





































Clinical Medicine Insights
Received 28 June 2021 | Revised 24 July 2021 | Accepted 19 Aug 2021 | Published Online 31 Aug 2021

DOI: https://doi.org/10.52845/CMI/2021-2-3-6
CMI JOURNAL 2 (3), 185−200 (2021) ISSN (O) 2694-4626 

REVIEW ARTICLE

Alcohol and Noncommunicable Diseases: Part II Cancer, Diabetes Mellitus,
Kidney Diseases, Alzheimer’s Disease, Arthritis

Shashi K. Agarwal, MD ∗
 

12227 US Highway 1, #309 North
Brunswick, NJ 08902 USA

Abstract
Excessive alcohol consumption is common. It leads to the development
of several NCDs and is associated with considerable disability and high
mortality. Its intake has been linked with an increase in many cancers,
including the common breast and prostate cancer. Light-to-moderate
drinking is associated with a lower incidence of type 2 diabetes, but ex-
cessive alcohol consumption leads to increased morbidity and mortality
in these patients. Compared with no consumption, moderate consump-
tion of alcohol-associated with a reduced risk of CKD. However, the
association with heavy alcohol intake and CKD is not clear, although
it also appears to be overall inverse in nature. Excessive alcohol intake
also targets the brain and promotes AD – although mild to moderate
intake may be safe. Alcohol consumption is negatively associated with
the prevalence of knee OA. There appears to be an inverse association
between alcohol consumption and RA incidence. Alcohol consumption,
usually when taken in more than a moderate amount. may also trigger
gout. In general, alcohol intake in low to moderate amounts appears to
be safe for NCDs described in this communication, except for cancer,
where no amount is a safe amount.
Keywords: alcohol, non-communicable diseases, cancer, diabetes mel-
litus, kidney diseases, Alzheimer’s disease, arthritis

Copyright : © 2021 The Authors. Published by Medical Editor and
Educational Research Publishers Ltd. This is an open access article
under the CC BY-NC-ND license
(https://creativecommons.org/licenses/by-nc-nd/4.0/).

1 INTRODUCTION

A lcohol consumption is common in our
society1. It is estimated that in 2016, 32.5%
of the world’s population had at least one

alcoholic drink in the past 12months2. Globally, men
tend to drink more than women3. A standard drink
contains 12–15 g of pure ethanol and this is found
in 12 ounces of regular beer, 5 ounces of wine, and
1.5 ounces of distilled spirits4. In most European

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ALCOHOL AND NONCOMMUNICABLE DISEASES: PART II CANCER, DIABETES MELLITUS, 
KIDNEY DISEASES, ALZHEIMER’S DISEASE, ARTHRITIS
countries, alcoholic drinks are often referred to as by
units, with one unit being equivalent to 8-10 grams
of alcohol, with typical drinks containing 1–3 units
of alcohol5. Moderate alcohol intake is considered as
two standard drinks a day for men and one standard
drink a day for women6,7. Heavy drinking is defined
as a long-term, high-dose intake, of >60 g/day in
men and >40 g/day in women8. Binge drinking is
considered as 4 or more drinks for women and 5
or more drinks for men over a 2-hour period9,10.
Compulsive excessive alcohol intake leads to alcohol
use disorder11. It is estimated that 20% of patients
seen by primary care physicians consume alcohol in
amounts that are harmful to their health12. Alcohol
was responsible for 8.9% in males and 2.3% in
females for disability-adjusted life years in 2016,
globally13. Griswold et al also calculated that in
2016, alcohol consumption was responsible for 6.8%
of male deaths and 2.2% of female deaths all over
the world13. Of these deaths in 2016, 21.3% were
due to digestive diseases, 19% due to cardiovascular
diseases and diabetes, 12.9% due to infectious dis-
eases, and 12.6% due to cancers14. The health-related
financial burden attributable to alcohol misuse is also
extremely high, and in 2010, it cost the United States
$249 billion15.
The relationship between alcohol consumption and
cardiovascular diseases (CVDs), respiratory dis-
eases, depression, and liver diseases was discussed
in Part I of this manuscript.

2 DISCUSSION

Noncommunicable diseases (NCD) are common
conditions affecting humans16. This part of the
manuscript discusses the relationship between al-

Supplementary information The online version of 
this article (10.52845/CMI/2021-2-3-6) contains 
supplementary material, which is available to autho-
rized users.

Corresponding Author: Shashi K. Agarwal, MD 
Shashi K. Agarwal, MD 2227 US Highway 1, #309 
North Brunswick, NJ 08902, USA
Email: usacardiologist@gmail.com

cohol and cancer, diabetes mellitus (DM), chronic
kidney disease (CKD), Alzheimer’s disease (AD),
and arthritis. Cancer is expected to replace CVDs
as the number one killer in the world17. The most
common global cancers are those involving the lung,
colorectum, stomach, and liver18. However, many
common cancers can be ‘cured’ if caught early19.
Breast cancer, the most common nonskin cancer
among women, if detected while still in localized
form has a 5-year survival rate of 98%, compared
with a survival rate of 72% by Stage III and just 22%
by Stage IV20,21. Many other cancers demonstrate
a similar prognosis depending on the time of their
diagnosis22. Basal cell carcinoma and squamous cell
carcinoma of the skin are the most common human
cancers and are 100% treatable if found early. Di-
agnosing cervical cancer in a pre-cancerous stage
can assure a near 100% survival rate. However, if
discovered in Sate III, the rate drops to just 32% and
if diagnosed in Stage IV, it is a dismal 16%. Prostate
cancer is 98% survivable for 5 or more years if it is
diagnosed when it is limited to the prostate gland.
while if diagnosed at Stage IV, the survival rate is
only about 28%. Colon cancer can be 90% survivable
if detected early; the survival drops to 39% if it is
detected when it has spread22. DM is one of the
most common metabolic disorders worldwide23. and
its prevalence is rapidly rising in low- and middle-
income countries24. According to the World Health
Organization, the number of people with diabetes
rose from 108 million in 1980 to 422 million in
201424. In the United States, 9.3% of Americans had
diabetes (29.1 million persons) in 2014, with a life-
time risk calculated at almost 40%25. It is caused by
a combination of defective insulin secretion by pan-
creatic β-cells and the inability of insulin-sensitive
tissues to respond to insulin26. Diabetes mellitus is
associated with significant microvascular (retinopa-
thy, nephropathy, and neuropathy) and macrovascu-
lar (coronary artery disease, stroke, peripheral artery
disease complications27,28. DM reduces the life ex-
pectancy of the affected individual by approximately
six years29. CKD refers to kidney damage or an
estimated glomerular filtration rate (eGFR) less than
60ml/min/1.73 mt2, persisting for 3 months or more,
irrespective of the cause30. It is a worldwide public
health31. In 2017, CKD affected almost 700 million

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people in the world32. Those affected with CKD
exceed those with diabetes, osteoarthritis, COPD,
asthma, or depressive disorders33. Hypertension and
diabetes mellitus are the main causes34. CKD is a
progressive disease, ultimately resulting in the need
for peritoneal dialysis or hemodialysis, or kidney
transplantation35. The major cause of morbidity and
mortality in CKD is due to cardiovascular events36.
CKD also leads to frequent hospitalization37and poor
quality of life38. CKD results in more deaths than
tuberculosis or HIV and is presently ranked as the
12th leading cause of death out of 133 conditions
in the world33. Dementia is a common worldwide
disease39, with ADbeing responsible for 50% to 70%
of these cases40,41. It is characterized by pathologies:
β-amyloid plaque deposition and neurofibrillary tan-
gles of hyperphosphorylated tau42. This disorder
continues to increase in low- and middle-income
countries43. Its etiology is unclear but appears to
be related to a complex interplay between genetic
and environmental factors44. AD produces cognitive
impairment and functional decline, often leading to
institutionalization45,46. There is no cure for AD,
and treatment remains symptomatic47. The QOL of
these patients is markedly reduced and AD remains
a major cause of death48. Arthritis is of many types,
and osteoarthritis is the most common49. It is a major
health concern, affecting about 240 million people
globally50. It reduces the quality of life and results in
considerable disability and mortality51. It usually af-
fects the knees and the hip, resulting in chronic pain,
stiffness, joint instability, and joint deformities52. It
is associated with considerable disability53. Patho-
logically, it is characterized by progressive cartilage
degradation, synovitis, osteophyte formation, and
subchondral bone sclerosis54. Osteoarthritis (OA)
cases are predicted to rise in the coming decades due
to the aging population, increasing obesity, and high
rates of traumatic knee injuries55. Rheumatoid arthri-
tis (RA) is autoimmune arthritis and is character-
ized by symmetrical polyarthritis oftenwith systemic
manifestations56,57. RA is often associated with per-
sistent pain, deformity, and disability58. It also ac-
celerates cardiovascular disease in these patients59.
Gout is an autoinflammatory joint arthritis60, caused
by the deposition ofmonosodium uratemicrocrystals
in joints and tissues61. Hyperuricemia is central to

its development62. In an acute flare-up, monoarthritis
develops rapidly and affects the big toe in 50% of
cases (other joints commonly affected include the
ankle, midtarsal, knee, wrist, finger, and elbow)63.
The affected joint is red, tender, hot, and tumid
with extreme pain64. Diagnosis may be confirmed by
finding monosodium urate crystals in synovial fluid
or tophus aspirates65.

2.1 CANCER

Alcohol is a known carcinogen66,67. Its consumption
increases the risk of several cancers68,69, especially
those affecting the mouth, throat, larynx, esophagus,
liver, colorectal tissues, and breast70. Bagnardi et al.
reviewed 222 articles in 2013, (comprising of about
92 000 light drinkers and 60 000 non-drinkers with
cancer and concluded that light drinking increases
the risk of oropharyngeal cancer by 17%; esophageal
squamous cell carcinoma by 30% and breast cancer
by 5%71. In a recent analysis, published in 2018,
Islami et al. found that alcohol intake was the third-
largest contributor to all cancer cases among women
and the fourth largest contributor among men72. In
women, besides causing 28.4% of esophageal can-
cers, 27.4% of the oral cavity and pharyngeal can-
cers and many breast cancers were associated with
alcohol72. Alcohol was associated with 46.3% of all
oral cavity and pharyngeal cancers in men72. They
estimated that alcohol intake was responsible for
5.6% of cancer cases and 4.0% of all cancer-related
deaths72. Alcohol intake has also been linked with an
increase in other cancers, such as gastric cancer73,
colo-rectal cancer74, prostate cancer75, and some
skin cancers76. It also increases the risk of a second
aerodigestive-tract cancer77. There may be a dose-
response relationship between alcohol and cancer78.
However, most people are unaware of the increased
risk of cancer even after the first drink79. The Amer-
ican Cancer Society recommends not drinking al-
cohol to lower cancer risk80. Despite these recom-
mendations, most people, including cancer survivors
continue to drink81.
Alcohol is an irritant to the upper aerodigestive
tract82. Acetaldehyde is the first and primarymetabo-
lite of alcohol and is strongly implicated in can-
cer development83. Its intake is associated with ab-

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normal production of reactive oxygen and nitrogen
species, aberrant DNA methylation, altered folate
metabolism, disturbed immune surveillance and in-
flammatory response and increased estrogen levels
in breast cancer cases84−86.

2.2 DIABETES MELLITUS

Alcohol intake is generally considered beneficial for
type 2 diabetes prevention, provided it is consumed
in moderate amount87. In a large study involving
22,778 twins and 580 incident cases of type 2 di-
abetes during 20 years of follow-up, Carlsson et
al documented this phenomenon88. Some previous
studies have estimated that moderate alcohol con-
sumptionmay reduce the incidence of type 2 diabetes
by 30%-40%89−91. In a recent meta-analysis of 20
observational studies, undertaken by Baliunas et al.
in 2009, a peak reduction in risk for type 2 dia-
betes mellitus (T2DM) was noted at 24 g/day among
women and 22 g/day among men, relative to never
drinkers, with risk increasing in a dose-dependent
manner above these levels92. However, in a major
meta-analysis of 38 studies representing 1,902,605
participants and 125,926 cases of type 2 diabetes,
Knott et al found a risk reduction only inwomen (<71
g/day) when compared to current non-drinkers and
never drinkers93. Irrespective of the level of alcohol
consumption, no risk reduction was noted in men93.
Several biological mechanisms have been proposed
to explain the apparent reduction in risk of T2DM
among moderate drinkers94. These include the anti-
inflammatory hypothesis, which posits that alcohol
may beneficially alter the expression of inflamma-
tory proteins94 and a possible stimulatory effect of
alcohol upon the synthesis of HDL95. After an anal-
ysis of results reported by 14 intervention studies,
alcohol consumption was associated with reduced
fasting insulin concentrations and improved insulin
sensitivity among women96. Reduced duration of
drinking, or initiating alcohol intake at a later age,
also appears to decrease the risk of T2DM97. Heavy
alcohol intake has been associated with a higher risk
for DM in many studies98,99. In a study of 2366
Koreans monitored over 10 years, consumption of
more than 2 units of alcohol per day was associated
with an increase in the risk of T2DM100. A reduction

in the maximum intake of alcoholic beverages not
only decreases the risk of development of T2DM but
also improves survival among established diabetic
subjects especially if this reduction is done in early
adulthood101,102.

Several mechanisms may cause this harm, in-
cluding alcohol-related increase in metabolic
syndrome103,104. The increase in alcohol-related
hypertension tends to aggravate cardiovascular
complications103. Long-term alcohol intake also re-
sults in pancreatic islet dysfunction and apoptosis104.
Overall, the relationship between alcohol consump-
tion and risk of T2DM appears to be J- or U-shaped
association105.

2.3 KIDNEY DISEASES

Comparedwith no consumption,moderate consump-
tion of alcohol may be associated with a reduced
risk of CKD106. Moderate alcohol use was associated
with a lower risk of CKD or end-stage kidney disease
(ESKD) in several previous reports107−110. In ameta-
analysis of prospective cohorts. not only moderate
but also high amounts of alcohol use have been asso-
ciatedwith a lower risk of incident CKDor ESKD111.
However, heavy alcohol consumption or chronic
alcohol consumption is positively associated with
CKD112−116. A Mendelian randomization study also
found a causal link between heavy alcohol intake and
an increased risk of end-stage kidney disease117. In
another Mendelian randomization study, Park et al
also confirmed the deleterious role of alcohol on the
risk of ESKD118.

Mechanisms of alcohol-induced kidney damage in-
clude oxidative stress injury, increase in blood
pressure, and activation of the renin-angiotensin-
aldosterone pathway119−121. Further alcohol and
other substances in alcohol may also influence kid-
ney function by effects on other body systems122,123.
Bottom line – alcohol is a double-edged sword in
CKD. It may be safe to drink to a low or moderate
degree with CKD but heavy or binge drinking is
harmful124.

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2.4 ALZHEIMER'S DISEASE

Several studies have documented the protective ef-
fects of low to moderate amounts of alcohol on
dementia125−127. Epidemiological studies have also
reported a similar effect in AD128. In a recent large
meta-analysis of 91 articles on AD, Anstey et al
confirmed this association129. Animal and cell cul-
ture studies also show that low or moderate con-
centrations of ethanol exhibit a protective effect on
AD in vitro and in vivo130-133. Heavy drinking
is however harmful to the brain134−138. In a 5-
year follow-up study of 13,342 men and women,
Piumati et al reported that reaction time declined
more with alcohol intake of 12 units per week when
compared to those who drank less134. In a large
study (of 31 million people over 5 years), researchers
found that alcohol use disorders were associated
with increased dementia risk135. Heavy alcohol in-
take induces harmful brain changes, cognitive im-
pairment, and dementia136,137. Similar deleterious
findings have been noted in AD patients with higher
alcohol intake138. Changes consistent with increased
cognitive deficits have also been noted in AD mice
models 1-month post alcohol drinking139. In the 23-
year UK Whitehall study (9087 participants), absti-
nence or heavy drinking were both associated with
a higher risk of dementia140. Overall, the association
between alcohol intake and dementia appears to be
U-shaped with low or moderate amounts of alcohol
being protective against Aβ toxicity in hippocampal
neurons and high intake increasing neuronal cell
death and neurodegeneration141. However, alcohol
drinking is not recommended for AD protection142.

2.5 ARTHRITIS

There is no concrete evidence of an association, ben-
eficial or otherwise, between moderate alcohol con-
sumption and OA143,144. This has been noted in the
Finnish cohort studywith an observation period of 22
years143 and the Nurses’ Health Study144. Moderate
amounts of alcohol intake are associated with anti-
inflammatory effects145. Zhang et al found no evi-
dence of alcohol consumption with hsCRP or knee
OA146. Some studies have found that chronic and ex-
cessive intake of alcohol raises inflammation147,148.

Kc et al noted pathological OA-like changes in ani-
mals with chronic alcohol intake149. A similar radi-
ological knee OA effect, rather than a symptomatic
effect, was seen in Korea in patients with alcohol
consumption150. The clinical implications of the re-
lationship between alcohol intake and OA. There-
fore. remain unclear. The 2009 the Swedish EIRA
study (Epidemiological Investigation of Rheumatoid
Arthritis) and the Danish CACORA study (Case-
Control Study on Rheumatoid Arthritis) found that
limited amounts of alcohol decrease the risk of RA
incidence151. Lu et al concluded that moderate alco-
hol intake was associated with a better functional sta-
tus in RA patients152. Another study found that low
levels of alcohol consumption (about three drinks per
week) over at least ten years lowered the risk of RA
incidence by half compared with non-drinkers153.
However, increased frequency of alcohol consump-
tion may be harmful in RA154. In the Västerbotten
Intervention Program cohort of 386 individuals, no
association was seen between alcohol intake and the
risk of RA155. Baker et al reported that RA patients
tend to reduce alcohol intake with higher disease
activity, disability, comorbidity, and poor quality of
life156. Overall, there appears to be no clear benefit
of alcohol consumption in RA. Alcohol may pre-
cipitate gout at lower urate levels157. Beer intake
appears to be more associated with gout than spirits,
and spirits more than wine158,159. Chronic alcohol
intake also is also harmful to gout patients160,161.
High alcohol intake may impair the production of
oxypurinol and stimulate urate production in the
body160,161.

3 CONCLUSION

Low to moderate alcohol intake appears to be safe,
and even protective in DM, CKD, and AD. There
may be no “safe” level of alcohol use when it comes
to cancer. No definite association can be gleaned
from published studies between alcohol and OA
and RA. Gout suffers may consider abstaining from
alcohol. High levels of alcohol intake are in general,
harmful for NCDs. The 2015 U.S. Dietary Guide-
lines for Americans strongly suggest restricting con-
sumption to≤2 drinks/day for men and≤1 drink/day

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ALCOHOL AND NONCOMMUNICABLE DISEASES: PART II CANCER, DIABETES MELLITUS, 
KIDNEY DISEASES, ALZHEIMER’S DISEASE, ARTHRITIS
for women. Alcohol consumption can lead to ad-
verse outcomes and therefore, non-drinkers should
not start drinking for health reasons.
Acknowledgment: None
Funding: None
Conflict of interest: None
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ALCOHOL AND NONCOMMUNICABLE DISEASES: PART II CANCER, DIABETES MELLITUS, 
KIDNEY DISEASES, ALZHEIMER’S DISEASE, ARTHRITIS

How to cite this article: Agarwal S.K,, MD. Alco-
hol and Noncommunicable Diseases: Part II 
Cancer, Diabetes Mellitus, Kidney Dis-eases, 
Alzheimer’s Disease, Arthritis. Clinical Medicine 
Insights. 2021;185−200. https://doi.org/10.5284 
5/CMI/2021-2-3-6

CMI JOURNAL 2 (3), 185−200 (2021) MEERP LTD 200


	Introduction
	Discussion
	CANCER
	DIABETES MELLITUS
	KIDNEY DISEASES
	ALZHEIMER'S DISEASE
	ARTHRITIS

	CONCLUSION

