The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 62:213-218 (2007)
© 2007 The Gerontological Society of America
Alcoholic Beverage Preference, 29-Year Mortality, and Quality of Life in Men in Old Age
Timo E. Strandberg,
Arto Y. Strandberg,
Veikko V. Salomaa,
Kaisu Pitkälä,
Reijo S. Tilvis and
Tatu A. Miettinen
1 Department of Public Health Science and General Practice, University of Oulu, Finland.
2 Oulu University Hospital, Unit of General Practice, Finland.
3 Department of Medicine, Geriatric Clinic, University of Helsinki, Finland.
4 KTL-National Public Health Institute, Helsinki, Finland.
Address correspondence to Timo E. Strandberg, MD, Department of Public Health Science and General Practice, University of Oulu and University Hospital, P.O. Box 5000, FIN-90014 Oulun Yliopisto, Finland. E-mail: timo.strandberg{at}oulu.fi
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Abstract
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Background. Harms of excessive alcohol consumption are obvious, but moderate wine consumption is frequently advocated for prevention of cardiovascular diseases. We compared 29-year mortality and quality of life in old age by alcoholic beverage preference (beer, wine, or spirits) in a cohort of men whose socioeconomic status was similar in their adult life.
Methods. In 1974, cardiovascular risk factors and beverage preference were assessed in 2468 businessmen and executives aged 40–55 years. Of them, 131 did not use alcohol, 455 did not report a single preference, and 694, 251, and 937 preferred beer, wine, and spirits, respectively. Quality of life with a RAND-36 Short Form (SF)-36 instrument was surveyed in 2000 in survivors. Mortality was retrieved from registers during the 29-year follow-up.
Results. Alcoholic beverage preference tracked well during the follow-up. Total alcohol consumption was not significantly different between preference groups. Men with wine preference had the lowest total mortality due to lower cardiovascular mortality. With the spirits group as the reference category and age, cardiovascular risk factors, and total alcohol consumption as covariates, wine drinkers had a 34% lower total mortality (relative risk 0.66; 95% confidence interval, 0.45–0.98); relative risk for beer preferers was 0.91 (95% confidence interval, 0.68–1.14). In 2000, wine preferers had the highest scores in all RAND-36 scales; general health (p =.007) and mental health (p =.01) were also significantly different.
Conclusion. In this male cohort from the highest social class, wine preference was associated with lower mortality and better quality of life in old age. Mortality advantage was independent of overall alcohol consumption and cardiovascular risk factors, but contributing personal characteristics or early life differences cannot be excluded.
EXCESSIVE alcohol consumption causes well-known ill effects (1). In contrast, favorable effects of moderate alcohol consumption, especially wine drinking, on cardiovascular diseases and mortality have been documented in numerous studies (cf. meta-analysis 2–5). Moderate alcohol consumption has also been associated with less dementia and better cognitive function (6–9). Especially red wine contains several substances with favorable biological, for example antioxidant, activity; therefore, wine consumption could even be advocated for cardiovascular prevention in middle-aged and elderly people (10). However, moderate users and wine preferers may simply be protected by other beneficial effects of their life course and lifestyle ("the healthy user bias") (11–16). Thus, controlling for confounders, especially social class (17), is important in observational studies. Moreover, alcohol consumption is usually a life-long habit, and the health effects should also be considered in the long-term, not only for 5- to 10-year follow-up times.
Similar to our earlier analysis of total alcohol consumption (18), we considered that all-cause mortality and quality of life in survivors are relevant endpoints for a follow-up study of the effects of consuming various alcoholic beverages. The men in our cohort are socioeconomically comparable in their adult life, and all of them were middle-aged and professionally active at baseline. This setting offers a clearer test for the effects of alcoholic beverages because the influence of social class on beverage preference is decreased.
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PARTICIPANTS AND METHODS
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Baseline Examinations in 1974 and Follow-Up Examination in 1986
The cohort and examinations have been described earlier (18,19). Initially, 3490 healthy men, mostly businessmen and executives born in 1919–1934, had participated in structured health check-ups during the 1960s and early 1970s at the Institute of Occupational Health in Helsinki. These health examinations—usually paid by their companies—were specifically directed to healthy men in leading positions in various private companies; consequently, the participants can be assumed to have similar social status and wealth in their adult life, and also during the follow-up. The men were evaluated with questionnaires and clinical and laboratory examinations in 1974. As 68 men had died by 1974 and 2721 men responded to the 1974 query, the response rate was 80%. Of these 2721 men, 2468 (91%) reported their beverage preference. Thus, overall we have data of the beverage preference of 72% of the original background population (Figure 1). In the questionnaires, participants were asked about their weekly alcohol consumption, and types of beverages consumed were reported by 2468 men. The participants were in positions of responsibility, and those with known alcoholism or psychiatric disturbances were excluded from the study at baseline. These exclusions are liable to diminish the possible effect of problem drinking on the results in this cohort. The pattern of drinking—for example, binge drinking—was not identified. Of the men, 131 did not use alcohol at all (abstinence group). In this study, one unit of alcohol ("restaurant unit": a bottle of beer, a glass of wine, one drink of spirits) was calculated to contain 14 g of alcohol. Alcohol preference was defined simply as the beverage that the man reported to consume the most, whatever the difference to other beverages. With this definition, 694 men preferred beer, 251 wine, and 937 spirits ("single preference," although most men consumed all beverages). In addition, 455 men reported similar amounts of two or three beverages. In the analyses we compared the three single preference groups unless otherwise stated.
At baseline in 1974, all the men were professionally active. Most of the men had various cardiovascular risk factors but only 115 (5%) had a known history of cardiovascular disease. Their alcohol preferences did not differ from the rest of the cohort. Weight and height were measured, and body mass index (BMI) was calculated as weight (kg) divided by height (m) squared. Some (1657) of the men also reported their weight at 25 years of age, which was used to calculate midlife weight gain (weight in 1974 minus reported weight at 25 years of age). In 1974 the men were also asked questions on how they rated their present health and physical fitness on a 5-step scale ("very good," "good," "fair," "poor," "very poor").
In 1985–1986, 1369 men were reassessed with questionnaires and laboratory examinations. This survey was only directed to those men who were clinically healthy in 1974 and had full data of baseline risk factors available. The survey included a question about alcohol consumption. Serum gamma-glutamyl transferase (gamma-GT) activity was measured in 203 men in conjunction with a metabolic study (20). Thus, we could compare reported alcohol consumption with a biochemical marker of alcohol (21) in a small sample of the cohort.
The 2000 Survey and Quality of Life
In 2000, a questionnaire was mailed to all survivors (n = 1781) and remailed once for nonrespondents; 1515 men (85.1%) responded (Figure 1). Baseline alcohol consumption was not different between respondents and nonrespondents (p =.32). Of the respondents, 1127 had also reported their baseline beverage preference. The questionnaire included items on demographic variables and lifestyle such as regular exercise and smoking status. The question on alcohol consumption was similar to that in the earlier surveys of 1974 and 1985–1986. In addition, the Finnish version of the RAND-36-Item Health Survey 1.0 (practically identical to the Short Form [SF]-36 health survey; 22,23) was embedded in the questionnaire. The eight RAND-36 scales (physical function, role physical, bodily pain, general health, vitality, social function, role emotional, and mental health) measure health-related quality of life, and the RAND-36 as a mailed questionnaire has been validated in the Finnish general population (22).
Mortality Follow-Up
Total mortality of the study population through December 31, 2002, was retrieved from the National Population Information System, which is a registry of all Finnish citizens. The register's assessment of vital status is reliable for people who permanently reside in Finland (over 95% of the present cohort), irrespective of whether they die in Finland or abroad. Moreover, the assessment of vital status is also quite reliable for Finnish citizens living permanently abroad. Causes of death through December 31, 1999 were determined from the countrywide computerized Cause of Death Register at Statistics Finland in which trained nosologists code causes of death. The causes were categorized into 3 groups: cardiovascular, cancer, or other causes.
Statistical Methods
NCSS statistical software (www.ncss.com) was used for the analyses. In the analyses, alcohol consumption was categorized as described above. Student's t tests, nonparametric tests, and analyses of covariance (ANCOVA) were used where appropriate to compare continuous variables, chi-square and trend tests were used to compare proportions, and Spearman rank coefficients were used to assess correlations. Differences in survival curves were analyzed with the log rank test. Relative risks (RR) with their 95% confidence intervals (CI) for mortality associated with alcoholic beverage preference at baseline were calculated using Cox's proportional hazards regression. Other risk factors were adjusted for in respective models. The eight RAND-36 scales were calculated from questionnaires (22,23). In statistical analyses, two-tailed tests were used and p values <.05 were taken as statistically significant.
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RESULTS
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Baseline
Baseline characteristics of the cohort according to baseline alcoholic beverage preference are shown in Table 1. Data from men reporting no alcohol intake (abstinence group, n = 131) or no single preference (n = 455) are shown for comparison. Of the men, 87% were categorized to consume alcohol moderately (mean consumption less than 3 drinks/d, 42 g/d), and only 13% reported high consumption (mean 5 drinks/d, 70 g/d); these proportions were not different between the preference groups. The men preferring spirits differed from the other two groups by having a higher BMI and serum triglycerides, also smoking was more frequent among this group. Total alcohol consumption was not significantly different between the groups. Self-report of subjective health and physical fitness in the three preference groups in 1974 showed that wine preference was associated with better profiles at baseline (Figure 2).
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Figure 2. Distribution of subjective physical fitness and subjective general health in 1974 according to the alcoholic beverage preference group. Numbers refer to the 5-step scale (1 = "very good," 2 = "good," 3 = "fair," 4 = "poor," 5 = "very poor") and p values indicate the difference between the preference groups
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Alcohol Consumption During Follow-Up
Reported alcohol consumptions in 1974 and 2000 were significantly correlated (r = 0.53, p <.0001). However, average total alcohol consumption had decreased in all preference groups in 2000 as compared to baseline. Reported average consumptions of alcohol among surviving beer (n = 356), wine (n = 127), and spirits drinkers (n = 404) in 2000 were 130.8, 149.4, and 136.2 g/wk, respectively (p =.46). The alcoholic beverage preference seemed to track well over the decades and was preserved in survivors in 2000 (Table 2). The 1974 data were essentially similar, albeit smaller when only the 2000 survivors were included (data not shown).Whereas beer drinkers had only cut their beer intake, wine drinkers tended to have increased beer consumption, and baseline spirit preferers had reduced their intake of spirits and increased their wine intake. It can be noted that wine drinkers had the lowest overall alcohol consumption in 1974 but the highest in 2000.
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Table 2. Average Weekly Consumption of Various Alcoholic Beverages in 1974 and 2000 According to Baseline Alcohol Preference.
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In 1985, reported alcohol consumption was significantly associated with gamma-GT activity in a sample of the cohort (r = 0.41, p <.0001). The correlation was significant in all preference groups.
Mortality
During the 29-year follow-up, 814 men (33.0% of the initial 1974 cohort) died. Among those who had reported a single preference in 1974 (n = 1882), there were 644 deaths (34.2%). Mortality was highest in the group preferring spirits (n = 346, 36.9%), and 224 (32.3%) and 74 (29.5%) in the groups preferring beer and wine, respectively. Unadjusted mortalities between the three groups were significantly different (p =.03); survival curves are shown in Figure 3. Analysis of causes of death (available up to 1999) revealed that the survival advantage in the group preferring wine was due to fewer cardiovascular deaths. Cardiovascular disease was the cause of death in 6.8% in the wine preference group versus 12.4% in the other two groups combined (RR 0.54; 95% CI, 0.33–0.89; p =.01). Total mortality was further analyzed with multivariate analyses using proportional hazards regression. In these analyses, beer and wine preference were compared with spirits preference (Table 3). Wine preference was associated with the lowest 29-year mortality irrespective of covariates, and in the fully adjusted model (age, baseline cardiovascular risk factors, and alcohol consumption as covariates) reduction in mortality was 34% (p =.03). Beer preference was not associated with significantly lower mortality as compared to spirits preference.
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Figure 3. Unadjusted survival curves of the baseline alcoholic beverage preference groups during the 29-year follow-up showing best survival for wine drinkers, intermediate for beer drinkers, and worst survival for spirits drinkers. p =.03 (log rank test) between the groups
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We also reran multivariate analyses in which the group of no single preference and the abstainers' group were included. In the fully adjusted model (with spirits preference as the reference group), the benefit in mortality remained statistically significant in favor of men preferring wine (RR 0.65; 95% CI, 0.44–0.96; p =.03). RRs for beer drinkers (0.91; 95% CI, 0.70–1.18), for men with no single preference (1.12; 95% CI, 0.89–1.40), and for abstainers (1.21; 95% CI, 0.79–1.86) were not statistically significant. If men with no single preference were the reference group, the RR for wine drinkers was even lower and highly statistically significant in the fully adjusted model (0.59; 95% CI, 0.40–0.86; p =.007).
Finally, we compared mortality in men who reported no wine consumption (n = 1034) to those with various levels of weekly wine consumption: 1–3 drinks (n = 936), 4–7 drinks (n = 348), and more than 7 drinks (n = 150). In the fully adjusted model, a U-shaped relationship was seen, with the group consuming 4–7 drinks having the lowest mortality (1–3 drinks: RR 0.99; 95% CI, 0.73–1.19; 4–7 drinks: RR 0.68; 95% CI, 0.48–0.96; more than 7 drinks: RR 0.79; 95% CI, 0.49–1.30).
2000 Survey and Quality of Life
In the 2000 questionnaire survey, there were 1127 men who had reported their baseline alcoholic beverage preference (439 beer, 155 wine, and 533 spirits). Response rates were 93%, 88%, and 90% in the beer, wine, and spirits preference groups, respectively. Over 90% were retired but 98% were still home dwelling. These characteristics were not different between the preference groups. The men preferring spirits continued to have higher BMI (26.2 kg/m2) than the other groups (25.6 and 25.4 kg/m2 in beer and wine drinkers, respectively; p =.007), and smoking was significantly more prevalent among them (p =.03). In turn, the men with preference for wine at baseline reported to exercise regularly more often in 2000 than did the men in other groups (p =.03).
Results of the health-related quality of life assessed with the RAND-36 questionnaire and adjusted for age and baseline smoking are shown in Figure 4. The men with wine preference at baseline had consistently the best scores on all eight RAND-36 scales, although the scores were statistically significantly higher only in the scales of general health (p =.007) and mental health (p =.01).
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Figure 4. Baseline alcoholic beverage preference and the eight scales of health-related quality of life RAND-36 in old age in 2000. Scales are adjusted for age and smoking status at baseline. p values indicate difference between the preference groups. A difference of at least 3 points is considered to be clinically important (23)
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DISCUSSION
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In our male cohort with similar socioeconomic status in adult life, preference of wine was associated with decreased mortality when compared with preference for beer or spirits over a follow-up of 29 years. This association persisted after various baseline covariates—including the total amount of alcohol consumed and important cardiovascular risk factors—were adjusted for. Wine preference was also associated with better scores in two scales (general health and mental health) of the RAND-36-assessed health-related quality of life in old age, but already at baseline wine preferers seemed to have better subjective health. In contrast, spirits preference was associated with worse risk profile at baseline and worse prognosis of survival and quality of life during follow-up. The results for beer drinkers were between those for wine and spirits preferers, but the differences were not statistically significant.
The present results are in accordance with the meta-analysis that showed an inverse association between wine consumption, and to a lesser extent beer consumption, and vascular risk (2). After that meta-analysis, a large study of almost 130,000 adults showed lower mortality risk associated with wine drinking (4). Our finding of better quality of life related to mental health in wine drinkers in old age is also supported by some earlier data (6–9). However, the question of cause and effect and the role of confounders—for example, social factors and cardiovascular risk factors—associated with wine preference has remained. Several studies have further considered the possibility that wine drinkers represent a special trait with overall healthy lifestyle and attitude toward life from a young age (11–16). A recent study from Denmark showed that customers buying wine at the supermarket made more healthy choices of other food items than did people who bought beer (24).
Our study has some strengths for studying the specific effects of alcoholic beverages. Because social class has an obvious influence on alcohol consumption, type of beverage, and alcohol-related mortality (25), our study with all men from the highest socioeconomic class in their adult life represents a cleaner test of the hypothesis in an area where social class may have an important confounding effect. We also measured several cardiovascular risk factors (including serum cholesterol) that were included in the multifactorial models, and we had information on alcoholic beverage preference after baseline during the follow-up. Moreover, our cohort mainly consisted of individuals who consume various alcoholic beverages ("mixed drinkers"). While this diminishes differences between beverage types, it also circumvents possible confounders associated with a uniform pattern. In addition, we related alcoholic beverage preference to the quality of life in old age when the baseline differences in alcohol preference still prevailed.
The results were based on a relatively large cohort of men with a substantial number of mortality endpoints during the follow-up of almost 30 years. The mortality verification by national registers was reliable. With knowledge of the Finnish culture, we also believe that the reporting of alcohol consumption was reliable in this cohort of Finnish businessmen and executives. This belief is further supported by the consistent pattern of reported consumption over the decades. The tracking of the beverage preference from 1974 through 2000 was good, and the reported alcohol intake was significantly correlated with several risk factors known to be associated with alcohol consumption (18). Furthermore, the serum concentration of gamma-GT [a biochemical indicator of alcohol consumption (21)] was available in a small subgroup, and it was related to reported alcohol consumption.
Our study has also some important limitations. This cohort consisted mainly of low to moderate middle-aged drinkers and included only a limited number of heavy drinkers, probably because the men were professionally active and healthy at baseline in 1974. It is also a limitation that we do not have information on drinking pattern and behavior; for example, binge drinking may have negative effects (5) and associate more with one type of beverage than with another. It is speculative, however, that binge drinking would have been more frequent in any particular preference group of our study, because most men were mixed drinkers. Also, as our study population was a selection of men from the highest social class, the extrapolation of the results to the general population (and especially to women) needs to be done cautiously. Furthermore, the men were "self-selected" to participate in health check-ups during the 1960s, and were thus probably health-conscious, but this hardly affects the present study on beverage preference. In contrast, as already stated, homogeneity would also be a strength, as the confounding effects of social status on alcohol consumption and quality of life could be minimized. Although we can assume that adult life social status and wealth (also during follow-up) were similar in our cohort, we were not able to adjust for differences in personal characteristics and early-life phenomena between the beverage preference groups. These can naturally induce residual confounding to the results, although data from the Whitehall II study of British civil servants indicated that adult socioeconomic status is a more important predictor of morbidity, attributable to, e.g., coronary heart disease, than is social status earlier in life (26). The high social status and homogeneity of the cohort has been taken for granted on the basis of work status; in the present database, we do not have data on childhood home circumstances or on type and length of education until in the 2002 survey (our unpublished results). At that time, when a third of the baseline cohort had died, surviving baseline spirits preferers had had less higher education (65%) than did the wine (77%) or beer drinkers (73%). In contrast, the education of the men with no single preference (76%) was similar to that of wine drinkers; still, their mortality was different (see Results). Average years of education were 12.8, 14.4, 14.1, 13.9, and 11.8 in the spirits, wine, beer, no preference, and abstainer groups, respectively (global p value <.0001). Also, the distribution of father's occupation differed marginally significantly (p =.05) between the preference groups, wine preferers tending to originate from families with higher social status (our unpublished results).
The profile of quality of life could not be assessed in 1974 as the RAND-36 did not exist at that time. The available data in Figure 2 nevertheless indicate that, in midlife, wine preference (as compared to other preference groups) is associated with better subjective health. Subjective general health has been found to associate best with a global measure of health-related quality of life (27). However, a question may arise whether these differences were a cause or consequence of wine consumption.
Conclusion
In this group of men from the highest social class in their adult life, the long-term overall health effects associated with wine preference were clearly beneficial when compared to other types of alcohol. Despite a conservative analysis including adjustment for cardiovascular risk factors and the amount of alcohol consumed, wine drinkers had a lower overall mortality and a better quality of life in old age. The results may thus support the idea that moderate consumption of wine has specific, beneficial effects on health. However, only a full life-course study (or a randomized trial) accounting for also pre-midlife characteristics could finally decide whether it is truly the characteristics of the alcoholic beverages—and not the characteristics of the people who make the choices—that account for these differences.
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Acknowledgments
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This work was supported by The Academy of Finland, the Päivikki and Sakari Sohlberg Foundation, the Helsinki University Central Hospital, and the Finnish Foundation for Cardiovascular Research.
Author contributions are as follows: Design of the experiment (T. E. S., A. Y. S., T. A. M.), collection of data (T. E. S., V. V. S., T. A. M., R. S. T.), analysis of data (A. Y. S., T. E. S., K. P., R. S. T.), writing and revising the manuscript (T. E. S., A. Y. S., V. V. S., K. P., T. A. M., R. S. T.).
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Footnotes
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Decision Editor: Darryl Wieland, PhD, MPH
Received January 24, 2006
Accepted May 19, 2006
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ALCOHOLIC BEVERAGE AND LONG-TERM MORTALITY IN ELDERLY PEOPLE LIVING AT HOME
J. Gerontol. A Biol. Sci. Med. Sci.,
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Abstract
Participants and Methods
