Principal long term
consequences related
to moderate consumption
of alcohol
Arthur Guerra de Andrade
Lúcio Garcia de Oliveira
INTRODUCTION
From social to problematic use, alcohol is consumed by approximately 2 billion
people.1,2 This consumption can be understood through multiple perspectives.
For example, from the public health point of view the consumption of alcohol
is a potential agent of sickness and mortality. The improper use of alcohol is
responsible, worldwide, for 3.2% of all deaths and 4% of loss of the Disease
Adjusted Life Years (DALY).3,4
In recent years, scientific evidence has indicated the importance of knowing
alcohol use patterns. Depending on the pattern, alcohol can elevate the risk in
developing health, family and occupational problems, among others. Along with
the total volume of alcohol consumed, the relevance of knowing the pattern of
consumption as an indicator of problems has been widely discussed.4 On the other
hand, some studies have reported that the pattern of use, especially moderate
use, can be beneficial, especially in regards to the development of cardiovascular
diseases.2-6
Alcohol and its consequences: dealing with multiple concepts
The definition of a pattern of consumption is multidimensional, and includes
within the context of drinking; the cultural relevance, the choice of drink, the
frequency of consumption (number of days per week), the quantity, the place (i.e.
at home, in a bar, in a restaurant etc.), whether it is consumed during meals or
not and finally, the individual characteristics of the drinker, whether biological,
genetic, socio-demographic or socio-economic.5 Aside from these, another
factor of interference is the quality of the alcoholic beverage, which serves as a
measurement for future problems due to the consumption of alcohol.
All of these factors, considered together, influence the resulting implications of
the drinking behavior, which will be briefly broached in this chapter.
The exact definition of different patterns of alcohol use makes the localization
of real limits possible – the damages and benefits commonly associated with the
consumption of alcohol. Unfortunately, its importance is still underestimated
and, for this reason, the investigation of pattern of consumption has not been
included in epidemiological surveys.7
Within the patterns of consumption much has been said about moderate use
in a preventive and beneficial role for some chronic sicknesses like cardiovascular
diseases, type II diabetes, cognitive functioning, among others.
CONCEPTUALIZATION OF THE TERM MODERATE USE
International definition by the WHO and by NIAAA
According to the World Health Organization (WHO), “moderate use” is an
inaccurate term that defines a pattern of consumption in which quantities of
alcohol are used without provoking health problems. Many times, moderate use
is employed as a synonym of social drinking and defined as non-problematic; this
way of drinking and its motivation are socially accepted according to the habits.
Many countries offer guidelines concerning consumption levels that are
considered safe, responsible or low-risk, generally defined in a clear way, by
government entities and non-governmental organizations (NGO). These
guidelines do not recommend the consumption of alcohol by minors or pregnant
36
Principal long term consequences related to moderate consumption of alcohol
women. However, for people who are in medical treatment which could be
altered by alcohol consumption, or for those who have a medical history
related to problems with the use of alcoholic beverages drinking should not be
recommended. Generally, these guidelines define the quantity of pure ethanol
in a standard unit of alcohol (different in every country) and offer advice to the
special populations which are at risk.
According to these guidelines, especially the ones that refer to standard units,
one unit of alcohol generally contains from 8 to 14 grams (g) of pure ethanol
(Table 1); among which Japan stands out, reaching almost 20 g.
In general terms, this variation shows that there is no international consensus
about the exact dimension of a standard unit for an alcoholic beverage. But,
according to the guidelines, moderate use has been considered a level or a
pattern of use in which there is less damage and an increase in health benefits,
in which the influences of gender and age of the drinker have been considered.
Due to of physiological differences, the levels of consumption considered
moderate are greater in men up to 65 years old, and less for older individuals.
In the United States, the National Institute on Alcohol Abuse and Alcoholism
(NIAAA) uses the term moderate use to refer to consumption which will not
cause individual damage to the drinker, nor cause social problems. In terms
of drinking units, moderate use is defined as the use of up to 14 g units per
week for men, up to 7 g per week for women and no more than 1 g per week
for individuals over 65 years of age (with the standard unit being 14 g of pure
ethanol). Abstinence for one or two days per week is advised. For daily levels,
this consumption can be translated into two alcoholic units for men (28 g)
and one for women (14 g). In addition to this, the definition of moderate
consumption in terms of daily units, is not absolute, with a variation from one
to five doses per day.8
Even though the levels stipulated by the NIAAA are reasonably similar to the
ones suggested by other countries, the exact definition of moderate use is still
controversial,6,8 especially due to the variation of the definition of a standard
unit. In contrast, it has been observed that some countries define moderate
37
Alcohol and its consequences: dealing with multiple concepts
consumption without defining a standard unit. Thus, the concept of moderate
use varies not only among countries, but also within each country. For example,
France and the United Kingdom recommend, in terms of consumption of daily
alcoholic units, quantities of alcohol greater than to the ones suggested by the
United States, recommending three and from three to four daily alcoholic units,
respectively. In countries such as Australia, Spain and Portugal the greatest
quantities of alcohol in the definition of moderate consumption are found,
reaching 42 g of alcohol daily.
There are countries in which moderate use is defined for specific beverages, as
in Romania (beer and wine); or where the definition in daily terms is correlated
to sex (i.e. Canada, Romania, Sweden and Switzerland). There are countries
that simply recommend the reduction or avoidance from consumption, without
clearly definition what the moderated use is (i.e. Indonesia, Luxembourg,
Thailand and Saudi Arabia).
The NIAAA indicates that the difficulties related to the definition of
moderate use are, to a certain point, the result of individual differences, since
the quantity of alcohol that a person can consume without being intoxicated
varies depending on experience, tolerance, metabolism, genetic vulnerability,
lifestyle, and period of time in which the consumption is realized (three doses
in one hour, for example, produce an alcohol concentration in the blood much
higher than three doses over three hours).8
Finally, there are countries which, even with the absence of official definitions
about moderate consumption, adopt international recommendations suggested
by the WHO9, as in:
•• women should not drink more than two daily units of alcohol;
•• men should not drink more than three daily units of alcohol;
•• drinking should be kept to the minimum possible, and the abstinence from
alcohol should be taken for two days a week;
•• in special situations there should be no consumption. For example, during
pregnancy, while driving a motor vehicle, during work (especially when operating
38
Principal long term consequences related to moderate consumption of alcohol
machines), while exercising, and if someone is already alcohol dependent, or has
other physical problems which would be aggravated while drinking.
The differences related to the definition of moderate consumption among
countries are illustrated in Table 1.
Table 1
DEFINITION DIFFERENCES OF MODERATE CONSUMPTION AMONG
COUNTRIES­
Country
Unit /
standard
drink
Recommended guidelines for adult ‘low risk’
consumption – maximum levels in grams of alcohol
Argentina
N/A
Some information via: www.vivamosreponsablemente.
com
Australia
10 g
Men: Max. 4 drinks/day - 6 drinks on any occasion
Women: Max. 2 drinks/day - 4 drinks on any one day
One or two alcohol-free days every week
Source: National Health and Medical Research Council
(NMRMC): www.nhmrc.gov.au and Australian Government Department of Health and Ageing: www.alcohol.
gov.au www.drinkwise.com.au
Austria
10 g
Men: 24 g/day
Hazardous drinking: 60 g/day
Women: 16 g/day
Hazardous drinking: 40 g/day
Source: Federal Ministry for Labour, Health and Social
Affairs: www.bmsg.gv.at
Belgium
N/A
There are no governmental guidelines
Canada
13,6 g
Men: 2 units/day, max. 14 units/week
Women: 2 units/day, max. 9 units/week
Source: Centre for Addiction and Mental Health: www.
camh.net and www.educalcool.qc.ca
Czech Republic
N/A
Men: 24 g/day
Women: 16 g/day
Source: National Institute of Public Health: www.szu.cz
and www.forum-psr.cz
Denmark
12 g
Men: 21 units/week
Women: 14 units/week
Source: National Board of Health: www.sst.dk and
www.goda.dk
(continue)
39
Alcohol and its consequences: dealing with multiple concepts
Table 1
(Cont.) DEFINITION DIFFERENCES OF MODERATE CONSUMPTION
AMONG COUNTRIES
Country
Unit /
standard
drink
Recommended guidelines for adult ‘low risk’
consumption – maximum levels in grams of alcohol
Finland
11 g
Men: 15 units/week
Women: 10 units/week
Source: www.alto.fi
France
10 g
Men: 3 units/day
Women: 2 units/day
Source: WHO International Guidelines Cited by the
Source: Health Ministry: www.2340.fr
Germany
12 g
Men: 3 units/day
Women: 2 units/day
Source: www.drinkingandyou.com
Greece
10 g
Men: 3 units/day
Women: 2 units/day
Source: Ministry of Health
Hong Kong
Defined as
“a drink”
Hungary
N/A
Responsible drinking info via: www.hafrac.com
Indonesia
N/A
Avoid drinking alcoholic beverages
Source: Ministry of Health Dietary Guideline State and
the National Dietary Guidelines
Iceland
N/A
Pregnant women are advise to abstain while pregnant
or if breast feeding. Source: Alcohol and Drug Abuse
Prevention Council
Ireland
10 g
Men: 21 units/week
Women: 14 units/week
Source: www.drinkaware.ie
Italy
12 g
Men: 2-3 units/day
Women: 1-2 units/day
Source: Ministry of Health: www.alcol.net
Japan
19.75 g
Men: 3 units/day, max. 21units/week
Women: 2-3 units/day, max. 14 units/day
Men: 1-2 units/day
Women: N/A
Source: Ministry of Health, Labour and Welfare
(continue)
40
Principal long term consequences related to moderate consumption of alcohol
Table 1
(Cont.) DEFINITION DIFFERENCES OF MODERATE CONSUMPTION
AMONG COUNTRIES
Country
Unit /
standard
drink
Luxembourg
N/A
Moderate consumption is promoted without a precise
definition
Malta
N/A
Responsible drinking guidelines: www,thesengroup.org
Mexico
Recommended guidelines for adult ‘low risk’
consumption – maximum levels in grams of alcohol
Responsible drinking advice: www.alcoholinformante.
org.mex
The
Netherlands
10 g
Men: 4 units/day
Women: 2 units/day
Source: www.stiva.nl and www.alcoholinfo.nl
New Zealand
10 g
Men: 3 units/day, max. 21 units/week
Women: 2 units/day, max. 14 units/week
Source: Alcohol Liquor Advisory Council www.alcohol.
org.nz
Norway
N/A
Visit: www.alkokutt.no
Poland
10 g
Men: 2 units/day
Women: 1 unit/day
Two alcohol free days per week recommended
Source: Parpa www.parpa.pl
Portugal
14 g
Men: 2-3 units/day
Women: 1-2 units/day
Source: National Council on Food and Nutrition
Romania
N/A
Men: 32.4 g of beer or 20.7 g of wine/day
Women 32.5 g of beer or 20.7 g of wine/day
Source: Ministry of Health
Singapore
N/A
Limit alcohol intake to not more than two standard
drinks a day (about 30 g alcohol)
Source: Ministry of Healthy National Dietary Guidelines
Slovenia
N/A
Men: 20 g/day, max. 50 g on any occasion
Women: 10 g/day, max. 30 g on any occasion
Source: Institute of Public Health
South Africa
N/A
Men: Max. 21 units/week
Women: Max. 14 units/week
Source: www.ara.co.za
(continue)
41
Alcohol and its consequences: dealing with multiple concepts
Table 1
(Cont.) DEFINITION DIFFERENCES OF MODERATE CONSUMPTION
AMONG COUNTRIES
Country
Unit /
standard
drink
Recommended guidelines for adult ‘low risk’
consumption – maximum levels in grams of alcohol
Spain
10 g
Men: Max. 40 g/day
Women: Max. 24 g/day
Source: Ministry of Healthy National Plan On Drugs www.
alcoholysociedad.org
Sweden
N/A
Men: Max. 20 g/day
Women: Max 20 g/day
Source: Swedish Research Council www.vr.se
Switzerland
10-12 g
Taiwan
N/A
Responsible drinking.
Source: www.tfbaf.org.tw
Thailand
N/A
Avoid or reduce the consumption of alcoholic beverages
Source: Ministry of Public Health
United Arab
Emirates
N/A
No official guidelines. Alcohol available in hotels to
guests and visitors. Expatriate residents must posses a
liquor permit. Retail outlets sell only to permit holders
for personal consumption. Providing alcohol to others is
forbidden
United
Kingdom
8g
Men: 3-4 units/day, max. 21 units/week
Women: 2-3 units/day, max. 14 units/week
Sources: Department of Health: www.units.nhs.uk and
www.drinkingandyou.com
USA
14 g
Men: 2 drinks/day, max. 14 units/week
Women: 1 drink/day, max. 7 units/week
Department of Agriculture & Department of Health &
Human Services; www.healthierus.gov/dietaryguidelines
and www.whatsadrink.com
Men: 2 units/day
Women: 2 units/day
Source: Swiss Federal Commission for Alcohol Problems
Source: Drinking & You.10
N/A = Not applicable.
Definition of moderate use of alcohol in Brazil
There is no definition of moderate use in Brazil. Statistical surveys about the
consumption of alcohol (Residential Surveys I and II about the Use of Psychotropic
42
Principal long term consequences related to moderate consumption of alcohol
Drugs) were done in 108 Brazilian cities with populations above 200,000
inhabitants11,12 with both general and specific populations, such as elementary and
high school students, adolescents and street kids.13,14 The survey referred only to
the prevalence of the use of alcohol (lifetime use, per month and per year), not
mentioning the pattern of consumption.
The First National Survey about the patterns of consumption of alcohol in the
Brazilian population15 analyzed how Brazilian adults drink. Combining the variables
of frequency and quantity of use, categories were identified and described by the
intensity of drinking; frequent heavy drinker, frequent drinker, less frequent drinker,
not frequent drinker and abstainer. Moderate use is not mentioned or identified
in the proposed categories, since a consumption of five daily doses of alcohol was
adopted as a limit.
In another epidemiologic survey done in the state of São Paulo, a representative
sample using different age groups, socio-economic conditions and education was
adopted (part of GENACIS – Alcohol, Gender and Drinking Problems: Perspective
of low and middle income countries, study by the World Health Organization
(WHO), and was one of the few Brazilian surveys which defined and investigated,
similar to the international standards, the term moderate use. This study defined
moderate use as the consumption of only three alcoholic doses, less than four per
occasion, on a weekly basis or more frequently (in the last 12 months). In spite of
this definition, the prevalence was very low, corresponding to 7% of the sample
studied.16
Generally thinking, it is perceived that even though the term moderate use or
moderated use is frequently adopted principally in public announcements about
alcoholic beverages, there is not an exact Brazilian definition that follows the
recommendations proposed by WHO and by NIAAA.
Public Opinion about moderate use in Brazil and in
the world
The lack of an international standard about the moderate use of alcohol is
reflected in the larger community, as the definition is difficult for the general
43
Alcohol and its consequences: dealing with multiple concepts
public to understand. Having conflicting, and often false information increases
the chances for the public to assume a risky behavior of drinking, exposing
themselves to negative relevant implications, either short, medium or long-term.
For example, according to a Canadian survey, 57% of the subjects interviewed
considered that moderate consumption was beneficial to their health17. A North
American survey, which was devoted to the study of public opinion about the
moderate use of alcohol, indicated that this behavior was associated with the false
idea of control, state in which a person is not drunk and there is an absence of
short-term negative consequences, with variations in the type of drink and the
setting or context of use. Others believed that moderate consumption does not
exist or it was equal between men and women.18
Yet, in general, the beneficial point of view on moderate use has been more
prevalent among men in the age group over 45. They are frequent drinkers, who
could be looking for an incentive, and in this belief, there is a kind of stimulus or
an excuse for consumption.17
In Brazil, even though there are no direct studies which deal directly with the
popular perception of moderate use, 80% of the people accept social drinking and
weekly drinking of one to two doses of alcohol – an opinion especially common
among male youths between 18 and 34 years old. This acceptance stands out more
when considering that 93.5% of the Brazilian population judges the daily use of
alcohol as a serious health risk.12
Altogether, these data indicate that there is a necessity for competent public
organizations to define and communicate to the population in an objective, clear
and transparent way what moderate use is, minimizing confusion and consequently,
the risks and dangers associated with this pattern of consumption.
ASSOCIATED PROBLEMS From moderate use to abuse/
dependence
Initially, the consumption of alcohol can happen in a search for relaxation
or to decrease stress and anxiety, mainly in social leisure and entertainment
situations. The NIAAA report alerts that people who do not drink or that are
44
Principal long term consequences related to moderate consumption of alcohol
moderate users can become alcoholics if they increase their consumption of
alcoholic beverages. A low estimate predicts that 5% to 7% of people who do
not consume alcohol or use it sporadically can have problems as a result of its
consumption.8
In Brazil, 52% of the citizens drink, while the other 48% are abstinent, have
either never drunk, or have consumed alcohol less than once a year. Regarding
the consequences associated with consumption, 12% of the Brazilian population
reported that they have already had an associated problem, among which 3% are
heavy users and 9%, especially men, are alcohol dependent, a difference that is
up to four times greater than the prevalence detected in women.15
In greater detail, about 30 million Brazilians have already had at least one
problem related to the use of alcohol during their lives. The prevalence of
drinkers with problems seems to decrease with age, going from 53% in the age
group of 18 to 24 years old, to 35% in over the age group over 60 years old.
Among the problems mentioned, physical ones are more common, followed
by family and social conflicts (with some episodes of violence), work, and legal
problems, among others.15
Once a harmful pattern of consumption is developed, it can either lead to
the drinkers maintaining their drinking habits for decades without developing
dependence, or they return to a problem-free pattern of ingestion. This last
situation is rarer, especially when the measure of severe dependence increases.19
The therapeutic response to alcoholism has a very low – only 1% of the patients
who recognize a developing alcoholic problematic habit look for help and have
a chance of being evaluated, diagnosed and motivated for the treatment, and
consequently reach the state of abstinence. However, independent of all of the
possible profiles of patients, there is still belief in the “Law of the Third”, which
means that in the treatment of alcoholics 1/3 recover, 1/3 present no significant
alteration and 1/3 get worse.19
In addition to the low therapeutic response, there is evidence that the
consumption of alcohol is beginning considerably earlier, making adolescents
and young adults more vulnerable to the problems and the consequences
45
Alcohol and its consequences: dealing with multiple concepts
associated with alcoholic consumption. In Brazil, at the age of 13.9, adolescents
report that they have already tried alcohol and regular consumption begins
around 14.6 years old15. In a Brazilian statistical survey done with 48,155
elementary and high school students, 65.2% of the interviewees said that they
had already consumed alcohol, with the greater number of them belonging to
the age group between 13 and 15 years old (61.7%). Besides this, 11.7% of the
adolescents say that they are frequent consumers and 6.7% affirm that they are
heavy consumers, or have consumed alcohol 20 or more times in the 30 days
before the interview.13
Aside from the early use of alcohol facilitating the development of abusive
use and dependence, minors have the tendency to expose themselves to risky
situations, such as early sexual activity, the practice of unsafe sex (without
protection), the existence of multiple sexual partners, unwanted pregnancies,
getting drunk and trying other drugs. This is due to the difficulty of assessing
the risk of the situation, since the individual is under the effect of alcohol, and
it can also influence the choice of peers and situations which favor them.20 It
is believed that the postponement to the introduction of the use of alcohol
could be a relevant factor of protection against being exposed to risky situations
and consequently, reduce health system costs due to alcohol, suggesting the
importance of the early implementation of prevention programs during
adolescence.­
Association of alcohol with other drugs
Many times, alcohol is consumed simultaneously with other psychotropic
substances, especially tobacco and marijuana, even though the alcohol-medicine
association (analgesics, stimulants, sedatives or tranquilizers) is largely mentioned,
mainly among adolescents and university students.21,22 The European School Survey
Project on Alcohol and Other Drugs (ESPAD) is a survey which investigated this
type of association among adolescents, in the age group between 15 to 18 years
old, from 39 European nations.22
46
Principal long term consequences related to moderate consumption of alcohol
An example of this type of association is the simultaneous consumption of
alcohol and tobacco. A North American survey conducted with 1,113 university
students from 18 to 24 years old, observed that there is a positive relation
between these uses, in a manner that any quantity of tobacco used would be, in
some form, related to the consumption of alcohol. Due to the fact that the use
of tobacco increases during the consumption of alcoholic beverages, it is believed
that alcohol stimulates this use, besides deviating the attention of the user over
the consumption. More than quantity, the frequency that alcohol is used is a
strong leading factor in the consumption of tobacco, and is associated with the
use of illegal drugs and the recreational use of medicine.23
Independently of the substance which alcohol is associated with, this type of
consumption is very dangerous because, besides predisposition to toxic reactions of
relevance by the user, the chances of developing abuse or dependence to associated
drugs are increased and damages cognitive function, capacity to reason, analysis,
judgment and predisposition of the individual to physical, emotional and socially
risky behaviors.21,24-26
Health Problems
Health problems are among the main consequences related to the use of
alcohol, considered the cause of more than 60 types of diseases4 of acute or chronic
development, contributing to around 4% of all worldwide cases of diseases and
creating a significant cost for healthcare system.27
The diseases associated with the consumption of alcohol can be grouped in
three categories, reflecting the nature of their conditions and the etiological
consumption of alcohol7:
•• health conditions fully attributed to the use of alcohol (100% of causality
relation): neuropsychiatric perturbations, alcoholic psychoses, abuse and
dependence of alcohol, fetal conditions and hepatic cirrhosis, and others;
•• chronic conditions in which alcohol is the contributing factor: mouth, orthopharynx and breast cancer, miscarriage, and others;
47
Alcohol and its consequences: dealing with multiple concepts
•• serious conditions in which alcohol is the contributing factor: automobile
accidents, falls, poisoning, drowning, homicide, suicide, and others.
The last category can be subdivided into non-intentional situations, as in
automobile accidents and falls, and intentional, as in self-harm, homicides and
suicides.4
All of the fetal conditions caused by the consumption of alcohol during pregnancy
are denominated the spectrum of fetal alcoholic disturbances. Among these
disturbances, in the most common cited is the fetal alcoholic syndrome (FAS).
The moderate consumption of alcohol has been especially harmful in cancer,
hepatic diseases and pregnancy situations, described as follows.
Cancer
The consumption of alcohol worldwide is responsible for the incidence
of 5.2% of the cases of cancer in men and 1.7% of the cases in women, a
development which occurs on a long term basis.28 It is estimated that 60% of
the incidence of cancer, especially in women, associated with the use of alcohol
has occurred in the form of breast cancer.29
There is strong evidence of an association with the use of alcohol and the
incidence of cancer in the upper digestive system (oral cavity, pharynx, esophagus
and larynx), but the magnitude of the relation to the incidence of anal, colon
and liver cancers is still controversial.30
Although the consumption of alcohol is positively related to a considerable
group of cancer cases, little is known about the relationship between moderate
use and incidences of cancer. A change in the pattern of consumption, from
heavy to moderate, has little influence in cancers development, but on the other
hand, if an abstainer began a moderate use of alcohol, the incidence of cancer
would increase in an excessive manner.31
The relationship between a pattern of moderate use of alcohol and the
incidence of cancer as well as with its related cause is still controversial, and
further research is necessary for a complete understanding.
48
Principal long term consequences related to moderate consumption of alcohol
Hepatic diseases
The abuse of alcohol is the greatest factor in death caused by hepatic diseases
in the United States, and 40% to 90% of those deaths are from hepatic cirrhosis.8
There is a parallel between the quantity of alcohol consumed (and the history of
its use) and the incidence of hepatic diseases.
Among the patterns of consumption moderate use of alcohol is not beneficial to
hepatic diseases, and causing the disease in susceptible individuals32. Even though
it is not known for sure the alcoholic dosage level responsible for these diseases,
studies suggest that 14 weekly alcoholic doses for men and seven weekly doses for
women can lead to the occurrence of hepatic diseases. However, other studies,
suggest higher doses. The NIAAA report suggests that hepatic cirrhosis is generally
associated with the consumption of five daily doses of alcohol for a period of at
least 5 years.8
The presence of other hepatic diseases, especially hepatitis B and C, significantly
increases the risk of hepatic damage when combined with the moderate or excessive
consumption of alcohol.33 Obesity and the exposure to drugs and other substances
associated with the consumption of alcohol also present additional risks in the
development of hepatic diseases.34
Due to these multiple interfering factors safe levels of alcohol consumption in
relation to hepatic diseases varies significantly from individual to individual.
Pregnancy
A North American population survey indicated that 30.3% of 4,088 pregnant
women declared that they had consumed alcohol during pregnancy. During
this interval, the pattern of consumption seemed to vary depending on their
socio-demographic and behavioral characteristics, such as age group, level of
education, social economical class, ethnic group, intention of getting pregnant,
use of tobacco during pregnancy, alcoholic use before pregnancy, and finally,
history of use of alcohol on a binge standard (defined as more than four alcoholic
doses in one occasion of consumption) in the 3 months prior to conception.
49
Alcohol and its consequences: dealing with multiple concepts
According to these authors, in the pre-gestational period women who had drunk
on a binge were eight times more likely to drink during pregnancy and 36 times
more likely to go on a binge during pregnancy.35
Aside from the previously outlined factors, a study done with pregnant women
attended by an obstetrical service of the Socialized Health System (SHS) in the
city of Ribeirao Preto, Sao Paulo, indicated that the exaggerated consumption of
alcohol during pregnancy could reflect a lack of structure in the emotional state
of these women (i.e. anxiety and depression).36
Independent of the underlying reasons, the consumption of alcohol during
pregnancy has teratogenic effects, which cause a series of cognitive, behavioral
and neurological damages. The continuum of disorders which follow this
consumption is known as fetal alcoholic syndrome disturbance (FASD), of which
the most commonly studied is the fetal alcoholic syndrome (FAS). Studies have
indicated that children and adolescents with FASD present serious encephalic
structural modifications, suggesting a deficit in the development and the healthy
organization of the nervous system37, which could be the basis of an incidence in
commonly reported cognitive, emotional and psychiatric deficits.37,38
In the specter of anomalies caused by the consumption of alcohol during
pregnancy, FAS is an evident characteristic, presented by irreversible neurological
damages, delayed growth and body malformations, especially in the face.
Cognitively, children exposed to the consumption of alcohol during pregnancy
are more impulsive and present attention and memory deficit – disturbances
that are more evident in children whose progenitors were heavy consumers
of alcohol during pregnancy.38 In the same manner, this standard of alcohol
consumption during pregnancy increases the risk of developing psychiatric
diseases in the adult phase, such as personality disorders or disorders related to
the use of alcohol or other substances.39,40
Although it is known that the consumption of alcohol negatively effects the
fetus, it is still not known for sure the minimum dose which causes this type of
problem. It is believed that FAS, for example, can attack any population, even
with moderate consumption or small quantities of alcohol during pregnancy41.
50
Principal long term consequences related to moderate consumption of alcohol
Another survey that investigated 501 women whose children presented behaviorial
problems indicated that only one weekly dose of alcohol was sufficient to cause
a behavioral alteration in childhood. According to this survey children who are
exposed to alcohol are 3.2 times more likely to present aggressiveness compared
to those that are not exposed.42
In spite of the results of many surveys, there is not any conclusion regarding
a quantity of alcohol which can be consumed safely during pregnancy. Since
there are no secure limits, a pregnancy would only be considered secure if it were
completely free of alcohol, suggesting that pregnant women should be alcohol
abstinent.
For this question to be answered, it is important that public authorities invest
in measures of prevention which identify and reduce the exposure of alcohol
during pregnancy. Another possible measure would be to counsel sexually active
and childbearing age women about the use of reliable contraceptive methods,
planning the pregnancy and interrupting of the consumption of alcohol before
pregnancy.
ASSOCIATED BENEFITS
Since the early 1990s numerous scientific epidemiological studies (prospective
and case controlled) of clinical intervention or experimental based models have
mentioned the relationship between moderate use of alcohol and the incidence and
progression of chronic diseases, in which gender, type of beverage and confounding
factors (social and demographical) must be considered.
Thus, moderate consumption of alcohol has been associated with a decrease in
mortality rates, which suggests a possible beneficial effect on health with this use.43,44
Many authors who focus their studies on the comprehension of the health effects
of moderate alcohol use describe this relation graphically, by a “J” curve43,45,46, in
which the benefits of alcohol use (in this case, the decrease of the death rate) are
possible until a certain point, and from this point on the consumption of alcohol
becomes damaging.
51
Alcohol and its consequences: dealing with multiple concepts
The beneficial effect of the moderate use of alcohol in the incidence and/or
development of some diseases, especially in relation to some cardiovascular diseases,
will be described in this section.
Cardiovascular diseases
There is not a consensus regarding the contribution of alcohol use in the
development of cardiovascular events, especially because drinking lightly or
moderately has favorable effects, while unfavorable effects are attributed to heavy
drinking. In what is referred to as moderate use, Klatsky et al47 was the first
to suggest the existence of an inverse association between this use and the risk
of developing cardiovascular events, illustrated in the graph by a “U” or a “J”
curve.45
Although this association is clear when considering the development of
coronary diseases, the relationship with the development of other cardiovascular
and non-cardiovascular events (i.e. cardiomyopathy, hypertension, arrhythmia,
hemorrhagic and ischemic brain stroke, and congestive cardiac insufficiency) is
still controversial, and seems to change depending on the type of event.
Recently, a revision about the effects of alcohol consumption on the incidence
of cardiovascular events indicated a disparity of action6, briefly mentioned and
divided by the type of cardiovascular event.
Myocardiopathy
This is a term that refers to a disease of the striated cardiac muscle. The most
common type is dilated myocardiopathy, in which there is an increase in the
dimension of the heart and a decrease in its propulsion strength. It is believed
that the chronic and heavy use of alcohol can cause this disease, although lighter
standards of consumption can also cause it, especially when associated with
co-factors such as the deficiency of thiamin (Vitamin B1), genetic factors, and
viral infection.
52
Principal long term consequences related to moderate consumption of alcohol
Hypertension
Although the exact biological mechanism of alcohol’s influence has not
been proposed, heavy use increases the risk of developing hypertension,
independent of nutritional factors – a relationship that has not been found in
light and moderate users. Aside from that, the heavy use of alcohol interferes
with medical treatment, while moderate use or abstention improve the results
of non-pharmacological interventions aimed at decreasing blood pressure (i.e.
weight loss, physical exercise and the restricted use of salt). In general terms,
some studies have suggested a graphic relation, in the form of a “J”, to identify
the interference of the use of alcohol on blood pressure, in which light drinkers
have a modest reduction in blood pressure levels.48
Arrhythmia
The risk of developing arrhythmia is greater among heavy consumers of alcohol,
while it has not been observed in light and moderate consumers. This increase
possibly occurs because of damages to the myocardium, the effects of alcohol on the
vagal reflex, on the conduction of nervous impulses and of refractory time and the
possible influences on the roles of catecholamine and acetaldehyde.
The Holiday Heart syndrome is one of the well-known arrhythmias, which is a
consequence of strongly abusing alcohol.
Stroke
Various studies have suggested that the heavy use of alcohol, as in going on
a binge, is associated with an elevated risk of incidence of cerebral hemorrhage.
Nevertheless, few studies have indicated the interference of alcohol in accordance
with the type of stroke, whether hemorrhagic (by rupture of the blood veins) or
ischemic (by occlusion).
Other studies indicate that heavy users are more likely to develop a hemorrhagic
stroke, although the risk of ischemic stroke from alcohol use is still not completely
explained.
53
Alcohol and its consequences: dealing with multiple concepts
Coronary diseases
Epidemiological studies have demonstrated a reduction in mortality rates
by acute myocardial heart attack and coronary diseases in moderate drinkers,
which indicates the cardioprotective effect of alcohol and what type of drink is
a relevant factor. Although this effect has been observed in the most common
types of beverages (wine, beer and distilled), it seems to be more prevalent
with wine drinkers and less in individuals who consume distilled beverages. A
significant difference between red and white wine is not made. Aside from this,
the beneficial effects of alcohol are influenced by the pattern of use and by the
personal characteristics of the drinker.
Heart failure
This is a syndrome functionally described by a situation in which cardiac function
is inadequate to attend to the real needs of the body, creating a clinical diagnosis
corresponding to congestive cardiac insufficiency, which can become complicated
with the development of acute edema of the lung and cardiogenic shock. In this
situation, the most common standard is the dilated myocardiopathy.
The risk of heart failure increased in heavy consumers of alcohol. Aside from
decreasing the incidence of cardiovascular diseases, there is scientific evidence
that moderate consumption can reduce the risk of its progression in individuals
who already present it, as well as in coronary disease patients. Then, comparing
with abstaining individuals, the light and moderate use could reduce the risk of
cardiovascular events occurring in subjects with high blood pressure, diabetes, and
other cardiac diseases.49,50
The beneficial effects of moderate consumption of alcohol extend to other
conditions such as type II diabetes, cognitive function, cardioprotective factors
and types of beverage.
54
Principal long term consequences related to moderate consumption of alcohol
Type II Diabetes
Nowadays, a world epidemic of obesity and diabetes mellitus has been witnessed,
and the main factors responsible for it are the exaggerated consumption of food
and lack of physical activity.
Although heavy drinking is associated with high levels of glucose and poor
adherence to the control of diabetes, moderate drinking has been associated
with a lower risk of development of diabetes with beneficial effects in glucose
metabolism and on insulin levels. A meta-analysis of 15 cohort studies indicated
the existence of a relation, graphically represented by a “U” curve, between the
consumption of alcohol and the development of diabetes type II, with a 30% to
40% reduction of risk for consumers of one to two daily doses of alcohol when
compared with abstaining individuals, both men and women.44,49
Moderate use presents more favorable effects and the type of alcoholic beverage
seems to have little influence on this risk.51 The exact action mechanisms of
moderate alcohol consumption in type II diabetes are not fully understood, but
it is possibly from the increase of cellular sensitivity to insulin52 or the decrease
in intolerance to glucose – hypotheses that have yet to be proven.
Cognitive functioning
Abusive and prolonged use of alcohol is associated with the occurrence of
dementia.
Dementia is the most common disorder which affects the elderly, of which
the relevant factors are gender, education, diet, and vascular issues. The two
most common types of dementia in the western population are Alzheimer’s and
vascular dementia.
Regarding the effect of alcohol, especially on the cognitive function of the drinker,
prospective studies have indicated that there is an association between the moderate
use of alcohol and the decreased risk of developing dementia53,54 compared to the
inherent risk for non drinkers or abstainers. In addition to this, when the influence of
gender is considered, the risk seems to be lower for men even though the amount of
55
Alcohol and its consequences: dealing with multiple concepts
alcohol ingested is equal.55 However, the influence of gender on cognitive function is
still controversial, since there are studies which affirm exactly the opposite.56,57 Thus,
a study which evaluated the mental function of 12,480 women with ages between
70 and 81 years old, who consumed up to 15 g daily of alcohol, showed that these
women presented a better performance in cognitive evaluation than the abstainers,
and maintained a better performance even 2 years after the first evaluation.56
If the type of beverage is considered, the consumption of wine diminishes the
risk of dementia, while the use of beer and distilled drinks seems to increase it – a
relationship that is still controversial.58 The mechanisms of alcoholic influence on the
risk of dementia seem to be secondary to the decrease of risk factors for cardiovascular
diseases, the possible improvement of the cholinergic neurotransmission in the
region referring to the hippocampus as well as to the inherent antioxidant effect of
alcohol, among others.59
Cardioprotective factors
The cardioprotective properties of moderate use are being continually studied.44
In model experiments, distinct biological mechanisms have been suggested and
described to explain the beneficial effects of alcohol, among which changes of
plasmatic profile of the lipids stand out, especially regarding the increased levels
of high density level cholesterol (HDL) and its subtypes.
These results have been corroborated by studies that analyze the cardioprotecive
factors on the incidence of coronary diseases, pointing out different mechanisms:
•• increased level of plasmatic HDL, especially of the subtypes HDL2 and HDL3,
which would make possible a reduction of the accumulated cholesterol in the
walls of the blood vessels and the decrease of oxidation of LDL (low-density
lipoprotein);
•• decrease of blood coagulation mechanisms;
•• reduction of stress or anxiolytic effects5,6.
56
Principal long term consequences related to moderate consumption of alcohol
However, the joint action of changes in vascular, myocardial, hemostatic and
endothelial functions seem to contribute to the reduction of the global risk of the
incidence of cardiovascular events, including the decrease of platelet aggregation,
inflammation, and a series of other factors.60
Light to moderate use of alcohol, though, depending on the cardiovascular
events, can be measured by other effects. A good example is that the effect of
alcohol consumption on arterial pressure, especially high blood pressure, ends
up controlling one of the risk factors of greatest relevance in the incidence of
cardiovascular diseases.
Interference of type of beverage
It is important to notice that the beneficial effects of moderate consumption
of alcohol on health, especially in the incidence of cardiovascular diseases, is not
generalized, since it varies depending on the type of beverage.
One of the first investigations on this theme suggests that the incidence of
coronary diseases was less prevalent in countries where wine is traditionally
consumed than in those where beer or distilled beverages were consumed.61
Currently, the cardioprotective effect with the moderate use of wine is noticeable
and scientifically proven, while the effect of beer or distilled beverages is still
controversial, in such a way that it is still difficult to reach a consensus.62,63
More than the effects of the beverage, per se, it is suggested that the pattern of
consumption of alcohol and the lifestyle of the drinker are the real interferences
of cardiovascular effects.
Although it is believed that there is a cardioprotective effect of wine, studies
have indicated the relevance of its nonalcoholic components, such as phenolic
antioxidant components and antithrombotic substances.64-68 Although the
differences in relation to the influence of the type of wine whether red or white,
have not been discussed the cardiovascular effects are similar in exclusive red,
white and other wine drinkers.69
57
Alcohol and its consequences: dealing with multiple concepts
Confounding variables
Although the risks and benefits associated with the moderate use of alcohol
does exist, it is important to consider that they can be signs of a wider psychosocial
behavior, or the findings could be due to interfering factors and are not necessarily
associated with the consumption of alcohol per se, suggesting that its effects are
not considered isolated, but as a part of a social and cultural context, or the lifestyle
of the drinker.
These interfering factors are commonly referred to as confounder factors or
confounding variables70,71, and vary depending on the alcohol consumption
characteristics or the biological variations of the drinker. Thus, regarding
consumption the beneficial effects can suffer interference from composition of
the beverage (i. e. wine has polyphenolic substances which can hide the effect of
ethanol) and of their pattern of use (quantity and frequency). When the user’s
characteristics are considered a real interference of alcohol varies depending on the
gender, education level, social economical condition, as well as general condition
of health, cognitive functioning, intelligence (IQ), psychiatric comorbidities,
lifestyle, diet, and other aspects.
Among these factors, especially lifestyle, wine consumers have a healthier
food diet than the beer or distilled beverage consumers because they purchase
olives, vegetables and products with less fat more frequently.71 This explains or
strengthens the beneficial health effects of alcohol. Then, it would be possible to
admit that the moderate consumption of alcohol associated with a healthy diet
had more positive effects than a combination of drinking and an unhealthy diet.
Aside from this, the consumption of alcohol alters ingestion and the metabolism
of fatty acids essential to a good diet, altering the regulation of homeostasis.72,73
For this reason, it is still not known if it is the use of alcohol or if it is the consumer
and their lifestyle which influence the risks of diseases associated with alcohol.
58
Principal long term consequences related to moderate consumption of alcohol
final considerations
Although the heavy use of alcohol has negatively impacted public health,
in parallel, there is evidence that indicates that there are benefits associated
with moderate use, especially with cardiovascular events. However, caution is
important when considering this relationship, since there are many difficulties
in estimating the real effects from the moderate consumption of alcohol, with
the tendency of the interviewee to underestimate his consumption. Thus,
unnecessary and dangerous generalizations should be avoided.
It is important to remember that the health effects of alcohol depend
principally on the medical history and the individual risks of the drinker. Since
doctors and other health professionals are instruments for the awareness and
change of individual habits, it is necessary to provide correct and up-to-date
information about the real effects of alcohol so that they can act as multipliers of
knowledge among their patients. The participation of the media in this process
is also fundamental.
Accurate information about the effects of moderate consumption is still
scarce, overall due to the lack of standardization of its definition. More research
is necessary for an understanding of the real relation between the pattern of
consumption of alcohol and its associated effects, aiming at spreading fundamental
and secure scientific recommendations to those who drink. Information should
be applied specifically to the original conditions, or to a determined group,
culture or country, for avoiding imprudent generalizations. In addition to this,
it is expected that public health authorities, with the intention of reducing the
harmful use of alcohol, transmit clearly and objectively the possible benefits
induced by the moderate use, and stimulate healthy practices of consumption.
In light of this lack of consensus and generalization of information some general
recommendations are suggested, including:
•• the general health risk of a heavy drinker can be decreased with the reduction
of consumption or by abstinence;
59
Alcohol and its consequences: dealing with multiple concepts
•• in virtue of the lack of knowledge about the risk of the progression to heavy
drinking, abstainers should not be indiscriminately counseled to drink;
•• most of people who are light or moderate drinkers should not change their
drinking habits, except in special circumstances.
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