Cardiovascular risk factors and confounders among nondrinking and moderate-drinking U.S. adults


      Studies suggest that moderate drinkers have lower cardiovascular disease (CVD) mortality than nondrinkers and heavy drinkers, but there have been no randomized trials on this topic. Although most observational studies control for major cardiac risk factors, CVD is independently associated with other factors that could explain the CVD benefits ascribed to moderate drinking.


      Data from the 2003 Behavioral Risk Factor Surveillance System, a population-based telephone survey of U.S. adults, was used to assess the prevalence of CVD risk factors and potential confounders among moderate drinkers and nondrinkers. Moderate drinkers were defined as men who drank an average of two drinks per day or fewer, or women who drank one drink or fewer per day.


      After adjusting for age and gender, nondrinkers were more likely to have characteristics associated with increased CVD mortality in terms of demographic factors, social factors, behavioral factors, access to health care, and health-related conditions. Of the 30 CVD-associated factors or groups of factors that we assessed, 27 (90%) were significantly more prevalent among nondrinkers. Among factors with multiple categories (e.g., body weight), those in higher-risk groups were progressively more likely to be nondrinkers. Removing those with poor health status or a history of CVD did not affect the results.


      These findings suggest that some or all of the apparent protective effect of moderate alcohol consumption on CVD may be due to residual or unmeasured confounding. Given their limitations, nonrandomized studies about the health effects of moderate drinking should be interpreted with caution, particularly since excessive alcohol consumption is a leading health hazard in the United States.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Mokdad A.H.
        • Stroup D.
        • Marks J.S.
        • Gerberding J.
        Actual causes of death in the United States, 2000.
        JAMA. 2004; 291: 1238-1245
      1. Centers for Disease Control and Prevention. Available at: Accessed December 10, 2004.

        • Stahre M.
        • Brewer R.D.
        • Naimi T.S.
        • et al.
        Alcohol-attributable deaths and years of potential life lost due to excessive alcohol use in the U.S.
        Morb Mortal Wkly Rep. 2004; 53: 866-870
        • Naimi T.S.
        • Brewer R.D.
        • Mokdad A.H.
        • Denny C.
        • Serdula M.
        • Marks J.S.
        Binge drinking among U.S. adults.
        JAMA. 2003; 289: 70-75
        • Wannamathee S.G.
        • Shaper A.G.
        Alcohol, coronary heart disease and stroke.
        Neuroepidemiology. 1998; 17: 288-295
        • Shaper A.G.
        • Wannamathee S.G.
        Epidemiological confounders in the relationship between alcohol and cardiovascular disease.
        in: Paoletti R. Klatsky A.L. Poli A. Zakhari S. Moderate alcohol consumption and cardiovascular disease. Kluwer, Dordrecht2000: 105-112
        • Criqui M.H.
        • Ringel B.L.
        Dies diet or alcohol explain the French paradox?.
        Lancet. 1994; 344: 1719-1723
        • Shaper A.G.
        • Wannamathee S.G.
        The J-shaped curve and changes in drinking habit.
        in: Chadwick D.J. Alcohol and cardiovascular disease. John Wiley and Sons, Chichester1998: 173-193
        • Criqui M.
        Do known cardiovascular risk factors mediate the effect of alochol on cardiovascular disease.
        in: Chadwick D.J. Alcohol and cardiovascular diseases. John Wiley and Sons, Chichester1998: 159-172
        • Rehm J.
        • Greenfield T.K.
        • Rogers J.D.
        Average volume of alcohol consumption, patterns of drinking, and all-cause mortality.
        Am J Epidemiol. 2001; 153: 64-71
        • Thun M.J.
        • Peto R.
        • Lopez A.D.
        • et al.
        Alcohol consumption and mortality among middle-aged men and elderly U.S. adults.
        N Engl J Med. 1997; 337: 1705-1714
        • Murray R.P.
        • Connett J.E.
        • Tyas S.L.
        • et al.
        Alcohol volume, drinking pattern, and cardiovascular disease morbidity adn mortality.
        Am J Epidemiol. 2002; 155: 242-248
        • Splaver A.
        • Lamas G.A.
        • Hennekins C.H.
        Homocysteine and cardiovascular disease.
        Am Heart J. 2004; 148: 34-40
        • Nelson D.E.
        • Holtzman D.
        • Waller M.
        • et al.
        Objectives and design of the Behavioral Risk Factor Surveillance System. 1998 (Paper presented at American Statistical Association National Meeting, Dallas TX)
        • Nelson D.E.
        Reliability and validity of measures from the Behavioral Risk Factor Surveillance System (BRFSS).
        Social Prev Med. 2001; 46: S3-S42
        • U.S. Department of Agriculture and U.S. Department of Health and Human Services
        Nutrition and your health dietary guidelines for Americans. 5th ed. Government Printing Office, Washington DC: U.S2000 (Home and Gardening Bulletin 232.)
        • Mattila K.J.
        • Valtonen V.V.
        • Nieminen M.
        • Huttunen J.K.
        Dental infection and the risk of new coronary events.
        Clin Infect Dis. 1995; 20: 588-592
        • Cahalin D.
        • Cisin I.H.
        • Crossley H.M.
        Demographic and sociological correlates of levels of drinking.
        in: American drinking practices. Rutgers Center on Alcohol Studies, New Brunswick NJ1969: 18-64
        • Dong M.
        • Giles W.H.
        • Felitti V.J.
        • et al.
        Insights into causal pathways for ischemic heart disease.
        Circulation. 2004; 110: 1761-1766
        • Williams J.E.
        • Paton C.C.
        • Siegler I.C.
        • et al.
        Anger proneness predicts coronary artery heart disease risk.
        Circulation. 2000; 101: 2034-2039
        • Parodi P.W.
        The French paradox unmasked.
        Med Hypotheses. 1997; 49: 313-318
        • Kopp P.
        Resveratrol, a phytoestrogen found in red wine. A possible explanation for the conundrum of the French paradox.
        Eur J Endocrinol. 1998; 138: 619-620
        • McNamee R.
        Confounding and confounders.
        Occup Environ Med. 2003; 60: 227-234
        • Szklo M.
        • Nieto F.J.
        Epidemiology. Aspen Publications, Gaithersburg MD2000
        • Tsubono Y.
        • Yamada S.
        • Nishino Y.
        • et al.
        Choice of comparison group in assessing the health effects of moderate alcohol consumption.
        JAMA. 2001; 286: 1177-1178
        • Mukmal K.J.
        • Conigrave K.M.
        • Mittleman M.A.
        • et al.
        Roles of drinking pattern and type of alcohol consumed in coronary heart disease in men.
        N Engl J Med. 2003; 348: 109-118
        • Rosen M.
        Drink to this: the evidence is growing: for most people, having one or two glasses of alcohol every day is healthier than not drinking at all.
        in: Health Science section, Boston Globe2004: C11 (April 6, C13.)
        • Zuger A.
        The case for drinking (all together now: in moderation!). New York Times, 2002 (December 31)
        • Hu F.B.
        • Manson J.E.
        • Stampfer M.J.
        • et al.
        Diet, lifestyle, and the risk of type 2 diabetes mellitus in women.
        N Engl J Med. 2001; 345: 790-797
        • Klatsky A.L.
        Drink to your health?.
        Scientific American. 2003; : 75-81
        • Raloff J.
        When drinking helps.
        Sci News. 2003; 163: 155-156
      2. Doyle M. Wine health claims allowed. Sacramento Bee. Available at: Accessed April 2, 2003.

      3. US Department of Health and Human Services and US Department of Agriculture. Dietary Guidelines for Americans 2005. Alcoholic Beverages. Available at: Accessed March 9, 2005.

        • Goldberg I.J.
        • Moska L.
        • Piano M.R.
        • Fisher E.A.
        Wine and your heart.
        Circulation. 2001; 103: 472-475
      4. National Cholesterol Education Project. The detection, evaluation and treatment of high blood cholesterol in adults (Adult Treatment Panel III). Available at: Accessed June 30, 2003.

        • Shepherd J.
        • Cobbe S.M.
        • Ford I.
        • et al.
        Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia.
        N Engl J Med. 1995; 333: 1301-1307
        • Wilson K.
        • Gibson N.
        • Willan A.
        • Cook D.
        Effect of smoking cessation on mortality after myocardial infarction.
        Arch Intern Med. 2000; 160: 339-344
        • Coffield A.B.
        • Maciosek M.V.
        • McGinnis M.J.
        • et al.
        Priorities among recommended clinical preventive services.
        Am J Prev Med. 2001; 21: 1-9