By Peter Jaret
One after another the guests arrived, flushed from climbing the steep steps up to the ancient stone house. Dish by dish, the long kitchen table filled with homemade local specialties. Friends of ours—one Greek, one Dutch—had restored this centuries-old house in the village of Agios San Marcos, on a steep hillside on the island of Corfu, and tonight they were throwing the Greek equivalent of a potluck to celebrate the arrival of their American guests. And what a feast! Grilled squid with lemon. A peppery fish stew called bourdeto. A salad of fresh arugula and another, called horiatiki, made with tomatoes, cucumbers, onions and feta. For dessert: a walnut cake and a melange of pineapple, kiwi, yogurt and honey. It was quintessential Mediterranean fare, a bounty of the foods we now associate with good health and long life—fish, leafy greens, tomatoes, garlic, olive oil, yogurt, walnuts and...
“Vino!” a voice called from the courtyard. Shouts and laughter followed. Nikos, a neighbor who lived down the hill, had enlisted one of the donkeys that are used to hoist heavy building materials up the steep paths to carry two five-gallon jugs filled at a nearby winery.
The wine. Of course! From the time the ancient Greeks sailed the “wine-dark seas” celebrated in The Odyssey and even before, alcoholic beverages have held a cherished place not only in Greece but in many Mediterranean cultures. “Where there is no wine,” a Greek proverb has it, “there is no love.” And there might not be such robust good health, either. Olive oil may have been the first darling of the Mediterranean diet, but lately, more and more research has focused on wine’s contribution to a healthy heart and long life.
It’s hardly news that drinking in moderation protects against heart disease—more than 100 studies have come to that conclusion. “But now we’re beginning to see that alcohol may protect against type 2 diabetes as well, a disease that is becoming a huge health problem among Americans,” says epidemiologist Eric Rimm, Sc.D., a leading authority on alcohol and health at the Harvard School of Public Health. People who drink moderately also appear to gain protection against age-related memory loss and even some forms of cancer. And though wine has been the focus of most research, the latest evidence suggests that alcoholic beverages of all kinds, in moderation, offer similar health benefits.
Drinking has a dark side, of course. Consuming too much increases the risk of high blood pressure, heart disease, liver disease and cancer. Alcoholism ruins lives and destroys families. According to the latest statistics, more than 17,000 traffic deaths a year are alcohol-related. That’s roughly 40 percent of all traffic fatalities. Especially worrisome is the fact that after declining from 1993 to 1997, episodes of alcohol-impaired driving are becoming more frequent, according to a report published in 2005 in the American Journal of Preventive Medicine. “We have to be very cautious when we talk about alcohol to acknowledge that it’s a double-edged sword,” says physician JoAnn Manson, M.D., Dr.P.H., chief of preventive medicine at Brigham & Women’s Hospital in Boston. “For people who abuse alcohol, the risks far outweigh any benefits.”
Still, for people who imbibe sensibly, the benefits are impressive. The heart-disease protection associated with a glass of alcohol a day is just about equal to what the latest generation of cholesterol-lowering drugs offers. Some experts in the field say that given the evidence, doctors have a duty to talk to patients, particularly those at risk of heart disease, about the effects, both good and bad, of alcohol.
Ancient Knowledge Trickles Down
in a sense, modern science is rediscovering what people have known intuitively through the ages. “From ancient Greek writings to the Bible, the historical record is filled with references to the health benefits of wine and beer,” says Joseph A. Hill, M.D., Ph.D., a cardiologist at the University of Texas Southwestern Medical Center. Farming may well have begun in order to ensure a reliable supply of ingredients needed to make alcoholic beverages. In ancient Egypt, mothers were enjoined to send their children to school with bread and beer for lunch. The Pilgrims decided to go ashore at Plymouth Rock not because they thought it was prime real estate but rather because they’d run out of beer on board, according to Hill. That’s less astonishing than it seems at first. For most of human history, as it happens, wine and other alcoholic beverages were the only safe things to drink; plain water was usually contaminated with harmful microbes.
Alcohol has also long been believed to possess medicinal qualities. Hippocrates himself recommended wine for a variety of ailments. And over the centuries, plenty of wits and sages have celebrated the virtues of drink. A bishop of the Spanish city of Seville once famously quipped: “I have enjoyed great health at a great age because every day since I can remember I have consumed a bottle of wine except when I have not felt well. Then I have consumed two bottles.”
Modern physicians first began to suspect that alcohol might protect against heart disease almost a century ago, when autopsies revealed that the arteries of heavy drinkers were remarkably free of atherosclerosis. Researchers in the 1970s began to look at large populations of people to compare drinkers and nondrinkers and their risk of heart disease. In 1974, Arthur Klatsky, M.D., a cardiologist at Kaiser Permanente Medical Center in Oakland, California, published the first epidemiological evidence that consuming alcohol was associated with a lower risk of coronary disease. In a recent update of those original findings, which now include data from 128,934 people who have been followed for more than 20 years, he and his colleagues calculated that people who imbibe one to two drinks a day enjoy a 32 percent lower risk of dying from coronary heart disease than those who abstain from alcohol.
“The benefits show up in men and women, in people with diabetes and without, in all ethnic groups, across the board,” says Klatsky. More than 100 studies, in fact, conducted in countries around the world, have confirmed that people who consume moderate amounts of alcohol are about one-third less likely to get heart disease or die of a heart attack than those who do not drink at all.
What’s so good about alcohol? Researchers first assumed that it worked like a solvent, clearing out clogged arteries the way drain cleaners unclog pipes. Now they say that alcohol protects against heart attacks chiefly by boosting levels of high-density lipoprotein (HDL)—popularly known as good cholesterol. Its counterpart, low-density lipoprotein, or LDL, accumulates on artery walls, eventually restricting blood flow. HDL is believed to act like a sort of truant officer, rounding up the bad particles from arteries and hustling them down to the liver, where they are removed from the body. “Research focused first on the dangers of LDL cholesterol. But we’re now beginning to realize that high levels of HDL cholesterol are extremely important for cardiovascular protection,” says Kenneth Mukamal, M.D., M.P.H., a researcher and internist at Beth Israel Deaconess Medical Center in Boston. “Unfortunately, we don’t yet have good medications that are effective at increasing HDL levels.” Exercise can boost the numbers, say researchers, but even regular exercise generally raises HDL by only about 3 milligrams per deciliter. Alcohol, in contrast, has been shown to boost levels by 10 to 13 mg/dL.
Alcohol protects in other ways too. Heart attack and stroke danger climbs with age in part because artery walls become rigid. In 2005, researchers at the National Institute on Aging found less stiffness in the arteries of moderate drinkers than in people who didn’t drink at all. Alcohol has also been shown to help prevent blood clots that might otherwise block blood supply to cardiac muscles, the cause of most heart attacks.
Staving Off Diabetes & Keeping the Mind Young
The benefits of alcohol go beyond heart-disease protection. One of the biggest surprises in recent years has been evidence that moderate drinking protects against diabetes. “By now something like a dozen studies have shown that people who drink moderately have less risk of diabetes and fewer complications if they do have the disease,” says Harvard’s Eric Rimm. Insulin resistance, which often occurs when people become overweight, is the hallmark of type 2 diabetes. Several small clinical trials have shown that moderate alcohol consumption improves insulin sensitivity. “That may be particularly important given the rise in obesity in the United States,” says Rimm. One reason moderate drinking is linked to lower danger of heart disease, in fact, may be that it helps prevent diabetes, which is known to increase cardiovascular risk.
What’s good for the heart also seems to be good for the head. A 2005 study of women between the ages of 65 and 79 conducted at Wake Forest University Baptist Medical Center in North Carolina found that those who consumed one or two drinks a day performed better on a variety of tests of cognitive function and dementia. A 1999 Boston University study similarly found that among both men and women, moderate drinkers performed better than abstainers on a host of mental-function tests. Researchers speculate that alcohol may protect the brain in exactly the same way it protects the heart: by keeping blood vessels healthy, thus ensuring that brain cells get all the nutrients they need. By preventing blood clots in the brain, alcohol may also reduce the risk of small cerebral strokes, which can impair memory and brain function.
And there may be one more reason to raise a glass to health. Several studies suggest that alcoholic beverages may even protect against certain forms of cancer. The findings are controversial, since excessive drinking is known to lead to liver cancer, and even moderate levels of alcohol can slightly raise a woman’s risk of breast cancer.
Still, in a small study published last year, Spanish researchers found that drinking red wine was associated with a 43 percent lower risk of lung cancer. And at the Fred Hutchinson Cancer Research Center in Seattle, researchers recently reported that prostate-cancer risk among men who drank four or more glasses of red wine a week was half what it was among nondrinkers.
Glad Tidings, Grave Concerns
By all rights, the glad tidings about alcohol should be reason to uncork a good bottle of Champagne and celebrate. More than half of American adults say they drink alcoholic beverages. The vast majority fall into the “light” to “moderate” drinking category, which means no more than one to two drinks daily. (One drink is usually defined as 12 ounces of beer, 5 ounces of wine or 1.5 ounces of 100-proof liquor. All have about 15 grams of alcohol.) If researchers are right, moderate drinkers are the healthier for it.
Yet health experts have remained remarkably reticent to trumpet the news about alcohol’s potential benefits. Make that more than reticent. In the mid-1970s, when data from the landmark Framingham Heart Study suggested that moderate drinking was associated with significantly lower heart-disease risk, officials from the National Institutes of Health insisted that the information be withheld from the published study, according to R. Curtis Ellison, M.D., professor of medicine at Boston University, a renowned researcher on alcohol and health. They went further, he says, urging the researchers to report that there was “no significant relationship” between alcohol and the incidence of heart disease—which was simply wrong.
Why? Part of the answer lies in history and culture. “We are a temperance nation,” says Ellison. “When it comes to alcohol, we’ve tended to see the choices as either getting drunk or abstaining.” Small wonder, then, that when positive data surfaced, federal officials feared that if scientists said anything good about alcohol, people would rush to the bottle and become alcohol abusers.
Other cultures view alcohol very differently, says Ellison. “Many Mediterranean countries see alcohol, particularly wine, simply as one of the pleasures of life, part of a meal to be enjoyed, like everything else, in moderation.” As Ernest Hemingway observed in A Moveable Feast, “In Europe we thought of wine as something as healthy and normal as food and also a great giver of happiness and well being and delight. Drinking wine was not a snobbism nor a sign of sophistication nor a cult; it was as natural as eating....”
Ironically, countries that tend to have the most nondrinkers also tend to have the most problem drinkers—with the fewest people falling within the moderate-drinking category. Of course, for some people, drinking can be dangerous, even deadly. While moderate amounts of alcohol protect the heart, too much actually raises the risk of high blood pressure, heart attacks, liver disease and other serious medical problems. In many studies that look at alcohol and health, in fact, the results typically trace what epidemiologists call a J-shaped curve. Nondrinkers turn out to be at slightly increased risk, indicated by the raised hook of the letter J. Risk drops for moderate drinkers (the falling curve of the bottom of the letter) and then rises precipitously for people who drink too much (the stem of the J).
The J-shaped curve demonstrates the age-old injunction to observe “moderation in all things.” (Or as a bit of anonymous doggerel puts it: “God in His goodness sent the grapes, to cheer both great and small; little fools will drink too much, and great fools not at all.”)
For health officials trying to make recommendations, however, defining too little and too much hasn’t been easy. Some studies show that risk may begin to climb after two drinks. Others see no problems at all until people reach four or five drinks a day. In some cases, the window of safety between too little and too much can be very narrow. One study found that women who drank half a drink a day lowered their risk of developing high blood pressure by 14 percent; those who consumed one and a half drinks raised the danger by 20 percent. The difference between benefit and risk, in other words, was just one drink.
Today, most official recommendations agree that one glass a day for women, two for men represents a reasonable guideline. And most experts agree on this, too: people who drink much more than that should be counseled to cut back or quit entirely.
If You Decline a Daily Tonic
But what about people who don’t drink? Should they be advised to start? In an editorial entitled “To Drink or Not to Drink?” published in The New England Journal of Medicine in 2003, Ira Goldberg, M.D., a physician at Columbia University College of Physicians and Surgeons in New York, says no. “If alcohol were a newly discovered drug (instead of a drink dating back to the dawn of human history), we can be sure that no pharmaceutical company would develop it to prevent cardiovascular disease,” he argues. The risks of excessive drinking are so serious that they outweigh the possible benefits. What’s more, many of those benefits can be gained in other ways: by eating a healthier diet, getting regular exercise and maintaining a healthy weight—advice that most Americans still have a long way to go in following.
Despite heading up several large studies that have illuminated alcohol’s benefits, epidemiologist Eric Rimm agrees. “I don’t think we should be telling people who don’t drink to start. People don’t drink for good reasons, either religious injunctions or a family history of alcohol abuse or because they simply don’t like it. But given what we know about both the risks and benefits, I do think doctors should be spending more time talking to patients about alcohol.”
Instead of issuing blanket official recommendations on alcohol, most experts say advice should be tailored to the individual, based on age, heart-disease risk, family history and personal medical history. Moderate drinking is most likely to benefit someone with at least one risk factor for heart disease, for instance (these include elevated cholesterol and a family history of heart trouble). “For a woman with a family history of early breast cancer and little risk of heart disease, the dangers are likely to outweigh the benefits,” says Manson at Brigham & Women’s Hospital. Women who are pregnant or trying to conceive are cautioned to abstain from alcohol entirely because of the risk of fetal alcohol syndrome, which results in birth defects and other abnormalities in infants.
Age is also a key factor in weighing risks and benefits. Since heart-disease hazard climbs with age, men aren’t likely to benefit at all until they hit their mid-thirties, women not until they reach menopause, when their heart-disease risk begins to climb. A 2002 British study found that for men under 35 and women under 55, the risks of drinking—including the dangers of alcohol-related accidents—exceed the benefits.
“It’s easy to say that a 25-year-old woman whose mother died of breast cancer shouldn’t be advised to drink alcohol,” says Ellison. “It’s also reasonable to tell a 70-year-old man with borderline high cholesterol and low HDL levels that drinking a glass or two a day could help protect him from cardiovascular disease.” The real challenge, he acknowledges, is advising people who fall in between those two extremes.
For people who already drink alcohol in moderation, the latest findings offer one more reason to enjoy a glass or two. To get the optimal health benefits from alcohol, research suggests, it’s wise to consume alcohol with a meal, for two reasons. First, food slows the rise of alcohol in the bloodstream, so it’s less likely to impair judgment or reflexes. Moreover, the anticlotting effect of alcohol is believed to offer the most protection just after a big meal, when fat particles in the blood increase and thus clots are more likely to form. And since that effect lasts only a matter of hours, experts say the best advice—if you drink—is to consume small to moderate amounts of alcohol most days of the week. “Drinking one glass of wine a day is not the same as drinking seven during the weekend,” says Ellison.
In the end, of course, although people around the world toast to their health when they raise a glass—Santé! (France), Bisochtak! (Egypt), Kampai! (Japan), Egészségedre! (Hungary)—alcohol is more than just a tonic. Alcoholic beverages are deeply woven into the rich tapestry of many cultures. They’re part of the way people in many places around the world have traditionally celebrated the gathering of friends and the observance of holidays.
“To take wine into your mouth,” the American writer Clifton Fadiman once observed, “is to savor a droplet of the river of human history.” So it certainly seemed that night on the island of Corfu, as the last daylight ebbed from the sky and, looking down from the balcony, we watched the Adriatic turn dark and the lights of town begin to blink on as the first stars appeared overhead. The bounteous food, wine made from local grapes, the generous laughter of friends, the sight of the last swallows dipping and playing in the honeysuckle-scented air over that sweeping vista of sea and sky—all of them have been savored here for centuries not for reasons of “should” and “shouldn’t” but simply for what they are: the unadorned pleasures of a good life.