Medical Tuesday Blog
A Review of Regional Medical Journals: Sonoma Medicine
WINE AS MEDICINE
Rachel Friedman, MD
. . . It’s a Saturday afternoon, and after a busy week of seeing patients as a family physician, I am behind the bar at the winery my husband and I own, guiding guests in a wine tasting. When I explain that I not only own a winery but also spend my week as a physician, they seem impressed and say with a touch of envy, “Wow! You are really living the dream!”
Am I? I never really dreamed of owning a winery or getting involved in winemaking. In fact, the sum total of my wine knowledge when I moved to Sonoma County was on the order of: Wine is made by fermenting grapes to produce alcohol. Some wine is red, some wine is white, and some wine is pink and called rosé. When I interviewed at the Santa Rosa Family Medicine Residency in 2007, my future professor Dr. Dave Schneider, a self-identified wine buff, offered a handout with recommendations for wine tasting. Other applicants seemed excited about the idea of living in wine country, but I didn’t take the handout and instead spent my post-interview afternoon finding a coffee shop and a running trail that would make me feel excited to call Sonoma County home.
So how did I get from there to here? After matching at the residency and moving to Santa Rosa, I did feign a bit of interest in wine, and by the end of my intern year I’d learned that I enjoyed a good Merlot and had added words and phrases like Russian River Valley and Gewürztraminer to my still limited wine vocabulary. At the same time, I had concerns about living in wine country, as I saw plenty of patients suffering the ravages of alcoholism and end-stage liver disease.
And then, as the story goes, I met someone. He was a former hospital lab technician who had experienced a eureka moment in 2001 when he found himself serendipitously sitting next to an apprentice winemaker. He realized that winemaking was a way to bring creativity and lifelong learning to the logic of science. He moved across the country to Napa shortly thereafter to start a new career as an aspiring winemaker.
On our first few dates, Marc wooed me with stories of running CBCs and erythrocyte sedimentation rates in hospital labs, along with promises of grape stomping, the obvious dream of anyone who grew up watching “I Love Lucy” reruns.
As our relationship and my second year of residency intensified, I was bored to tears by Marc’s passionate monologues about rootstock and clonal selection during weekend drives along the vineyard-studded back roads of Sonoma County. Nonetheless, I was struck by his passion for his craft, and as a physician I could identify with his commitment to lifelong learning: the notion of diving deep into specialized knowledge and skill while geeking out on science.
As we got engaged and started talking about starting a life together, a family, and at some point, in 2011, a winery, I hesitated about the winery. I wasn’t sure how I felt about condoning a career devoted to making alcohol, a substance that has the potential to wreak such havoc on people’s bodies, relationships and lives. Yet, as I learned more about the winemaking process, I realized that Marc’s love for winemaking had as little to do with wine as an alcoholic beverage as my love for medicine has to do with using pain medications as a narcotic. I began to realize that winemaking, and medicine, are very similar fields.
The thrill of medicine for me (and winemaking for Marc) is in acquiring a foundation of scientific knowledge and skill, paired with the overlay of experience, lifelong learning, creative problem solving, hands-on skills and artistry applied to complex situations and personalized practice style. My primary connection as a family physician is to people, understanding the processes that occur inside their bodies when they are healthy or get sick, and finding ways to control those processes to restore health. The winemaker’s primary connection is to grapes and yeast, understanding the processes that occur when they are combined, and finding ways to control those processes to create wine that captures the best flavors for the people who drink it.
Delving into winemaking and starting a small business has taught me so many things, along with finally supplying a use for all that organic chemistry! When was the last time you calculated molarity or considered the structure of an aromatic polyphenol? If you’re a physician in clinical practice, it was probably sometime in med school, years ago. If you’re a winemaker, it might have been yesterday. One of my favorite parts about winemaking has been getting a refresher in all the basic sciences I learned during my pre-med and medical training in a way that is not only fun, but also amenable for teaching people when I talk about the science of wine.
My favorite aspect of wine science is understanding how the process of winemaking brings out the flavors in wine, and how those flavor molecules interact with our tongues, noses, brains and memories to produce the experience of wine tasting.
Wine is made by crushing grapes and adding yeast to the grape juice in a fermentation process that produces alcohol and carbon dioxide. During fermentation, yeast uses the sugars in the grape juice as food, and as the yeast enzymes cut off sugar molecules attached to aromatic polyesters and other aroma precursor molecules, they liberate these molecules, producing the aromas that characterize a particular wine. Different grape varietals have different aroma precursors, and different yeast strains chop up the sugar side chains in different ways.
The aromas of wine refer to specific aromatic compounds that our brains associate with a specific scent: you can identify the aromas of coffee, peppermint or strawberry just by smell, with your eyes closed. Primary aromas in wine, such as fruit, flowers or herbs, derive from the grape varietal used. Pinot Noir, for instance, may contain aromas of cherry. The molecules that trigger our brains to associate with a certain familiar smell can lead to the subjective experience of wine tasting. One person’s cherry association may be another’s cranberry or strawberry, or even cherry cola.
Secondary and tertiary aromas—sometimes called the wine bouquet and consisting of earthier flavors, nut and spice—emerge from the winemaking and aging process—whether from the inclusion of seeds and stems during fermentation, the types of oak barrels used, or the yeast. Other factors that contribute to the sensory experience of winetasting include the acidity of the wine, the alcohol content and tannins. I could go on for days about the science of food and wine pairing, but it’s time to move on to the aspect of wine science perhaps most relevant to physicians: the health benefits of wine.
The therapeutic range for wine is a narrow window: one 4- or 5-ounce glass a day on average for women, one or two glasses a day for men. Drink more and the risks escalate dramatically, in a classic J-shaped curve. Even drinking modestly over the recommended amount may increase risk of breast and colorectal cancers; and any binge drinking seems to increase breast cancer risk independent of total alcohol intake. A recent meta-analysis found a dose-dependent increase in breast cancer risk with increased intake of wine.1 Interestingly, increasing folate levels may mitigate the increased risk of both breast and colorectal cancer in alcohol drinkers. The lowest non-zero intake level appears to be protective and to reduce risks, adding further evidence to the recommendation to limit alcohol or wine intake, but not necessarily to fully abstain.
Known risks aside, epidemiologic studies have consistently shown health benefits for alcohol intake, especially red wine, within the narrow therapeutic window. Modest intake of alcohol produces consistently strong evidence for overall cardiovascular benefit, decreased cardiovascular morbidity and mortality, and decreased all-cause mortality.2
How does alcohol, and red wine in particular, confer these benefits? While excessive wine drinking likely increases the risk of type 2 diabetes, studies have actually found decreased metabolic risk with moderate drinking. The recent CASCADE trial randomized 224 adults with type 2 diabetes to drink mineral water, white wine or red wine with dinner for two years. Red wine was associated with significantly increased HDL levels, improved glycemic control and reduction of cardiometabolic risk.3 Ethanol thus appears to play a role in glucose and fatty acid metabolism, though red wine seems to have benefit beyond that of just the alcohol it contains.
One source of health benefits in wine distinct from other alcoholic beverages may be resveratrol, a polyphenol found primarily in the skins of fruits such as grapes, blueberries and raspberries.4 Making grapes into wine increases the resveratrol content, with red wine containing far more resveratrol than whites because red-wine grapes are fermented with their skins, thus increasing the duration of resveratrol extraction. Pinot Noir seems to have higher concentrations of resveratrol than other red wines.
Resveratrol’s benefits may include decreasing inflammatory markers, increasing HDL, and downregulating pro-inflammatory genes, along with some anti-cancer effects.5 Resveratrol may also play a role in reducing risk of neurodegenerative disorders and in modifying cardiac ion channel activity to regulate heart rhythm in atrial fibrillation. Although preliminary studies in animals and humans suggest benefits of increased resveratrol intake,6 other studies of resveratrol supplementation have not yet yielded results sufficient to warrant encouraging patients to supplement with resveratrol alone. A glass of red wine a day is probably a better route.
Another contender in the quest for understanding the exact mechanisms for red wine’s health benefits is quercetin, a flavonoid found in apples, berries and red wine. Studies of supplementation with quercetin have shown benefits in blood pressure reduction in hypertensive patients.7 Another promising avenue of research is the role of quercetin and other red wine polyphenols in protecting against the oxidative stress and pathology implicated in Alzheimer’s, Parkinson’s and other increasingly common neurodegenerative diseases.8 As with resveratrol, there isn’t any clear proof that isolating quercetin into a supplement is beneficial; we may do best by continuing to promote a plant-based Mediterranean diet, with dark chocolate and red wine adding extra dosing of healthy polyphenols. . ,9
Above all, physicians should be advocates for health and wellness. In the right setting and context, and paired with the right foods, wine can be a factor in promoting higher quality of life, health and wellness. Wine can bring people together to share the experience of eating meals, and it can act as a social lubricant to enable meaningful connections, thereby improving people’s sense of community and enjoyment of life. Cheers! ::
Dr. Friedman, a Santa Rosa family physician, is a co-owner of Orpheus Wines in Kenwood.
Read the entire article at Sonoma Medicine . . .
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