Jan 24, 2000

Introductory materials:

Dr. Shoemaker is a pediatrician in Santa Cruz County and since 1985 the winemaker at Salamandre  Wine Cellars in Aptos--a tiny "mom and pop" winery making Pinot Noir, Chardonnay, Merlot, and recently moving toward Syrah and Primitivo.

He co-authored "The French Paradox and Beyond" with  Keith Marton and Lew Perdue in 1992, and also wrote for several wine trade journals on wine and health regularly in the late '80s through mid '90s. He was the medical advisor to the Wine Institute for much of that time, involving a great deal of national and international collaboration with figures will known to Medical Friends of Wine, including Curt Ellison, Serge Renaud, Arthur Klatsky, and David Pittman.

Dr. Shoemaker last addressed MFW in 1992 regarding Fetal Alcohol Syndrome.

Good evening, Friends, and thank you for the invitation to return to your gathering. Thank you, especially, to Sandy Margolis MD for his gracious preparations and suggestions for this talk... and for his thoughtful invitation to my wife, who is also named Sandie...and who keeps our winery solvent.

For the decade of the 1990's, we enjoyed the steady  unfurling of credible scientific knowledge regarding the relationship of moderate wine drinking with healthy living, which of course carried a delightful--and uncommonly consistent--message. To show that we are living  in blessed times, we concurrently enjoyed a phenomenal growth of the variety and quality of our California wines. The Medical Friends of Wine have contributed substantially to both of these areas of welcome progress as  scientists, teachers, advisors, as consumers...and as I have discovered this evening , growers and winemakers. Tonight, we will discuss whether the reported health benefits of wine drinking relate simply to the alcohol content of the beverage, or whether there is truly something distinctive about the beverage we celebrate. In other words: Is it really true?

The answers--based in science-- include characteristics of our raw material, our subsequent cellar practices, notably the role of heat.

Our social customs--how we behave in the presence of an open container--are also critically relevant. The answers will, indeed, validate what we  know intuitively to be true.

I will take a middle path between biochemistry lecture, Winemaking 101, and lyrical wine praise, all of which you have received from more accomplished experts.

As we all know,  most of the epidemiologic studies of the mid and late 80's and early 90's demonstrated longer life spans for moderate drinkers when compared to heavy drinkers and abstainers. The differences were largely due to a significantly diminished incidence of atheroschlerotic catastrophes of heart and brain. As an unanticipated bonus, a host of other positive health effects were documented involving other organ systems, often confounding investigators who were prospecting for contrary results.

The study design of these early reports typically did not discriminate between beverage types, or did so in an epidemiologically "soft" fashion.  However, since the news first leaked to the public with a distinctively French accent, by that eloquent pair of docs Curt Ellison and Serge Renaud, wine, especially red wine, received an abundance of good press. Skeptics, including some of our colleagues who have spent their careers struggling against alcohol abuse, at first cried out that the alcohol data must be flawed. Some stubbornly refused to accept that "dose" might influence the balance of help and harm. Some went further to say that, regardless of truthfulness, publicizing anything good about alcohol was dangerous for public health, implying that the public could not be  trusted with objective information. While practically no legitimate scientist can uphold that line regarding moderate alcohol consumption in this new century, many remain bitter at what they perceive as the exploitation  of this news by friends of wine. Newer studies are now prospectively designed to better segregate different beverage types, and it will be intruiguing to watch them mature, but we really have a great deal of information right now that is powerfully convincing: Wine is different, and it is better.

Before making direct comparisons between beverage types, though, let's quickly review the physiology of atheroschlerosis, our primary health nemesis in America. Atheroschlerosis hurts us with a long, silent phase lasting decades, followed by an abrupt crisis lasting perhaps hours. In the long phase, lipid deposits accumulate in the walls of small and large vessels. Oxidation of these lipid deposits creates local tissue

irritation, fibrosis, and insidious impingement of the lumen. Acutely, a small rent in the vascular endothelium creates an attractant for platelets which further impedes or obstructs flow through the vessel. Subsequent clot formation results in serious obstruction and ischemic injury to distal tissues over the next few hours. Alcohol affects both the long  and the short phases, and, additively, so do substances uniquely found in wine.

To elaborate, alcohol raises HDL cholesterol and reduces net commerce of lipid deposition in vessels over the decades of the  "long phase." Alcohol may also reduce insulin resistance, which in some people at high cardiac risk may be a crucial factor in vascular injury. In the short, acute phase, alcohol stimulates the production of  TPA, tissue plasminogen activator, which interferes with the propogation and organization of intravascular clots. TPA production rises within 1-2 hours of ingestion of alcohol, and slowly subsides for a day. Recently,  investigators at Stanford have noted that alcohol may additionally improve the tolerance of myocardial cells to ischemia.

Wine phenolics also influence both the long and short phases. Several of these substances favorably influence HDL concentrations. These effects are variable based upon color of the wine, source of the grapes, age, and processing, but critically they are additive to the effects of the ethanol. Additionally,  wine-derived antioxidants effectively retard lipoprotein oxidation at the cellular level. Affecting the short, crisis phase, wine phenolics interfere with platelet aggregation at the site of a vascular intimal rent,  creating a supplemental protective effect to that of ethanol --importantly at a different point in the clotting cascade.

Returning to our discussion of differences between types of brew, let's start in the vineyard. When we pick a lug of fresh grapes, we have harvested plenty of water and sugar, which of course will ferment to create an 11 to 15% solution of ethanol. We also have stems, seeds, and probably most critically, skins. The skins give us most of the flavor and nearly all of the color in our wines. Together with tannins and phenolics derived from stems and seeds, they also provide the astringency that gives wine its unique match with foods. Dozens of wine phenolics, including resveratrol, quercetin, catechins, boast a remarkable variety of welcome health effects including antioxidant, cholesterol modification, and antiplatelet  properties. As MFW has heard in other presentations, these substances appear in substantial quantities in the finished wine. Critically, beyond the vitro effects, they are absorbed by healthy people, appear in the  bloodstream in physiologically meaningful amounts, and create measurable in vivo changes in humans. Red wine typically contains 10 to 20 times more phenolics than white, by virtue of extended skin contact and maceration in the fermenter, but white wine still has meaningful amounts of biologically active phenolics.

By contrast, grain--the principal source of carbohydrate substrate for fermentations of beer and spirits-- has  minimal amounts of similar materials. In contrast to the fresh and immediate fermentation of ripe grapes, grain is harvested when all the green has dried to brown...and then it may be stored for months in a silo before delivery to the brewer.

The harvest is only the beginning. Let's discuss heat.

Grapes are usually cool at harvest, especially with contemporary winemaking. After crushing the grapes, a red wine fermentation never gets hotter than a summer day, and a white wine fermentation rarely waxes warmer than an April morning. Grain based beverages, by contrast, are mashed at about 150 F, and then boiled out the wazoo. (The surgeons and radiologists in the audience know exactly where that is, I'm

sure.) Spirits are then boiled again during distillation, and many beers are pasteurized at bottling. Not only are many biologically active and potentially beneficial substances neutralized in the repeated heating, certainly lost in distillation, but other new substances may be thermally created. This consideration may prove relevant to the slowly evolving  understanding of the differential associations of wine, beer, and spirits with cancers, especially breast cancer. Breast cancer is one of the very few, perhaps the only one, where there may be a weak association with  moderate alcohol consumption. Beverage types have shown different statistical influences in a number of studies, but this information is quite young and unsettled.

The processing differences don't stop with heating. How about flavorings? Fine wine is usually stored in oak, which slowly adds elements of flavor and some phenolic compounds and vanillins primarily of aesthetic, not biological importance. However, no flavor additives can be legally placed in table wine. Beer, of course, has hop flavor admitted in the wort boiling stage. Hop blossoms of course are a fine plant product, but a weak contributor of biologically active materials in the quantities used in beer making, expecially after kiln drying and subsequent prolonged boiling. Many spirits have proprietary flavorings added after fermentation, and it's hard to make any generalizations about these.

All of these fermented beverages are cloudy initially, and American consumers demand see-through clarity. Regarding clarification, there are perhaps more similarities than differences. The bulk of wine  clarification occurs over many months with gradual settling of particulate materials. Beer can't afford this luxury considering the production turnaround demands and premium upon freshness, but this difference is perhaps minor. Most beers and many wines will see some type of fining--the use of materials which pass through the liquid and pull out haze. These materials may remove some of the tannins from wine, but contribute little or nothing to the biochemical profile of the finished beverage. Filtration is fairly often used as a final pre-bottling step for all beverage types, but does not significantly alter beverage content at the  molecular level.

After the beverages find their way to a sealed container, important differences remain, and these may turn out to be equally or more important than the biochemical differences. Wine is typically served to accompany an evening meal, traditionally on a daily basis--and I do hope that's the way it is for you except for your on-call nights. Spirits are not typically consumed with meals, beer perhaps more often, but  both are more commonly drunk away from the dinner table. Beer and spirits are more likely to be consumed on an episodic schedule. Do these differences in customs matter? Yes, indeed. Drinking wine with a meal, both the  alcohol and the antioxidants enter the bloodstream in perfect synchrony with the post prandial tide of lipids, where the beneficial efects are optimally matched with our preventive needs. Recall, those would be effects on lipoprotein oxidation in vessel walls and anti-platelet aggregation effects from the wine phenolics, in addition to the TPA boosting effects of the ethanol. These effects subside over a day, right in time for refreshment at tomorrow night's meal.

Finally, wine consumption typically involves different consumer behavior from beer and spirits. Wine is usually drunk in a socially integrative setting--that is: people  sitting down together, talking, enjoying a mutually pleasurable experience. The consumption reaches a natural termination when the bottle is empty and the meal is cleared, which is usually not late at night. While nothing keeps beer or spirits from being enjoyed the same way, in America at least, it doesn't often happen that way. The potential for acute and chronic abuse, attractiveness to underage drinkers, and the expected decorum for drinkers of the three beverages are all notably different, perhaps most critically the disproportionately small number of DUI's for wine drinkers

My conclusion is that wine tastes good, it makes my  wife's wonderful cooking even more exciting, and on a population scale moderate consumption contributes to a diminution of life-limiting illnesses. If it has any health effects upon me individually, they are likely to be positive, although my personal behavior and genetic traits could betray the statistics. Fortunately, one can enjoy the health benefits of moderate drinking right along with the other well documented preventive health strategies that we teach and practice. In fact, I'd strongly recommend having "one of each." As far as comparisons to beer and spirits, yes, wine is better, and red wine is the best. However, like so many  other things, balance and moderation are healthier than any zealous absolutism. When I'm finished crushing grapes, please hand me a hearty, hoppy beer. If we're going to discuss managed care seriously, I'd like a shot  of a barrel-aged tequila first.

Thank you for your attention, and again, for your generous hospitality.

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