Association between alcohol consumption and arterial hypertension

Introduction/Aim: Arterial hypertension is a condition of chronically elevated levels of arterial blood pressure of 140/90 mmHg and higher, and is one of the leading causes of death, both worldwide and in Serbia. The aim of this study is to examine the association between the consumption of alcoholic beverages and arterial hypertension.

Methods: This cross-sectional study included 57 participants of both sexes (30 women and 27 men), over 18 years of age, from the wider area of the City of Pančevo, who were not on antihypertensive therapy. A survey was conducted to collect data on alcohol consumption, using the modified Food Frequency Questionnaire at a Glance of the National Institutes of Health, Bethesda, Maryland, USA. Measurement of arterial blood pressure was performed according to the recommended procedure, wherein the mean value was calculated, and the level of arterial blood pressure was categorized, in accordance with the classification of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH), from 2018. The data was processed in SPSS (Statistical Package for Social Sciences), the Fisher's exact test was applied, with the statistical significance threshold set at p < 0.05. The results are presented in textual and tabular form.

Results: In the analyzed population, of the 43 participants who did not engage in risky alcohol consumption, 35 (81.4%) participants did not have hypertension, while 8 (18.6%) participants had hypertension. Among the 14 participants who engaged in risky alcohol consumption, 13 (92.9%) participants did not have hypertension, while one (7.1%) participant had hypertension. There was no statistically significant difference regarding the presence of hypertension with respect to the frequency of alcohol consumption (p > 0.05).

Conclusion: There is no association between the consumption of alcoholic beverages and arterial hypertension.

INTRODUCTION

The cardiovascular system consists of a group of tissues and organs whose function is to distribute the liquid medium - blood to peripheral tissues and organs, so as to carry out the exchange of substances and gases and enable metabolism. One of the most important cardiovascular parameters is arterial blood pressure (ABP), which enables the generation of perfusion pressure within the capillary bed in the tissue [1]. ABP must be at an appropriate level in order for blood flow through the tissue to take place efficiently, however, chronically elevated values of arterial blood pressure result in increased risk of life-threatening pathophysiological mechanisms [2]. In most cases, hypertension is idiopathic (of unknown origin), with genetic predisposition and polygenic inheritance most likely being at its root (familial predisposition, participation of a large number of genes with the obligatory effect of environmental factors, such as stress, nutrition, etc.) [3]. Risk factors for the occurrence of hypertension can be divided into those that can be influenced and those that cannot be influenced. Among the risk factors that can be influenced are the following: poor diet (which includes excessive consumption of salt, foods rich in saturated fats and trans fats, and insufficient consumption of fruits and vegetables), smoking, alcohol consumption, lack of physical activity, stress, as well as the presence of other comorbidities such as diabetes mellitus and other similar conditions. Risk factors which we have no control over include the following: age, sex, race, and genetic predisposition [2].

Hypertension remains the leading cause of death in modern societies worldwide, with over 10 million deaths per year [4]. World Health Organization (WHO) data show that more than 40.0% of people above the age of 25 years have hypertension; in Europe this percentage is even higher (over 45.0%), while in Serbia it is about 43.0% [5].

According to the data of the World Health Organization, in 2019, around 2.3 billion people aged 15 and over had consumed alcohol in the preceding 12 months, and the average consumption per person was 6.4 l of pure alcohol per year [6].

Alcoholic beverages are the most prevalent psychoactive substance in Serbia. In the population aged 18 to 64 years, more than 70.0% had consumed an alcoholic beverage at least once in the preceding 12 months (82.1% of men and 62.4% of women) [7]. A third of the adult population in Serbia (31.6%) had consumed alcohol two to three times in the 30 days preceding the survey. Daily consumption of alcoholic beverages in Serbia, according to the results of the same survey, was present in 3.4% of the population. The popularity of beer, wine and spirits is fairly evenly distributed, however, almost half of alcohol consumers in Serbia prefer beer [8].

Recommendations for alcohol consumption vary, depending on the country and the organization that issues them. According to the US National Institute on Alcohol Abuse and Alcoholism, moderate alcohol consumption for healthy adults means up to one drink per day, for women, and up to two drinks per day, for men. One standard drink contains about 14 g of alcohol, which corresponds to one 355 ml bottle of beer, one 148 ml glass of wine or one 44 ml glass of spirits [9].

However, it is important to note that alcohol consumption is not recommended to all individuals, especially people with certain health conditions, such as pregnant women, people suffering from alcohol abuse, and people with chronic diseases [9].

Recommendations on risky drinking also vary. However, general guidelines that are often applied are that drinking more than four standard drinks per day or more than 14 standard drinks per week, for men, and more than three standard drinks per day or more than 7 standard drinks per week, for women, is considered risky [9].

The mechanisms of the effect of alcohol on ABP are complex and have as yet not been fully elucidated. A number of possible mechanisms have been proposed, such as central nervous system imbalance, impaired baroreceptor control, increased sympathetic activity, stimulation of the renin-angiotensin-aldosterone system, increased cortisol levels, increased vascular reactivity due to increased intracellular calcium levels, stimulation of the endothelium to release vasoconstrictors, and loss of relaxation due to inflammation and oxidative damage to the endothelium, leading to inhibition of endothelium-dependent nitric oxide production. Loss of relaxation due to inflammation and oxidative damage to the endothelium by angiotensin II is the main cause of alcohol-induced hypertension [10].

Alcohol has acute and chronic effects on ABP. A high dose of alcohol (> 30 g of alcohol for men and > 20 g of alcohol for women) has a biphasic effect on ABP, reducing blood pressure up to 12 hours after consumption and increasing ABP 13 hours or more upon consumption. A high dose of alcohol increases the heart rate at any point in time after consumption, up to 24 hours after alcohol intake. The findings of this study are relevant mainly for healthy men, since only a small number of women were included in the research [11].

Continuous consumption of over 30 g of alcohol per day, significantly and dose-dependently increases the risk of hypertension. Differences in the sensitivity of arterial blood pressure to alcohol intake exist among different ethnic groups, as well as between sexes [12].

In the study by Santana et al., conducted in 2018, it was determined that low and moderate drinking of alcoholic beverages (≤ 2 glasses of an alcoholic beverage per day, for men and ≤ 1 glass of an alcoholic beverage per day, for women) had protective effects, in terms of hypertension and coronary heart disease, but there was no evidence for this, while there is evidence that longterm alcohol consumption leads to hypertension. This research was focused on gender differences in the sensitivity of blood pressure to alcohol consumption. Men had a relative risk of hypertension when consuming one to two drinks per day. On the other hand, women did not have an increased risk of hypertension when consuming one to two drinks per day, but they had a significantly higher risk of hypertension, as compared to men, when consuming alcohol exceeding this amount [13].

The possible beneficial effects of moderate alcohol consumption must be weighed against the harmful effects of heavy consumption, including the increased risk of hypertension, cardiomyopathy, and hemorrhagic stroke. Intake of more than three drinks per day is associated with an increase in ABP, while consumption of an average of more than four drinks per day leads to an increase in systolic pressure by 5 – 6 mmHg and in diastolic pressure by 2 – 4 mmHg [14].

The aim of this study is to determine whether there is an association between the consumption of alcoholic beverages and arterial hypertension in respondents of both sexes, older than 18 years, who are not on antihypertensive therapy, residing in the wider area of the City of Pančevo.

METHODOLOGY

This cross-sectional study included 57 respondents of both sexes (30 women and 27 men), older than 18 years, who were not taking antihypertensive therapy, residing in the wider area of the City of Pančevo. The research was conducted in December 2022.

For the purpose of collecting data on the consumption of alcoholic beverages, a survey was conducted using a modified version of the Food Frequency Questionnaire at a Glance, of the National Institutes of Health, Bethesda, Maryland, USA [15]. The questionnaire contains questions related to most food groups, but for the purpose of this research, only questions related to alcoholic beverages (beer, white wine, red wine, and spirits) were used. The questions referred to the average use of alcoholic beverages during the preceding year and the frequency of their consumption (one to three times a month, once a week, two to four times a week, once a day, two to three times a day, more than four times a day, or never). Based on the frequency of alcohol consumption, two categories (groups) of respondents were defined – risky drinkers and non-risky drinkers, for each type of alcoholic beverage separately, as well as for all alcoholic beverages in total. Respondents who indicated that they consumed alcohol once a week or less were categorized as non-risky, while those who drank more than once a week were categorized as risky.

ABP was measured in keeping with the recommended procedure for routine measuring of blood pressure, in the doctor’s office, under standardized conditions, and in keeping with the ESC/ESH recommendations from 2018 [16]. In all 57 subjects, arterial blood pressure was measured with an analog sphygmomanometer. Before ABP was measured, subjects were placed in a quiet environment for five minutes. ABP was measured on both upper arms using the appropriate cuff size in relation to upper arm circumference (ABP was measured on both arms to detect possible differences between them, the arm with the higher value was taken as the reference). Three ABP measurements were recorded and were spaced 1 – 2 minutes apart. The last two measurements were taken for the average ABP value. The ABP stage was determined for each subject, according to the accepted criteria for hypertension (≥ 140/90 mmHg). When ABP was measured in the doctor’s office, the categories (groups) of subjects were determined – the category of those with hypertension and those without hypertension. The classification of the level of ABP was determined in keeping with the ESC/ESH recommendations from 2018 [16].

The data were processed using SPSS (Statistical Package for Social Sciences) software, with the application of descriptive statistics (frequency of subjects according to arterial blood pressure category) and inferential statistics for hypothesis testing. Differences between groups were examined using the Fisher's exact test, with a confidence level of 95% and a statistical significance threshold of p < 0.05. The results are presented in textual and tabular form.

RESULTS

The study involved 57 subjects of both sexes, of whom 30 (52.6%) women and 27 (47.4%) men, of the average age 36.37 ± 4.35 years.

The age structure of the respondents was as follows: in the 18 – 30 years category there were 20 respondents (35.1%); in the 31 – 45 years category there were 25 respondents (43.8%); in the 46 – 60 years category there were 11 respondents (19.3%); while one respondent (1.7%) was over 60 years old.

Respondent structure according to the category of ABP in the entire examined group is presented in Table 1.

Table 1. Respondent structure according to the category of arterial blood pressure

In the examined group, there largest number of subjects, i.e., 16 (28.1%) of them had optimal blood pressure (up to 120/80 mmHg), a slightly smaller number of subjects had normal and borderline blood pressure, there were 13 (22.8%) subjects with stage one hypertension (140 – 159/90 – 99 mmHg), while only one subject had stage two hypertension (160 – 179/100 – 109 mmHg).

The differences between the number of respondents with hypertension/without hypertension and the frequency of beer consumption are presented in Table 2.

Table 2. Differences between the number of respondents with hypertension/ without hypertension and the frequency of beer consumption

Of the 57 respondents who consumed beer, 43 (75.4%) subjects did not have hypertension, while 14 (24.6%) subjects had hypertension. Of the 53 respondents who were non-risky beer drinkers, 40 (70.2%) subjects did not have hypertension, while 13 (22.8%) subjects had hypertension. Of the four respondents who were risky beer drinkers, three (5.3%) subjects did not have hypertension, while one (1.8%) subject had hypertension.

There is no statistically significant difference regarding the presence of hypertension in relation to the frequency of beer consumption (p > 0.05)

The differences between the number of respondents with hypertension/without hypertension and the frequency of white wine consumption are presented in Table 3.

Table 3. Differences between the number of respondents with hypertension/ without hypertension and the frequency of white wine consumption

Of the 57 respondents who consumed white wine, 43 (75.4%) subjects did not have hypertension, while 14 (24.6%) subjects had hypertension. Of the 53 respondents who were non-risky white wine drinkers, 39 (68.4%) subjects did not have hypertension, while 14 (24.6%) subjects had hypertension. Of the four (7.0%) subjects who were risky white wine drinkers, none of the subjects had hypertension.

There is no statistically significant difference regarding the presence of hypertension in relation to the frequency of white wine consumption (p > 0.05).

The differences between the number of participants with hypertension/without hypertension and the frequency of red wine consumption are presented in Table 4.

Table 4. Differences between the number of respondents with hypertension/ without hypertension and the frequency of red wine consumption

Of the 57 respondents who consumed red wine, 43 (75.4%) subjects did not have hypertension, while 14 (24.6%) subjects had hypertension. Of the 56 subjects who were non-risky red wine drinkers, 42 (73.7%) subjects did not have hypertension, while 14 (24.6%) subjects had hypertension. The one (1.8%) respondent who was a risky red wine drinker did not have hypertension.

There is no statistically significant difference regarding the presence of hypertension in relation to the frequency of red wine consumption (p > 0.05).

The differences between the number of respondents with hypertension/without hypertension and the frequency of hard liquor (spirits) consumption are presented in Table 5.

Table 5. Differences between the number of respondents with hypertension/ without hypertension and the frequency of hard liquor (spirits) consumption

Of the 57 respondents who consumed spirits, 43 (75.4%) subjects did not have hypertension, while 14 (24.6%) subjects had hypertension. Of the 54 respondents who were non-risky spirits drinkers, 40 (70.2%) subjects did not have hypertension, while 14 (24.6%) subjects had hypertension. Of the three (5.3%) respondents who were risky spirits drinkers, none had hypertension.

There is no statistically significant difference regarding the presence of hypertension in relation to the frequency of spirits consumption (p > 0.05).

In addition, we examined the relationship between hypertension and the frequency of the consumption of all alcoholic beverages, by grouping all respondents into non-risky drinkers of all alcoholic beverages and risky drinkers of all alcoholic beverages, and we have presented these results in Table 6 .

Table 6. Association between the consumption of alcoholic beverages and arterial hypertension

Of the 57 respondents who consumed alcoholic beverages, 48 (84.2%) subjects did not have hypertension, while 9 (15.8%) subjects had hypertension. Of the 43 respondents who were non-risky drinkers of alcoholic beverages, 35 (81.4%) subjects did not have hypertension, while 8 (18.6%) subjects had hypertension. Of the 14 respondents who were risky drinkers of alcoholic beverages, 13 (92.9%) subjects did not have hypertension, while one (7.1%) subject had hypertension.

There is no statistically significant difference regarding the presence of hypertension in relation to the frequency of the consumption of alcoholic beverages (p > 0.05).

The relationship between hypertension and the consumption of alcoholic beverages was also verified by the Spearman’s correlation coefficient, which showed that there is no statistically significant correlation between the presence of hypertension and the consumption of alcoholic beverages (ρ = -0.135, without significance).

DISCUSSION

The aim of this study was to determine whether there is a statistically significant association between alcohol consumption and hypertension among respondents in Serbia. A total of 57 respondents of both sexes and of the average age of 36.37 ± 4.35 years participated in the study. In the examined group, there were most, i.e., 16 (28.1%) subjects with optimal blood pressure (up to 120/80 mmHg), there was a slightly smaller number of those with normal and borderline blood pressure, while there were 13 (22.8%) respondents with stage one hypertension (140 – 159/90 – 99 mmHg), and only one respondent with stage two hypertension (160 – 179/100 – 109 mmHg). Most of the respondents (43) consumed a moderate quantity of alcoholic beverages (less than once a week), while the percentages of hypertension were similar in all categories of alcohol consumption.

The results showed that, in this sample of respondents, no statistically significant association was found between hypertension and the frequency of alcohol consumption (beer, white wine, red wine, and spirits).

It is important to note that these results only apply to this sample of respondents and that further research on a larger sample would be necessary to confirm these findings.

Numerous studies have addressed this topic. Most studies suggest that high-dose alcohol consumption leads to elevated ABP, but the relationship between light to moderate alcohol consumption remains controversial [17]. A review of dozens of longitudinal studies found that a maximum of one alcoholic drink per day may be associated with a reduced risk of certain cardiovascular diseases, compared to abstinence from alcohol [18]. Some other reviews of longitudinal studies suggest that only some categories of the population benefit from alcohol consumption. In women, who consume a maximum of 5 g of alcohol per day, a slight protective effect is noticeable in the prevention of hypertension. However, in men there is a linear relationship between alcohol consumption and hypertension, even at minimal doses, especially in Asian men [19].

During the previous decade, it has been established that more than half of the deaths in Serbia were the result of cardiovascular insults, to which hypertension contributes significantly. However, no association has been established between the consumption of alcohol, i.e., its individual types (brandy, beer, wine), and the presence and frequency of hypertension [20].

CONCLUSION

In this study, no statistically significant association was found between the consumption of alcoholic beverages (beer, white wine, red wine, and spirits) and arterial hypertension, in subjects of both sexes, over 18 years of age, who were not on antihypertensive therapy.

The recommendation for further research is to create the conditions for longitudinal studies, in order to obtain data on the influence of alcohol on arterial blood pressure.

LIST OF ABBREVIATIONS/ACRONYMS

USA – United States of America
ESC – European Society of Cardiology
ESH – European Society of Hypertension
SPSS – Statistical Package for Social Sciences
ABP – arterial blood pressure
WHO – World Health Organization