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(Hypertension. 1995;25:1106-1110.)
© 1995 American Heart Association, Inc.

Articles

Relationship of Alcohol Intake With Blood Pressure in Young Adults

Matthew W. Gillman; Nancy R. Cook; Denis A. Evans; Bernard Rosner; Charles H. Hennekens

From the Division of Preventive Medicine (M.W.G., N.R.C., C.H.H.) and the Channing Laboratory (D.A.E., B.R.), Department of Medicine, Brigham and Women's Hospital; the Department of Ambulatory Care and Prevention, Harvard Community Health Plan, Harvard Medical School (M.W.G., N.R.C., C.H.H.), Boston, Mass; and the East Boston (Mass) Neighborhood Health Center (M.W.G., D.A.E., C.H.H.).

	Abstract

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Abstract The objective of this study was to examine the relationship of usual current alcohol intake with systolic and diastolic pressures among young adults. Participants were 316 men and women, aged 18 to 26 years, from East Boston, Mass. At each of three weekly visits we obtained three blood pressure measurements on each subject using a random-zero sphygmomanometer. Using an interviewer-administered questionnaire, we obtained information about quantity and frequency of alcohol intake during the previous month. The lowest systolic pressure levels were in subjects consuming 1 to <2 drinks per day. Adjusted for age, sex, and body mass index, systolic pressure was higher by 4.0 mm Hg (95% confidence interval [CI], 0.5 to 7.6 mm Hg) in abstainers, 3.6 mm Hg (95% CI, 0.5 to 6.6 mm Hg) in those who drank <1 drink per day, 0.4 mm Hg (95% CI, -4.7 to 5.5 mm Hg) in those who drank 2 to <3 drinks per day, and 8.1 mm Hg (95% CI, 2.9 to 13.4 mm Hg) in those who drank 3 drinks per day. Levels of diastolic pressure were lowest in those consuming 2 to <3 drinks per day. Adjustment for pulse rate, smoking, medication use, and family history of hypertension did not alter the results. These results suggest a J-shaped association of alcohol intake with blood pressure level in young adults, with the lowest levels in consumers of 1 to 3 drinks per day.

Key Words: blood pressure • alcohol • cross-sectional studies

	Introduction

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The first report of an association between alcohol intake and blood pressure (BP) was published in 1915, when Lian¹ noted that French servicemen who consumed more than 3 L of wine per day had a prevalence of hypertension four times greater than their "sober" (only 1 L/d) counterparts. Since that time, numerous cross-sectional^{2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17} and cohort^{2 6 10 18 19 20} studies have shown consistently that excess alcohol intake is related to elevated BP as well as to the prevalence and incidence of hypertension. In addition, several intervention studies^{21 22 23 24} have shown that cessation of alcohol drinking lowers BP. Investigators have estimated that 5% to 30% of hypertension is attributable to alcohol consumption.^{3 11 12 25 26} Clinicians now often advise hypertensive patients to reduce or stop drinking.²⁷

However, questions remain about certain aspects of the alcohol-BP association. Most of the published data have been in middle-aged individuals. Fewer data exist among young adults, and some available data suggest a weaker association.^{5 17} In addition, because the pathophysiology remains uncertain, it is not clear whether repetitive drinking of small amounts or occasional drinking of large amounts is more important.^{4 28 29 30} Moreover, there is disagreement about the effect, if any, of light to moderate alcohol intake on BP. Some researchers have found a linear relationship of alcohol with BP,² others a threshold only above which there is an association,³ and still others a J- or U-shaped association,^{4 6} with the nadir among light to moderate alcohol users.

The purpose of this study was to examine the association of alcohol intake with BP level among young adults. For the present analysis, we used BP data obtained from multiple weekly visits and multiple measurements per visit on each subject as well as usual alcohol intake and a large number of potential confounding factors.

	Methods

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Subjects and Measurements
This analysis involved 316 men and women, aged 18 to 26 years, from East Boston, Mass, an urban, working-class community. During 1989 and 1990, the subjects participated in the follow-up phase of a prospective cohort study of BP tracking and prediction from childhood to early adulthood. Further details have been published previously.³¹ Briefly, we obtained measurements on each subject at up to three weekly visits, most of which were at subjects' homes. Of the 316 participants with BP information from at least one visit, 277 (87.7%) completed all three visits, and 296 (93.7%) completed at least two visits. This study was approved by the human subjects review board of the East Boston Neighborhood Health Center, and each subject provided informed consent.

We measured BP following the protocols of the Hypertension Detection and Follow-up Program.³² Specifically, observers underwent standardization training to minimize interobserver variability. Hawksley random-zero sphygmomanometers (WA Baum Co, Inc) were used to decrease digit preference. Appropriately sized cuffs were used, and each BP measurement was made in the right arm with the subject comfortably seated and quiet after a 5-minute rest, the forearm at heart level, and the stethoscope in the antecubital fossa. Systolic BP and diastolic BP, both Korotkoff phase IV (muffling) and phase V (disappearance) were recorded. Date and time of recording were noted. Observers were blinded to BP values obtained at previous visits. At each visit, the three BP measurements were taken at 1-minute intervals. Pulse rate, height, and weight were also measured.

At each subject's first visit and after BP measurements had been obtained, we gathered information from an interviewer-administered questionnaire to ascertain usual alcohol intake. For each type of alcohol (beer, wine, and liquor), we asked subjects if they had consumed any over the past month, and if so, the number of times and usual number of drinks each time. This questionnaire also contained information concerning medication type, dosage, and frequency in the preceding week; whether a health care provider had ever told the subject that he or she had high BP; whether a health care provider had ever told one or both of the subject's parents that they had high BP; and the quantity of current and past cigarette use.

Data Analysis
We first computed descriptive statistics for variables of interest. For beer, wine, and liquor separately, we computed usual intake by multiplying the number of times the subject had drunk the beverage over the past month by the usual number of drinks at each time. To combine the types of alcohol, we assumed that a can of beer contains 13.2 g alcohol; a glass of wine, 10.8 g; and a drink of liquor, 15.1 g. For these analyses we defined a drink as 13.2 g alcohol (ie, a "beer can" equivalent of alcohol). We assigned each subject into one of five intake categories: none in the past month or an average of <1, 1 to <2, 2 to <3, or 3 drinks per day. For BP, we calculated the mean for each visit and then averaged these over all visits. We report Korotkoff phase V diastolic pressures.

To examine crude relations of alcohol intake with BP, we examined systolic and diastolic BP by intake category. We then performed ANCOVA to examine the effect of usual alcohol intake on BP level, while controlling for the effects of other variables. We included a variable if adding it to the model altered the effect estimate of any alcohol category on BP by at least 10%. We considered 1 to <2 drinks per day to be the referent category because of our a priori hypothesis of lowest BP associated with this amount of consumption and because the relatively large number of subjects yielded the most stable estimates.

	Results

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Of 177 women and 139 men participating in the study, all were white except two of Chinese descent. Table 1 shows mean BP, pulse rate, height, and weight by sex. As expected, BP levels were higher in men than in women.

View this table: [in this window] [in a new window]   Table 1. Blood Pressure, Pulse Rate, Height, and Weight by Sex

The range of usual alcohol intake was from 0 to 133.8 g/d, with the median 4.1 g/d. Only 5% of subjects consumed more than 38.7 g/d. Men (median, 10.3 g/d) were generally heavier drinkers than women (median, 2.2 g/d). This difference by sex is also reflected in Table 2, which shows the distribution of alcohol intake by category. Reported alcohol use in these young adults was on average less than that reported among older individuals.^{2 3 4}

View this table: [in this window] [in a new window]   Table 2. Univariate Relationship of Usual Alcohol Intake With Blood Pressure

We also show in Table 2 the crude relationship of alcohol intake with systolic and diastolic BP, separately for each sex. For both men and women and for both systolic and diastolic BP, there appears to be a J- or U-shaped relationship between alcohol intake and systolic BP, with levels lowest in those consuming 1 to <2 or 2 to <3 drinks per day and higher in subjects consuming either more or less alcohol.

The multivariate model used to control for the effects of covariates included age, sex, and body mass index (kilograms per meter squared). Adjustment for pulse rate (beats per minute), cigarette smoking (yes/no or number of cigarettes), parental history of high BP (none, one, or two parents), and medication use (including a separate term for oral contraceptives) did not alter the effect estimates for alcohol intake by our predetermined threshold of at least 10%. We therefore did not include these variables in the model. Like the univariate analyses, the results of the multivariate model (Table 3) also demonstrated a J-shaped association between usual alcohol intake and systolic BP level. The differences between the average adjusted BP level of those consuming 1 to <2 drinks per day compared with abstainers were 4.0 mm Hg (95% confidence interval [CI], 0.5 to 7.6 mm Hg); compared with those drinking <1 drink per day, 3.6 mm Hg (95% CI, 0.5 to 6.6 mm Hg); compared with those drinking 2 to <3 drinks per day, 0.4 mm Hg (95% CI, -4.7 to 5.5 mm Hg); and compared with those drinking 3 drinks per day, 8.1 mm Hg (95% CI, 2.9 to 13.4 mm Hg). The highest systolic BP levels were in those consuming 3 drinks per day (Figure, top).

View this table: [in this window] [in a new window]   Table 3. Analysis of Covariance for Relationship of Usual Alcohol Intake With Blood Pressure

View larger version (91K): [in this window] [in a new window]   Figure 1. Bar graphs show mean systolic (top) and diastolic (bottom) blood pressures, adjusted for age, sex, and body mass index, by category of usual alcohol intake. Data are from 316 young adults from East Boston, Mass.

There was also a suggestion of a J-shaped curve for the association of usual alcohol intake with diastolic BP (Figure, bottom). Table 3 shows that diastolic BP among those consuming 1 to <2 drinks per day (our a priori referent group) was approximately midway between subjects with the highest BP values and those with the lowest. Consumers of 2 to <3 drinks per day had the lowest diastolic BP values. Compared with this group, higher levels were present in abstainers, by 5.1 mm Hg (95% CI, 0.2 to 10.1); in consumers of <1 drink per day, by 5.5 mm Hg (95% CI, 0.9 to 10.1); in consumers of 1 to <2 drinks per day, by 3.1 mm Hg (95% CI, -2.0 to 8.2); and in consumers of 3 drinks per day, by 3.8 mm Hg (95% CI, -2.4 to 10.1).

	Discussion

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These data in young adults indicate a J-shaped association between usual alcohol intake and systolic BP, and they suggest a similar relation with diastolic BP. These findings persisted after controlling for age, sex, and body mass index and examining the effects of other potential confounding factors, including pulse rate, family history of hypertension, cigarette smoking, and medication use.

The finding of a J-shaped association is consistent with some^{4 6} but not all^{2 3} previous studies of the alcohol-BP association. Some authors^{4 6} have suggested that previously demonstrated higher BP among abstainers compared with those drinking light to moderate amounts of alcohol is due either to confounding, because the abstainers are different in other ways related to higher BP levels, or to bias, because of disproportionate underreporting among the abstainers. Because our subjects were young adults, mostly in their early 20s, it is highly unlikely that there were a significant number of abstainers with unrecognized serious disease giving rise to higher BP values. Likewise, we found little or no confounding effects of several variables, including body mass index, that could have explained the observed differences. In addition, the study was conducted in a largely Italian-American community where light to moderate alcohol intake is usual. Thus it seems unlikely that those whose intake was truly relatively heavy would report no alcohol intake at all. Unfortunately, we had no data on illicit drug use or on physical activity or diet, but most previous studies have not found these latter two factors to be confounders of the alcohol-BP relationship.³³ Although we cannot exclude confounding as an explanation, these considerations lead us to believe the most plausible interpretation of the data to be that there are higher BP levels in young adults who abstain as well as those who drink 3 drinks per day compared with those consuming 1 to <2 or 2 to <3 drinks per day.

Inaccurate measures of individuals' BP may obscure true relationships. In this study, we used the average value of each subject's BP measured three times on each of three weekly visits. Such multiple measures tend to mitigate the effects of the large within-person variability of BP³⁴ and allow investigation of associations with relatively few subjects. However, the sample size did preclude our examining relationships separately for different types of alcoholic beverages.

Some previous studies have noted a smaller effect of alcohol on BP among younger compared with older adults.^{5 17} Although in the present study, which involved only young adults, we cannot compare younger and older age groups directly, we can compare our results with those from other studies that used subjects in the same age range. For instance, in the study of young adults of Dyer et al,¹⁷ the differences in systolic BP between men reporting no intake and those with the heaviest average intake—more than approximately 4 drinks per day—was 3.2 mm Hg for white men and 4.4 mm Hg for black men. The differences for women were only 1.4 and -0.2 mm Hg, respectively, although the category of heaviest intake comprised consumers of approximately 3+ drinks per day, less than the men. In three of the four sex/race groups, differences in diastolic BP were less than those in systolic BP. No U or J shape was evident. The study of Fortmann et al⁵ showed weak associations of alcohol intake with BP in young adults, but they used only one BP measurement in their analyses, and few subjects consumed more than 2 drinks per day. Our results are similar to those of Dyer et al¹⁷ in one respect: the effects on diastolic BP were smaller than those on systolic BP. In contrast with their findings, however, we found relatively large effects of heavy drinking among young adult subjects, in addition to the overall J-shaped relationships. Elevations of 8 mm Hg in systolic BP and 3 to 4 mm Hg in diastolic BP among those consuming 3 drinks per day in the present data are consistent with the effect seen in other studies of mostly older individuals.³³ In some previous studies, a U- or J-shaped relationship was found only for women, with a linear or threshold association for men.^{3 4} In our data, the curvilinear association was apparent in both men and women. Our data for women, however, are limited by the small number of heavier drinkers among the women. Furthermore, study subjects were almost exclusively white and relatively homogeneous ethnically. Generalization of our results to racial and ethnic groups other than those we studied may not be warranted.

Questions remain about the mechanisms by which heavy alcohol intake raises BP. Some studies, including those trials showing a rapid reduction of BP with abstinence, suggest a direct effect.^{21 22} Others, however, have found that alcohol consumed during the 24 hours before BP measurement was more strongly related to elevated BP level than consumption in the previous 6 days.^{4 30} This finding suggested that repeated withdrawal from alcohol is at least as likely an explanation for elevated BP. Recent human experimental data from Abe et al³⁵ support this explanation: depressor effects of alcohol intake on BP last for several hours but may be followed by a later rise in BP. It is also not known how drinking lighter amounts, such as the 1 to <2 or 2 to <3 drinks per day found in our data, could be related to lower BP values. Depressor effects may predominate over withdrawal effects at low levels of intake, especially if the frequency of intake is low.³⁵ Additionally, drinking small to moderate amounts of alcohol may reduce anxiety and tension, which have been related to the incidence of hypertension.³⁶ Furthermore, there may be characteristics of consumers of light to moderate amounts of alcohol, unrelated to measured confounders such as body mass, that are associated with both alcohol intake and BP. To clarify these relationships in future epidemiological studies, data on BP in the several hours following alcohol intake would be useful.

Even when the relative absence of heavy drinkers in this study population is taken into account, our results are consistent with the finding that increased alcohol intake among young adults is associated with higher systolic BP. We emphasize that reduction of high alcohol intake is a useful nonpharmacological approach to lowering elevated BP. However, we have also shown the lowest average BP among our subjects to be in those who drank 1 to <2 or 2 to <3 drinks per day. The difference between BP in these subjects and that of the other groups of subjects was approximately 4 to 8 mm Hg for systolic BP and 3 to 5 mm Hg for diastolic BP. These differences, although not great for an individual subject, may have large effects on morbidity and mortality when applied to a wider population.³⁷ Most authors now believe that alcohol intake has an inverse relationship with coronary heart disease^{38 39} and a U- or J-shaped relationship with total mortality,^{40 41} with the lowest death rates among those who drink 1 to 3 drinks per day. The beneficial influences of alcohol intake on lipids and perhaps thrombotic factors^{39 42} may explain part of this protective effect. Our finding of a J-shaped relationship, although not in agreement with all studies of alcohol intake and BP, may reflect an additional pathway by which light to moderate alcohol intake protects against coronary heart disease and death.

	Acknowledgments

 
This research was supported by grants from the National Heart, Lung, and Blood Institute (HL-25268 and R29 HL-48236), the Charles H. Hood Foundation, the RGK Foundation, and the Sawyer Foundation. Dr Gillman was supported by the Harvard General Internal Medicine and Faculty Development Fellowship Program, by the Andrew Mellon Clinical Epidemiology Fellowship at Harvard Medical School, and by a Physician-Investigator Award from the American Heart Association, Massachusetts Affiliate (No. 13-PI406-890). He is the recipient of a Merck/Society for Epidemiologic Research Clinical Epidemiology Fellowship. The authors thank the staff of the East Boston Neighborhood Health Center, in particular Dr James O. Taylor and Mary Ellen Keough. We also appreciate the technical assistance of Martin Van Denburgh and a helpful review of this manuscript by Dr R. Curtis Ellison.

	Footnotes

 
Reprint requests to Dr Matthew W. Gillman, Department of Ambulatory Care and Prevention, HMS/HCHP, 126 Brookline Ave, Boston, MA 02215.

Received August 31, 1994; first decision October 19, 1994; accepted January 3, 1995.

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