Ditte Johansen

Type of Alcohol Consumed and Mortality from All Causes, Coronary Heart Disease, and Cancer

Several population studies from different countries have shown a J-shaped relation between intake of alcohol and mortality from all causes (1-6). Studies comparing different countries have found a strong inverse relation between incidence rates of coronary heart disease and wine consumption but a weak or nonexistent relation for consumption of beer or spirits (7-9). The findings that different types of alcoholic beverages have different effects on mortality are indirectly supported by several clinical and experimental studies (10-12). In contrast, prospective studies have shown that beer (13), spirits (14), and wine (15) may have protective effects. However, most of these investigations were based on populations with one predominant type of alcohol consumption; this precluded valid comparison of the effects of the three different types of alcohol. We sought to analyze the effect of intake of different types of alcohol on mortality from all causes, coronary heart disease, and cancer in several large Danish cohort studies. Methods The Copenhagen Centre for Prospective Population Studies is based on three study samples: that of the Copenhagen City Heart Study; that of the Copenhagen County Centre of Preventive Medicine (the former Glostrup Population Studies), which includes six cohorts; and that of the Copenhagen Male Study (16-18). The study samples of the Copenhagen City Heart Study, initiated in 1976, and the Copenhagen County Centre of Preventive Medicine, initiated in 1964, were randomly selected within age strata from the populations residing in defined areas in greater Copenhagen. For the Copenhagen Male Study, initiated in 1971, employees of 14 large companies in Copenhagen were invited to participate. The mean participation rate in all studies was 80% (range, 69% to 88%). The combined study sample comprises 13 064 men and 11 459 women for whom information on alcohol intake and lifestyle-related variables, described below, was complete. Alcohol Intake Participants of the Copenhagen City Heart Study and the studies in the Copenhagen County Centre of Preventive Medicine were asked about their current average weekly intake of beer, wine, and spirits. In the Copenhagen Male Study, participants were asked about their average daily intake of beer, wine, and spirits on weekdays (Monday through Thursday) and weekends (Friday through Sunday); these reports were combined to estimate weekly alcohol consumption. Persons in our study who did not drink alcohol because they were receiving disulfiram or other medication were excluded from the analysis. One bottle of beer contains 11.6 g of alcohol, and 12 g is an approximate average for one serving of wine or spirits. We grouped participants into five categories on the basis of total intake of alcohol: less than 1 drink/wk (nondrinkers), 1 to 7 drinks/wk, 8 to 21 drinks/wk, 22 to 35 drinks/wk, and more than 35 drinks/wk. Intake of beer, wine, and spirits was categorized similarly; however, because of the frequency of end point data, more than 21 drinks/wk is the highest intake category for the individual types of beverages. Smoking Status Participants reported whether they were never-smokers, former smokers, or current smokers. Current smokers reported grams of tobacco smoked per day in the form of cigarettes (1 g/d), small cigars (3 g/d), cigars (5 g/d), and pipe tobacco (50 g/package). Five groups were defined: never-smokers, former smokers, smokers of 1 to 14 g of tobacco daily, smokers of 15 to 24 g of tobacco daily, and smokers of more than 24 g of tobacco daily. Education Participants reported the number of years that they attended school. Three groups were defined: fewer than 8 years, 8 to 11 years, and 12 or more years of school education. Physical Activity Participants reported whether they were physically active during leisure time. Four groups were defined: sedentary (<2 h/wk), light activity (2 to 4 h/wk), moderate activity (>4 h/wk, noncompetitive) and heavy activity (>4 h/wk, competitive). Body Mass Index Body weight and height were measured while the participant was wearing light clothes and no shoes. Body mass index was calculated as weight in kg divided by height in meters squared. Five categories of body mass index were defined: less than 20.0 kg/m2, 20.0 to 24.9 kg/m2, 25.0 to 29.9 kg/m2, 30.0 to 34.9 kg/m2, and 35.0 kg/m2 or more. Changes in Lifestyle-Related Variables When participants were re-examined during follow-up, the newly obtained values for alcohol intake, smoking status, physical activity, and body mass index were used to replace the old values in the statistical analyses. Observation time and vital status were included in the modeling accordingly. Follow-up Participants were followed from date of entry into the study to date of death, loss to follow-up, emigration, or end of follow-up, whichever came first. The vital status of populations was followed by using each participants unique identification number in the national Central Person Register until 9 January 1995. Fewer than 1% of the participants were lost to follow-up. Causes of death were obtained from the National Board of Health and were defined by using codes from International Classifications of Diseases, Eighth Revision (codes 410.0 to 414.0 for coronary heart disease and codes 140.0 to 209.0 for cancer). According to a previous study, the reported diagnoses for these grouped codes have proven to be sufficiently valid (20). Statistical Analysis We performed Poisson regression (21) by using SAS/STAT software (22) to estimate the effect of alcohol intake on the risk for death. These models generate estimates of relative risk that are adjusted for confounders. Each model included the following potential confounders as categorical variables: age, cohort study, sex, education, body mass index, physical activity, and smoking status. Owing to collinearity, it was impossible to include both the amount by type of beverage (beer, wine, or spirits) consumed and total alcohol intake in the same regression. We therefore estimated the influence of alcohol according to number of drinks consumed per week [0, 1 to 7, 8 to 21, 22 to 35,>35] in three regressions: 1) total alcohol consumption in drinks per week, without considering beverage type; 2) alcohol consumption in drinks of each beverage per week, without considering the total intake; and 3) percentage of total alcohol intake consumed as wine (0%, 1% to 30%,>30%). Effects that were insignificant according to the likelihood ratio test (5% level) were removed by backward elimination. A term indicating interaction between total alcohol intake and percentage alcohol consumed as beer, wine, or spirits was included in the analyses to assess whether the effects of beer, wine, and spirits differed at different levels of total alcohol intake; no such effects were identified, as judged from the fit of the model. Likewise, no interaction was found between sex and intake of different types of beverage in terms of mortality. Results A total of 4275 women and 1635 men drank less than 1 drink per week; 64 women and 1032 men drank 35 or more drinks per week. Of 13 613 participants who drank alcohol, 12 846 (69%) included wine in their intake (Table 1). During 257 859 person-years of follow-up, 4833 participants died; of these, 1075 died of coronary heart disease and 1552 died of cancer. Table 1. Baseline Characteristics of the Study Participants Baseline Characteristics Compared with participants who drank alcohol but no wine, those for whom wine made up more than 30% of their total alcohol intake were more likely to be women and have a higher educational level but were less likely to be smokers (Table 1). Participants for whom wine made up more than 30% of their alcohol intake were similar to those who drank no alcohol in terms of smoking habits, body mass index, and physical activity. Across categories of total alcohol intake, mean alcohol intake within the different categories of wine drinking was similar; for example, among participants who drank 8 to 21 drinks/wk, those who drank no wine, those who drank 1% to 30% wine, and those who drank more than 30% wine had a mean alcohol intake of 13.3, 13.7, and 12.8 drinks/wk, respectively. However, among light drinkers (1 to 7 drinks/wk), those who drank 1% to 30% of their alcohol as wine had a slightly higher mean intake than did those who avoided wine and those who drank more than 30% of their alcohol intake as wine. Thus, assessment of the effects of wine intake may not be subject to residual confounding by total alcohol intake when controlled for as specified. Total Alcohol Intake and Mortality We found J-shaped relations between total alcohol intake and all-cause mortality in the three substudies. Pooled analyses also revealed J-shaped relations (Table 2). When nondrinkers were used as the reference group (relative risk, 1.00), intake of 1 to 7 drinks per week carried a relative risk of 0.82 (95% CI, 0.76 to 0.88) and intake of more than 35 drinks per week carried a relative risk of 1.10 (CI, 0.95 to 1.26). Alcohol intake was negatively related to death from coronary heart disease and positively related to death from cancer (Table 2). Table 2. Relative Risk for Death with Regard to Total Alcohol Intake and Intake of Beer, Wine, and Spirits Intake of Beer, Wine, and Spirits and Mortality Light to moderate intake of beer or spirits had a small effect on death from all causes (Table 2). This finding contrasted with the effect of wine intake on mortality: Participants who drank 8 to 21 glasses of wine per week had a relative risk for death from all causes of 0.76 (CI, 0.67 to 0.86). Intake of fewer than 22 drinks of beer, wine, and spirits per week all carried lower risk for death from coronary heart disease; the reduction in risk was of the same magnitude for beer and wine drinking but was smaller and not statistically significant for spirits drinking. Furthermore, light to moderate drinkers of wine had

Food buying habits of people who buy wine or beer: cross sectional study

Abstract Objective To investigate whether people who buy wine buy healthier food items than those who buy beer. Design Cross sectional study. Setting Supermarkets in Denmark. Data Information on number, type of item, and total charge from 3.5 million transactions over a period of six months. Results Wine buyers bought more olives, fruit and vegetables, poultry, cooking oil, and low fat cheese, milk, and meat than beer buyers. Beer buyers bought more ready cooked dishes, sugar, cold cuts, chips, pork, butter or margarine, sausages, lamb, and soft drinks than wine buyers. Conclusions Wine buyers made more purchases of healthy food items than people who buy beer.

Changes in alcohol intake and mortality: a longitudinal population-based study.

Background: Using alcohol intake at one point in time, numerous studies have shown a J- or U-shaped relation with all-cause mortality. Mortality is lowest among the light to moderate drinkers, with the risk of dying from coronary heart disease higher among nondrinkers and the risk of dying from cancer higher among heavy drinkers. We studied whether changes in individual alcohol intake result in corresponding changes in mortality. Methods: In a longitudinal study of 6644 men and 8010 women, age 25 to 98 years, who had attended at least 2 health surveys with a 5-year interval between them, we addressed the risk of death after combinations of changes in alcohol intake. Results: Mortality after changes in alcohol intake was consistent with the mortality observed among those who reported stable drinking. Stable drinkers showed a U-shaped all-cause mortality, with relative risks of 1.29 (95% confidence interval [CI] = 1.13–1.48) for nondrinkers (<1 drink per week) and 1.32 (1.15–1.53) for heavy drinkers (>13 drinks per week) compared with light drinkers (1 to 6 drinks per week). For coronary heart disease mortality, stable nondrinkers had a relative risk of 1.32 (0.97–1.79) compared with stable light drinkers and those who had reduced their drinking from light to none increased their risk (1.40; 1.00–1.95), and those who had increased from nondrinking to light drinking reduced their relative risk ratio (0.71; 0.44–1.14). Cancer mortality was increased in all groups of heavy drinkers. Conclusion: Persons with stable patterns of light and moderate alcohol intake had the lowest all-cause mortality. Individual changes in alcohol intake were followed by corresponding changes in mortality.

Alcohol Intake, Type of Beverage, and Risk of Breast Cancer in Pre- and Postmenopausal Women

BACKGROUND Most studies of the relation between alcohol consumption and breast cancer have shown a modestly increased risk, although the results are still conflicting. METHODS The aim of this prospective population-based cohort study was to assess the influence of alcohol intake and type of beverage (beer, wine, or spirits) on breast cancer risk in relation to menopausal status. Among 13,074 women aged 20 to 91 years, we examined the relationship between breast cancer risk, total alcohol intake, and type of alcohol in relation to menopausal status. The women were classified as premenopausal or as postmenopausal at younger than 70 years or 70 years or more. RESULTS During follow-up, 76 premenopausal and 397 postmenopausal women developed breast cancer. Premenopausal women who had an intake of more than 27 drinks per week had a relative risk of breast cancer of 3.49 (95% confidence limits, 1.36-8.99) compared with light drinkers (p = 0.011), whereas there were no differences in risk in the lower-intake categories. The increased risk of breast cancer among premenopausal women was independent of the type of alcohol. Postmenopausal women older than 70 years of age who had an intake of more than six drinks per week of spirits had a relative risk of breast cancer of 2.43 (95% confidence limits, 1.41-4.20) compared with women who consumed less than one drink of spirits per week (p = 0.0014). CONCLUSIONS Total alcohol intake of more than 27 drinks per week increases breast cancer risk in premenopausal women independently of the type of alcohol. Among postmenopausal women, an intake of spirits of more than six drinks per week increases breast cancer risk.

Type of alcohol and drinking pattern in 56,970 Danish men and women.

Objective: To describe drinking patterns among individuals who prefer drinking wine, beer or spirits.Design: Cross-sectional study obtaining detailed information on intake of wine, beer and spirits and on frequency of alcohol intake. Adjustment for gender, age, smoking habits, educational attainment and body mass index.Setting: Denmark.Subjects: 27,  151 men and 29,  819 women, randomly selected from Copenhagen and Aarhus, Denmark.Main outcome measures: Drinking pattern—steady or binge drinking.Results: A vast majority (71%) of both men and women preferred wine or beer. At all levels of total alcohol intake, beer drinkers were most likely to be frequent drinkers. Thus, light drinkers of beer had an odds ratio for being frequent drinkers of 1.97 (95% confidence limits 1.50–2.58) as compared to light drinkers of wine (total alcohol intake 3–30 drinks per month), while people who preferred beer had an odds ratio of 1.29 (1.19–1.40) compared with wine drinkers in the moderate drinking category (31–134 drinks per month). There were no significant differences in total alcohol intake between individuals preferring different alcoholic beverages.Conclusion: If binge drinking is less healthy than steady drinking, the relation between wine intake and coronary heart disease mortality could be subject to negative confounding, since beer drinkers seem to have the most sensible drinking pattern.Sponsorship: Danish Cancer Society and the Danish National Board of Health.European Journal of Clinical Nutrition (2000) 54, 174–176

Intake of Beer, Wine and Spirits and Risk of Heavy Drinking and Alcoholic Cirrhosis

Studies have suggested that wine drinkers are at lower risk of death than beer or spirit drinkers. The aim of this study is to examine whether the risk of becoming a heavy drinker or developing alcoholic cirrhosis differs among individuals who prefer different types of alcoholic beverages. In a longitudinal setting we found that both the risk of becoming a heavy or excessive drinker (above 14 and 21 drinks per week for women and above 21 and 35 drinks per week for men) and the risk of developing alcoholic cirrhosis depended on the individuals preference of wine, beer or spirits. We conclude that moderate wine drinkers appear to be at lower risk of becoming heavy and excessive drinkers and that this may add to the explanation of the reported beverage-specific differences in morbidity and mortality.

Nonlinear relation between alcohol intake and high-density lipoprotein cholesterol level: results from the Copenhagen City Heart Study.

BACKGROUND It has been suggested that the level of high-density lipoprotein cholesterol (HDL-C) in the blood can be used as a marker of recent alcohol intake. However, before using HDL-C as a predictor of alcoholism, the relation between alcohol intake and HDL-C in the entire range of consumption must be explored. Most studies model the relation between alcohol intake and HDL-C linearly, although a threshold effect is expected. The objective of this study was to evaluate the shape of the relation between intake of alcohol and HDL-C and to determine whether there are differential effects of beer, wine, and spirits on HDL-C and whether they remain after adjusting for total alcohol. METHOD The relation between alcohol intake and HDL-C was investigated by means of generalized additive models using data from the Copenhagen City Heart Study. RESULTS A nonlinear effect of alcohol improved the model fit significantly, and the nonlinearity of alcohol was highly significant in both men and women. The relation was concave: HDL-C was stable in men and women who drank more than approximately 35 and 20 drinks per week, respectively. We found a significant nonlinear term of wine on HDL-C in men after adjustment for total alcohol intake. CONCLUSIONS There was a concave relation between alcohol intake and HDL-C, indicating a threshold effect of alcohol on HDL-C. The association between wine and HDL-C in men after adjusting for total alcohol intake may be due to residual lifestyle confounding.

Drinking pattern and mortality in Danish nurses

Background/Objective:Moderate alcohol consumption has beneficial effects on survival. Sex differences, however, have been suggested implying less beneficial effect among women. We examined the impact of alcohol consumed on weekdays and at weekends, respectively, on risk of death among women.Subjects and methods:At baseline in 1993, a total of 17 772 female members of the Danish Nurse Association completed questionnaires on alcohol intake and other lifestyle factors. The influence of alcohol intake on risk of death was analyzed using Cox proportional hazard model.Results:Alcohol intake of 1–3 drinks per week was associated with the lowest risk of death. Intake above six drinks per weekend (Friday through Sunday) increased risk of death from all causes by 3% for each additional drink consumed per weekend (corresponding to an increased risk by 9% per drink per weekend day). Consumption of one or more drinks per weekday (Monday, Tuesday, Wednesday or Thursday) increased risk by 4% for each additional drink consumed per day.Conclusions:The results indicated an increasing risk of death for intake above six drinks per weekend and of one or more drinks per weekday.