Moderate Consumption of Beer and Its Effects on Cardiovascular and Metabolic Health: An Updated Review of Recent Scientific Evidence

Abstract

There is growing interest in the potential health-related effects of moderate alcohol consumption and, specifically, of beer. This review provides an assessment of beer-associated effects on cardiovascular and metabolic risk factors to identify a consumption level that can be considered “moderate”. We identified all prospective clinical studies and systematic reviews that evaluated the health effects of beer published between January 2007 and April 2020. Five of six selected studies found a protective effect of moderate alcohol drinking on cardiovascular disease (beer up to 385 g/week) vs. abstainers or occasional drinkers. Four out of five papers showed an association between moderate alcohol consumption (beer intake of 84 g alcohol/week) and decreased mortality risk. We concluded that moderate beer consumption of up to 16 g alcohol/day (1 drink/day) for women and 28 g/day (1–2 drinks/day) for men is associated with decreased incidence of cardiovascular disease and overall mortality, among other metabolic health benefits.

1. Introduction

In recent years, there has been an increasing interest in the potential health-related effects of moderate alcohol consumption. Although the harmful effects of excessive alcohol use are well established, the association of low-to-moderate alcohol consumption with health-related benefits is still controversial, since the results of available studies are not homogeneous and reaching clear conclusions is challenging. This lack of consensus is observed in alcohol consumption guidelines published in the last five years, which use different terminology (“risky drinking”, “moderate consumption”, or “low-risk drinking”) as well as different drinking thresholds [1,2,3,4,5,6] (Table 1). Furthermore, other variables, such as differences in concentrations of non-alcoholic components (i.e., polyphenols), may confound the beneficial effects of specific alcoholic drinks [7,8].

Beer is an alcoholic beverage frequently consumed in Europe. In 2018, the average yearly beer consumption in Europe was 72 L per capita, with a few countries (Czech Republic, Austria, and Germany) consuming more than 100 L per capita per year [9]. However, patterns of consumption differ across the region varying from predominantly meal-associated drinking in Mediterranean countries, to high rates of heavy episodic drinking in Central and Eastern Europe, and relatively frequent consumption both with and outside of meals in Central Western Europe [10].

Beer is mainly composed of water, but it is also rich in nutrients—carbohydrates, amino acids, minerals, vitamins, and polyphenols—resulting from a multi-step brewing and fermentation process [7,11,12,13]. Hop flowers, used as a bittering and flavoring agent [14], contain phenolic compounds, including prenylated flavonoids [15,16], which have been shown in vitro to have different antioxidant, anticarcinogenic, anti-inflammatory, oestrogenic, and antiviral biological activities [7,17]. Xanthohumol is the most abundant of these compounds and, in addition to potential bioactivity [7,18], it also inhibits platelet activation without increasing the bleeding risk [19]. Thus, brewing processes have been optimized to achieve the highest possible content of xanthohumol [20]. Regarding antioxidant content, ale beers have been reported to display a higher antioxidant activity than lager beers due to the higher fermentation temperature in the brewing process. However, despite these enrichment processes, controversy remains as to the bioavailability of the phenolic compounds in beer [21,22,23].

Alcohol content in regular beers varies between 3% and 6% alcohol by volume [11]. There is vast scientific literature on excessive alcohol consumption. Indeed, chronically high alcohol intake acts as a toxin to the heart and vascular system and may also exacerbate pre-existing heart disorders. However, low-to-moderate amounts of alcohol intake might have beneficial effects on the cardiovascular (CV) system, since it increases high-density lipoprotein cholesterol (HDL) and reduces arterial stiffness (both effects shown specifically with beer) [21,22,24,25], and also decreases fibrinogen, platelet activation and aggregation, as well as blood oxidative stress and inflammatory parameters [26,27,28]. The alcohol content of beer might also have an effect on glucose homeostasis [29]. Alcohol contributes to total calorie intake and may increase weight when consumed in excess [30,31]. Non-alcoholic components also contribute to the energy content of beer. Thus, Public Health England lists the mean energy content of alcohol-free beers at seven kilocalories/100 g [32]. Overall, 28% of the total monthly kilocalories contributed by beer among regular drinkers derive from its non-alcoholic ingredients [33].

Taken together, the biological activity of phenolic compounds in beer and the possible association of alcohol intake with mortality, CV risk [34,35,36], and glucose metabolism [37,38,39,40,41,42,43] may contribute to the putative health-related effects of moderate beer consumption. Conversely, excess beer consumption may be associated with weight increase and associated morbidities [30].

We conducted an analysis of all reviews, meta-analyses, and longitudinal, prospective, cohort studies published from January 2007 to April 2020 regarding beer consumption and its relationship with CVD and mortality risk, with the objective of evaluating the average intake of beer that could be considered “moderate” based on the reported consumption. Furthermore, we aimed to identify several differences shown in specific population subgroups in the selected studies.

2. Materials and Methods

In April 2020, a literature search of papers published after January 2007 was conducted using PubMed EMBASE, and through reference list cross-checking of previous meta-analyses, prospective clinical studies, and systematic reviews in humans, evaluating beer effects on health. The search strategy retrieved citations from databases containing the subject heading “beer” in combination with “health”, “cardiovascular”, “mortality”, “obesity”, “diabetes”, “young”, “women”, or “alcoholism”. The search terms were adapted for use with both bibliographic databases (Table 2).

Original eligible papers, based on their title/abstract, were obtained and reviewed to select those meeting the inclusion criteria: clinical studies in humans with prospective cohort design, plus systematic reviews and meta-analyses evaluating beer effects on health since 2007, and publications that authors considered could provide additional information on the subject. A total of 13 reviews (narrative or systematic reviews and/or meta-analysis), 9 prospective cohort studies, and 1 open-label, randomized, cross-over study were selected (Table 3).

3. Results

A summary of related studies is shown in Table 4. Two reviews referring specifically to beer, reported that moderate consumption (up to 55 g alcohol/day; i.e., 385 g/week) showed a beneficial effect on non-fatal CV events [34,57]. Both reviews found that the highest effect was associated with moderate beer or wine consumption, suggesting that the polyphenolic content of these beverages probably contributes to the observed CV benefits [34,57].

These data are in agreement with most findings from reviews/meta-analyses and cohort studies, which report a protective effect of moderate alcohol drinking for CVD compared to abstention, former drinking, or occasional drinking [22,34,47,49,56,57,60]. Only the review by Toma et al. does not support these conclusions; the authors suggest that this protective effect may be a confounder due to the inclusion of former drinkers in the non-drinkers group [48]. However, the prospective cohort study by Bell et al., conducted in almost 2 million people, took these potential confounders into consideration, and also found a positive effect of moderate drinking (112 g/week in women and 168 g/week in men) on CV risk [49]. Costanzo et al. found a negative (although not significant) association between spirits and vascular events, suggesting alcohol content, and not solely polyphenols, may also play a role in cardiovascular events [57]. Moreover, as Roerecke et al. [54] noted that distinctions between former drinkers and lifetime abstainers might not be sufficient for an accurate analysis, based on the heterogeneity of reasons underlying non-drinkers’ decision not to drink, which might further confound the results. Finally, drinking patterns may also play a key role in outcomes [54], since self-reported weekly intakes might include alcohol consumed during the weekend during a binge, which would be associated with worse CV results.

Gender Differences

Due to the paucity of separate data for men and women, none of the beer-specific CVD studies stratified their conclusions by gender. The meta-analysis by Roerecke et al. [54] noted that women are more sensitive to the protective effect of moderate alcohol consumption, based on a previous meta-analysis [56], which showed a steeper J-curve for ischemic heart disease (IHD), mortality and morbidity in women than in men. The detrimental effect on CV risk of binge drinking seems to be lower in women than in men [49,60], and an increased risk of heart failure has been observed in abstemious women compared with moderate drinkers [49]. In addition, Snow et al. [60] observed that the beneficial effects of low and/or moderate usual consumption on CV risk were only evident in younger women (aged 18–34), whereas cardio-protection became evident at middle (aged 35–49) or older age (aged 50–64) in men. Overall, these gender differences may be due to hormonal changes over the life course or to a lower lifetime consumption of total alcohol.

4. Moderate Beer Consumption and Mortality

A summary of related studies is shown in Table 5. The systematic review by de Gaetano et al. [34] suggested that a J-shaped relationship also exists between beer consumption and all-cause mortality. The lowest mortality risk was observed in subjects with low to moderate alcohol consumption compared to abstainers or heavy drinkers, with the lowest risk at beer consumption of 84 g alcohol/week [34].

Studies on general alcohol consumption have similar conclusions. A prospective cohort study by Suadicani et al. found an association between wine consumption and all-cause mortality, with a consistent effect at 84 g alcohol/week, and a larger effect seen with higher consumption in men with non-O blood type [34,61]. However, a meta-analysis by Stockwell et al. [53] suggested that, when the necessary adjustments for study design characteristics are implemented, no association of moderate alcohol consumption with mortality is observed. Two later prospective studies, with well-adjusted variables, confirmed the association between lower risk of total and CV mortality [49,51] and moderate alcohol consumption defined by 168 g/week, 24 g/day for men and 112 g/week, 16 g/day for women in the Bell et al. study [49] or by 43–196 g/week for men and 43–98 g/week for women in the Xi et al. study [51].

Gender Differences

In the EPIC study, beer consumption in women was more strongly related than wine consumption to overall mortality for amounts >21 g/week compared with the reference category (0.7–20.3 g/week) [69]. On the other hand, in the study by Xi et al., the protective effect of low and moderate alcohol consumption against all-cause and CV disease (CVD) mortality was more pronounced in women [51]. Thus, it seems that women may be both more sensitive to the protective effects against mortality of moderate beer intake and to the risk effects of higher amounts.

5. Moderate Beer Consumption and Obesity, Diabetes, and Osteoporosis

Table 6 details the studies on this subject. Although beer seems to have a direct effect on weight gain [52], and on waist circumference in men [59], there is not enough evidence to confirm whether moderate intake (<500 mL/day) is associated with general or abdominal obesity [55], although daily amounts ≥500 mL increase the risk of not losing weight [59]. In this regard, Padro et al., have reported that the moderate consumption of either alcoholic (30 g/day for men; 15 g/day for women) or non-alcoholic beer for four weeks did not increase the body weight of obese individuals [46]. Furthermore, moderate beer consumption was associated with increases in the anti-oxidative properties of high-density lipoprotein, which facilitate the efflux of cholesterol [46].

Based on the reviewed diabetes studies [43,50], moderate alcohol consumption may decrease diabetes risk in men. A meta-analysis of 13 prospective studies, with 397,296 participants, showed that wine consumption was associated with a significant reduction of the risk for type 2 diabetes mellitus (T2DM), with a pooled relative risk of 0.85, whereas beer or spirits consumption led to a slight trend towards a decreasing risk for T2DM (relative risk 0.96 and 0.95, respectively) [70]. Chronic alcohol consumption, however, is considered a risk factor for T2DM, which may be triggered by a deterioration in glucose tolerance, alterations in signalling of peptides involved in appetite regulation, and dysfunction and apoptosis of pancreatic β-cells [71,72].

Data on bone mineral density (BMD) and fracture risk have been less conclusive, probably due to the few studies available, and both relatively high and low levels of alcohol consumption have shown benefits for bone health. Thus, the consumption of both beer and wine at doses up to 60 g/day in men alone in the study by Yin et al. [58], and up to 13 drinks/week (182 g/week) in the study by Mukamal et al. [62], were shown to increase BMD and/or decrease risk of fracture in the elderly. Even very low levels of consumption were associated with a decreased fracture risk. Considering beer specifically, consumption of <1 beer/week (<14 g/week) in men and women was significantly associated with a lower risk of hip fracture (HR 0.66, 95%CI 0.44–0.99) [62]. Notably, low-alcohol beer consumption in women was associated with increased lumbar BMD [58], suggesting that, beyond the putative positive effect of alcohol on BMD, the non-alcoholic components of beer may also be involved. Other compounds present in beer (e.g., phytoestrogens such as 8-prenylnaringenin) act synergically with silicon to stimulate osteoblast cells, improve bone structure, and help remineralize bone and teeth [44]. The polyphenolic fraction, flavonoids, and the silicon content in beer may contribute to the positive effects on bone metabolism [45]. The protective effect of polyphenols has also been proven in human studies, where they reduced systolic and diastolic pressure and reduced lipoprotein cholesterol serum levels, among others [73]. The cardioprotective role of polyphenols in beer (traditional or alcohol-free) in particular has been reported in individuals with high cardiovascular risk [8,74].

Gender Differences

With regard to obesity, the study by Schütze et al. [59] suggested that only men observe a risk for an increase in waist circumference (WC) with beer consumption of >500 mL/day. In women, beer-abstainers showed lower relative odds for WC gain compared with their very low-level drinking counterparts (1 to <125 mL/day), which was close to significance.

Similar gender differences were seen in the diabetes studies. Cullman et al. found that alcohol effect on glucose metabolism was different between men and women [43], depending on amounts of consumption and alcohol type; overall, in individuals with normal glucose tolerance, a decrease in T2DM risk was observed in occasional consumers of beer and wine vs abstainers among men, and in high consumers (≥192 g/week) of wine vs occasional consumers among women. This cohort study showed that men who were high consumers of beer and had baseline normal glucose tolerance had a significantly increased risk of developing abnormal glucose regulation (OR 1.63, CI 1.07–2.48 for pre-diabetes plus T2DM and OR 1.84, CI 1.13–3.01 for pre-diabetes) compared to occasional drinkers [43]. Men abstainers had a significantly higher risk of developing abnormal glucose regulation (OR 2.13, CI 1.03–4.39) than occasional beer drinkers, suggesting occasional beer consumption may be protective in men. Data for beer consumption in women were not provided in the Cullman et al. study. When considering individuals with normal glucose tolerance or pre-diabetes at baseline, the only significant difference found when using occasional drinking as a reference was the case of women with low consumption of total alcohol, who showed a decreased risk of T2DM (OR 0.41, CI 0.22–0.79). Most studies reviewed by Polsky et al. [50] also showed differences between men and women. In one study, a lower risk for T2DM was only observed in women who consumed alcohol (any quantity; no dose-relationship observed) compared to lifetime abstainers, but this was not found in men [75]. Another study showed that in men alone, a moderate alcohol consumption (10–14.9 g/day) was associated with a reduced risk of T2DM with respect to very low consumption (0.01–4.9 g/day), linked to wine consumption [76].

Regarding BMD, the study by Yin et al. [58] found that alcohol intake was positively associated only in men with an increase in the percentage of spinal and hip BMD after two years, whereas in women, lumbar spine BMD at baseline was positively associated with frequency of low-alcohol beer consumption (beta = 0.034 g/cm² per category, p = 0.002).

6. Discussion

Despite the paucity of studies specifically exploring beer-related health effects, available data suggest that moderate beer consumption is associated with a decreased risk for non-fatal CV events and total mortality. For other health effects, such as those on general or abdominal obesity, study data have generally been inconclusive, although a recent small study suggests that moderate consumption of either alcoholic or non-alcoholic beer does not increase body weight in obese individuals [46]. Furthermore, moderate beer consumption has been associated with decreased diabetes risk (only in men), and with an increase in BMD, which lowers the risk of fracture in the elderly.

Although the available evidence supports the health benefits of moderate beer consumption in adults (aged ≥ 18 years), study heterogeneity makes it difficult to establish the precise quantity of beer needed to obtain these benefits. Different units of measurement (i.e., grams of alcohol or non-standardized drinks per day vs. standard drink units), and different definitions of consumption levels limit the direct comparison of these studies. Nevertheless, given the ranges of alcohol consumption associated with observed benefits in CVD (40–252 g/week for men; 21–210 g/week for women), mortality (75–196 g/week for men; 75–112 g/week for women), and diabetes, obesity, and osteoporosis (12–350 g/week for men; 12–210 g/week for women), a conservative upper limit of moderate beer drinking in men could be ≤196 g/week (approximately 1–2 beers per day). Available studies suggest that women may present a higher sensitivity to beer effects and, therefore, their upper limit of moderate consumption may be slightly lower at ≤112 g/week (approximately 1 beer per day). Notably, these values are similar to the low-risk drinking guidelines established by many countries (Table 1) [1,2,3,4,5,6]. Importantly, evaluating the overall effect of alcohol consumption on health is challenging, given it can be linked to improved benefits in CVD, as shown in this study, but it can also be associated with an increased risk of cancer [77]. Notably, moderate alcohol consumption varies between reports, and large-scale studies are warranted to adequately evaluate the role that specific ranges of alcohol consumption play in health.

Aside from gender differences, alcohol-associated health benefits might be modulated by intrinsic characteristics of populations, including their socioeconomic status [68] and/or diet and general lifestyle. In a well-established example, the Mediterranean diet—historically associated with high life expectancy and low CVD rates—is characterized by its high consumption of fresh foods, low consumption of animal fats, and low-to-moderate consumption of wine, generally with meals [78]. Indeed, the food pyramid recommended by the Spanish Society of Community Nutrition reflects the Mediterranean diet and includes fermented alcoholic beverages (wine, beer, and cider) among foods and drinks advised for an optional, occasional, and moderate consumption [3]. Importantly, this inclusion of alcoholic beverages in the food pyramid regards its consumption with meals, not alone. The inclusion of optional alcohol in the food pyramid is in agreement with data that shows that daily moderate beer consumption in the context of a Mediterranean diet is associated with favourable changes in the blood lipid profile [24].

The moderate consumption of alcohol ≤196 g/week (≤28 g/day or 1–2 beers daily) or ≤112 g/week (≤16 g/day or 1 beer daily) for men and women, respectively, has been associated with a variety of health benefits. However, it must be noted that weekly recommended amounts of alcohol should be spread across several days and not include episodes of heavy alcohol use or “binge drinking”, as irregular heavy drinking is associated with a higher risk of ischemic heart disease [79]. This episodic heavy drinking is defined by the World Health Organization as consumption of ≥60 g (approximately ≥6 drinks) per occasion [80] and by the United States National Institute on Alcohol Abuse and Alcoholism [81] as consumption of ≥5 drinks (male) or ≥4 drinks (female) in less than 2 h. While moderate regular drinking is associated with a lower risk of ischemic heart disease compared with abstention [54,82], excessive or binge drinking not only increases the risk of CV events, but also the risk of all-cause mortality [51,83]. Therefore, consumption of moderate amounts of alcohol should be always considered in the context of the Mediterranean lifestyle (moderate quantities of alcohol consumed as part of a meal), as a strategy to promote a more socially responsible consumption, avoiding excessive alcohol intake, often associated with Nordic European, as well as Central and Eastern Europeans and Anglo-Saxon alcohol consumers [10,84]. In a recent study using data from 123,219 men and women who were followed up to 34 years of age, the authors reported that the adherence of the participants to five low-risk lifestyle-related factors (never smoking, normal weight, regular physical activity, healthy diet, and moderate alcohol consumption) could prolong life expectancy at age 50 years by 14.0 and 12.2 years for female and male US adults, respectively, compared with individuals who adopted no low-risk lifestyle factors [85].

In developing this review, we considered the possibility that study sponsors might bias published results. Reported funding sources and conflict of interests (COIs) were assessed for every study selected for this review. Out of the selected studies, only three were directly funded by alcohol-related foundations [34,55,57], and COIs were reported by some of their authors. In addition, the sponsors of these three studies declared no intervention in the study execution and writing, and no differences in study results were observed regardless of funding source.

In conclusion, we consider that an approximate intake of 10–16 g alcohol/day (1 beer/day) for women and 20–28 g alcohol/day (1–2 beers/day) for men could be defined as moderate beer drinking, providing that the consumption is distributed throughout the week with no heavy episodic or “binge drinking” on a single occasion, especially during weekends. Moderate beer drinking decreases CV risk and overall mortality. In addition, moderate consumption decreases diabetes risk in men, increases BMD, lowering the risk of fracture in the elderly, and does not seem to be associated with general or abdominal obesity. Furthermore, moderate beer drinking should be considered within the context of mealtime consumption, as the custom in Mediterranean countries. Future studies should refine the quantity of beer considered as low-to-moderate consumption, which is the lowest risk level, and further determine the possible health benefits associated with moderate beer drinking.

Although research in this field is acquiring great interest and possible benefits are being found, the authors of this article insist on not recommending the consumption of alcohol in children, adolescents, pregnant women, adults under medication, or at work when using machinery (or driving). In addition, the consumption of alcohol must be always accompanied by meals and excess must be avoided.

Acknowledgements

AcknowledgmentsWe thank Almudena Pardo-Mateos who provided professional writing services.

Competing interests

Conflicts of InterestR.E. reports grants from Spanish Institute of Health “Carlos III” (Spain), Cerveza y Salud (Spain), Fundación Dieta Mediterranea (Spain), and grants from Bicentury SA (Spain), Grand Fountaine (Spain), Novartis SA (Spain), and Uriach Laboratories (Spain). He is also a member of the Cerveza y Salud Scientific Committee. Further, personal fees for given lectures from Brewers of Europe (Belgium), Fundacion Cerveza y Salud (Spain), Pernaud-Ricard (Mexico), Instituto Cervantes (Alburquerque, USA), Instituto Cervantes (Milan, Italy), Instituto Cervantes (Tokyo, Japan), Lilly Laboratories (Spain), Prodeca—Generalitat de Catalunya (Spain), Wine and Culinary International, International Forum (Spain), and non-financial support from Harvard School of Public Health (Boston, USA), Columbia University (NYC, USA), ERAB (Belgium), Fundació Clinic (Spain), and Fundació Bosch i Gimpera (Spain). A.M. reports having received research funding from the Cerveza y Salud Information Centre, the Spanish arm of European Brewers Association, and being a member of the Cerveza y Salud Scientific Committee. F.J.T. reports having received speaker’s bureau and consultant/advisory board fees from Cerveza y Salud, AstraZeneca, Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly and Company, GlaxoSmithKline, Janssen Pharmaceuticals, Merck Sharpe & Dohme, Novartis Pharmaceuticals Co., Novo Nordisk, Sanofi, and Regeneron Pharmaceuticals, L.S.-M., V.P., F.J.P.-J. declare not to have competing interests.

References

1. Kalinowski A., Humphreys K.. Governmental Standard Drink Definitions and Low-Risk Alcohol Consumption Guidelines in 37 Countries. Addiction. 2016 doi:10.1111/add.13341 PubMed
2. Arbesu J.A., Armenteros del Olmo L., Casquero R., Goncalves F., Guardia Serecigni J., López Santiago A. et al. Manual de Consenso Sobre Alcohol En Atención Primaria. 2016
3. Aranceta-Bartrina J., Partearroyo T., López-Sobaler A.M., Ortega R.M., Varela-Moreiras G., Serra-Majem L. et al. Updating the Food-Based Dietary Guidelines for the Spanish Population: The Spanish Society of Community Nutrition (Senc) Proposal. Nutrients. 2019 doi:10.3390/nu11112675 PubMed
4. UK Chief Medical Officers’ Low Risk Drinking Guidelines. 2016
5. 2015–2020 Dietary Guidelines for Americans. 2015
6. Alcohol Drinking Guidelines. 2018
7. Arranz S., Chiva-Blanch G., Valderas-Martínez P., Medina-Remón A., Lamuela-Raventós R.M., Estruch R.. Wine, Beer, Alcohol and Polyphenols on Cardiovascular Disease and Cancer. Nutrients. 2012 doi:10.3390/nu4070759 PubMed
8. Chiva-Blanch G., Magraner E., Condines X., Valderas-Martínez P., Roth I., Arranz S. et al. Effects of Alcohol and Polyphenols from Beer on Atherosclerotic Biomarkers in High Cardiovascular Risk Men: A Randomized Feeding Trial. Nutr. Metab. Cardiovasc. Dis.. 2015 doi:10.1016/j.numecd.2014.07.008 PubMed
9. European Beer Trends-Statistics Report | 2019 Edition. 2020
10. Shield K.D., Rylett M., Rehm J.. Public Health Gains and Missed Opportunities. Trends in Alcohol Consumption and Attributable Mortality in the WHO European Region, 1990–2014: A Report to the WHO European Region. 2016
11. Missbach B., Majchrzak D., Sulzner R., Wansink B., Reichel M., Koenig J.. Exploring the Flavor Life Cycle of Beers with Varying Alcohol Content. Food Sci. Nutr.. 2017 doi:10.1002/fsn3.472 PubMed
12. Sohrabvandi S., Mortazavian A.M., Rezaei K.. Health-Related Aspects of Beer: A Review. Int. J. Food Prop.. 2012 doi:10.1080/10942912.2010.487627
13. Romeo J., Díaz L., González-Gross M., Wärnberg J., Marcos A.. Contribución a La Ingesta de Macro y Micronutrientes Que Ejerce Un Consumo Moderado de Cerveza. Nutr. Hosp.. 2006 PubMed
14. Hill S.T., Sudarsanam R., Henning J., Hendrix D.. HopBase: A Unified Resource for Humulus Genomics. Database J. Biol. Databases Curation. 2017 doi:10.1093/database/bax009 PubMed
15. Carvalho D.O., Curto A.F., Guido L.F.. Determination of Phenolic Content in Different Barley Varieties and Corresponding Malts by Liquid Chromatography-Diode Array Detection-Electrospray Ionization Tandem Mass Spectrometry. Antioxidants. 2015 doi:10.3390/antiox4030563 PubMed
16. Řehová L., Škeříkova V., Jandera P.. Optimisation of Gradient HPLC Analysis of Phenolic Compounds and Flavonoids in Beer Using a CoulArray Detector. J. Sep. Sci.. 2004 doi:10.1002/jssc.200401916 PubMed
17. Gerhäuser C.. Beer Constituents as Potential Cancer Chemopreventive Agents. Eur. J. Cancer. 2005 doi:10.1016/j.ejca.2005.04.012 PubMed
18. Liu M., Hansen P.E., Wang G., Qiu L., Dong J., Yin H. et al. Pharmacological Profile of Xanthohumol, a Prenylated Flavonoid from Hops (Humulus Lupulus). Molecules. 2015 doi:10.3390/molecules20010754 PubMed
19. Xin G., Wei Z., Ji C., Zheng H., Gu J., Ma L. et al. Xanthohumol Isolated from Humulus Lupulus Prevents Thrombosis without Increased Bleeding Risk by Inhibiting Platelet Activation and MtDNA Release. Free Radic. Biol. Med.. 2017 doi:10.1016/j.freeradbiomed.2017.02.018 PubMed
20. Wunderlich S., Zürcher A., Back W.. Enrichment of Xanthohumol in the Brewing Process. Mol. Nutr. Food Res.. 2005 doi:10.1002/mnfr.200500051 PubMed
21. Humia B.V., Santos K.S., Barbosa A.M., Sawata M., Mendonça M.d.C., Padilha F.F.. Beer Molecules and Its Sensory and Biological Properties: A Review. Molecules. 2019 doi:10.3390/molecules24081568 PubMed
22. Sacanella Anglés I., Casas Rodriguez R., Viñas Esmel E., Castro Barquero S., Sacanella Meseguer E.. Prevención de La Enfermedad Cardiovascular y Bebidas Alcohólicas Fermentadas. ¿Realidad o Ficción?. Nutr. Hosp.. 2019 doi:10.20960/nh.02811 PubMed
23. Williamson G., Manach C.. Bioavailability and Bioefficacy of Polyphenols in Humans. II. Review of 93 Intervention Studies. Am. J. Clin. Nutr.. 2005 doi:10.1093/ajcn/81.1.243S PubMed
24. Romeo J., González-Gross M., Wärnberg J., Díaz L.E., Marcos A.. Effects of Moderate Beer Consumption on Blood Lipid Profile in Healthy Spanish Adults. Nutr. Metab. Cardiovasc. Dis.. 2008 doi:10.1016/j.numecd.2007.03.007 PubMed
25. Nishiwaki M., Kora N., Matsumoto N.. Ingesting a Small Amount of Beer Reduces Arterial Stiffness in Healthy Humans. Physiol. Rep.. 2017 doi:10.14814/phy2.13381 PubMed
26. Rimm E.B., Williams P., Fosher K., Criqui M., Stampfer M.J.. Moderate Alcohol Intake and Lower Risk of Coronary Heart Disease: Meta-Analysis of Effects on Lipids and Haemostatic Factors. Br. Med. J.. 1999 doi:10.1136/bmj.319.7224.1523 PubMed
27. Di Castelnuovo A., Costanzo S., di Giuseppe R., de Gaetano G., Iacoviello L.. Alcohol Consumption and Cardiovascular Risk: Mechanisms of Action and Epidemiologic Perspectives. Future Cardiol.. 2009 doi:10.2217/fca.09.36 PubMed
28. Piano M.R.. Alcohol’s Effects on the Cardiovascular System. Alcohol Res. Curr. Rev.. 2017 doi:10.35946/arcr.v38.2.06 PubMed
29. Hätönen K.A., Virtamo J., Eriksson J.G., Perälä M.M., Sinkko H.K., Leiviskä J. et al. Modifying Effects of Alcohol on the Postprandial Glucose and Insulin Responses in Healthy Subjects. Am. J. Clin. Nutr.. 2012 doi:10.3945/ajcn.111.031682 PubMed
30. Traversy G., Chaput J.P.. Alcohol Consumption and Obesity: An Update. Curr. Obes. Rep.. 2015 doi:10.1007/s13679-014-0129-4 PubMed
31. Block G.. Foods Contributing to Energy Intake in the US: Data from NHANES III and NHANES 1999–2000. J. Food Compos. Anal.. 2004 doi:10.1016/j.jfca.2004.02.007
32. Roe M., Pinchen H., Church S., Finglas P.. McCance and Widdowson’s The Composition of Foods Seventh Summary Edition and Updated Composition of Foods Integrated Dataset. Nutr. Bull.. 2015 doi:10.1111/nbu.12124
33. Tujague J., Kerr W.C.. Energy Intake Estimates of Respondent-Measured Alcoholic Beverages. Alcohol Alcohol.. 2009 doi:10.1093/alcalc/agn081 PubMed
34. De Gaetano G., Costanzo S., di Castelnuovo A., Badimon L., Bejko D., Alkerwi A. et al. Effects of Moderate Beer Consumption on Health and Disease: A Consensus Document. Nutr. Metab. Cardiovasc. Dis.. 2016 doi:10.1016/j.numecd.2016.03.007 PubMed
35. Kawano Y.. Physio-Pathological Effects of Alcohol on the Cardiovascular System: Its Role in Hypertension and Cardiovascular Disease. Hypertens. Res.. 2010 doi:10.1038/hr.2009.226 PubMed
36. Gardner J.D., Mouton A.J.. Alcohol Effects on Cardiac Function. Compr. Physiol.. 2015 doi:10.1002/cphy.c140046 PubMed
37. Shi L., Shu X.O., Li H., Cai H., Liu Q., Zheng W. et al. Physical Activity, Smoking, and Alcohol Consumption in Association with Incidence of Type 2 Diabetes among Middle-Aged and Elderly Chinese Men. PLoS ONE. 2013 doi:10.1371/journal.pone.0077919 PubMed
38. Sato K.K., Hayashi T., Harita N., Koh H., Maeda I., Endo G. et al. Relationship between Drinking Patterns and the Risk of Type 2 Diabetes: The Kansai Healthcare Study. J. Epidemiol. Community Health. 2012 doi:10.1136/jech.2010.109777 PubMed
39. Marques-Vidal P., Vollenweider P., Waeber G.. Alcohol Consumption and Incidence of Type 2 Diabetes. Results from the CoLaus Study. Nutr. Metab. Cardiovasc. Dis.. 2015 doi:10.1016/j.numecd.2014.08.010 PubMed
40. Wei M., Gibbons L.W., Mitchell T.L., Kampert J.B., Blair S.N.. Alcohol Intake and Incidence of Type 2. Diabetes Care. 2000 doi:10.2337/diacare.23.1.18 PubMed
41. Wannamethee S.G., Shaper A.G., Perry I.J., Alberti K.G.M.M.. Alcohol Consumption and the Incidence of Type II Diabetes. J. Epidemiol. Community Health. 2002 doi:10.1136/jech.56.7.542 PubMed
42. Athyros V.G., Liberopoulos E.N., Mikhailidis D.P., Papageorgiou A.A., Ganotakis E.S., Tziomalos K. et al. Association of Drinking Pattern and Alcohol Beverage Type with the Prevalence of Metabolic Syndrome, Diabetes, Coronary Heart Disease, Stroke, and Peripheral Arterial Disease in a Mediterranean Cohort. Angiology. 2008 doi:10.1177/0003319707306146 PubMed
43. Cullmann M., Hilding A., Östenson C.G.. Alcohol Consumption and Risk of Pre-Diabetes and Type 2 Diabetes Development in a Swedish Population. Diabet. Med.. 2012 doi:10.1111/j.1464-5491.2011.03450.x PubMed
44. Osorio-Paz I., Brunauer R., Alavez S.. Beer and Its Non-Alcoholic Compounds in Health and Disease. Crit. Rev. Food Sci. Nutr.. 2019 doi:10.1080/10408398.2019.1696278 PubMed
45. Redondo N., Nova E., Díaz-Prieto L.E., Marcos A.. Effects of Moderate Beer Consumption on Health. Nutr. Hosp.. 2018 doi:10.20960/nh.2286 PubMed
46. Padro T., Muñoz-García N., Vilahur G., Chagas P., Deyà A., Antonijoan R.M. et al. Moderate Beer Intake and Cardiovascular Health in Overweight Individuals. Nutrients. 2018 doi:10.3390/nu10091237 PubMed
47. Wood A.M., Kaptoge S., Butterworth A., Nietert P.J., Warnakula S., Bolton T. et al. Risk Thresholds for Alcohol Consumption: Combined Analysis of Individual-Participant Data for 599 912 Current Drinkers in 83 Prospective Studies. Lancet. 2018 doi:10.1016/S0140-6736(18)30134-X PubMed
48. Toma A., Paré G., Leong D.P.. Alcohol and Cardiovascular Disease: How Much Is Too Much?. Curr. Atheroscler. Rep.. 2017 doi:10.1007/s11883-017-0647-0 PubMed
49. Bell S., Daskalopoulou M., Rapsomaniki E., George J., Britton A., Bobak M. et al. Association between Clinically Recorded Alcohol Consumption and Initial Presentation of 12 Cardiovascular Diseases: Population Based Cohort Study Using Linked Health Records. BMJ. 2017 doi:10.1136/bmj.j909 PubMed
50. Polsky S., Akturk H.K.. Alcohol Consumption, Diabetes Risk, and Cardiovascular Disease Within Diabetes. Curr. Diabetes Rep.. 2017 doi:10.1007/s11892-017-0950-8 PubMed
51. Xi B., Veeranki S.P., Zhao M., Ma C., Yan Y., Mi J.. Relationship of Alcohol Consumption to All-Cause, Cardiovascular, and Cancer-Related Mortality in U.S. Adults. J. Am. Coll. Cardiol.. 2017 doi:10.1016/j.jacc.2017.06.054 PubMed
52. Fresán U., Gea A., Bes-Rastrollo M., Ruiz-Canela M., Martínez-Gonzalez M.A.. Substitution Models of Water for Other Beverages, and the Incidence of Obesity and Weight Gain in the SUN Cohort. Nutrients. 2016 doi:10.3390/nu8110688 PubMed
53. Stockwell T., Zhao J., Panwar S., Roemer A., Naimi T., Chikritzhs T.. Do “Moderate” Drinkers Have Reduced Mortality Risk? A Systematic Review and Meta-Analysis of Alcohol Consumption and All-Cause Mortality. J. Stud. Alcohol Drugs. 2016 doi:10.15288/jsad.2016.77.185 PubMed
54. Roerecke M., Rehm J.. Alcohol Consumption, Drinking Patterns, and Ischemic Heart Disease: A Narrative Review of Meta-Analyses and a Systematic Review and Meta-Analysis of the Impact of Heavy Drinking Occasions on Risk for Moderate Drinkers. BMC Med.. 2014 doi:10.1186/s12916-014-0182-6 PubMed
55. Bendsen N.T., Christensen R., Bartels E.M., Kok F.J., Sierksma A., Raben A. et al. Is Beer Consumption Related to Measures of Abdominal and General Obesity? A Systematic Review and Meta-Analysis. Nutr. Rev.. 2013 doi:10.1111/j.1753-4887.2012.00548.x PubMed
56. Roerecke M., Rehm J.. The Cardioprotective Association of Average Alcohol Consumption and Ischaemic Heart Disease: A Systematic Review and Meta-Analysis. Addiction. 2012 doi:10.1111/j.1360-0443.2012.03780.x PubMed
57. Costanzo S., di Castelnuovo A., Donati M.B., Iacoviello L., de Gaetano G.. Wine, Beer or Spirit Drinking in Relation to Fatal and Non-Fatal Cardiovascular Events: A Meta-Analysis. Eur. J. Epidemiol.. 2011 doi:10.1007/s10654-011-9631-0 PubMed
58. Yin J., Winzenberg T., Quinn S., Giles G., Jones G.. Beverage-Specific Alcohol Intake and Bone Loss in Older Men and Women: A Longitudinal Study. Eur. J. Clin. Nutr.. 2011 doi:10.1038/ejcn.2011.9 PubMed
59. Schütze M., Schulz M., Steffen A., Bergmann M.M., Kroke A., Lissner L. et al. Beer Consumption and the “Beer Belly”: Scientific Basis or Common Belief?. Eur. J. Clin. Nutr.. 2009 doi:10.1038/ejcn.2009.39 PubMed
60. Snow W.M., Murray R., Ekuma O., Tyas S.L., Barnes G.E.. Alcohol Use and Cardiovascular Health Outcomes: A Comparison across Age and Gender in the Winnipeg Health and Drinking Survey Cohort. Age Ageing. 2009 doi:10.1093/ageing/afn284 PubMed
61. Suadicani P., Hein H.O., Gyntelberg F.. Wine Intake, ABO Phenotype, and Risk of Ischemic Heart Disease and All-Cause Mortality: The Copenhagen Male Study-a 16-Year Follow-Up. Alcohol. 2008 doi:10.1016/j.alcohol.2008.05.007 PubMed
62. Mukamal K.J., Robbins J.A., Cauley J.A., Kern L.M., Siscovick D.S.. Alcohol Consumption, Bone Density, and Hip Fracture among Older Adults: The Cardiovascular Health Study. Osteoporos. Int.. 2007 doi:10.1007/s00198-006-0287-7 PubMed
63. O’Donnell M.J., Chin S.L., Rangarajan S., Xavier D., Liu L., Zhang H. et al. Global and Regional Effects of Potentially Modifiable Risk Factors Associated with Acute Stroke in 32 Countries (INTERSTROKE): A Case-Control Study. Lancet. 2016 doi:10.1016/S0140-6736(16)30506-2 PubMed
64. Smyth A., Teo K.K., Rangarajan S., O’Donnell M., Zhang X., Rana P. et al. Alcohol Consumption and Cardiovascular Disease, Cancer, Injury, Admission to Hospital, and Mortality: A Prospective Cohort Study. Lancet. 2015 doi:10.1016/S0140-6736(15)00235-4 PubMed
65. Di Castelnuovo A., Costanzo S., Bagnardi V., Donati M.B., Iacoviello L., de Gaetano G.. Alcohol Dosing and Total Mortality in Men and Women: An Updated Meta-Analysis of 34 Prospective Studies. Arch. Intern. Med.. 2006 doi:10.1001/archinte.166.22.2437 PubMed
66. Renaud S.C., Guéguen R., Siest G., Salamon R.. Wine, Beer, and Mortality in Middle-Aged Men from Eastern France. Arch. Intern. Med.. 1999 doi:10.1001/archinte.159.16.1865 PubMed
67. Wannamethee S.G., Shaper A.G.. Type of Alcoholic Drink and Risk of Major Coronary Heart Disease Events and All-Cause Mortality. Am. J. Public Health. 1999 doi:10.2105/AJPH.89.5.685 PubMed
68. Nielsen N.R., Schnohr P., Jensen G., Grønbæk M.. Is the Relationship between Type of Alcohol and Mortality Influenced by Socio-Economic Status?. J. Intern. Med.. 2004 doi:10.1046/j.1365-2796.2003.01268.x PubMed
69. Ferrari P., Licaj I., Muller D.C., Andersen P.K., Johansson M., Boeing H. et al. Lifetime Alcohol Use and Overall and Cause-Specific Mortality in the European Prospective Investigation into Cancer and Nutrition (EPIC) Study. BMJ Open. 2014 doi:10.1136/bmjopen-2014-005245 PubMed
70. Huang J., Wang X., Zhang Y.. Specific Types of Alcoholic Beverage Consumption and Risk of Type 2 Diabetes: A Systematic Review and Meta-Analysis. J. Diabetes Investig.. 2017 doi:10.1111/jdi.12537 PubMed
71. Kim J.Y., Lee D.Y., Lee Y.J., Park K.J., Kim K.H., Kim J.W. et al. Chronic Alcohol Consumption Potentiates the Development of Diabetes through Pancreatic β-Cell Dysfunction. World J. Biol. Chem.. 2015 doi:10.4331/wjbc.v6.i1.1 PubMed
72. Kim S.J., Kim D.J.. Alcoholism and Diabetes Mellitus. Diabetes Metab. J.. 2012 doi:10.4093/dmj.2012.36.2.108 PubMed
73. Potì F., Santi D., Spaggiari G., Zimetti F., Zanotti I.. Polyphenol Health Effects on Cardiovascular and Neurodegenerative Disorders: A Review and Meta-Analysis. Int. J. Mol. Sci.. 2019 doi:10.3390/ijms20020351 PubMed
74. Chiva-Blanch G., Condines X., Magraner E., Roth I., Valderas-Martínez P., Arranz S. et al. The Non-Alcoholic Fraction of Beer Increases Stromal Cell Derived Factor 1 and the Number of Circulating Endothelial Progenitor Cells in High Cardiovascular Risk Subjects: A Randomized Clinical Trial. Atherosclerosis. 2014 doi:10.1016/j.atherosclerosis.2013.12.048 PubMed
75. Hodge A.M., English D.R., O’Dea K., Giles G.G.. Alcohol Intake, Consumption Pattern and Beverage Type, and the Risk of Type 2 Diabetes. Diabet. Med.. 2006 doi:10.1111/j.1464-5491.2006.01864.x PubMed
76. Rasouli B., Ahlbom A., Andersson T., Grill V., Midthjell K., Olsson L. et al. Alcohol Consumption Is Associated with Reduced Risk of Type2 Diabetes and Autoimmune Diabetes in Adults: Results from the Nord-Trøndelag Health Study. Diabet. Med.. 2013 doi:10.1111/j.1464-5491.2012.03713.x PubMed
77. Bagnardi V., Rota M., Botteri E., Tramacere I., Islami F., Fedirko V. et al. Alcohol Consumption and Site-Specific Cancer Risk: A Comprehensive Dose-Response Meta-Analysis. Br. J. Cancer. 2015 doi:10.1038/bjc.2014.579 PubMed
78. Willett W.C., Sacks F., Trichopoulou A., Drescher G., Ferro-Luzzi A., Helsing E. et al. Mediterranean Diet Pyramid: A Cultural Model for Healthy Eating. Am. J. Clin. Nutr.. 1995 doi:10.1093/ajcn/61.6.1402S PubMed
79. Global Status Report on Alcohol and Health 2018. 2018
80. National Institute on Alcohol Abuse and Alcoholism Governments Confront Drunken Violence. Bull. World Health Organ.. 2010 doi:10.2471/BLT.10.010910 PubMed
81. NIAAA Council Approves Definition of Binge Drinking. NIAAA Newsl.. 2004
82. Ruidavets J.B., Ducimetière P., Evans A., Montaye M., Haas B., Bingham A. et al. Patterns of Alcohol Consumption and Ischaemic Heart Disease in Culturally Divergent Countries: The Prospective Epidemiological Study of Myocardial Infarction (PRIME). BMJ. 2010 doi:10.1136/bmj.c6077 PubMed
83. Horvat P., Stefler D., Murphy M., King L., McKee M., Bobak M.. Alcohol, Pattern of Drinking and All-Cause Mortality in Russia, Belarus and Hungary: A Retrospective Indirect Cohort Study Based on Mortality of Relatives. Addiction. 2018 doi:10.1111/add.14189 PubMed
84. Serra-Majem L., Aranceta J.. Carta al Editor. Réplica: “La Recomendación Del Consumo de Alcohol En Las ‘Guías Alimentarias Para La Población Española’. Un Mensaje Demasiado Ambiguo”. Nutr. Hosp.. 2017 doi:10.20960/nh.827.3 PubMed
85. Li Y., Pan A., Wang D.D., Liu X., Dhana K., Franco O.H. et al. Impact of Healthy Lifestyle Factors on Life Expectancies in the Us Population. Circulation. 2018 doi:10.1161/CIRCULATIONAHA.117.032047 PubMed