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Prospective Study of Moderate Alcohol Consumption and Risk of Hypertension in Young Women
Ravi Thadhani, MD, MPH;
Carlos A. Camargo, Jr, MD, DrPH;
Meir J. Stampfer, MD, DrPH;
Gary C. Curhan, MD, ScD;
Walter C. Willett, MD, DrPH;
Eric B. Rimm, ScD
Arch Intern Med. 2002;162:569-574.
ABSTRACT
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Background Heavy alcohol consumption is associated with an increased risk of hypertension.
However, the effect of moderate alcohol consumption; the specific effects
of wine, beer, and liquor; and the pattern of drinking in relation to risk
of hypertension among young women are unclear.
Methods We prospectively examined the association between alcohol consumption
and subsequent risk of hypertension among 70 891 women 25 to 42 years
of age.
Results During the 8 years of follow-up, 4188 cases (5.9%) of incident hypertension
were reported. After adjustment for multiple covariates, the association between
alcohol consumption and risk of hypertension followed a J-shaped curve. Compared
with nondrinkers, the risk of developing hypertension according to average
number of drinks consumed per day was as follows: 0.25 or less, 0.96 (95%
confidence interval [CI], 0.89-1.03); 0.26 to 0.50, 0.86 (95% CI, 0.75-0.98);
0.51 to 1.00, 0.92 (95% CI, 0.82-1.04); 1.01 to 1.50, 1.00 (95% CI, 0.80-1.24);
1.51 to 2.00, 1.20 (95% CI, 0.92-1.58); and more than 2.0 drinks, 1.31 (95%
CI, 1.02-1.68). Exclusion of past drinkers yielded similar results. Among
women in the highest category of alcohol consumption, there was a suggestion
that the increased risk of hypertension was present regardless of the specific
beverage consumed (beer, wine, or liquor). Episodic drinking, defined as consumption
of more than 10.5 drinks over 3 or fewer days per week, was not associated
with increased risk of hypertension (relative risk, 0.80; 95% CI, 0.51-1.23).
Conclusions The association between alcohol consumption and risk of chronic hypertension
in young women follows a J-shaped curve, with light drinkers demonstrating
a modest decrease in risk and more regular heavy drinkers demonstrating an
increase in risk.
INTRODUCTION
HYPERTENSION is an important cause of disability and mortality and has
been linked to several disorders, including coronary and cerebrovascular disease
and renal insufficiency.1-3
Persuasive epidemiologic evidence suggests that heavy alcohol consumption
is strongly associated with increased risk of hypertension,4
and approximately 3% to 8% of high blood pressure in women is attributable
to alcohol consumption.5 Activation of the
sympathetic nervous system and alteration of vascular tone have been hypothesized
as the probable mechanisms involved to explain this relationship.6 Light to moderate drinking, a more socially acceptable
behavior,4 has been associated with a reduced
risk of ischemic stroke7 and coronary heart
disease8 among women. Despite these data, the
effects of light to moderate drinking on blood pressure in young women have
not been established.
The overwhelming number of studies that have examined the relationship
between alcohol intake and risk of hypertension have been among men or limited
to cross-sectional design.4 More important,
in the light to moderate range, it remains unclear whether the association
is linear or J-shaped, or whether there is a threshold effect. Other issues
that have not been adequately addressed include the individual effect of specific
beverages (beer, wine, liquor) on blood pressure, and whether episodic or
binge drinking is associated with increased risk of hypertension. To address
these issues, we examined prospectively the association between alcohol intake
and risk of hypertension during an 8-year period in a cohort of 70 891
young women.
SUBJECTS AND METHODS
STUDY POPULATION
The Nurses' Health Study II is a prospective cohort study of 116 671
female nurses in the United States who were 25 to 42 years old at baseline
in 1989. This cohort is followed up by biennial mailed questionnaires focusing
on various lifestyle factors and health outcomes; the follow-up rate exceeds
90% for every 2-year period, and there is almost complete (98%) follow-up
on mortality data.9 The institutional review
board of our hospital has approved this study.
EXPOSURE ASSESSMENT—ALCOHOL INTAKE
In 1989, the baseline questionnaire included questions on the average
intake of alcoholic beverages (beer, wine, and liquor) during the past year.
Nurses responded to the following question: "During the past year, what was
your usual consumption of these (beer, wine, liquor) alcoholic beverages?"
Intake of each beverage was ascertained in 9 categories (number of drinks):
none or less than 1 per month, 1 to 3 per month, 1 per week, 2 to 4 per week,
5 to 6 per week, 7 to 13 per week, 14 to 24 per week, 25 to 39 per week, and
40 or more per week. Total amount of alcohol consumed was estimated at 12.8
g for a bottle or can of beer (12 oz), 11 g for a glass of wine (4 oz), and
14 g for a shot of liquor (1.5 oz). Total alcohol intake was computed as the
sum of the intake from beer, wine, and liquor. Beverage-specific consumption
was also calculated and analyzed separately. For analysis, a standard drink
was considered 12 g of alcohol. In addition, women were asked to respond to
the following: "In a typical week during the past year, on how many days did
you consume an alcoholic beverage of any type?" A total of 8 responses was
possible (0 to 7 days per week). Overall, these measures of frequency and
quantity were used to define average number of drinks consumed per day and
episodic drinking (see "Statistical Analysis" subsection).
Reliability and validity of the questionnaire measure of alcohol intake
were evaluated in a subset of women participating in a similar study. Among
173 of these women, alcohol intake was assessed by multiple 1-week diet records
in 1980 and by questionnaire in both 1980 and 1981. When compared with the
diet records, the correlation was 0.86 for alcohol assessed from the questionnaire
in 1980 and 0.90 for the 1981 questionnaire.10
Alcohol intake as measured by each of the methods has been correlated with
plasma concentrations of high-density lipoprotein (r
= 0.40, P<.001),11
similar to the dose-response found in closely monitored metabolic studies.12
Baseline questions on history of alcohol consumption were used to define
past drinkers and to identify women with past heavy alcohol use ( 40 drinks
per week). Women in the latter group were excluded (see "Exclusions" subsection).
We examined the relationship between episodic drinking, or drinking
large amounts of alcohol during a short period, and risk of hypertension by
means of 2 different definitions: the primary definition, consumption of more
than 10.5 drinks over 1 to 3 days per week, and a more strict definition,
consumption of 12 or more drinks over 1 to 3 days per week.
ASSESSMENT OF COVARIATES
Exposure status for all potential confounders including height, weight,
family history of hypertension, race, smoking, physical activity, history
of elevated cholesterol level, and oral contraceptive use was defined by responses
on the baseline questionnaire. Body mass index (BMI) was calculated as weight
in kilograms divided by the square of height in meters. In nurses, self-reported
weights were highly correlated with actual measurements (r = 0.96).13 A validation study of recalled
weight at 18 years of age compared recalled weight with records from physical
examinations conducted at college or nursing school entrance. The correlation
between recalled and measured BMI at age 18 years was 0.84 (P<.01).14
ASSESSMENT OF INCIDENT HYPERTENSION
In 1989, women reported a history of hypertension and their usual systolic
and diastolic blood pressure (7 categories). On questionnaires sent biennially
from 1991 to 1997, women were asked to report development of physician-diagnosed
hypertension in the preceding 2 years. We examined the validity of the response
to this question in 2 populations of similar nurses. The false-positive rate
was examined in a sample of 100 nurses reporting a diagnosis of high blood
pressure.15 Sixty-two gave permission to review
their medical records, and complete records were obtained for 51 women. All
had recorded values of blood pressure greater than 140/90 mm Hg, and for 39
(77%), blood pressure was greater than 160/95. To investigate the false-negative
rate, blood pressure was measured in a sample of 161 nurses without a history
of high blood pressure. Among these women, 7% had a blood pressure greater
than 140/90 mm Hg, but none had a blood pressure greater than 160/95 mm Hg.
EXCLUSIONS
A total of 116 671 women were enrolled in the Nurses' Health Study
II in 1989. We excluded women who reported a history of hypertension before
1991 (n = 7847); no physical examination within 2 years of the baseline questionnaire
or a report of a systolic blood pressure of 135 mm Hg or more or a diastolic
blood pressure of 90 mm Hg or more; history of myocardial infarction, cancer
(except nonmelanoma skin cancer), diabetes, stroke, seizures, or hepatitis
(infectious or otherwise); antihypertensive medication use; or alcohol intake
of more than 40 drinks per week at any age. We also excluded women who gave
birth during the follow-up period (n = 22 936), because pregnancy may
have altered future alcohol consumption. All exclusions were made before the
analyses. A total of 70 891 women remained eligible for analysis, and
among these women, approximately 98% had 4 years or more of follow-up.
STATISTICAL ANALYSIS
Alcohol consumption assessed in 1989 was divided into 7 categories—none,
0.25 drink per day or less, 0.26 to 0.50, 0.51 to 1.00, 1.01 to 1.50, 1.51
to 2.00, and more than 2.00 drinks per day—and modeled as indicator
variables to allow for nonlinear associations. For all analyses, nondrinkers
(never drinkers and past drinkers) were considered the referent category,
and all analyses were repeated after exclusion of past drinkers from the referent
category.
To determine whether a change in drinking pattern over time may have
affected our findings, we compared the results of analyses based on the cumulative
incidence restricted to the first 4 years of follow-up (from 1989 to1993)
with results when the cumulative incidence was ascertained with up to 8 years
of follow-up. The results did not materially change when either period was
used; thus, data with 8 years of follow-up are presented.
We calculated relative risks as the incidence of hypertension among
women with a given alcohol intake divided by the corresponding rate among
abstainers. In addition, stratified analyses were performed to assess the
possibility of confounding and effect modification. To test for effect modification,
we added to the multivariate model the product of the interaction term (as
indicator variables) and each of the levels of alcohol consumption. Exposures
were not updated, and thus logistic regression was used to adjust for potential
confounding factors.
Beverage-specific effects were examined both in models that included
only those reporting consumption of a single beverage and in models with all
women combined to assess the independent effect of each beverage adjusted
for the consumption of the other beverages. In the analyses of episodic drinking,
the model also included women who drank regularly (5-7 days per week) and
those who drank less frequently (1-4 days per week). We calculated 95% confidence
intervals (CIs) for each relative risk (RR) and 2-sided P values for all analyses.
RESULTS
During the 8 years of follow-up (403 151 person-years), 4188 incident
cases of hypertension (5.9%) were identified. The characteristics according
to baseline alcohol consumption are presented in Table 1. A total of 27 070 (38%) reported no drinking at baseline,
and 957 (1%) reported an average alcohol consumption of more than 2 drinks
per day. Mean BMI and the frequency of reported history of elevated cholesterol
level reached a nadir among women who consumed 1.01 to 1.50 drinks per day.
In addition, women who drank increasing amounts of alcohol were more likely
to be current or past smokers and oral contraceptive users. Most other baseline
characteristics were similar across the drinking categories.
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Table 1. Baseline Characteristics of 70 891 Women According to
Average Alcoholic Drinks per Day*
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In the age-adjusted analysis, the relative risk of hypertension according
to level of alcohol consumption followed a J-shaped curve. After adjustment
for other confounding factors including BMI, the J-shaped relationship became
more pronounced (Table 2). Compared
with women who abstained, the relative risk of hypertension was lowest among
women drinking 0.25 to 0.50 drinks per day (RR, 0.86; 95% CI, 0.75-0.98) and
highest among women drinking more than 2 drinks per day (RR, 1.31; 95% CI,
1.02-1.68). We explored which potential confounders altered the J-relationship
and found that, after adjustment for BMI, addition of the other covariates
to the model altered the shape only slightly. We explored the possibility
that bias was introduced by including past drinkers in the nondrinker referent
category; however, excluding past drinkers yielded the same J-relationship
(data not shown). In this model, compared with abstainers, the risk of hypertension
among past drinkers was 0.78 (95% CI, 0.52-1.15). The association between
alcohol intake and risk of hypertension did not appreciably vary by level
of any of the covariates examined (eg, BMI and smoking).
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Table 2. Risk of Hypertension According to Average Alcoholic Drinks
per Day in 70 891 Women*
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For beer, wine, and liquor, we examined separate models including only
women who reported consumption of a specific beverage compared with abstainers.
Thereafter, we included all women in the cohort by simultaneously including
indicator variables for categories of consumption of beer, wine, and liquor
into a single logistic model. The purpose of this analysis was to determine
the independent effect of each beverage adjusted for the consumption of the
other beverages. The overall results were similar (data not shown), and the
results of the all-inclusive model are presented in Table 3. There was a suggestion that light-beer drinking was inversely
associated with risk of hypertension. Although there were few cases in the
higher categories of consumption (eg, >0.5 drink per day), risk tended to
increase beyond consumption of 1.0 drink per day regardless of the specific
beverage consumed.
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Table 3. Risk of Hypertension According to Average Drinks of a Specific
Beverage Consumed per Day
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Finally, we examined different patterns of alcohol consumption and risk
of hypertension. In our initial analyses (Table 2), we found a suggestion of an increased risk of hypertension
among women consuming more than 1.5 drinks per day. Therefore, we initially
examined risk by means of the following definition of episodic drinking: consumption
of more than 10.5 drinks (>1.5 drinks per day x 7 days) over 1 to 3
days. After adjustment for potential confounders, the risk of hypertension
was not increased among women in this category of consumption (n = 469) (RR,
0.80; 95% CI, 0.51-1.23), but was increased among women who drank more than
1.5 drinks per day for at least 5 days per week (n = 1190) (RR, 1.44; 95%
CI, 1.15-1.81). The risk among women who drank 1.5 drinks per day or less
but who drank for at least 5 days per week was not increased (n = 2175) (RR,
0.99; 95% CI, 0.81-1.22). We then used a more strict definition of episodic
drinking: consumption of at least 12 drinks over 1 to 3 days. Even with this
more strict definition, episodic drinkers were not at increased risk of chronic
hypertension (RR, 1.03; 95% CI, 0.61-1.74), but with only 16 cases in this
category, we could not exclude the possibility of risk.
COMMENT
In this study of 70 891 women, the association between alcohol
intake and risk of hypertension followed a J-shaped curve. Among women who
consumed on average 0.26 to 0.50 drink per day, the risk of developing hypertension
was lower by 14% compared with nondrinkers. An increased risk of hypertension
was evident beyond consumption of 2 drinks per day, but when episodic drinkers
were separated from this analysis, elevated risk was evident among regular
drinkers who consumed more than 1.5 drinks per day. We did not observe a beverage-specific
effect, and we also did not observe a positive association between episodic
drinking and increased risk of chronic hypertension.
More than 130 cross-sectional publications have addressed the relationship
of moderate alcohol consumption and risk of hypertension.4
These studies have reported discrepant findings, with differences that can
be attributed to chance, bias, or unadjusted confounding. Prospective studies
have not focused specifically on the relationship between moderate drinking
and blood pressure, and instead support a threshold association for hypertension,
with an increased risk among women who consume 2 or more drinks per day.4 Witteman et al16 examined
the alcohol–blood pressure relationship in the Nurses' Health Study
I among more than 58 000 women aged 34 to 59 years. Women consuming less
than 1 drink per day had a slightly lower risk of hypertension (RR, 0.9; 95%
CI, 0.8-1.0), whereas women consuming 2 to 3 drinks per day had an adjusted
RR of 1.4 (95% CI, 1.2-1.7). In our cohort of even younger women, we too found
a J-shaped relationship with a reduced risk among women consuming up to one-half
glass of an alcoholic beverage per day. Furthermore, the risk of hypertension
was increased by 44% among women who drank more than 1.5 drinks per day at
least 5 days per week. This threshold is slightly lower than that previously
reported and may relate to a more precise assessment of drinking pattern.
Some have argued that the J-shaped relationship to hypertension may
be the result of previously hypertensive individuals lowering their alcohol
intake.17 If these individuals are included
in the reference category, the risk of hypertension among those considered
nondrinkers may be falsely elevated. We excluded women who at baseline reported
hypertension, an elevated systolic or diastolic blood pressure, use of antihypertensive
medications, hypertension-related conditions (ie, myocardial infarction, diabetes,
or stroke), or past consumption of excessive amounts of alcohol. We also examined
models with and without past drinkers in the reference category, since past
drinkers may have stopped drinking for other medical reasons,18
but the results did not materially change from those in Table 2.
There is strong interest in beverage-specific health effects, with some
suggesting that red wine is the most effective beverage with respect to cardiovascular
risk reduction.19-20 Beverage-specific
effects may be due to differences in the constituents of each beverage, or
consumption of a specific beverage may be a marker for a more beneficial drinking
pattern.21 For example, in Western society,
wine tends to be consumed in smaller amounts with meals,22
which may blunt the alcohol–blood pressure association.23
In addition, an individual's preference for one beverage type over another
has been correlated with demographic and behavioral factors that may influence
blood pressure, such as exercise and diet.4, 18
After controlling for many of these lifestyle factors, the risk of developing
hypertension in the highest categories of consumption across all beverages
was similar. The number of women drinking at the extremes of consumption,
however, was small, and so the CIs were wide. We did find that light-beer
drinking was protective against chronic hypertension. Cross-sectional data
from Japan also suggest a protective blood pressure effect among exclusive
beer drinking compared with drinking other beverages.24
Given the overlapping CIs associated with the beverage-specific estimates,
however, further studies are needed to verify these results and to assess
whether any protective effect is due to the nonalcoholic ingredients associated
with beer consumption or to other lifestyle factors associated with beer consumption.
The health effects of drinking may depend on drinking pattern,25 and failure to differentiate episodic from regular
drinkers may obscure real associations.4, 26
Although some cross-sectional studies suggest that daily drinking is associated
with a stronger alcohol–blood pressure association than episodic drinking,25-26 others do not.27
We found that the risk of hypertension was increased among more regular (eg,
daily) drinkers who consumed more than 1.5 drinks per day, but not among episodic
drinkers. Indeed, removal of episodic drinkers from our initial analysis demonstrated
that, among more regular drinkers, risk was increased at a level slightly
lower (1.5 vs 2.0 drinks per day) than that previously reported.4
Adverse consequences of episodic drinking, including acute cerebrovascular
and cardiovascular events28-29
and injury,30 however, suggest that this behavior
is unsafe for other reasons.
We were unable to assess the short-term effects of alcohol consumption
on blood pressure.31 Therefore, although episodic
drinking may have been associated with acute elevation in blood pressure,32 in our study this behavior was not associated with
chronic hypertension unless heavier consumption extended to most days of the
week. The biological mechanisms of alcohol-induced hypertension are not clear,
but investigators continue to debate whether the hypertensive effect is due
to withdrawal or directly mediated by alcohol itself.6, 33
Although we initially excluded past heavy users of alcohol, we subsequently
examined these women to assess the effect of drinking 25 or more drinks per
week before the start of the study and found no noticeable elevated risk (RR,
1.02; 95% CI, 0.72-1.46) of hypertension. We could not, however, assess whether
these women were binge or regular drinkers and the time since their last drink.
Nonetheless, this result suggests that the ill effects of heavy past drinking,
at least with respect to risk of developing chronic hypertension, do not persist.
The limitations of this study deserve mention. We relied on self-reported
diagnosis of hypertension, the validity of which was discussed in detail herein.
In addition, self-reported physician diagnosis of hypertension was a strong
predictor of myocardial infarction and stroke among women participating in
the Nurses' Health Study I.34 We also relied
on self-reported consumption of alcohol, the validity of which was also described.
It is likely that the greatest degree of reporting error occurs at the highest
levels of consumption. Therefore, the level of consumption at which we attribute
increased risk (>1.5 drinks per day) may be a modest underestimate, but the
level of intake associated with a slight decrease in risk of hypertension
( 0.5 drinks per day) is unlikely to be substantially biased. Finally,
we studied mainly white nurses; therefore, our results may not pertain to
women of other racial or ethnic groups.
In conclusion, prospective data on light to moderate alcohol consumption
and risk of hypertension in young women are sparse. Our prospective study
of 70 891 women suggests that the association between alcohol consumption
and risk of hypertension follows a J-shaped curve that is still present even
after adjustment for potential confounding factors and several possible biases.
These data exclude a strong effect of moderate alcohol consumption and risk
of chronic hypertension. Our results also suggest that the risk of hypertension
with heavy drinking (>1.5 drinks per day) is evident regardless of beverage
consumed. Finally, whereas episodic drinking does not appear to increase a
woman's risk of hypertension, regular consumption of more than 1.5 drinks
per day is associated with an increased risk. These data refine our understanding
of alcohol consumption and risk of hypertension and may be used by primary
physicians in counseling young women.
AUTHOR INFORMATION
Accepted for publication July 17, 2001.
This study was supported by research grants HL-03804, HL-03533, and
AA-11181 from the National Institutes of Health, Bethesda, Md.
Corresponding author and reprints: Ravi Thadhani, MD, MPH, Channing
Laboratory, 181 Longwood Ave, Boston, MA 02115 (e-mail: rthadhani{at}partners.org).
From the Channing Laboratory, Department of Medicine, Brigham and Women's
Hospital (Drs Thadhani, Camargo, Stampfer, Curhan, Willett, and Rimm); Renal
Unit (Drs Thadhani and Curhan) and Department of Emergency Medicine (Dr Camargo),
Massachusetts General Hospital; Departments of Nutrition and Epidemiology,
Harvard School of Public Health (Drs Stampfer, Willett, and Rimm); and Harvard
Medical School (Drs Thadhani, Camargo, Stampfer, Curhan, Willett, and Rimm),
Boston, Mass.
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Am. J. Clin. Nutr. 2008;87:1455-1463.
ABSTRACT
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Alcohol Consumption and the Risk of Hypertension in Women and Men
Sesso et al.
Hypertension 2008;51:1080-1087.
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Wine, Diet, and Arterial Hypertension
Carollo et al.
ANGIOLOGY 2007;58:92-96.
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Alcohol Consumption and Risk for Coronary Heart Disease among Men with Hypertension
Beulens et al.
ANN INTERN MED 2007;146:10-19.
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Coronary Atherosclerosis and Alcohol Consumption: Angiographic and Mortality Data
Femia et al.
Arterioscler. Thromb. Vasc. Bio. 2006;26:1607-1612.
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Low-fat dairy consumption and reduced risk of hypertension: the Seguimiento Universidad de Navarra (SUN) cohort
Alonso et al.
Am. J. Clin. Nutr. 2005;82:972-979.
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Moderate Alcohol Consumption Is Associated With Reduced Arterial Stiffness in Older Adults: The Rotterdam Study
Mattace-Raso et al.
J. Gerontol. A Biol. Sci. Med. Sci. 2005;60:1479-1483.
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Moderate Alcohol Consumption Lowers the Risk of Type 2 Diabetes: A meta-analysis of prospective observational studies
Koppes et al.
Diabetes Care 2005;28:719-725.
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Olive oil, the Mediterranean diet, and arterial blood pressure: the Greek European Prospective Investigation into Cancer and Nutrition (EPIC) study
Psaltopoulou et al.
Am. J. Clin. Nutr. 2004;80:1012-1018.
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Alcohol consumption and prognosis in patients with left ventricular systolic dysfunction after a myocardial infarction
Aguilar et al.
J Am Coll Cardiol 2004;43:2015-2021.
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Media Violence Research and Youth Violence Data: Why Do They Conflict?
Olson
Acad. Psychiatry 2004;28:144-150.
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Alcohol Consumption and Cardiovascular Disease Mortality in Hypertensive Men
Malinski et al.
Arch Intern Med 2004;164:623-628.
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Alcohol Consumption in Relation to Aortic Stiffness and Aortic Wave Reflections: A Cross-Sectional Study in Healthy Postmenopausal Women
Sierksma et al.
Arterioscler. Thromb. Vasc. Bio. 2004;24:342-348.
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Alcohol Consumption and Carotid Atherosclerosis in Older Adults: The Cardiovascular Health Study
Mukamal et al.
Arterioscler. Thromb. Vasc. Bio. 2003;23:2252-2259.
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Moderate alcohol intake and renal function decline in women: a prospective study
Knight et al.
Nephrol Dial Transplant 2003;18:1549-1554.
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Moderate alcohol intake and renal function decline in women: a prospective study
Knight et al.
Nephrol Dial Transplant 2003;18:1549-1554.
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