blood pressure in many people, for example, which is especially dangerous for those with hypertension (chronic high blood pressure), doctors say.

Over time, this kind of heavy drinking raises a person’s risk of liver and digestive diseases, cardiomyopathy (a weakening of the heart muscle), not to mention suicide and depression.

It is a truly morbid list--but one that does not apply to moderate drinkers, as far as doctors can tell. While some argue that a substance that’s toxic in large doses must be damaging in smaller amounts, there’s no solid evidence linking the diseases of problem drinking to those of moderate drinking, says Dr. Meir Stampfer, a professor of nutrition and epidemiology at the Harvard School of Public Health.

Even people with hypertension who drink moderately seem to enjoy the same 30% or so reduction in heart disease risk, according to a recent Harvard study of 14,125 physicians with a history of high blood pressure. “Heavy drinking is clearly related to high blood pressure,” Klatsky says, “but light drinking has no relationship to high blood pressure at all. A lot of people with hypertension are benefiting from a glass of wine or a beer a day.”

Alcohol can interact with antihypertensive drugs and cause spells of lightheadedness, or dizziness, cardiologists say, and hypertensives should be aware of those problems. “I don’t tell people on these drugs they can’t have a drink,” says Dr. Vincent De Quattro, a cardiologist at the USC School of Medicine. “But I tell them to be careful, to be moderate, to sip it slowly.”

So far, doctors have firm evidence of one major health risk from moderate drinking: breast cancer. On average, women who have a drink a day increase their risk of developing the cancer by about 10%, compared with nondrinkers, according to Dr. Michael Thun, chief of epidemiological research at the American Cancer Society.

“If your sole concern were breast cancer, then the best thing to do would be to abstain entirely,” Thun says. “But after menopause, the risk of heart disease increases and becomes greater than the risk of breast cancer. So it’s a complex equation for women.”

Is it proved that alcohol causes this reduced risk? It’s not. Something else about moderate drinkers may be protecting their hearts, such as genetic factors, different diets or other healthy habits. To rule out all of these elements, doctors would have to follow thousands of adults for years, controlling their diets and other details of their everyday lives, including their level of drinking.

“You can see how that would be almost impossible to do, practically and ethically,” Klatsky says.

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But contrary to the American Heart Assn.’s advisory, researchers insist they have documented direct evidence that alcohol improves cholesterol readings.

One’s risk of getting heart disease, cardiologists say, is related to the ratio of bad (LDL) cholesterol molecules to good (HDL) ones in their bloodstream. The bad cholesterol molecules tend to deliver fats to artery walls, doctors say; and the good stuff helps the body clear the bad away. A diet rich in fruit, vegetables and whole grains, for example, can drive down levels of the bad LDL molecules by 10% to 20% in some people--translating directly into a 10% to 20% reduced risk of heart disease, doctors report.

Alcohol appears to tweak the cholesterol from the other end. Numerous trials now demonstrate that a drink or two a day raises good (HDL) cholesterol levels by about 12%, on average, alcohol researchers say, and that bump in HDL confers a reduced heart disease risk in the range of 20% to 25%.

Short of taking drugs, doctors say, the only other way to raise HDL is through regular exercise, or smoking cessation, if you’re a smoker.

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All evidence considered, says Stampfer, the cardio-protective effects of moderate drinking are at least as well documented as those from just about any other lifestyle factor--from eating fiber or fruit and vegetables, to exercise and weight loss. And combining all these behaviors can be particularly powerful. In a study published last summer, for instance, Stampfer and Rimm estimated that people with particularly unhealthy habits could reduce their risk of developing heart disease by up to 82% through five lifestyle changes: avoiding tobacco; exercising regularly; eating a good diet; keeping weight under control; and drinking moderately.

“If you took the drinking out, it went down to about a 65% reduction in risk,” Rimm says, “so it’s just one of many things you can do, and not the most important one. I think that one reason [health officials] are afraid to come out and say moderate drinking lowers risk of heart disease is because they worry that people will forget the other things they can do--like eat a good diet and exercise--thinking they can get the same protection from drinking.”

So far, there’s no good evidence that’s happening, researchers say. Many nondrinkers avoid alcohol for good reasons, such as religion or history of alcoholism. And generally speaking, doctors are very reluctant to encourage the habit. “If patients ask, ‘Doctor, may I have a glass of wine?’ I usually tell them, ‘Yes, sure,’ ” De Quattro says. “But I don’t advise people to start drinking.”

And most people don’t ask. The choice to have a drink or not remains a social, personal decision, not a medical one.

“Just like there are good alternatives to moderate drinking to protect your heart,” says Fisher, the heart disease researcher, “there are also other reasons to drink. Like enjoyment. I’ve got 600 bottles of red wine in my basement, and the truth is, I’d enjoy that wine even if it didn’t raise my HDL levels.”