November 8, 2010


Question from a reader: Greetings, I enjoy your nephrology blog. My best friend’s blood pressure is stage 1 and seldom reaches stage 2. He is taking lisinopril 5mg a day, follows a special diet, and exercises 2-3 times a week; however, he drinks Whiskey and sometimes beer at least three times a week. Is there a direct effect from alcohol with blood pressure? If yes, is there a specific type of alcohol that has less of an effect? Do we have to send him for treatment? Kindly advise in this regard. Your help in this matter will be highly appreciated.

Thank you so much for your question. Alcohol affects the body in many ways, both positively and negatively.

Excess alcohol intake is associated with increased blood pressure. Drinking more than 2 drinks a day increases the risk for hypertension. The effect is more likely to occur once a person imbibes more than 5 drinks a day.

People who drink alcohol usually engage in other risky behaviors that are not very heart healthy. Such behaviors include tobacco abuse and overeating. So it can be hard to assess alcohol’s effect on risk alone. Another way to assess the relationship between alcohol and blood pressure is to see what happens to blood pressure when patients stop alcohol. When patients stop alcohol, the average decline in blood pressure is 3 mm HG systolic (the top number) and 2 mm HG diastolic (the bottom number). That’s not a big drop, and certainly not enough of a drop to decrease the blood pressure of a stage II hypertensive to goal (greater than 160/100 down to less than 140/90).

Your friend will likely need to continue his lisinopril even if he stops drinking. In fact, if he has stage II hypertension, he will probably need to increase his blood pressure medicine. He should exercise more if he can because the recommendations for exercise have increased.

In previous medical blogs, I have discussed surrogate markers as assessors of risk (such as cholesterol) versus hard endpoints (such as heart attack, stroke, and death). There are studies that have been done looking at the relationship between alcohol use and the hard endpoint death in both men and women in the United States, Europe, and other countries. It turns out that there is a ” J Curve” relationship between alcohol use and mortality.

The figure shows the relationship between the relative risk of total mortality and the number of drinks per day of alcohol consumed for both men and women. It also compares countries and describes the relationship between total mortality and grams of alcohol drunk per day (see below). I’ll describe the lower part of the figure first and then apply the information to the top part of the figure.

A relative risk of 1 compared to the rest of the population suggests that there is no benefit or risk to drinking alcohol. If the line goes below 1, the risk of dying is decreased by a certain percentage. If the line goes above 1, the risk of dying is increased by a certain percentage.

So for men in the United States, 1/2 a drink seems to have the greatest benefit and appears to reduce the risk of death by 18% (100% – 82% = 18%). Men in the U.S. can drink up to 3 drinks daily and have “protection from death.” After that amount, the line crosses 1 and the risk starts to increase in a dose dependent fashion. In other words, the risk of death (mortality) increases in men once they start consuming more than 3 drinks a day.

The curve looks like the letter “J,” and that’s why it is called a J-curve. In other words, a benefit to the “therapy” occurs, maxes out at a particular amount of alcohol, and then declines. Too much therapy results in harm after the line crosses 1.

Sidebar: Blood pressure treatment follows a similar J-curve pattern. Your blood pressure can be too low, and most experts suggest a blood pressure of 130/80 as an ideal goal.

I find it interesting that men in other countries, including Europe, appear to be able to drink more and still have a decreased risk of mortality. For European men, the line crosses 1 at 7 drinks per day. Some call this phenomenon the French paradox. Some studies suggest the consumption of red wine and beer over spirits can explain the effect. Other studies suggest that the type of alcohol doesn’t matter: alcohol is alcohol, and the number of grams per day and the pattern of consumption (for example daily moderation versus binge drinking) is more important. The figures above suggest that 5 grams per day of alcohol provides the maximum benefit. That’s about 1/2 a beer per day.

Here is how to convert per cent alcohol content to grams of alcohol. Let’s take a 12 ounce beer with an alcohol content of 4.5% and convert the % of alcohol in the beverage to grams of alcohol:

  1. 12 oz = 355 ml (1 ml = 0.0338140225589 ounces so 12 / 0.033 = 355)
  2. 4.5% of 355 ml is the milliliter content of alcohol in the beverage. Our beer has 16 ml of alcohol in it (0.045 x 355 = 16)
  3. 16 ml of alcohol is 12.8 g of alcohol (1 milliliter of alcohol weighs 0.8 grams). (16 x 0.8 = 12.8)

Women appear to respond to alcohol in a similar fashion as men. A J-curve is present. The maximum benefit appears to occur at 1/2 a drink. However, the protective effect of alcohol seems to vanish at 2 and 1/2 drinks. Drinking more than 2 and 1/2 drinks appears to increase the risk of mortality in women.

Some physicians do not recommend alcohol for many reasons. Alcohol use can cause the following problems:

  • Alcohol has calories which can increase your weight. Some drinks have a lot of sodium which increases blood pressure.
  • Your liver can be adversely affected by drinking too much alcohol.
  • Alcohol on a daily basis gets expensive.
  • There is a link between alcohol consumption and the development of certain types of cancer.
  • Women who are pregnant or are anticipating pregnancy should not consume alcoholic beverages.

Most importantly, alcohol can be an addictive substance. Some opine the harm associated with a person’s becoming addicted to alcohol make alcohol use too risky to recommend to patients (unless everything else has been tried and there is nothing left to recommend). Doctors use the CAGE questionnaire to determine if a patient needs counseling for alcohol addiction:

  1. Have you ever felt you should cut down on your drinking?
  2. Have people annoyed you by criticizing your drinking?
  3. Have you ever felt bad or guilty about your drinking?
  4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?

The CAGE questionnaire is a screening tool. If a patient says yes to 2 or more of the CAGE questions, there is a concern for alcohol dependence (sensitivity = 93%, specificity = 76%). From Bernadt, MW; Mumford, J; Taylor, C; Smith, B; Murray, RM (1982). “Comparison of questionnaire and laboratory tests in the detection of excessive drinking and alcoholism.”

If your friend says yes to 2 or more questions, you might want to recommend counseling for alcohol dependence regardless of the affect of alcohol on hypertension and mortality.

On the news, I hear different recommendations regarding the amount of alcohol men and women can drink to decrease their risk. The latest data I have seen suggest that 1 drink a day for both men and women provides the greatest benefit. Men can imbibe up to 3 drinks a day while women can have up to 2 drinks a day and still have some protection from death. That said, if you are drinking alcohol for health, consider some other options that have a greater benefit to risk ratio. These options include stopping smoking, diet, exercise, blood pressure control with 4 dollar a month medication, and cholesterol control.

Disclaimer: Please talk with your physician, provider, and pharmacist prior to going forward with consuming alcohol to promote your health. Many medications interact with alcohol, so you must use caution.

  1. Shashank

    i am diabetic and 22 years old (I've had type 1 since i was 8) .i have a drink occasionally, but i don't drink beer (loaded with carbs) i usually drink sugar free redbull and vodka .it has never had much of an effect on my blood sugar but then again i don't let myself get drunk so i don't lose control. i had a diabetic friend die at the age 17 due to the fact that she funneled way too many beers at a party and passed out and no one realized her blood sugar had shot up above 1000 and she flat lined and never came out of a coma. everything should be done in moderation.

  2. Tess Brich

    Thank you for this informative article. The question I have is directed toward iclub folk: I am wondering if "most experts suggest a blood pressure of 130/80 as an ideal goal." why the Alegent iClub knocks points off your health score if your SBP = or > 120 mmHg and not at 130 mmHg threshold?

  3. Michael Aaronson

    Thank you Tess for your provocative question. In my opinion, points should not be taken off unless your blood pressure is higher than 130/80. My understanding is that there is little experimental data to suggest that lowering blood pressure below the threshold of 130/80 improves outcomes. In fact, experts in hypertension suggest the presence of a "J curve" with respect to hypertension. In other words, if providers decrease the blood pressure by too much, we may be doing more harm than good. For example, since the coronary arteries are perfused during diastole, if the lower number is too low, there is a concern that the heart will not get the oxygen it needs to pump correctly, causing problems. That said, when we look at population based data, those with blood pressures of less than 120/80 tend to have the lowest mortality. That's where the 120 comes from. There is no consensus regarding ideal blood pressure. So it could be argued that both numbers are correct.

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