December 2008 Issue
Alcohol: Functional Food or Addictive Drug?
By Carol Ann Brannon, MS, RD, LD
Today’s Dietitian
Vol. 10 No. 12 P. 8
CDR Learning Codes: 2000, 2010, 4040, 5350; Level 1
“Eat well, drink in moderation, and sleep sound, in these three good health abound.” — Latin Proverb
The importance of a good diet and adequate sleep in relation to optimal health is indisputable; however, the message regarding drinking alcohol is less clear. Fermented beverages have long been part of man’s diet. There are ancient reports of its medicinal properties, as well as its addictive and destructive effects. And throughout history, there have been passionate debates regarding alcohol’s pros and cons.
So, is alcohol a functional food or an addictive drug? It depends. Recommendations regarding alcohol intake are conditional and must be individualized. The merits of moderate drinking must be juxtaposed with the hazards of excessive drinking and the potential for addiction by high-risk individuals. This article will address some of these issues.
Alcohol 101
Ethyl alcohol or ethanol (CH3CH2OH) is found in beer, wine, and liquor. It is chemically distinct from other types of alcohol, such as isopropyl (rubbing alcohol), that would be toxic if ingested. In its purest form, ethanol is colorless, odorless, and has a boiling temperature lower than water. It provides 7 kilocalories per gram.1
Ethanol is produced through the natural process of fermentation, which occurs when plant sugars (typically in grains or fruits) interact with yeast, resulting in the production of enzymes that convert the sugars to ethanol. Beer and wine can be produced from natural fermentation. Liquor, unlike beer and wine, is distilled after fermentation.1
Beer: Man has been brewing and enjoying beer for longer than recorded history. Centuries ago, it was the mealtime beverage. Beer is made from four basic ingredients: barley, hops, water, and yeast. Beer making begins with the germination or sprouting of barley seed. Barley, a grain similar to wheat, is soaked in water for several days and then held for five days at about 60˚F to facilitate germination. During germination, enzymes (alpha-amylases and beta-amylases) are naturally created that convert starches to sugars. It is important to stop germination when the amylases are present but before they can convert most of the starch into sugar. Once germination stops, the malt is crushed to separate the grain kernels from the husks.
The crushed malt, called grist, is mixed with water and placed in a mash tun (vat) where it undergoes “mashing,” a process during which the naturally produced enzymes convert starch into sugar, particularly maltose. The mash tun usually contains a slotted false bottom or something similar that serves as a strainer, allowing for the separation of the liquid from the mash solids.2
The process of separating the liquid from the grains is known as lautering. The separated liquid, called wort, is transferred from the mash tun into a large tank or “cooper” for boiling, which is done to terminate enzymatic activity. This is when hops, the flower of the hop vine and a member of the hemp family (Cannabaceae), are added. There are a variety of hops, each with a different taste, aroma, and degree of bitterness. The addition of hops also inhibits the formation of certain bacteria that can spoil beer.2
Next, the wort is placed in a “whirlpool” for cooling and clarification before going into a fermentation vessel where yeast is added to convert the sugars to alcohol. Yeast is also responsible for the carbon dioxide in beer. Lastly, beer is transferred into a conditioning tank for a week to several months. The beer is filtered to remove yeast and other particles before being served or packaged.2
Beer has food value. An average 12-ounce glass of beer provides about 150 kilocalories, 1 gram of protein, and 13 grams of carbohydrates; it contains substantial amounts of certain B vitamins (niacin, pantothenic acid, B6, and folate) and smaller amounts of thiamine, riboflavin, vitamin B12, biotin, and several minerals (magnesium, selenium, potassium, and phosphorus). Beer does contain gluten, and this fact should not be overlooked when counseling clients on gluten-free diets.3
There may be cardiovascular benefits to drinking beer. One study in the Czech Republic attributed beer’s beneficial effect on heart health to its folate content. Plasma folate levels are inversely related to total plasma homocysteine levels. Increased plasma homocysteine levels are associated with increased risk of cardiovascular disease.4
There are two broad categories of beer: ale and lagers. Ale and lagers differ in similar ways as red and white wines differ (see Chart 1).
Wine: Wine is made from specially cultivated grapes, and growers carefully select the variety of grapes they will grow based on their particular soil and climate. Grapevines start their cycle in April, flower within about six weeks, and are harvested in the fall. Grapes are considered ripe when they have achieved the proper balance of sugar and acidity. The composition of grapes is about 80% water and 20% sugar. Wine grapes are harvested when their sugar content is high, since high sugar content is necessary for yeast to act on the sugar and convert it to alcohol during fermentation. In contrast, table, or eating, grapes are harvested when their sugar content is relatively low. Wine grapes are smaller and have thinner skins than table grapes, which need thicker skins so they can be handled and transported.4,5
Wines are divided into two basic categories: red and white. A wine’s color comes from contact with the grape skins. Red, or more accurately purple-blue, grapes generally produce red wines, and white or yellow grapes produce white wines. Both red and white grapes have a yellow-gray inside. Red grapes can be used to make white wine if their skins are removed before fermentation. After harvesting, the grapes are placed into vats where yeast can form naturally on them. Fermentation occurs, resulting in the conversion of grape juice into ethyl alcohol. After fermentation, the new wine is drawn off the vats and placed into wooden barrels or stainless steel tanks for aging before bottling.4,5
Many scientific studies have indicated that moderate wine drinking protects against cardiovascular disease; may offer selected protection from cancer, cognitive decline, and dementia; enhance lung function; and increase longevity.6-13
These proposed health benefits are largely attributed to the rich variety of phytochemicals in wine, especially red wine. A rich variety of phenolics; flavonoids; and resveratrol, a class of stilbenes, are found in wine. On average, a 4-ounce glass of wine contains about 200 different types of polyphenols. The flavonoids, found in fruits, red wine, tea, chocolate, and beer, are the most abundant dietary polyphenols in our diet; more than 4,000 have been identified. Evidence supports a positive association between dietary flavonoid intake and overall good health.7
Increasing attention has been focused on resveratrol, a strong antioxidant found in grape skins, red wines, and in smaller amounts in grape juice, mulberries, and peanuts. Resveratrol, thought to be responsible for wine’s health benefits, has been used in traditional Japanese and Chinese medicines for centuries.5,14,15
Most recently, research using mice has shown that resveratrol improves tissue maintenance and reduces the development of degenerative diseases associated with aging. Researchers are looking into extracting resveratrol for use in new and yet-to-be-developed “antiaging” drugs. GlaxoSmithKline is investing more than $700 million in researching the potential antiaging effect of resveratrol. More research, particularly clinical trials, are needed before recommending resveratrol supplements.13
Liquors: Liquors (eg, whiskey, rum, vodka, brandy, gin) are created from mash. After fermentation, the liquid undergoes distillation. Liquors, sometimes called spirits, contain no added sugar and contain at least 35% alcohol by volume. Be careful to distinguish liquors from liqueurs, which are sweetened and flavored with herbs, fruit, spices, flowers, nuts, or roots.1
Distillation is a simple mechanical process that starts with boiling fermented fruit or grain mixtures. Since alcohol boils at a lower temperature than other liquids, it turns into steam sooner and becomes separated from those liquids. The steam is caught in a cooling tube and is transferred into a different container where it cools and is converted back into liquid. The liquids that do not boil are left behind. When the alcohol liquid is distilled several times, it can produce up to 95% pure ethanol. Thus, liquors are more potent than beer and wine. Unlike wine, liquor stops aging once it is bottled, though it’s best to store liquor in a cool, dark place and to drink within one year after opening the bottle.1
The ethanol content of beer, wine, and liquor varies widely (see Chart 2). Proof refers to the standard measurement of the alcohol content in an alcoholic beverage. The proof is determined based on a formula that expresses ethanol concentration or percentage. The proof of an alcohol-containing beverage or food can be found on the label of that product. As a rule, the proof number is twice the percentage of alcohol in the product. Thus, the 95% ethanol liquor noted above would be labeled “190 proof.” The majority of distilled spirits sold in liquor stores are 80 proof (40%) and 100 proof (50%), although some highly concentrated forms of rum and whiskey may run as high as 75% (150 proof), and grain alcohol sold in some states can achieve 95% (190 proof).1
Functional Food or Addictive Drug?
Alcoholic beverages all have some food value, even if only in terms of calories. The FDA defines food as “…articles used for food or drink or components of any such article; a substance that provides taste, aroma, or nutritive value.”16 We know that foods have other functions than nutrition, taste, and aroma, and the term functional foods has been coined to designate foods that contain physiologically active components (phytochemicals) that provide health benefits beyond basic nutrition. Simply put, basic nutrition provides for normal growth and development; “beyond nutrition” refers to disease protection.5,16 There is no legal or regulatory definition for functional foods; they are regulated in the same way as all foods.5,16
The FDA defines a drug as any substance or mixture of substances manufactured, sold, or represented for use in the diagnosis, treatment, mitigation, or prevention of a disease, disorder, abnormal physical state, or symptoms thereof, in man or animal, or restoring, correcting, or modifying functions in man or animal.5,17
The dilemma for dietitians is that both definitions describe alcohol to some degree, and there is no unanimity in government policies regarding it. Although alcohol exerts pharmacological effects (alters mood, concentration, coordination, and reflexes), the FDA regulates it as a food but restricts its sale and use to adults. However, Health and Human Services and other government agencies categorize alcohol as a drug. The phrase substance abuse has been replaced with “alcohol and other drug abuse.”18 Alcohol can be addictive; some individuals, depending on their genetic makeup or family history, are more susceptible to alcoholism. Heavy drinking is a major cause of preventable deaths worldwide; about 50% of fatal traffic accidents are alcohol related.18,19
Thus, the answer to whether ethanol is a functional food or addictive drug lies partly in the amount and pattern of alcohol intake.
According to the Dietary Guidelines for Americans and the American Heart Association, moderate drinking is defined as one drink per day for women, one to two drinks per day for men, and one drink daily for people aged 60 and older (see Chart 3). However, various studies may define “moderate” drinking as less than or more than one to two drinks per day. Dietitians should note what constitutes “a drink” in reviewing scientific studies.5
Numerous health benefits, especially cardiovascular protection, are associated with moderate alcohol intake.1,5,6 The key is adhering to a moderate intake. Chart 4 outlines moderate, at risk, and heavy drinking.
Health Benefits of Ethanol
There is evidence supporting the health benefits of moderate alcohol intake. It will be helpful to review some of the significant findings from various clinical studies regarding alcohol, particularly wine, and health.1,5,6
• Cardiovascular protection: In l992, a study by Renaud and de Lorgeril formally established the truth of the “French Paradox” and proposed that a moderate intake of red wine is associated with the low mortality rate in populations that consume a high-fat diet and have high blood cholesterol levels. More than 60 prospective studies support this hypothesis.1,5,6
In addition, a prospective cohort study involving more than 36,000 healthy French men found that moderate wine drinking was associated with lower hypertension-related mortality.20
Moderate alcohol consumption is associated with a lower risk of myocardial infarction, but whether alcohol is truly protective or whether the amount, type, or pattern of intake is the most important factor remains unclear. A study involving slightly more than 4,000 participants in Costa Rica found that low to moderate consumption, defined as one to two drinks per week, was independently associated with a reduced risk of heart attack.21
• Lungs: Recent studies indicate that moderate wine drinking (one to three drinks daily) may improve lung function and capacity and even suppress lung diseases such as chronic obstructive pulmonary disease, emphysema, and chronic bronchitis. A study involving 1,555 men and women demonstrated that white wine was more strongly related to improved lung function than red wine. One glass of wine daily equaled 1.5% higher lung function, which could increase life expectancy by one or two years. A daily intake of three glasses of wine improved lung capacity by 3%.9
• Brain/nervous system: A recent study involving 6,000 participants reported that alcohol abstainers had about twice the odds of developing dementia compared with light drinkers (those drinking between one and six drinks weekly). Moderate drinkers (those drinking seven to 14 drinks weekly) had a 31% less chance of developing dementia, while heavy drinkers (those drinking 15 or more drinks weekly) had a 22% lower risk of developing dementia.8 More research is needed to clarify these findings.
• Cancer protection: Wine drinking, specifically red wine, is proposed to reduce the risk of breast, ovarian, and lung cancers, but more research is needed to prove the link between alcohol and cancer.5,21,22,24,25
• Lifestyles: Studies have found that moderate drinkers are healthier overall than abstainers or heavy drinkers. However, is the better health of moderate wine drinkers due to the wine or to the typical lifestyles of most wine drinkers? Data collected from the University of North Carolina Alumni Heart Study at Duke University Medical Center showed that women prefer wine while men prefer beer. The incomes of wine drinkers were higher than nondrinkers and drinkers of other alcoholic beverages. Wine drinkers reported eating healthier diets (eating more servings of fruits and vegetables and fewer servings of red or fried meats) and their diets were lower in saturated fats and cholesterol and higher in fiber compared with those who preferred beer or other alcoholic beverages. In addition, wine drinkers were less likely to smoke, more likely to exercise, and had a lower mean body mass index.26
In summary, the evidence supporting moderate alcohol intake, particularly red wine, for cardiovascular health is strong, but more research is needed.27 Although some studies have suggested wine is more beneficial, the evidence is inconclusive.5,6 While epidemiological or observational studies can support the hypothesis that moderate alcohol intake is beneficial these studies cannot be definitive in declaring direct cause and effect.6
Health Risks
There is a risk-reward calculation to be made. The negative effects of heavy alcohol drinking are well documented and include an increase in mortality rates, hypertriglyceridemia, hypertension, stroke, and an increased risk of developing mouth and throat cancers. Although prospective studies associate moderate alcohol consumption with decreased total mortality rates, higher daily alcohol intake is associated with an increase in total mortality rates.1,5,6 Daily intake of more than one to two drinks is a clear risk factor for hypertension.6 There is agreement that chronic, heavy alcohol intake increases a person’s risk for all types of strokes, especially hemorrhagic strokes. The effect of moderate alcohol intake on stroke risk is unclear due to conflicting findings of various studies.27
Additionally, alcohol is a known depressant, as it slows down brain activity and reflexes. Long-term abuse can lead to addiction.1,18 Chart 5 provides a summary of the benefits and risks.
Conclusion
The effects of alcohol in the body are complex. Alcohol offers each individual a different spectrum of benefits and risks determined by each person’s unique personal and family history, genetic makeup, and health condition. Whether or not to drink alcohol, especially for “medicinal purposes,” requires careful balancing of these benefits and risks. Generally speaking, the risks of alcohol drinking appear to exceed benefits until about middle age, when cardiovascular disease becomes a concern. The risk of overindulging and being involved in an alcohol-related accident is higher in young adults. Certain health conditions and medications are contraindicated with alcohol (see Chart 6).5,18
It appears that one to two drinks per day—particularly of red wine—with meals may provide some health benefits. However, consumers need to have a clear understanding of what constitutes moderate intake. Also, it appears that nonalcoholic grape juice and a diet high in fruits and vegetables offer the same benefits and disease protection.28 Moderate drinking should not be advocated as a proactive strategy for good health.
It may be prudent to remember the words of King Solomon: “Wine is a mocker … whoever is led astray by it is not wise.”
— Carol Ann Brannon, MS, RD, LD, is a consulting dietitian at Fowler YMCA and in private practice in Georgia.
Chart 1: Ales and Lagers2
|
Yeast |
Brewing/Aging Temperature |
Characteristics/Flavor |
Ales |
Flocculate at top of the fermentation tank Prefer 60° to 70°F |
Aged for few weeks |
Complex, flavorful |
Lagers |
Flocculate at bottom of the fermentation tank Prefer 46° to 55°F |
Aged weeks to months at 32° to 45°F |
Clean, clear |
Chart 2: Proof and Percent Ethanol in Different Types of Beverages1
Beverage |
Proof |
Percent Ethanol |
Beer |
8 to 12 |
4 to 6 |
Wine |
14 to 28 |
7 to 14 |
Liquor |
80 to 190 |
40 to 95 |
Chart 3: Serving Sizes1,5
|
One Drink* Equals |
Beer |
12 ounces |
Wine |
5 ounces |
Distilled Liquor |
1.5 ounces (80 proof) |
*One drink provides about 12 to 14 grams of ethanol.
Chart 4: Classifications of Alcohol Drinking5
|
Moderate |
At Risk |
Heavy |
Women; women and men aged 60 or older |
≤ 1 drink/day; |
> 7 drinks/week or |
> 3 drinks/day; |
Men |
≤ 2 drinks/day; |
> 14 drinks/week or |
> 5 drinks/day; |
Chart 5: Proposed Health Benefits vs Adverse Effects of Alcohol5,6
Health Benefits Associated With Moderate Intake* |
Adverse Effects Associated With Moderate Intake* |
Adverse Effects Associated With Heavy Intake** |
Protection against CHD:
¯ CHD mortality |
Hypertension |
Addiction to alcohol
Fetal alcohol syndrome |
* Moderate intake equals an average of one to two drinks per day.
** Heavy intake equals chronically drinking more than three drinks per day.
Chart 6: Contraindications for Alcohol Intake5,18
| Do not drink if you have a history of: | Potential Alcohol-Drug Interactions |
Are pregnant or could become pregnant |
|
Learning Objectives
After completing this continuing education exercise, the student will be able to:
1. Explain the chemical process of converting fruit or grain into alcohol.
2. Explain which components of beer may have cardiovascular benefits.
3. Explain the likely reasons why wine has numerous health benefits.
4. Discuss the dilemma of recommending even moderate alcohol consumption to clients.
5. Discuss at length the potential benefits of alcohol intake on cardiovascular, neurological, respiratory, and immune functions.
6. Discuss the risk vs. benefit analysis of light, moderate, and heavy alcohol consumption.
Examination
1. In the United States, alcohol is:
a. regulated as a functional food by the USDA.
b. regulated by the FDA as a drug.
c. regulated by the FDA as a food.
d. regulated as a functional food by the FDA.
e. regulated by the Drug Enforcement Agency.
2. Moderate alcohol intake:
a. is no more than three drinks per day.
b. is defined as one drink per day for men and women.
c. is defined as one drink per day for women and one to two for men.
d. is difficult to define.
e. varies from individual to individual and is based on body weight.
3. Longevity or mortality rates are:
a. increased in those who abstain from alcohol.
b. increased in moderate wine drinkers only.
c. is relatively the same for moderate drinkers and abstainers.
d. decreased in moderate beer drinkers.
e. not affected by alcohol intake.
4. _______________ is distilled after fermentation.
a. Whiskey
b. Red wine
c. Ale beer
d. Lager beer
e. All of the above
5. ________ contains folate, vitamin B6, and other B vitamins.
a. Red wine
b. White wine
c. Distilled liquors
d. Beer
e. All of the above
6. A preliminary study found that risk of developing dementia was:
a. highest in heavy drinkers.
b. decreased in moderate drinkers.
c. lowest in abstainers.
d. not affected by alcohol intake.
e. None of the above
7. Compared with abstainers and heavy drinkers, moderate wine drinkers typically:
a. eat a healthier diet, including fruits and vegetables.
b. have a lower body mass index.
c. exercise regularly.
d. All of the above
e. consume a higher fat diet and exercise less.
8. The risk of hypertension is:
a. increased with the intake of just one drink per day.
b. increased with the intake of two or more alcoholic drinks per day.
c. decreased with the intake of two or more alcoholic drinks per day.
d. decreased in women but not in men who drink two or more glasses of wine daily.
e. not affected by alcoholic intake.
9. An excessive or heavy alcohol intake is associated with:
a. increased risk of stroke.
b. mouth and throat cancers.
c. liver diseases.
d. alcohol addiction.
e. All of the above
10. It is recommended that women:
a. who do not drink begin drinking 5 ounces of wine daily to prevent breast cancer.
b. who are pregnant limit alcohol intake to one to two drinks per week.
c. who already drink limit intake to one drink (5 ounces of wine, 12 ounces of beer, or 1.5 ounces of liquor) per day.
d. drink 12 ounces of beer twice weekly to ensure the intake of B vitamins and folate.
e. avoid alcohol after menopause for cardiovascular health.
References
1. Centers for Disease Control and Prevention. Alcohol: Frequently asked questions. Available at: http://www.cdc.gov/alcohol/faqs.htm. Accessed September 13, 2008.
2. Eddings B. Beer styles 101: All beers are either ales or lagers. Available at: http://beer.about.com/od/beerstyles/a/BeerStyles101.htm. Accessed September 25, 2008.
3. Glaser G. You’re better off with beer: Beer and your health. All About Beer Magazine. 2002;23(3).
4. Mayer O, Simon J, Rosolova H. A population study of the influence of beer consumption on folate and homocysteine concentrations. Eur J Clin Nutr. 2001;55(7):605-609.
5. Tasters Guild New York. How wine is made. Available at: http://www.tastersguildny.com/howwineismade.shtml. Accessed September 20, 2008.
6. Goldberg IJ, Mosca L, Piano MR, Fisher EA. Wine and your heart: A science advisory for healthcare professionals from the Nutrition Committee, Council on Epidemiology and Prevention, and Council on Cardiovascular Nursing of the American Heart Association. Circulation. 2001;103(3):472-475.
7. Scalbert A, Williamson G. Dietary intake and bioavailability of polyphenols. J Nutr. 2000;130(8S Suppl):2073S-2085S.
8. Mukamal KJ, Kuller LH, Fitzpatrick AL, et al. Prospective study of alcohol consumption and risk of dementia in older adults. JAMA. 2003;289(11):1405-1413.
9. Catchpole H. Now red wine can help the lungs. Available at: http://www.abc.net.au/science/news/stories/s976895.htm. Accessed February 4, 2004.
10. Parks DA, Booyse FM. Cardiovascular protection by alcohol and polyphenols: Role of nitric oxide. Ann N Y Acad Sci. 2002;957:115-121.
11. Sacanella E, Vázquez-Agell M, Mena MP, et al. Down-regulation of adhesion molecules and other inflammatory biomarkers after moderate wine consumption in healthy women: A randomized trial. Am J Clin Nutr. 2007;86(5):1463-1469.
12. Baik I, Shin C. Prospective study of alcohol consumption and metabolic syndrome. Am J Clin Nutr. 2008;87(5):1455-1463.
13. Barger JL, Kayo T, Vann JM, et al. A low dose of dietary resveratrol partially mimics caloric restriction and retards aging parameters in mice. PLoS ONE. 2008;3(6):e2264.
14. Balk J. Resveratrol and cancers of the prostate and breast. Alternative Medicine Alert. 2002;11.
15. Waterhouse AL. Wine and heart disease. Chemistry and Industry. 1995:338-341.
16. Hasler CM, Bloch AS, Thomson CA, Enrione E, Manning C. Position of the American Dietetic Association: Functional foods. J Am Diet Assoc. 2004;104(5):814-826.
17. Ross S. Functional foods: The Food and Drug Administration perspective. Am J Clin Nutr. 2000;71(6 Suppl):1735S-1738S.
18. Center for Substance Abuse Treatment. What Is Substance Abuse Treatment? A Booklet for Families. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2004.
19. Alcohol Problems and Solutions. Alcohol abuse. Available at: http://www2.potsdam.edu/hansondj/AlcoholAbuse.html. Accessed September 15, 2008.
20. Renaud SC, Gueguen R, Conard P, et al. Moderate wine drinkers have lower hypertension-related mortality: A prospective cohort study in French men. Am J Clin Nutr. 2004;80(3):621-625.
21. Kabagambe EK, Baylin A, Ruiz-Narvaez E, Rimm EB, Campos H. Alcohol intake, drinking patterns, and risk of nonfatal acute myocardial infarction in Costa Rica. Am J Clin Nutr. 2005;82(6):1336-1345.
23. Purdie DM, Webb PM, Siskind V, Bain CJ, Green AC. The different etiologies of mucinous and nonmucinous epithelial ovarian cancer by histologic type. Gynecol Oncol. 2003;88(1):S145-S148.
24. Eng ET, Ye JJ, Williams D, et al. Suppression of estrogen biosynthesis by procyanidin dimers in red wine and grape seeds. Cancer Res. 2003;63:8516-8522.
25. Freudenheim JL, Ritz J, Smith-Warner SA, et al. Alcohol consumption and risk of lung cancer: A pooled analysis of cohort studies. Am J Clin Nutr. 2005;82(3):657-667.
26. Barefoot JC, Grønbæk M, Feaganes JR, et al. Alcoholic beverage preference, diet, and health habits in the UNC Alumni Heart Study. Am J Clin Nutr. 2002;76(2):466-472.
27. Gutjahr E, Gmel G, Rehm J. Relation between average alcohol consumption and disease: An overview. Eur Addict Res. 2001;7(3):117-127.
28. Lampe JW. Health effects of vegetables and fruit: Assessing mechanisms of action in human experimental studies. Am J Clin Nutr. 1999;70(3 Suppl):475S-490S.
