International Journal of Obesity (1998) 22, 1178±1183
ß 1998 Stockton Press All rights reserved 0307±0565/98 $12.00
http://www.stockton-press.co.uk/ijo
In¯uence of alcohol consumption and various
beverages on waist girth and waist-to-hip ratio
in a sample of French men and women
J Dallongeville1,2*, N MareÂcaux1, P DucimetieÁre3, J FerrieÁres4, D Arveiler5, A Bingham3, JB Ruidavets4, C Simon6
and P Amouyel1
1
INSERM CJF 95-05 and 2DeÂpartement d'AtheÂroscleÂrose, Institut Pasteur de Lille, 59019 Lille cedex; 3INSERM U-258, HoÃpital
Broussais, 75674 Paris cedex 14; 4DeÂpartement d'EpideÂmiologie, Faculte de MeÂdecine, 31073 Toulouse cedex; 5Laboratoire
d'EpideÂmiologie et de Sante Publique, Faculte de MeÂdecine, 67085 Strasbourg cedex and 6Groupe d'Etudes en Nutrition, HoÃpitaux
Universitaires de Strasbourg, 67098 Strasbourg cedex, France
OBJECTIVE: The goal of the present study was to assess the association between alcohol consumption and
abdominal fat deposition in France, a country where wine is the most commonly consumed alcoholic beverage.
METHODS: We analyzed the association between alcohol consumption and various markers of body weight, in a
population sample recruited in three distinct geographical areas of France (MONICA centers). This sample included
men (n ˆ 1778) and women (n ˆ 1730) aged 35 ± 64 y, randomly selected from electoral rolls. Alcohol consumption was
assessed with a quantitative frequency questionnaire.
RESULTS: Alcohol intake ranged from 0 ± 1655 ml of alcohol per week. Wine was the main source of alcohol,
representing 67% of total alcohol intake in both genders. In men, there was no association between alcohol intake
and body mass index (BMI) or body weight, whereas in women, alcohol consumption was inversely correlated with
BMI (P < 0.0001) and body weight (P < 0.0002). In men, total alcohol consumption was positively associated with
waist-to-hip ratio (WHR, P < 0.0002) and waist girth (P < 0.004), independently of BMI. Similarly, in women, positive
associations were found between alcohol intake and WHR (P < 0.0001) as well as waist girth (P < 0.0001), independently of BMI. In a linear regression model including types of beverages and usual confounders, reporting consumption of either wine, beer or spirit was poorly associated with WHR in men, whereas wine (P < 0.0008) and beer
(P < 0.0001) consumptions were both positively associated with WHR in women. However, there was no evidence of a
statistically signi®cant heterogeneous effect of wine, beer and spirits on WHR in both genders.
CONCLUSION: In a sample of representative French people, in whom wine is the most common alcoholic beverage,
alcohol consumption is associated with greater WHR independently of BMI in both men and women.
Keywords: obesity; abdominal fat; alcohol; alcoholic beverages; epidemiology
Introduction
Alcohol is a dense source of energy and a psychostimulant drug which affects appetite and food intake.
A number of epidemiological studies have reported
associations between alcohol consumption and body
weight or body mass index (BMI).1 ± 4 These correlations are usually positive5 ± 7 or not relevant in
men8 ± 10 and negative in women,6,7,9 ± 11 indicating a
complex relationship. Alcohol intake also appears to
affect body fat distribution. Waist-to-hip ratios
(WHRs) are greater in male and female drinkers
than in abstainers.12 ± 16
However, these ®ndings are not consistent among
studies. A number of reasons explains this complexity.
Among these, the type of alcoholic beverage may
have a substantial impact.5,6,11,14,17 Most studies on
*Correspondence: Dr Jean Dallongeville, Institut Pasteur de Lille,
1 rue du Professeur Calmette, 59019 Lille cedex, France.
Received 17 March 1998; revised 15 June 1998; accepted
1 July 1998
the relationship between alcohol intake and body
weight were conducted in North America7,10,11,14,16 ± 18 and Scandinavia,5,19 two regions
where the drinking patterns differ substantially from
the French.20 ± 22 Since drinking habits are changing
worldwide in favour of wine consumption,23 ± 25 it
becomes important to know whether the relationship
between alcohol intake and body fat distribution also
applies to countries where wine is a popular beverage.
Therefore, the goal of the present study was to
determine the association between alcohol consumption and various phenotypic markers of body weight
in a large sample of representative French people
(from three geographical areas located in the North,
East and South of France), for whom wine is the most
common beverage.
Methods
The participants were recruited in the framework of
the third World Health Organisation (WHO)MONICA (Multinational monitoring of trends and
Alcohol and waist-to-hip ratio
J Dallongeville et al
determinants in cardiovascular disease) population
survey, between 1994 ± 1997, in three different areas
of France: the Urban Community of Lille (Lille;
North), the Bas-Rhin (Strasbourg; East) and the
Haute-Garonne (Toulouse; South) administrative
areas. The sample included subjects aged 35 ± 64 y,
strati®ed by town size, randomly selected from the
electoral rolls, to obtain the necessary quota of 200
participants for each gender and each 10 y age stratum. A total number of 3508 (1778 men and 1730
women) was recruited in the three centers (601=594 in
Lille, 563=568 in Strasbourg, 614=568 in Toulouse).
The protocol was approved by the appropriate Ethical
Committees according to the regulations in France.
Participants were examined at home or at the health
center of the area. After signing an informed consent,
they were administered a standard questionnaire and
physical measurements were made by a specially
trained nurse, as explained in the MONICA manual
(MONICA manual, memo 214, March 1992). The
questionnaire covered questions on health, socioeconomic factors, physical activity, smoking, personal
medical history, family history, attitudes and knowledge concerning several diseases and current drug
therapy. A total of 31 questions were used to assess
drinking patterns, time and place of consumption, type
of alcohol and alcohol addiction. This questionnaire
allows the identi®cation of individuals that may
underreport their alcohol intake. Alcohol consumption
was assessed by a quantitative frequency questionnaire, detailing every day of the week, every type of
alcoholic beverage and representative of the last 12
months. Drinking habits were then translated into ml
of alcohol per week, using the mean of quantity
consumed each day and the exact alcohol contents
of the drink. In modeling, total alcohol intake was
expressed as the sum of ml of alcohol per week from
wine, beer and cider, and spirits. A total of 168
subjects were excluded from the analysis, because
they had changed their drinking habits during the
year (n ˆ 106), or they presented an alcohol addiction
syndrome (n ˆ 53) or alcoholic liver diseases (n ˆ 9).
The anthropometric measurements included height
(to the nearest cm), body weight (at the nearest even
decimal), waist (at a level midway between lower rib
margin and iliac crest; to the nearest 0.5 cm) and hip
girth (measurement of maximum circumference over
the buttocks; to the nearest 0.5 cm) and were taken
with subjects in light clothing without shoes. Body
mass index (BMI) was computed as weight (kg)
divided by height squared (m2). Waist-to-hip ratio
(WHR) was calculated as waist girth (cm) divided
by hip girth (cm). Physical activity was assessed
during work and leisure times, on working days and
week-ends. Subjects were declared active if they had a
physical activity greater than 15 min walking per day.
Smoking habits were determined with questions on
present and past habits, number and type of cigarettes,
cigars or pipe smoked per day. Smokers were de®ned
as individuals currently smoking at least one cigarette
per day. Educational level was classi®ed into three
categories (primary school=secondary school and
technical training=university). Data on levels of
income tax were also recorded.
Statistical analyses were performed using the SAS
statistical software release 6.12 (SAS Institute Inc,
Cary, NC). Univariate comparisons were made using
the chi-square test for categorical variables and oneway ANOVA for continuous variables. Correlation
between continuous variables was measured with the
Spearman coef®cient. The effect of alcohol on body
fat mass markers was assessed using the general linear
model procedure. For the sake of this analysis, alcohol
consumption was reported in three categories: abstainers, weekly alcohol intake ˆ 0; light drinkers, drinkers with consumption lower than the median of the
group; moderate and heavy drinkers, alcohol intake median intake of the group, for each gender.
The role of the type of beverage on body fat markers
was analyzed with a multivariate linear procedure
after adjusting for confounding variables. The b,
standard error and P value are presented for each
variable in the model. F test was used to test for
heterogeneity of b. The level of statistical signi®cance
was P < 0.01.
Results
In the present sample, alcohol intake varies from nil to
1655 ml of alcohol=week. Men reported more alcohol
intake than women (median 210 ml=week (range 0 ±
1655) vs 32 ml=week (0 ± 1145), respectively). Figure
1 illustrates the distribution of alcohol consumption
for both men and women. There were twice as many
women in the group of individuals drinking < 100 ml
of alcohol per week than men. Whereas there were
consistently more men in the group declaring
> 200 ml of alcohol per week than women. Table 1
shows the characteristics of the participants according
to their total alcohol intake by gender. Univariate
analysis revealed a signi®cant difference in age
Figure 1 Distribution of alcohol consumption (ml of alcohol per
week) in men and women.
1179
Alcohol and waist-to-hip ratio
J Dallongeville et al
1180
Table 1
Clinical and socioeconomical characteristics according to alcohol consumption
Men (n)
Alcohol intake (ml=week)
Age (y)
Geographical area (%)
North
East
South
Educational level (%)
Primary
Secondary and technical
University
Level of income tax (%)
No income tax
< 5000 FF=y
5000 ± 15000 FF=y
> 15000 FF=y
Physical activity (% active)
Smokers (%)
Women (n)
Alcohol intake (ml=week)
Age (y)
Geographical area (%)
North
East
South
Educational level (%)
Primary
Secondary and technical
University
Level of income tax (%)
No income tax
< 5000 FF=y
5000 ± 15000 FF=y
> 15000 FF=y
Physical activity (% active)
Smokers (%)
Number of children
Abstainers
Light drinkers
Moderate and heavy drinkers
263
0
48 8
705
120 (8 ± 259)
51 9
706
448 (260 ± 1655)
52 9
23.9
25.9
50.2
30.7
36.0
33.3
40.2
28.6
31.2
17.9
43.3
38.8
15.7
43.4
40.9
20.7
49.1
30.2
30.1
13.3
29.7
26.9
48.7
22.2
639
0
51 9
15.0
13.6
36.9
34.5
48.6
16.1
509
41 (5 ± 89)
50 9
19.0
16.1
33.9
31.0
41.2
34.5
518
181 (90 ± 1145)
51 8
24.9
33.2
41.9
34.8
36.9
28.3
43.8
28.6
27.6
32.4
39.6
28.0
26.1
43.4
30.5
29.0
38.6
32.4
30.1
16.0
30.7
23.2
39.4
14.3
2.3 1.6
21.6
16.9
28.9
32.6
35.6
14.6
2.1 1.3
25.7
15.9
28.5
29.9
31.8
18.5
2.2 1.4
P
±
0.0001
0.001
0.001
0.001
0.01
0.001
±
NS
0.001
NS
0.01
NS
NS
NS
Values are means s.d. or %. Chi square analysis was used for qualitative data and one-way ANOVA for
quantitative data. Values for alcohol intake are median and range in brackets. NS ˆ not statistically
signi®cant.
(P < 0.0001), geographical distribution (P < 0.001),
level of education (P < 0.001), physical activity
(P < 0.01) and smoking status (P < 0.001), among
abstainers, light and heavy drinking men. Differences
in geographical distribution (P < 0.001) and level of
income tax (P < 0.01) were observed in women.
Figure 2 shows the alcohol distribution in both men
and women. Most alcohol was provided by wine
(67.5% and 66.3% of total alcohol intake for men
and women, respectively), followed by beer (22.0%
and 21.2%, respectively) and hard liquor (10.5% and
12.5%, respectively). The pattern of beverage selection
was similar between men and women (w2: not statistically signi®cant (NS)), as well as between light and
heavy consumers in both men and women (w2: NS).
There were signi®cant correlations between the alcohol
provided by wine and beer (r ˆ 0.27, P < 0.0001), by
wine and hard liquor (r ˆ 0.45, P < 0.0001) and by beer
and hard liquor (r ˆ 0.32, P < 0.0001).
Table 2 presents body weight, BMI, waist and hip
girths and WHR, as a function of alcohol intake in
men and women. In men, alcohol consumption was
positively associated with WHR (P < 0.001) but not
with body weight, BMI, waist and hip girths. Further
adjustment on BMI revealed a relationship between
Figure 2 Percentage of alcohol intake according to type of
beverage in men and women.
alcohol intake and waist girth (P < 0.004) or WHR
(P < 0.0002). In women, alcohol intake was negatively associated with body weight (P < 0.0002),
BMI (P < 0.0001), hip girth (P < 0.0001), but not
with WHR and waist girth. However, additional
adjustment on BMI revealed a signi®cant association
between alcohol consumption and waist girth
(P < 0.0001) or WHR (P < 0.0001). After adjustment
on BMI, hip girth was no longer associated with
alcohol consumption.
Alcohol and waist-to-hip ratio
J Dallongeville et al
Table 2
1181
Obesity phenotype variables according to alcohol consumption status
Men
Weight (kg)
BMI (kg=m2)
Waist girth (cm)
Hip girth (cm)
WHR
Women
Weight (kg)
BMI (kg=m2)
Waist girth (cm)
Hip Girth (cm)
WHR
Abstainers
Light drinkers
Moderate and heavy drinkers
Pa
Pb
78.7 13.8
(79.3)
26.4 4.2
(26.8)
93.5 12.3
(94.9)
100.3 8.3
(101.1)
0.93 0.07
(0.937)
80.4 12.4
(80.3)
26.7 3.7
(26.8)
95.7 10.7
(95.9)
101.3 7.1
(101.2)
0.94 0.06
(0.946)
80.9 13.4
(81.1)
26.9 4.1
(26.9)
96.7 10.8
(96.1)
101.1 7.6
(100.9)
0.95 0.06
(0.951)
NS
±
NS
±
NS
0.004
NS
NS
0.001
0.0002
68.4 15.0
(68.2)
26.6 5.7
(26.5)
85.4 14.8
(83.6)
103.6 12.7
(102.3)
0.82 0.08
(0.815)
66.7 12.9
(66.3)
25.7 4.8
(25.5)
83.7 12.7
(84.3)
102.0 10.4
(102.3)
0.82 0.08
(0.823)
65.6 12.9
(65.1)
25.3 4.8
(25.1)
84.0 13.2
(85.3)
101.2 10.6
(102.3)
0.83 0.08
(0.832)
0.0002
±
0.0001
±
NS
0.0001
0.0001
NS
NS
0.0001
BMI ˆ body mass index; WHR ˆ Waist-to-hip ratio.
Values are mean s.d. General linear model was used to compare means. P values are for linear trends.
a
Data adjusted for age, geographical area, income tax level, educational level, physical activity, cigarette smoking
(number of cigarettes=d) and parity for women. bAdditional adjustment for body mass index. Adjusted mean values
are presented in brackets. NS ˆ not statistically signi®cant.
Table 3
Linear regression of type of alcohol on waist-to-hip ratio (WHR)
Men (n ˆ 1674)
Wine
Beer and cider
Spirits
BMI
Cigarettes
Age
Physical activity
Women (n ˆ 1666)
Wine
Beer and cider
Spirits
BMI
Cigarettes
Age
Physical activity
b
s.e.
Pa
Pb
0.0123
0.0248
0.0375
0.0458
0.0029
0.0168
7 0.0084
0.0068
0.0111
0.0220
0.0017
0.0013
0.0016
0.0026
0.069
0.026
0.088
0.0001
0.029
0.0001
0.001
}
NS
0.0599
0.1567
0.0718
0.0286
0.005
0.0179
7 0.0074
0.0178
0.0289
0.0644
0.0017
0.0025
0.0021
0.0035
0.0008
0.0001
0.26
0.0001
0.044
0.0001
0.035
}
NS
BMI ˆ body mass index.
General linear model was used to test the effect of alcohol from various beverages. The b, standard
error (s.e.) and Pa value are presented for each variable in the model. Data were adjusted for BMI,
cigarette smoking, age, physical activity, geographical area, income tax level, educational level and
parity for women. b based on continuous variables were calculated for the following variations: 1 litre
of alcohol=week from wine, beer, or spirits, 10 y of age, 5 units of BMI, 10 cigarettes=d. b for physical
activity was computed using the following reference category: physical activity, no. Pb: P value of Ftest used to test the heterogeneity among b from wine, beer and spirits. NS: not statistically
signi®cant.
Table 3 summarizes the relationship between the
type of beverage and WHR. Multivariate general:
linear model adjusting for BMI, number of cigarettes,
age, physical activity, geographical area, income tax
and educational levels and parity for women, was used
to test the speci®c effects of beverages on WHR. In
men, reporting consumption of either wine, beer or
spirits was poorly associated with WHR. In women,
drinking wine (P < 0.0008) and beer (P < 0.0001)
were both positively associated with WHR. Furthermore, a test of homogeneity of b was used to determine
whether different beverages had signi®cantly different
impacts on WHR. This analysis revealed no statistical
evidence for heterogeneity among the effects of wine,
beer and spirits in both men and women. Similar
results were found with waist girth (data not shown).
Alcohol and waist-to-hip ratio
J Dallongeville et al
1182
Discussion
The present study was conducted in a representative
sample of French subjects from three geographically
distinct areas: North, East and South of France. Wine
was the principal source of alcoholic calories in the
three regions. Yet, alcohol consumption was positively associated with waist girth and WHR, after
adjustments for BMI, in both men and women. Total
alcohol intake, rather than a speci®c beverage, was
associated with increased waist girth and WHR. These
observations suggest that, in a population where wine
is the most common beverage, total alcohol intake
determines fat distribution and drinking wine does not
protect from increasing abdominal fat deposition.
Total alcohol consumption was positively correlated with WHR in both French men and women.
This is in agreement with ®ndings in American subjects,14,16 European men,12 as well as in Italian
women.15 The association was independent of confounding variables including BMI, age, physical
activity, socioeconomic factors and smoking status.
Furthermore, in contrast with the effect of alcohol on
BMI, the impact of alcohol consumption on WHR was
positive in both men and women, suggesting a speci®c
effect of alcohol on abdominal fat deposition. Some
experimental evidence supports this association. Alcohol affects appetite and modulates the homeostasis of
steroid, insulin and thyroid hormones.26 These hormones are involved, to a certain extent, in the regulation of energy balance and affect fat-tissue enzymatic
activities, which may promote abdominal fat deposition.27 Moreover, sexual steroid hormones, which are
affected by alcohol consumption, play an important
role in the regulation of body fat distribution.28,29
The impact of speci®c alcoholic beverages (wine,
beer or spirits) on abdominal fat deposition is not
clearly known. The common belief, supported by a
number of epidemiological studies, is that drinking
beer promotes abdominal fat distribution14 and that
wine, in contrast, has no effect5 or is associated with
lower WHR.17 One limitation to these studies is that
they were conducted in the US14,17 or Finland,5 where
beer is a major source of alcohol and wine consumption is more prevalent in educated people. Such
cultural and educational differences are likely to be
important sources of confusion. In France, wine is the
principal drink in the population and is consumed in
large amounts allowing the assessment of its impact
on body fat distribution. As such, drinking wine does
not seem to protect from abdominal fat accumulation.
When the impact of speci®c beverages is analyzed,
adjusting for confounders, there is no clear evidence
for a consistent and homogeneous association between
a given beverage and WHR, in men. These results are
in agreement with previous studies6,11 which did not
demonstrate any relationship between BMI or WHR
and speci®c beverages. The ®ndings in women are
slightly different, since reporting both wine and beer
consumptions was associated with increased WHR.
However, since there was no evidence for a statistical
difference among beverages in both genders, it suggests that factors other than the beverage itself, such
as differences in drinking patterns, life style factors,
unaccountable correlates of beverage choices or total
alcohol intake, explain this association. Thus, the
results of the present study neither support the idea
that wine consumption prevents abdominal fat deposition in men and women, nor do they suggest that any
beverage has a speci®c effect on abdominal fat depot.
Conclusion
In a sample of representative French people, in whom
wine is the principal alcoholic beverage, alcohol
consumption is associated with a greater WHR in
both men and women. Alcohol per se rather than
any alcoholic beverage consumption was associated
with increased WHR.
Acknowledgements
The authors would like to thank the Centre d'Examen
de Sante de Strasbourg for its logistic support. The
WHO-MONICA population study developed in
France was supported by grants from the Conseil
ReÂgional du Nord-Pas de Calais, the Caisse Primaire
d'Assurrance Maladie de SeÂlestat, the Association
ReÂgionale de Cardiologie d'Alsace, ONIVINS,
Parke-Davis Laboratory, the Mutuelle GeÂneÂrale de
l'Education Nationale (MGEN), the ReÂseau National
de Sante Publique, the Direction GeÂneÂrale de La
SanteÂ, the Institut National de la Sante Et de la
Recherche MeÂdicale (INSERM), the Institut Pasteur
de Lille and the Unite d'Evaluation du Centre Hospitalier et Universitaire de Lille.
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