Alcohol, health and cardiovascular disease

Masip, J.; Germà Lluch, J.R.

doi:10.1016/j.rceng.2019.07.001

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En la primera fila se muestra el volumen aproximado equivalente a 1UBE de las bebidas más frecuentes según su graduación. En la fila inferior se muestra una aproximación a las cantidades o «raciones» más habituales de consumo. Contenido de alcohol de una bebida=volumen (dl)×graduación×0,79* (*factor de conversión). UBE: unidad de bebida estándar=10g de alcohol." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. Masip, J.R. Germà Lluch" "autores" => array:2 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Masip" ] 1 => array:2 [ "nombre" => "J.R." 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(B) Diagram of the curves observed for cardiovascular disease and all-cause mortality when non-drinkers and ex-drinkers are included. (C) Diagram of the curves observed in all-cause mortality for alcohol consumers, according to the predominant beverage type." ] ] ] "textoCompleto" => "BackgroundThe consumption of alcoholic beverages traces back to the dawn of the human species. Our hunter-gatherer predecessors already consumed alcoholic beverages from the fermentation of fruits, grains and even honey.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Following the Neolithic era (approximately 10,000 BC), the development of agriculture enabled the cultivation and production of beverages similar to beer and wine.Wine was key element in ancient Rome, and the Catholic Church has included wine in its liturgy for the past 2000 years, ascribing it divine properties. Alcoholic beverages have since been present at almost all levels of society. By the 20th century, the regular consumption of wine, beer, liquor and other alcoholic beverages during meals and leisure activities had become a standard practice in the Western world. It is not surprising that there are few religious, social and occasionally academic celebrations that are not accompanied by alcoholic beverages.These habits have been endorsed in recent decades by the publication of epidemiological studies that have supported the hypothesis that there is a negative correlation between moderate alcohol consumption and cardiovascular disease (CVD),<a class="elsevierStyleCrossRef" href="#bib0010">2</a> a highly relevant fact given that CVD is the main cause of death in industrialized countries.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> The hypothesis resulted from the French paradox, a term that arose from the decreasing incidence of CVD in France, despite being a country with a high consumption of saturated fats. This phenomenon was attributed to the high consumption of wine by the French population due to the effect of some of its bioactive components such as polyphenols.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> Others have argued that the result was probably a benefit shared with alcohol.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> A similar scenario was observed in countries of Southern Europe and was also related to the Mediterranean diet, which has been shown to reduce CVD mortality<a class="elsevierStyleCrossRef" href="#bib0030">6</a> and that initially included red wine along with other key constituents such as olive oil, fruit, fish, vegetables and nuts.Numerous mechanisms have been proposed to explain the possible benefit that moderate alcohol consumption can have on the heart, including increased fibrinolysis and HDL cholesterol; reduced plasma viscosity, fibrinogen concentration, platelet aggregation and inflammatory response; and improved endothelial function and antioxidant effects.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>Similarly, a beneficial effect has been observed from the polyphenolic components of wine (especially red wine) on some types of cancer, an effect analogous to that observed in CVD. In breast cancer, these polyphenols (resveratrol, quercetin and catechin) have a structure similar to estrogens and can act as agonists and antagonists of the estrogen receptor<a class="elsevierStyleCrossRef" href="#bib0040">8</a> and can in turn regulate the peripheral transformation of androgens to estrogens by acting on the aromatases.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>Although they do not recommend drinking alcohol, numerous scientific societies (among them the European Society of Cardiology<a class="elsevierStyleCrossRef" href="#bib0050">10</a> and the US Dietary Guidelines)<a class="elsevierStyleCrossRef" href="#bib0055">11</a> have therefore included as healthy the regular consumption of a moderate quantity of alcohol in the diet, which they set at 20 g of alcohol per day for men (2 small glasses of wine) and 10 g for women, due to their lower acetylation capacity.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> However, a number of recent publications have since questioned this recommendation and the entire theory of moderate consumption.Alcohol consumptionThere is considerable worldwide geographical variability in alcohol consumption. The amount is usually measured in grams and depends on the volume of liquid and its proof. To uniformly quantify the amount, the standard drink unit (SDU) has been proposed in recent years and corresponds to 10 g of pure alcohol, a figure that can vary in some countries. <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows the most common beverages in our community and their SDU equivalence.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>When we analyze the worldwide patterns of alcohol consumption, we see that alcohol use is clearly higher among men than among women (almost double) and increases progressively with age.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> Alcohol consumption is higher in countries with a high sociodemographic index and includes all Western countries.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> The highest alcohol consumption rate is in Europe, although in recent years the rate has dropped, while in southeast Asia the rate has risen.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> In 2016, 60–79% of the Spanish male population were estimated to be regular drinkers (mean consumption, 5.6 SDUs/day), while 40–60% of the Spanish female population were considered regular drinkers (mean consumption, 2.1 SDUs/day).<a class="elsevierStyleCrossRef" href="#bib0070">14</a> The consumption has varied little in the past 15 years (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>A quarter of all alcohol consumed worldwide is “not registered”, i.e., unaccounted in the official statistics on taxes or alcohol sales.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> In Spain, the maximum unregistered rate is estimated at 15%.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> Moreover, almost half of all alcohol consumption recorded worldwide is in the form of spirits, with beer and wine in second and third place, respectively.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> In Spain, most alcohol consumption in terms of liters per capita is of beer (54%), with a significant increase in recent decades, followed by liquor (28%) and wine (18%), whose consumption has fallen drastically during the same period.<a class="elsevierStyleCrossRef" href="#bib0080">16</a>The risks of alcoholIn contrast to the possible benefit of moderate alcohol consumption, the harmful use of alcohol has a significant social impact and is a risk factor for premature death and disability worldwide, due not only to its direct toxic effects on the body resulting from its likely carcinogenic, teratogenic, myopathic, myelotoxic and neurotoxic effects but also indirectly due to the increase in aggression, accidents and greater susceptibility to other risks. Alcoholic cardiomyopathy,<a class="elsevierStyleCrossRef" href="#bib0085">17</a> cirrhosis and thiamine-deficiency diseases such as polyneuropathy and Wernicke–Korsakoff syndrome are well-known examples of the direct impact of alcohol. The harmful use of alcohol is not only affected by the quantity of alcohol consumed but also by the patterns of consumption; drunkenness and “binge drinking” (extreme and uncontrolled drinking over a short period), which is very common among young adults, have a highly negative impact on health.In Spain, alcohol and drugs (along with tobacco) are the main risk factors leading to death and disability, surpassing arterial hypertension, a high body mass index, hypercholesterolemia, hyperglycemia and atmospheric pollution.<a class="elsevierStyleCrossRef" href="#bib0090">18</a>In 2010, the World Health Organization (WHO) approved a number of strategies to achieve a relative reduction of 10% in the harmful use of alcohol by 2025.<a class="elsevierStyleCrossRef" href="#bib0095">19</a> These measures have been recently endorsed in the 2018 report that attempts to involve politicians, states and societies (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRef" href="#bib0100">20</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Nations and communities have also adopted measures. The Spanish Ministry of Health has published an extensive document in 2007<a class="elsevierStyleCrossRef" href="#bib0105">21</a> on preventing the problems resulting from alcohol use. More recently, Catalonia started the “Alcohol is Everyone’s Problem” campaign.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> The statistics are striking: approximately 3 million deaths annually are attributed to alcohol use worldwide, and 10% of the deaths occur among those aged 15-49 years, either due to accident or disease.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> In Catalonia, a mean of 50 people daily are treated for alcohol poisoning, and approximately 30% of adolescents (14–18 years) stated having engaged in binge drinking at least once in the past month. Alcohol is the substance that creates the greatest demand for treatment in drug addiction centers and that causes the most damage to third parties.It is therefore clear that the harmful use of alcohol constitutes a major social problem, and measures aimed at controlling it are necessary and should involve all of society.Scientific studiesNumerous studies have analyzed the relationship between alcohol use and mortality. In 2006, a meta-analysis of 34 prospective studies that included more than 1 million participants and more than 90,000 deaths described a J curve, with reduced mortality in low consumption and a progressive increase in deaths with greater intake.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> The lowest mortality risk was observed with 6 g/day (approximately half a drink/day). However, compared with no alcohol consumption, the meta-analysis observed a risk reduction with up to 4 drinks/day for men and 2 drinks/day for women. Subsequently, the same group analyzed the mortality of patients who had already had a CVD event and reported that low-moderate consumption (5–10 g/day) reduced total mortality and that up to 26 g/day reduced cardiovascular mortality.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> A national survey in the United States found similar results, with a lower risk for fewer than 2 drinks/day.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> Another subsequent meta-analysis of 18 studies showed similar results, with a reduced mortality risk by CVD with the consumption of 2.5–14.9 g/day.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> However, a study conducted in England, based on health surveys in a population older than 50 years, found that the benefits of moderate alcohol consumption were restricted to women older than 65 years.<a class="elsevierStyleCrossRef" href="#bib0135">27</a> A cohort study of 47,921 women aged 30–49 years living in Sweden and followed-up for 15 years revealed that, compared with not drinking, low to moderate alcohol consumption (0.1–19.9 g/day) showed a statistically significant inverse association with overall mortality, but the reduction in risk in these young women was limited to CVD and not to cancer.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> Similarly, the epidemiological study PURE, conducted in 12 countries and encompassing 114,970 adults, showed a limited benefit for moderate consumption. The study showed that, compared with nondrinkers, the drinkers had lower myocardial infarction rates but greater rates of cancer and injuries.<a class="elsevierStyleCrossRef" href="#bib0145">29</a> The intense drinkers had higher mortality, while the moderate drinkers saw a benefit only in countries with high economic levels, which suggests that other factors such as income-related lifestyles could be associated with the benefit of a moderate consumption pattern.In light of these results, it seems clear that, with differential nuances, there is evidence that moderate alcohol consumption reduces the risk of CVD. However, many of the studies on which this statement is based have been subject of criticism because, in addition to lifelong abstainers, the studies included sporadic drinkers and ex-drinkers in the no-alcohol group. Ex-drinkers are a group with a poorer prognosis due to having other conditions that required them to abandon alcohol consumption. A meta-analysis, adjusted for the bias of abstemious patients and nondrinkers,<a class="elsevierStyleCrossRef" href="#bib0150">30</a> and a randomized Medelian analysis<a class="elsevierStyleCrossRef" href="#bib0155">31</a> did not replicate the J curve.Alcohol and cancerIn parallel with the observation of the beneficial effect on CVD, the impact of alcohol on the incidence of cancer has been the subject of debate. Initial studies showed a protective effect conditioned by the weight of alcohol intake. Thus, a 2013 meta-analysis showed that alcohol increased the risk of cancer but that low doses (<25 g/day) in men could reduce this risk.<a class="elsevierStyleCrossRef" href="#bib0160">32</a> A cohort study of 16,320 participants conducted in South Korea showed higher mortality among the drinkers but with a J curve, with lower overall mortality and cancer mortality in the population with low alcohol consumption (<90 g/week).<a class="elsevierStyleCrossRef" href="#bib0165">33</a> Similarly, a case-controlled study comparing 250 patients with colorectal cancer against 250 healthy individuals concluded that the association between the amount of alcohol ingested and the presence of cancer also followed a J curve.<a class="elsevierStyleCrossRef" href="#bib0170">34</a> While there was a deleterious effect with consuming large quantities of alcohol, a moderate intake had a protective effect, both in men and women, which was possibly related to wine consumption.Until recently and despite the proven association with the dose, the threshold of consumption that determined a clinically significant risk was not exactly known. Many of the previously mentioned studies have been criticized for the bias introduced by ex-drinkers. A new analysis adjusted for the data from this population reported that alcohol increased the risk of cancer at any level of consumption.<a class="elsevierStyleCrossRef" href="#bib0175">35</a> Similarly, a new meta-analysis showed that alcohol, at any dose, increased the risk of oral, pharyngeal, esophageal, laryngeal, liver, breast and colorectal cancer.<a class="elsevierStyleCrossRef" href="#bib0180">36</a> It appears that the direct toxic effect at the cellular level of acetaldehyde could play an important role. Therefore, the American Association of Clinical Oncology issued an open warning regarding the association between alcohol and cancer and proposed control measures especially for the younger population,<a class="elsevierStyleCrossRef" href="#bib0185">37</a> along the same line as the WHO (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRef" href="#bib0080">16</a>Recent studies. A change in paradigm?Highly relevant studies have been published in the past 2 years that have reconsidered the paradigm of alcohol and health.On one hand, a new broad study was published that reinforced the benefit of moderate alcohol consumption. In 2017, Xi et al. published the analysis of 13 serial surveys from the US National Health Interview Survey (NHIS) that encompassed 333,247 participants categorized into 6 groups: abstainers, occasional drinkers, ex-drinkers and currently light, moderate and heavy drinkers.<a class="elsevierStyleCrossRef" href="#bib0190">38</a> The results showed that heavy drinkers (>14 drinks/week) and binge drinkers (≥1 binge drinking/week) had a higher cancer mortality and all-cause mortality risk. The light or moderate drinkers (≤14 drinks/week for men and ≤7 drinks/week for women) had a lower cardiovascular and all-cause mortality risk, reproducing the known J curve. An analysis by other researchers of the drinking patterns from the same NHIS database, comparing them with those of 93,653 individuals from the US Veterans Administration, showed that, if one considered the intake of 1–2 drinks on each occasion, the greatest benefit was achieved by drinking 3 times/week, given that daily consumption slightly increased the risk compared with this level.<a class="elsevierStyleCrossRef" href="#bib0195">39</a>Another study published the same year and conducted in South Korea with a smaller sample (8333 participants) and a 10-year follow-up also showed that low-moderate alcohol consumption (<15 g/day) reduced the risk of myocardial infarction and coronary artery disease but also showed that the reduction was not significant when occasional drinkers were added to the reference group.<a class="elsevierStyleCrossRef" href="#bib0200">40</a> The authors found demographic similarities between light and occasional drinkers.On the other hand, we have the published report from the Global Burden of Disease (GBD) on the effects of alcohol and health. The GBD is a regional and global research program that evaluates mortality and disability caused by the main diseases, injuries and risk factors worldwide. The GBD was founded in 1990 and has worked closely with the Institute of Health Metrics and Evaluation of the University of Washington and with the WHO. The program currently has 1800 researchers in 127 countries. The latest global report published in 2017<a class="elsevierStyleCrossRef" href="#bib0205">41</a> presented the factors that most influenced what the program defines as disability-adjusted life years or years lost due to disability or premature death (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). The GBD estimated that alcohol was the seventh primary component of DALY risk worldwide in 2016 and was the factor that had risen the most in importance, affecting men the most. Alcohol was the main risk factor for the 15–49-year age group. The GBD found that alcohol consumption had increased in countries with low to medium economic levels. Therefore, a year later, the program published the specific data from the analysis of alcohol,<a class="elsevierStyleCrossRef" href="#bib0065">13</a> with extensive supplemental material.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> The authors remarked that their analysis had provided a methodological improvement in terms of estimating alcohol consumption based on several aspects such as analyzing 694 individual and populational data sources, including the alcohol consumption of tourists and of unrecorded alcohol and performing a meta-analysis with a new analytical method of relative and individual risk on 23 health results associated with dose-response. The study showed that, at the global level, alcohol increased the risk of a number of diseases without there being a benefit to low doses, except for diabetes, ischemic heart disease and ischemic stroke, which decreased the risk. However, there were also a number of diseases for which low doses did not raise or lower the risk (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia>A highly relevant study published in 2018 by Wood et al.<a class="elsevierStyleCrossRef" href="#bib0210">42</a> analyzed 599,912 alcohol drinkers from 83 studies, encompassing 19 countries with high economic levels. The study revealed that there was a positive curvilinear relationship with all-cause mortality and that the lowest risk level was an intake of ≤100 g/week, which corresponded to the flat part of the curve (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). As in previous studies, the study found a negative relationship with CVD at low doses, especially with myocardial infarction, which decreased with any level of alcohol consumption. However, there was a positive almost linear relationship for the incidence of stroke, another type of CVD, hypertensive heart disease, aortic aneurysm and even heart failure, the latter of which contradicted a recent study called Atherosclerosis Risk in Communities, which reported a reduction in the incidence of heart failure with an intake of <7 drinks/week.<a class="elsevierStyleCrossRef" href="#bib0215">43</a> In the study by Wood et al., an intake >100 g/week reduced life expectancy the younger the population and the greater the intake. The authors concluded that the recommended limit for alcohol consumption should be reduced to 100 g/week and that for other CVD (except for myocardial infarction), there is no safe level of consumption. It is worth indicating that in this study the risk of all-cause hypertensive heart disease and stroke increased in the drinkers, in contrast with the data from the GBD that indicated a reduction in ischemic stroke and a neutral effect on hypertensive heart disease in the light drinkers.<elsevierMultimedia ident="fig0020"></elsevierMultimedia>It is also worth noting that these results only included individuals who drink. When nondrinkers (53,851) and ex-drinkers (29,726) were included (data published in the supplemental material), both groups had a greater risk of overall mortality (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). The data were even more striking when analyzing cardiovascular events. Although it is a well-known fact that ex-drinkers are a population at greater risk, the data from the nondrinkers are surprising and were highlighted in the editorial comments.<a class="elsevierStyleCrossRef" href="#bib0220">44</a> This subgroup had a higher proportion of individuals with diabetes and a lower educational level (34.9% of the non-drinkers were university educated, compared with 37.2% of the ex-drinkers and 51% of the drinkers) but had an increased risk despite the higher proportion of women (70% among non-drinkers, compared with 51% and 44% for ex-drinkers and drinkers, respectively) and performed more moderately intense physical activity (75.7% vs. 62.8% and 50%, respectively).Moreover, a recent study conducted in London provided another argument for proponents of moderate alcohol consumption. The Whitehall II study analyzed a cohort of 9087 middle-aged individuals (35–55 years) followed-up for 23 years and reported that there was an increased risk of dementia in the abstainers and drinkers of >14 units/week.<a class="elsevierStyleCrossRef" href="#bib0225">45</a>Lastly, a recently published study (April 2019) in China reinforced the threshold of consumption of 100 g/week. The study analyzed a population of 500,000 individuals, mostly men (98%), who were followed-up for 10 years. Of these, 161,498 were genotyped for 2 variants that change alcohol metabolism and determine the pattern of consumption.<a class="elsevierStyleCrossRef" href="#bib0230">46</a> The conventional epidemiological analysis reproduced the U curve for myocardial infarction, stroke and intracerebral hemorrhage, with a maximum level of risk reduction with a consumption of 100 g/week. However, the mean alcohol intake predicted by the genotype (ignoring the drinking patterns and in a Mendelian randomization) did not result in this U curve. The study found that alcohol increased systolic pressure, stroke and hemorrhage and was neutral for myocardial infarction.Considerations regarding moderate alcohol consumptionAlthough epidemiological studies have shown high levels of association between alcohol consumption and numerous diseases, there have been no randomized trials that have revealed a causality. The Moderate Alcohol and Cardiovascular Health trial, a multicenter trial sponsored by the National Institutes of Health and the National Institute of Alcohol Abuse and Alcoholism, is the only randomized trial to date that has analyzed the impact of moderate alcohol consumption (15 g/day) on cardiovascular disease and type 2 diabetes. However, the trial was prematurely interrupted in May 2018 after including 105 patients, due to conflicts of interest created by the private funding (more than 70%) from industrial alcohol manufacturers.<a class="elsevierStyleCrossRef" href="#bib0235">47</a> We can therefore conclude that the level of evidence on the impact of a moderate consumption on health is not high.However, recent studies have indicated that any alcohol consumption can increase the risk of various neoplasias (especially in the gastrointestinal tract and breasts), atrial fibrillation and hypertension. This finding is counteracted by the evidence that moderate consumption reduces the risk of CVD (especially myocardial infarction and diabetes) and dementia, effects that are more significant in countries in the industrialized world, which have greater alcohol consumption and a specific drinking pattern. Therefore, the decision to consume alcohol is individual and should be determined by personal factors, family history and social context. In any case and based on current data, the accepted limits of 140–200 g of alcohol/week for men and 70–100 g for women should be reduced to 100 g/week or less (equivalent to 7–10 drinks weekly), given that it appears that these levels do not increase all-cause mortality. Based on the premise that alcohol consumption should not be started for health purposes and in contrast to total abstention with the social burden that represents, these levels of alcohol consumption might be acceptable for middle-aged and elderly individuals but should exclude, in line with a recent consensus document,<a class="elsevierStyleCrossRef" href="#bib0240">48</a> young adults, pregnant women, individuals with addiction, those with arrhythmias, liver or pancreatic diseases and those at risk of gastrointestinal or breast cancer. Moreover, all measures proposed by the WHO to fight excessive consumption and prevent binge drinking should be implemented. In this respect, the Mediterranean diet, with moderate alcohol consumption combined with meals, could be a recommended example of a healthy drinking pattern. Although wine (especially red wine) has a high polyphenol content (hydrolysable tannins, resveratrol, etc.) that has been confirmed to have beneficial health effects in numerous experimental studies, a clear superiority over other alcoholic drinks has not been demonstrated.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Nevertheless, the recent study by Wood et al. found that there was a lower risk for those who predominantly drank wine compared with those who predominantly drank liquor or beer (Fig. 4 C). Other studies<a class="elsevierStyleCrossRefs" href="#bib0245">49,50</a> have also found that wine drinkers had greater protection than non-drinkers or those who did not drink wine; however, there are also studies that have found advantages with beer and even with liquor.<a class="elsevierStyleCrossRefs" href="#bib0005">1,51</a>Conflicts of interestJM and JRGL are members of the scientific committee of the Research Foundation on Wine and Nutrition." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1521551" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1379690" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1521552" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1379689" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Alcohol consumption" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "The risks of alcohol" "secciones" => array:2 [ 0 => array:3 [ "identificador" => "sec0020" "titulo" => "Scientific studies" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Alcohol and cancer" ] ] ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Recent studies. A change in paradigm?" ] ] ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Considerations regarding moderate alcohol consumption" ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-03-18" "fechaAceptado" => "2019-05-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1379690" "palabras" => array:8 [ 0 => "Alcohol" 1 => "Wine" 2 => "Health" 3 => "Cardiovascular disease" 4 => "Cancer" 5 => "Moderate consumption" 6 => "Harmful consumption" 7 => "Binge drinking" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1379689" "palabras" => array:8 [ 0 => "Alcohol" 1 => "Vino" 2 => "Salud" 3 => "Enfermedad cardiovascular" 4 => "Cáncer" 5 => "Consumo moderado" 6 => "Consumo nocivo" 7 => "Atracón" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Recent epidemiological studies have shown that alcohol consumption can increase the risk of arterial hypertension, atrial fibrillation and gastrointestinal and breast cancer. Various sectors are therefore promoting abstinence from alcohol. However, light alcohol consumption has once again been shown to reduce the risk of myocardial infarction and diabetes but with an unclear effect on cerebrovascular disease. The decision to consume alcohol should therefore be an individual one based on personal factors. A level of consumption <100 g/week for men (less for women) appears not to increase all-cause mortality, while high consumption or binge drinking significantly increases mortality risk. All measures to prevent this type of consumption, especially among the younger population, should therefore be applied. There are data indicating an advantage of wine over other beverages, but they are not conclusive." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Estudios epidemiológicos recientes han demostrado que el consumo de alcohol puede aumentar el riesgo de hipertensión arterial, fibrilación auricular y de cáncer digestivo y de mama, por lo que diversos estamentos están promoviendo la abstinencia. Sin embargo, también han vuelto a confirmar que el consumo ligero de alcohol puede reducir el riesgo de infarto de miocardio y de diabetes, no quedando claro el efecto en la enfermedad cerebrovascular. Por ello, la decisión del consumo de alcohol debe ser individual y basada en factores personales. Un nivel de consumo <100 gr/semana en hombres (menor en mujeres), parece que no aumenta la mortalidad por cualquier causa, mientras que consumos elevados o en forma de atracón (“binge”), incrementan significativamente el riesgo de mortalidad, por lo cual deben aplicarse todas las medidas para prevenir este tipo de consumo, especialmente en la población más joven. Hay datos que apuntan una ventaja del vino frente a las otras bebidas pero no son concluyentes." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Masip J and Germà Lluch JR. Alcohol, salud y enfermedad cardiovascular. Rev Clin Esp. 2021;221:359–368." ] ] "multimedia" => array:7 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1186 "Ancho" => 2176 "Tamanyo" => 192518 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Equivalence of alcoholic drinks. The first row shows the approximate volume equivalent to 1 SDU of the most common drinks according to their proof. The bottom row shows an approximation of the most common quantities or “portions” of alcohol consumption. Alcohol content of a beverage = volume (dL) × proof × 0.79* (*conversion factor). SDU: standard drink unit = 10 g of alcohol." ] ] 1 => array:9 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: GBD 2016 alcohol collaborators<a class="elsevierStyleCrossRef" href="#bib0065">13</a>; Supplement appendix 2: GBD 2016 Alcohol Collaborators.<a class="elsevierStyleCrossRef" href="#bib0070">14</a>" "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 3272 "Ancho" => 2162 "Tamanyo" => 272459 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "(A) Percentage of population that drinks alcohol, worldwide and for Spain. A similar percentage can be observed in the various study periods. (B) Mean consumption of standard alcohol drinks by inhabitant. An increasing trend worldwide in men and a reduction in Spain for men and women can be observed." ] ] 2 => array:9 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: GBD 2016 alcohol collaborators<a class="elsevierStyleCrossRef" href="#bib0065">13</a>; Supplement appendix 2: GBD 2016 Alcohol Collaborators.<a class="elsevierStyleCrossRef" href="#bib0070">14</a>" "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2128 "Ancho" => 2918 "Tamanyo" => 341799 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Curves representative of the impact of alcohol consumption on the risk of various diseases, grouped according to whether there is a direct increase from 0 (graph and column on the left) or with a flat section of the curve for low alcohol consumption, i.e. with no impact (graph and center column) or a reduction with low alcohol consumption (graph and column on the right). The numbers in parentheses in the center column are equal to the SDUs that show a flat curve or below 0. *Unintentional injuries, self-harm or traffic accidents." ] ] 3 => array:9 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Wood et al.<a class="elsevierStyleCrossRef" href="#bib0210">42</a>" "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 3504 "Ancho" => 1536 "Tamanyo" => 315948 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "(A) Diagram of the curves observed for the risk of cardiovascular disease and all-cause mortality in drinkers, mainly in countries with high economic levels. (B) Diagram of the curves observed for cardiovascular disease and all-cause mortality when non-drinkers and ex-drinkers are included. (C) Diagram of the curves observed in all-cause mortality for alcohol consumers, according to the predominant beverage type." ] ] 4 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">World Health Organization (WHO)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Increase excise taxes on alcoholic beverages. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Enact and enforce bans or comprehensive restrictions on exposure to alcohol advertising (across multiple types of media). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Enact and enforce restrictions on the physical availability of retailed alcohol (via reduced hours of sale). \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2615149.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">American Association of Clinical Oncology<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical strategies of alcohol screening and brief intervention provided in clinical settings. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Regulate alcohol outlet density Increase alcohol taxes and prices. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Maintain limits on days and hours of sale. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Enhance enforcement of laws prohibiting sales to minors. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Restrict youth exposure to advertising of alcoholic beverages. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Resist further privatization of retail alcohol sales in communities with current government control. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Include alcohol control strategies in comprehensive cancer control plans. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2615150.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Global status report on alcohol and health 2018<a class="elsevierStyleCrossRef" href="#bib0080">16</a>." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "LoConte et al.<a class="elsevierStyleCrossRef" href="#bib0185">37</a>" ] ] ] "descripcion" => array:1 [ "en" => "Proposed measures for reducing harm alcohol consumption." ] ] 5 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "The 5 main causes of death and disability according to the Global Burden of Disease in the past 25 years and the place occupied by alcohol.Source: GBD 2016 Risk Factors Collaborators.<a class="elsevierStyleCrossRef" href="#bib0205">41</a>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; 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By the 20th century&#44; the regular consumption of wine&#44; beer&#44; liquor and other alcoholic beverages during meals and leisure activities had become a standard practice in the Western world&#46; It is not surprising that there are few religious&#44; social and occasionally academic celebrations that are not accompanied by alcoholic beverages&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">These habits have been endorsed in recent decades by the publication of epidemiological studies that have supported the hypothesis that there is a negative correlation between moderate alcohol consumption and cardiovascular disease &#40;CVD&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> a highly relevant fact given that CVD is the main cause of death in industrialized countries&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The hypothesis resulted from the French paradox&#44; a term that arose from the decreasing incidence of CVD in France&#44; despite being a country with a high consumption of saturated fats&#46; This phenomenon was attributed to the high consumption of wine by the French population due to the effect of some of its bioactive components such as polyphenols&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Others have argued that the result was probably a benefit shared with alcohol&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> A similar scenario was observed in countries of Southern Europe and was also related to the Mediterranean diet&#44; which has been shown to reduce CVD mortality<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and that initially included red wine along with other key constituents such as olive oil&#44; fruit&#44; fish&#44; vegetables and nuts&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Numerous mechanisms have been proposed to explain the possible benefit that moderate alcohol consumption can have on the heart&#44; 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numerous scientific societies &#40;among them the European Society of Cardiology<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and the US Dietary Guidelines&#41;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> have therefore included as healthy the regular consumption of a moderate quantity of alcohol in the diet&#44; which they set at 20&#8239;g of alcohol per day for men &#40;2 small glasses of wine&#41; and 10&#8239;g for women&#44; due to their lower acetylation capacity&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> However&#44; a number of recent publications have since questioned this recommendation and the entire theory of moderate consumption&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Alcohol consumption</span><p id="par0035" class="elsevierStylePara elsevierViewall">There is considerable worldwide geographical variability in alcohol consumption&#46; The amount is usually measured in grams and depends on the volume of liquid and its proof&#46; To uniformly quantify the amount&#44; the standard drink unit &#40;SDU&#41; has been proposed in recent years and corresponds to 10&#8239;g of pure alcohol&#44; a figure that can vary in some countries&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the most common beverages in our community and their SDU equivalence&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">When we analyze the worldwide patterns of alcohol consumption&#44; we see that alcohol use is clearly higher among men than among women &#40;almost double&#41; and increases progressively with age&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Alcohol consumption is higher in countries with a high sociodemographic index and includes all Western countries&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The highest alcohol consumption rate is in Europe&#44; although in recent years the rate has dropped&#44; while in southeast Asia the rate has risen&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> In 2016&#44; 60&#8211;79&#37; of the Spanish male population were estimated to be regular drinkers &#40;mean consumption&#44; 5&#46;6&#8239;SDUs&#47;day&#41;&#44; while 40&#8211;60&#37; of the Spanish female population were considered regular drinkers &#40;mean consumption&#44; 2&#46;1&#8239;SDUs&#47;day&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The consumption has varied little in the past 15 years &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">A quarter of all alcohol consumed worldwide is &#8220;not registered&#8221;&#44; i&#46;e&#46;&#44; unaccounted in the official statistics on taxes or alcohol sales&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> In Spain&#44; the maximum unregistered rate is estimated at 15&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Moreover&#44; almost half of all alcohol consumption recorded worldwide is in the form of spirits&#44; with beer and wine in second and third place&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> In Spain&#44; most alcohol consumption in terms of liters per capita is of beer &#40;54&#37;&#41;&#44; with a significant increase in recent decades&#44; followed by liquor &#40;28&#37;&#41; and wine &#40;18&#37;&#41;&#44; whose consumption has fallen drastically during the same period&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">The risks of alcohol</span><p id="par0050" class="elsevierStylePara elsevierViewall">In contrast to the possible benefit of moderate alcohol consumption&#44; the harmful use of alcohol has a significant social impact and is a risk factor for premature death and disability worldwide&#44; due not only to its direct toxic effects on the body resulting from its likely carcinogenic&#44; teratogenic&#44; myopathic&#44; myelotoxic and neurotoxic effects but also indirectly due to the increase in aggression&#44; accidents and greater susceptibility to other risks&#46; Alcoholic cardiomyopathy&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> cirrhosis and thiamine-deficiency diseases such as polyneuropathy and Wernicke&#8211;Korsakoff syndrome are well-known examples of the direct impact of alcohol&#46; The harmful use of alcohol is not only affected by the quantity of alcohol consumed but also by the patterns of consumption&#59; drunkenness and &#8220;binge drinking&#8221; &#40;extreme and uncontrolled drinking over a short period&#41;&#44; which is very common among young adults&#44; have a highly negative impact on health&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In Spain&#44; alcohol and drugs &#40;along with tobacco&#41; are the main risk factors leading to death and disability&#44; surpassing arterial hypertension&#44; a high body mass index&#44; hypercholesterolemia&#44; hyperglycemia and atmospheric pollution&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In 2010&#44; the World Health Organization &#40;WHO&#41; approved a number of strategies to achieve a relative reduction of 10&#37; in the harmful use of alcohol by 2025&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> These measures have been recently endorsed in the 2018 report that attempts to involve politicians&#44; states and societies &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Nations and communities have also adopted measures&#46; The Spanish Ministry of Health has published an extensive document in 2007<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> on preventing the problems resulting from alcohol use&#46; More recently&#44; Catalonia started the &#8220;Alcohol is Everyone&#8217;s Problem&#8221; campaign&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> The statistics are striking&#58; approximately 3 million deaths annually are attributed to alcohol use worldwide&#44; and 10&#37; of the deaths occur among those aged 15-49 years&#44; either due to accident or disease&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> In Catalonia&#44; a mean of 50 people daily are treated for alcohol poisoning&#44; and approximately 30&#37; of adolescents &#40;14&#8211;18 years&#41; stated having engaged in binge drinking at least once in the past month&#46; Alcohol is the substance that creates the greatest demand for treatment in drug addiction centers and that causes the most damage to third parties&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">It is therefore clear that the harmful use of alcohol constitutes a major social problem&#44; and measures aimed at controlling it are necessary and should involve all of society&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Scientific studies</span><p id="par0075" class="elsevierStylePara elsevierViewall">Numerous studies have analyzed the relationship between alcohol use and mortality&#46; In 2006&#44; a meta-analysis of 34 prospective studies that included more than 1 million participants and more than 90&#44;000 deaths described a J curve&#44; with reduced mortality in low consumption and a progressive increase in deaths with greater intake&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> The lowest mortality risk was observed with 6&#8239;g&#47;day &#40;approximately half a drink&#47;day&#41;&#46; However&#44; compared with no alcohol consumption&#44; the meta-analysis observed a risk reduction with up to 4&#8239;drinks&#47;day for men and 2&#8239;drinks&#47;day for women&#46; Subsequently&#44; the same group analyzed the mortality of patients who had already had a CVD event and reported that low-moderate consumption &#40;5&#8211;10&#8239;g&#47;day&#41; reduced total mortality and that up to 26&#8239;g&#47;day reduced cardiovascular mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> A national survey in the United States found similar results&#44; with a lower risk for fewer than 2 drinks&#47;day&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> Another subsequent meta-analysis of 18 studies showed similar results&#44; with a reduced mortality risk by CVD with the consumption of 2&#46;5&#8211;14&#46;9&#8239;g&#47;day&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> However&#44; a study conducted in England&#44; based on health surveys in a population older than 50 years&#44; found that the benefits of moderate alcohol consumption were restricted to women older than 65 years&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> A cohort study of 47&#44;921 women aged 30&#8211;49 years living in Sweden and followed-up for 15 years revealed that&#44; compared with not drinking&#44; low to moderate alcohol consumption &#40;0&#46;1&#8211;19&#46;9&#8239;g&#47;day&#41; showed a statistically significant inverse association with overall mortality&#44; but the reduction in risk in these young women was limited to CVD and not to cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Similarly&#44; the epidemiological study PURE&#44; conducted in 12 countries and encompassing 114&#44;970 adults&#44; showed a limited benefit for moderate consumption&#46; The study showed that&#44; compared with nondrinkers&#44; the drinkers had lower myocardial infarction rates but greater rates of cancer and injuries&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> The intense drinkers had higher mortality&#44; while the moderate drinkers saw a benefit only in countries with high economic levels&#44; which suggests that other factors such as income-related lifestyles could be associated with the benefit of a moderate consumption pattern&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In light of these results&#44; it seems clear that&#44; with differential nuances&#44; there is evidence that moderate alcohol consumption reduces the risk of CVD&#46; However&#44; many of the studies on which this statement is based have been subject of criticism because&#44; in addition to lifelong abstainers&#44; the studies included sporadic drinkers and ex-drinkers in the no-alcohol group&#46; Ex-drinkers are a group with a poorer prognosis due to having other conditions that required them to abandon alcohol consumption&#46; A meta-analysis&#44; adjusted for the bias of abstemious patients and nondrinkers&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> and a randomized Medelian analysis<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> did not replicate the J curve&#46;</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Alcohol and cancer</span><p id="par0085" class="elsevierStylePara elsevierViewall">In parallel with the observation of the beneficial effect on CVD&#44; the impact of alcohol on the incidence of cancer has been the subject of debate&#46; Initial studies showed a protective effect conditioned by the weight of alcohol intake&#46; Thus&#44; a 2013 meta-analysis showed that alcohol increased the risk of cancer but that low doses &#40;&#60;25&#8239;g&#47;day&#41; in men could reduce this risk&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> A cohort study of 16&#44;320 participants conducted in South Korea showed higher mortality among the drinkers but with a J curve&#44; with lower overall mortality and cancer mortality in the population with low alcohol consumption &#40;&#60;90&#8239;g&#47;week&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> Similarly&#44; a case-controlled study comparing 250 patients with colorectal cancer against 250 healthy individuals concluded that the association between the amount of alcohol ingested and the presence of cancer also followed a J curve&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> While there was a deleterious effect with consuming large quantities of alcohol&#44; a moderate intake had a protective effect&#44; both in men and women&#44; which was possibly related to wine consumption&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Until recently and despite the proven association with the dose&#44; the threshold of consumption that determined a clinically significant risk was not exactly known&#46; Many of the previously mentioned studies have been criticized for the bias introduced by ex-drinkers&#46; A new analysis adjusted for the data from this population reported that alcohol increased the risk of cancer at any level of consumption&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> Similarly&#44; a new meta-analysis showed that alcohol&#44; at any dose&#44; increased the risk of oral&#44; pharyngeal&#44; esophageal&#44; laryngeal&#44; liver&#44; breast and colorectal cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> It appears that the direct toxic effect at the cellular level of acetaldehyde could play an important role&#46; Therefore&#44; the American Association of Clinical Oncology issued an open warning regarding the association between alcohol and cancer and proposed control measures especially for the younger population&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> along the same line as the WHO &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Recent studies&#46; A change in paradigm&#63;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Highly relevant studies have been published in the past 2 years that have reconsidered the paradigm of alcohol and health&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">On one hand&#44; a new broad study was published that reinforced the benefit of moderate alcohol consumption&#46; In 2017&#44; Xi et al&#46; published the analysis of 13 serial surveys from the US National Health Interview Survey &#40;NHIS&#41; that encompassed 333&#44;247 participants categorized into 6 groups&#58; abstainers&#44; occasional drinkers&#44; ex-drinkers and currently light&#44; moderate and heavy drinkers&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> The results showed that heavy drinkers &#40;&#62;14&#8239;drinks&#47;week&#41; and binge drinkers &#40;&#8805;1&#8239;binge drinking&#47;week&#41; had a higher cancer mortality and all-cause mortality risk&#46; The light or moderate drinkers &#40;&#8804;14&#8239;drinks&#47;week for men and &#8804;7&#8239;drinks&#47;week for women&#41; had a lower cardiovascular and all-cause mortality risk&#44; reproducing the known J curve&#46; An analysis by other researchers of the drinking patterns from the same NHIS database&#44; comparing them with those of 93&#44;653 individuals from the US Veterans Administration&#44; showed that&#44; if one considered the intake of 1&#8211;2 drinks on each occasion&#44; the greatest benefit was achieved by drinking 3 times&#47;week&#44; given that daily consumption slightly increased the risk compared with this level&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Another study published the same year and conducted in South Korea with a smaller sample &#40;8333&#8239;participants&#41; and a 10-year follow-up also showed that low-moderate alcohol consumption &#40;&#60;15&#8239;g&#47;day&#41; reduced the risk of myocardial infarction and coronary artery disease but also showed that the reduction was not significant when occasional drinkers were added to the reference group&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> The authors found demographic similarities between light and occasional drinkers&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">On the other hand&#44; we have the published report from the Global Burden of Disease &#40;GBD&#41; on the effects of alcohol and health&#46; The GBD is a regional and global research program that evaluates mortality and disability caused by the main diseases&#44; injuries and risk factors worldwide&#46; The GBD was founded in 1990 and has worked closely with the Institute of Health Metrics and Evaluation of the University of Washington and with the WHO&#46; The program currently has 1800 researchers in 127 countries&#46; The latest global report published in 2017<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> presented the factors that most influenced what the program defines as disability-adjusted life years or years lost due to disability or premature death &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The GBD estimated that alcohol was the seventh primary component of DALY risk worldwide in 2016 and was the factor that had risen the most in importance&#44; affecting men the most&#46; Alcohol was the main risk factor for the 15&#8211;49-year age group&#46; The GBD found that alcohol consumption had increased in countries with low to medium economic levels&#46; Therefore&#44; a year later&#44; the program published the specific data from the analysis of alcohol&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> with extensive supplemental material&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The authors remarked that their analysis had provided a methodological improvement in terms of estimating alcohol consumption based on several aspects such as analyzing 694 individual and populational data sources&#44; including the alcohol consumption of tourists and of unrecorded alcohol and performing a meta-analysis with a new analytical method of relative and individual risk on 23 health results associated with dose-response&#46; The study showed that&#44; at the global level&#44; alcohol increased the risk of a number of diseases without there being a benefit to low doses&#44; except for diabetes&#44; ischemic heart disease and ischemic stroke&#44; which decreased the risk&#46; However&#44; there were also a number of diseases for which low doses did not raise or lower the risk &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">A highly relevant study published in 2018 by Wood et al&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> analyzed 599&#44;912 alcohol drinkers from 83 studies&#44; encompassing 19 countries with high economic levels&#46; The study revealed that there was a positive curvilinear relationship with all-cause mortality and that the lowest risk level was an intake of &#8804;100&#8239;g&#47;week&#44; which corresponded to the flat part of the curve &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; As in previous studies&#44; the study found a negative relationship with CVD at low doses&#44; especially with myocardial infarction&#44; which decreased with any level of alcohol consumption&#46; However&#44; there was a positive almost linear relationship for the incidence of stroke&#44; another type of CVD&#44; hypertensive heart disease&#44; aortic aneurysm and even heart failure&#44; the latter of which contradicted a recent study called Atherosclerosis Risk in Communities&#44; which reported a reduction in the incidence of heart failure with an intake of &#60;7&#8239;drinks&#47;week&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> In the study by Wood et al&#46;&#44; an intake &#62;100&#8239;g&#47;week reduced life expectancy the younger the population and the greater the intake&#46; The authors concluded that the recommended limit for alcohol consumption should be reduced to 100&#8239;g&#47;week and that for other CVD &#40;except for myocardial infarction&#41;&#44; there is no safe level of consumption&#46; It is worth indicating that in this study the risk of all-cause hypertensive heart disease and stroke increased in the drinkers&#44; in contrast with the data from the GBD that indicated a reduction in ischemic stroke and a neutral effect on hypertensive heart disease in the light drinkers&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">It is also worth noting that these results only included individuals who drink&#46; When nondrinkers &#40;53&#44;851&#41; and ex-drinkers &#40;29&#44;726&#41; were included &#40;data published in the supplemental material&#41;&#44; both groups had a greater risk of overall mortality &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; The data were even more striking when analyzing cardiovascular events&#46; Although it is a well-known fact that ex-drinkers are a population at greater risk&#44; the data from the nondrinkers are surprising and were highlighted in the editorial comments&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> This subgroup had a higher proportion of individuals with diabetes and a lower educational level &#40;34&#46;9&#37; of the non-drinkers were university educated&#44; compared with 37&#46;2&#37; of the ex-drinkers and 51&#37; of the drinkers&#41; but had an increased risk despite the higher proportion of women &#40;70&#37; among non-drinkers&#44; compared with 51&#37; and 44&#37; for ex-drinkers and drinkers&#44; respectively&#41; and performed more moderately intense physical activity &#40;75&#46;7&#37; vs&#46; 62&#46;8&#37; and 50&#37;&#44; respectively&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Moreover&#44; a recent study conducted in London provided another argument for proponents of moderate alcohol consumption&#46; The Whitehall II study analyzed a cohort of 9087 middle-aged individuals &#40;35&#8211;55 years&#41; followed-up for 23&#8239;years and reported that there was an increased risk of dementia in the abstainers and drinkers of &#62;14 units&#47;week&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Lastly&#44; a recently published study &#40;April 2019&#41; in China reinforced the threshold of consumption of 100&#8239;g&#47;week&#46; The study analyzed a population of 500&#44;000 individuals&#44; mostly men &#40;98&#37;&#41;&#44; who were followed-up for 10 years&#46; Of these&#44; 161&#44;498 were genotyped for 2 variants that change alcohol metabolism and determine the pattern of consumption&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> The conventional epidemiological analysis reproduced the U curve for myocardial infarction&#44; stroke and intracerebral hemorrhage&#44; with a maximum level of risk reduction with a consumption of 100&#8239;g&#47;week&#46; However&#44; the mean alcohol intake predicted by the genotype &#40;ignoring the drinking patterns and in a Mendelian randomization&#41; did not result in this U curve&#46; The study found that alcohol increased systolic pressure&#44; stroke and hemorrhage and was neutral for myocardial infarction&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Considerations regarding moderate alcohol consumption</span><p id="par0135" class="elsevierStylePara elsevierViewall">Although epidemiological studies have shown high levels of association between alcohol consumption and numerous diseases&#44; there have been no randomized trials that have revealed a causality&#46; The Moderate Alcohol and Cardiovascular Health trial&#44; a multicenter trial sponsored by the National Institutes of Health and the National Institute of Alcohol Abuse and Alcoholism&#44; is the only randomized trial to date that has analyzed the impact of moderate alcohol consumption &#40;15&#8239;g&#47;day&#41; on cardiovascular disease and type 2 diabetes&#46; However&#44; the trial was prematurely interrupted in May 2018 after including 105 patients&#44; due to conflicts of interest created by the private funding &#40;more than 70&#37;&#41; from industrial alcohol manufacturers&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> We can therefore conclude that the level of evidence on the impact of a moderate consumption on health is not high&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">However&#44; recent studies have indicated that any alcohol consumption can increase the risk of various neoplasias &#40;especially in the gastrointestinal tract and breasts&#41;&#44; atrial fibrillation and hypertension&#46; This finding is counteracted by the evidence that moderate consumption reduces the risk of CVD &#40;especially myocardial infarction and diabetes&#41; and dementia&#44; effects that are more significant in countries in the industrialized world&#44; which have greater alcohol consumption and a specific drinking pattern&#46; Therefore&#44; the decision to consume alcohol is individual and should be determined by personal factors&#44; family history and social context&#46; In any case and based on current data&#44; the accepted limits of 140&#8211;200&#8239;g of alcohol&#47;week for men and 70&#8211;100&#8239;g for women should be reduced to 100&#8239;g&#47;week or less &#40;equivalent to 7&#8211;10 drinks weekly&#41;&#44; given that it appears that these levels do not increase all-cause mortality&#46; Based on the premise that alcohol consumption should not be started for health purposes and in contrast to total abstention with the social burden that represents&#44; these levels of alcohol consumption might be acceptable for middle-aged and elderly individuals but should exclude&#44; in line with a recent consensus document&#44;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> young adults&#44; pregnant women&#44; individuals with addiction&#44; those with arrhythmias&#44; liver or pancreatic diseases and those at risk of gastrointestinal or breast cancer&#46; Moreover&#44; all measures proposed by the WHO to fight excessive consumption and prevent binge drinking should be implemented&#46; In this respect&#44; the Mediterranean diet&#44; with moderate alcohol consumption combined with meals&#44; could be a recommended example of a healthy drinking pattern&#46; Although wine &#40;especially red wine&#41; has a high polyphenol content &#40;hydrolysable tannins&#44; resveratrol&#44; etc&#46;&#41; that has been confirmed to have beneficial health effects in numerous experimental studies&#44; a clear superiority over other alcoholic drinks has not been demonstrated&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Nevertheless&#44; the recent study by Wood et al&#46; found that there was a lower risk for those who predominantly drank wine compared with those who predominantly drank liquor or beer &#40;Fig&#46; 4&#8239;C&#41;&#46; Other studies<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49&#44;50</span></a> have also found that wine drinkers had greater protection than non-drinkers or those who did not drink wine&#59; however&#44; there are also studies that have found advantages with beer and even with liquor&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;51</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0145" class="elsevierStylePara elsevierViewall">JM and JRGL are members of the scientific committee of the Research Foundation on Wine and Nutrition&#46;</p></span></span>"
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          "titulo" => "References"
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    "fechaRecibido" => "2019-03-18"
    "fechaAceptado" => "2019-05-27"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1379690"
          "palabras" => array:8 [
            0 => "Alcohol"
            1 => "Wine"
            2 => "Health"
            3 => "Cardiovascular disease"
            4 => "Cancer"
            5 => "Moderate consumption"
            6 => "Harmful consumption"
            7 => "Binge drinking"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1379689"
          "palabras" => array:8 [
            0 => "Alcohol"
            1 => "Vino"
            2 => "Salud"
            3 => "Enfermedad cardiovascular"
            4 => "C&#225;ncer"
            5 => "Consumo moderado"
            6 => "Consumo nocivo"
            7 => "Atrac&#243;n"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Recent epidemiological studies have shown that alcohol consumption can increase the risk of arterial hypertension&#44; atrial fibrillation and gastrointestinal and breast cancer&#46; Various sectors are therefore promoting abstinence from alcohol&#46; However&#44; light alcohol consumption has once again been shown to reduce the risk of myocardial infarction and diabetes but with an unclear effect on cerebrovascular disease&#46; The decision to consume alcohol should therefore be an individual one based on personal factors&#46; A level of consumption &#60;100&#8239;g&#47;week for men &#40;less for women&#41; appears not to increase all-cause mortality&#44; while high consumption or binge drinking significantly increases mortality risk&#46; All measures to prevent this type of consumption&#44; especially among the younger population&#44; should therefore be applied&#46; There are data indicating an advantage of wine over other beverages&#44; but they are not conclusive&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Estudios epidemiol&#243;gicos recientes han demostrado que el consumo de alcohol puede aumentar el riesgo de hipertensi&#243;n arterial&#44; fibrilaci&#243;n auricular y de c&#225;ncer digestivo y de mama&#44; por lo que diversos estamentos est&#225;n promoviendo la abstinencia&#46; Sin embargo&#44; tambi&#233;n han vuelto a confirmar que el consumo ligero de alcohol puede reducir el riesgo de infarto de miocardio y de diabetes&#44; no quedando claro el efecto en la enfermedad cerebrovascular&#46; Por ello&#44; la decisi&#243;n del consumo de alcohol debe ser individual y basada en factores personales&#46; Un nivel de consumo &#60;100&#8239;gr&#47;semana en hombres &#40;menor en mujeres&#41;&#44; parece que no aumenta la mortalidad por cualquier causa&#44; mientras que consumos elevados o en forma de atrac&#243;n &#40;&#8220;binge&#8221;&#41;&#44; incrementan significativamente el riesgo de mortalidad&#44; por lo cual deben aplicarse todas las medidas para prevenir este tipo de consumo&#44; especialmente en la poblaci&#243;n m&#225;s joven&#46; Hay datos que apuntan una ventaja del vino frente a las otras bebidas pero no son concluyentes&#46;</p></span>"
      ]
    ]
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as&#58; Masip J and Germ&#224; Lluch JR&#46; Alcohol&#44; salud y enfermedad cardiovascular&#46; Rev Clin Esp&#46; 2021&#59;221&#58;359&#8211;368&#46;</p>"
      ]
    ]
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Equivalence of alcoholic drinks&#46; The first row shows the approximate volume equivalent to 1&#8239;SDU of the most common drinks according to their proof&#46; The bottom row shows an approximation of the most common quantities or &#8220;portions&#8221; of alcohol consumption&#46; Alcohol content of a beverage&#8239;&#61;&#8239;volume &#40;dL&#41;&#8239;&#215;&#8239;proof&#8239;&#215;&#8239;0&#46;79&#42; &#40;&#42;conversion factor&#41;&#46; SDU&#58; standard drink unit&#8239;&#61;&#8239;10&#8239;g of alcohol&#46;</p>"
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        "fuente" => "Source&#58; GBD 2016 alcohol collaborators<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>&#59; Supplement appendix 2&#58; GBD 2016 Alcohol Collaborators&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Percentage of population that drinks alcohol&#44; worldwide and for Spain&#46; A similar percentage can be observed in the various study periods&#46; &#40;B&#41; Mean consumption of standard alcohol drinks by inhabitant&#46; An increasing trend worldwide in men and a reduction in Spain for men and women can be observed&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Curves representative of the impact of alcohol consumption on the risk of various diseases&#44; grouped according to whether there is a direct increase from 0 &#40;graph and column on the left&#41; or with a flat section of the curve for low alcohol consumption&#44; i&#46;e&#46; with no impact &#40;graph and center column&#41; or a reduction with low alcohol consumption &#40;graph and column on the right&#41;&#46; The numbers in parentheses in the center column are equal to the SDUs that show a flat curve or below 0&#46; &#42;Unintentional injuries&#44; self-harm or traffic accidents&#46;</p>"
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        "fuente" => "Source&#58; Wood et al&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Diagram of the curves observed for the risk of cardiovascular disease and all-cause mortality in drinkers&#44; mainly in countries with high economic levels&#46; &#40;B&#41; Diagram of the curves observed for cardiovascular disease and all-cause mortality when non-drinkers and ex-drinkers are included&#46; &#40;C&#41; Diagram of the curves observed in all-cause mortality for alcohol consumers&#44; according to the predominant beverage type&#46;</p>"
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Increase excise taxes on alcoholic beverages&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Enact and enforce bans or comprehensive restrictions on exposure to alcohol advertising &#40;across multiple types of media&#41;&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Enact and enforce restrictions on the physical availability of retailed alcohol &#40;via reduced hours of sale&#41;&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">American Association of Clinical Oncology<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Clinical strategies of alcohol screening and brief intervention provided in clinical settings&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Regulate alcohol outlet density Increase alcohol taxes and prices&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Maintain limits on days and hours of sale&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Enhance enforcement of laws prohibiting sales to minors&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Restrict youth exposure to advertising of alcoholic beverages&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Resist further privatization of retail alcohol sales in communities with current government control&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Include alcohol control strategies in comprehensive cancer control plans&#46;&nbsp;\t\t\t\t\t\t\n
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Global status report on alcohol and health 2018<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">LoConte et al&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p>"
            ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Proposed measures for reducing harm alcohol consumption&#46;</p>"
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          "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The 5 main causes of death and disability according to the Global Burden of Disease in the past 25 years and the place occupied by alcohol&#46;</p><p id="spar1035" class="elsevierStyleSimplePara elsevierViewall">Source&#58; GBD 2016 Risk Factors Collaborators&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a></p>"
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:51 [
            0 => array:3 [
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              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Wine and cardiovascular health&#46; A comprehensive review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "S&#46; Haseeb"
                            1 => "B&#46; Alexander"
                            2 => "A&#46; Baranchuk"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1161/CIRCULATIONAHA.117.030387"
                      "Revista" => array:6 [
                        "tituloSerie" => "Circulation"
                        "fecha" => "2017"
                        "volumen" => "136"
                        "paginaInicial" => "1434"
                        "paginaFinal" => "1448"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28993373"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prospective study of alcohol consumption and risk of coronary disease in men"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "E&#46;B&#46; Rimm"
                            1 => "E&#46;L&#46; Giovannucci"
                            2 => "W&#46;C&#46; Willett"
                            3 => "G&#46;A&#46; Colditz"
                            4 => "A&#46; Ascherio"
                            5 => "B&#46; Rosner"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/0140-6736(91)90542-w"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "1991"
                        "volumen" => "338"
                        "paginaInicial" => "464"
                        "paginaFinal" => "468"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1678444"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Factors associated with cardiac mortality in developed countries with particular reference to the consumption of wine"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "A&#46;S&#46; St Leger"
                            1 => "A&#46;L&#46; Cochrane"
                            2 => "F&#46; Moore"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/s0140-6736(89)92659-7"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "1979"
                        "volumen" => "1"
                        "paginaInicial" => "1017"
                        "paginaFinal" => "1020"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2565492"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Polyphenols synergistically inhibit oxidative stress in subjects given red and white wine"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46; Pignatelli"
                            1 => "A&#46; Ghiselli"
                            2 => "B&#46; Buchetti"
                            3 => "R&#46; Carnevale"
                            4 => "F&#46; Natella"
                            5 => "G&#46; German&#242;"
                          ]
                        ]
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