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Moderate Consumption of Beer and Its Effects on Cardiovascular and Metabolic Health: An Updated Review of Recent Scientific Evidence

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There is growing interest in the potential health-related effects of moderate alcohol consumption and, specifically, of beer. This review provides an assessment of beer-associated effects on cardiovascular and metabolic risk factors to identify a consumption level that can be considered “moderate”. We identified all prospective clinical studies and systematic reviews that evaluated the health effects of beer published between January 2007 and April 2020. Five of six selected studies found a protective effect of moderate alcohol drinking on cardiovascular disease (beer up to 385 g/week) vs. abstainers or occasional drinkers. Four out of five papers showed an association between moderate alcohol consumption (beer intake of 84 g alcohol/week) and decreased mortality risk. We concluded that moderate beer consumption of up to 16 g alcohol/day (1 drink/day) for women and 28 g/day (1–2 drinks/day) for men is associated with decreased incidence of cardiovascular disease and overall mortality, among other metabolic health benefits.
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nutrients
Review
Moderate Consumption of Beer and Its Effects on
Cardiovascular and Metabolic Health: An Updated Review of
Recent Scientific Evidence
Ascensión Marcos 1, *, Lluís Serra-Majem 2,3 , Francisco Pérez-Jiménez 2,4, Vicente Pascual 5,
Francisco JoséTinahones 2,6 and Ramón Estruch 2,7


Citation: Marcos, A.; Serra-Majem,
L.; Pérez-Jiménez, F.; Pascual, V.;
Tinahones, F.J.; Estruch, R. Moderate
Consumption of Beer and Its Effects
on Cardiovascular and Metabolic
Health: An Updated Review of
Recent Scientific Evidence. Nutrients
2021,13, 879. https://doi.org/
10.3390/nu13030879
Academic Editor: Ana Baylin
Received: 15 January 2021
Accepted: 3 March 2021
Published: 9 March 2021
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Attribution (CC BY) license (https://
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4.0/).
1Institute of Food Science, Technology and Nutrition (ICTAN), Spanish National Research Council (CSIC),
28040 Madrid, Spain
2CIBER Physiopathology of Obesity and Nutrition, Carlos III Institute of Health, 28222 Madrid, Spain;
lluis.serra@ulpgc.es (L.S.-M.); md1pejif@uco.es (F.P.-J.); fjtinahones@hotmail.com (F.J.T.);
restruch@clinic.cat (R.E.)
3Research Institute of Biomedical and Health Sciences, University of Las Palmas de Gran Canaria,
35016 Las Palmas, Spain
4Lipid and Atherosclerosis Unit, Maimonides Biomedical Research Institute of Córdoba (IMIBIC), UGC of
Internal Medicine, Reina Sofia University Hospital, University of Córdoba, 14004 Córdoba, Spain
5Palleter Health Centre, CEU University—Cardenal Herrera, 12005 Castellón, Spain; pascual_vic@gva.es
6Endocrinology, Nutrition, Diabetes and Obesity Unit, Institute of Biomedical Research in Málaga (IBIMA),
Virgen de la Victoria Hospital, University of Málaga, 29010 Málaga, Spain
7Department of Internal Medicine, Hospital Clinic, August Pi i Sunyer Biomedical Research
Institute (IDIBAPS), University of Barcelona, 08036 Barcelona, Spain
*Correspondence: amarcos@ictan.csic.es
Abstract:
There is growing interest in the potential health-related effects of moderate alcohol con-
sumption and, specifically, of beer. This review provides an assessment of beer-associated effects
on cardiovascular and metabolic risk factors to identify a consumption level that can be considered
“moderate”. We identified all prospective clinical studies and systematic reviews that evaluated
the health effects of beer published between January 2007 and April 2020. Five of six selected stud-
ies found a protective effect of moderate alcohol drinking on cardiovascular disease (beer up to
385 g/week) vs. abstainers or occasional drinkers. Four out of five papers showed an association be-
tween moderate alcohol consumption (beer intake of 84 g alcohol/week) and decreased mortality risk.
We concluded that moderate beer consumption of up to 16 g alcohol/day (1 drink/day) for women
and 28 g/day (1–2 drinks/day) for men is associated with decreased incidence of cardiovascular
disease and overall mortality, among other metabolic health benefits.
Keywords: alcohol; moderate drinking; mortality; diabetes; obesity; osteoporosis
1. Introduction
In recent years, there has been an increasing interest in the potential health-related
effects of moderate alcohol consumption. Although the harmful effects of excessive alcohol
use are well established, the association of low-to-moderate alcohol consumption with
health-related benefits is still controversial, since the results of available studies are not
homogeneous and reaching clear conclusions is challenging. This lack of consensus is
observed in alcohol consumption guidelines published in the last five years, which use
different terminology (“risky drinking”, “moderate consumption”, or “low-risk drinking”)
as well as different drinking thresholds [
1
6
] (Table 1). Furthermore, other variables,
such as differences in concentrations of non-alcoholic components (i.e., polyphenols), may
confound the beneficial effects of specific alcoholic drinks [7,8].
Nutrients 2021,13, 879. https://doi.org/10.3390/nu13030879 https://www.mdpi.com/journal/nutrients
Nutrients 2021,13, 879 2 of 24
Table 1. Low-risk drinking guidelines.
Country. Year
Guidelines 1 SDU = g Pure Alcohol Term Daily a,b (g Alcohol) Weekly a,b (g Alcohol)
Spain. 2016
Socidrogalcohol consensus on
alcohol in Primary Care [2]
1 SDU = 10 g
Wine: 1 glass
Beer: 1 beer (200 mL)
Spirits: 25 g
Risky consumption
(starting at) Women: 20 g
Men: 40–60 g Women: 140 g
Men: 280 g
Spain. 2019
Update Dietary Guidelines for
the Spanish population [3]1 SDU = 10 g Moderate consumption
(upper limit) Women: <20 g
Men: <40 g -
-
UK. 2016
UK Chief Medical Officers’ Low
Risk Drinking Guidelines [4]
1SDU=8g
Wine: 1 glass (125 mL)
(11% ABV)
Low-risk drinking (upper
limit) -
-Women: 112 g
Men: 112 g
USA. 2015
Dietary guidelines [5]
1 SDU = 14 g
Wine: 5 oz or 147.9 mL
(12% ABV)
Beer: 12 oz or 354.9 mL
(5% ABV)
Spirits: 1.5 oz or 44.4 mL
(40% ABV)
Moderate drinking (upper
limit) Women: 14 g
Men: 28 g -
-
Canada. 2018
Canada low-risk alcohol
drinking guidelines [6]
1 SDU c13 g
Wine: 142 mL (12% ABV)
Beer: 341 mL (5% ABV)
Spirits: 43 mL (40% ABV)
Recommended limit -
-Women: 130 g
Men: 210 g
37 countries. 2016 [1] 1 SDU = 8–20 g Low-risk drinking (upper
limits range) Women: 10–42 g
Men: 10–56 g Women: 98–140 g
Men: 150–280 g
ABV: Alcohol by volume; SDU: Standard drinking unit.
a
When amounts were expressed in number of SDUs, they were converted to
grams.
b
Daily and weekly values are listed as published in respective guidelines. Weekly values may not reflect a week’s worth (7 days) of
daily allowance. c13 g is inferred from the different beverages considered as 1 SDU.
Beer is an alcoholic beverage frequently consumed in Europe. In 2018, the average
yearly beer consumption in Europe was 72 L per capita, with a few countries (Czech
Republic, Austria, and Germany) consuming more than 100 L per capita per year [
9
].
However, patterns of consumption differ across the region varying from predominantly
meal-associated drinking in Mediterranean countries, to high rates of heavy episodic
drinking in Central and Eastern Europe, and relatively frequent consumption both with
and outside of meals in Central Western Europe [10].
Beer is mainly composed of water, but it is also rich in nutrients—carbohydrates,
amino acids, minerals, vitamins, and polyphenols—resulting from a multi-step brew-
ing and fermentation process [
7
,
11
13
]. Hop flowers, used as a bittering and flavoring
agent [
14
], contain phenolic compounds, including prenylated flavonoids [
15
,
16
], which
have been shown
in vitro
to have different antioxidant, anticarcinogenic, anti-inflammatory,
oestrogenic, and antiviral biological activities [
7
,
17
]. Xanthohumol is the most abundant
of these compounds and, in addition to potential bioactivity [
7
,
18
], it also inhibits platelet
activation without increasing the bleeding risk [
19
]. Thus, brewing processes have been
optimized to achieve the highest possible content of xanthohumol [
20
]. Regarding antioxi-
dant content, ale beers have been reported to display a higher antioxidant activity than
lager beers due to the higher fermentation temperature in the brewing process. However,
despite these enrichment processes, controversy remains as to the bioavailability of the
phenolic compounds in beer [2123].
Alcohol content in regular beers varies between 3% and 6% alcohol by volume [
11
].
There is vast scientific literature on excessive alcohol consumption. Indeed, chronically
high alcohol intake acts as a toxin to the heart and vascular system and may also exacerbate
pre-existing heart disorders. However, low-to-moderate amounts of alcohol intake might
have beneficial effects on the cardiovascular (CV) system, since it increases high-density
lipoprotein cholesterol (HDL) and reduces arterial stiffness (both effects shown specifically
with beer) [
21
,
22
,
24
,
25
], and also decreases fibrinogen, platelet activation and aggregation,
as well as blood oxidative stress and inflammatory parameters [
26
28
]. The alcohol content
of beer might also have an effect on glucose homeostasis [
29
]. Alcohol contributes to total
calorie intake and may increase weight when consumed in excess [
30
,
31
]. Non-alcoholic
Nutrients 2021,13, 879 3 of 24
components also contribute to the energy content of beer. Thus, Public Health England
lists the mean energy content of alcohol-free beers at seven kilocalories/100 g [
32
]. Overall,
28% of the total monthly kilocalories contributed by beer among regular drinkers derive
from its non-alcoholic ingredients [33].
Taken together, the biological activity of phenolic compounds in beer and the possible
association of alcohol intake with mortality, CV risk [
34
36
], and glucose metabolism
[3743]
may contribute to the putative health-related effects of moderate beer consumption. Con-
versely, excess beer consumption may be associated with weight increase and associated
morbidities [30].
We conducted an analysis of all reviews, meta-analyses, and longitudinal, prospective,
cohort studies published from January 2007 to April 2020 regarding beer consumption and
its relationship with CVD and mortality risk, with the objective of evaluating the average
intake of beer that could be considered “moderate” based on the reported consumption.
Furthermore, we aimed to identify several differences shown in specific population sub-
groups in the selected studies.
2. Materials and Methods
In April 2020, a literature search of papers published after January 2007 was con-
ducted using PubMed EMBASE, and through reference list cross-checking of previous
meta-analyses, prospective clinical studies, and systematic reviews in humans, evaluating
beer effects on health. The search strategy retrieved citations from databases containing
the subject heading “beer” in combination with “health”, “cardiovascular”, “mortality”,
“obesity”, “diabetes”, “young”, “women”, or “alcoholism”. The search terms were adapted
for use with both bibliographic databases (Table 2).
Table 2. Literature search terms.
Data Base Search Syntax No. Articles
PubMed
((Beer[MeSH Major Topic]) and (“2007”[Date—Publication]:
“2020/04/01”[Date—Publication])) and (health or mortality or
cardiovascular or diabetes or obesity or women or men or gender or
young or adolescent or age or alcoholism)
82
Filtered by:
Clinical study
Comparative study
Multicenter study
Observational study
Randomized controlled trial
Systematic reviews
EMBASE
‘beer’/de and ‘beer’:ab,ti and ((‘health’/de or ‘mortality’/de or
‘cardiovascular’/de or ‘diabetes’/de or ‘obesity’/de or ‘female’/de or
‘male’/de or ‘sex’/de) and difference or ‘adolescent’/de or ‘young
adult’/de or ‘alcoholism’/de) and ((article)/lim or (review)/lim) and
((adolescent)/lim or (young adult)/lim or (adult)/lim or (middle
aged)/lim or (aged)/lim or (very elderly)/lim) and (humans)/lim and
(clinical study)/lim and (2007–2017)/py
210
Original eligible papers, based on their title/abstract, were obtained and reviewed
to select those meeting the inclusion criteria: clinical studies in humans with prospective
cohort design, plus systematic reviews and meta-analyses evaluating beer effects on health
since 2007, and publications that authors considered could provide additional information
on the subject. A total of 13 reviews (narrative or systematic reviews and/or meta-analysis),
9 prospective cohort studies, and 1 open-label, randomized, cross-over study were selected
(Table 3).
Nutrients 2021,13, 879 4 of 24
Table 3. Papers selected for review.
Alcohol/Beer Paper Study Type Related Subject
Osorio-Paz et al. 2019 [44] Review CV
Sacanella et al. Nutr Hosp. 2019 [22] Review CV
Humia et al. Molecules 2019 [21] Review CV
Redondo et al. Nutr Hosp 2018 [45] Review CV and osteoporosis
Padro et al. Nutrients 2018 [46] Prospective randomized cross-over
Obesity (metabolic syndrome)
Wood et al. Lancet. 2018 [47] System. Review/Meta CV and Mortality
Toma et al. Curr Atheroscler Rep. 2017 [48] Review CV
Bell et al. BMJ 2017 [49] Prospective cohort CV
Polsky et al. Curr Diab Rep. 2017 [50] System. Review Diabetes
Xi et al. J Am Coll Cardiol. 2017 [51] Prospective population-based cohort Mortality
de Gaetano et al. Nutr Metab Cardiovasc Dis.
2016 [34]Review CV and Mortality
Fresán et al. Nutrients. 2016 [52] Prospective cohort Obesity
Stockwell et al. J. Stud. Alcohol Drugs. 2016 [53] System. Review/Meta Mortality
Roerecke et al. BMC Med. 2014 [54] System. Review/Meta CV
Bendsen et al. Nutr Rev. 2013 [55] System. Review/Meta Obesity
Cullmann et al. Diabetic Medicine. 2012 [43] Prospective cohort Diabetes
Roerecke et al. Addiction. 2012 [56] System. Review/Meta CV
Costanzo S, et al. Eur J Epidemiol. 2011 [57] System. Review/Meta CV
Yin et al. Eur J Clin Nutr. 2011 [58] Prospective cohort Osteoporosis
Schütze et al. Eur J Clin Nutr 2009 [59] Prospective cohort Obesity
Snow et al. Age and Ageing. 2009 [60] Prospective cohort CV and Mortality
Suadicani et al. Alcohol. 2008 [61] Prospective cohort Mortality
Mukamal et al. Osteoporos Int. 2007 [62] Prospective population-based cohort Osteoporosis
CV. Cardiovascular.
3. Results
A summary of related studies is shown in Table 4. Two reviews referring specifically
to beer, reported that moderate consumption (up to 55 g alcohol/day; i.e., 385 g/week)
showed a beneficial effect on non-fatal CV events [
34
,
57
]. Both reviews found that the
highest effect was associated with moderate beer or wine consumption, suggesting that
the polyphenolic content of these beverages probably contributes to the observed CV
benefits [34,57].
Nutrients 2021,13, 879 5 of 24
Table 4. Summary of the main cardiovascular (CV) studies.
Study
Funding/COI a
Design (Mean/Median
Years of Follow-Up) n
Categories of
Consumption/Type of
Drink
Variables Reference
Group (HR = 1) Outcomes/Conclusions b
Costanzo et al., 2011 [57]
Cervisia Consulenze
and
Istituto Nazionale per la
Comunicazione.
Systematic
review-meta-analysis
12 prospective studies (n
ranged from 1373 to
87,536) and 6
case-control studies (n
ranged from 616 to 1746)
Wine, beer, and spirits
Fatal non-fatal CHD,
CHD, CVD, AMI, stroke,
CHD mortality, IHD
mortality, CVD mortality
AND/OR total mortality.
13 studies: J-shaped relationship
for beer and CV risk.
16 studies: J-shaped relationship
between wine intake and CV
risk. 12 studies reporting
separate data on wine or beer
consumption: two closely
overlapping dose-response
curves.
Roerecke et al., 2012 [56]
Global Burden of
Disease Study and
by the grant “Drinking
Patterns & Ethnicity:
Impact on Mortality
Risks”, NIAAA
Systematic
review-meta-analysis
44 observational studies
including 957,684
participants
Lifetime abstainer.
Occasional:
2.5–11.99 g/week;
12–23.99 g/week;
24–35.99 g/week
/
Alcohol in general
IHD Lifetime
abstainers
Cardioprotection was observed
in all strata, and substantial
heterogeneity was noted across
studies. Wide confidence
intervals observed particularly
for average consumption of
1–2 drinks per day.
Roerecke et al., 2014 [54]
The European
Community’s Seventh
Framework
Programme—
Addictions and Lifestyle
in Contemporary
Europe—Reframing
Addictions Project.
Systematic review and
meta-analysis
7 studies for the
meta-analysis
For the meta-analysis:
Current drinkers with an
average alcohol
consumption <30 g/day
of pure alcohol with or
without HED
/
Alcohol in general
IHD Lifetime
abstainers
Beneficial effect of low alcohol
consumption without HED
episodes as compared to
life-time abstainers
Wood et al., 2018 [47]
Various government,
private, and
pharmaceutical sources.
/ None declared.
Systematic review and
meta-analysis
83 prospective studies
including 599,912
participants
Current drinkers
/
Alcohol in general, also
separate analyses for
wine, beer, and spirits
Mortality, stroke, CHD,
AMI, heart failure, fatal
hypertensive disease,
fatal aortic aneurysm
Lowest baseline
alcohol
consumption
category
(0–25 g/week)
Threshold for lowest risk of
all-cause mortality was
~100 g/week. Association
between alcohol consumption
and total CVD risk showed
higher HR for beer and spirits
than for wine.
Nutrients 2021,13, 879 6 of 24
Table 4. Cont.
Study
Funding/COI a
Design (Mean/Median
Years of Follow-Up) n
Categories of
Consumption/Type of
Drink
Variables Reference
Group (HR = 1) Outcomes/Conclusions b
de Gaetano et al., 2016
[34]
Assobirra, the
Italian Association of the
Beer and Malt
Industries/Some authors
were consultants for the
Web Newsletter
of Assobirra, or were
on the board/received
lecture fees from FIVIN,
the Beer and
Health Foundation,
ERAB, or Cerveceros
de España.
Systematic review
7 prospective studies
(nranged from 1373 to
87,526) and 4
case-control studies (n
ranged from 937 to
1514)
Wine, beer, and spirits
Fatal non-fatal CHD,
AMI, CHD, CHD
mortality, AND/OR
CVD mortality.
Some benefit of beer against CVD
Toma et al., 2017 [48]/
None declared Review
1 case-control study
(INTERSTROKE [63];
n= 26,919) and 1
prospective study
(PURE; [64]
n= 114,970)
INTERSTROKE:
low-moderate alcohol
use: 14 drinks/w in
women and 21
drinks/w in men.
/
Alcohol in general
INTERSTROKE: any
stroke, ischemic stroke,
and hemorrhagic stroke
PURE: mortality, CVD,
myocardial infarction,
stroke, and a composite
of all outcomes, which
also included
alcohol-related cancers
and injury.
INTERSTROKE:
Non-drinkers or
former drinkers.
PURE:
Non-drinkers
INTERSTROKE:
Low-moderate alcohol use was
associated with stroke (OR: 1.14;
95%CI 1.01–1.28), ischemic stroke
(OR: 1.07; 0.93–1.23) and
hemorrhagic stroke (OR: 1.43;
1.17–1.74).
PURE: Current drinking was
associated with reduced
myocardial infarction (HR: 0.76;
95% CI 0.63–0.93). In addition, it
was associated with a reduced
composite outcome in
high-income and
upper-middle-income countries
(HR 0.84 (0.77–0.92)), but not in
lower-middle-income and
low-income countries (HR 1.07
(0.95–1.21); p-interaction < 0.0001).
Nutrients 2021,13, 879 7 of 24
Table 4. Cont.
Study
Funding/COI a
Design (Mean/Median
Years of Follow-Up) n
Categories of
Consumption/Type of
Drink
Variables Reference
Group (HR = 1) Outcomes/Conclusions b
Bell et al., 2017 [49]
National Institute for
Health Research,
Welcome Trust, the
Medical Research
Council prognosis
research strategy
Partnership and other
government
health-related agencies. /
None declared
Prospective cohort
(6 y) 1,937,360 (51% women)
Non-drinkers. Former
drinkers. Occasional
drinkers: drinks rarely or
occasionally. Moderate:
Men: 21 SDU/week or 3
SDU/day. Women: 14
SDU/w or 2 SDU/da.
Heavy drinkers
/
Alcohol in general
12 common symptomatic
manifestations of CVD.
Aggregated CVD (all CV
endpoints other than
stable angina).
Moderate
drinkers
Non-drinking: unstable angina
(HR 1.33, 95% CI 1.21 to 1.45),
myocardial infarction (1.32, 1.24
to1.41), unheralded coronary
death (1.56, 1.38 to 1.76), heart
failure (1.24, 1.11 to 1.38),
ischemic stroke (1.12, 1.01 to
1.24), peripheral arterial disease
(1.22, 1.13 to 1.32), and
abdominal aortic aneurysm
(1.32, 1.17 to 1.49). Heavy
drinking: unheralded coronary
death (HR 1.21, 95%CI 1.08 to
1.35), heart failure (1.22, 1.08 to
1.37), cardiac arrest/sudden
coronary death (1.50, 1.26 to
1.77), transient ischemic attack
(1.11, 1.02 to 1.21), ischemic
stroke (1.33, 1.09 to 1.63),
intra-cerebral hemorrhage (1.37,
1.16 to 1.62), peripheral arterial
disease (1.35, 1.23 to 1.48);
myocardial infarction (0.88, 0.79
to 1.00) and stable angina (0.93,
0.86 to 1.00).
Nutrients 2021,13, 879 8 of 24
Table 4. Cont.
Study
Funding/COI a
Design (Mean/Median
Years of Follow-Up) n
Categories of
Consumption/Type of
Drink
Variables Reference
Group (HR = 1) Outcomes/Conclusions b
Snow et al., 2009 [60]
None declared
Prospective cohort
(10 y) 1154 (574 women)
1 SDU: 13 g ethanol.
Men: Light: 0.65–5.77
g/day; Moderate:
5.78–18.1 g/day; Heavy:
>18.1 g/day. HED: 8
drinks/episode in past
year
Women: Light: 0.65–2.92
g/day; Moderate:
2.93–9.15 g/day; Heavy:
>9.15 g/day. HED:
frequency of 8
drinks/episode
/
Alcohol in general
CHD events;
hypertension; Other
CVD
Lifetime
abstainers and
occasional
drinkers who
consumed <0.05
drinks (<0.65 g)
per day.
Men for CHD events: Heavy:
HR: 0.28 (0.08–0.93) p= 0.037 in
old men; HED: 4.13 (1.46
11.62)
p= 0.0073 in middle-aged men.
Men for hypertension: HED:
HR 1.62 (0.99–2.63), p= 0.054 in
old men.
Men for other CVD: Light: HR
0.54 (0.28
1.04), p= 0.066 in old
men; Heavy: HR 0.40
(0.190.85, p= 0.017 in old men.
Women for hypertension:
Light: HR 0.26 (0.07–1.01),
p= 0.052 in young women.
Women for other CVD: Light:
HR 0.23 (0.080.65), p= 0.0057
and Moderate: HR 0.14
(0.050.45), p= 0.0009 in young
women.
AMI: Acute myocardial infarction; COI: Conflict of interest; CV. Cardiovascular; CVD: Cardiovascular disease; CHD: Coronary heart disease; ERAB: European Foundation for Alcohol Research; FIVIN: the
Foundation for Wine and Nutrition Research; HED: Heavy Episodic Drinking; HR: Hazard Ratio; IHD: Ischemic heart disease; OR: Odds Ratio; SDU: Standard drinking unit.
a
When funding is provided by
industries and/or foundations that might represent a conflict of interest, it is written in bold.
b
Outcomes for prospective studies and meta-analyses, and Conclusions for reviews. Adjustments: Costanzo
et al., 2011: All by age and 15 of the 18 studies, in addition, by one or more of the following: sex, race, education, marital status, country of birth, smoking, total alcohol intake, exercise intensity, depression
score, frequent aspirin use, cholesterol, BMI, diabetes, hyper-lipidemia, cancer, physical activity, cohabitation, coffee, consumption of other beverage types, total daily energy and saturated fat intake, intake of
vegetables, fruit, fish, saturated and trans fatty acids, socioeconomic status, history of heart dis-ease, AMI, hypertension, etc. Roerecke et al., 2012: Where needed, the effect sizes of reference categories were
re-calculated to reflect abstainers as the reference category. Former drinkers were excluded from all analyses. Those consuming > 72 g/day were excluded from all analyses because of scarcity of data. Roerecke
et al., 2014: All studies were adjusted for age and smoking status, five for education and other indicators for socio-economic status, and four each for BMI and marital status. Wood et al., 2018: Age, smoking
status, history of diabetes. de Gaetano et al., 2016: All by age and 8 of the 11 studies, in addition, by one or more of the following: sex, race, education, marital status, country of birth, smoking, total alcohol
intake, exercise intensity, depression score, frequent aspirin use, cholesterol, BMI, diabetes, hyperlipidaemia, cancer, physical activity, cohabitation, coffee, consumption of other beverage types, total daily energy
and saturated fat intake, intake of vegetables, fruit, fish, saturated and trans fatty acids, socioeconomic status, history of heart disease, AMI, hypertension, etc. Bell et al., 2017: Adjusted for age (and age
2
), sex,
socioeconomic deprivation, and smoking status. Snow et al., 2009: Adjusted for marital status, cigarette smoking status and educational level.
Nutrients 2021,13, 879 9 of 24
These data are in agreement with most findings from reviews/meta-analyses and
cohort studies, which report a protective effect of moderate alcohol drinking for CVD
compared to abstention, former drinking, or occasional drinking [
22
,
34
,
47
,
49
,
56
,
57
,
60
].
Only the review by Toma et al. does not support these conclusions; the authors suggest that
this protective effect may be a confounder due to the inclusion of former drinkers in the
non-drinkers group [
48
]. However, the prospective cohort study by Bell et al., conducted
in almost 2 million people, took these potential confounders into consideration, and also
found a positive effect of moderate drinking (112 g/week in women and 168 g/week
in men) on CV risk [
49
]. Costanzo et al. found a negative (although not significant)
association between spirits and vascular events, suggesting alcohol content, and not solely
polyphenols, may also play a role in cardiovascular events [
57
]. Moreover, as Roerecke
et al. [
54
] noted that distinctions between former drinkers and lifetime abstainers might
not be sufficient for an accurate analysis, based on the heterogeneity of reasons underlying
non-drinkers’ decision not to drink, which might further confound the results. Finally,
drinking patterns may also play a key role in outcomes [
54
], since self-reported weekly
intakes might include alcohol consumed during the weekend during a binge, which would
be associated with worse CV results.
Gender Differences
Due to the paucity of separate data for men and women, none of the beer-specific CVD
studies stratified their conclusions by gender. The meta-analysis by Roerecke et al. [
54
]
noted that women are more sensitive to the protective effect of moderate alcohol consump-
tion, based on a previous meta-analysis [
56
], which showed a steeper J-curve for ischemic
heart disease (IHD), mortality and morbidity in women than in men. The detrimental
effect on CV risk of binge drinking seems to be lower in women than in men [
49
,
60
], and
an increased risk of heart failure has been observed in abstemious women compared with
moderate drinkers [
49
]. In addition, Snow et al. [
60
] observed that the beneficial effects
of low and/or moderate usual consumption on CV risk were only evident in younger
women (aged 18–34), whereas cardio-protection became evident at middle (aged 35–49) or
older age (aged 50–64) in men. Overall, these gender differences may be due to hormonal
changes over the life course or to a lower lifetime consumption of total alcohol.
4. Moderate Beer Consumption and Mortality
A summary of related studies is shown in Table 5. The systematic review by de Gae-
tano et al. [
34
] suggested that a J-shaped relationship also exists between beer consumption
and all-cause mortality. The lowest mortality risk was observed in subjects with low to
moderate alcohol consumption compared to abstainers or heavy drinkers, with the lowest
risk at beer consumption of 84 g alcohol/week [34].
Nutrients 2021,13, 879 10 of 24
Table 5. Summary of main mortality studies.
Study
Funding/COI a
Design
(Mean/Median
Years of Follow-Up)
n(Women)
Categories of Alcohol
Consumption/Type of
Drink
Variable/s Reference
Group (HR = 1) Outcomes/Conclusions b
de Gaetano et al.,
2016 [34]
Assobirra, the
Italian Association of
the Beer and Malt
Industries/ Some
authors were
consultants for the
Web Newsletter
of Assobirra, or were
on the
board/received
lecture fees from
Fundación Cerveza y
Salud, FIVIN, the
Beer and
Health Foundation,
ERAB, or
Cerveceros
de España.
Systematic review Wine, beer, and spirits All-cause mortality
Evidence suggests a J-shaped
relationship between alcohol
consumption and total mortality, with
lower risk for moderate alcohol
consumers than for abstainers or heavy
drinkers.
Specific data on beer are not conclusive,
although some results indicate a
positive role of drinking beer in
moderation (1 drink/day, about 12 g of
ethanol) against mortality for any cause
1 meta-analysis of 34
prospective studies
[65]
Over 1 million adults
Low to moderate
Women: 1 drink/day.
Men: 2 drinks/day
/
Wine, beer, and spirits
All-cause mortality
Low to moderate consumption of
alcohol significantly reduces total
mortality, while higher doses increase it
1 Prospective cohort
[66]
(12–18 y)
36,250 men Wine and beer CV death
All-cause mortality Non-drinkers
Moderate wine or beer drinking
reduced the risk of CV death.
Only moderate wine drinking was
associated with lower all-cause
mortality: RR: 0.67 (0.58 to 0.77;
p< 0.001)
1 Prospective cohort
[67]
(16.8 y)
7735 British men 40–59 y
old
1 SDU: Half pint beer
(8–10 g alcohol).
Frequency:
Non-drinkers;
Occasional (1–2
SDU/month); Weekend
drinkers; Daily or on
most days. Quantity:
1–2, 3–6, >6
/
Wine, beer, and spirits
All-cause mortality Occasional
drinkers
Regular beer drinking [HR: 0.84 (0.71 to
1.01)] showed no significant difference
vs. occasional drinking
Nutrients 2021,13, 879 11 of 24
Table 5. Cont.
Study
Funding/COI a
Design
(Mean/Median
Years of Follow-Up)
n(Women)
Categories of Alcohol
Consumption/Type of
Drink
Variable/s Reference
Group (HR = 1) Outcomes/Conclusions b
1 Prospective cohort
[68]
Copenhagen City
Heart Study (25 y)
14,223 adults
1 SDU: 1 bottle beer (12 g
alcohol). Never, Hardly
ever, Monthly, Weekly
Daily: 1–2 SDUs
Daily: >2 SDUs
/
Wine, beer, and spirits
All-cause mortality Never beer
drinkers
In men, monthly beer intake (RR: 0.86
(0.77 to 0.97)) was associated with lower
mortality, and daily intake >2 beers (RR:
1.14 (1.02 to 1.27)) to increased risk.
In women the associations were not
statistically significant: Monthly beer
intake (RR: 0.98 (0.88 to 1.08)), and daily
intake >2 beers (RR: 1.31 (0.92 to 1.88))
At a medium education level, monthly
beer intake was associated with lower
risk (RR: 0.87 (0.77 to 0.97)), and at low
[RR:1.20 (1.07 to 1.34) and medium
education level (RR:1.18 (1.02 to 1.37)),
>2 beers daily was associated with
increased risk.
1 Prospective cohort
[69]
(12.6 y)
380,395 adults (247,795
women)
For beer:
Never. Light: 0.1–2.9
g/day, 3–9.9 g/day,
10–19.9 g/day, 20–39.9
g/day (only for men).
20 g/day (extreme for
women)
40 g/day (extreme for
men)
/
Wine and beer
All-cause mortality Light consumers
(0.1–2.9 g/day)
In women:
Compared to low-level consumers,
lifetime non-drinkers (HR: 1.06; 1.02 to
1.12), and consumers of beer at amounts
3 g/day displayed significantly
higher overall mortality risk.
In men:
Lifetime non-drinkers (HR: 1.07; 0.98 to
1.16) and consumers of 3–9.9 g/day
(HR: 1.04; 0.98 to 1.10) showed no
significant differences compared to
light consumers.
Consumers of beer amounts
10 g/day
displayed a significantly higher overall
mortality risk.
Nutrients 2021,13, 879 12 of 24
Table 5. Cont.
Study
Funding/COI a
Design
(Mean/Median
Years of Follow-Up)
n(Women)
Categories of Alcohol
Consumption/Type of
Drink
Variable/s Reference
Group (HR = 1) Outcomes/Conclusions b
Stockwell et al., 2016
[53]
None declared
Systematic
review/meta-
analysis of 87 studies
(13.4 y)
3998,626 adults
Abstainer. Former
drinker. Occasional:
<1.30 g/day. Low: 1.30
to <25 g /day. Medium:
25 to <45 g/day
High: 45 to <65 g/day.
Higher: 65 g/day
/
Alcohol in general
All-cause mortality
Abstainer OR
occasional
drinker
Standard adjustment: Significant
protective effect for low-volume (RR:
0.86 (0.83 to 0.90); p< 0.0001) and
occasional drinkers (RR: 0.84 (0.79 to
0.89); p< 0.0001) as compared with
abstainers.
Abstainers were at significantly higher
risk (RR: 1.19 (1.12 to 1.27); p< 0.0001)
as compared to occasional drinkers.
Full adjustment: No significant
protection was estimated for occasional
(RR: 0.95 (0.85 to 1.05)), low-volume
(RR: 0.97 (0.88 to 1.07)), or
medium-volume drinkers (RR: 1.07
(0.97 to 1.18)) as compared with
abstainers.
Xi et al., 2017 [51]
None declared
Population survey
data linked to
mortality data
(8.2 y)
333,247 adults
1 SDU: 14 g alcohol.
Lifetime abstainers.
Lifetime infrequent
drinkers. Former
drinkers. Current light
drinkers. Moderate: >3
to 14 drinks/w for
men or >3 to 7
drinks/w for women.
Heavy drinkers. Binge
drinking
/
Alcohol in general
All-cause, cancer, or
CVD mortality.
Lifetime
abstainers
All cause-mortality: Decreased for
Light (HR 0.79 (0.76 to 0.82)) and
Moderate (HR 0.78 (0.74 to 0.82))
drinkers.
Increased in Heavy: HR: 1.11 (1.04 to
1.19) and binge (HR: 1.13 (1.04 to 1.23))
drinkers.
CVD-specific mortality: Light: HR 0.74
(0.69 to 0.80); Moderate: HR 0.71 (0.64
to 0.78)
Nutrients 2021,13, 879 13 of 24
Table 5. Cont.
Study
Funding/COI a
Design
(Mean/Median
Years of Follow-Up)
n(Women)
Categories of Alcohol
Consumption/Type of
Drink
Variable/s Reference
Group (HR = 1) Outcomes/Conclusions b
Suadicani, 2008 [61]
The King Christian
X’s Foundation, The
Danish Medical
Research Council,
The Danish Heart
Foundation, and The
Else & Mogens
Wedell Wedellsborg
Foundation.
Prospective cohort
(16 y)
3022 Caucasian males
53–74 y old
1 SDU: 10–12 g ethanol
/
Wine, beer, and spirits
All-cause and
IHD-related death
within the different
blood phenotypes
Alcohol
abstainers
(comparison only
for wine
drinkers)
For beer, the median (P20, P80) number
of drinks/week among those with the
non-O phenotype was significantly
higher in those who died (overall
mortality): 10.5 (0, 15.5) vs 7.5 (0, 10.5);
p0.001.
The effect of wine intake on all-cause
mortality among middle-aged and
elderly men may depend on ABO
phenotypes. Among non-O phenotype,
drinking 1–8 drinks/w: HR: 0.8 (0.7 to
1.8) and drinking >8 drinks/w: HR: 0.7
(0.6 to 0.98)
Bell et al., 2017 [49]
National Institute for
Health Research,
Welcome Trust, the
Medical Research
Council prognosis
research strategy
Partnership and
other government
health-related
agencies.
Prospective cohort
(6 y) 1937,360 (51% women)
1 SDU c: 8 g
Non-drinkers. Former
drinkers
Occasional drinkers:
drinks rarely or
occasionally. Moderate:
Men: 21 SDU/w or 3
SDU/day. Women: 14
SDU/w or 2 SDU/day
Heavy drinkers
/
Alcohol in general
CV death and all-cause
mortality
Moderate
drinkers
Non-drinkers (former and occasional
drinkers removed) had an increased
risk of CV death (HR: 1.32 (1.27 to 1.38))
and all-cause mortality (HR: 1.24 (1.20
to 1.28)).
CV. Cardiovascular; CVD: Cardiovascular disease; ERAB: European Foundation for Alcohol Research; FIVIN: the Foundation for Wine and Nutrition Research; HR: Hazard Ratio; IHD: Ischemic heart disease; OR:
Odds Ratio; SDU: Standard drinking unit; (to): 95%CI
a
When funding is provided by industries and/or foundations that might represent a conflict of interest, it is written in bold.
b
Outcomes for prospective
studies and meta-analyses, and Conclusions for reviews.
c
Since Bell et al. follow UK guidelines, 1 SDU was assumed to be 8 g alcohol. Adjustments: de Gaetano et al., 2016: (A) 1 Prospective cohort [
67
]; For age,
social class, smoking, physical activity, body mass index, lung function, evidence of CHD on questionnaire, diabetes, and regular medication. (B) 1 Prospective cohort [
68
]; For other types of alcohol, sex, smoking,
body mass index, physical activity in leisure time, cohabitation, and education. (C) 1 Prospective cohort [
69
]; For age at recruitment, BMI and height, former drinking, time since alcohol quit-ting, smoking status,
duration of smoking, age at start smoking, educational attainment, and energy intake. In women also for menopausal status, ever use of replacement hormones and number of full-term pregnancies. Stockwell
et al., 2016: Standard adjustment for between-study variation in covariates: Former drinker, Occasional (<1.30 g/day), Low volume (1.30 to <25 g /day), Medium volume (25 to <45 g/day), High volume (45 to
<65 g/day), Higher volume (65 g/day), All drinkers combined. Full adjustment for study characteristics: median age at intake, sex, Caucasian/non-Caucasian, drinking measure adequacy, former drinker bias,
and occasional drinker bias. Xi et al., 2017: Model 1: Adjusted for age, sex, and race or ethnicity. Model 2: Additional adjustments for education, marital status, body mass index, physical activity, smoking, and
diabetes) Bell et al., 2017: HRs adjusted for age (and age 2), sex, socioeconomic deprivation, and smoking status. Suadicani, 2008: Age adjusted (only for wine drinking).
Nutrients 2021,13, 879 14 of 24
Studies on general alcohol consumption have similar conclusions. A prospective
cohort study by Suadicani et al. found an association between wine consumption and
all-cause mortality, with a consistent effect at 84 g alcohol/week, and a larger effect seen
with higher consumption in men with non-O blood type [
34
,
61
]. However, a meta-analysis
by Stockwell et al. [
53
] suggested that, when the necessary adjustments for study design
characteristics are implemented, no association of moderate alcohol consumption with
mortality is observed. Two later prospective studies, with well-adjusted variables, con-
firmed the association between lower risk of total and CV mortality [49,51] and moderate
alcohol consumption defined by 168 g/week, 24 g/day for men and 112 g/week, 16 g/day
for women in the Bell et al. study [
49
] or by 43–196 g/week for men and 43–98 g/week for
women in the Xi et al. study [51].
Gender Differences
In the EPIC study, beer consumption in women was more strongly related than wine
consumption to overall mortality for amounts >21 g/week compared with the reference
category (0.7–20.3 g/week) [
69
]. On the other hand, in the study by Xi et al., the protective
effect of low and moderate alcohol consumption against all-cause and CV disease (CVD)
mortality was more pronounced in women [
51
]. Thus, it seems that women may be both
more sensitive to the protective effects against mortality of moderate beer intake and to the
risk effects of higher amounts.
5. Moderate Beer Consumption and Obesity, Diabetes, and Osteoporosis
Table 6details the studies on this subject. Although beer seems to have a direct
effect on weight gain [
52
], and on waist circumference in men [
59
], there is not enough
evidence to confirm whether moderate intake (<500 mL/day) is associated with general or
abdominal obesity [
55
], although daily amounts
500 mL increase the risk of not losing
weight [
59
]. In this regard, Padro et al., have reported that the moderate consumption
of either alcoholic (30 g/day for men; 15 g/day for women) or non-alcoholic beer for
four weeks did not increase the body weight of obese individuals [
46
]. Furthermore,
moderate beer consumption was associated with increases in the anti-oxidative properties
of high-density lipoprotein, which facilitate the efflux of cholesterol [46].
Nutrients 2021,13, 879 15 of 24
Table 6. Summary of main obesity, diabetes, and osteoporosis studies.
Study
Funding/COI a
Design (Mean/Median
Years of Follow-Up) n(Women)
Categories of Alcohol
Consumption/Type of
Drink
Variable/s Reference Group
(HR = 1) Outcomes/Conclusions b
Fresan et al., 2016 [52]
The Spanish Ministry of
Health, the Navarra
Regional Government, and
the University of
Navarra.
Prospective cohort
(4 y) 15,765 adults
Beverages groups:
Water, low/non-caloric
beverages (diet soda
beverages, coffee without
sugar), milk, juice, and
sugared coffee (dairy
products, juices, coffee with
sugar).
Occasional consumption
(SSSBs and spirits). Wine,
beer
Change in BW and
new-onset obesity No substitution
Substitution of one beer with one serving
of water per day at baseline was related to
a lower incidence of obesity (OR 0.81,
95%CI 0.69 to 0.94 and OR 0.84, 95%CI 0.71
to 0.98, when further adjusted for the
consumption of other beverage groups)
and to higher weight loss (328 g, 95%CI
566 to 89).
Bendsen et al., 2013 [55]
The Dutch Beer Institute
(funded by the Dutch
Brewers)/ Three of the
authors are employed by or
are board members of the
Dutch Beer Institute.
Systematic review of 35
observational studies and
12 experimental studies
Meta-analyses:
14 observational studies (11
cross-sectional and 3
prospective) included in
dose-response graphs. 10
intervention studies (6 beer
vs non-alcoholic beer and 4
beer vs control) included in
quantitative synthesis
1 SDU beer =
330 mL, 4.6% alcohol =
12 g/drink.
/
Beer
BW increase, BMI,
and abdominal
obesity (WC and
WHR)
Control:
Non-drinkers or in
the absence of
non-drinkers, the
group with the
lowest beer intake
Low or
non-alcoholic beer
Dose-response graphs: High beer intake
(>4 L/w) was associated with a higher
degree of abdominal obesity in men.
Quantitative synthesis: High beer
consumption (about 1000 mL/day; 5%
alcohol) did not result in increased BW
compared with control groups but did
result in increased BW compared with low-
or non-alcoholic beer groups (mean
difference 0.73 kg, 95% CI: 0.53 to 0.92;
z = 7.39, p< 0.0001, I2 = 0%)
Schütze et al., 2009 [59]
The German Cancer Aid,
the German Federal
Ministry of
Education and Research
and the European Union.
Prospective cohort
(8.5 y) 20,625 (12,749 women)
WOMEN:
No beer. Very light: >0 to
<125 mL/day. Light: 125
to <250 mL/day. Moderate:
250 mL/d
MEN:
No beer. Very light: >0 to
<250 mL/day. Light: 250
to <500 mL/day. Moderate:
500 to <1000 mL/day
Heavy: 1000 mL/day
/
Beer
WC change
BW change Very light
MEN: Moderate beer consumption
showed significant lower relative odds for
WC loss (OR 0.44, 95%CI 0.24 to 0.80)
WOMEN: Although beer-abstaining
women showed significantly lower
relative odds (OR.0.88; CI 0.81, 0.96) for
WC gain compared with their
very-low-level-drinking counterparts,
significance was lost once the model was
adjusted by HC change; however, the new
OR was on the border of significance
(OR.0.91; CI 0.83, 1.00)
Nutrients 2021,13, 879 16 of 24
Table 6. Cont.
Study
Funding/COI a
Design (Mean/Median
Years of Follow-Up) n(Women)
Categories of Alcohol
Consumption/Type of
Drink
Variable/s Reference Group
(HR = 1) Outcomes/Conclusions b
Padro et al., 2018 [46]
Fundacion Cerveza y
Salud, Madrid, Spain; The
European Foundation for
Alcohol Research; Spanish
Ministry of Economy and
Competitiveness of Science;
Institute of Health Carlos
III.
Open-label, prospective
randomized, two-arm,
longitudinal cross-over 36 (15 women)
WOMEN:
330 mL/day normal or
non-alcoholic beer (15
g/day or 0 g/day alcohol)
MEN:
660 mL/day normal or
non-alcoholic beer (30
g/day or 0 g/day alcohol)
/
Beer
BMI
T2D
Lipid Profile
Moderate beer consumption (traditional or
alcohol-free) does not increase body
weight in obese healthy individuals or
have negative effects on the vascular
system. Moderate consumption was
associated with reduced risk of
dyslipidemia, increased anti-oxidative
properties of high-density lipoprotein, and
increased efflux of cholesterol.
Polsky et al., 2017 [50]
None declared Systematic Review of 96
studies 18 studies included more
than 10,000 subjects each. Alcohol in general Moderate alcohol consumption generally
reduces diabetes risk.
Cullman et al. 2012 [43]
The Swedish Research
Council; the Swedish
Diabetes Association; the
Swedish Council
of Working Life and Social
research; and
Novo Nordisk Scandinavia.
Prospective cohort
(8–10 y)
5128 adults (3058 women)
with normal glucose
tolerance and 111 (41
women) with pre-diabetes.
35–56 y old
Abstainers
Total alcohol
Occasional: 0.01–1.49 g/day
in women, 0.01–6.79 g/day
in men. Low: 1.50–4.71
g/day in women, 6.80–13.01
g/day in men. Medium:
4.72–8.75 g/day in women,
13.02–22.13 g/day in men.
High: 8.76 g/day in
women, 22.14 g/day in
men
Wine
Occasional: 0.32 g/day in
women, 0.99 g/day in
men. Medium: 0.33–1.65
g/day in women, 1–4.99
g/day in men. High: 1.66
g/day in women,
5 g/day
in men
Beer (only in men)
Occasional: 0.99 g/day.
Medium: 1–4.99 g/day.
High: 5 g/day
/
Wine, beer and spirits
PreD
T2D
PreD + T2D
Occasional drinkers
Normal glucose tolerance at baseline
MEN: High alcohol: Higher risk of preD +
T2D (OR 1.42, 95% CI 1.00–2.03). High
beer: Higher risk of preD + T2D (OR 1.63,
95% CI 1.07–2.48) and higher risk of preD
(OR 1.84, 95% CI 1.13–3.01)
Abstainers vs occasional wine or beer
drinkers: Higher risk of preD + T2D (OR
2.01, 95%CI 1.01–3.98 and OR 2.13, 95%CI
1.03–4.39, respectively).
WOMEN: High wine: lower risk of preD
(OR 0.66, 95% CI 0.43–0.99)
Normal glucose tolerance or preD at
baseline
WOMEN: Low alcohol: Lower risk of T2D
(OR 0.41, 95% 0.22–0.79). Medium wine:
Lower risk of T2D (OR 0.46, 95%CI
0.24–0.88)
Nutrients 2021,13, 879 17 of 24
Table 6. Cont.
Study
Funding/COI a
Design (Mean/Median
Years of Follow-Up) n(Women)
Categories of Alcohol
Consumption/Type of
Drink
Variable/s Reference Group
(HR = 1) Outcomes/Conclusions b
Yin et al., 2011 [58]
National Health and
Medical Research Council
of Australia, Tasmanian
Government and
Royal Hobart Hospital
Acute Care Programme.
Prospective cohort
(2 y) 862 (49% women)
Mean age 63 y, range 51–81
1SDU: 10 g alcohol
Frequency:
Never, <once a month, 1–3
days/month, 1/2/3/4/5/6
days /wk, every day.
Amount
30mL spirits: 1 glass. 1 can
beer: 2 glasses. 1 bottle
wine (750 mL): 6 glasses. 1
bottle sherry (750 mL): 12
glasses. g/day
/
Wine, beer, and spirits
BMD change
Total alcohol intake in men positively
predicted change in BMD at the lumbar
spine and hip (beta = 0.008% and 0.006%
per year per gram of alcohol intake,
p< 0.05).
The frequency of drinking red wine was
positively associated with percentage
change in BMD at the lumbar spine in men
(beta= 0.08% per year per class, p= 0.048).
At baseline, lumbar spine BMD was
positively associated with frequency of
low-alcohol beer drinking in women
(beta = 0.034 g/cm(2) per category,
p= 0.002).
Mukamal et al., 2007 [62]
The National Heart, Lung,
and Blood Institute. The
National Institute on
Ageing.
Prospective
population-based cohort
study
(12 y If no hip fracture
7.5 y If hip fracture)
5865
60 y
1 SDU: 12-ounce can or
bottle of beer, 6-ounce glass
of wine, and 1 shot of liquor.
1 SDUc= 14 g
Categories
Long-term abstainers,
former drinkers, <1
drink/w, 1–6 drinks/w,
7–13 drinks/w, 14
drinks/w
/
Wine, beer, and spirits
Hip fracture
BMD Long-term
abstainers
Strong, graded, positive relationship
between greater alcohol consumption and
greater BMD up to 13 drinks/week.
U-shaped relationship between alcohol
intake and risk for hip fracture (quadratic
trend: p= 0.02), with lower HRs in
intermediate drinking categories.
Drinking <1 beer/w showed a
significantly lower risk of hip fracture (HR
0.66, 95%CI 0.44–0.99).
BMD: Bone Mineral Density; BMI: Body mass index; BW: Body weight; COI: Conflict of interest; HR: Hazard Ratio; OR: Odds Ratio; PreD: Pre-diabetes; SDU: Standard drinking unit; SSSBs: Sugar-sweetened
soda beverages; T2D: Type 2 diabetes; WC: Waist circumference; WHR: Waist-to-hip ratio.
a
When funding is provided by industries and/or foundations that might represent a conflict of interest, it is written in
bold.
b
Outcomes for prospective studies and meta-analyses, and Conclusions for reviews.
c
14 g are inferred from the amounts of the different beverages constituting 1 SDU and the American guidelines. White
rows: Diabetes studies; Light grey rows: Obesity studies; Dark grey rows: Osteoporosis studies. Adjustments: Fresan et al., 2016: Sex, age, age squared, baseline BMI, physical activity, smoking habit, personal
and family history of obesity, following a special diet, adherence to the Mediterranean dietary pattern, snacking between meals, weight change during the five years prior to baseline, and total energy intake from
other sources than the exchanged beverages. When the analyses were carried out for group of beverages, an additional adjustment for servings per day of other groups was conducted. Schütze et al., 2009: Age,
physical activity, smoking, change in smoking status, alcohol in g/d from other alcoholic beverages, education, waist circumference at baseline, total non-beer energy intake, incident diseases during follow-up
time and for women, additionally for menopausal status. Further adjustment for concurrent changes in body weight and hip circumference. Cullman et al., 2012: Age, BMI, tobacco use, physical activity, family
history of diabetes and education (and the other beverage types when analyzing a specific beverage) Yin et al., 2011: Age, body mass index, physical activity, medication, calcium intake, and smoking. Mukamal
et al., 2007: Age, sex, race, current weight, and height. Further adjustment: Smoking status, difficulty arising from a chair or bed, arthritis, diabetes, hypertension, clinical cardiovascular disease, previous cancer,
weight in early teens, leisure-time physical activity, visual problems, MMSE score, and use of estrogens, thiazide-type diuretics, and thyroid agents.
Nutrients 2021,13, 879 18 of 24
Based on the reviewed diabetes studies [
43
,
50
], moderate alcohol consumption may
decrease diabetes risk in men. A meta-analysis of 13 prospective studies, with 397,296
participants, showed that wine consumption was associated with a significant reduction of
the risk for type 2 diabetes mellitus (T2DM), with a pooled relative risk of 0.85, whereas beer
or spirits consumption led to a slight trend towards a decreasing risk for T2DM (relative
risk 0.96 and 0.95, respectively) [
70
]. Chronic alcohol consumption, however, is considered
a risk factor for T2DM, which may be triggered by a deterioration in glucose tolerance,
alterations in signalling of peptides involved in appetite regulation, and dysfunction and
apoptosis of pancreatic β-cells [71,72].
Data on bone mineral density (BMD) and fracture risk have been less conclusive,
probably due to the few studies available, and both relatively high and low levels of alcohol
consumption have shown benefits for bone health. Thus, the consumption of both beer
and wine at doses up to 60 g/day in men alone in the study by Yin et al. [
58
], and up to
13 drinks/week (182 g/week) in the study by Mukamal et al. [
62
], were shown to increase
BMD and/or decrease risk of fracture in the elderly. Even very low levels of consumption
were associated with a decreased fracture risk. Considering beer specifically, consumption
of <1 beer/week (<14 g/week) in men and women was significantly associated with
a lower risk of hip fracture (HR 0.66, 95%CI 0.44–0.99) [
62
]. Notably, low-alcohol beer
consumption in women was associated with increased lumbar BMD [
58
], suggesting that,
beyond the putative positive effect of alcohol on BMD, the non-alcoholic components
of beer may also be involved. Other compounds present in beer (e.g., phytoestrogens
such as 8-prenylnaringenin) act synergically with silicon to stimulate osteoblast cells,
improve bone structure, and help remineralize bone and teeth [
44
]. The polyphenolic
fraction, flavonoids, and the silicon content in beer may contribute to the positive effects
on bone metabolism [
45
]. The protective effect of polyphenols has also been proven in
human studies, where they reduced systolic and diastolic pressure and reduced lipoprotein
cholesterol serum levels, among others [
73
]. The cardioprotective role of polyphenols in
beer (traditional or alcohol-free) in particular has been reported in individuals with high
cardiovascular risk [8,74].
Gender Differences
With regard to obesity, the study by Schütze et al. [
59
] suggested that only men observe
a risk for an increase in waist circumference (WC) with beer consumption of >500 mL/day.
In women, beer-abstainers showed lower relative odds for WC gain compared with their
very low-level drinking counterparts (1 to <125 mL/day), which was close to significance.
Similar gender differences were seen in the diabetes studies. Cullman et al. found
that alcohol effect on glucose metabolism was different between men and women [
43
], de-
pending on amounts of consumption and alcohol type; overall, in individuals with normal
glucose tolerance, a decrease in T2DM risk was observed in occasional consumers of beer
and wine vs abstainers among men, and in high consumers (
192 g/week) of wine vs
occasional consumers among women. This cohort study showed that men who were high
consumers of beer and had baseline normal glucose tolerance had a significantly increased
risk of developing abnormal glucose regulation (OR 1.63, CI 1.07–2.48 for pre-diabetes plus
T2DM and OR 1.84, CI 1.13–3.01 for pre-diabetes) compared to occasional drinkers [
43
].
Men abstainers had a significantly higher risk of developing abnormal glucose regulation
(OR 2.13, CI 1.03–4.39) than occasional beer drinkers, suggesting occasional beer consump-
tion may be protective in men. Data for beer consumption in women were not provided
in the Cullman et al. study. When considering individuals with normal glucose tolerance
or pre-diabetes at baseline, the only significant difference found when using occasional
drinking as a reference was the case of women with low consumption of total alcohol,
who showed a decreased risk of T2DM (OR 0.41, CI 0.22–0.79). Most studies reviewed
by Polsky et al. [
50
] also showed differences between men and women. In one study, a
lower risk for T2DM was only observed in women who consumed alcohol (any quantity;
no dose-relationship observed) compared to lifetime abstainers, but this was not found
Nutrients 2021,13, 879 19 of 24
in men [
75
]. Another study showed that in men alone, a moderate alcohol consumption
(10–14.9 g/day) was associated with a reduced risk of T2DM with respect to very low
consumption (0.01–4.9 g/day), linked to wine consumption [76].
Regarding BMD, the study by Yin et al. [
58
] found that alcohol intake was positively
associated only in men with an increase in the percentage of spinal and hip BMD after two
years, whereas in women, lumbar spine BMD at baseline was positively associated with
frequency of low-alcohol beer consumption (beta = 0.034 g/cm2per category, p= 0.002).
6. Discussion
Despite the paucity of studies specifically exploring beer-related health effects, avail-
able data suggest that moderate beer consumption is associated with a decreased risk
for non-fatal CV events and total mortality. For other health effects, such as those on
general or abdominal obesity, study data have generally been inconclusive, although a
recent small study suggests that moderate consumption of either alcoholic or non-alcoholic
beer does not increase body weight in obese individuals [
46
]. Furthermore, moderate beer
consumption has been associated with decreased diabetes risk (only in men), and with an
increase in BMD, which lowers the risk of fracture in the elderly.
Although the available evidence supports the health benefits of moderate beer con-
sumption in adults (aged
18 years), study heterogeneity makes it difficult to establish the
precise quantity of beer needed to obtain these benefits. Different units of measurement
(i.e., grams of alcohol or non-standardized drinks per day vs. standard drink units), and
different definitions of consumption levels limit the direct comparison of these studies.
Nevertheless, given the ranges of alcohol consumption associated with observed benefits in
CVD (40–252 g/week for men; 21–210 g/week for women), mortality (75–196 g/week for
men; 75–112 g/week for women), and diabetes, obesity, and osteoporosis (12–350 g/week
for men; 12–210 g/week for women), a conservative upper limit of moderate beer drinking
in men could be
196 g/week (approximately 1–2 beers per day). Available studies suggest
that women may present a higher sensitivity to beer effects and, therefore, their upper limit
of moderate consumption may be slightly lower at
112 g/week (approximately 1 beer
per day). Notably, these values are similar to the low-risk drinking guidelines established
by many countries (Table 1) [
1
6
]. Importantly, evaluating the overall effect of alcohol
consumption on health is challenging, given it can be linked to improved benefits in CVD,
as shown in this study, but it can also be associated with an increased risk of cancer [
77
].
Notably, moderate alcohol consumption varies between reports, and large-scale studies are
warranted to adequately evaluate the role that specific ranges of alcohol consumption play
in health.
Aside from gender differences, alcohol-associated health benefits might be modu-
lated by intrinsic characteristics of populations, including their socioeconomic status [
68
]
and/or diet and general lifestyle. In a well-established example, the Mediterranean diet—
historically associated with high life expectancy and low CVD rates—is characterized by
its high consumption of fresh foods, low consumption of animal fats, and low-to-moderate
consumption of wine, generally with meals [
78
]. Indeed, the food pyramid recommended
by the Spanish Society of Community Nutrition reflects the Mediterranean diet and in-
cludes fermented alcoholic beverages (wine, beer, and cider) among foods and drinks
advised for an optional, occasional, and moderate consumption [
3
]. Importantly, this
inclusion of alcoholic beverages in the food pyramid regards its consumption with meals,
not alone. The inclusion of optional alcohol in the food pyramid is in agreement with data
that shows that daily moderate beer consumption in the context of a Mediterranean diet is
associated with favourable changes in the blood lipid profile [24].
The moderate consumption of alcohol
196 g/week (
28 g/day or 1–2 beers daily)
or
112 g/week (
16 g/day or 1 beer daily) for men and women, respectively, has been
associated with a variety of health benefits. However, it must be noted that weekly recom-
mended amounts of alcohol should be spread across several days and not include episodes
of heavy alcohol use or “binge drinking”, as irregular heavy drinking is associated with a
Nutrients 2021,13, 879 20 of 24
higher risk of ischemic heart disease [
79
]. This episodic heavy drinking is defined by the
World Health Organization as consumption of
60 g (approximately
6 drinks) per occa-
sion [
80
] and by the United States National Institute on Alcohol Abuse and Alcoholism [
81
]
as consumption of
5 drinks (male) or
4 drinks (female) in less than 2 h. While moderate
regular drinking is associated with a lower risk of ischemic heart disease compared with
abstention [
54
,
82
], excessive or binge drinking not only increases the risk of CV events, but
also the risk of all-cause mortality [
51
,
83
]. Therefore, consumption of moderate amounts of
alcohol should be always considered in the context of the Mediterranean lifestyle (mod-
erate quantities of alcohol consumed as part of a meal), as a strategy to promote a more
socially responsible consumption, avoiding excessive alcohol intake, often associated with
Nordic European, as well as Central and Eastern Europeans and Anglo-Saxon alcohol
consumers [
10
,
84
]. In a recent study using data from 123,219 men and women who were
followed up to 34 years of age, the authors reported that the adherence of the participants
to five low-risk lifestyle-related factors (never smoking, normal weight, regular physical
activity, healthy diet, and moderate alcohol consumption) could prolong life expectancy at
age 50 years by 14.0 and 12.2 years for female and male US adults, respectively, compared
with individuals who adopted no low-risk lifestyle factors [85].
In developing this review, we considered the possibility that study sponsors might
bias published results. Reported funding sources and conflict of interests (COIs) were
assessed for every study selected for this review. Out of the selected studies, only three
were directly funded by alcohol-related foundations [
34
,
55
,
57
], and COIs were reported
by some of their authors. In addition, the sponsors of these three studies declared no
intervention in the study execution and writing, and no differences in study results were
observed regardless of funding source.
In conclusion, we consider that an approximate intake of 10–16 g alcohol/day (1 beer/day)
for women and 20–28 g alcohol/day (1–2 beers/day) for men could be defined as moderate
beer drinking, providing that the consumption is distributed throughout the week with
no heavy episodic or “binge drinking” on a single occasion, especially during weekends.
Moderate beer drinking decreases CV risk and overall mortality. In addition, moderate
consumption decreases diabetes risk in men, increases BMD, lowering the risk of fracture
in the elderly, and does not seem to be associated with general or abdominal obesity.
Furthermore, moderate beer drinking should be considered within the context of mealtime
consumption, as the custom in Mediterranean countries. Future studies should refine the
quantity of beer considered as low-to-moderate consumption, which is the lowest risk level,
and further determine the possible health benefits associated with moderate beer drinking.
Although research in this field is acquiring great interest and possible benefits are
being found, the authors of this article insist on not recommending the consumption of
alcohol in children, adolescents, pregnant women, adults under medication, or at work
when using machinery (or driving). In addition, the consumption of alcohol must be
always accompanied by meals and excess must be avoided.
Author Contributions:
Conceptualization, methodology and writing—review: A.M., L.S.-M., F.P.-J.,
V.P., F.J.T. and R.E. All authors have read and agreed to the published version of the manuscript.
Funding:
This study was partially supported by the “Centro de Información Cerveza y Salud”. The
funding organization has not had any role in the data collection, their analysis and interpretation,
nor in the right to approve or disapprove publication of the finished manuscript.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement:
No new data were created or analyzed in this study. Data sharing is
not applicable to this article.
Acknowledgments:
We thank Almudena Pardo-Mateos who provided professional writing services.
Nutrients 2021,13, 879 21 of 24
Conflicts of Interest:
R.E. reports grants from Spanish Institute of Health “Carlos III” (Spain),
Cerveza y Salud (Spain), Fundación Dieta Mediterranea (Spain), and grants from Bicentury SA
(Spain), Grand Fountaine (Spain), Novartis SA (Spain), and Uriach Laboratories (Spain). He is also
a member of the Cerveza y Salud Scientific Committee. Further, personal fees for given lectures
from Brewers of Europe (Belgium), Fundacion Cerveza y Salud (Spain), Pernaud-Ricard (Mexico),
Instituto Cervantes (Alburquerque, USA), Instituto Cervantes (Milan, Italy), Instituto Cervantes
(Tokyo, Japan), Lilly Laboratories (Spain), Prodeca—Generalitat de Catalunya (Spain), Wine and
Culinary International, International Forum (Spain), and non-financial support from Harvard School
of Public Health (Boston, USA), Columbia University (NYC, USA), ERAB (Belgium), FundacióClinic
(Spain), and FundacióBosch i Gimpera (Spain). A.M. reports having received research funding from
the Cerveza y Salud Information Centre, the Spanish arm of European Brewers Association, and
being a member of the Cerveza y Salud Scientific Committee. F.J.T. reports having received speaker’s
bureau and consultant/advisory board fees from Cerveza y Salud, AstraZeneca, Amgen, Boehringer
Ingelheim, Bristol-Myers Squibb, Eli Lilly and Company, GlaxoSmithKline, Janssen Pharmaceuticals,
Merck Sharpe & Dohme, Novartis Pharmaceuticals Co., Novo Nordisk, Sanofi, and Regeneron
Pharmaceuticals, L.S.-M., V.P., F.J.P.-J. declare not to have competing interests.
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... The renin-angiotensin system (RAS) is perhaps the most important and powerful endocrine system affecting blood pressure control. It is an automatic been the subject of numerous studies in recent years, demonstrating that moderate beer consumption is beneficial to health [30][31][32][33][34][35][36][37][38][39][40][41]. Beer is a significant source of nutrients and health-promoting elements, including B vitamins (folic acid, riboflavin, niacin, thiamine, pantothenic acid, biotin, and vitamin B12), minerals (magnesium, calcium), carbohydrates (soluble fiber), natural antioxidants, and other substances derived from its primary ingredients (malted barley, hops, water, and yeast) [30][31][32][33][34][35][36][37][38][39]. ...
... It is an automatic been the subject of numerous studies in recent years, demonstrating that moderate beer consumption is beneficial to health [30][31][32][33][34][35][36][37][38][39][40][41]. Beer is a significant source of nutrients and health-promoting elements, including B vitamins (folic acid, riboflavin, niacin, thiamine, pantothenic acid, biotin, and vitamin B12), minerals (magnesium, calcium), carbohydrates (soluble fiber), natural antioxidants, and other substances derived from its primary ingredients (malted barley, hops, water, and yeast) [30][31][32][33][34][35][36][37][38][39]. Numerous studies indicate that moderate beer consumption in healthy adults is compatible with a balanced diet and that it protects the body from oxidation and cellular aging, potentially preventing or delaying cardiovascular diseases, among others [9,[30][31][32][33][34][35][36][37][38][39]42,43]. ...
... Beer is a significant source of nutrients and health-promoting elements, including B vitamins (folic acid, riboflavin, niacin, thiamine, pantothenic acid, biotin, and vitamin B12), minerals (magnesium, calcium), carbohydrates (soluble fiber), natural antioxidants, and other substances derived from its primary ingredients (malted barley, hops, water, and yeast) [30][31][32][33][34][35][36][37][38][39]. Numerous studies indicate that moderate beer consumption in healthy adults is compatible with a balanced diet and that it protects the body from oxidation and cellular aging, potentially preventing or delaying cardiovascular diseases, among others [9,[30][31][32][33][34][35][36][37][38][39]42,43]. ...
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... Most of these compounds originate from malt, with only approximately 20% being derived from hops [2]. Consuming beer in low-to-moderate amounts has been shown to lower the risk of heart disease, compared to both non-drinkers and heavy drinkers [3]. This suggests that beer might have some heart-protective benefits, likely due to its polyphenol content. ...
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... Briefly, cells were plated in 12-well plates and maintained in culture for 24 h. After that, cells were treated with five scalar volumes (i.e., 36,18,9,4.5, and 2.25 µL) of each extract stock solution or with 1% Triton X-100 (positive control) for four hours. In the case of EtOH-containing extracts (Extracts 1), the highest volume of stock solution used (i.e., 36 µL) contributed to a maximum EtOH concentration in the treatment which was always lower than 0.5% (v/v), which has been shown, in preliminary tests, to not affect cell viability in this cell line. ...
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... Hops and malt contribute significant amounts of polyphenols, minerals (such as calcium, iron, magnesium, phosphorus, potassium, zinc, manganese, and selenium), as well as vitamins to beer [6]. Marcos et al. found that moderate beer consumption is beneficial for cardiovascular health and metabolism [7]. ...
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... In recent years, many not widely known beer styles and types have gained popularity. Brewers can use special malts, different varieties of hops, the addition of fruit and other botanicals (including functional additives), and different strains and species of yeast to interest the consumer. Traditionally, beer contains 3-6% ABV (alcohol by volume), but beers with much higher as well as lower alcohol content can be found on the market (Marcos et al., 2021). It is the latter that has been gaining popularity in recent years. ...
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Traditionally fermented alcoholic drinks are made with locally sourced ingredients and traditional knowledge, and they are typically drank in the immediate area of production. The ingredients are sources of microbial contamination in these drinks. This study aimed to update the mycoflora and evaluate levels of Ochratoxin A (OTA) and aflatoxins contamination of some local beverages (Raffia Sap 'Palm wine' and sorghum beer 'Pito') in the Ho municipality, Volta Region, Ghana. Standard mycological analyses were carried out on the samples and the plates were incubated for 5-7 days at 28 ± 1 °C. Mycotoxin levels in the samples were quantified using High-Performance Liquid Chromatography coupled to a fluorescence detector (HPLC-FLD) was used. Deterministic models recommended by a Joint FAO/WHO Expert Committee on Additives were used to assess cancer risk. The fungal counts of palm wine samples in the Ho municipality recorded were in a range of 3.29-4.59 log10 CFU/ml, while pito samples recorded a fungal range between 2.55 and 4.08 log10 CFU/ml. A total of 13 fungal species, namely; Aspergillus niger, Aspergillus terreus, Aspergillus flavus, Aspergillus fumigatus, Fusarium oxysporum, Fusarium oligosporus, Fusarium verticillioides, Trichoderma harzianum, Rhizopus stolonifer, Penicillium verrucosum, Rhodotorula mucilaginosa., Mucor racemosus and Yeasts were isolated from both palm wine and pito samples. Notably, ochratoxin A (OTA) quantities ranged between 5.50 and 14.93 μg/kg for both samples while Total aflatoxins ranged between LOD-10.70 μg/kg for pito. No aflatoxins were detected in palm wine. Consumer risk assessment values computed for both moderate and heavy drinkers ranged between 4.08-40.20 ng/kg bw/day, 13.88-50.44, and 0.314-1.156 cases/10, Research Discover Food (2024) 4:167 | https://doi.org/10.1007/s44187-024-00242-0 great diversity. Cancer Risk assessments for the mycotoxins suggested a potential health hazard to the consumers of these beverages in the Ho municipality.