Health Effects of Red Wine Consumption: Comparison
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Please note this is a comparison between Version 1 by Mauro Lombardo and Version 2 by Dean Liu.

A strong controversy persists regarding the effect of red wine (RW) consumption and health. Guidelines for the prevention of cardiovascular diseases (CVD) and cancers discourage alcohol consumption in any form, but several studies have demonstrated that low RW intake may have positive effects on CVD risk. 

  • antioxidants
  • diabetes mellitus
  • type 2
  • wine
  • red
  • CVD
  • flavonoids

1. Introduction

Wine is an alcoholic beverage produced by the fermentation of crushed grapes. The different types of grapes and wine-making processes affect the colour and strength of the final beverage. The alcohol content varies from approximately 9 to 15% ethanol (ET) per volume [1]. Red wine (RW) contains other nutrients such as monosaccharides (e.g., glucose and fructose), variable levels of micronutrients (e.g., potassium, calcium, iron, magnesium, copper) and some B vitamins. More than 100 polyphenol compounds, including flavonoids and non-flavonoids, have been identified in RW, and to a lesser extent in white wine (WW) [2].
There is a strong ambiguity surrounding RW consumption and health [3]. Guidelines for the prevention of cardiovascular and neoplastic diseases advise against alcohol consumption, but drinking low-to-moderate amounts of wine may have some beneficial effects on cardiovascular disease risk (CVD) in certain populations [4]. Prospective cohort studies have demonstrated that any form of alcohol increases the risk of cancer [5]. In fact, the European Code Against Cancer advises limiting or eliminating alcohol consumption [6], and the International Agency for Research on Cancer has classified the consumption of alcoholic beverages as carcinogenic to humans (Group 1) in a dose-response manner. High alcohol consumption has been correlated with an increased risk of cancers of mouth, pharynx and larynx, oesophagus (squamous cell carcinoma), liver, colorectum, breast (before and after menopause), and stomach, in addition to many other diseases, such as cirrhosis, infectious diseases, CVD, diabetes, neuropsychiatric conditions, and early dementia [3][4][5].
In contrast, possible health benefits from RW intake have also been revealed, as RW contains less alcohol than spirits, and has greater antioxidant effects due to its higher polyphenol content. In fact, according to O’Keefe and colleagues, lower rates of death, T2DM, CVD, congestive heart failure, and stroke are associated with light-to-moderate habitual RW intake [1]. Even stronger results have been obtained in the framework of a healthy Mediterranean diet (MD) [2]. According to Renaud and de Lorgeril, the “French paradox” is the observation of a low prevalence of ischaemic heart disease despite a high intake of saturated fat: this phenomenon is accredited to the consumption of RW and its cardioprotective effect [7][8]. Haseeb and colleagues [9] described the composition of RW and the effects of its polyphenols on chronic CVD, and according to the authors, the polyphenols in RW could synergistically confer benefits against chronic CVD, if consumption remains within the maximum doses suggested by guidelines (one 125 mL glass for women and two glasses for men).

2. Antioxidant Status

The antioxidant effects of RW consumption were evaluated in 19 studies. Moderate amounts of RW, in the context of an MD, showed beneficial effects on the oxidative status of healthy subjects due to the increased expression of antioxidant enzymes involved in the reduction in circulating ROS, such as catalase (CAT), superoxide dismutase 2 (SOD2), and glutathione peroxidase 1 (GPX1) [10]. Antioxidant effects of RW consumption have been described for various conditions, including type 2 diabetes mellitus (T2DM) and acute CVD, as well as in elderly people [11][12][13][14][15]. This protective effect seems to be related to its high polyphenolic content. The plasma concentration of polyphenols was particularly higher in individuals consuming RW, compared with those consuming WW, resulting in the higher inhibition rate of oxidative stress. Of note, the described antioxidant effect may be dependent on a synergism between the different polyphenols contained in RW [16]. Accordingly, RW may have more powerful antioxidant effects than gin [17] and WW [18], for example, which have a lower content of polyphenols. The antioxidant effect of RW is also mediated by other bioactive compounds. It has been shown that moderate doses of RW increase blood concentrations of homovanillic acid, a typical biomarker of dopamine turnover, in healthy volunteers. Homovanillic acid is also a phenolic metabolite, so the increased blood concentrations of this biomarker could result from the metabolism of RW phenolic compounds [19]. RW’s antioxidants also suppress the post-prandial activation of NF-κB, an oxidative-stress-related transcription factor involved in the regulation of inflammatory responses [12][20]. Similarly, oxidized guanine species and protein carbonyl levels were significantly decreased in the RW group in CAD patients [21]. Importantly, it is well established that the beneficial effects observed after RW consumption, in terms of the increased activity of antioxidant enzymes, are not due to the alcohol content in wine, but to the polyphenolic composition. De-alcoholised red wine (DRW) could therefore be an excellent source of antioxidants with protective properties in conditions linked to oxidative stress [22]. On the other hand, plasma antioxidant capacity, measured through the ferric reducing antioxidant power (FRAP) in healthy subjects, was similarly increased by DRW and RW deprived of polyphenols. The authors hypothesised that increased FRAP after polyphenol-stripped RW consumption could be primarily explained by the increase in plasma urate, which is also a strong antioxidant with free radical scavenging and metal chelating capabilities [23]. Conversely, Blackhurst et al. demonstrated that RW consumption increased plasma antioxidant catechin levels, but did not affect the postprandial peroxidation status of chylomicrons after a high-fat meal. Moreover, RW did not increase the oxygen radical absorbance capacity (ORAC) in fasting subjects after a meal [24]. Interestingly, one glass of RW displayed lower amounts of bioavailable flavonols than one glass of tea or 15 g of red onion (RO), although urinary excretion of quercetin after wine consumption did not differ from that measured after onion consumption and was higher than that after tea, suggesting that RW has similar antioxidant activity and could therefore prevent LDL oxidation [25]. In contrast, Chiu et al. demonstrated that RO has greater antioxidant protection on plasma LDL [26]. It is notable that the alcohol content of 375 mL RW/day increased oxidative stress in a 4-week RCT [27]. Similarly, Addolorato and colleagues demonstrated that ET could increase lipid peroxidation parameters and reduce antioxidant capacity, although these effects were attenuated when ET was consumed in beer or RW [28].

3. Cardiovascular Function

The effects of RW consumption on cardiovascular function were evaluated in seven studies. Acute RW consumption, in comparison with gin, had a greater down-regulatory effect on genes related to atherosclerosis progression in men with high CVD risk, probably due to the higher phenolic content [29]. In patients with stable angina pectoris, the acute intake of low doses of RW did not significantly affect ischemic pre-conditioning (IPC) during exercise stress testing [30]. Acute RW and DRW consumption did not improve coronary epicardial diameters or flow rate, even though both beverages reduced vasoconstrictive peptide endothelin-1 levels [31]. Moderate consumption of RW over 1–2 weeks did not reduce CVD risks by altering either the coronary microcirculation or haemorrheology [32]. In a two-year randomised controlled trial, moderate wine intake did not affect total carotid plaque volume, although the subjects with the greatest baseline plaque severity displayed a small regression in plaque burden [33]. In young healthy individuals, low blood concentrations of ET following RW intake had an acute depressant effect on left ventricular (LV) performance, but an increase in some indices of right ventricular function [34], suggesting that low ET doses may impair LV function. A lifestyle modification intervention (including RW consumption) did not affect the blood flow velocity of the internal carotid or middle cerebral artery in patients with carotid atherosclerosis [35]. Most of the enrolled patients were receiving statin therapy, however, which could have hidden the beneficial effects on blood flow velocity and thus affected the study results. Overall, low consumption of RW did not significantly improve CVD parameters even in long-term studies, suggesting that other factors modulated by RW account for the CVD risk. None of the RCTs included in this review assessed the effects of RW on atrial fibrillation and other cardiac arrhythmias.

4. Coagulation Pathway and Platelet Function

The effect of RW consumption on coagulation and platelet function was evaluated in eleven studies. These studies were conducted for up to three weeks, although one study ran for three months [36]. The intake of RW during a meal significantly decreased thrombotic activation, in terms of the plasma levels of prothrombin fragments 1 + 2 and activated factor VII [11], and fibrinogen concentrations [37], indicating inhibitory effects on the coagulation system. A sustained viscosity-reducing effect of plasma was observed after three weeks of RW consumption. A reduced viscosity was retained after three weeks of abstention [37]. RW intake led to a significant reduction in the aggregation ability of platelets against platelet activating factor (PAF), regardless of the ET percentage content [38]. RW decreased [12] or did not affect [39] concentrations of plasminogen activator inhibitor-1 (PAI-1), a risk factor for thrombosis and atherosclerosis, more negatively than ET itself [39]. RW and beer could reduce von Willebrand factor (vWF) levels. The vWF factor promotes the adhesion of platelets to damaged blood vessel walls and then acts as a bridge between one platelet and another, promoting clot formation. RW consumption did not increase the PAI-1/tPA ratio, which is associated with increased CV risk, an effect observed after the intake of other alcoholic beverages [40]. Thus, RW, but not ET alone, reduced the specific activity of platelet-activating factor and RW had a weak but significant inhibition effect on platelet activation. This RW effect is greater than that of WW, probably due to the higher polyphenol content [41]. Three studies did not demonstrate that RW had a favourable effect on coagulation and platelet function. The consumption of RW or WW with dinner did not affect the platelet count, platelet function, or viscoelastic properties of the blood taken the next morning [42]. In a study comparing a MD with a high-fat diet, the moderate consumption of RW resulted in a significant increase in platelet aggregation and secretion, but did not significantly modify the bleeding time or plasma vWF concentrations [36]. Similarly, there were no differences in fibrinogen and D-dimer levels after two weeks of drinking RW [32]. In contrast, Banach et al. observed a significant increase in PAI-1 concentration in the RW-drinking group [43]. Overall, RW intake shows the ability to reduce platelet aggregation and the process of coagulation.

5. Endothelial Function and Arterial Stiffness

The effect of RW consumption on endothelial function was evaluated in 15 studies. The consumption of RW may have positive effects on endothelial function according to most of the studies considered. These effects, in term of increased flow-mediated dilatation (FMD), have been clearly demonstrated in patients with hypercholesterolemic [44] and CAD [45]. Polyphenols were shown to play an important role in inducing RW-mediated acute vasodilation and a reduction in von Willebrand factor levels in healthy subjects [40][46]. These data suggest that polyphenols play a role in mediating RW effects on endothelial function [46]. Notably, in healthy subjects, a daily consumption of 100 mL of RW for three weeks led to increased levels of circulating endothelial progenitor cells (EPC), probably mediated by the increased bioavailability of plasma nitric oxide, with potential cardiovascular protective effects. In vitro studies showed that resveratrol could recapitulate the effects of RW on EPC function [47]. When flow-mediated vasodilation was examined, a single dose of DRW increased endothelium-dependent vasodilation in response to hyperaemia, whereas ingestion of RW induced vasodilation without affecting the percentage increase in artery diameter [48]. ET consumption dilates the brachial artery and increases muscle sympathetic nerve activity, heart rate, and cardiac output with dose-dependent effects. These acute effects are not modified by RW polyphenols [49], suggesting that the content of polyphenols in RW, rather than ethanol, exerts cardiovascular protective actions [44]. Accordingly, RW’s antioxidants can counteract the acute effects of smoking on the endothelium [50]. Other studies have shown that RW has no effect or an unfavourable effect on endothelial function. Intake of a moderate amount of RW did not increase endothelial function [13]. In postmenopausal dyslipidaemic women, the intake of DRW and RW for six weeks was not associated with significant changes in vascular function or arterial stiffness, in comparison with women consuming water [51]. Similarly, the regular daily consumption of RW for a four-week period did not alter endothelial function [52]. Of note, Banach and colleagues demonstrated that a high acute consumption of RW in a previously abstinent population can lead to a significant increase in plasma concentrations of a potent vasoconstrictor (endothelin-1) [43]. Similarly, an intake of 375 mL RW/day for four weeks increased vasoconstrictor eicosanoids [27][53]. Although rapid alcohol consumption causes vasodilation at the level of the distributing artery as well as at the arteriolar level, a reduction in FMD has been observed in subjects consuming RW or an alcoholic beverage with a low content of polyphenols, suggesting that the polyphenols contained in RW may not be able to preserve the endothelial function [54].

6. Hypertension

The effect of RW consumption on blood pressure (BP) was evaluated in 13 studies. Six studies lasted up to four weeks [27][49][52][55][56][57][58]. Only one study evaluated the effect over a longer time span of six months [59]. The ingestion of 250 mL RW at lunch resulted in a reduction in postprandial BP in subjects with hypertension and central obesity [60]. Consumption of either RW or DRW resulted in decreased systolic blood pressure (SBP) in patients with coronary artery disease [61]. These data were confirmed in another study that evaluated the effects of RW in combination with smoking on haemodynamic parameters. Both RW and DRW were able to prevent the increase in peripheral SBP induced by smoking. Notably, both RW and DRW were able to decrease postprandial wave reflexes, with RW having a more pronounced effect, suggesting that the alcohol present in RW contributes to reducing the augmentation index [62]. Interestingly, Chiva-Blanch et al. [55] demonstrated that DRW consumption for four weeks, compared to RW or gin, led to a reduction in SBP and diastolic blood pressure (DBP), with a parallel increase in plasma NO concentration, which may mediate the observed effects on BP. Other studies have found no effect from moderate RW consumption on BP. In patients with T2DM who were alcohol abstainers, consuming RW for six months had no effect on their mean 24-h BP. A more pronounced BP-lowering effect was noted among fast ET metabolisers, however [59]. In subjects consuming different beverages (i.e., RW, ethanol, water) no intervention was able to affect blood pressure [49]. RW containing 24–31 g of alcohol per day, administered for four weeks, increased 24-h BP and heart rate (HR) but reduced waking BP in well-controlled T2DM subjects [58]. RW was described as having adverse effects on BP by Barden and colleagues, who showed that a dose of 375 mL RW/day for four weeks increased BP, plasma levels of CYP450 vasoconstrictor eicosanoids and oxidative stress [27]. It has been suggested that increased plasma levels in the vasoconstrictor 20-HETE promote BP elevation and potentially contribute to the BP elevation associated with a binge drinking pattern [53]. Similarly, regular consumption of 200–300 mL RW/day in healthy premenopausal women raised HR and 24-h SBP and DBP. In the DRW group, BP values were similarly elevated [63], and accordingly, Zilkens et al. also demonstrated that polyphenols do not play a significant role in mitigating the effects of alcohol in increasing BP in men [52]. Other authors have shown that postprandial RW ingestion has a moderate effect on increasing DBP, but not SBP [57].

7. Immune Function and Inflammatory Status

The effects of RW consumption on the immune system and inflammatory status were evaluated by 14 studies. Most were conducted for a period of up to four weeks, and only one study was conducted for 12 weeks [64]. The serum levels of pro-inflammatory cytokines (IL-6 and TNF-a) and serum levels of acute-phase proteins (hs-CRP and fibrinogen) did not show a significant change after the acute consumption of various alcoholic beverages, including RW [40]. Watzl et al. also reported that postprandial consumption [65] and moderate daily consumption for two weeks [66] of RW or DRW in healthy men had no negative effects on human immune cell function. Similarly, RW did not affect the plasma levels of lipid mediators of inflammation resolution (SPMs) in patients with T2DM [64]. No significant changes were demonstrated in the plasma levels of hs-CRP, IL-6, IL-18, VCAM-1, CASP-1, MMP-9, TIMP-1, APO B, cystatin C, or ICAM-1 [67]. Avellone et al. [68] showed that LDL/HDL, fibrinogen, factor VII, plasma C-reactive protein, and antibodies to oxidised LDL were markedly reduced, while HDL-C, Apo A1, TGFbeta1, t-PA, PAI, and total plasma antioxidant capacity were significantly elevated, indicating the beneficial effects of RW on levels of CV risk biomarkers. Conversely, the study by Banach et al. [43] demonstrated a negative effect on the fibrinolytic system and endothelial function (increased tPA:Ag, PAI:Ag and E-1) of consuming different types of alcoholic beverages, including RW, on haemostatic factors. Several studies have shown that the intake of RW led to a decrease in inflammatory or immune biomarkers in the serum. Moderate alcohol consumption, such as RW, marginally reduced fibrinogen levels in healthy subjects [69]. RW was more effective than WW in promoting a reduction in serum inflammatory biomarkers, CAM expression on monocyte surface membranes, and monocyte adhesion to endothelial cells [23]. Another study detected favourable effects of RW only in participants with high cytokine levels, in particular for cytokines that promote initial inflammation such as TNF-α, IL-6, and IFN-γ [70]. Furthermore, lower secretion of ΤNFα was observed after 8 weeks of intake in the RW group versus the ET group [71]. A Cava rosé wine, with a medium-level polyphenol content, has been shown to reduce the inflammatory markers of atherosclerosis (adhesion molecules, cytokines, and the CD40/CD40L system) to a greater extent than other alcoholic beverages without polyphenols [72]. Consumption of 375 mL of RW/day for four weeks also increased SPMs, in particular, resulting in higher levels of 18 -HEPE, RvD1, and 17R-RvD1, capable of attenuating excessive inflammation [27]. In contrast to the other studies, Williams and colleagues demonstrated that, in men with CVD, the consumption of moderate amounts of RW acutely increased plasma IL-6 levels, probably in response to alcohol-induced oxidative stress in the liver [73].

8. Lipid Profile and Homocysteine Levels

The effects of RW consumption on the lipid profile were evaluated by 23 studies. The moderate consumption of RW could have a modest beneficial effect on lipoproteins and cellular cholesterol efflux compared with an alcohol solution [74]. Accordingly, alcohol consumption could promote a reverse cholesterol transport pathway (RCTP), the process by which cholesterol is directed from the peripheral tissues to the liver via HDL for subsequent excretion in the bile, regardless of alcoholic beverage type (RW, beer, or spirits) [75]. Similarly, Chiva-Blanch et al. reported that RW may reduce plasma concentrations of lipoprotein (a), which is responsible for transporting cholesterol in the blood and is considered a CVD risk factor that does not respond to standard therapy for low density lipoprotein (LDL) reduction [76]. Two Sicilian RWs were shown to have positive effects on several cardiovascular risk factors, including HDL and Apo A1, in a total of 48 subjects of both sexes [68]. A study by Tsang and colleagues also revealed that oxidised LDL levels were reduced, while HDL cholesterol concentrations increased modestly after RW consumption in healthy volunteers [14]. Another study reported a 34% reduction in LDL in the RW group, compared with controls [77]. A randomised cross-over trial comparing the effects of a moderate intake of RW with alcoholic beverages without polyphenols on plasma antioxidant vitamins, lipid profile, and the oxidability of LDL particles, demonstrated that RW would provide additional lipid benefits due to its antioxidant effects by decreasing plasma levels of MDA, SOD, and oxidised LDL [17]. Notably, RW daily consumption associated with lifestyle changes, including moderate physical exercise for 20 weeks, improved the LDL/HDL ratio in patients with carotid atherosclerosis [78]. A study investigating the potential contribution of ET components in inducing beneficial effects on the lipid profile level demonstrated that RW consumption for four weeks induced an improvement in HDL and fibrinogen plasma levels compared with control groups drinking water, with or without red grape extract [79]. In a recent study by Briansó-Llort and colleagues, RW rich in resveratrol had positive effects on total cholesterol, in healthy volunteers [80]. Other studies did not demonstrate beneficial effects of RW consumption on lipid metabolism [21][44]. The ingestion of DRW, but not RW, decreased circulating F2-isoprostanes, a prostaglandin-like compound formed from the free-radical-mediated oxidation of arachidonic acid [81]. It was supposed that phenolic compounds would have a beneficial effect on lipid peroxidation if consumed separately from alcohol. Similarly, consumption of DRW containing 880 mg total polyphenols in dyslipidaemic postmenopausal women did not change triglyceride levels or postprandial chylomicrons. The same study demonstrated a 35% increase in postprandial TG levels following RW consumption, compared to the control group [82]. An intake of 300 mL RW did not reduce LDL oxidation in healthy subjects [83] and did not affect lipid peroxidation in postprandial chylomicrons [24][84]. RW consumption did not lead to any increase in HDL and the lipid profile was unchanged in RW vs. WW [85]. No change in serum HDL cholesterol was observed in diabetic patients with consumption of RW (24–31 g alcohol/day) compared to DRW or water [58]. Similarly, in subjects with T2DM, daily intake of 150 mL of muscadine grape wine (MW) or de-alcoholised MW had no significant effect on the lipid profile compared to the other groups [86]. LDL-cholesterol levels were reduced in subjects without steatosis at baseline, but there were no changes in HDL or triglycerides levels with moderate RW consumption for three months. In contrast, hepatic triglyceride content increased [87]. An intake of RO extract, which is very rich in polyphenols, showed greater cholesterol-lowering efficacy than RW [26]. RW intake was not observed to elevate plasma homocysteine levels in T2DM subjects [58]. Conversely, 24 g/day alcohol given as RW to healthy men for two weeks significantly increased homocysteine levels [18].

10. Body Composition, Type 2 Diabetes, and Glucose Metabolism

The effect of RW consumption on body weight, body composition, and adipocytokines levels was evaluated by six studies. When part of an energy-restricted regimen, moderate RW consumption, with or without alcohol, improved glycaemic control in diabetic patients, with a parallel improvement in several metabolic parameters related to antioxidant status [86]. Accordingly, moderate wine consumption did not promote weight gain or abdominal adiposity in controlled diabetic patients following the Mediterranean diet [88], nor did fat accumulate in subcutaneous and abdominal fat depots in healthy subjects with a waist circumference above 94 cm [89]. A study that focused on two types of RW with different resveratrol content showed that the consumption of neither RW changed BMI [80]. Interestingly, healthy subjects consuming RW for 14 days displayed increased plasma levels of leptin, the main adipokine with the primary function of regulating energy balance, while no significant increase in plasma levels of adiponectin and other adipocytokines was observed [67]. Djurovic et al. revealed that RW could induce an increase in circulating leptin levels in females, but not in males [90]. Thirteen studies evaluated the effects of RW consumption on glucose metabolism. A significant decrease in insulin and an increase in the fasting glucose-to-insulin ratio were demonstrated among T2DM subjects given DRW [86]. In another study, the RW group exhibited lower insulin levels and HOMA scores compared with the control group, while other metabolic parameters were similar [91]. Increased oxidative stress may play a role in the progression of diabetic nephropathy, a microvascular complication of diabetes. It has been demonstrated that RW consumption reduces urinary protein levels, as well as urinary 8-OHdG and urinary L-FABP, in patients with diabetic nephropathy, thus providing protective effects against the clinical progression of chronic kidney disease [92]. These results suggest that RW, but not WW, has protective effects in diabetic patients, probably due to its ability to reduce oxidative stress. In another study, fasting blood glucose remained unchanged, while basal insulin and HOMA-IR values decreased significantly in the groups in which RW and DRW (30% and 22%, respectively) were consumed compared to gin [76]. A moderate intake of RW in adults with obesity and metabolic syndrome (MetS) resulted in a reduction in MetS risk markers and improved gut microbiota composition [93]. Moderate RW consumption significantly reduced fasting glucose levels, especially in subjects with higher basal A1C levels, but not postprandial levels: the reduction in A1C levels was not statistically significant [94]. On the other hand, RW consumption during a meal induced an increase in plasma glucose and insulin similar to that observed after a meal without wine in diabetic patients. Nevertheless, wine ingestion with the meal counterbalanced the decrease in plasma levels of total radical antioxidant parameters (TRAP) induced by food in the postprandial phase, with beneficial effects on LDL oxidation and thrombotic activation in these patients [11]. The insulin sensitivity index (ISI), assessed with a hyperinsulinaemic euglycemic clamp, was not affected by moderate RW consumption, in healthy subjects with visceral fat accumulation [89]. Interestingly, although both RW and WW tended to improve the glucose metabolism after two years in diabetic patients, only WW significantly reduced plasma glucose levels and HOMA-IR scores, compared to the control group [59]. Notably, moderate RW consumption did not alter the plasma mediators of inflammation in patients with T2DM [64]. No significant differences in fasting plasma glucose levels were revealed in a 14-day pilot study that compared two types of RW with different resveratrol contents [80]. Thus, no fasting glycaemic changes were detected in CAD [21] and hypercholesterolaemic [44] patients after ingesting RW. Taken together, these results suggest that RW consumption in association with a meal may improve glycaemic control in diabetic patients, without affecting the body weight of patients with T2DM.

10. Gut Microbiota and Gastrointestinal Tract

Seven studies evaluated the effects of RW consumption on the gut microbiota and gastrointestinal tract. Moderate consumption of RW (16 g ethanol/day) over three months promoted an increase in hepatic triglyceride content, without developing steatosis, in healthy subjects. Interestingly, the authors also observed a significant reduction in LDL cholesterol levels [87]. A clinical study focused on the effects of different alcoholic beverages on the postprandial functionality of the digestive system in terms of gastric emptying kinetics and orocaecal transit, and demonstrated that RW had an inhibitory effect on the gastric emptying of solid food, as well as on meal-induced gallbladder emptying, compared with beer and whisky, in healthy volunteers. No effect was observed on the orocaecal transit time of food [95]. These results suggest that RW, obtained by fermentation only, affects the motor functions of the digestive tract and of the gallbladder differently from other alcoholic beverages, depending on the ET concentration. Three studies evaluated the effects of RW consumption for four weeks on the gut microbiota. First, RW polyphenols inhibit non-beneficial bacteria from the human microbiota and promote the growth of probiotic bacteria such as bifidobacteria in healthy male volunteers. RW particularly modulated the growth of select beneficial gut bacteria species, with a parallel improvement in blood pressure, lipid profile, and inflammatory status, linked to changes in the bifidobacteria number [56]. Another study demonstrated that RW consumption induced a significant increase in amounts of Bifidobacterium and Prevotella with a negative correlation with lipopolysaccharide (LPS) plasma concentration [96]. Similar results in terms of increased faecal microbial diversity, have been obtained both in healthy individuals [93][97] and in patients with metabolic alterations associated with obesity [98]. Plasma trimethylamine N-oxide (TMAO) did not differ between people receiving the RW intervention and ET abstention [97].  

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