How Many Drinks
a
Day?
Alcohol has been the subject of much debate throughout the ages, and it continues to stimulate much of the same. The effects of alcohol are not all to one side of the medical issue. Indeed, recently there has been quite a bit of data to suggest that alcohol may have a beneficial effect on atherosclerosis, which may be seen in a lower rate of coronary heart disease (CHD) in some settings. Elsewhere in this issue (p 1973), Hennekens et al, in a novel approach toward reducing bias in a case-control study, have reported that alcohol has a protective effect against coronary disease. In addition, their study is one of the first to show that the good effect of drinking can be got from beer, wine, or spirits. Just how alcohol lowers the CHD rate is yet to be unraveled. At present the story seems to go as follows: Alcohol increases high-density lipoprotein (HDL) levels, a finding that has been rather uniform in a diversity of populations.1 Also, HDL seems to work in our bodies as a scavenger to remove cholesterol from cholesterol deposits and initiate transport of such choles¬ terol back to the liver, where it eventually is excreted in the bile. Also, HDL blocks internalization of the low-density lipoproteins (LDLs), which may be the major mechanism by which our cells fill up with fat droplets—one of the basic elements of the cellular expression of atherosclerosis. High intake of alcohol lowers the LDL level, probably the most atherogenic lipoprotein particle system we have. Of course, alcohol raises very-low-density lipoprotein (VLDL) levels, but this is one of the least well understood effects of alcohol. The average person who drinks increases his VLDL level only temporarily; it is only in the upper 596 of the drinkers where the fasting VLDL levels rise. Analyses that do not take this into account miss an important point.2 Barboriak and associates' have shown an inverse correlation of alcohol with lesions of coronary atherosclerosis in 2,000 angiograms. To wit, the more alcohol one drank, the cleaner that person's coronary arteries. Of course, as mentioned earlier, not all of the news about alcohol is good. For those interested in the total health of the individual, the data from Framingham indicate that the relation¬ ship of alcohol to health is of a U-shaped distribution. Zero intake of alcohol seems less healthful than a moderate intake, equivalent to two drinks (two beers, two glasses of wine, two glasses of spirits, or two highballs) per day. Higher intakes of alcohol are associated with increased rates of all the wellknown problems that alcohol produces from nutritional,
gastrointestinal, neurological, cardiological, hématologie, pul¬ monary, electrolyte, and cancer problems. Thus, the problem seems simple—just two a day and that's it. Unfortunately, recent research into the etiology of alcoholism Address editorial communications to the Editor, 535 N Dearborn
gives us cause for concern. There have been three studies comparing orphans' alcoholism with alcoholism in their adoptive parents and in their biologic parents, whom they barely knew. In Iowa," Denmark,' and Sweden,6 the results all have followed the same pattern. Orphans' alcoholism correlates far better with their biologic parents than with the environment in which they were raised. This suggests that people are born with a biologic makeup that can enhance the addictive qualities of alcohol. What they could be exactly is still probably a mystery. The metabolism of alcohol in the body begins with alcohol dehydrogenase located primarily in the liver. This enzyme converts alcohol to acetaldehyde. Increased activity of this reaction is associated with alcohol preference in animals. Children of alcoholic parents have higher levels of acetaldehyde in response to a standard alcohol challenge. On the other hand, too rapid accumulation of acetaldehyde is thought to explain aversion to drinking in the Japanese, and very high levels of acetaldehyde producing unpleasant side effects occur when one takes alcohol while receiving tetraethylthiuram disulfide (disulfiram). This drug inhibits the enzyme aldehyde dehydrogenase, which rapidly
dissipates acetaldehyde.
In addition, certain genetic markers (ABO secretors), enzyme markers (monoamine oxidase), and some prostaglandin abnor¬ malities are among other mechanisms that are under investiga¬ tion to explain why people are born to handle alcohol
differently. The problem with all of this is that it may be dangerous to tell some people to take two drinks a day when, given their constitutional makeup, one could fairly predict they could not stop at two. Thus, what started out as prudent advice turned into advice that led to cardiac death of alcoholic cardiomyopathy rather than to an extension of life by lowering coronary atherosclerosis. With 17 million alcoholics in this country we perhaps have message for which this country is not yet ready. W. P.
a
Castelli, MD
National Institutes of Health National Heart Institute Framingham, Mass 1. Castelli WP, Gordon T, Hjortland MD, et al: Alcohol and blood lipids. Lancet 2:153-155, 1977. 2. Bottiger LE, Carlson LA, Haltman E, et al: Serum lipids in alcoholics. Acta Med Scand 199:357-361, 1976. 3. Barboriak JJ, Anderson AJ, Rimm A, et al: Alcohol and coronary arteries. Alcoholism 3:29-32, 1979. 4. Cadoret RJ, Gath A: Inheritance of alcoholism in adoptees. Brit J Psychiatry 132:252-258, 1978. 5. Goodwin DW, Schulsinger F, Hermansen L, et al: Alcohol problems in adoptees raised apart from alcoholic biological parents. Arch Gen Psychiatry 28:238-243, 1973. 6. Bohman M: Some genetic aspects of alcoholism and criminality: A population of adoptees. Arch Gen Psychiatry 35:269-276, 1978.
St, Chicago, IL 60610.
Downloaded From: http://jama.jamanetwork.com/ by a University of Calgary User on 05/25/2015
a
Day?
Alcohol has been the subject of much debate throughout the ages, and it continues to stimulate much of the same. The effects of alcohol are not all to one side of the medical issue. Indeed, recently there has been quite a bit of data to suggest that alcohol may have a beneficial effect on atherosclerosis, which may be seen in a lower rate of coronary heart disease (CHD) in some settings. Elsewhere in this issue (p 1973), Hennekens et al, in a novel approach toward reducing bias in a case-control study, have reported that alcohol has a protective effect against coronary disease. In addition, their study is one of the first to show that the good effect of drinking can be got from beer, wine, or spirits. Just how alcohol lowers the CHD rate is yet to be unraveled. At present the story seems to go as follows: Alcohol increases high-density lipoprotein (HDL) levels, a finding that has been rather uniform in a diversity of populations.1 Also, HDL seems to work in our bodies as a scavenger to remove cholesterol from cholesterol deposits and initiate transport of such choles¬ terol back to the liver, where it eventually is excreted in the bile. Also, HDL blocks internalization of the low-density lipoproteins (LDLs), which may be the major mechanism by which our cells fill up with fat droplets—one of the basic elements of the cellular expression of atherosclerosis. High intake of alcohol lowers the LDL level, probably the most atherogenic lipoprotein particle system we have. Of course, alcohol raises very-low-density lipoprotein (VLDL) levels, but this is one of the least well understood effects of alcohol. The average person who drinks increases his VLDL level only temporarily; it is only in the upper 596 of the drinkers where the fasting VLDL levels rise. Analyses that do not take this into account miss an important point.2 Barboriak and associates' have shown an inverse correlation of alcohol with lesions of coronary atherosclerosis in 2,000 angiograms. To wit, the more alcohol one drank, the cleaner that person's coronary arteries. Of course, as mentioned earlier, not all of the news about alcohol is good. For those interested in the total health of the individual, the data from Framingham indicate that the relation¬ ship of alcohol to health is of a U-shaped distribution. Zero intake of alcohol seems less healthful than a moderate intake, equivalent to two drinks (two beers, two glasses of wine, two glasses of spirits, or two highballs) per day. Higher intakes of alcohol are associated with increased rates of all the wellknown problems that alcohol produces from nutritional,
gastrointestinal, neurological, cardiological, hématologie, pul¬ monary, electrolyte, and cancer problems. Thus, the problem seems simple—just two a day and that's it. Unfortunately, recent research into the etiology of alcoholism Address editorial communications to the Editor, 535 N Dearborn
gives us cause for concern. There have been three studies comparing orphans' alcoholism with alcoholism in their adoptive parents and in their biologic parents, whom they barely knew. In Iowa," Denmark,' and Sweden,6 the results all have followed the same pattern. Orphans' alcoholism correlates far better with their biologic parents than with the environment in which they were raised. This suggests that people are born with a biologic makeup that can enhance the addictive qualities of alcohol. What they could be exactly is still probably a mystery. The metabolism of alcohol in the body begins with alcohol dehydrogenase located primarily in the liver. This enzyme converts alcohol to acetaldehyde. Increased activity of this reaction is associated with alcohol preference in animals. Children of alcoholic parents have higher levels of acetaldehyde in response to a standard alcohol challenge. On the other hand, too rapid accumulation of acetaldehyde is thought to explain aversion to drinking in the Japanese, and very high levels of acetaldehyde producing unpleasant side effects occur when one takes alcohol while receiving tetraethylthiuram disulfide (disulfiram). This drug inhibits the enzyme aldehyde dehydrogenase, which rapidly
dissipates acetaldehyde.
In addition, certain genetic markers (ABO secretors), enzyme markers (monoamine oxidase), and some prostaglandin abnor¬ malities are among other mechanisms that are under investiga¬ tion to explain why people are born to handle alcohol
differently. The problem with all of this is that it may be dangerous to tell some people to take two drinks a day when, given their constitutional makeup, one could fairly predict they could not stop at two. Thus, what started out as prudent advice turned into advice that led to cardiac death of alcoholic cardiomyopathy rather than to an extension of life by lowering coronary atherosclerosis. With 17 million alcoholics in this country we perhaps have message for which this country is not yet ready. W. P.
a
Castelli, MD
National Institutes of Health National Heart Institute Framingham, Mass 1. Castelli WP, Gordon T, Hjortland MD, et al: Alcohol and blood lipids. Lancet 2:153-155, 1977. 2. Bottiger LE, Carlson LA, Haltman E, et al: Serum lipids in alcoholics. Acta Med Scand 199:357-361, 1976. 3. Barboriak JJ, Anderson AJ, Rimm A, et al: Alcohol and coronary arteries. Alcoholism 3:29-32, 1979. 4. Cadoret RJ, Gath A: Inheritance of alcoholism in adoptees. Brit J Psychiatry 132:252-258, 1978. 5. Goodwin DW, Schulsinger F, Hermansen L, et al: Alcohol problems in adoptees raised apart from alcoholic biological parents. Arch Gen Psychiatry 28:238-243, 1973. 6. Bohman M: Some genetic aspects of alcoholism and criminality: A population of adoptees. Arch Gen Psychiatry 35:269-276, 1978.
St, Chicago, IL 60610.
Downloaded From: http://jama.jamanetwork.com/ by a University of Calgary User on 05/25/2015
