Current issues of ACP Journal Club are published in Annals of Internal Medicine


Review: High alcohol intake increases mortality in both men and women


ACP J Club. 2007 Jul-Aug;147:A11. doi:10.7326/ACPJC-2007-147-1-A11

To the Editor

Dr. Shekelle's commentary (1) on the article “Alcohol dosing and total mortality in men and women: an updated meta-analysis of 34 prospective studies” in the March/April issue was disappointing and full of the bias that one does not expect to find in a journal that prides itself on letting the evidence do the talking. The chosen title of the commentary, “Review: high alcohol intake increases mortality in both men and women,” exposes Dr. Shekelle's insistence on seeing the glass 1/10 empty rather than 9/10 full. Despite the prospective nature of the cohort studies and the overwhelming support for mild-to-moderate alcohol consumption, Dr. Shekelle refuses to acknowledge that there could be a true mortality benefit, instead choosing to state only that “when measured this way, there is a J-shaped association.”

The author's 2 criticisms of the study methods are curious: He impugns the practice of measuring self-reported alcohol consumption, despite validation of this technique and proven correlations between self-reported consumption and other markers of alcohol use, such as biochemical markers and patient injuries (2-4). Indeed, the accepted assumption is that self-report may underestimate, rather than overestimate, actual intake. If this is the case, then the mortality benefit may actually extend to relatively higher, rather than lower, amounts of alcohol consumption. Dr.

Shekelle's other point, that alcohol consumption may be a marker for other healthy lifestyle behaviors, is an unsupported conjecture that seems far-fetched at best.

In all, Dr. Shekelle's personal bias against any alcohol use impairs his ability to interpret strong data in a way that should honestly and meaningfully alter patient care.

Joshua Blum, MD
Denver Health and Hospital AuthorityUniversity of Colorado Health Sciences Center
Colorado, Denver, USA

In response

I sympathize with Dr. Blum's conclusion that moderate alcohol intake decreases mortality. These data seem consistent and compelling. Why not recommend it? My hesitancy comes from the fact that I have read this story before—too many times, in fact. Vitamin E, hormone replacement therapy, β-carotene, folate: All have been promoted as healthful based on strong, consistent epidemiologic data and a strong, plausible biological rationale. Yet when subjected to the scrutiny of a randomized clinical trial, all of these substances have shown no evidence for the benefits claimed for them, and in some cases, have been shown to actually cause harm (5-8). These findings have made me more skeptical than ever of observational studies of association. I believe that before we can make broad policy conclusions recommending patients take such substances to prevent conditions they currently show no evidence of having—particularly substances known to also cause harm (like alcohol)—we simply must have better evidence than that of observational studies. I don't tell patients to stop who, like myself, enjoy a glass of wine with dinner. But I certainly would not tell an abstemious patient that he or she should start drinking in order to prolong their life.

Paul Shekelle, MD, PhD
Greater Los Angeles Veterans Affairs Healthcare System
Santa Monica, California, USA


1. Shekelle P.Commentary on Review: High alcohol intake increases mortality in both men and women. ACP Journal Club. 2007 Mar-Apr;146:48. Comment on: Di Castelnuovo A, Costanzo S, Bagnardi V, et al. Alcohol dosing and total mortality in men and women: an updated meta-analysis of 34 prospective studies. Arch Intern Med. 2006;166:2437-45. [PubMed ID: 17159008]

2. Carlsson S, Hammar N, Hakala P, et al. Assessment of alcohol consumption by mailed questionnaire in epidemiological studies: evaluation of misclassification using a dietary history interview and biochemical markers. Eur J Epidemiol. 2003;18:493-501. [PubMed ID: 12908714]

3. Mukamal KJ, Mittleman MA, Longstreth WT Jr., et al. Self-reported alcohol consumption and falls in older adults: cross-sectional and longitudinal analyses of the cardiovascular health study. J Am Geriatr Soc. 2004;52:1174-9. [PubMed ID: 15209658]

4. Sommers MS, Dyehouse JM, Howe SR, et al. Manharth M. Validity of self-reported alcohol consumption in nondependent drinkers with unintentional injuries. Alcohol Clin Exp Res. 2000;24:1406-13. [PubMed ID: 11003207]

5. The Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group. The effect of vitamin E and beta carotene on the incidence of lung cancer and other cancers in male smokers. N Engl J Med. 1994;330:1029-35. [PubMed ID: 8127329]

6. Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of antioxidant vitamin supplementation in 20, 536 high-risk individuals: a randomised placebo-controlled trial. Lancet. 2002;360:23-33. [PubMed ID: 12114037]

7. Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in health postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial. JAMA. 2002;288:321-33. [PubMed ID: 12117397]

8. Shekelle P. Commentary on Lowering homocysteine with folic acid and B vitamins did not prevent vascular events in vascular disease, and Lowering homcysteine with folic acid and B vitamins did not prevent vascular events after myocardial infarction. Comment on ACP Journal Club. 2006;145:2-3. Comment on: Lonn E, Yusuf S, Arnold MJ, et al. Homocysteine lowering with folic acid and B vitamins in vascular disease. N Engl J Med. 2006;354:1567-77. [PubMed ID: 16531613] Bønaa KH, Njølstad I, Ueland PM, et al. Homocysteine lowering and cardiovascular events after acute myocardial infarction. N Engl J Med. 2006;354:1578-88. [PubMed ID: 16531614]