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Original Research Communications |
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Objective: Our objective was to study the association between intake of different alcoholic beverages and selected indicators of a healthy diet.
Design: This was a cross-sectional study conducted in Copenhagen and Aarhus, Denmark, from 1995 to 1997, and included 23284 men and 25479 women aged 50–64 y. The main outcome measures were groups of selected foods that were indicators of a healthy dietary pattern.
Results: Wine, as compared with other alcoholic drinks, was associated with a higher intake of fruit, fish, cooked vegetables, salad, and the use of olive oil for cooking in both men and women. Men who preferred beer and spirits had odds ratios of 0.42 (95% CI: 0.39, 0.45) and 0.51 (95% CI: 0.43, 0.60), respectively, for a high intake of salad compared with those who preferred wine. Higher wine intake was associated with a higher intake of healthy food items compared with intake of 
2.5 glasses of wine/mo; odds ratios for drinkers of between 30 and 135 glasses of wine/mo for all the chosen indicators of healthy diet varied between 1.23 and 4.20, and were all strongly significant.
Conclusion: Wine drinking is associated with an intake of a healthy diet. This finding may have implications for the interpretation of previous reports of the relation between type of alcoholic beverage and mortality.Am J Clin Nutr 1999;69:49–54.
Key Words: Drinking patterns • wine intake • dietary habits • alcoholic beverages • alcohol intake • cross-sectional study • Denmark • Diet, Cancer and Health Study
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Mortality from ischemic heart disease has been attributed to a diet low in fruit, vegetables, and fish and high in saturated fat (5–9). Variation in diet associated with the preferred drink may explain why wine seems to have an additional beneficial effect on ischemic heart disease mortality. We studied the relation between wine drinking and the intake of selected food items in a cohort of 50–64-y-old men and women who participated in the Danish Diet, Cancer and Health Study.
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SUBJECTS AND METHODS |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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All cohort members completed a detailed, 192-item food-frequency questionnaire. A description of the development and validation of the questionnaire was published previously (10, 11). In addition, all participants filled in a questionnaire about known risk factors for cancer development such as previous alcohol intake, smoking habits, education, and health. Anthropometric measurements were obtained, including height, weight, and waist and hip circumferences. The study protocol was approved by the Copenhagen Ethical Committee on Human Studies.
Intake of wine, beer, and spirits
Alcohol intake was recorded as the average frequency of intake of specific amounts of each beverage over the preceding year: beer (one bottle), wine (one glass), and spirits, eg, schnapps, whiskey, or gin (one drink). Twelve possible response categories regarding the number of drinks of each type of beverage ranged from never to 
8 drinks/d. The consumption of red and white wine was not differentiated. Intake of light and strong beer was converted to standard beer based on ethanol content.
For calculation of total alcohol intake, all types of alcohol consumption were converted to number of drinks per month. A preferer of a specific beverage type was a person whose intake of the preferred beverage constituted 50% of the total alcohol intake. If intake of none of the specific beverage types exceeded 50%, the person was categorized as a mixed drinker. The participants who reported an intake of wine 2.5 drinks/mo were categorized as non-wine drinkers, whereas the remaining participants were categorized on the basis of increasing wine intake (2.6–30, 31–134, and 135 drinks/mo), ie, 3 groups with a weekly, a low-to-moderate daily, and a high daily intake, respectively.
Dietary habits
Frequencies of intake of fish, cooked vegetables, salad, and fruit were determined from the food-frequency questionnaire. For each food item the intake was categorized as high or low. The cutpoints were defined as close to the median of the distribution as possible. The same cutpoints were used for men and women. A high intake of fish was defined as 1 serving/wk, of vegetables and salad as 2/wk, and of fruit 2/d.
In the questionnaire, the participants indicated which type of fat they preferred for cooking. Two groups of participants were formed—one group of participants who preferred olive oil and one group who used other types of fat for cooking. In Denmark, one-third of the fat intake is as fat spread on bread, and rye bread is the most frequently used type of bread. Therefore, another 2 groups were formed, users and nonusers of fat spread on bread.
Lifestyle
In the lifestyle questionnaire, educational attainment was estimated from length of higher education as none, short (<3 y), medium (3–4 y), or high (>4 y). Cigarette smoking was defined as current, past, or never. Current smokers were defined as participants who reported smoking 1 cigarette/d for at least the past year.
Body mass index (BMI) was calculated as weight (kg) per height squared (m). When measured for body weight, height, and waist and hip circumferences (with a measuring tape) the participants were dressed in light underwear. Waist circumference was measured as the smallest horizontal circumference between the ribs and iliac crest. Hip circumference was measured at the level of maximum extension of the buttocks. Waist-to-hip ratio was used as a measure of adipose tissue distribution.
Statistical methods
Baseline characteristics of the participants were computed for the different alcoholic beverage preference groups as well as for categories of wine intake. Differences in baseline characteristics between the wine group and the other groups combined were tested for significance by using t tests and chi-square tests in SAS (SAS Institute Inc, Cary, NC). Because of differences in drinking and dietary habits, these analyses are presented separately for men and women. Further descriptive analyses were performed for participants with high and low intakes of selected indicator foods.
The bivariate associations between beverage preference groups and groups characterized by increasing wine intake and high and low intakes of indicator foods were described in logistic regression models (12). Using the wine preference group and the group with wine intake <2.5 drinks/mo, respectively, as the reference group, odds ratios were calculated. High odds ratios indicated what was considered relatively healthy dietary habits.
The following covariates were included in a multiple logistic regression analysis: age, education, smoking habits, total alcohol intake, and BMI when relevant. All logistic regression analyses were conducted separately for men and women. The estimated odds ratios are presented with 95% CIs. Tests were based on the likelihood ratio test statistic (12). The SAS/STAT software for UNIX was used for statistical analyses (13).
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RESULTS |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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). Fifty-four percent of the women and 30% of the men preferred wine. The group who preferred wine compared with all other groups combined had a lower mean age, lower proportion of current smokers, lower BMI, and lower waist-to-hip ratio (P < 0.05). Wine drinkers included a significantly higher percentage of persons with higher education (P < 0.05).
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). The category of drinkers of <2.5 glasses of wine/mo comprised a mixture of teetotalers and drinkers of beer and spirits. This group had a relatively high percentage of current smokers and a low percentage of persons with a high educational level. A stepwise increase from light wine drinkers (2.5–30 drinks/mo) to heavy wine drinkers coincided with an increase in the proportion of smokers as well as in amount of higher education. No major differences or clear associations between a high and low intake of the dietary variables were found for total alcohol intake (results not shown).
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. A preference for wine compared with a preference for beer or spirits in both men and women was associated with a higher intake of fruit, fish, vegetables, and salad, and a stronger preference for olive oil for cooking (Tables 4 and 5). The proportion of wine drinkers who used fat spread on bread was lower than for the other preference groups. The adjusted odds ratio for the beer preference group was 0.60 (0.56, 0.66) for salad for women. This means that the proportion of women who preferred beer and had high intakes of salad was only 60% of the proportion in the wine preference group. The highest adjusted odds ratio for women preferring beer was 0.84 (0.77, 0.92) for those with a high intake of fish, whereas for men the odds ratios were between 0.40 (0.35, 0.45) for those with a preference of olive oil for cooking and 0.69 (0.65, 0.74) for those with a high intake of fish, all compared with those with a preference for wine. The same overall pattern was seen for spirit drinkers compared with wine drinkers, although the odds ratios were not quite as low as for beer drinkers. Adjustment, where it was relevant, for age, education, smoking habits, total alcohol intake, and BMI did not substantially change the associations, except for the intake of fruit among abstainers.
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and 7). A trend test including the whole range of wine intake (log transformed) was significant for all dietary items (P < 0.0001). Drinkers of 30–135 drinks of wine/mo (1–3 glasses of wine/d), however, had the highest adjusted odds ratios with regard to most of the specific dietary components. The strongest associations for both men and women were for the use of olive oil for cooking. In men drinking 4 glasses of wine/d, an odds ratio of 4.57 (3.44, 6.07) for using olive oil was observed. Except for salad, men had higher odds ratios than women in these analyses. Adjustment where relevant for age, educational level, smoking habits, total alcohol consumption, and BMI did not consistently change the associations.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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A high intake of fruit, vegetables, and fish and a low intake of saturated fat has been shown to reduce risk of ischemic heart disease morbidity as well as mortality in several studies (5–9). Diet may thus play an important role in the complex interaction between alcoholic beverage type and ischemic heart disease. However, very little attention has been paid to the relation between alcohol beverage choice and diet.
In our study, we found a strong relation between wine intake and healthy diet. A preference for wine in both men and women was associated with a higher intake of fruit, fish, cooked vegetables, and salad, and a strong preference for olive oil for cooking. A similar strong association was seen between increasing wine intake and healthy food habits.
A cross-sectional study like the present does not allow causal inference. It is likely that the drinking and dietary habits developed together during adulthood in the individuals examined. This means that one of the factors may confound the seemingly important effect of the other.
The low response rate (36%) in our study increased the likelihood of selection bias—the possibility that we selected only healthy (with regard to diet) wine drinkers or unhealthy non-wine drinkers to our cohort. However, we have no reason to believe that these groups should be especially willing to participate in this study. Furthermore, the range of alcohol intake, as well as the variation in dietary intake, indicate that we have a representative sample with regard to dietary habits.
Recall bias could be introduced by some subjects (ie, wine drinkers) being more aware of what is a healthy diet (ie, high intake of fruit, cooked vegetables, salad, and olive oil) and reporting a higher intake of these items. The true difference between wine drinkers and drinkers of beer and spirits would then be lower than reported here. This, on the other hand, entails the possibility of a true additional beneficial effect of wine in a cohort study adjusted for diet.
Where relevant in the analyses, we adjusted for age, education, smoking habits, BMI, and total alcohol intake. For both educational level and smoking we used a rather crude measurement for which reason residual confounding cannot be totally excluded, eg, we controlled for current smoking status but did not distinguish between pipe, cigarette, or cigar smoking.
Most studies on total alcohol intake have not differentiated beverage types and reported either no association or a less healthy diet with increasing alcohol intake (16–21). One Finnish study found that female wine drinkers had a significantly higher intake of carotenoids and male wine drinkers had the highest intake of vitamin C, which indicates an overall higher consumption of fruit and vegetables in the wine preference group (22), as in the present study. Klatsky et al (23) reported that traits of persons who preferred wine were in general more favorable to health than those of beer and spirits drinkers. Wine preferers smoked the least and had more years of formal education as well as the lowest BMI (23). This agrees with the findings in our study, although we found a strong positive association between an increasing intake of wine and the percentage of current smokers. Adjustment for these traits did not, however, change the associations between wine drinking and a healthy diet.
In conclusion, there seems to be a strong association between intake of different types of alcoholic beverages and dietary habits. This difference may be an isolated Danish phenomenon. Nevertheless, it may have important implications for the interpretation of the results from the Copenhagen City Heart Study, in which wine intake was associated with lower mortality from cardiovascular disease as well as from other causes of death (3). The question whether the relation between dietary habits and cardiovascular disease mortality as well as all-cause mortality is strong enough to seriously confound relations between intake of alcoholic beverages and disease development or mortality still remains to be answered in a prospective study.
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FOOTNOTES |
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2 Supported by the Danish Cancer Society and the Danish National Board of Health.
3 Address reprint requests to A Tjønneland, The Danish Cancer Society, Institute of Cancer Epidemiology, Strandboulevarden 49, Box 839, DK-2100 Copenhagen Ø, Denmark. E-mail: annet{at}cancer.dk.
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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