Adrian Baranchuk, MD, FACC, FRCPC, FCCS, Sohaib Haseeb, BSc and Bryce Alexander, BSc*
Most people enjoy wine as a social drink, taking pleasure in its flavours during recreational and personal occasions.1 It is a fermented beverage enjoyed for its diverse flavours. In 2016, the global wine consumption was 241 million hectoliters, with the United States being the largest global consumer, followed by France and Italy, and Canada among the top-15 countries worldwide.2 Despite its wide accessibility, excessive consumption and chronic misuse are risk factors that increase the global disease burden.3 Wine contains >500 compounds, composed of ethanol, water, sugars and carbohydrates, minerals, organic acids, and polyphenols, among others. The detailed chemical composition of wine can be viewed in Figure 1
Serious health concerns are associated with wine and alcohol if taken in excess or binged upon – including, but not limited to, sudden cardiac death, liver cirrhosis, alcoholic cardiomyopathies, and cardiac rhythm disorders, most importantly atrial fibrillation.4 People, including healthcare professionals, have varying positions regarding alcoholic intake and its benefit to cardiovascular health. There is mounting evidence of an apparent cardioprotective potential conferred by wine, especially red wine, but this mostly epidemiological observation has been heavily scrutinized since the 1980s by physicians and scientists alike, pointing to the inconsistencies and confounds associated with this study design.5 Recommendations for diet, exercise, and smoking are clear to our healthcare practitioners; however, recommendations for alcohol consumption are less obvious, publicly misunderstood, and highly variable between literature.4 In light of this, let’s consider the scientific evidence regarding the risks and benefits of wine, relevant metrics of calculation, and recommendations from various scientific institutions, to provide a just account to healthcare professionals and alcohol drinkers.
Wine became a drink of scientific intrigue in the late 20th century after large, prospective, cross-cultural studies6 reported a negative correlation for ischemic heart disease (IHD) with a light-to-moderate consumption of alcoholic beverages, especially wine.7 This phenomenon soon became known as the French Paradox, a term coined by epidemiologists Serge Renaud and Michel de Lorgeril who observed a relatively low rate of IHD mortality in France despite a consumption of a diet rich in cholesterol and saturated fats.8 This started extensive research into wine to explore its potential as a cardioprotective agent. A large body of epidemiological and experimental literature ensued in the following decades, trying to examine this paradoxical situation and comparing wine to other alcoholic beverages. Ecological, case-controlled, and cohort studies found inconsistent evidence, some reporting wine’s superiority in reducing IHD-associated mortality,9 with others finding inverse associations with a moderate controlled intake for all three beverages.10 As there are methodological discrepancies within studies and no direct comparison trials have been conducted, one should be cautious when interpreting this evidence as causal in nature. Lifestyle factors including diet and exercise should be considered in addition to drinking patterns to improve cardiovascular disease risk.
Benefits of wine: Macro- and micro-level analysis
Wine is obtained through grape must fermentation and possesses multi-ring structured compounds known as polyphenols.11 The water and ethanol components of wine dominate the other constituents, namely polyphenols (Figure 2), however ethanol and polyphenols are considered the bioactive components of wine in cardiovascular health, found to impart antioxidant and anti-inflammatory properties to wine in in-vivo and population-based studies.12–14
Polyphenols from red wine can be divided into two groups: flavonoids and non-flavonoids. Flavonoids are plant-based compounds, naturally present in grapes and wine, and have been found to inhibit low-density lipoprotein (LDL)-oxidation, prevent endothelial dysfunction,15 and consequently reduce atherosclerosis development.16 Non-flavonoids are the more popular of the two classes, with resveratrol being the most publicly well-known, garnering media attention as a supplement.17 It has been subjected to many preclinical and clinical investigations and has been reported to be an important contributor in the French paradox. However, evidence has been inconsistent across basic-science and population-based studies, but it continues to be an active topic of investigation in the media.1,18 On a macro level, epidemiological and experimental literature finds a light-to-moderate intake of wine and alcohol to be inversely associated with IHD, blood pressure, oxidative stress, and insulin bioavailability (Figure 3).1 A controlled and sustained consumption is reported to improve high-density-lipoproteins19 and nitric oxide bioavailability, decrease low-density-lipoprotein oxidation,14 and reduction of C-reactive proteins to decrease inflammation.20
Measures of consumption: Standard drink
A standard drink is an often publicly misunderstood metric, widely used when assessing alcoholic intake. It was first introduced to allow drinkers to calculate their own consumption and evaluate if they were within the safe limits. One standard drink always corresponds to the same amount of pure ethanol, regardless of the type of drink being consumed.21 To the general public, standard drinks are represented in amounts of beers, wine, or spirits as mathematical numbers are hard to comprehend. However, it is quite apparent from the literature that the definition of “1 standard drink” is highly variable, and discrepant between countries.22
According to the World Health Organization (WHO) manual for Hazardous and Harmful Drinking, 1 standard drink equals 10 grams of pure ethanol.23 In an effort to prevent excessive and binge-drinking, these guidelines are often publicized as part of educational campaigns, although there is a lack of evidence of their effectiveness;24 however it can be argued that the confusing and variable nature of reporting guidelines could be a reason they go undervalued. The WHO manual has translated one standard drink into common conventional drink sizes for ease of understanding for healthcare professionals (Table 1).1 These values vary between vendors but are within commonly observed ranges, therefore proving valuable for healthcare professionals and general consumers alike.
Type of Beverage
|Standard Drink Equivalent||Quantitative Metric|
1 glass of wine; 1 small glass of sherry
140 mL (12% strength); 90 mL (18% strength)
1 can of beer
330 mL (5% strength)
1 shot of whisky, gin, vodka; 1 small
40 mL (40% strength); 70 mL (25% strength)
Table 1. The World Health Organization’s equivalents for one standard drink expressed in terms of commonly consumed alcoholic beverages. Reproduced from Haseeb et al1 with permission from authors.
Drinking guidelines: What do the cardiovascular societies say?
Various societies have introduced drinking guidelines to promote a safe drinking culture. The WHO recommendation is to consume no more than 2 std./day with at least 2 days of abstinence per week.23 The American Heart Association recommends alcohol in moderate amounts to drinkers and cautions against alcohol consumption to non-drinkers. Guidelines are defined as ≤ 1-2 drinks/day for males, and ≤ 1 drink/day for females, with 1 drink equal to 12 ounces (oz.) of beer, 4 oz. of wine, 1.5 oz. of 80-proof spirits.25 A recent cross-sectional study by Buykx et al. reports that drinking guidelines are not well-known to general consumers despite the guidelines being in place for almost two decades.24
Despite wine, and on a broader scale, alcohol, being a risk factor to general and cardiovascular health, it is a widely popular beverage of choice among adults. Numerous investigations report a controlled and sustained light-to-moderate intake to be beneficial for the cardiovascular profile, although this evidence is inconsistent. Low-risk drinking guidelines are in place to combat excessive and binge-consumption, and largely promote a culture of moderation to drinkers.
*Adrian Baranchuk, MD, FACC, FRCPC, FCCS, Sohaib Haseeb, BSc and Bryce Alexander, BSc
Division of Cardiology, Queen’s University, Kingston, Ontario, Canada
- Haseeb S, Alexander B, Baranchuk A. Wine and Cardiovascular Health: A Comprehensive Review. Circulation. 2017;136:1434–1448.
- International Organisation of Vine and Wine. OIV Statistical Report on World Vitiviniculture. 2017. http://www.oiv.int/public/medias/5479/oiv-en-bilan-2017.pdf. Accessed January 24, 2018.
- Fernández-Solà J. Cardiovascular risks and benefits of moderate and heavy alcohol consumption. Nat Rev Cardiol. 2015;12:576–587.
- Baranchuk A, Alexander B, Haseeb S. Drinking red wine is good for you — or maybe not. The Washington Post; 2017. https://www.washingtonpost.com/national/health-science/drinking-red-wine-is-good-for-you–or-maybe-not/2017/12/01/49f55e7a-cbd3-11e7-aa96-54417592cf72_story.html. Accessed January 24, 2018.
- Ferrières J. The French paradox: lessons for other countries. Heart. 2004;90:107–111.
- Leger ASS, Cochrane AL, Moore F. FACTORS ASSOCIATED WITH CARDIAC MORTALITY IN DEVELOPED COUNTRIES WITH PARTICULAR REFERENCE TO THE CONSUMPTION OF WINE. The Lancet. 1979;313:1017–1020.
- Levantesi G, Marfisi R, Mozaffarian D, Franzosi MG, Maggioni A, Nicolosi GL, Schweiger C, Silletta M, Tavazzi L, Tognoni G, Marchioli R. Wine consumption and risk of cardiovascular events after myocardial infarction: Results from the GISSI-Prevenzione trial. Int J Cardiol. 2013;163:282–287.
- Renaud S, de Lorgeril M. Wine, alcohol, platelets, and the French paradox for coronary heart disease. Lancet Lond Engl. 1992;339:1523–1526.
- Grønbæk M. Type of Alcohol Consumed and Mortality from All Causes, Coronary Heart Disease, and Cancer. Ann Intern Med. 2000;133:411.
- Roerecke M, Rehm J. Alcohol consumption, drinking patterns, and ischemic heart disease: a narrative review of meta-analyses and a systematic review and meta-analysis of the impact of heavy drinking occasions on risk for moderate drinkers. BMC Med. 2014;12:182.
- Markoski MM, Garavaglia J, Oliveira A, Olivaes J, Marcadenti A. Molecular Properties of Red Wine Compounds and Cardiometabolic Benefits. Nutr Metab Insights. 2016;9:51–57.
- Covas MI, Gambert P, Fitó M, de la Torre R. Wine and oxidative stress: Up-to-date evidence of the effects of moderate wine consumption on oxidative damage in humans. Atherosclerosis. 2010;208:297–304.
- Hertog MGL, Feskens EJM, Kromhout D, Hertog MGL, Hollman PCH, Hertog MGL, Katan MB. Dietary antioxidant flavonoids and risk of coronary heart disease: the Zutphen Elderly Study. The Lancet. 1993;342:1007–1011.
- Nigdikar SV, Williams NR, Griffin BA, Howard AN. Consumption of red wine polyphenols reduces the susceptibility of low-density lipoproteins to oxidation in vivo. Am J Clin Nutr. 1998;68:258–265.
- Perez-Vizcaino F, Duarte J, Andriantsitohaina R. Endothelial function and cardiovascular disease: Effects of quercetin and wine polyphenols. Free Radic Res. 2006;40:1054–1065.
- Mano T, Masuyama T, Yamamoto K, Naito J, Kondo H, Nagano R, Tanouchi J, Hori M, Inoue M, Kamada T. Endothelial dysfunction in the early stage of atherosclerosis precedes appearance of intimal lesions assessable with intravascular ultrasound. Am Heart J. 1996;131:231–238.
- Smoliga JM, Baur JA, Hausenblas HA. Resveratrol and health – A comprehensive review of human clinical trials. Mol Nutr Food Res. 2011;55:1129–1141.
- Bonnefont-Rousselot D. Resveratrol and Cardiovascular Diseases. Nutrients. 2016;8.
- Araya J, Rodrigo R, Orellana M, Rivera G. Red wine raises plasma HDL and preserves long-chain polyunsaturated fatty acids in rat kidney and erythrocytes. Br J Nutr. 2001;86:189–195.
- Kaur G, Rao LVM, Agrawal A, Pendurthi UR. Effect of wine phenolics on cytokine-induced C-reactive protein expression. J Thromb Haemost. 2007;5:1309–1317.
- Mongan D, Long J. Standard drink measures throughout Europe; peoples’ understanding of standard drinks and their use in drinking guidelines, alcohol surveys and labelling. Dublin Irel Health Res Board. 2015.
- Kalinowski A, Humphreys K. Governmental standard drink definitions and low-risk alcohol consumption guidelines in 37 countries. Addiction. 2016;111:1293–1298.
- Babor TF, Higgins-Biddle JC. Brief Intervention for Hazardous and Harmful Drinking: A Manual for Use in Primary Care. Geneva, Switzerland: World Health Organization; 2001. http://apps.who.int/iris/bitstream/10665/67210/1/WHO_MSD_MSB_01.6b.pdf. Accessed January 24, 2018.
- Buykx P, Li J, Gavens L, Hooper L, Gomes de Matos E, Holmes J. Self-Reported Knowledge, Correct Knowledge and use of UK Drinking Guidelines Among a Representative Sample of the English Population. Alcohol Alcohol. 2018.
- American Heart Association. Alcohol and Heart Health. http://www.heart.org/HEARTORG/HealthyLiving/HealthyEating/Nutrition/Alcohol-and-Heart-Health_UCM_305173_Article.jsp#.Wm5rYKinFPY. Accessed January 24, 2018.