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Effects of moderate beer consumption on blood lipid profile in healthy Spanish adults
Nutrition, Metabolism & Cardiovascular Diseases (2008) 18, 365e372
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/nmcd
Effects of moderate beer consumption on blood lipid profile in healthy Spanish adults ´lez-Gross, Julia Wa ¨rnberg, Javier Romeo*, Marcela Gonza ´n Marcos Ligia E. Dı´az, Ascensio Grupo Inmunonutricio´n, Departamento de Metabolismo y Nutricio´n, Instituto del Frı´o, Consejo Superior de Investigaciones Cientı´ficas, C/Jose´ Antonio Novais, 10, 28040 Madrid, Spain Received 7 November 2006; received in revised form 26 March 2007; accepted 29 March 2007
KEYWORDS Moderate beer consumption; Blood lipid profile; Cholesterol; Healthy adults
Abstract Background and aims: To analyse the association of moderate beer consumption on the blood lipid profile in healthy Spanish adults. Methods and results: The study had an intervention longitudinal design in which each subject established their own control with a previous wash-out phase. After a 30-day alcohol abstinence period, 57 healthy volunteers were submitted to a daily moderate intake of beer for 30 days. Serum total cholesterol, HDL-cholesterol, triacylglycerols, GOT, GPT, GGT and glucose values, as well as blood erythrocytes, haemoglobin, haematocrit and MCV levels, together with anthropometric parameters were determined at the beginning of the study (baseline levels) (a), after 1 month of alcoholic abstinence (b) and after 1 month of moderate beer consumption (c). Dietary intake was assessed twice by a 7-day dietary record. HDL-cholesterol, erythrocytes, haematocrit and MCV levels increased significantly (p < 0.05) after moderate beer consumption in women. In men, a decrease in HDL-cholesterol levels was observed after alcohol abstention. Haematocrit and MCV counts also increased significantly (p < 0.05) in men after moderate beer consumption. There were no dietary changes during the study. Conclusion: In healthy Spanish adults, the effects of moderate beer consumption during 1 month were associated with favourable changes on the blood lipid profile. ª 2007 Elsevier B.V. All rights reserved.
Introduction
* Corresponding author. Tel.: þ34 91 544 5607; fax: þ34 91 549 3627. E-mail address: [email protected] (J. Romeo).
Several epidemiological studies have reported an association between moderate alcohol consumption and lower risk of ischaemic heart disease and ischaemic stroke [1e5]. This relation remains controversial, as do the roles of beverage type and drinking pattern. For example, Mukamal et al. [6]
0939-4753/$ - see front matter ª 2007 Elsevier B.V. All rights reserved. doi:10.1016/j.numecd.2007.03.007
366 found this protective effect only for wine, in fact this rich polyphenol drink seems to be the most extensive beverage studied in this direction. Particularly, de Gaetano et al. [7] indicated a significant negative association of moderate wine consumption (150e300 ml daily) with the risk of major cardiovascular events. Another study confirmed that regular and moderate consumption of wine, red more than white; exert cardioprotective effects through beneficial changes in lipid profile [8]; Naissides et al. [9] has recently found that regular consumption of full-complement red wine reduces cardiovascular disease (CVD) risk by improving fasting lipid levels in hypercholesterolaemic post-menopausal women. Other health benefits of regular light-to-moderate alcohol consumption include lower risk for dementia and cognitive impairment [10,11]; decreased risk of diabetes and reduced risk of osteoporosis [12]. La Vecchia et al. [13] found also that moderate beer drinking was not associated with elevated colon or rectal cancer risk. Reviewing the literature, our research group has proposed, in accordance with other researchers and international organisations [14e17], and considering a risk/benefit relationship, that moderate alcohol consumption can be defined in terms of 10e12 g/day for women and 20e24 g/day for men [18,19], taking the particular female susceptibility into account [20e23]. This is also in accordance with the tolerable upper alcohol intake levels proposed by Burger et al. [24] for the German population. Apart from alcohol, other interesting components of beer to highlight are total carbohydrate and soluble fibre contents and minerals, trace elements and vitamins such as phosphorous, silicon, magnesium, potassium, niacin, riboflavin, piridoxin, folates and vitamin B12, as well as polyphenols [18,25e27]. Beer intake can provide plasma with significant protection from oxidative stress; and isohumulones, the bitter substances derived from hops, may prevent obesity, atherosclerosis and type 2 diabetes and could also regulate lipid metabolism [28]. To the best of our knowledge, human intervention studies with specific alcoholic beverages are scarce in the literature, probably due to the ethical questions of this type of studies. In order to assess the effects of moderate beer consumption on eating patterns, erythrocytes, hepatic enzymes and lipid profile we embarked on an intervention study in a sample of healthy Spanish adults classified as low-to-moderate alcoholic beverage consumers, also exploring gender differences due to female susceptibility [20e23].
Methods Subjects Sixty healthy adults (31 men and 29 women) aged 25e 50 years (mean age SD was 35.0 6.1 and 37.6 9.2 years for men and women, respectively) voluntarily agreed to participate in the study. All the women were pre-menopausal except one. They were recruited at the School of Pharmacy of the Complutense University of Madrid through advisements. Before blood sampling, each subject was evaluated and all anamnesis data were registered and reviewed to judge the subject’s medical status witch was confirmed in the baseline blood analysis. Only medically healthy subjects
J. Romeo et al. with normal range haematology and biochemical status were included in this study. Thus, subjects presenting chronic, metabolic, or acute diseases (e.g., dyslipoproteinaemia, asthma, food allergy) or taking any medications that are thought to have possible effects on lipid metabolism or immune function were excluded from the study. Subjects with any acute medical conditions such as minor infections (upper respiratory illness) were also excluded. From the 60 selected subjects, 57 completed the study: two women (one who could not be present for the last blood sampling and the other one who was prescribed to take corticoids during the experiment) and one man (who missed the second appointment) were excluded. For the purpose of the present study and to discriminate population variation, subjects included in the study were either non-drinkers or social drinkers (<30 g and <15 g ethanol per day, for males and females, respectively), and none of the participants had a personal or family history of alcoholism, were heavy smokers or were pregnant. Following presentation of the study protocol, written informed consent was obtained from volunteers included in the study according to the Declaration of Helsinki as last revised by the World Medical Council at the 52nd General Assembly of the World Medical Association in October 2000 in Edinburgh, UK. The study was approved by the Human Research Review Committee of the Universidad Complutense of Madrid, School of Pharmacy.
Study design An intervention design with a previous wash-out phase was used to analyse the effect of moderate beer intake. The study lasted 2 months. Volunteers were instructed to go on with their habitual lifestyle and dietary habits during this period, except for those related to alcoholic beverage consumption. During the first month, participants were instructed to abstain from any alcohol consumption. During the second month, subjects were asked to add to their habitual diet a daily moderate amount of alcohol according to the literature already mentioned [18,19,22,23]; that is, 330 ml (11 g) for women (one standard beer can) and 660 ml (22 g) for men (two standard beer cans). Beer (Pils style) cans were provided by the sponsor of the study and given to all volunteers. They were instructed to drink the beer with meals. Throughout the study, participants were asked to maintain their usual dietary habits and level of physical activity. Adherence was evaluated by two 7-day dietary records, by personal interviews or telephone calls twice a week. Blood samples were taken at the beginning of the study (a), after 1 month of alcoholic abstinence (b) and after 1 month of moderate beer consumption (c).
Measurements Blood glucose, lipid profile, hepatic function-related enzymes and red cell blood profile Blood samples were taken three times for each subject: at the beginning of the study (a), after 1 month of alcoholic abstinence (b) and after 1 month of moderate beer consumption (c). After an overnight fast (12-h fast), subjects came to our
Effects of moderate beer consumption
367
laboratory at the School of Pharmacy for blood sampling between 08:00 and 10:00 h. Blood samples were collected by puncture of the cubital vein. For biochemical analyses, the blood was collected in SST-Vacutainer (BD) and serum was separated by centrifugation at 3000 rpm for 15 min at 22e 24 C, divided into aliquots and frozen and stored at 80 C until withdrawal for analysis. Total cholesterol (mg/dL), HDL-cholesterol (mg/dL), triacylglycerol (mg/dL), GOT (U/ L), GPT (U/L), GGT (U/L), and glucose (g/dL) were analysed with a biochemical autoanalyser (Olympus model AU2700). All serum analysis was performed at the end of the study, in order to have the three samples from each subject analysed in the same run, to avoid systematic errors. Coefficients of variance (%) of lipid variables and hepatic enzymes were 2.2% for total cholesterol, 2.4% for HDL-cholesterol, 2.74% for triacylglycerols, 3.85% for GOT, 3.74% for GPT and 0.84% for GGT. VLDL-cholesterol and LDL-cholesterol were calculated from existing cholesterol, HDL-cholesterol and triacylglycerols values [32]. The LDL-cholesterol/HDL-cholesterol and total cholesterol/HDL-cholesterol ratios were also calculated. Red cell blood profile [erythrocytes, haemoglobin, haematocrit and mean corpuscular volume (MCV)] using whole blood collected into EDTA-K3E-Vacutainer (BD) was assessed using an automated analyser (Technicon H1, Bayer, Tarrytown, NY). Dietary intake Dietary intake was assessed twice by means of a 7-day dietary record, during the last week of the wash-out period (b) and during the last week of the beer-period (c). Prior to obtaining food records, subjects were instructed on portion size control, and the importance of recording complete data. Afterwards, each record was evaluated by a dietician for completeness and accuracy with participants being asked to provide additional information about any unclear food item. Dietary record data were analysed for energy and nutrient content using the Spanish Food Composition Tables [33]. The aim of the dietary study was mainly to analyse dietary patterns as well as energy and macronutrient intake, in order to ensure that the volunteers did not change their dietary habits during the intervention or, maybe, detect dietary patterns that could be affected by the introduced beer intake. Body composition At the beginning of the study (a), after 1 month of washout (b) and after 1 month of intervention (c), anthropometric
measurements were performed with subjects barefooted and wearing underwear. Body weight (kg) was measured using a standard balance beam (Seca), precision 100 g, range 0e150 kg. Body height (cm) was measured using a precision stadiometer (Seca), precision 0.2 cm, range 70e200 cm, included in the balance. The subjects stood straight in an upright position, the feet together, knees straight, heels, buttocks and back touched the back part of the stadiometer and the head was horizontal to the Frankfurt line. Circumferences (cm) were measured with a non-elastic tape, precision 0.1 cm, range 0e150 cm, the subject in a standing position. Waist circumference was measured applying the tape horizontally midway between the lowest rib margin and the iliac crest about the level of the umbilicus, at the end of gentle expiration. Hip circumference was measured at the point yielding the maximum circumference over the buttocks, with the tape held in a horizontal plane.
Statistical analysis All statistical analyses were performed using SPSS software (version 11.5, SPSS Inc., Chicago, IL). All data were normally distributed. One-factor repeated-measures analysis of variance using the general linear model was performed to identify differences between experimental treatments [at start (a), washout (b) and beer (c)]. Paired Bonferroni test for (a)e(b), (a)e(c) and (b)e(c) was performed for each gender. The correlation matrix between parameters at (a), (b) and (c) was studied. Student’s t-test was used to compare means on dietary data between abstinent and moderate beer consumption periods. Variables are shown as mean standard deviation (SD). The level of significance was set at p < 0.05.
Results Characteristics of the subjects at start As shown in Table 1, all subjects were normal weight at the start. Blood glucose, lipid profile, hepatic function-related enzymes and erythrocyte parameters were also within normal values at the beginning of the study (Tables 2 and 3).
Table 1 Anthropometric characteristics of the volunteers tested at baseline (a), after 1 month of alcohol abstinence (b) and after 1 month of moderate beer consumption (c) Women (n Z 24) Weight (kg) Body mass index (kg/m2) Waist circumference (cm) Hip circumference (cm) Waist-to-hip ratio
Men (n Z 30)
Baseline (a)
Abstinence (b)
Beer (c)
Baseline (a)
Abstinence (b)
Beer (c)
62.76 8.63 24.40 3.52 74.65 9.58 96.53 6.15 0.80 0.05
62.57 8.25 24.31 3.25 77.67 5.02 95.69 4.68 0.81 0.03
63.04 8.53 24.59 3.24 77.56 4.58 95.40 4.45 0.81 0.04
77.00 8.93 25.54 2.38 87.53 3.80 96.56 2.70 0.89 0.03
76.77 8.72 25.33 2.26 88.24 3.09 96.03 2.53 0.90 0.03
77.31 9.01 25.65 2.35 87.90 2.82 96.03 1.89 0.90 0.03
Values are mean SD. No significant differences between abstinence and beer consumption periods. Bonferroni paired test (p < 0.05).
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J. Romeo et al.
Table 2 Serum glucose, lipid profile and hepatic enzymes in women and men at baseline (a), after 1 month of alcohol abstinence (b) and after 1 month of moderate beer consumption (c) Women (n Z 27) Glucose (mg/dL) Total cholesterol (mg/dL) HDL-cholesterol (mg/dL) LDL-cholesterol (mg/dL) VLDL-cholesterol (mg/dL) Triacylglycerols (mg/dL) GOT (U/L) GPT (U/L) GGT (U/L)
Men (n Z 30)
Baseline (a)
Abstinence (b) Beer (c)
Baseline (a)
Abstinence (b) Beer (c)
88.07 9.73 190.44 31.57*,# 60.70 11.50* 114.70 31.71 15.00 5.66 75.11 28.07 15.55 4.58 7.59 4.57 14.22 9.20
90.44 8.08 186.11 30.2* 57.77 14.25* 113.07 26.29 15.26 4.54 76.37 22.98 15.51 4.07 8.77 4.61 13.85 7.34
97.54 16.07 209.40 31.38 44.20 6.68* 138.40 27.35 26.04 12.26 135.11 65.83 20.13 5.67 13.00 5.82* 22.93 14.98*,#
92.96 5.88 204.86 34.9 41.33 7.01# 138.56 33.37 25.26 10.68 132.27 59.98 20.73 5.13 15.00 7.17# 19.96 9.51*
90.96 12.72 196.18 34.04# 66.88 12.44# 114.22 29.97 15.07 5.31 74.96 26.72 16.25 3.54 9.70 5.48 14.88 7.44
92.96 7.77 211.20 29.67 46.50 7.92* 138.68 28.25 25.15 11.30 126.04 55.64 20.86 5.12 14.00 6.09*,# 21.63 9.34#
Values are mean SD. Different symbols show significant differences [Bonferroni paired test (p < 0.05) between: baseline levels (a), after 1 month of alcohol abstinence (b), and after 1 month of moderate beer consume (c)].
Clinical and laboratory measurements Total glucose and total cholesterol levels, HDL-cholesterol, LDL-cholesterol, VLDL-cholesterol, triacylglycerols, GOT, GPT, GGT, erythrocytes, haemoglobin, haematocrit and MCV are summarised in Tables 2 and 3. No changes were found in total glucose and total cholesterol after alcohol abstention (b) and after moderate beer consumption (c) in both women and men. Throughout the study triacylglycerol levels remained unchanged in both women and men. Total cholesterol and HDL-cholesterol levels increased significantly after moderate beer consumption in women (Table 2). In men, a significant decrease in HDL-cholesterol levels was observed after alcohol abstention. These values were recouped significantly to basal levels after moderate consumption of beer (Table 2). No changes in LDL-cholesterol and VLDL-cholesterol were found after moderate consumption of beer in both women and men. While total cholesterol/HDL-cholesterol ratio decreased in women and men (Fig. 1), the LDL-cholesterol/ HDL-cholesterol ratio only decreased significantly (p < 0.05) in females after 1 month of beer intake (Fig. 2). In regard of hepatic enzymes, serum GOT, GPT and GGT levels remained unchanged during both intervention periods (Table 2). In women, erythrocytes, haematocrit and MCV levels increased significantly after moderate beer
consumption compared to the abstinence period. (Table 3); in men, haematocrit and MCV levels also increased, while erythrocytes and haemoglobin values remained unchanged after moderate beer consumption.
Diet and volunteers’ characteristics Mean daily dietary intake (energy, proteins, carbohydrates, fat, cholesterol, dietary fibre and alcohol) and data for the two intervention periods (the last week of the washout and the last week of the moderate beer consumption phase) are shown in Table 4. No significant differences in mean daily dietary energy, macronutrients and fibre intakes were found except with alcohol intake. Weekly food intake (g) classified by groups for both periods are shown in Table 5. A few significant differences in food intake were observed between the two periods. During the moderate consumption of beer a significant reduction of sauces and seasoning intake was observed in both men and women. Women also showed a significant reduction in dairy product intake together with an increase in pre-cooked foods. On the other hand, no changes were found in body mass index (kg/m2) and in waist-to-hip ratio after moderate beer consumption in both men and women (Table 1).
Table 3 Haematology parameters in women and men, at baseline (a), after 1 month of alcohol abstinence (b) and after 1 month of moderate beer consumption (c) Women (n Z 27) Baseline (a) 12
Erythrocytes (10 /L) Haemoglobin (g/dL) Haematocrit (%) MCV (fL)
4.22 0.26* 13.07 1.08 38.13 3.19* 90.26 5.02*
Men (n Z 30) Abstinence (b) 4.26 0.25* 13.10 1.14 37.89 3.10* 88.83 5.07#
Beer (c)
Baseline (a) #
4.37 0.28 13.33 1.28 39.44 3.35# 90.26 5.19*
4.86 0.31* 14.87 0.82 43.35 2.48* 89.22 3.70*
Abstinence (b) #
4.93 0.37* 14.99 1.01 43.15 3.00* 87.54 3.39#
Beer (c) 4.99 0.33# 15.02 0.96 44.70 2.76# 89.62 3.64*
Values are mean SD. Different symbols show significant differences [Bonferroni paired test (p < 0.05) between: baseline levels (a), after 1 month of alcohol abstinence (b), and after 1 month of moderate beer consumption (c)].
Effects of moderate beer consumption
*
Men
#
369
Women
TOTAL CHOLESTEROL/HDL RATIO
* *#
5,5
# 5,0 4,5 4,0
* *
#
3,5 3,0 2,5
(a)
(b)
(c)
Figure 1 Total cholesterol/HDL-cholesterol ratio at baseline levels (a), after 1 month of alcohol abstinence (b) and after 1 month of moderate beer consumption (c), in both women and men. Different symbols show significant differences [Bonferroni paired test (p < 0.05) between: baseline levels (a), after 1 month of alcohol abstinence (b), and after 1 month of moderate beer consumption (c)].
Discussion The present study demonstrates the positive effect of moderate beer consumption on HDL-cholesterol, the effect being greater in women than in men. Interestingly, in both genders alcohol abstentions reduced HDL-cholesterol and beer consumption increased the values beyond the levels at the start. Our results confirm the data obtained in crosssectional studies [34e36] and in the intervention studies performed up-to-date [9,29,30,37e42] about the positive and significant effect of alcoholic beverages on HDL levels, and that non-drinkers have lower HDL levels. A large part of the beneficial effects of alcohol on cardiovascular morbidity and mortality has been ascribed to its potential to
*
4,0
Men
#
Women
LDL/HDL RATIO
3,5 3,0 2,5
*
* #
2,0 1,5 1,0
(a)
(b)
(c)
Figure 2 LDL-cholesterol/HDL-cholesterol ratio at baseline levels (a), after 1 month of alcohol abstinence (b) and after 1 month of moderate beer consumption (c), in both women and men. Different symbols show significant differences [Bonferroni paired test (p < 0.05) between: baseline levels (a), after 1 month of alcohol abstinence (b), and after 1 month of moderate beer consumption (c)].
increasing HDL-cholesterol levels [31,42e44]. Few studies have tried to analyse the specific influence of particular alcoholic beverages on HDL-cholesterol levels. However, Naissides et al. found an increased HDL-cholesterol in post-menopausal women after 6 weeks of moderate red wine consumption (400 ml/day), most of them have concluded that the effects are mostly independent of the kind of alcoholic beverage [34,37,45]. For example Baer et al. [42] measured the effect after 8 weeks of moderate alcohol consumption (15 g and 30 g) on CVD risk factors in post-menopausal women and found an improvement in lipid profiles. Regarding beer consumption, Hartung et al. [41] studied the effect of alcohol dose on plasma HDL-cholesterol after 3 weeks of alcohol abstinence and after consumption of one and three cans (340 mg) of beer per day in 49 healthy men. The authors found a decrease in HDLcholesterol after abstinence from alcohol and an increase after beer consumption. The same authors found in 1983 [39] that 1065 ml of beer per day produced a significant increase of HDL-cholesterol level in inactive men. The gender effect in the relationship between HDL-cholesterol and consumption of alcoholic beverages has been examined by Parker et al. [46] in 1516 individuals. Both beer and liquor were independently associated with increased HDL-cholesterol in the total group, in men and in women after covariates were controlled for. Wine was associated with a significant increase in HDL-cholesterol in women only. In the recent study published by Avellone et al. [30], drinking red wine for 4 weeks significantly increased HDL levels, but data were presented for the whole group so the gender effect was not considered. In our study, the most relevant gender effect can be seen on HDL-cholesterol levels after beer consumption. One of the differences between alcoholic beverages could be the effect on triacylglycerols. In the cross-sectional study performed by Freiberg et al. [47], alcohol consumption was significantly associated with lower odds ratios for the prevalence of elevated serum triacylglycerols, the association being more favourable in beer and wine drinkers. Sierksma et al. [38] found that serum triacylglycerols levels were not affected after 3 weeks of daily beer intake (alcohol intake equalled 40 and 30 g for men and women, respectively). Although this consumption doubled and trebled the alcohol amounts given in our study (22 g/day and 11 g/day for men and women, respectively), our results are consistent with these data, as triacylglycerol levels remained unchanged in both women and men after moderate beer consumption. With regard to the effect of moderate beer intake on the other blood lipid values, LDL-cholesterol and total cholesterol levels, our data are consistent with various data in the literature [30,45], and seem to be independent of type of alcoholic beverage. If cardiovascular risk is analysed by means of the two calculated indices, we can observe that both total cholesterol/HDL-cholesterol and LDL-cholesterol/HDL-cholesterol ratios decrease significantly (p < 0.05) after 1 month of beer intake. The same effect (p < 0.01) on the LDL-cholesterol/HDL-cholesterol ratio was observed by Avellone et al. [30] in healthy middle-aged Italian adults after 4 weeks of daily drinking of 250 ml of red wine. In our study, there were specific gender effects and only in females did the LDL-cholesterol/HDL-cholesterol ratio decrease.
370
J. Romeo et al.
Table 4 Mean daily dietary intake of energy, macronutrients, fibre and alcohol after 1 month of alcohol abstinence (b) and after 1 month of moderate beer consumption (c) Women (n Z 27) Energy (kcal) Proteins (g) Carbohydrates (g) Fat (g) Saturated (g) Monounsaturated (g) Polyunsaturated (g) Cholesterol (mg) Dietary fibre (g) Alcohol (g)
Men (n Z 30)
Abstinence (b)
Beer (c)
Abstinence (b)
Beer (c)
1777 410.4 79.32 14.4 212.9 62.61 71.24 19.29 24.24 6.81 27.52 8.00 10.32 3.23 307.1 107.1 14.73 4.1 0 0.01
1888 476.6 78.64 15.38 226.05 66.34 71.68 23.19 24.08 7.98 27.61 9.8 10.15 4.88 300.1 160.6 16.39 6.49 11.44 5.49þ
2251 762.5 103.08 33.35 278.9 112.7 87.99 32.5 29.35 12.65 32.22 11.89 12.82 5.87 364.1 130.1 20.25 11.78 0 0.01
2307 496.2 100.86 21.02 263.2 76.37 87.17 21.99 28.92 8.33 31.81 8.24 12.98 4.85 397.6 119.3 18.44 8.05 20.5 0.02þ
Values are mean SD. þ Significant differences between abstinence and beer consumption periods. Student’s t-test (p < 0.05).
Utility of gamma-glutamyl transpeptidase (GGT) and mean corpuscular volume (MCV) is well established in alcoholic liver disease and is an optimal biomarker of excessive drinking [48e50]. While GGT levels remained unchanged, MCV levels increased significantly (p < 0.05) in both women and men after beer intake when compared to the levels after the abstention period, but interestingly not when compared to baseline activity. Although no significant changes were observed in GGT levels, adherence to the study protocol can be corroborated with the trend to decrease after alcohol abstention and to increase after moderate beer consumption in both women and men. These data are consistent with those obtained by Sierskma et al. [38]. Furthermore, Sillanaukee et al. [51] showed that the consumption of 40 g of alcohol during 3 weeks did not increase liver enzyme activity. Regarding the rest of the haematological parameters and keeping in mind that alcohol abuse results in diverse patterns of haematological alterations [52e54], our results indicate that
moderate beer consumption has a positive effect on haematological parameters enlarging their values compared to baseline and abstinence. In women, indeed it cannot be excluded that the small shift in the phase of their menstrual cycle is not responsible for such a difference rather than the change in beer consumption. However, a tendency in weight gain has been observed after beer consumption in both women and men but no significant changes were observed in the anthropometric and body composition parameter determined in our study [55]. Bobak et al. [56] studied the relation between beer and obesity in a cross-sectional study and concluded that beer intake is unlikely to be associated with a largely increased body mass index (BMI). In any case, taking into account the limited number of subjects and limited duration of our study, further study is necessary to establish the relation between beer consumption and weight gain. The inclusion of beer in the diet did not influence the energy intake of our subjects. A single negative impact on
Table 5 Weekly food intake (g) classified by food groups after 1 month of alcohol abstinence (b) and after 1 month of moderate beer consumption (c) Women (n Z 27) Cereals (g) Dairy products (g) Eggs (g) Sugars (g) Oils (g) Vegetables (g) Pulses (g) Fruit (g) Meat (g) Fish (g) Sauces/seasonings (g) Pre-cooked (g) Appetisers (g)
Men (n Z 30)
Abstinence (b)
Beer (c)
Abstinence (b)
Beer (c)
1316 580.5 2632 1027 213.1 137.2 117.1 67.23 117.9 58.76 1524 658.1 105.3 66.21 1457 828.3 875.9 300.2 676.3 307.8 3.64 3.92 208.5 176.5 61.91 43.03
1339 624.7 2203 770.9þ 199.41 151.8 132.9 106.6 98.00 51.47 1352 626.1 146.3 138.7 1628 901.4 908.8 342.1 545.9 342.9 2.13 2.50þ 315.0 237.5þ 157.5 162.3
1672 1037 2715 1756 238.5 157.0 151.43 127.7 98.36 69.00 1446 736.4 231.0 219.0 1626 1089 1196 485.2 594.7 360.5 4.42 4.62 340.1 275.2 92.92 87.91
1530 661.4 2446 1027 272.0 129.7 149.5 111.3 93.80 58.76 1347 571.0 205.0 182.6 1387 1179 1329 645.8 528.2 390.8 1.89 2.16þ 344.2 244.3 91.00 64.64
Values are mean SD. þ Significant differences between abstinence and beer consumption periods. Student’s t-test (p < 0.05).
Effects of moderate beer consumption eating patterns can be observed in the reduction (p < 0.05) of dairy product intake in women. But a further analysis of the nutrient intake has indicated that this does not correlate with a significant reduction in calcium intake [57], even though this aspect should be considered in further studies. In the current study, there are a few limitations that warrant further discussion. The main limitation is that the study design does not include an adequate control group (alcohol-free beer or pure alcohol mixed with another nonalcoholic beverage) and the duration of the intervention. Some of the differences observed in the women could result from a small, but maybe important, shift in the phase of their menstrual cycle. The major mechanism appears to be the well known ability of alcohol to raise HDL-C concentrations, but further research is needed to determine which ingredients in beer are responsible for the documented health benefits in humans and to identify other lifestyle confounders and to analysis of other mechanisms of a specific effect of beer on CVD. In conclusion, in healthy Spanish adults the effects of moderate beer consumption during 1 month were associated with favourable changes on the blood lipid profile. It is important to highlight that the positive effect on lipid profile of moderate alcohol intake has been well documented in several studies in men and post-menopausal women, but the present study has studied the effects of beer intake in both sexes, confirming its positive effects also in women aged 25e50 years. A more complex study design (latin-square) or longitudinal studies with a longer intervention period are necessary to establish the more global effect of moderate alcohol intake on health.
Acknowledgements The study design, data collection and analysis, and reporting, were independent of the funding organisation (Centro de Informacio ´n Cerveza y Salud, Madrid, Spain). Consejo Superior de Investigaciones Cientı´ficas (CSIC) has no financial interest with any industry. None of the authors had any conflicts of interest. The authors also wish to thank Ms. Laura Barrios (CSIC) for her remarkable assistance with the statistical analysis of the data.
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372 [28] KondoBeer K. health: preventive effects of beer components on lifestyle-related diseases. Biofactors 2004;22:303e10. [29] Hansen AS, Marckmann P, Dragsted LO, Finne IL, Nielsen SE, Gronbaek M. Effect of red wine and red grape extract on blood lipids, haemostatic factors, and other risk factors for cardiovascular disease. Eur J Clin Nutr 2005;59:449e55. [30] Avellone G, Di Garbo V, Campisi D, De Simone R, Raneli G, Scaglione R, et al. Effects of moderate Sicilian red wine consumption on inflammatory biomarkers of atherosclerosis. Eur J Clin Nutr 2006;60:41e7. [31] Ruf JC. Alcohol, wine and platelet function. Biol Res 2004;37: 209e15. [32] Wallach J. Interpretacio ´n Clı´nica de las pruebas de laboratorio. 4th ed. Madrid; 2003. [33] Moreiras O, Carbajal A, Cabrera L y Cuadrado C. Tablas de composicio ´n de alimentos. Madrid: Ed. Pira ´mide; 2001. [34] Ruidavets JB, Ducimetiere P, Arveiler D, Amouyel P, Bingham A, Wagner A, et al. Types of alcoholic beverages and blood lipids in a French population. J Epidemiol Community Health 2002;56:24e8. [35] Schroder H, Ferrandez O, Jimenez J, Sanchez-Font A, Marrugat J. Cardiovascular risk profile and type of alcohol beverage consumption: a population-based study. Ann Nutr Metab 2005;49:100e6. [36] Brenner H, Rothenbacher D, Bode G, Marz W, Hoffmeister A, Koenig W. Coronary heart disease risk reduction in a predominantly beer-drinking population. Epidemiology 2001;12:390e5. [37] van der Gaag MS, van Tol A, Vermunt SH, Scheek LM, Schaafsma G, Hendriks HF. Alcohol consumption stimulates early steps in reverse cholesterol transport. J Lipid Res 2001;42:2077e83. [38] Sierksma A, van der Gaag MS, Kluft C, Hendriks HF. Moderate alcohol consumption reduces plasma C-reactive protein and fibrinogen levels; a randomized, diet-controlled intervention study. Eur J Clin Nutr 2002;56:1130e6. [39] Hartung GH, Foreyt JP, Mitchell RE, Mitchell JG, Reeves RS, Gotto Jr AM. Effect of alcohol intake on high-density lipoprotein cholesterol levels in runners and inactive men. JAMA 1983;249:747e50. [40] Masarei JR, Puddey IB, Rouse IL, Lynch WJ, Vandongen R, Beilin LJ. Effects of alcohol consumption on serum lipoprotein-lipid and apolipoprotein concentrations. Results from an intervention study in healthy subjects. Atherosclerosis 1986; 60:79e87. [41] Hartung GH, Foreyt JP, Reeves RS, Krock LP, Patsch W, Patsch JR, et al. Effect of alcohol dose on plasma lipoprotein subfractions and lipolytic enzyme activity in active and inactive men. Metabolism 1990;39:81e6. [42] Baer DJ, Judd JT, Clevidence BA, Muesing RA, Campbell WS, Brown ED, et al. Moderate alcohol consumption lowers risk factors for cardiovascular disease in postmenopausal women fed a controlled diet. Am J Clin Nutr 2002;75:593e9.
J. Romeo et al. [43] Gaziano JM, Buring JE, Breslow JL, Goldhaber SZ, Rosner B, VanDenburgh M, et al. Moderate alcohol intake, increased levels of high-density lipoprotein and its subfractions, and decreased risk of myocardial infarction. N Engl J Med 1993;329: 1829e934. [44] Schlienger JL. Alcohol and cardiovascular system: mechanisms of the protective effects. Pathol Biol 2001;49:764e8. [45] Djousse L, Arnett DK, Eckfeldt JH, Province MA, Singer MR, Ellison RC. Alcohol consumption and metabolic syndrome: does the type of beverage matter? Obes Res 2004;12:1375e85. [46] Parker DR, McPhillips JB, Derby CA, Gans KM, Lasater TM, Carleton RA. High-density-lipoprotein cholesterol and types of alcoholic beverages consumed among men and women. Am J Public Health 1996;86:1022e7. [47] Freiberg MS, Cabral HJ, Heeren TC, Vasan RS, Curtis Ellison R. Alcohol consumption and the prevalence of the Metabolic Syndrome in the US: a cross-sectional analysis of data from the Third National Health and Nutrition Examination Survey. Diabetes Care 2004;27:2954e9. [48] Helander A. Biological markers in alcoholism. J Neural Transm 2003;66:15e32. [49] Anttila P, Jarvi K, Latvala J, Romppanen J, Punnonen K, Niemela O. Biomarkers of alcohol consumption in patients classified according to the degree of liver disease severity. Scand J Clin Lab Invest 2005;65:141e51. [50] Baral N, Pokhrel S, Lamsal M, Yadav BN, Sah SP. Utility of gamma-glutamyl transpeptidase and mean corpuscular volume in alcoholic liver disease. Southeast Asian J Trop Med Publ Health 2005;36:1007e10. [51] Sillanaukee P, van der Gaag MS, Sierksma A, Hendriks HF, Strid N, Ponnio M, et al. Effect of type of alcoholic beverages on carbohydrate-deficient transferrin, sialic acid, and liver enzymes. Alcohol Clin Exp Res 2003;27:57e60. [52] Whitehead TP, Robinson D, Allaway SL, Hale AC. The effects of cigarette smoking and alcohol consumption on blood haemoglobin, erythrocytes and leucocytes: a dose related study on male subjects. Clin Lab Haematol 1995;17:131e8. [53] Ballard HS. The hematological complications of alcoholism. Alcohol Health Res World 1997;21:42e52. [54] Latvala J, Parkkila S, Niemela O. Excess alcohol consumption is common in patients with cytopenia: studies in blood and bone marrow cells. Alcohol Clin Exp Res 2004;28:619e24. [55] Romeo J, Gonza ´lez-Gross M, Wa ¨rnberg J, Dı´az LE, Marcos A. ¿Influye la cerveza en el aumento de peso? Efectos de un consumo moderado de cerveza sobre la composicio ´n corporal. Nutr Hosp 2007;22:223e8. [56] Bobak M, Skodova Z, MarmotBeer M. obesity: a cross-sectional study. Eur J Clin Nutr 2003;57:1250e3. [57] Romeo J, Dı´az LE, Gonza ´lez-Gross M, Wa ¨rnberg J, Marcos A. Contribucio ´n a la ingesta de macro y micro nutrientes que ejerce un consumo moderado de cerveza. Nutr Hosp 2006;2: 86e93.
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Effects of moderate beer consumption on blood lipid profile in healthy Spanish adults ´lez-Gross, Julia Wa ¨rnberg, Javier Romeo*, Marcela Gonza ´n Marcos Ligia E. Dı´az, Ascensio Grupo Inmunonutricio´n, Departamento de Metabolismo y Nutricio´n, Instituto del Frı´o, Consejo Superior de Investigaciones Cientı´ficas, C/Jose´ Antonio Novais, 10, 28040 Madrid, Spain Received 7 November 2006; received in revised form 26 March 2007; accepted 29 March 2007
KEYWORDS Moderate beer consumption; Blood lipid profile; Cholesterol; Healthy adults
Abstract Background and aims: To analyse the association of moderate beer consumption on the blood lipid profile in healthy Spanish adults. Methods and results: The study had an intervention longitudinal design in which each subject established their own control with a previous wash-out phase. After a 30-day alcohol abstinence period, 57 healthy volunteers were submitted to a daily moderate intake of beer for 30 days. Serum total cholesterol, HDL-cholesterol, triacylglycerols, GOT, GPT, GGT and glucose values, as well as blood erythrocytes, haemoglobin, haematocrit and MCV levels, together with anthropometric parameters were determined at the beginning of the study (baseline levels) (a), after 1 month of alcoholic abstinence (b) and after 1 month of moderate beer consumption (c). Dietary intake was assessed twice by a 7-day dietary record. HDL-cholesterol, erythrocytes, haematocrit and MCV levels increased significantly (p < 0.05) after moderate beer consumption in women. In men, a decrease in HDL-cholesterol levels was observed after alcohol abstention. Haematocrit and MCV counts also increased significantly (p < 0.05) in men after moderate beer consumption. There were no dietary changes during the study. Conclusion: In healthy Spanish adults, the effects of moderate beer consumption during 1 month were associated with favourable changes on the blood lipid profile. ª 2007 Elsevier B.V. All rights reserved.
Introduction
* Corresponding author. Tel.: þ34 91 544 5607; fax: þ34 91 549 3627. E-mail address: [email protected] (J. Romeo).
Several epidemiological studies have reported an association between moderate alcohol consumption and lower risk of ischaemic heart disease and ischaemic stroke [1e5]. This relation remains controversial, as do the roles of beverage type and drinking pattern. For example, Mukamal et al. [6]
0939-4753/$ - see front matter ª 2007 Elsevier B.V. All rights reserved. doi:10.1016/j.numecd.2007.03.007
366 found this protective effect only for wine, in fact this rich polyphenol drink seems to be the most extensive beverage studied in this direction. Particularly, de Gaetano et al. [7] indicated a significant negative association of moderate wine consumption (150e300 ml daily) with the risk of major cardiovascular events. Another study confirmed that regular and moderate consumption of wine, red more than white; exert cardioprotective effects through beneficial changes in lipid profile [8]; Naissides et al. [9] has recently found that regular consumption of full-complement red wine reduces cardiovascular disease (CVD) risk by improving fasting lipid levels in hypercholesterolaemic post-menopausal women. Other health benefits of regular light-to-moderate alcohol consumption include lower risk for dementia and cognitive impairment [10,11]; decreased risk of diabetes and reduced risk of osteoporosis [12]. La Vecchia et al. [13] found also that moderate beer drinking was not associated with elevated colon or rectal cancer risk. Reviewing the literature, our research group has proposed, in accordance with other researchers and international organisations [14e17], and considering a risk/benefit relationship, that moderate alcohol consumption can be defined in terms of 10e12 g/day for women and 20e24 g/day for men [18,19], taking the particular female susceptibility into account [20e23]. This is also in accordance with the tolerable upper alcohol intake levels proposed by Burger et al. [24] for the German population. Apart from alcohol, other interesting components of beer to highlight are total carbohydrate and soluble fibre contents and minerals, trace elements and vitamins such as phosphorous, silicon, magnesium, potassium, niacin, riboflavin, piridoxin, folates and vitamin B12, as well as polyphenols [18,25e27]. Beer intake can provide plasma with significant protection from oxidative stress; and isohumulones, the bitter substances derived from hops, may prevent obesity, atherosclerosis and type 2 diabetes and could also regulate lipid metabolism [28]. To the best of our knowledge, human intervention studies with specific alcoholic beverages are scarce in the literature, probably due to the ethical questions of this type of studies. In order to assess the effects of moderate beer consumption on eating patterns, erythrocytes, hepatic enzymes and lipid profile we embarked on an intervention study in a sample of healthy Spanish adults classified as low-to-moderate alcoholic beverage consumers, also exploring gender differences due to female susceptibility [20e23].
Methods Subjects Sixty healthy adults (31 men and 29 women) aged 25e 50 years (mean age SD was 35.0 6.1 and 37.6 9.2 years for men and women, respectively) voluntarily agreed to participate in the study. All the women were pre-menopausal except one. They were recruited at the School of Pharmacy of the Complutense University of Madrid through advisements. Before blood sampling, each subject was evaluated and all anamnesis data were registered and reviewed to judge the subject’s medical status witch was confirmed in the baseline blood analysis. Only medically healthy subjects
J. Romeo et al. with normal range haematology and biochemical status were included in this study. Thus, subjects presenting chronic, metabolic, or acute diseases (e.g., dyslipoproteinaemia, asthma, food allergy) or taking any medications that are thought to have possible effects on lipid metabolism or immune function were excluded from the study. Subjects with any acute medical conditions such as minor infections (upper respiratory illness) were also excluded. From the 60 selected subjects, 57 completed the study: two women (one who could not be present for the last blood sampling and the other one who was prescribed to take corticoids during the experiment) and one man (who missed the second appointment) were excluded. For the purpose of the present study and to discriminate population variation, subjects included in the study were either non-drinkers or social drinkers (<30 g and <15 g ethanol per day, for males and females, respectively), and none of the participants had a personal or family history of alcoholism, were heavy smokers or were pregnant. Following presentation of the study protocol, written informed consent was obtained from volunteers included in the study according to the Declaration of Helsinki as last revised by the World Medical Council at the 52nd General Assembly of the World Medical Association in October 2000 in Edinburgh, UK. The study was approved by the Human Research Review Committee of the Universidad Complutense of Madrid, School of Pharmacy.
Study design An intervention design with a previous wash-out phase was used to analyse the effect of moderate beer intake. The study lasted 2 months. Volunteers were instructed to go on with their habitual lifestyle and dietary habits during this period, except for those related to alcoholic beverage consumption. During the first month, participants were instructed to abstain from any alcohol consumption. During the second month, subjects were asked to add to their habitual diet a daily moderate amount of alcohol according to the literature already mentioned [18,19,22,23]; that is, 330 ml (11 g) for women (one standard beer can) and 660 ml (22 g) for men (two standard beer cans). Beer (Pils style) cans were provided by the sponsor of the study and given to all volunteers. They were instructed to drink the beer with meals. Throughout the study, participants were asked to maintain their usual dietary habits and level of physical activity. Adherence was evaluated by two 7-day dietary records, by personal interviews or telephone calls twice a week. Blood samples were taken at the beginning of the study (a), after 1 month of alcoholic abstinence (b) and after 1 month of moderate beer consumption (c).
Measurements Blood glucose, lipid profile, hepatic function-related enzymes and red cell blood profile Blood samples were taken three times for each subject: at the beginning of the study (a), after 1 month of alcoholic abstinence (b) and after 1 month of moderate beer consumption (c). After an overnight fast (12-h fast), subjects came to our
Effects of moderate beer consumption
367
laboratory at the School of Pharmacy for blood sampling between 08:00 and 10:00 h. Blood samples were collected by puncture of the cubital vein. For biochemical analyses, the blood was collected in SST-Vacutainer (BD) and serum was separated by centrifugation at 3000 rpm for 15 min at 22e 24 C, divided into aliquots and frozen and stored at 80 C until withdrawal for analysis. Total cholesterol (mg/dL), HDL-cholesterol (mg/dL), triacylglycerol (mg/dL), GOT (U/ L), GPT (U/L), GGT (U/L), and glucose (g/dL) were analysed with a biochemical autoanalyser (Olympus model AU2700). All serum analysis was performed at the end of the study, in order to have the three samples from each subject analysed in the same run, to avoid systematic errors. Coefficients of variance (%) of lipid variables and hepatic enzymes were 2.2% for total cholesterol, 2.4% for HDL-cholesterol, 2.74% for triacylglycerols, 3.85% for GOT, 3.74% for GPT and 0.84% for GGT. VLDL-cholesterol and LDL-cholesterol were calculated from existing cholesterol, HDL-cholesterol and triacylglycerols values [32]. The LDL-cholesterol/HDL-cholesterol and total cholesterol/HDL-cholesterol ratios were also calculated. Red cell blood profile [erythrocytes, haemoglobin, haematocrit and mean corpuscular volume (MCV)] using whole blood collected into EDTA-K3E-Vacutainer (BD) was assessed using an automated analyser (Technicon H1, Bayer, Tarrytown, NY). Dietary intake Dietary intake was assessed twice by means of a 7-day dietary record, during the last week of the wash-out period (b) and during the last week of the beer-period (c). Prior to obtaining food records, subjects were instructed on portion size control, and the importance of recording complete data. Afterwards, each record was evaluated by a dietician for completeness and accuracy with participants being asked to provide additional information about any unclear food item. Dietary record data were analysed for energy and nutrient content using the Spanish Food Composition Tables [33]. The aim of the dietary study was mainly to analyse dietary patterns as well as energy and macronutrient intake, in order to ensure that the volunteers did not change their dietary habits during the intervention or, maybe, detect dietary patterns that could be affected by the introduced beer intake. Body composition At the beginning of the study (a), after 1 month of washout (b) and after 1 month of intervention (c), anthropometric
measurements were performed with subjects barefooted and wearing underwear. Body weight (kg) was measured using a standard balance beam (Seca), precision 100 g, range 0e150 kg. Body height (cm) was measured using a precision stadiometer (Seca), precision 0.2 cm, range 70e200 cm, included in the balance. The subjects stood straight in an upright position, the feet together, knees straight, heels, buttocks and back touched the back part of the stadiometer and the head was horizontal to the Frankfurt line. Circumferences (cm) were measured with a non-elastic tape, precision 0.1 cm, range 0e150 cm, the subject in a standing position. Waist circumference was measured applying the tape horizontally midway between the lowest rib margin and the iliac crest about the level of the umbilicus, at the end of gentle expiration. Hip circumference was measured at the point yielding the maximum circumference over the buttocks, with the tape held in a horizontal plane.
Statistical analysis All statistical analyses were performed using SPSS software (version 11.5, SPSS Inc., Chicago, IL). All data were normally distributed. One-factor repeated-measures analysis of variance using the general linear model was performed to identify differences between experimental treatments [at start (a), washout (b) and beer (c)]. Paired Bonferroni test for (a)e(b), (a)e(c) and (b)e(c) was performed for each gender. The correlation matrix between parameters at (a), (b) and (c) was studied. Student’s t-test was used to compare means on dietary data between abstinent and moderate beer consumption periods. Variables are shown as mean standard deviation (SD). The level of significance was set at p < 0.05.
Results Characteristics of the subjects at start As shown in Table 1, all subjects were normal weight at the start. Blood glucose, lipid profile, hepatic function-related enzymes and erythrocyte parameters were also within normal values at the beginning of the study (Tables 2 and 3).
Table 1 Anthropometric characteristics of the volunteers tested at baseline (a), after 1 month of alcohol abstinence (b) and after 1 month of moderate beer consumption (c) Women (n Z 24) Weight (kg) Body mass index (kg/m2) Waist circumference (cm) Hip circumference (cm) Waist-to-hip ratio
Men (n Z 30)
Baseline (a)
Abstinence (b)
Beer (c)
Baseline (a)
Abstinence (b)
Beer (c)
62.76 8.63 24.40 3.52 74.65 9.58 96.53 6.15 0.80 0.05
62.57 8.25 24.31 3.25 77.67 5.02 95.69 4.68 0.81 0.03
63.04 8.53 24.59 3.24 77.56 4.58 95.40 4.45 0.81 0.04
77.00 8.93 25.54 2.38 87.53 3.80 96.56 2.70 0.89 0.03
76.77 8.72 25.33 2.26 88.24 3.09 96.03 2.53 0.90 0.03
77.31 9.01 25.65 2.35 87.90 2.82 96.03 1.89 0.90 0.03
Values are mean SD. No significant differences between abstinence and beer consumption periods. Bonferroni paired test (p < 0.05).
368
J. Romeo et al.
Table 2 Serum glucose, lipid profile and hepatic enzymes in women and men at baseline (a), after 1 month of alcohol abstinence (b) and after 1 month of moderate beer consumption (c) Women (n Z 27) Glucose (mg/dL) Total cholesterol (mg/dL) HDL-cholesterol (mg/dL) LDL-cholesterol (mg/dL) VLDL-cholesterol (mg/dL) Triacylglycerols (mg/dL) GOT (U/L) GPT (U/L) GGT (U/L)
Men (n Z 30)
Baseline (a)
Abstinence (b) Beer (c)
Baseline (a)
Abstinence (b) Beer (c)
88.07 9.73 190.44 31.57*,# 60.70 11.50* 114.70 31.71 15.00 5.66 75.11 28.07 15.55 4.58 7.59 4.57 14.22 9.20
90.44 8.08 186.11 30.2* 57.77 14.25* 113.07 26.29 15.26 4.54 76.37 22.98 15.51 4.07 8.77 4.61 13.85 7.34
97.54 16.07 209.40 31.38 44.20 6.68* 138.40 27.35 26.04 12.26 135.11 65.83 20.13 5.67 13.00 5.82* 22.93 14.98*,#
92.96 5.88 204.86 34.9 41.33 7.01# 138.56 33.37 25.26 10.68 132.27 59.98 20.73 5.13 15.00 7.17# 19.96 9.51*
90.96 12.72 196.18 34.04# 66.88 12.44# 114.22 29.97 15.07 5.31 74.96 26.72 16.25 3.54 9.70 5.48 14.88 7.44
92.96 7.77 211.20 29.67 46.50 7.92* 138.68 28.25 25.15 11.30 126.04 55.64 20.86 5.12 14.00 6.09*,# 21.63 9.34#
Values are mean SD. Different symbols show significant differences [Bonferroni paired test (p < 0.05) between: baseline levels (a), after 1 month of alcohol abstinence (b), and after 1 month of moderate beer consume (c)].
Clinical and laboratory measurements Total glucose and total cholesterol levels, HDL-cholesterol, LDL-cholesterol, VLDL-cholesterol, triacylglycerols, GOT, GPT, GGT, erythrocytes, haemoglobin, haematocrit and MCV are summarised in Tables 2 and 3. No changes were found in total glucose and total cholesterol after alcohol abstention (b) and after moderate beer consumption (c) in both women and men. Throughout the study triacylglycerol levels remained unchanged in both women and men. Total cholesterol and HDL-cholesterol levels increased significantly after moderate beer consumption in women (Table 2). In men, a significant decrease in HDL-cholesterol levels was observed after alcohol abstention. These values were recouped significantly to basal levels after moderate consumption of beer (Table 2). No changes in LDL-cholesterol and VLDL-cholesterol were found after moderate consumption of beer in both women and men. While total cholesterol/HDL-cholesterol ratio decreased in women and men (Fig. 1), the LDL-cholesterol/ HDL-cholesterol ratio only decreased significantly (p < 0.05) in females after 1 month of beer intake (Fig. 2). In regard of hepatic enzymes, serum GOT, GPT and GGT levels remained unchanged during both intervention periods (Table 2). In women, erythrocytes, haematocrit and MCV levels increased significantly after moderate beer
consumption compared to the abstinence period. (Table 3); in men, haematocrit and MCV levels also increased, while erythrocytes and haemoglobin values remained unchanged after moderate beer consumption.
Diet and volunteers’ characteristics Mean daily dietary intake (energy, proteins, carbohydrates, fat, cholesterol, dietary fibre and alcohol) and data for the two intervention periods (the last week of the washout and the last week of the moderate beer consumption phase) are shown in Table 4. No significant differences in mean daily dietary energy, macronutrients and fibre intakes were found except with alcohol intake. Weekly food intake (g) classified by groups for both periods are shown in Table 5. A few significant differences in food intake were observed between the two periods. During the moderate consumption of beer a significant reduction of sauces and seasoning intake was observed in both men and women. Women also showed a significant reduction in dairy product intake together with an increase in pre-cooked foods. On the other hand, no changes were found in body mass index (kg/m2) and in waist-to-hip ratio after moderate beer consumption in both men and women (Table 1).
Table 3 Haematology parameters in women and men, at baseline (a), after 1 month of alcohol abstinence (b) and after 1 month of moderate beer consumption (c) Women (n Z 27) Baseline (a) 12
Erythrocytes (10 /L) Haemoglobin (g/dL) Haematocrit (%) MCV (fL)
4.22 0.26* 13.07 1.08 38.13 3.19* 90.26 5.02*
Men (n Z 30) Abstinence (b) 4.26 0.25* 13.10 1.14 37.89 3.10* 88.83 5.07#
Beer (c)
Baseline (a) #
4.37 0.28 13.33 1.28 39.44 3.35# 90.26 5.19*
4.86 0.31* 14.87 0.82 43.35 2.48* 89.22 3.70*
Abstinence (b) #
4.93 0.37* 14.99 1.01 43.15 3.00* 87.54 3.39#
Beer (c) 4.99 0.33# 15.02 0.96 44.70 2.76# 89.62 3.64*
Values are mean SD. Different symbols show significant differences [Bonferroni paired test (p < 0.05) between: baseline levels (a), after 1 month of alcohol abstinence (b), and after 1 month of moderate beer consumption (c)].
Effects of moderate beer consumption
*
Men
#
369
Women
TOTAL CHOLESTEROL/HDL RATIO
* *#
5,5
# 5,0 4,5 4,0
* *
#
3,5 3,0 2,5
(a)
(b)
(c)
Figure 1 Total cholesterol/HDL-cholesterol ratio at baseline levels (a), after 1 month of alcohol abstinence (b) and after 1 month of moderate beer consumption (c), in both women and men. Different symbols show significant differences [Bonferroni paired test (p < 0.05) between: baseline levels (a), after 1 month of alcohol abstinence (b), and after 1 month of moderate beer consumption (c)].
Discussion The present study demonstrates the positive effect of moderate beer consumption on HDL-cholesterol, the effect being greater in women than in men. Interestingly, in both genders alcohol abstentions reduced HDL-cholesterol and beer consumption increased the values beyond the levels at the start. Our results confirm the data obtained in crosssectional studies [34e36] and in the intervention studies performed up-to-date [9,29,30,37e42] about the positive and significant effect of alcoholic beverages on HDL levels, and that non-drinkers have lower HDL levels. A large part of the beneficial effects of alcohol on cardiovascular morbidity and mortality has been ascribed to its potential to
*
4,0
Men
#
Women
LDL/HDL RATIO
3,5 3,0 2,5
*
* #
2,0 1,5 1,0
(a)
(b)
(c)
Figure 2 LDL-cholesterol/HDL-cholesterol ratio at baseline levels (a), after 1 month of alcohol abstinence (b) and after 1 month of moderate beer consumption (c), in both women and men. Different symbols show significant differences [Bonferroni paired test (p < 0.05) between: baseline levels (a), after 1 month of alcohol abstinence (b), and after 1 month of moderate beer consumption (c)].
increasing HDL-cholesterol levels [31,42e44]. Few studies have tried to analyse the specific influence of particular alcoholic beverages on HDL-cholesterol levels. However, Naissides et al. found an increased HDL-cholesterol in post-menopausal women after 6 weeks of moderate red wine consumption (400 ml/day), most of them have concluded that the effects are mostly independent of the kind of alcoholic beverage [34,37,45]. For example Baer et al. [42] measured the effect after 8 weeks of moderate alcohol consumption (15 g and 30 g) on CVD risk factors in post-menopausal women and found an improvement in lipid profiles. Regarding beer consumption, Hartung et al. [41] studied the effect of alcohol dose on plasma HDL-cholesterol after 3 weeks of alcohol abstinence and after consumption of one and three cans (340 mg) of beer per day in 49 healthy men. The authors found a decrease in HDLcholesterol after abstinence from alcohol and an increase after beer consumption. The same authors found in 1983 [39] that 1065 ml of beer per day produced a significant increase of HDL-cholesterol level in inactive men. The gender effect in the relationship between HDL-cholesterol and consumption of alcoholic beverages has been examined by Parker et al. [46] in 1516 individuals. Both beer and liquor were independently associated with increased HDL-cholesterol in the total group, in men and in women after covariates were controlled for. Wine was associated with a significant increase in HDL-cholesterol in women only. In the recent study published by Avellone et al. [30], drinking red wine for 4 weeks significantly increased HDL levels, but data were presented for the whole group so the gender effect was not considered. In our study, the most relevant gender effect can be seen on HDL-cholesterol levels after beer consumption. One of the differences between alcoholic beverages could be the effect on triacylglycerols. In the cross-sectional study performed by Freiberg et al. [47], alcohol consumption was significantly associated with lower odds ratios for the prevalence of elevated serum triacylglycerols, the association being more favourable in beer and wine drinkers. Sierksma et al. [38] found that serum triacylglycerols levels were not affected after 3 weeks of daily beer intake (alcohol intake equalled 40 and 30 g for men and women, respectively). Although this consumption doubled and trebled the alcohol amounts given in our study (22 g/day and 11 g/day for men and women, respectively), our results are consistent with these data, as triacylglycerol levels remained unchanged in both women and men after moderate beer consumption. With regard to the effect of moderate beer intake on the other blood lipid values, LDL-cholesterol and total cholesterol levels, our data are consistent with various data in the literature [30,45], and seem to be independent of type of alcoholic beverage. If cardiovascular risk is analysed by means of the two calculated indices, we can observe that both total cholesterol/HDL-cholesterol and LDL-cholesterol/HDL-cholesterol ratios decrease significantly (p < 0.05) after 1 month of beer intake. The same effect (p < 0.01) on the LDL-cholesterol/HDL-cholesterol ratio was observed by Avellone et al. [30] in healthy middle-aged Italian adults after 4 weeks of daily drinking of 250 ml of red wine. In our study, there were specific gender effects and only in females did the LDL-cholesterol/HDL-cholesterol ratio decrease.
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Table 4 Mean daily dietary intake of energy, macronutrients, fibre and alcohol after 1 month of alcohol abstinence (b) and after 1 month of moderate beer consumption (c) Women (n Z 27) Energy (kcal) Proteins (g) Carbohydrates (g) Fat (g) Saturated (g) Monounsaturated (g) Polyunsaturated (g) Cholesterol (mg) Dietary fibre (g) Alcohol (g)
Men (n Z 30)
Abstinence (b)
Beer (c)
Abstinence (b)
Beer (c)
1777 410.4 79.32 14.4 212.9 62.61 71.24 19.29 24.24 6.81 27.52 8.00 10.32 3.23 307.1 107.1 14.73 4.1 0 0.01
1888 476.6 78.64 15.38 226.05 66.34 71.68 23.19 24.08 7.98 27.61 9.8 10.15 4.88 300.1 160.6 16.39 6.49 11.44 5.49þ
2251 762.5 103.08 33.35 278.9 112.7 87.99 32.5 29.35 12.65 32.22 11.89 12.82 5.87 364.1 130.1 20.25 11.78 0 0.01
2307 496.2 100.86 21.02 263.2 76.37 87.17 21.99 28.92 8.33 31.81 8.24 12.98 4.85 397.6 119.3 18.44 8.05 20.5 0.02þ
Values are mean SD. þ Significant differences between abstinence and beer consumption periods. Student’s t-test (p < 0.05).
Utility of gamma-glutamyl transpeptidase (GGT) and mean corpuscular volume (MCV) is well established in alcoholic liver disease and is an optimal biomarker of excessive drinking [48e50]. While GGT levels remained unchanged, MCV levels increased significantly (p < 0.05) in both women and men after beer intake when compared to the levels after the abstention period, but interestingly not when compared to baseline activity. Although no significant changes were observed in GGT levels, adherence to the study protocol can be corroborated with the trend to decrease after alcohol abstention and to increase after moderate beer consumption in both women and men. These data are consistent with those obtained by Sierskma et al. [38]. Furthermore, Sillanaukee et al. [51] showed that the consumption of 40 g of alcohol during 3 weeks did not increase liver enzyme activity. Regarding the rest of the haematological parameters and keeping in mind that alcohol abuse results in diverse patterns of haematological alterations [52e54], our results indicate that
moderate beer consumption has a positive effect on haematological parameters enlarging their values compared to baseline and abstinence. In women, indeed it cannot be excluded that the small shift in the phase of their menstrual cycle is not responsible for such a difference rather than the change in beer consumption. However, a tendency in weight gain has been observed after beer consumption in both women and men but no significant changes were observed in the anthropometric and body composition parameter determined in our study [55]. Bobak et al. [56] studied the relation between beer and obesity in a cross-sectional study and concluded that beer intake is unlikely to be associated with a largely increased body mass index (BMI). In any case, taking into account the limited number of subjects and limited duration of our study, further study is necessary to establish the relation between beer consumption and weight gain. The inclusion of beer in the diet did not influence the energy intake of our subjects. A single negative impact on
Table 5 Weekly food intake (g) classified by food groups after 1 month of alcohol abstinence (b) and after 1 month of moderate beer consumption (c) Women (n Z 27) Cereals (g) Dairy products (g) Eggs (g) Sugars (g) Oils (g) Vegetables (g) Pulses (g) Fruit (g) Meat (g) Fish (g) Sauces/seasonings (g) Pre-cooked (g) Appetisers (g)
Men (n Z 30)
Abstinence (b)
Beer (c)
Abstinence (b)
Beer (c)
1316 580.5 2632 1027 213.1 137.2 117.1 67.23 117.9 58.76 1524 658.1 105.3 66.21 1457 828.3 875.9 300.2 676.3 307.8 3.64 3.92 208.5 176.5 61.91 43.03
1339 624.7 2203 770.9þ 199.41 151.8 132.9 106.6 98.00 51.47 1352 626.1 146.3 138.7 1628 901.4 908.8 342.1 545.9 342.9 2.13 2.50þ 315.0 237.5þ 157.5 162.3
1672 1037 2715 1756 238.5 157.0 151.43 127.7 98.36 69.00 1446 736.4 231.0 219.0 1626 1089 1196 485.2 594.7 360.5 4.42 4.62 340.1 275.2 92.92 87.91
1530 661.4 2446 1027 272.0 129.7 149.5 111.3 93.80 58.76 1347 571.0 205.0 182.6 1387 1179 1329 645.8 528.2 390.8 1.89 2.16þ 344.2 244.3 91.00 64.64
Values are mean SD. þ Significant differences between abstinence and beer consumption periods. Student’s t-test (p < 0.05).
Effects of moderate beer consumption eating patterns can be observed in the reduction (p < 0.05) of dairy product intake in women. But a further analysis of the nutrient intake has indicated that this does not correlate with a significant reduction in calcium intake [57], even though this aspect should be considered in further studies. In the current study, there are a few limitations that warrant further discussion. The main limitation is that the study design does not include an adequate control group (alcohol-free beer or pure alcohol mixed with another nonalcoholic beverage) and the duration of the intervention. Some of the differences observed in the women could result from a small, but maybe important, shift in the phase of their menstrual cycle. The major mechanism appears to be the well known ability of alcohol to raise HDL-C concentrations, but further research is needed to determine which ingredients in beer are responsible for the documented health benefits in humans and to identify other lifestyle confounders and to analysis of other mechanisms of a specific effect of beer on CVD. In conclusion, in healthy Spanish adults the effects of moderate beer consumption during 1 month were associated with favourable changes on the blood lipid profile. It is important to highlight that the positive effect on lipid profile of moderate alcohol intake has been well documented in several studies in men and post-menopausal women, but the present study has studied the effects of beer intake in both sexes, confirming its positive effects also in women aged 25e50 years. A more complex study design (latin-square) or longitudinal studies with a longer intervention period are necessary to establish the more global effect of moderate alcohol intake on health.
Acknowledgements The study design, data collection and analysis, and reporting, were independent of the funding organisation (Centro de Informacio ´n Cerveza y Salud, Madrid, Spain). Consejo Superior de Investigaciones Cientı´ficas (CSIC) has no financial interest with any industry. None of the authors had any conflicts of interest. The authors also wish to thank Ms. Laura Barrios (CSIC) for her remarkable assistance with the statistical analysis of the data.
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