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Moderate alcohol use can be good for the heart if rich, fatal if poor

AlcoholuseModerately frequent alcohol users have a lower risk of dying from cardiovascular disease (CVD) than infrequent drinkers and this is more pronounced among those with high socio-economic status, found a large Norwegian Institute of Public Health cohort study. Very frequent alcohol consumption is associated with increased CVD mortality risk of CVD but only among those with low socio-economic position.

Very frequent consumption of alcohol is associated with an increased risk of dying from cardiovascular disease, but only among people in the lowest socioeconomic position, according to a research study by Eirik Degerud from the Norwegian Institute of Public Health in Oslo, and colleagues.

Individuals with low socio-economic position are known to consume alcohol less frequently than those in higher positions, but experience a higher rate of alcohol-related hospitalizations and deaths. Degerud and colleagues analysed socio-economic and health survey data, as well as cause of death information, on 207,394 Norwegian adults who were born before 15 October, 1960 and completed mandatory censuses in Norway between 1960 and 1990.

Moderately frequent alcohol consumers (2–3 times per week) had a lower risk of dying from cardiovascular disease than infrequent drinkers, and this association was more pronounced among people in the highest socio-economic position. Very frequent consumption of alcohol (4–7 times per week) was associated with an increased risk of dying from cardiovascular disease among people in the lowest socioeconomic position. The authors also report that weekly binge drinkers had higher risk of dying from cardiovascular disease than those who did not binge drink in the past year, but the risk did not seem to differ by socioeconomic position.

“It is unclear if (these difference in risk) reflects differential confounding of alcohol consumption with health-protective or damaging exposures or differing effects of alcohol on health across socio-economic groups,” the authors say. “The heterogeneity between groups in the population needs to be assessed when making population recommendations regarding alcohol consumption.”

In an accompanying Perspective, Jurgen Rehm and Charlotte Probst of Canada’s Centre for Addiction and Mental Health write that the new findings are an important piece of the puzzle in understanding the complex interactions between socio-economic position and mortality. An implication of the new paper, they say, is that “it is not appropriate simply to extrapolate from risks associated with alcohol use in higher-income populations to address lower-income populations where the impact of alcohol use is highest.”

Abstract
Background: Socioeconomically disadvantaged groups tend to experience more harm from the same level of exposure to alcohol as advantaged groups. Alcohol has multiple biological effects on the cardiovascular system, both potentially harmful and protective. We investigated whether the diverging relationships between alcohol drinking patterns and cardiovascular disease (CVD) mortality differed by life course socioeconomic position (SEP).
Methods and findings: From 3 cohorts (the Counties Studies, the Cohort of Norway, and the Age 40 Program, 1987–2003) containing data from population-based cardiovascular health surveys in Norway, we included participants with self-reported information on alcohol consumption frequency (n = 207,394) and binge drinking episodes (≥5 units per occasion, n = 32,616). We also used data from national registries obtained by linkage. Hazard ratio (HR) with 95% confidence intervals (CIs) for CVD mortality was estimated using Cox models, including alcohol, life course SEP, age, gender, smoking, physical activity, body mass index (BMI), systolic blood pressure, heart rate, triglycerides, diabetes, history of CVD, and family history of coronary heart disease (CHD). Analyses were performed in the overall sample and stratified by high, middle, and low strata of life course SEP. A total of 8,435 CVD deaths occurred during the mean 17 years of follow-up. Compared to infrequent consumption (<once/month), moderately frequent consumption (2–3 times per week) was associated with a lower risk of CVD mortality (HR = 0.78, 95% CI 0.72, 0.84) overall. HRs for the high, middle, and low strata of SEP were 0.66 (95% CI 0.58, 0.76), 0.87 (95% CI 0.78, 0.97), and 0.79 (95% CI 0.64, 0.98), respectively, compared with infrequent users in each stratum. HRs for effect modification were 1.30 (95% CI 1.10, 1.54, p = 0.002; middle versus high), 1.23 (95% CI 0.96, 1.58, p = 0.10; low versus high), and 0.96 (95% CI 0.76, 1.21, p = 0.73; low versus middle). In the group with data on binge drinking, 2,284 deaths (15 years) from CVDs occurred. In comparison to consumers who did not binge during the past year, HRs among frequent bingers (≥1 time per week) were 1.58 (95% CI 1.31, 1.91) overall, and 1.22 (95% CI 0.84, 1.76), 1.71 (95% CI 1.31, 2.23), and 1.85 (95% CI 1.16, 2.94) in the strata, respectively. HRs for effect modification were 1.36 (95% CI 0.87, 2.13, p = 0.18; middle versus high), 1.63 (95% CI 0.92, 2.91, p = 0.10; low versus high), and 1.32 (95% CI 0.79, 2.20, p = 0.29; low versus middle). A limitation of this study was the use of a single measurement to reflect lifetime alcohol consumption.
Conclusions: Moderately frequent consumers had a lower risk of CVD mortality compared with infrequent consumers, and we observed that this association was more pronounced among participants with higher SEP throughout their life course. Frequent binge drinking was associated with a higher risk of CVD mortality, but it was more uncertain whether the risk differed by life course SEP. It is unclear if these findings reflect differential confounding of alcohol consumption with health-protective or damaging exposures, or differing effects of alcohol on health across socioeconomic groups.

Authors
Eirik Degerud, Inger Ariansen, Eivind Ystrom, Sidsel Graff-Iversen, Gudrun Høiseth, Jørg Mørland, George Davey Smith, Øyvind Næss

[link url="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002476"]PLOS Medicine abstract[/link]
[link url="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002477"]PLOS Medicine perspective[/link]

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