During World War I, Dr Camille Lian, a reserve officer in the French army, studied the association of wine and spirits with blood pressure in a group of 150 soldiers aged 42 and 43 years old.
After careful blood-pressure measurements, Dr Lian divided the soldiers into four drinking categories according to their reported intake of wine and spirits in peacetime: “sober” (below 1.0 liter of wine/day, no apéritifs, eau de vie, or liqueur); “moyens buveurs” (1.0–1.5 liter/day, no spirits); “grands buveurs” (2.0–2.5 liter/day and a few glasses of eau de vie or liqueur) and “très grands buveurs” (at least 3.0 liter/day and 5–6 glasses of spirits). Dr Lian found high blood pressure in 6.25% of sober soldiers; 7.54% of moderate drinkers; 17.54% of heavy drinkers, and 25% of the très grands buveurs.1
Alcohol and blood pressure
A meta-analysis of 20 studies of alcohol consumption and blood pressure (90,160 cases of hypertension) found an increasing risk of hypertension from 19% in men drinking 1–2 drinks/day, 51% associated with 3–4 drinks/day, and 74% with ≥ 5 drinks/day. In women, there was no increased risk for 1–2 drinks/day but 42% increased risk for consumption beyond this level.2
All alcohol assessments were based on subjective measurements, which may entail information bias. Data from the Kaiser Permanente study suggested that the increased prevalence of hypertension among persons reporting 1–2 drinks per day appeared to be partially due to underreporting of alcohol intake.3 A meta-analysis of 32 randomized controlled trials involving 767 participants found little to no effect on blood pressure by one drink.4
Hypertension and drinking pattern
The relationship between alcohol consumption and hypertension is well established; however, the mechanism through which alcohol increases blood pressure remains elusive, and the drinking pattern may modify the association. In the majority of studies, the assessment of alcohol has been focused primarily on average quantity of alcohol consumed during a period of time. The first attempt to look at the pattern of drinking and hypertension was a study of Italian men and women that found a higher prevalence of hypertension in individuals consuming wine outside meals compared with drinkers of wine with meals.5 A study of a sample of current drinkers from western New York (with a substantially different drinking culture) found odds ratios for hypertension of 1.41 for drinking outside meals versus 0.90 for daily drinking with food, after adjustment for the amount of alcohol consumed.6
Daily drinking and intake with food are core elements of the Mediterranean alcohol-drinking pattern (MADP), and the SUN Prospective Cohort Study found low MADP adherence (score <2) significantly associated with a higher incidence of hypertension hazard ratio 1.81, as compared to the high-adherence (score >7) category, which had similar risk of hypertension as abstainers.7
Must people with hypertension be abstinent?
People with a diagnosis of hypertension should expect questions from their physician about their lifestyle, including alcohol drinking habits. If alcohol intake exceeds an average of one or two drinks per day or includes binge-drinking, reduction in alcohol intake should be considered along with other lifestyle changes that might be relevant, such as weight reduction, limitation of sodium intake, or more exercise.
Given that hypertension is associated with a doubled risk for cardiovascular disease (CVD), and given the potential protective effects of alcohol against CVD and ischemic stroke, the topic of balancing the risks and benefits is of particular importance for those with high blood pressure. The relationship between drinking habits and blood pressure, CVD, and all-cause mortality has been studied in thousands of patients with hypertension from all over the world: US physicians; hypertensive men attending UK hospital clinics; US women from the WHI study; Japanese men from the Suita study; French men from a study by Serge Renaud; men and women from the Danish Diet, Cancer and Health study; and US men from the Health Professionals Follow-Up study.
For the majority of people with hypertension over the age of 60 who adhere to MADP, one drink a day in women and one or two drinks a day in men appears to be associated with the greatest net health benefits and the lowest risk.8
1. C Lian, “L’alcoolisme, cause d’hypertension arterielle,” Bulletin de l’Académie Nationale de Médecine 74 (1915), pp.525–28.
2. M Roerecke et al, “Sex-specific associations between alcohol consumption and incidence of hypertension: A systematic review and meta-analysis of cohort studies,” Journal of the American Heart Association 2018;7:e008202.
3. AL Klatsky et al, “Higher prevalence of systemic hypertension among moderate alcohol drinkers: An exploration of the role of underreporting,” The Journal of Studies on Alcohol and Drugs 67 (2006), pp.421–28.
4. S Tasnim et al, “Effect of alcohol on blood pressure,” Cochrane Database of Systematic Reviews 2020, issue 7, art. no. CD012787.
5. M Trevisan et al, “Alcohol consumption, drinking pattern and blood pressure: Analysis of data from the Italian National Research Council Study,” International Journal of Epidemiology 16 (1987), pp.520–27.
6. S Stranges et al, “Relationship of Alcohol Drinking Pattern to Risk of Hypertension,” Hypertension 44 (2004), pp.813–19.
7. A Hernández-Hernández et al, “Mediterranean Alcohol-Drinking Pattern and Arterial Hypertension in the Seguimiento Universidad de Navarra (SUN) Prospective Cohort Study,” Nutrients 15 (2023), p.307.
8. CJ Bulpitt, “How many alcoholic drinks might benefit an older person with hypertension?” Journal of Hypertension 23 (2005), pp.1947–51.