by Jason Fung
Paracelsus, a German doctor practicing in the sixteenth century, wrote, “Whether wine is a nourishment, medicine, or poison is a matter of dosage.” Paracelsus is considered the father of toxicology and is credited with creating the essential rule, “The dose makes the poison.” The use of smaller doses of “toxic” substances for health is called hormesis. Some examples of toxic substances we use to promote health include botulinum toxin (Botox) and rat poison (Coumadin, used for thinning the blood). The principle also might apply to red wine.
Even Thomas Jefferson wrote, “Wine of long habit has become indispensable to my health.” Famous French biologist Louis Pasteur wrote that he found “wine to be the most healthful and hygienic of beverages.” And in the writings in which William Heberden described angina pectoris, he noted “wines and spirituous liquors afford considerable relief”; he believed that wine was a potent coronary vasodilator.8
However, this attitude that red wine was a factor in longevity and important for maintaining good cardiovascular health changed dramatically in the early twentieth century as public opinion embraced the idea that alcohol was toxic in any dose. This culminated in Prohibition in many nations of the world, including the United States from 1920 to 1933.
During Prohibition, all sales, transportation, and drinking of alcohol were banned. The leaders of the Prohibition movement were concerned about the many problems associated with alcoholism, including health problems, such as liver cirrhosis, and numerous social problems, like domestic violence and absenteeism. The temperance movement began in the early nineteenth century, but it gained strength with The Anti-Saloon League, which formed in 1893. Prohibition planted the idea that a complete ban on alcohol and related businesses would be a great boon to public health.
Alcohol consumption did indeed dramatically fall in 1920, with estimates that per-capita alcohol use dropped by about 30 percent. But further reductions were impossible because of illegal imports, moonshine, and organized crime. Prohibition finally was repealed; however, it left the impression among the public that all alcohol was bad for health. Abstinence was considered a virtue, and this viewpoint persisted through the rest of the twentieth century.
Improbably, as we moved into the twenty-first century, studies consistently found that moderate alcohol consumption reduced heart disease. Red wine provided the greatest protection.9 However, consuming large amounts of alcohol is a slippery slope because higher amounts are still associated with greater mortality and higher risk for heart failure and arrhythmias. The dose makes the poison.
THE FRENCH PARADOX: IS RED WINE THE SECRET INGREDIENT?
Since the 1960s Americans have believed that eating too much fat would cause heart disease. In a desperate attempt to expunge fat from our diet, we cut the visible fat off meat, ate low-fat skinless chicken breasts, and drank low-fat dairy. Meanwhile, citizens of France continued to enjoy their traditional full-fat cheeses and fatty cuts of meat. The French ate almost three times as much of the reviled animal fats compared to Americans but had almost half the heart disease.10 We call this “The French Paradox,”11 although it could easily apply to people in Greece or Spain who also consume diets relatively high in saturated fat but have a low rate of death from heart disease. Much of this “paradox” is explained by the fact that natural animal fats don’t cause heart disease, which is an understanding that is still evolving. We address types of fats in more detail in Chapter 11.
Scientific investigation into this paradox led researchers onto a surprising new path to uncovering the benefits of red wine. The French Paradox is unique because of the much higher rate at which the French consume alcohol compared to the people of other countries.12 France produces more wine than any other country in the world and ranks second in the number of vineyards (just behind Spain). Although red wine was previously thought to be a risk factor for heart disease, it increasingly is viewed as a protective factor.
The first inklings of the surprising notion that low-moderate alcohol intake could be beneficial came in 1979. Researchers surveyed eighteen developed countries, including Canada and the United States, to look for factors related to heart disease deaths.⁹ The researchers were not interested in wine at all. Instead, their main interest was the correlation between the number of doctors and nurses and improved health care for the patient. Surprisingly, countries with more doctors also had more heart disease. Because the research also included information about health and alcohol use, the researchers were able to examine outcomes related to alcohol consumption. For example, increased alcohol intake was associated with more road accident deaths, which underscores the importance of not drinking and driving.
Fig. 9.1: Wine consumption and cardiac death in developed countries13
The researchers uncovered that the most powerful protective factor against heart disease was moderate alcohol consumption, which was a completely unexpected result. As they looked further into the phenomenon by separating wine, beer, and spirits, researchers found that the protective effect occurred only in the wine drinkers.
Since this study, many other studies have confirmed this unanticipated finding, proving that the results were no fluke.
RED WINE RESEARCH
The Copenhagen city heart study followed almost 20,000 individuals for twelve years;14 once again, moderate daily intake of alcohol was associated with less risk of death (see Figure 9.2). As in the 1979 study, the positive effect was limited to wine and was not observed with either beer or spirits.
Fig. 9.2: The relationship of relative mortality risk and wine consumption
The benefits of drinking wine were not trivial. People who drank three to five drinks per day died at a rate almost half those who never drank wine (relative risk 0.51). That’s a stunning benefit.
A French study showed that moderate alcohol intake was associated with a 33 percent reduced risk of death from all causes but showed no benefit for beer.15 In China, where alcohol intake is primarily from rice wine, a study noted a smaller but still significant 19 percent reduction in risk of death.16 Data from the Cancer Prevention Study II, which covered almost 1.2 million Americans, revealed a 30 to 40 percent lower risk of death with moderate alcohol use (see the following graph). The greatest benefits occurred with one drink per day. Excessive alcohol use was still found to be dangerous, particularly in younger people, for whom there was an increased risk of violent deaths and accidents. Excessive alcohol in older people increased the risk of liver cirrhosis.17
Fig. 9.3: Alcohol consumption and mortality
Other studies corroborated what was found in the Cancer Prevention Study II by showing a lower risk of all-cause mortality and coronary heart disease with moderate alcohol consumption (see Figure 9.4).
Fig. 9.4: Alcohol, particularly red wine, may decrease the risk of coronary heart disease and death18
Data from the United States shows what you might expect. Moderate alcohol reduces cardiovascular disease, but further drinking does not increase the benefits. Drinking more alcohol increased the risk of alcohol-augmented conditions, including liver disease and certain cancers, which negates some of the beneficial effects. In military recruits, greater alcohol consumption increased the risk of death, mostly from accidents, suicide, and violence.19
Most recently, the Women’s Health Study demonstrated once again that, compared to no alcohol use, moderate drinking was associated with a 35 percent reduced risk of overall death and a 51 percent reduced risk of cardiovascular death.20 One of the longest studies, the Zutphen study, followed 1,373 men over 40 years. This study found that, compared to abstinence, moderate drinking (about a half glass per day) might prolong life by five years!21
It is important to note that many of these studies examine daily alcohol intake rather than binge drinking. Drinking one to two glasses of wine daily with dinner is different from drinking four bottles once a week. Context is vitally important. Alcohol is a powerful weapon in the fight for longevity, but, like any weapon, it cuts both ways. Used poorly and withou
t knowledge, it will hurt the user.
Consume red wine with food
One reason why studies in the United States have not shown results as impressive as European studies is that Europeans almost always consume their wine with dinner, which is not always the case in the United States. Americans tend to drink socially, whereas our European counterparts view wine as part of the meal. Drinking red wine with a meal maximizes one of the main health benefits of the wine, which is its ability to decrease after-meal spikes in lipids and glucose. Drinking red wine with a meal decreases the amount and time that VLDL, cholesterol remnant particles, and glucose come in contact with your blood vessels. These particles can cause damage to the endothelium and promote endothelial dysfunction, which can lead to hypertension and atherosclerosis in the arteries.
MECHANISMS OF BENEFIT
Wine contains approximately 12 to 15 percent alcohol by volume. Alcohol itself might have some healthy effects, but more likely it’s the other bioactive compounds in red wine that are responsible for the benefits. Polyphenols in red wine potentially reduce the clotting tendency of blood and reduce LDL oxidation (see Figure 9.5).22
Fig. 9.5: The benefits of plant flavonoids
Red wine, and alcohol in general, beneficially affects cholesterol, particularly raising high-density lipoprotein, known as HDL or “good” cholesterol (see Figure 9.6).23
Fig. 9.6: Alcohol intake and HDL levels
Wine, as well as some other alcoholic beverages and tea, contains biologically active constituents called polyphenols. Red wine is produced from the entire grape, including the skin and seed, whereas white wine is produced after the skin has been removed. Red wine is macerated with the skin and seeds for several weeks, and this results in up to ten times the amount of polyphenols depending upon the specifics of the type of grape and its specific fermentation process. Red wines contain 750 to 1060 milligrams per liter of flavonoids compared to 25 to 30 milligrams in white wines.24
One polyphenol is exclusive to red wine: resveratrol. Resveratrol comes from grape skins, so the only significant dietary source of this polyphenol comes from red wine.[20] Since its discovery, many supplement companies rushed to make resveratrol tablets. Unfortunately, the supplements were not effective at promoting health because resveratrol is absorbed in the body only when it is ingested as wine. At concentrations found after consuming red wine, resveratrol can increase endothelial nitric oxide synthase and promotes an increase in nitric oxide (NO). Nitric oxide is a biological gas, which dilates the arteries, prevents atherosclerosis, and protects against blood clots due to its antiplatelet effects. Polyphenols can act as potent antioxidants and reduce platelet clumping and thus thin the blood and relax the blood vessels through endothelial NO release. Resveratrol prolongs life in yeast by activation of the longevity gene Sirt1, the same gene implicated for the effect of calorie restriction. For this reason, Sirtuins are known as “the enzymes of youth.”25
Moderate alcohol consumption also reduces inflammation, blood clotting,26 and blood pressure.27 A meta-analysis of fifteen human studies estimated that alcohol consumption reduced the systolic blood pressure (the top number) by 3.31 mmHg and the diastolic blood pressure by 2.04 mmHg.28 Although these reductions seem rather small, the benefit is greater than the reduction researchers observed with salt restriction, and that reduction launched a vicious fifty-year attack on salt. Just like salt, moderate alcohol intake is associated with less heart disease, not more.
High insulin levels and insulin resistance are the core causes of metabolic syndrome, which substantially raises the risk of future heart disease and stroke. The Normative Aging Study from Harvard University,29 including its 30 years of follow-up, discovered that moderate intake of alcohol was associated with significantly lower insulin levels and insulin resistance than either the high-intake or no-alcohol group. In 2005, the American Diabetes Association found a highly significant 30 percent reduction in type 2 diabetes with moderate drinking.30 Researchers estimated that the reduction in heart disease deaths with moderate alcohol was largely attributable to the following things:
• Improved cholesterol profiles
• Improved blood glucose/diabetes31
• Improvement in inflammation/blood clotting
• Blood pressure reduction
The remaining benefits of alcohol are largely through unknown mechanisms.
How much red wine should you drink?
The 2015–2020 Dietary Guidelines for Americans recommend moderate consumption of alcohol (two drinks per day for men and one drink per day for women). A standard drink is defined as 14 grams of pure ethanol. A meta-analysis of fifty-one studies indicates that consuming around 12.5 grams of alcohol per day is associated with the lowest risk for coronary heart disease for women, and 25 grams in men.32 For most red wines, which are around 12.5 percent ethanol, about 3 ounces of red wine per day may be optimal for women, and 6 ounces of red wine per day for men. For people who are in certain high-risk situations, such as children, women who are pregnant or breastfeeding, alcoholics, and those taking medications that interact with alcohol, this recommendation does not apply, and you should avoid alcohol.
Six red wine tips
1. Drink red wine with meals. This decreases blood glucose levels34 and prevents blood pressure increases that may happen when alcohol is taken alone.
2. Marinate meats in red wine before cooking. This decreases the formation of carcinogenic chemicals (heterocyclic amines) that might be formed with high-heat cooking.
3. French and Brazilian red wines, pinot noir, and Lambrusco are great choices. They have the highest concentrations of resveratrol and polyphenols that may protect the heart and brain.
4. If you can’t drink alcohol, try de-alcoholized red wine, which may have similar benefits.
5. Drink moderate amounts daily and avoid binge drinking.33
6. Many wines contain loads of added sugar, so it’s important to consume a low-sugar wine, such as those from Dry Farm Wines (www.dryfarmwines.com). Here are some advantages of Dry Farm Wines: They’re sugar free, mold free, and gluten free; they’re low in sulfites; they have no additives; and they have a low alcohol content (less than 12.5%).
Coffee
The story of coffee dates back to the ancient coffee forests of Ethiopia.35 Legend tells of a goat herder named Kaldi who discovered coffee when he noticed that some of his goats became energetic and would not sleep at night after eating the berries from a certain tree. The berries were turned into a drink, and people discovered that it provided energy and alertness. And so coffee cultivation was born. The trade of coffee first became popular in the Arabian Peninsula, and by the sixteenth century coffee had spread to Persia, Egypt, Syria, and Turkey. By the seventeenth century, coffee had made its way to Europe; shortly after, it spread to the rest of the world.36
BENEFITS OF COFFEE
In the United States, coffee is the second-most widely consumed beverage (after water) and the main source of caffeine intake among adults. Coffee is a complex beverage containing more than 1,000 compounds, many with known biological activity, such as caffeine, diterpene alcohols, chlorogenic acid, lignans, and trigonelline. It’s the single largest source of antioxidants in the American diet. A typical 8-ounce cup of coffee contains anywhere from 95 to 200 milligrams of caffeine, whereas decaffeinated coffee contains only 5 to 15 milligrams of caffeine per 8 ounces.37 The caffeine content of coffee may play a role in delivering some of its health benefits.
Coffee consumption is associated with a lower risk for type 2 diabetes mellitus.38 Coffee reduces two-hour post-glucose challenge blood sugar levels by an average of 13.1 percent39 and reduces hemoglobin A1C (a measure of overall glucose exposure) by 7.5 percent. Waist circumference, a key indicator of metabolic syndrome, significantly decreased, but only in the caffeinated coffee group. When a person consumes 300 milligrams of caffeine per day, their energy expenditure increases by 80 kilocalories per day,40 which may have been enough to account for the differenc
e in waist circumference. Although caffeine can acutely decrease insulin sensitivity in humans,41 the effects over a longer term seem beneficial.
Two large meta-analyses confirm an inverse relationship between coffee intake and the risk of type 2 diabetes, and they demonstrate the clear dose-response relationship. Drinking more coffee lowers the risk of type 2 diabetes.42 Drinking four to six cups of coffee daily is associated with a 28 percent reduction in the risk of developing type 2 diabetes, whereas drinking more than six cups shows a 35 percent reduction. A large Japanese study with thirteen years of follow-up found a 42 percent decreased risk of type 2 diabetes in people who drink coffee frequently.43
Although coffee might be beneficial, what people add to the coffee (cream and sugar) is not so benign. As Dr. DiNicolantonio and two other colleagues have said, “If looking for longevity, say yes to the coffee, no to the sugar.”44
There are other benefits to coffee drinking. Drinking five cups of instant caffeinated or decaffeinated coffee improved adipocyte and liver function, respectively, via changes in adiponectin and fetuin-A concentrations.45 Drinking two to five cups (16 to 40 ounces) of coffee per day is associated with lower rates of mortality, death from cardiovascular disease, type 2 diabetes, liver disease, Parkinson’s, depression, and suicide.46