DOES EDUCATION LEVEL EFFECT HOW KENT STATE UNIVERSITY FEMALE FACULTY and STAFF PERCEIVE the HEALTH ASPECTS of WINE? a Thesis

DOES EDUCATION LEVEL EFFECT HOW KENT STATE UNIVERSITY FEMALE FACULTY AND STAFF PERCEIVE THE HEALTH ASPECTS OF WINE?

A thesis submitted to the Kent State University College of Education, Health, and Human Services in partial fulfillment of the requirements for the degree of Master of Science.

By:

Jenna Lynn Iannello

May 2012

Thesis written by

Jenna Lynn Iannello

B.S. Bowling Green State University, 2010

M.S. Kent State University, 2012

Approved by

______, Director, Master’s Thesis Committee Natalie Caine-Bish

______, Member, Master’s Thesis Committee Nancy Burzminski

______, Member, Master’s Thesis Committee Kele Ding

Accepted by

______, Director, School of Health Sciences Lynne Rowan

______, Dean, College of Education, Health and Human Services Daniel Mahony

IANNELLO, JENNA L., M.S., May 2012 Nutrition and Dietetics

DOES EDUCATION LEVEL EFFECT HOW KENT STATE UNIVERSITY FEMALE FACULTY AND STAFF PERCEIVE THE HEALTH ASPECTS OF WINE? (95 pp.)

Director of Thesis: Natalie Caine-Bish, Ph.D., R.D., L.D.

The purpose of this study was to measure if education level of female faculty and

staff at a Midwest university impacted the perception of the health effects of red wine

consumption. Secondly, to measure if the sample perceived health benefits or risks of

other types of alcohol. Female faculty and staff members (n=503, ages 22-76 years)

participated in an online questionnaire. The questionnaire included questions on the

perception of the health aspects of alcohol. Variables measured included the belief and

reasons for consumption, drinking characteristics, and health belief of alcohol types.

Independent t-tests were used to determine differences in perceptions of health benefits of

red and white wine, beer, and liquor between faculty and staff. The data were compiled

and analyzed using social sciences (SPSS) software (version 18.0.3). There was no

significant difference in perception of the possible cardiovascular health benefits of red

wine between faculty and staff. However, significant differences in perception were

found between faculty and staff on health benefits and consequences of beer, liquor, and

white wine (p ≤ 0.05). Both faculty and staff perceived that red wine may have positive

health benefits for cardiovascular disease, but did not perceive any other benefits to red

wine and had mixed perceptions of benefits and consequences of other alcohol types.

This disconnect suggests a need for more public education of wines impact on health, as well as additional alcohol and health outcome research.

ACKNOWLEDGEMENTS

I would like to thank my thesis advisor, Dr. Natalie Caine-Bish, and my other thesis committee members, Dr. Nancy Burzminski and Dr. Kele Ding for the invaluable time, guidance, comments, reviews, and advice they provided to confirm that my thesis was the finest it could possibly be. I would also like to express my thankfulness to all of the Kent State University female faculty and staff members who took the time to participate in my study, without whom this study would not be possible.

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TABLE OF CONTENTS

Page ACKNOWLEDGEMENTS ...... iii

LIST OF TABLES ...... vii

CHAPTER I. INTRODUCTION ...... 1 Problem Statement ...... 4 Purpose Statement ...... 5 Hypothesis ...... 5 Operational Definitions ...... 5

II. REVIEW OF LITERATURE ...... 7 Types of Alcohol...... 7 Wine ...... 7 Beer ...... 7 Liquor ...... 7 Nutrient Content of Alcohol ...... 8 Nutrient Composition...... 8 Effect of Alcohol on Energy Intake and Appetite ...... 11 Compounds in Alcohol ...... 13 Phenolic and polyphenolic compounds ...... 13 Congeners ...... 14 Current Intakes of Alcohol...... 15 Metabolism of Alcohol Consumption ...... 16 Physiological Health Effects ...... 16 Absorption...... 16 Metabolic pathways ...... 17 Lipid composition and protein distribution...... 18 Physical Health Effects ...... 20 Recommendations of Alcohol Consumption ...... 21 Women vs. Men ...... 21 Who Should Not Drink ...... 22 Reasons for Consumption ...... 22 Physiological Benefits ...... 22 Health ...... 23 Reasons for Health Belief ...... 24 Socioeconomic Status ...... 24 Culture...... 25 iv

Associated Health Risks ...... 28 Injuries, Violence, and Addiction ...... 28 Associated Health Benefits and/or Complications of Alcohol ...... 29 Alcohol Type and Health ...... 29 Wine ...... 29 The french paradox ...... 33 Beer and liquor ...... 33 Alcohol and Disease Risk ...... 34 Cardiovascular diseases ...... 34 Alzheimer’s disease and dementia ...... 35 Liver disease ...... 37 Type 2 diabetes mellitus ...... 38 Cancer ...... 39 Head and neck ...... 40 Digestive tract and pancreas ...... 40 Breast ...... 42

III. METHODOLOGY ...... 45 Purpose ...... 45 Variables ...... 45 Participants ...... 45 Survey Design ...... 45 Part One ...... 46 Part Two ...... 46 Part Three ...... 47 Procedures ...... 47

IV. JOURNAL ARTICLE ...... 49 Introduction ...... 49 Methodology ...... 52 Sample ...... 52 Measures ...... 52 Perception of the health aspects of wine questionnaire ...... 52 Procedure ...... 52 Statistical Analysis ...... 53 Results ...... 54 Discussion ...... 66 Limitations ...... 72 Applications ...... 73 Conclusion ...... 74

APPENDICES ...... 76 APPENDIX A. STUDY CONSENT FORM ...... 77 APPENDIX B. PERCEPTION OF THE HEALTH ASPECTS OF WINE QUESTIONNIARE AND DEMOGRAPHIC QUESTIONS ...... 80 APPENDIX C. E-MAIL TO PARTICIPANTS...... 86 REFERENCES ...... 88

LIST OF TABLES

Table Page

1. U.S. Standard Drink Types Containing 0.6 Ounces of Pure Alcohol ...... 9

2. Calorie Content of Standard U.S. Alcoholic Beverages ...... 10

3. Demographic Data of Kent State University Female Faculty and Staff (N=493) ...... 55

4. Drinking Characteristics of Kent State University Female Faculty and Staff (N= 493) ...... 57

5. Comparison of Health Beliefs of Alcohol Between Faculty and Staff (N=493) ...... 58

6. Level of Agreement with the Role of Red Wine on Health Outcome Between Faculty and Staff (N=493) ...... 60

7. Level of Agreement with the Role of White Wine on Health Outcome Between Faculty and Staff (N=493) ...... 63

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CHAPTER I

INTRODUCTION

Wine has been produced since before recorded history in Asia Minor and the

Mediterranean basin (Wright, Bruhn, Heymann, & Bamforth, 2008). In the United States, prior to regulations restricting the use of health claims, beer was described as a tonic, health boosting beverage (Wright et al., 2008). Currently, most studies show that moderate alcohol consumption, particularly wine, is associated with a lowered mortality

(Engs, 1996; Saliba & Moran, 2010; Szmitko & Verma, 2005; Bauer, 2008; Castelnuovo,

Rotondo, Iacoviello, Donati, & Gaetano, 2002; Gronbaek, Deis, Thorkild, Becker,

Schnorh, & Jensen, 1995; USDHHS, 2000; Gronbaek, 2001).

The Dietary Guidelines for Americans, published by the United States

Department of Agriculture (USDA), includes reliable information on what we should eat to be healthy (USDA, 1997). The guidelines are developed with advice from leading nutrition experts, stating “If you do drink alcohol, do so in moderation.” It is not recommend that those who do not consume alcohol to begin drinking (USDA, 1997). As

a whole, women in the U. S., and other cultures, are more likely to abstain, drink less, and

drink less frequently compared to men (Engs, 1996).

Epidemiologic evidence has shown that those who drink high quantities of

alcohol are at an increased risk for health problems (NIH, 2000; USDHHS, 2000; USDA,

1997; USDA, 2010). Other studies have suggested that individuals who abstain from

using alcohol may be at greater risk for a variety of conditions, than those who consume small to moderate amounts of alcohol (NIH, 2000; Shaper, 1990). Moderate alcohol consumers tend to have better health and live longer lives than heavy consumers and abstainers (NIH, 2000, Gronbaek, 2001).

Intake of any alcoholic beverage appears to be beneficial to health, but some studies suggest that red wine confers additional health benefits (Szmitko & Verma, 2005;

Saliba & Moran, 2010; Castelnuovo et al., 2002, Gronbaek et al., 1995). Regular consumption of red wine has been suggested as the explanation for the “French Paradox.”

The “French Paradox” supports the idea that the low incidence of coronary atherosclerosis in France, compared to Western countries, may be due to the red wine consumption, despite the high intake of saturated fat in the French diet (Engs, 1996).

This benefit from red wine may be due to its chemical composition. Polyphenolic compounds in red wine, such as flavonoids and resveratrol, may play a role in limiting the initiation and progression of atherosclerosis (Szmitko & Verma, 2005). Flavonoids and resveratrol have been associated as antioxidants, preventing molecules known as

“free radicals” from causing cellular damage in the body (Bauer, 2008; Gronbaek, 2001;

Luchsinger, Ming-Xin, Siddiqui, Shea, & Mayeux, 2004). Red wine provides a significant amount more resveratrol compared to white, because the longer the skin is kept on the grape, the greater amount of resveratrol (Bauer, 2008).

The Copenhagen City Heart Study provided the first support for a more pronounced cardioprotective effect for red wine, compared to other alcohol beverages

(Szmitko & Verma, 2005). The study compared 13,285 men and women for 12 years,

suggesting that those who drank wine had half the risk of dying from coronary heart

disease (CHD) or stroke, opposed to those who never drank wine. Those who drank beer

and spirits did not experience the same health advantage (Szmitko & Verma, 2005).

There has been an increase of studies document an association between lower CHD risk

and alcohol consumption (USDHHS, 2000; Gronbaek, 2001).

Some studies have suggested that alcohol intake can also reduce risk of dementia

and Alzheimer’s disease (Luchsinger et al., 2004; Ruitenberg et al., 2002). Moderate

alcohol intake has been associated with a decreased risk of dementia, mostly in European

studies (Luchsinger et al., 2004). In a cohort of individuals aged 65 years and older, light

to moderate alcohol intake was associated with a lower risk of dementia and Alzheimer’s

disease (Luchsinger et al., 2004).

Some research on alcohol consumption and breast cancer supports an increased

risk of disease. One study, comparing breast cancer risk with beverage-specific alcohol intake, found a positive association in alcohol consumption and the risk of invasive breast cancer in women (Smith-Warner et al., 1998). Women who consumed 60 grams per day or more of alcohol had a 31% higher risk of invasive breast cancer.

Some research shows how demographic characteristics can impact health belief

and consumption of alcohol. In a study by Minugh, Rice, and Young (1998),

demographic characteristics constituted the primary source for variation of quantity

alcohol consumed. The relationship between demographic variables and alcohol

consumption was the same for quantity and frequency, with the exception of education.

Women and men both drank more frequently as education increased, whereas quantity consumed was inversely correlated with education. Perceived health status, in both sexes, was related to how often and how much individuals reported drinking (Minugh et al.,

1998). More favorable health perceptions were related to frequent drinking, whereas negative health perceptions were associated with greater alcohol consumption (Minugh et al., 1998).

Problem Statement

The reasons that people consume wine vary largely, as it plays a role in social activities, from the business lunch, to the special occasions (USDHHS, 2000). Reduced stress, improved mood, increased sociability, and relaxation are the most commonly reported psychosocial benefits of drinking alcohol (USDHHS, 2000). Drinking wine has become one way that humans cope with feelings of anxiety, anger, and sadness when faced with traumatic experiences (Beseler, Aharonovich, & Hasin, 2011).

Medical literature on wine is pointing to the health benefit outcomes with consumption (Engs, 1996; Saliba & Moran, 2010; Szmitko & Verma, 2005; Bauer, 2008;

Castelnuovo et al., 2002; Gronbaek et al., 1995; USDHHS, 2000; Gronbaek, 2001). A study by Minugh, Rice, and Young (1998), found that individuals drank more frequently as education increased, whereas quantity consumed was inversely correlated with education. There needs to be a focus on whether or not education level has an effect on

the perception of wine, as there is minimal research available that compares health belief of wine and education level.

Purpose Statement

The purpose of this research is to determine whether education level plays a role in the way that KSU female faculty and staff perceive the effects of red wine consumption on health. Secondly, to measure if the sample perceived health benefits or risks of other types of alcohol.

Hypothesis

KSU female faculty will perceive moderate red wine consumption as a benefit to health and staff will not perceive moderate red wine consumption as a benefit to health.

Operational Definitions

Alcohol abuse: When drinking leads to problems, but not physical addiction.

Alcoholism: Having signs of physical addiction to alcohol and continues to drink, despite problems with physical health, mental health, and social, family, or job responsibilities.

Binge drinking: Four or more drinks during a single occasion for females, and five or more drinks during a single occasion for men.

Faculty: An educator who works at a college or university.

Heavy drinking: More than one drink per day on average for females, and more than two drinks per day on average for males.

Staff: An employee who is a member of a staff of workers.

The French Paradox: The substances present in wine, but not in beer and spirits, may be responsible for the lower mortality amongst wine drinkers.

CHAPTER II

REVIEW OF LITERATURE

Types of Alcohol

Wine

Wines vary largely of 10-22% alcohol content (WHO, 2011). The most common wines are produced from grapes. However, wines are also made from a variety of different fruits, such peaches, plums, and apricots. A few key components affect the taste and quality of the wine; such as, the soil that grapes and/or other fruits are grown and the weather conditions in the growing season (WHO, 2011). When the fruits are ripe, they are crushed and fermented in bins to create wine (WHO, 2011).

Beer

Beer is 4-8% alcohol content, and produced by the fermentation process (WHO,

2011). Wort, a liquid mix is prepared by combining yeast and malted cereal, such as corn, rye, wheat, or barely (WHO, 2011). The fermentation of the wort mix is what produces alcohol and carbon dioxide, promoting fermentation. Fermentation is stopped before it is completed with beer in order to limit the alcohol content (WHO, 2011).

Liquor

Spirits include brandy, gin, rum, tequila, vodka, and whisky (WHO, 2011).

Brandy is distilled from fermented fruit juices. The color of brandy comes either from casks or from caramel that is added, and is usually aged in ask casks. Brandy is typically

about 40-50% alcohol by volume (WHO, 2011). Gin is a distilled beverage that is a combination of alcohol, water, and other various flavors. Gin does not improve with age so it is not stored in wooden casks. Rum is a distilled beverage made from fermented molasses or sugarcane juice and is aged for at least three years. Rum is typically 40-55%

alcohol by volume (WHO, 2011). Tequila is produced through the distillation of

fermented juices of the mescal plant, species of the agave plant (American Bartenders

School, 2011). Vodka is distilled from a fermented mash of grain, differing in whiskey

by being distilled at a high proof, 190 or above, then processed further to remove the

flavor (American Bartenders School, 2011). Whiskey is produced by distilling the

fermented juice of cereal grains (corn, rye, or barely). Whiskey is typically 40-55%

alcohol by volume (WHO, 2011).

Nutrient Content of Alcohol

Nutrient Composition

Alcohol is a fermentation product of carbohydrates, both sugars and starches,

supplying calories in beverages and in food (Duyoff, 2006). Although alcoholic

beverages tend to lack nutrients, they are the second highest source of energy of all the

micronutrients, as alcohol provides about seven calories per gram (Foster & Marriott,

2006). Carbohydrates and protein provide four calories per gram, and fat provides nine

calories per gram of fat. For example, a 1.5 ounce “shot” of vodka may be around 40%

alcohol, up to 0.6 ounces of alcohol, which contributes about 100 calories. In the United

States, a drink is considered to be half an ounce, or 15 grams of alcohol, which is

equivalent to 12 ounces or beer, five ounces of wine, or 1.5 ounces of 80-proof distilled spirits (NIAAA, 2000).

Alcohol is a top calorie contributor in the diets of many American adults (USDA,

2010). The amount of calories in a drink is determined by how much alcohol is present, and for mixed drinks, the other ingredients in the drink often a lot of calories (Duyoff,

2006). Since alcohol is often consumed in mixtures with other beverages, the calorie content of additional mixers should be considered when calculating the calorie content of alcoholic beverages (USDA, 2010).

In the U. S., a standard drink is any drink that contains 0.6 ounces (14 grams or

1.2 tablespoons) of pure alcohol (CDC, 2011). See Table 1 for standard drink types in the U.S. that contain 0.6 ounces of pure alcohol. Although the calorie levels vary by alcoholic drink, standard drink sizes usually supply about the same amount of alcohol

(Table 2).

Table 1. U.S. Standard Drink Types Containing 0.6 Ounces of Pure Alcohol Drink Type Amount (Ounces) Beer 12 Wine Cooler 12 Malt Liquor 8 Wine 5 80-Proof Distilled Spirits or 1.5 Liquor *(Data from Centers for Disease Control and Prevention (CDC), 2011).

Table 2. Calorie Content of Standard U.S. Alcoholic Beverages Drink Type Amount (Ounces) Calories Beer 12 150 Light Beer 12 100 Dry Wine 5 100 Wine Cooler 12 180 80-Proof Distilled 1.5 100 Spirits Liquor or Cordial 1.5 160 *80-proof distilled spirits or liquor with an added mixer, such as a soft drink, adds more calories. *(Data from The American Dietetic Association (ADA); Complete Food and Nutrition Guide, 2006).

The quantity of vitamins and minerals in beers and wines vary largely, depending on a number of factors. For example, the micronutrient content in wine is affected by the grape used, production method, harvest time, storage, yeast variety used during

fermentation, and the different additives that are added to the wine. Sometimes vitamin

C may be added to wine in order to stabilize it. Yeast contains high levels of B vitamins,

as the variation in different yeasts makes a difference in the nutrient content. Liqueurs

may also contain protein and fat owing to the addition of egg or cream (Foster & Marriott,

2006). Beers contain small amounts of some micronutrients, including B vitamins and

some minerals, and wines contain several trace elements, including iron, potassium,

copper, and sodium (Foster & Marriott, 2006).

The alcohol content of one drink depends on the serving size and type of alcoholic

beverage. When restaurants advertise “special” alcoholic drinks on menus, they tend to

contain more alcohol because they’re bigger serving sizes. The average percentage of

alcohol by volume (ABV) varies largely among different alcoholic drinks. Beer is 4-6%

ABV, low alcohol beer is 0-2% ABV, wine coolers are 4-5.5% ABV, wines are 9-13%

ABV, distilled spirits (37-45% ABV, and liquors are 20-40% ABV (Foster & Marriott,

2006).

Additionally, there are products on store shelves that may be confused by their title. These products vary in their alcohol content, as consumers may not understand what they are consuming when reading the titles of the beverages. “Near beer” is a malt beverage that has alcohol content below 0.5%. “Low-alcohol or reduced-alcohol beer” is a malt beverage with less than 2.5% alcohol and an “alcohol-free malt beverage” contains

0.0% alcohol. A “flavored malt beverage” (beer, lager, ale, porter, stout) is flavored after fermentation, possibly with juice, juice concentrate, or fruit. “Aperitif wine,” often made from a grape wine and brandy, has an alcohol content of 15-24%. “Fortified wine”

(dessert wine) has brandy or distilled spirits added to it, and is 14-24% alcohol. “Table wine” (red wine, white wine, and sweet table wine) contains about 7-14% alcohol.

“Low-alcohol wine” is a wine or fermented fruit beverage, containing less than 7% alcohol and may consist of more sugars than other wines. A “wine cooler” is less than

7% alcohol, and is a diluted wine product by adding sugar, water, and/or fruit juice

(Duyoff, 2006).

Effect of Alcohol on Energy Intake and Appetite

Alcohol consumption has been known to have an effect on an individuals’ energy intake, as alcohol can impact one’s food intake (Foster & Marriott, 2006). Pathways for appetitive drive states in the limbic cortex appear responsible for the craving of alcohol

and drugs (Miller & Goldsmith, 2001). Also, some studies have found that alcohol

exposure can produce a robust increase in actual alcohol craving (Reid, Flammino,

Starosta, Palamar, & Franck, 2006).

The effects of alcohol on food intake have been studied in laboratory-based

studies and observational studies (Foster & Marriott, 2006). Laboratory studies have

been used to measure physiological indicators associated with food intake, such as

appetite hunger or satiation. Observational studies have found trends in energy intake

according to levels of alcohol consumption. Generally, both of these studies

demonstrated that individuals are unlikely to decrease their food intake to compensate for

the energy from alcohol during the day (Westerterp-Plantenga & Verwegen, 1999).

Previous studies have indicated that alcohol can act as an appetite stimulant, resulting in a greater overall intake of energy from a test meal after alcohol consumption

(Westerterp-Plantenga & Verwegen, 1999). The mechanism of how alcohol stimulates

appetite is not known, but it is known that alcohol affects neurotransmitters and certain

hormones, such as leptin. Changes to any of these components in the body could affect

an individuals’ food intake (Foster & Marriott, 2006).

An additional study by Yeomans found that significantly more energy was

consumed following alcohol than no alcohol (Yeomans, 2010). This effect was

demonstrated in the study, as a less amount of food was eaten after the alcohol – free

juice drink, and more was consumed after the same juice drink with added alcohol

(Yeomans, 2010). Additionally, there was no evidence that the effect of alcohol on

intake was due to restrained eating, nor did alcohol increase liking for the test foods.

Alcohol consumption was found to increase appetite once food had been tasted,

suggesting alcohol may increase food-related reward. Data suggests that the effects of

alcoholic drinks represent a complex interaction between physiological effects of alcohol

and expectations and associations generated by past experience of alcoholic drinks

(Yeomans, 2010).

Compounds in Alcohol

Phenolic and polyphenolic compounds. Some alcoholic beverages contain plant-derived bioactive phenolic compounds, known as flavonoids. Plants produce phenolic and polyphenolic compounds as secondary metabolites, which have a diverse range of effects in vitro that are suggestive of a putative role in the prevention of chronic diseases (Foster & Marriott, 2006).

Red wines, and to a much less extent, white wines, are a rich source of a variety of phenolic and polyphenolic compounds. In red wine production, with lengthy extraction, the fermented wine must contain up to 40% of the phenolics that were originally present in the whole grapes. White wine contains lower levels or an absence of skin and seed-derived phenolics, making the phenolics much lower than that found in red wine. The geographic origin of the grapes also plays a role in the range of concentrations of phenolic and polyphenolic compounds available (Foster & Marriott, 2006).

Whisky contains phenolic compounds also; quercetin, vanillin, and ellagic, gallic and syringic acids, which are extracted from the wooden casks during maturation. The phenolic profile depends on how long the spirit has been matured.

Beer contains phenolic and polyphenolic compounds produced from barely and hops used in the production of beer. The amount of polyphenolic compounds in beer is comparable to those that are found in white wine, and even some red wines. There is also some evidence supporting that there is a decent amount of antioxidants in beer, resulting in increases in antioxidant capacity of plasma after consumption. The idea of antioxidants in beer is still unclear, but there is some supporting evidence (Foster &

Marriott, 2006). Wine, beer, and whiskies contain phenolic and polyphenolic compounds in a variety of quantities. These compounds may have health-promoting effects; however their precise roles remain largely unclear (Foster & Marriott, 2006).

Congeners. The fermentation of alcohol produces bioactive compounds, known as congeners, and distil over with the alcohol. The fermentation process produces around

95% alcohol, 5% fusel oil, higher alcohols, aldehydes and esters, and a mixture of organic acids (Foster & Marriott, 2006).

The maturation of the liquor changes fusel oil and allows the special flavor to the spirit, as congeners contribute to the taste, smell, and appearance of alcoholic beverages.

The side effects of a hangover are attributed to congeners in the alcoholic beverages

(Foster & Marriott, 2006).

Current Intakes of Alcohol

Overall, Europe has the highest alcohol consumption worldwide. This trend is

said to be associated with the increased alcohol consumption among the younger

European population (Health Promotion Agency, 2011).

Wine-producing countries have been known to have the highest per capita alcohol

intake; however, this is now stabilizing compared with non-wine producing countries.

This trend is said to be due to increased accessibility and lower costs (Foster & Marriott,

2006).

In 2000, it was found that 44% of the U.S. adult population is current drinkers

who have consumed at least 12 drinks in the preceding year (NIAAA, 2000). According

to the Centers for Disease Control and Prevention, over half of the adult population drank alcohol in the past 30 days. Approximately 5% of the total population drank heavily, while 15% binge drank (CDC, 2011). Binge drinking is defined as four or more drinks during a single occasion for females, and five or more drinks during a single occasion for men. Heavy drinking is defined as more than one drink per day on average for females, and more than two drinks per day on average for males (CDC, 2011). It has also been found that about 14 million Americans, or 7.4% of the population, meet the diagnostic criteria of alcohol abuse or alcoholism (NIAAA, 2000).

Metabolism of Alcohol Consumption

Physiological Health Effects

Absorption. Alcohol has been studied at length for more than a century, yet its mechanism of action still remains controversial (Ingólfsson & Andersen, 2011). Alcohol is a water-soluble molecule that is absorbed throughout the gastrointestinal tract, controlled mostly by gastric emptying (Foster & Marriott, 2006). Through a process called diffusion, alcohol circulates in the blood and is distributed through the water in the body after absorbed. It will diffuse more quickly into organs with a rich blood supply, such as the lungs, but little alcohol enters body fat, due to its solubility in fat (Foster &

Marriott, 2006). The liver is where the most exposure to alcohol occurs, as blood is received directly from the stomach and small bowel through the hepatic portal vein.

Absorption occurs most rapidly when drinks are consumed on an empty stomach.

The type of alcohol will have an effect on rate of absorption, and the amount absorbed can be measured by the blood alcohol concentration (Foster & Marriott, 2006). The rate of absorption will vary between individuals, depending on the speed the drink was consumed, and whether food was eaten while drinking. Certain drugs may also interfere with gastric emptying, either slowing down or increasing the rate of absorption, and affecting the concentration of alcohol in the blood (Foster & Marriott, 2006). Like other drugs of abuse, alcohol, acts on multiple targets in brain and body to produce a complex array of effects (Roma et al., 2008). Gender and body size, also have an impact on the rate of alcohol absorption. For example, an average woman drinking the same amount of

an average man of the same size will become intoxicated more quickly, due to her higher

percentage of body fat. Also, women tend to have smaller statures, having smaller

volumes of blood, and resulting in a higher concentration of alcohol in the blood (Foster

& Marriott, 2006).

Metabolic pathways. After alcohol is absorbed, it is metabolized immediately.

This is due to the body having no capacity to store alcohol, in contrast to other

macronutrients, and its toxic properties. The liver is the primary site where metabolism

occurs, but some is immediately metabolized in the stomach by an enzyme responsible for breaking down alcohol, called alcohol dehydrogenase (Foster & Marriott, 2006).

Only about 2-5% of alcohol is excreted unchanged in the breath, urine, or sweat.

In an individual who is healthy, most of the alcohol consumed is metabolized and removed from the blood at a constant rate of about six grams per hour. However, this rate varies largely amongst individuals depending on many factors, including drug intake, frequency of alcohol intake, age, bodyweight, and genetics, and liver size (Foster &

Marriott, 2006). Gender has also been found to play a role in the speed of alcohol

metabolism, as females have less alcohol dehydrogenase. The decreased activity of this

enzyme in the females’ gastric mucosa forces them to metabolize alcohol more slowly,

with a steeper rise in blood alcohol concentration when drinking (Foster & Marriott,

2006).

Alcohol is metabolized in three different stages. In the first stage, alcohol is

oxidized to acetaldehyde, with the most common route is through the Nicotinamide

adenine dinucleotide (NAD)-linked enzyme alcohol dehydrogenase (AHD).

Acetaldehyde is more toxic than alcohol; therefore, it is quickly oxidized to acetate

through the enzyme acetaldehyde dehydrogenase (ALDH). Acetyl CoA synthetase converts a large proportion of acetate to acetyl co-enzyme A (acetyl CoA), where it is further oxidized to provide energy, via the Krebs cycle. Due to a genetic polymorphism, some individuals are unable to oxidize acetaldehyde efficiently. Therefore, when alcohol is consumed, they are exposed to high acetaldehyde levels, causing side effects that include headaches and facial flushing. This problem is most commonly found in the

Asian population (Foster & Marriott, 2006).

Lipid composition and protein distribution. Alcohols are known modulators of lipid bilayers, and membrane protein function (Ingólfsson & Andersen, 2011). There

have been a variety of terms to describe the changes in bilayer properties that occur,

reflecting different experimental methods. The biological efficacy of alcohols of various

chain lengths often displays a cutoff effect. For shorter alcohols, the potency increases

with increasing chain length (Ingólfsson & Andersen, 2011). Beyond a certain chain

length, further increases in length have less effect on potency, and may reduce it. The

cutoff effect is found in a variety of systems: Alcohols with chain lengths less than or

equal to six, which increase the formation of the photo activated form of rhodopsin in 1-

palmitoyl-2-oleylphosphatidylcholine lipid vesicles, whereas longer alcohols decrease its

formation (Ingólfsson & Andersen, 2011). In Xenopus oocytes, ethanol through 1-

butanol potentiate nicotinic acetylcholine receptor currents, and longer alcohols inhibit

them. The cutoff effect could be related to steric hindrances in alcohol-protein relations

(Ingólfsson & Andersen, 2011). However, this could also reflect alcohol-bilayer interactions that are more multifaceted than estimated from a partition model. The interaction between an alcohol’s affinity for a protein and limited solubility can also lead to a cutoff effect. It has been found that short-chain alcohols cause increases in volume when dividing into dimyristoylphosphatidycholine bilayers, where longer alcohols cause decreases in volume (Ingólfsson & Andersen, 2011). These cutoff effects tend to occur when the chain length of the alcohol is equal to half the acyl chain length of the bilayer- forming lipids.

There is also evidence for direct alcohol interactions with membrane proteins.

Membrane proteins’ alcohol sensitivity has been related to specific protein regions, as some responses can be modulated by amino acid substitutions (Ingólfsson & Andersen,

2011). In a recent study, in order to determine the bilayer-modifying potencies of alcohols, gramicidin (gA)-based fluorescence assay was used. The gA channels are formed by the transbilayer dimerization to two non-conducting subunits. The channel’s hydrophobic length is usually less than the bilayer’s hydrophobic thickness, due to the adaptation to accommodate the channel (Ingólfsson & Andersen, 2011). This adaptation is related to the deformation of the bilayer, as the gA channels serve as molecular force probes to assess changes in the lipid bilayer properties. The data suggests that the biological actions of alcohol arise from a combination of specific membrane protein-

alcohol interactions, as well as alcohol induced changes in membrane proteins

(Ingólfsson & Andersen, 2011).

Physical Health Effects

Most data supports that heavy alcohol intake (greater than 30 grams or greater

than three drinks per day) is associated with increased risk of weight gain/obesity, while

light to moderate drinking is not (Foster & Marriott, 2006). However, not all studies

have been consistent with findings, with the exception that very heavy drinkers (greater

than 49 grams of alcohol per day) have a low BMI. These inconsistent findings may be

related to various methodology problems linked to studies measuring alcohol (Foster &

Marriott, 2006).

It has been found that alcohol intake contributes to over 10% of the total calorie

intake of adult drinkers in the U. S. (Williamson et al., 1987). In females, body mass

index (BMI) is found to be inversely related to alcohol intake at intakes less than or equal

to 50 grams per day. However, at higher intakes of alcohol, BMI has been found to

increase with alcohol consumption in females. In men, there is no such relation in BMI

and alcohol intake (Westerterp-Plantenga & Verwegen, 1999).

Additionally, epidemiologic studies of alcohol intake have found that moderate

alcohol consumers total energy intake increases when alcohol is introduced to the diet

(Westerterp-Plantenga & Verwegen, 1999). This idea suggests that alcohol-derived energy is additive and not recognized or regulated by the body.

In a study done in 1987, it was found that alcohol had a substantial association with lower body weight in women, and the association was similar to the effect of smoking (Williamson et al., 1987). For women who drank less than 14 times per week, there was evidence of a dose-response of alcohol on body weight. However, the weight- lowering effect of alcohol in women was diminished at the highest level of drinking

(Williamson et al., 1987).

Recommendations of Alcohol Consumption

Women vs. Men

In the U.S., the latest consensus states that men should consume no more than one to two drinks per day, and women should consume no more than one drink per day (CDC,

2011). Women are recommended a less amount of alcohol than males because women have less activity of an enzyme that helps metabolize alcohol (USDA, 1997). One drink counts as 12 ounces of regular beer, five ounces of wine, and 1.5 ounces of 80-proof distilled spirits.

The recommendations are defined by moderate drinking, used by the U.S.

Department of Agriculture and the Dietary Guidelines for Americans (USDA, 1997).

Since alcohol carries the risk of dependency and excess consumption, which can lead to serious health problems. Therefore, the Dietary Guidelines (DG) recommend that those who do drink alcoholic beverages do so in moderation (USDA, 1997). The DG do not recommend that those who do not consume alcohol begin drinking. Virtually, the same

advice has been given has been given from the USDA on alcohol consumption since

1980 (USDA, 1997).

Who Should Not Drink

The DG also caution that certain individuals should not drink alcohol. Individuals who should not drink include children and adolescents, women who are pregnant or trying to conceive, those who cannot restrict their drinking to moderate levels, individuals who are planning to drive or take part in activities that require attention, and those using certain prescriptions or over-the-counter medications (USDA, 1997). If alcohol is consumed by a mother when pregnant, major birth defects, including fetal alcohol syndrome, can occur (USDA, 1997).

Reasons for Consumption

Physiological Benefits

Alcohol plays a role in many social activities, from the business related lunch, to the parties, and to the special occasions (USDHHS, 2000). Factors that have an influence on drinking include, but are not limited to, culture, the setting, and people’s expectations about alcohol’s effects (USDHHS, 2000). However, there is little research on the extent to which these factors may be associated with drinking behaviors (Shaw, Krause, Liang,

& McGeever, 2011).

Reduced stress, improved mood, increased sociability, and relaxation are the most commonly reported psychosocial benefits of drinking alcohol (USDHHS, 2000).

Drinking alcohol is one way that humans cope with feelings of anxiety, anger, and

sadness when faced with traumatic experiences (Beseler et al., 2011).

Terrorism, a fateful trauma, provides a natural experiment in which factors affecting subsequent alcohol consumption can be investigated. After the fateful trauma to the World Trade Center (WTC) on September 11, 2001, there was an increase in alcohol consumption among Manhattan adults (Adams & Boscarino, 2006). Further, increases in drinking were still present two years after the WTC attack. Alcohol consumption after September 11 was significantly higher in those who were within five

miles of the WTC, compared to those further away (Adams & Boscarino, 2006).

Health

Despite considerable research, relationships among gender, alcohol consumption,

and health remain controversial, due to potential confounding by health-related attitudes

and practices associated with drinking (Polen, Green, Perrin, Anderson, & Weisner,

2010).

In a study comparing drinking patterns with gender and health, more frequent

heavy drinkers was associated with worse health-related attitudes and values, worse

feelings about visiting the doctor, and worse health-related practices (Polen et al., 2010).

The most frequent heavy drinkers reported less collaborative relationships with their

doctors, disliked going to the doctors, less confident they could change health practices,

less likely to value the respect of others, and were attached less importance to

religious/spiritual beliefs. However, women, compared to men, were more concerned

about their doctor’s disapproval of their health practices, placed less value on an exciting life, and attached more importance to religious/spiritual beliefs (Polen et al., 2010).

Women were more likely than men to cope with stress by smoking or drinking.

Relationships between health-related practices and alcohol was differed by gender, and daily or almost daily heavy drinking was associated with significantly lower physical and mental health for women compared to men (Polen et al., 2010).

The study suggested that drinking status is independently related to physical health, mental health, and vitality, even after controlling for the health-related attitudes, values, and practices expected to confound relationships. Among current drinkers, women who engage in frequent heavy drinking had worse physical and mental health than males (Polen et al., 2010).

Reason for Health Belief

Socioeconomic Status

In a study by Minugh et al. (1998), women and men both drank more frequently as education increased, whereas quantity consumed was inversely correlated with education. Also, men who were employed drank alcohol in greater quantities. Heavier drinking occurred among never-married, divorced, and separated individuals, and being divorced or separated as opposed to single, was associated with more frequent drinking for women, but not for men (Minugh et al., 1998). Older age was associated with frequent drinking, whereas being younger was found to have greater alcohol intake.

Perceived health status, in both sexes, was related to how often and how much

individuals reported drinking (Minugh et al., 1998). The findings showed that more

favorable subjective health perceptions were related to frequent drinking, whereas

negative health perceptions were associated with greater consumption. There was also a

significant association between alcohol intake and the individual belief that alcohol is a risk factor for oral cancer (Minugh et al., 1998). This indicates that greater knowledge of the risks of oral cancer was related to more frequent drinking and heavier alcohol consumption.

Culture

The benefits to those who drink during social occasions are greatly influenced by culture (USDHHS, 2000). A dominant theme has emerged in analyses of drinking patterns among members of various ethnic minorities in the influence of stressors related to social adjustment to the U.S. culture (Caetano, Clark, & Young, 1998). Between acculturative stress, socioeconomic stress, and minority stress, they are distinct forces that often require coping strategies. Acculturative stress is typically felt by immigrants who are faced with the turmoil of leaving their homeland and adapting to a new society

(Caetano et al., 1998). Socioeconomic stress is often experienced by ethnic minorities who feel disempowered because of inadequate financial resources and limited social class

standing. Minority stress can also be experienced do to the tensions that minorities may

encounter from racism (Caetano et al., 1998).

Linking social adjustment stressors to drinking patterns is partially based on the

Durkheim theory of anomic and Leighton’s theory of mental illness and social

disintegration (Caetano et al., 1998). Durkheim’s theory suggests that rapid cultural

change causes a condition called anomic. Anomic is “the absence within a society of

common social norms and controls.” In this condition, one may lack clear behavioral

guidelines, possibly resulting in self-destructive tendencies (i.e. alcohol abuse,

depression). Further, Leighton’s theory suggests that social disintegration and lack of

social unity, often precipitates psychological distress (Caetano et al., 1998). Similar to

Durkheim’s theory, this recommends that rapid social change can cause high stress levels that result in deviant behaviors.

Specifically, Hispanic cultural norms promote male alcohol consumption and female abstention (Caetano et al., 1998). One explanation for heavy drinking patterns among Hispanic men, particularly Mexican-Americans, is related to something called

“exaggerated machismo.” This concept implies that Hispanic men strive to appear strong

and drink large amounts of alcohol. However, comparing machismo in a mixture of

white, black, and Mexican-American men, found that that machismo was related to

alcohol use among men regardless of ethnicity (Caetano et al., 1998).

Drinking patterns among blacks have been thought of as a result from social disorganization (Caetano et al., 1998). Years ago, heavy drinking was a common characteristic of blacks’, as research characterized the blacks’ attitudes toward alcohol as more liberal than those of whites. The mass migration of blacks from the rural South to

the Northern areas of the U.S. in the 1900s appears to have resulted in increased alcohol consumption. Other research has indicated that the attitudes of blacks toward drinking tend to be more conservative than those of whites (Caetano et al., 1998).

Asian-Americans have been considered a “model minority,” with high rates of abstention and low rates of heavy alcohol use. Researchers suggest that this may be due to the flushing of the skin response that many Asians experience with alcohol. Flushing is associated with reduced drinking for “fast flushers”, of Asians with liberal attitudes on the Korean culture (Caetano et al., 1998). Cultural values, such as the ancient Confucian and Taoist philosophies in the Chinese and Japanese, may also have an impact on lower consumption. The emphasis on conformity and harmony in those philosophies is believed to promote a moderate drinking style, reinforcing moderate drinking and sanctions against drunkenness (Caetano et al., 1998). Similarly, traditional Japanese culture focuses on interdependence, restraint, and group achievement, possibly contributing to more controlled drinking. Additionally, most drinking in Asian cultures takes place in prescribed social situations, possibly limiting the likelihood of alcohol abuse.

The “Firewater Myth” has been associated with Native Americans, suggesting they have a predisposed heavy alcohol consumption, being unable to control their drinking when intoxicated (Caetano et al., 1998). This myth dates back to the late 1600s, when British settlers, French trappers, and other colonial observers in North America noted the presumed insistence of Native Americans on drinking to the point of

intoxication and the resulting alcohol induced debauchery. However, the Firewater Myth

is insufficient to explain drinking among Native Americans, as there is no evidence

existing to demonstrate increased reactivity to alcohol among Native Americans,

compared to other ethnic groups (Caetano et al., 1998). Also, alcohol use varies widely

among the different Native American tribes. For example, the Navajo tend to view social

drinking as acceptable, whereas the Hopi consider drinking irresponsible.

Associated Health Risks

Injuries, Violence, and Addiction

Alcohol consumption has been linked to illness and injury, disruption of family

and social relationships, impact on perceived health, emotional problems, violence

aggression, and legal problems. The risk of these consequences varies widely, depending

on the situation (NIAAA, 2000). Research has found a trend in the increased risk of

adverse effects on society as the average alcohol intake among individuals increases

(USDHHS, 2000).

Alcohol intake and increased risk of injury are associated, specifically including

automobile crashes, falls, and fires. The increased risk of injury is likely due to the

reduced cognitive function, impaired physical coordination and performance, and

increased risk-taking behavior (USDHHS, 2000). Evidence has shown a dose-response relationship between intake and injury risk, as the more a person drank, the greater the risk, with no level of drinking to be without risk.

Alcohol addiction, or problem drinking, touches drinkers’ families, friends, and

communities (Harvard School of Public Health, 2011). According to the National

Epidemiologic Survey on Alcohol and Related Conditions (NESARC), 8.5% of adults in

the U. S. meet the criteria for an alcohol use disorder, 2% meet the criteria for a drug use

disorder, and 1.1% meets the criteria for both. Research has established that some of the

risk for addiction to both alcohol and drugs is inherited (NIAAA, 2008). Children of

alcoholics are 50-60% more likely to develop alcohol use disorders than people in the

general population (NIAAA, 2008).

Patterns of alcohol consumption also increase the risk of violence and the likelihood that aggressive behavior will accelerate. As alcohol interacts with personality characteristics, including impulsiveness and other factors related to a personal tendency for violence (USDHHS, 2000).

Associated Health Benefits and/or Complications of Alcohol

Alcohol Type and Health

Wine. Studies suggest that there may be different effects on health of different types of alcohol beverages (Gronbaek, 2001). Currently, most studies appear to show that moderate alcohol consumption, wine in particular, is associated with a lowered mortality (Engs, 1996; Saliba & Moran, 2010; Szmitko & Verma, 2005; Bauer, 2008;

Castelnuovo et al., 2002; Gronbaek et al., 1995; USDHHS, 2000; Gronbaek, 2001).

It has been suggested that those who preferred wine were at lower risk of death

from cardiovascular disease (CVD) than beer and spirit drinks. The substances present in

wine, but not in beer and spirits, may be responsible for the lower mortality amongst wine drinkers (Gronbaek, 2001). Wine contains several components of possible anticarcinogenic effects, some common in fruits and vegetables, known as antioxidants which may inhibit carcinogenesis (Gronbaek, 2001). It has been suggested that beer and spirits, but not wine, contain nitrosamines, which are thought to possess carcinogenic properties (Gronbaek, 2001).

The Copenhagen City Heart Study provided the first support for a more pronounced cardio protective effect for red wine, compared to other alcohol beverages

(Szmitko & Verma, 2005). The study compared 13,285 men and women for 12 years, suggesting that those who drank wine had half the risk of dying from CHD or stroke, opposed to those who never drank wine. Interestingly enough, those who drank beer and spirits did not experience the health advantage (Szmitko & Verma, 2005).

The benefit of red wine has been supported further by an analysis of 13 studies involving 209,418 participants (Szmitko & Verma, 2005). A 32% risk reduction of atherosclerotic disease was found with red wine intake, as opposed to a 22% risk reduction with beer consumption. This benefit from red wine may be due to its chemical composition. Red wine provides a significant amount more resveratrol compared to white, because the longer the skin is kept on the grape during wine making, the greater concentration of resveratrol (Bauer, 2008). During white wine production, the skin is removed before fermentation, giving white wines a lower concentration in resveratrol compared to red.

It is generally believed that the French paradox is related to the consumption of

red wine and not white wine or champagne (Dudley et al., 2008). However, recent

evidence supporting that white wine could be as cardio protective as red wine (Dudley et

al., 2008). Initial studies focused on cardio protection with red wines because white wine

contains little to no resveratrol. Red wines are produced from the grapes that include

their skins, which contain resveratrol, whereas white wines are made from grapes without

their skins (Dudley et al., 2008).

Direct evidence supported that grapes without skin could possess cardio

protective properties, and hence the cardio protective abilities could be translated into

white wines (Dudley et al., 2008). Although white wines contain little to no resveratrol,

they have other protective antioxidants such as cinnamics acid, tyrosol, and

hydroxytyrosol. Tyrosol and hydroxytyrosol are phenolic compounds that are also found

in olive oil, which are present in olives either as free or conjugated forms as steroids or

aglycones (Dudley et al., 2008). This suggests that white wines may possess cardio protective ability comparable to that of red wines if the wines are rich in tyrosol and/or hydroxytyrosol (Dudley et al., 2008).

A study completed in 2011, (Schufelt et al., 2011) compared red to white wine consumption with risk of breast cancer in healthy postmenopausal women. Results showed that red wine was associated with significantly higher free testosterone and lower sex hormone binding globulin, as well as significantly higher luteinizing hormone level versus white wine in postmenopausal women (Schufelt et al., 2011). Red versus white

wine treatment is associated with changes in serum hormones consistent with an

aromatase inhibitor (AI) in healthy premenopausal women. Outcomes suggest that red

wine may serve as a nutritional AI, as it does not appear to increase breast cancer risk,

while white wine may increase risk as it did not serve as a nutritional AI (Schufelt et al.,

2011).

Another study, comparing red to white wine, found that red wine was more efficient than white wine in inhibiting cholesterol oxidation (Tian, Wang, Abdallah,

Prinyawiwatkul, & Xu, 2011). However, the two red (Chenin blanc and Sauvignon blanc) or two white wines (Merlot and Cabernet Sauvignon) compared had similar antioxidant activities in inhibiting cholesterol oxidation. The difference among inhibiting cholesterol oxidation showed that red wine had 50 times higher capability in inhibiting cholesterol oxidation, compared to white wine (Tian et al., 2011). White wines are generally made from free running juice without grape mash, having no contact with the grape skin. The lower antioxidant activity of the white wines compared with red wines could be due to the lower antioxidant activity polyphenolics content (Tian et al., 2011).

In a 12 year study, it was found that risk of dying steadily decreased with an increasing intake of wine for both men and women for all causes of mortality (Engs,

1996). The relative risk of dying was 1.00 for the subjects who never drank wine, compared to 0.5 for those who drank three to five glasses a day. This statistic suggests that drinking three to five glasses of wine a day decreases ones risk of mortality by half, compared to those who are non drinkers.

The french paradox. When looking at the “French paradox”, it has been suggested that wine may have beneficial health effects (Gronbaek, 2001). The “French

Paradox” supports the idea that the low incidence of coronary atherosclerosis in France, compared to Western countries, may be due to the red wine consumption, despite the high intake of saturated fat in the French diet. Additionally, “folk wisdom” through proverbs, has suggested that “wine builds the blood” and “wine is the milk of the elderly”

(Engs, 1996). Drinking small amounts of wine with meals in Southern Europe may have developed an antiquity based upon folk observations that moderate drinking is associated with longevity and health among women and men (Engs, 1996).

Beer and liquor. A meta-analysis of 26 studies on the relationship between wine or beer consumption and CVD risk as completed in 2002 (Castelnuovo et al., 2002). The analysis found a 32% reduction of overall vascular risk associated with drinking wine.

Not only were nonfatal vascular end points significantly reduced in wine drinkers, but so was CVD mortality. Further, beer drinking was also associated with a reduced risk of vascular events, but at a lower extent than that observed with wine (Castelnuovo et al.,

2002). However, a study in 1995 found that low to moderate consumption of wine was associated with lower mortality from cardiovascular and CVD and other causes

(Gronbaek et al., 1995). Similar intakes of spirits implied an increased risk, while beer consumption did not affect mortality. Furthermore, results implied that the increasing mortality among heavy drinkers may be explained primarily by the effect of drinking spirits (Gronbaek et al., 1995).

Alcohol and Disease Risk

Cardiovascular diseases. CVD accounts for more deaths among Americans than any other group of diseases. Of all causes of death, CHD is first (USDHHS, 2000).

Alcohol can serve as both a risk factor and a potential protective factor for CVD, and the

cardiovascular system (NIAAA, 2000; USDHHS, 2000; Gronbaek, 2001).

Studies have reported a reduced risk of death from CHD across a wide range of

alcohol consumption levels (NIAAA, 2000). More specifically, studies have found that

low to moderate levels of alcohol intake is most associated a protective effect against

CHD. Mortality from CHD was lower in countries where wine was the predominant type

of alcohol, as opposed to countries where beer or spirits were the beverages mainly

consumed (Gronbaek, 2001). In addition to a decreased risk of CVD, incidence of

ischemic stroke, and lung and upper digestive tract cancer were lower as well, compared

to non-wine drinkers.

However, an association between moderate drinking and lower risk of CHD does

not necessarily mean that alcohol itself is the cause of the lower risk. For example,

higher mortality risk among abstainers may be attributable to mental health,

socioeconomic employment status, overall health, and health habits such as smoking,

rather than the participants’ nonuse of alcohol (Fillmore et al., 1998). Additionally, it is

important to understand that the seeming benefits of moderate drinking on CHD are

offset at higher alcohol intakes by increased risk of death from other types of heart

disease, trauma, cancer, and liver cirrhosis (NIAAA, 2000).

The relationship between alcohol consumption and stroke has been studied

comparing risk of ischemic and hemorrhagic strokes. An ischemic stroke is the

predominant type of stroke, resulting from blockage of a blood vessel, whereas

hemorrhagic stroke is due to is due to rupture of a blood vessel (NIAAA, 2000). No

differences have been found in risk patterns for the two strokes, but clear evidence has

been found that heavy drinking is associated with increased stroke risk, especially in

women (NIAAA, 2000).

The Cancer Prevention Study II found that in men, all levels of drinking were

associated with a decreased risk of stroke death. However, in women, the decreased risk

was significantly only among those consuming one drink or less per day (Thun et al.,

1997). The relationship between alcohol intake and blood pressure is important because

hypertension is a major risk factor for stroke as well as for CHD. Studies comparing

lower levels of alcohol use with abstention, findings are mixed. Some studies have found

low alcohol consumption to have no effect on blood pressure or to result in a small

reduction, while in other studies blood pressure increased when alcohol intake increased

(USDHHS, 2000).

Alzheimer’s disease and dementia. Alzheimer’s disease affects nearly 50% of those older than 85 years. With some treatments to Alzheimer’s disease having reserved success, preventative measures of the disease are needed (Luchsinger et al., 2003). The

prevalence of dementia is expected to increase significantly with the aging of the

population. Moderate intake of alcohol has been associated with a decreased risk of

dementia, mostly in European studies (Luchsinger et al., 2004). There is a scarcity of data on the relationship between alcohol intake and the incidence of dementia in the elderly in the U.S.

In a cohort of individuals aged 65 years and older, light to moderate alcohol consumption was associated with lower risk of dementia and Alzheimer’s disease, while intake of liquor and beer was not associated with incidence of dementia (Luchsinger et al.,

2004). Data also suggested that light to moderate alcohol consumption was not associated with a lower risk of dementia or Alzheimer’s disease. Results of the study summarized that intake of up to three daily servings of wine was associated with a lower risk of Alzheimer’s disease (Luchsinger et al., 2004).

One reason why alcohol would be expected to decrease the risk of Alzheimer’s disease would be due to antioxidant mechanisms. Studies have shown that oxidation has an important role in Alzheimer’s disease, and there is continuing research on the prevention of Alzheimer’s disease with antioxidant vitamins. Alcohol has antioxidant effects, and wine has been found to have important antioxidant effects (Luchsinger et al.,

2004).

The Rotterdam Study reported that higher dietary intakes of vitamins C and E were associated with a lower risk of Alzheimer’s disease (Ruitenberg et al., 2002).

Another study comparing antioxidant vitamin intake and disease risk, found no association between higher vitamin C and beta carotene intake, and incident dementia

(Luchsinger et al., 2003). It is possible that the conflicting results of the two studies

could be due to smaller the Rotterdam Study having a longer follow-up time, possibly leading to more opportunity to finding an association.

Liver disease. The liver is the most important organ governing essential biochemical activities in the human body (Baskaran, Periyasamy, & Rajagopalan, 2010).

It has great ability to detoxify and synthesize useful substances, and therefore damage to the liver has severe consequences (Baskaran et al., 2010). Oxidative stress to the liver that is ethanol-induced, is known to play a major role n causing liver damage. Oxidative stress is the imbalance between the prooxidant and antioxidant status, from increased production of reactive oxygen species or decreased levels of antioxidant defense in several tissues and organs (Baskaran et al., 2010). Therefore, increased ingestion of alcohol, mainly through its metabolism, produces injury of the liver.

There is absolutely no question that alcohol abuse contributes to liver-related morbidity and mortality in the U.S. Excessive alcohol consumption is the main diet- related risk factor for liver cancer in Western countries (Foster & Marriott, 2006). Ways that alcohol affects the liver include inflammation and cirrhosis or progressive liver scarring (NIAAA, 2000). Nearly 900,000 people in the U.S. suffer from cirrhosis, with a

40-90% of cases estimated to have a history of alcohol abuse (USDHHS, 2000).

The risk of liver disease is related to how much a person drinks, as the risk is low at low levels of consumption, and significantly high with higher levels of consumption.

This relationship was shown in the Cancer Prevention Study II, in middle-aged and

elderly adults (Thun et al., 1997). Some evidence also suggests that women are more

susceptible to the negative effects of alcohol on the liver.

It is well established that alcohol intake is a cause of chronic liver disease (Allen

et al., 2009). Findings from the National Cancer Institute in 2009, found that moderate

alcohol intake in women is associated with increased risk of liver cancer (Allen et el.,

2009).

Type 2 diabetes mellitus. The prevalence of type 2 Diabetes Mellitus (DM) is

rising to epidemic proportions (Koppes, Dekker, Hendricks, Bouter, & Heine, 2005).

Between 2000 and 2030, a 37% increase in the worldwide prevalence of diabetes is predicted. Obesity, related to lifestyle factors have been shown to be greatly responsible for this problem. Alcohol consumption is a lifestyle factor that has been suggested to be relevant with respect to the risk of type 2 DM (Koppes et al., 2005).

There is indication that moderate alcohol consumption of one to three drinks per day is associated with a decreased risk of type 2 DM by 30-40%, when compared with the lowest consumers (Koppes et al., 2005). However, heavy alcohol consumption appears to be associated with an increased risk of type 2 DM (Carlsson et al., 2005).

In 2005, the first meta-analysis was conducted on the relationship between alcohol consumption and the risk of type 2 DM (Koppes et al., 2005). There was about a

30% reduced risk of type 2 DM in alcohol consumers of 6-48 grams per day, compared with heavier consumers or abstainers (Koppes et al., 2005). The lower type 2 DM risk in moderate drinkers was consistent over most of the included studies. However, the risk

estimates differed more across studies than was expected from the sampling error within studies (Koppes et al., 2005). It is noteworthy to remember that individuals with DM should avoid heavy alcohol consumption because of its harmful effects on lipid metabolism, blood pressure, and other cardiovascular risk factors (Foster & Marriott,

2006).

Cancer. Alcohol has been linked to multiple cancers, including cancers of the head and neck, digestive tract, and breast (NIAAA, 2000). Alcohol is established as a cause of cancer of various tissues in the airway and digestive tract, including the mouth, pharynx, larynx, and esophagus. Research suggests that cancer risk of the upper digestive tract is associated with both the concentration of alcohol in beverages and quantity of drinks consumed (USDHHS, 2000). People who use mouthwash are also at an increased risk of the oral cavity and pharynx cancers. Research suggests that there is a dramatic increase in cancers of the oral cavity, pharynx, larynx, and esophagus, when both tobacco and alcohol are being used by an individual (USDHHS, 2000).

Specifically in women, data suggests that low to moderate alcohol consumption is known to increase the risk for of certain cancers also. However, little is known about the effect of moderate intakes of alcohol, or of particular types of alcohol, on cancer risk, except for breast cancer. The 2009 Million Women Study found that each additional drink regularly consumed per day for women up to the age of 75, increased cancer rates

(Allen et al., 2009). Per 1,000 women in developed countries, there were about 11 for breast cancer, one for cancers of the oral cavity and pharynx, one for cancer of the rectum,

and 0.7 each for cancers of the esophagus, larynx, and liver. This study summarized that

there is a possible excess of about 15 cancers per 1,000 women up to age 75 (Allen et al.,

2009). The amount of alcohol consumed in the female population was associated with a

significantly increased risk of cancers of the oral cavity and pharynx, esophagus, larynx,

rectum, liver, breast, and all cancers combined (Allen et al., 2009).

Head and neck. In a study done by the American Association for Cancer

Research, it was found that alcohol consumption has a role in laryngeal carcinogenesis in

women. However, an association was only found with those females who were heavy

alcohol drinkers (Gallus et al., 2003). It was also found that alcohol consumption is a much weaker risk factor for laryngeal cancer than cigarette smoking in Italian women.

These outcomes are in line with the findings of studies conducted in men and women in the U.S., Korea, and Turkey (Gallus et al., 2003). In terms of population attributable risk for laryngeal cancer in women, tobacco smoking accounted for 78% on incidence, alcohol consumption for 34%, and the combination of the two factors of tobacco and alcohol for 82% (Gallus et al., 2003).

Digestive tract and pancreas. Incidence rates for adenocarcinomas of the esophagus and gastric cardia have risen steeply in the U.S. and Europe over past decades

(Gammon et al., 1997). An increased risk of gastric cancer with alcohol drinkers has been identified in some studies, but not in the majority of cohort studies. There are reasonable mechanisms in which alcohol may play a role in gastric cancer, specifically in the gastric cardia, the uppermost part of the stomach joining the esophagus (USDHHS,

2000). The connection between alcohol use and gastric inflammation is clear, but

progression to neoplasia is less understood and likely involves other factors in addition to

alcohol (Single, Ashley, Bondy, Rankin, & Rehm, 2000).

In a study including 261 cases of adenocarcinoma of the gastric cardia, found no

association with total alcohol intake, or for beer, wine, or spirits separately, after

controlling for smoking (Gammon et al., 1997). The interaction between alcohol intake

and smoking and the development of gastric cancers is not well understood, and the

likelihood of a correlated interaction of these risk factors cannot be dismissed (Single et

al., 2000).

Alcohol is a cause of chronic inflammation of the pancreas. A link between

alcohol intake and pancreatic cancer is conceivable, but is not proven (USDHHS, 2000).

Cancer of the pancreas is the 10th most common incident cancer among women in the

U.S. Prognosis with this disease is poor, with a one year survival rate of less than 20%,

making it the fourth leading cause of cancer death in women (Harnack, Anderson,

Folsom, Sellers, & Kushi, 1997). A number of studies have been done to determine

whether coffee, tea, and/or alcohol consumption increase the risk of pancreatic cancer,

but results are inconsistent. A study by the American Association for Cancer Research

found no evidence to support a relationship between alcohol or coffee consumption and

risk of pancreatic cancer (Harnack et al., 1997). In a particular cancer study done in Iowa women, associations were found of both alcoholic beverage and coffee consumption with pancreatic cancer incidence, independent of age and cigarette smoking. The relationship

of alcoholic beverages with pancreatic cancer incidence persisted among nonsmokers

(Harnack et al., 1997). The Iowa study found no clear mechanism to explain their finding

that alcohol consumption increases risk of pancreatic cancer.

However, it was found that alcohol consumption, together with a high-fat diet, is believed to be a risk factor for chronic calcifying pancreatitis, which is associated with an increased risk of pancreatic cancer (Lowenfels et al., 1993). Pancreatitis risk is increased by about 3% in people with heavier drinking patterns, and alcohol abuse is the leading cause of chronic pancreatitis, accounting for 70% of cases (Heuberger, 2009). The role of low-dose alcohol intake in pancreatitis is unclear, but there is some research to support that light-to-modest ethanol consumption accelerates the disease process, increasing severity (Heuberger, 2009).

Breast. Women who drink about one alcoholic beverage daily have a 10-30%

higher risk of incident breast cancer than nondrinkers (Longnecker, 1994). Alcohol

consumption is associated with a linear increase in breast cancer incidence in women

over the range of consumption reported by most women. Among women who consume

alcohol regularly, reducing alcohol consumption is a potential means to reduce breast

cancer risk (Smith-Warner et al., 1998). However, the relationship between alcohol intake and breast cancer risk is still controversial, even though over 50 epidemiologic studies have examined the association (Longnecker, 1994).

A study completed in 2009, with few women who regularly drink more than three alcoholic drinks per day, showed a significant increase risk of breast cancer, along with

other cancers including esophagus, larynx, oral cavity and pharynx, rectum, and liver

(Allen et al., 2009). The association of alcohol with breast cancer risk was similar among

women who drank wine exclusively and other drinkers, consistent with findings from a

meta-analysis of six cohort studies. Also, the findings indicated that breast cancer risk is

similar in women who drink white wine, red wine, or a mixture of both (Allen et al.,

2009).

Further, a study by the American Medical Association, in 1998, compared breast

cancer risk with beverage-specific alcohol intake. The study found a positive association

in alcohol consumption and the risk of invasive breast cancer in women (Smith-Warner et

al., 1998). Women who consumed 60 grams per day or more of alcohol had a 31%

higher risk of invasive breast cancer. When comparing alcohol types to risk, 2.8-5.6

glasses of wine, 2.3-4.5 bottles of beer, or 2.0-4.0 shots of liquor, continuous estimates of alcohol intake from wine, beer, and liquor were each positively associated with breast cancer risk in the multivariate analyses (Smith-Warner, 1998).

It has been suggested that increased breast cancer, associated with alcohol

consumption, may be reduced with adequate folate intake (Feigelson et al., 2003). Data

has also recommended that adequate folate levels may ease the risk of breast cancer

associated with alcohol consumption. The mechanism behind folate and breast cancer

emphasizes the interference of folate absorption, transport, metabolism, and influence of

tissue folate stores with alcohol intake (Feigelson et al., 2003). In a study conducted by the American Association for Cancer Research, a positive association was found between

alcohol consumption and breast cancer. However, a relationship between folate and alcohol consumption could not be identified (Feigelson et al., 2003).

Chapter III

METHODOLOGY

Purpose

Variables

This was a quantitative study, using convenience sampling. The independent variables are faculty and staff, and the dependent variable is health belief.

Participants

Participants included KSU female faculty and staff members. Potential participants were contacted through e-mail, which were obtained from the Human

Resources (HR) department at KSU. According to HR, there are 1,786 female faculty and staff members. The e-mail with the survey link was offered to all female faculty and staff, who are at least 21 years of age. The consent form stated that if they are not 21 years of age or older, they cannot proceed with the survey.

Survey Design

The survey was developed with the help of two surveys used in previous studies

(Saliba & Moran, 2010; Wright et al., 2008). Demographic questions were helped to be established from Saliba & Moran’s study, while questions asking of health belief and

reasons for consumption were referenced from Wright et al., from a study of the health aspects of alcoholic beverages.

When the participants received the e-mail with the survey link, there was a short introduction introducing them to the research. Once they clicked on the link, the consent form appeared first, further explaining the study, and asked for their consent prior to beginning the survey. Once consent was given, the survey began, starting with question one. Demographic questions were asked first, followed by questions about their belief of the health effects of wine, and reasons for consumption.

Part One

The survey began with six demographic questions, asking their education level, ethnicity, income level, age, whether or not they are a faculty or staff member, and whether they are a full-time or part-time employee at KSU. Obtaining whether the participant was a faculty or staff member was one of the most important demographic questions, as this was the primary variable used to compare health belief of wine.

Part Two

Questions 7-34 asked if they agreed or disagreed with questions regarding the health benefit of both red and white wine. There were additional questions asking on their level of agreement of the health benefit of beer and liquor. Questions were also asked on whether or not red and/or white wine can increase or decrease certain disease risks. To verify their level of agreement, a five point Likert scale, including an "I don't know" option, was used.

Part Three

Questions 35-40 also used the five point Likert scale, asking about their reasons

for consumption of wine. Questions 41-47 asked participants to answer with either a

“yes” or “no,” asking further questions about reasons for consumption.

Procedures

Electronic surveys, developed using Survey Monkey, were used to send the

survey link and collect responses from KSU female faculty and staff members. E-mails

were sent to 1,786 female faculty and staff members, two times. The first e-mail was

sent on Monday, January 16th, and the second reminder e-mail was sent on Tuesday,

January 24th, asking for participation from those who had not completed the survey.

There were seven batches of sent mail that included about 200 e-mail addresses each,

when e-mails were sent out. The first time e-mails were sent, potential participants could

see who received the e-mail; however, the second round of e-mails were sent as a blind

cc, so that recipients of the e-mail could not be identified.

Participants were fully informed about the study and told that the research study is

being conducted on level of education and health belief of wine consumption.

Participants were told electronically, before completing the survey, that they must be a female faculty or staff member at KSU, and at least 21 years of age, to participate.

Participants gave their electronic, informed consent before beginning the survey (when

they clicked the link to begin the survey).

An incentive of ten, $10.00 grocery store gift cards were given to participants.

When the initial e-mail was sent, the first five participants to complete the survey, and provided their e-mail address, were given a gift card. When the second reminder e-mail was sent to participants, an additional five gift cards were given to the first five participants who submitted the survey, and who provided their e-mail address, at that time. Participants were not identifiable with their questionnaire results, as all surveys were anonymous.

The data were compiled and analyzed using social sciences (SPSS) software

(version 18.0.3). Differences between health belief of wine consumption and demographic variables between faculty and staff were compared using independent t-tests.

Frequencies were also calculated for demographics and drinking characteristics. The sum scores for the health beliefs in red wine consumption were also analyzed. Comparison of belief of both red and white wine between faculty and staff members were also evaluated using frequencies and percent scores calculated from the survey. Significant differences that were found have been established and reported, as analyses were considered statistically significant at p ≤ 0.05.

CHAPTER IV JOURNAL ARTICLE Introduction Wine has been produced since before recorded history in Asia Minor and the

Mediterranean basin (Wright et al., 2008). In the United States, prior to regulations restricting the use of health claims, beer was described as a tonic, health boosting beverage (Wright et al., 2008). Currently, most studies show that moderate alcohol consumption, particularly wine, is associated with a lowered mortality (Engs, 1996;

Saliba & Moran, 2010; Szmitko & Verma, 2005; Bauer, 2008; Castelnuovo et al., 2002;

Gronbaek et al., 1995; USDHHS, 2000; Gronbaek, 2001).

The Dietary Guidelines for Americans, published by the United States

Epidemiologic evidence has shown that those who drink high quantities of alcohol are at an increased risk for health problems (NIH, 2000; USDHHS, 2000; USDA, 1997; USDA,

2010). Other studies have suggested that individuals who abstain from using alcohol may be at greater risk for a variety of conditions, than those who consume small to moderate amounts of alcohol (NIH, 2000; Shaper, 1990). Moderate alcohol consumers tend to have better health and live longer than heavy consumers and abstainers (NIH, 2000;

Gronbaek, 2001).

Some studies suggest that red wine confers additional health benefits, opposed to

other types of alcohol (Szmitko & Verma, 2005; Saliba & Moran, 2010; Castelnuovo et

al., 2002, Gronbaek et al., 1995). Regular consumption of red wine has been suggested

as the explanation for the “French Paradox.” The “French Paradox” supports the idea

that the low incidence of coronary atherosclerosis in France, compared to Western

countries, may be due to the red wine consumption, despite the high intake of saturated

fat in the French diet (Engs, 1996). This benefit from red wine may be due to its

chemical composition of polyphenolic compounds, such as flavonoids and resveratrol

(Szmitko & Verma, 2005). Red wine provides a significant amount more resveratrol

compared to white, because the longer the skin is kept on the grape, the greater amount of

resveratrol (Bauer, 2008).

The Copenhagen City Heart Study provided the first support for a more

pronounced cardioprotective effect for red wine, compared to other alcohol beverages

(Szmitko & Verma, 2005). Those who drank wine had half the risk of dying from CHD

or stroke, opposed to those who never drank wine. Those who drank beer and spirits did

not experience the same health advantage (Szmitko & Verma, 2005).

Some studies have suggested that alcohol intake can reduce risk of dementia and

Alzheimer’s disease (Luchsinger et al., 2004; Ruitenberg et al., 2002). Moderate alcohol

intake has been associated with a decreased risk of dementia, mostly in European studies

(Luchsinger et al., 2004). However, some research on alcohol consumption and breast cancer supports an increased risk of disease. One study, comparing breast cancer risk

with beverage-specific alcohol intake, found a positive association in alcohol consumption and the risk of invasive breast cancer in women (Smith-Warner et al., 1998).

Some research shows how demographic characteristics can impact health belief and consumption of alcohol. In a study by Minugh et al. (1998), demographic characteristics constituted the primary source for variation of quantity alcohol consumed.

The relationship between demographic variables and alcohol consumption was the same for quantity and frequency, with the exception of education. Women and men both drank more frequently as education increased, whereas quantity consumed was inversely correlated with education. Perceived health status, in both sexes, was related to how often and how much individuals reported drinking (Minugh et al., 1998). More favorable health perceptions were related to frequent drinking, whereas negative health perceptions were associated with greater alcohol consumption (Minugh et al., 1998). The purpose of the present investigation is to determine whether education level plays a role in the way that KSU female faculty and staff perceive the effects of red wine consumption on health.

Secondly, to measure if the sample perceived health benefits or risks of other types of alcohol. The research hypothesis was KSU female faculty will perceive moderate red wine consumption as a benefit to health and staff will not perceive moderate red wine consumption as a benefit to health.

Methodology

Sample

Five hundred and three KSU female faculty and staff participated in the study, but only 493 participants were included because 10 participants did not answer at least 50% of the questionnaire and were not included in the study. Subjects qualified for the study if they were a female faculty or staff member at KSU, and if they were 21 years of age or older. The subjects for this study were recruited through the Human Resources department at KSU, in order to obtain their e-mail addresses and send the questionnaire.

Measures

Perception of the health aspects of wine questionnaire. The study sample completed an online questionnaire, consisting of 41 questions asking their belief and reasons for consumption of red wine and other alcohol types. There were also six demographic questions asking about education level, income, age, ethnicity, and position at KSU. This questionnaire was developed with the help of two surveys used in previous studies (Saliba & Moran, 2010; Wright et al., 2008).

Procedure

Electronic surveys, developed using Survey Monkey, were used to send the survey link and collect responses from KSU female faculty and staff members. E-mails were sent to 1,786 female faculty and staff members, two times. The first e-mail was sent on Monday, January 16th, and the second reminder e-mail was sent on Tuesday,

January 24th, asking for participation from those who had not completed the survey.

There were seven batches of sent mail that included about 200 e-mail addresses each, when e-mails were sent out. The first time e-mails were sent, potential participants could see who received the e-mail; however, the second round of e-mails were sent as a blind cc, so that recipients of the e-mail could not be identified.

Participants were fully informed about the study and told that the research study is being conducted on level of education and health belief of wine consumption.

Participants were told electronically, before completing the survey, that they must be a female faculty or staff member at KSU, and at least 21 years of age, to participate.

Participants gave their electronic, informed consent before beginning the survey (when they clicked the link to begin the survey).

An incentive of ten, $10.00 grocery store gift cards were given to participants.

Statistical Analysis

The data were compiled and analyzed using social sciences (SPSS) software

(version 18.0.3). Differences between health belief of red wine consumption and demographic variables between faculty and staff were compared using independent t-tests.

Results

The purpose of this study was to measure if education level played a role in the way that KSU female faculty and staff perceived the health effects of red wine consumption. Secondly, to measure if the sample perceived health benefits or risks of other types of alcohol. The study sample completed an online questionnaire, consisting of 41 questions asking their belief and reasons for consumption of red wine and other alcohol types. There were also six demographic questions asking about education level, income, age, ethnicity, and position at KSU. Five hundred and three KSU faculty and staff participated in the study, but only 493 participants were included because 10 participants did not answer at least 50% of the questionnaire and were excluded from the study. The surveys response rate was 28.16% for those who participated in the study at

KSU.

The majority of participants were white (89%), as opposed to other ethnicities, and a masters degree (34.5%) was the most common education level (Table 3).

Participants were mostly middle class, as 35.1% made $30,000-$50,000 a year. The

majority of the participants were staff members, with 65.3% being staff and 34.3% being faculty members. Furthermore, 93.7% of participants were full-time. The mean age of participants was 46.50 ± 11.27 years, with a range of 22 to 76 years.

Table 3. Demographic Data of Kent State University Female Faculty and Staff (N=493) Demographic N % Education High School 57 11.6 Certificate/Diploma 24 4.9 Bachelor Degree 93 18.9 Masters Degree 170 34.5 Doctoral 128 26.0 Other 21 4.3

Ethnicity White 439 89.0 American Indian 2 0.4 Alaska Native 0 0.0 Asian 7 1.4 Black/African American 39 7.9 Native Hawaiian and Other 2 0.4 Pacific

Income level <$30,000 76 15.4 $30,000 - $50,000 173 35.1 $50,001 - $75,000 145 29.4 $75,001 - $100,000 58 11.8 $100,001 - $200,000 36 7.3 $>$200,000 1 0.2

Position at KSU Faculty 169 34.3 Staff 322 65.3

Employment Status Full-Time 462 93.7 Part-Time 26 5.3

Table 4 describes the alcohol drinking characteristics between KSU female faculty and staff participants. Results showed that majority of the participants drink alcohol (85.8% faculty, 88.2% staff). Further, it was reported that the most popular alcoholic beverage consumed was wine, as 76.9% of faculty and 75.5% of staff drank red wine, and 79.3% of faculty and 76.4% of staff drank white wine. Limiting the amount of wine consumption due to religious or cultural beliefs was not found to be a characteristic of participants. When looking at beer and liquor consumption, roughly half of both faculty and staff reported drinking both beer and liquor.

Table 5 describes alcohol health beliefs between female faculty and staff members. The faculty and staff members’ responses were analyzed by using an independent t-test, with equal variances not assumed. Significant differences (p ≤ 0.05) were demonstrated between faculty and staff on the possible health benefits of beer and liquor, and harmful health consequences of red and white wine consumption. The other questions about health belief of alcohol consumption demonstrated no significant difference in faculty and staff on the level of agreement. Both faculty and staff believed there may be benefits to red wine consumption, showing no significant difference between the two groups.

Table 4. Drinking Characteristics of Kent State University Female Faculty and Staff (N= 493) Characteristics Position Agreement N % Due to my cultural beliefs, I limit the amount of wine Faculty Yes 24 14.2 I consume. No 145 85.8

Staff Yes 36 11.2 No 284 88.2

Due to my religious beliefs, I limit the amount of Faculty Yes 12 7.1 wine I consume. No 156 92.3

Staff Yes 35 10.9 No 443 89.9

I do not drink alcoholic beverages. Faculty Yes 23 13.6 No 145 85.8

Staff Yes 35 10.9 No 284 88.2

I drink red wine. Faculty Yes 130 76.9 No 39 23.1

Staff Yes 243 75.5 No 78 24.2

I drink white wine. Faculty Yes 134 79.3 No 35 20.7

Staff Yes 246 76.4 No 75 23.3

I drink beer. Faculty Yes 82 48.5 No 84 49.7

Staff Yes 165 51.2 No 156 48.4

I drink liquor. Faculty Yes 95 56.2 No 70 41.4

Staff Yes 187 58.1 No 202 41.0

Table 5. Comparison of Health Beliefs of Alcohol Between Faculty and Staff1 (N=493) Std. Position Mean Significance Deviation There are possible health Faculty 4.35 0.789 benefits with red wine 0.520 consumption. Staff 4.40 0.807

There are possible health Faculty 3.53 1.35 benefits with white wine 0.269 consumption. Staff 3.67 1.23

There are possible health Faculty 3.14 1.58 benefits with beer 0.022* consumption. Staff 2.81 1.47

There are possible benefits Faculty 2.81 1.53 with liquor consumption. 0.002* Staff 2.37 1.39

Red wine may have Faculty 3.53 1.25 harmful effects to your 0.009* health. Staff 3.20 1.38

White wine may have Faculty 3.63 1.24 harmful effects to your 0.049* health. Staff 3.40 1.33

Beer may have harmful Faculty 3.94 1.18 effects to your health. 0.223 Staff 3.80 1.16

Liquor may have harmful Faculty 4.11 1.14 effects to your health. 0.130 Staff 3.94 1.21 1Means were calculated from the following Likert Scale: 1=Strongly Disagree; 2=Disagree; 3=Neutral; 4=Agree; 5=Strongly Agree; 6=I Don’t Know *Values were considered significant at p ≤ 0.05.

When comparing the level of agreement of the health outcomes of both red and

white wine, most participants were unsure about the possible health outcomes, regarding

increased or decreased risk of diseases. Table 6 represents the difference in level of agreement with the role of red wine on health outcome between faculty and staff. No

difference was found when comparing health outcome belief of red wine. Both faculty

and staff supported that risk of developing coronary heart disease can decrease with red

wine consumption (51.5% faculty, 54.0% staff). They also agreed that risk developing

liver disease can increase with red wine consumption (33.1% faculty, 25.8% staff), and

disagreed that liver disease can decrease with red wine consumption (37.3% faculty,

26.7% staff). Participants also displayed that they did not know the role that red wine

plays in the risk of developing dementia and Alzheimer’s disease, type 2 diabetes, and

cancer.

Table 7 represents the difference in level of agreement with the role of white wine

on health outcome between faculty and staff. A difference was found in the role white

wine can impact liver disease. Faculty (39.6%) strongly disagreed that white wine can

decrease risk of liver disease, while staff (30.4%) did not know the impact. When asked

if liver disease risk increases with white wine consumption, 27.8% of faculty agreed, and

27.8% faculty did not know, while majority of the staff (28.0%) staff did not know

(24.8% staff agreed). Participants also displayed that they do not know the role that

white wine plays in the risk of developing coronary heart disease, dementia and

Alzheimer’s disease, type 2 diabetes mellitus, and cancer.

Table 6. Level of Agreement with the Role of Red Wine on Health Outcome Between Faculty and Staff (N=493) I n, Strongly Disagre Strongly Neutral Agree Don’t % Disagree e Agree Know Risk of developing Faculty n 1 7 22 87 38 14 Coronary Heart Disease can % 0.6 4.1 13.0 51.5 22.5 8.3 decrease with red wine consumption. Staff n 6 16 23 174 73 29

% 1.9 5.0 7.1 54.0 22.7 9.0

Risk of developing Faculty n 4 19 45 32 12 57 dementia and Alzheimer’s % 2.4 11.2 26.6 18.9 7.1 33.7 Disease can decrease with red wine consumption. Staff n 10 30 86 62 19 114

% 3.1 9.3 26.7 19.3 5.9 35.4

Risk of developing Faculty n 11 45 38 10 5 59 Type 2 Diabetes Mellitus can % 6.5 26.6 22.5 5.9 3.0 34.9 decrease with red wine consumption. Staff n 17 48 82 38 9 127

% 5.3 14.9 25.5 11.8 2.8 39.4

Risk of developing Faculty n 13 31 37 31 7 49 cancer can decrease with red wine % 7.7 18.3 21.9 18.3 4.1 29.0 consumption.

Staff n 15 39 83 68 18 97

% 4.7 12.1 25.8 21.1 5.6 30.1

I n, Strongly Strongly Don’t Disagree Neutral Agree % Disagree Agree Kno w Risk of developing Faculty n 32 63 25 7 1 38 liver disease decrease with red % 18.9 37.3 14.8 4.1 0.6 22.5 wine consumption.

Staff n 47 86 71 21 8 85

% 14.6 26.7 22.0 6.5 2.5 26.4

Risk of developing Faculty n 20 73 29 13 7 26 Coronary Heart Disease can % 11.8 43.2 17.2 7.7 4.1 15.4 increase with red wine consumption. Staff n 40 139 48 24 11 56

% 12.4 43.2 14.9 7.5 3.4 17.4

Risk of developing Faculty n 13 51 40 5 5 54 dementia and Alzheimer’s % 7.7 30.2 23.7 3.0 3.0 32.0 Disease can increase with red wine consumption. Staff n 34 82 76 16 6 106

% 10.6 25.5 23.6 5.0 1.9 32.9

Risk of developing Faculty n 8 31 37 23 13 57 Type 2 Diabetes Mellitus can % 4.7 18.3 21.9 13.6 7.7 33.7 increase with red wine consumption. Staff n 17 66 78 34 12 110

% 5.3 20.5 24.2 10.6 3.7 34.2

I n, Strongly Strongly Disagree Neutral Agree Don’t % Disagree Agree Know Risk of developing Faculty n 9 46 34 14 13 50 cancer can increase with red wine % 5.3 27.2 20.1 8.3 7.7 29.6 consumption.

Staff n 30 83 82 24 7 91

% 9.3 25.8 25.5 7.5 2.2 28.3

Risk of developing Faculty n 4 16 22 56 31 38 liver disease can increase with red % 2.4 9.5 13.0 33.1 18.3 22.5 wine consumption.

Staff n 11 42 74 83 46 64

% 3.4 13.0 23.0 25.8 14.3 19.9

Table 7. Level of Agreement with the Role of White Wine on Health Outcome Between Faculty and Staff (N=493) I n, Strongly Strongly Disagree Neutral Agree Don’t % Disagree Agree Know Risk of developing Faculty n 9 30 41 23 7 59 Coronary Heart Disease can decrease with white % 5.3 17.8 24.3 13.6 4.1 34.9 wine consumption.

Staff n 14 59 93 44 5 106

% 4.3 18.3 28.9 13.7 1.6 32.9

Risk of developing Faculty n 10 30 42 12 5 70 dementia and Alzheimer’s Disease % 5.9 17.8 24.9 7.1 3.0 41.4 can decrease with white wine consumption. Staff n 17 54 91 20 2 137

% 5.3 16.8 28.3 6.2 0.6 42.5

Risk of developing Faculty n 11 48 37 5 3 65 Type 2 Diabetes Mellitus can decrease % 6.5 28.4 21.9 3.0 1.8 38.5 with white wine consumption. Staff n 24 66 78 21 2 130

% 7.5 20.5 24.2 6.5 0.6 40.4

Risk of developing Faculty n 13 43 41 9 4 58 cancer can decrease with white wine % 7.7 25.4 24.3 5.3 2.4 34.3 consumption.

Staff n 19 67 81 24 2 123

% 5.9 20.8 25.2 7.5 0.6 38.2

I n, Strongly Strongly Disagree Neutral Agree Don’t % Disagree Agree Know Risk of developing liver Faculty n 25 67 24 1 2 50 disease can decrease with white wine % 14.8 39.6 14.2 0.6 1.2 29.6 consumption.

Staff n 41 90 66 23 3 98

% 12.7 28.0 20.5 7.1 0.9 30.4

Risk of developing Faculty n 7 42 41 14 8 57 Coronary Heart Disease can increase with white % 4.1 24.9 24.3 8.3 4.7 33.7 wine consumption.

Staff n 20 80 82 20 5 113

% 6.2 24.8 25.5 6.2 1.6 35.1

Risk of developing Faculty n 8 37 45 5 4 70 dementia and Alzheimer’s Disease % 4.7 21.9 26.6 3.0 2.4 41.4 can increase with white wine consumption. Staff n 19 54 88 22 4 133

% 5.9 16.8 27.3 6.8 1.2 41.3

Risk of developing Faculty n 6 21 34 33 12 60 Type 2 Diabetes Mellitus can increase % 3.6 12.4 20.1 19.5 7.1 35.5 with white wine consumption. Staff n 14 46 81 45 9 125

% 4.3 14.3 25.2 14.0 2.8 38.8

I n, Strongly Strongly Disagree Neutral Agree Don’t % Disagree Agree Know Risk of developing Faculty n 8 31 42 14 9 63 cancer can increase with white wine % 4.7 18.3 24.9 8.3 5.3 37.3 consumption.

Staff n 15 58 87 25 6 125

% 4.7 18.0 27.0 7.8 1.9 38.8

Risk of developing liver Faculty n 3 13 25 47 31 47 disease can increase with white wine % 1.8 7.7 14.8 27.8 18.3 27.8 consumption.

Staff n 12 30 64 80 40 90

% 3.7 9.3 19.9 24.8 12.4 28.0

Discussion

The purpose of this study was to measure if education level played a role in the way that KSU female faculty and staff perceived the effects of red wine consumption on health, along with other types of alcohol. The study results indicated no significant difference in education level and perception of the possible health benefits of red wine consumption, therefore; the research hypothesis was rejected. However, significant differences were found between faculty and staff members on the possible health benefits with beer and liquor consumption, and that red and white wine may have harmful effects to health.

The data demonstrated that majority of the participants indicated that they were drinkers, as most responded no to the question “I do not drink alcoholic beverages.”

Participants were predominantly wine drinkers, as opposed to beer or liquor drinkers.

With majority of the participants being current drinkers in the present investigation, this behavior could have impacted their responses by denying any health risk there could be to drinking alcohol. Past research by Hansen, Raynor, & Wolkenstein (1990), suggested that individuals who drink more tend to deny the potential harm that may result from alcohol consumption. In the present investigation, this is not a problem if participants are consuming the USDA guidelines for alcohol, but if they are exceeding guidelines, this is a problem which requires more education on the health effects of alcohol. The USDA guidelines are defined by moderate drinking since alcohol carries the risk of dependency and excess consumption, which can lead to serious health problems. The guidelines

recommend that those who do drink alcoholic beverages do so in moderation and those who do not consume alcohol, do not begin drinking (USDA, 1997).

The results showing no significant difference in education level and the perception of the possible health benefits of red wine is conflicting with other research.

Past research has found that education level and income have a significant impact, and are related to the variance in health knowledge (Beier & Ackerman, 2003; Mortensen,

Jensen, Sanders, & Reinisch, 2002; Saliba & Carmen, 2010; Palsdottir, 2008). Previous research has found that wine drinking was significantly associated with higher socioeconomic status (Mortensen et al., 2002), and that individuals with more education are more likely to seek health information than those with lower education (Palsdottir,

2008; Bier & Ackerman, 2003).

In the present investigation, perhaps the reason there was not a difference in education level and knowledge, could be that support staff at a university may be more educated, opposed to support staff in other work environments. This higher level of knowledge in university support staff may be due to knowledge sharing. According to

Lauring & Selmer (2011), knowledge sharing is the provision of information, know-how, and feedback in the context. The process of knowledge sharing engagement requires that work individuals engage in close interactions, allowing observing and learning from each other. This idea of knowledge sharing was found in a previous study comparing social climates at universities (Lauring & Selmer, 2011).

Futhermore, research on the health benefits of red wine is more accepted as a

society, and more readily available to the public. For example, sales of red wine

increased after there was positive media coverage reporting on two studies in November,

2006 supporting the health benefits issued from the Harvard Medical School and the

National Institute on Aging (Fielding, 2007).

Overall, most faculty and staff agreed that risk of developing CHD can decrease with red wine consumption (51.5% faculty, 54.0% staff). Participants were also in disagreement with the statement that risk of developing CHD can increase with red wine consumption. Reasons for the agreement of the decreased risk of CHD and red wine may be due to the abundance of research connecting decreased CHD with red wine (Gronbaek,

2001; Szmitko & Verma, 2005; Dudley et al., 2008; Bauer, 2008). The Copenhagen City

Heart Study (Szmitko & Verma, 2005) suggested that those who drank wine had half the risk of dying from CHD or stroke, opposed to those who never drank wine.

The significant differences that were found between faculty and staff on the possible health benefits with beer consumption, supports past research linking higher education to greater health knowledge (Beier & Ackerman, 2003; Mortensen et al., 2002;

Saliba & Carmen, 2010; Palsdottir, 2008). As faculty were found to be neutral, with the health benefits of beer consumption, and staff was in disagreement. A study by

Castelnuovo et al. (2002) found that beer drinking was associated with a reduced risk of vascular events, but at a lower extent than that observed with wine. The difference in response from the present investigation could be due to information regarding the

possible health benefits of beer is harder to find, as there is less research and media supporting the information.

Faculty perceived red and white wine to have harmful effects significantly more than staff. This is in agreement with research supporting greater health knowledge with higher education (Beier & Ackerman, 2003; Mortensen et al., 2002; Saliba & Carmen,

2010; Palsdottir, 2008) The consumption requirements to achieve health benefits of red wine is defined as 1-2 drinks per day, as one drink counts as five ounces of wine

(Szmitko & Verma, 2005). However, the USDA guidelines conclude that if moderate consumption of 1-2 drinks per day, of any alcohol type, is exceeded, harmful health effects can occur (USDA, 1997). Though there was a mathematical significance found between faculty and staff with the harmful effects of wine, and benefits of beer, the mean differences between groups were minute and there may not be a practical difference between groups.

Neither faculty nor staff perceived that liquor had health benefits, but faculty significantly perceived the lack of health benefits to be greater than staff. The present investigation may have found this because those who consume liquor (56.2% faculty,

58.1% staff), may justify their habit by believing that liquor may not have negative health outcomes. As stated previously, research by Hansen et al. (1999), those who drink more tend to deny any potential harm that may result from alcohol consumption. Gronbaek et al. (1995) found that moderate consumption of spirits did not show a benefit and was associated with increased mortality from cardiovascular and CVD. The responses from

health belief of liquor prove that both faculty and staff understand the negative health

consequences that can occur from liquor consumption.

Majority of participants proved that they were unsure about the possible health

outcomes with wine consumption, as most responses included “I don’t know,” when

asked if consumption increased or decreased disease risk. However, even though

participants were unsure of the health effects of wine, responses showed they were

mostly drinkers, with wine being most popular. This suggests that drinkers are

consuming wine because of other reasons besides health (USDHHS, 2000). Previous

research suggests that the most common reasons for people to consume alcohol are to

reduce stress, improve mood, increase sociability, and to relax (USDHHS, 2000).

Few responses did however show that they were aware of the harmful effects of

alcohol consumption with some disease states. For example, most agreed that risk of

developing liver disease can increase with red wine consumption (33.1% faculty, 25.8%

staff). The responses agreeing with an increased risk of liver disease with red wine consumption is supported by past research that there is no question that alcohol abuse contributes to liver-related morbidity and mortality in the U.S. (Foster & Marriott, 2006).

However, it was not surprising to find that participants did not know the possible

benefits of red wine consumption in respect to dementia, Alzheimer’s disease, and type 2

DM. Reasons for this disconnect is likely due to there not being a lot of research

available to the public supporting benefits of red wine in these two diseases. Another

possible reason for this disconnect could be from the public focus on the “French

Paradox,” the decreased risk of CHD from red wine (Gronbaek, 2001), and there is less research focusing on other health benefits from red wine. A previous study by

Luchsinger et al. (2004) summarized that intake of up to three daily servings of wine was associated with a lower risk of Alzheimer’s disease (Luchsinger et al., 2004). Other previous studies also found moderate alcohol consumption (one to three drinks per day) is associated with a decreased risk of type 2 DM by 30-40%, compared with the lowest consumers (Koppes et al., 2005).

When comparing level of agreement with white wine consumption, majority of faculty and staff did not know the health effects, except for risk of liver disease. Faculty

(39.6%) strongly disagreed that white wine could decrease risk of liver disease, while

30.4% of staff did not know. With the question asking if white wine could increase risk of liver disease, 27.8% of faculty did not know and 27.8% of faculty agreed. However, majority of staff, 28.0% did not know if there was an increased risk of liver disease with white wine, while 24.8% agreed there was increased risk.

The lack of understanding in the role of white wine on health outcome was expected to be evident in the present investigation. The possible reason for this is because although wine is highly associated with health benefits (Engs, 1996; Saliba &

Moran, 2010; Szmitko & Verma, 2005; Bauer, 2008; Castelnuovo et al., 2002; Gronbaek et al., 1995; USDHHS, 2000; Gronbaek, 2001), majority of the research is supporting red and not white wine. Past research suggests that the difference in red to white wine may be due to the higher resveratrol contained in red wine compared to white (Bauer, 2008).

This scientific evidence is highly publicized in the media for the public to hear of.

However, even though it is generally believed that the “French Paradox” is related to the consumption of red wine and not white wine or champagne, recent evidence has supported that white wine could be as cardio protective as red wine (Dudley et al., 2008).

Since the role of white wine on health outcome is not yet certain, the public is unsure and understandably so, and are likely to be forming their own health beliefs of white wine.

Limitations

This study does not come without limitations. In the present investigation, most participants were white, as opposed to other ethnicities. Past studies have shown that people’s beliefs about the effects of alcohol vary depending on their ethnicity (Johnstone,

1994). Various ethnic or racial groups also differ in the degree of people’s beliefs of alcohol on health (Ellis, Zucker, & Fitzgerald, 1997). Therefore, since most of the participants were white, the data to responses may not represent the population.

Also, the questionnaire process may not be reliable. Participants were not monitored while taking the online questionnaire and therefore were free to research the correct answer, instead of answering with their belief.

With most of the participants being drinkers, responses of the health outcomes with alcohol may be skewed as past research has suggested that people who consume alcohol can be in denial of the health outcomes. Furthermore, since the comparison of education level was at a university, the staff members, as opposed to faculty, are likely to have more knowledge with being in a higher educated environment. With the staff being

more educated at a university work place, this could be a considerable limitation the study. Lastly, the middle class income level, which was most popular in the study, may be another limitation as it is not representative of a diverse population.

Applications

Findings from the present investigation imply that KSU female faculty and staff are knowledgeable about the benefits of red wine consumption. Participants proved that they perceive the French Paradox to be true, and that red wine can decrease risk of CHD.

They are also aware of the USDA guidelines of alcohol consumption, and that exceeding these can have harmful effects, likely to cause liver disease. However, it was evident that their perception of alcohols effect was uncertain on the less mainstream diseases, such as dementia, Alzheimer’s disease, and type 2 DM. Overall, the perception of KSU female faculty and staff was in line with current research on the health effects of wine and alcohol consumption.

A few factors that may impact ones perception of red wine consumption include stress level and lifestyle. For example, faculty members at a university may have higher stress levels, opposed to other professions. Teaching was once viewed as a low stress occupation, with light workloads, flexibility, and conference trips (Iqbal, 2011).

However, recent studies suggest that university faculty is among the most stressed occupational group, which may lead to greater overall alcohol consumption, possibly impacting their perception of wine. As stated previously, individuals who drink more may tend to deny the potential harm that may result from alcohol (Hansen et al., 1990).

Lifestyle differences may also impact perception, as increased workplace flexibility may enforce more positive lifestyle behaviors (Grzywacz, 2008). Individuals who perceived an increase in their flexibility were more likely to have overall healthy lifestyle behaviors

(Grzywacz, 2008). This study implies that faculty and staff who have workplace flexibility, may be more health conscious than others, which could influence perception.

Whether an individual is highly educated, or of lower education, it is important to make them aware of the health outcomes with alcohol consumption. Furthermore, it is necessary for registered dietitians to understand the USDA guidelines for alcohol consumption, serving sizes, nutritional facts, and impact to disease states in order to provide accurate education to patients. Therefore, it is also important for professionals in the dietetics field to expand the research realm on knowledge of alcohol on health, and the effects of alcohol to health (Ciliska, Peirson, & Muresan, 2007).

Conclusion

The study demonstrated there was no difference in the perception of the possible health benefits of red wine consumption and level of education, in KSU female faculty and staff members. However, with most of the participants being drinkers, and in an educated university environment, further research is needed in order to further compare different populations. Results of the study suggest that individuals do understand there is a health benefit with red wine consumption, however; they are unsure of the health outcomes that can occur with consumption beyond cardiovascular benefits. This

disconnect suggests a need for more public education of wines impact on health, as well as additional alcohol and health outcome research.

APPENDICES

APPENDIX A

STUDY CONSENT FORM

Appendix A Study Consent Form

Informed Consent Form to Participate in Research Study Welcome to “The Perception of the Health Aspects of Wine,” a web-based experiment that examines the belief of wine consumption. Before taking part in this study, please read the consent form below and click on the “Next” button at the bottom of the page if you understand the statements and freely consent to participate in the study. This study involves a web-based experiment designed to understand whether education effects the way that Kent State University female faculty and staff perceive the health aspects of wine. The study is being conducted by Jenna Iannello, student of Kent State University, and it has been approved by the Kent State University Institutional Review Board. No deception is involved, and the study involves no more than minimal risk to participants (i.e., the level of risk encountered in daily life). Participation in the study takes about 5 – 10 minutes and is strictly anonymous. Participants begin by answering demographic questions, following with questions about health belief of wine, and reasons for consumption. All responses are treated as confidential, and in no case will responses from individual participants be identified. Rather, all data will be pooled and published in an aggregate form only. Participants should be aware, however, that the experiment is not being run from a “secure” https server of the kind typically used to handle credit card transactions, so there is a small possibility that responses could be viewed by unauthorized their parties (e.g., computer hackers). An incentive will be given to 10 participants, with a $10.00 grocery store gift card. The first five participants who submit the survey, and provide their e-mail address, will be given a gift card. When a reminder e-mail is sent to take the survey, an additional five $10.00 gift cards will be given to the first five participants to submit the survey at that time. Subjects will not be identifiable with their questionnaire results, as all surveys will be anonymous. Participation is voluntary, refusal to take part in the study involves no penalty or loss of benefits to which participants are otherwise entitled, and participants may withdrawal from the study at any time without penalty or loss of benefits to which they are otherwise entitled. If participants have further questions about this study or their rights, or if they wish to lodge a complaint or concern, they may contact the principal investigator, Jenna Iannello, at [email protected]; or the Kent State University Institutional Review Board, at (330) 672-2704.

If you are 21 years of age or older, understand the statements above, and freely consent to participate in the study, click on the “Next” button below to begin the survey.

APPENDIX B

PERCEPTION OF THE HEALTH ASPECTS OF WINE QUESTIONNAIRE AND DEMOGRAPHIC QUESTIONS

Appendix B

Perception of the Health Aspects of Wine Questionnaire and Demographic Questions

Part One - Demographic Characteristics: 1) What is your education level? a. High School b. Certificate/diploma c. Bachelor degree d. Masters degree e. Doctoral f. Other

2) What is your ethnic background? a. White b. American Indian c. Alaska Native d. Asian e. Black/African American f. Native Hawaiian and Other Pacific Islander

3) What is your individual income level (your income only)? a. <$30,000 b. $30,000-$50,000 c. $50,001-$75,000 d. $75,001-$100,000 e. $100,001-$200,000 f. >$200,000

4) What is your Age? ______

5) Are you a faculty or staff member at Kent State University? □Faculty Member □Staff Member

6) Are you full-time or part-time at Kent State University? □Full-Time □Part-Time

Part Two - Health: 7) Please answer whether you agree or disagree with the following questions. Strongly Disagree Neutral Agree Strongly Don’t Question Disagree Agree Know (1) (2) (3) (4) (5) There are possible health benefits with red wine consumption. There are possible health benefits with white wine consumption. There are possible health benefits with beer consumption. There are possible health benefits with liquor consumption. Red wine may have harmful effects to your health. White wine may have harmful effects to your health. Beer may have harmful effects to your health. Liquor may have harmful effects to your health.

8) Please answer whether you agree or disagree with the following questions, on red wine consumption. Strongly Disagree Neutral Agree Strongly Don’t Question Disagree Agree Know (1) (2) (3) (4) (5) Risk of developing Coronary Heart Disease can decrease with red wine consumption. Risk of developing dementia and Alzheimer’s Disease can decrease with red wine consumption. Risk of developing Type 2 Diabetes Mellitus can decrease with red wine consumption. Risk of developing cancer can decrease with red wine consumption. Risk of developing liver disease decrease with red wine consumption. Risk of developing Coronary Heart Disease can increase with red wine consumption. Risk of developing dementia and Alzheimer’s Disease can increase with red wine consumption. Risk of developing Type 2 Diabetes Mellitus can increase with red wine consumption. Risk of developing cancer can increase with red wine consumption. Risk of developing liver disease can increase with red wine consumption.

9) Please answer whether you agree or disagree with the following questions, on white wine consumption. Strongly Disagree Neutral Agree Strongly Don’t Question Disagree Agree Know (1) (2) (3) (4) (5) Risk of developing Coronary Heart Disease can decrease with white wine consumption. Risk of developing dementia and Alzheimer’s Disease can decrease with white wine consumption. Risk of developing Type 2 Diabetes Mellitus can decrease with white wine consumption. Risk of developing cancer can decrease with white wine consumption. Risk of developing liver disease can decrease with white wine consumption. Risk of developing Coronary Heart Disease can increase with white wine consumption. Risk of developing dementia and Alzheimer’s Disease can increase with white wine consumption. Risk of developing Type 2 Diabetes Mellitus can increase with white wine consumption. Risk of developing cancer can increase with white wine consumption. Risk of developing liver disease can increase with white wine consumption.

Part Three-Reasons for Consumption: 10) Please answer whether you agree or disagree with the following questions, on reasons for consumption. Strongly Disagree Neutral Agree Strongly Don’t Question Disagree Agree Know (1) (2) (3) (4) (5) I consume wine when I am celebrating a special occasion. I consume wine when I want to reduce stress and/or improve my mood. I consume wine because it makes me more sociable. I consume wine because I believe there are health benefits with consumption. I do not consume wine because I believe the negative health effects out way the possible benefits. I consume wine simply because I like the taste, and I do not consider other factors.

11) Please answer the following with either “Yes” or “No.” Due to my cultural beliefs, I limit the amount of wine I consume. ___ Due to my religious beliefs, I limit the amount of wine I consume. ___ I do not drink alcoholic beverages. ___ I drink red wine. ___ I drink white wine. ___ I drink beer. ___ I drink liquor. ___

12) If you would like to be eligible for a $10.00 grocery store gift card, please enter your e-mail address below. The first five participants who submit the survey, and who provide their e-mail address, will be given a gift card. ______

APPENDIX C

E-MAIL TO PARTICIPANTS

Appendix C

E-mail to Participants

Good Morning / Afternoon / Evening! My name is Jenna Iannello, a graduate student at

Kent State University (KSU) enrolled in the Masters of Nutrition/Dietetic Internship

Program. I am conducting a thesis on behalf of KSU female faculty and staff members, on perception of the health beliefs of wine. The purpose of this research is to determine whether education level plays a role in the way that KSU female faculty and staff perceive wine consumption on health.

The questionnaire takes 5-10 minutes to complete. Grocery stores gift cards of$10.00 each will be given to the first five participants who submit the survey. The survey is completely confidential; your comments will not be identified. However, if you would like to be eligible for the gift card, please send your e-mail with your completed survey.

Thank you in advance for your time!

If you would like to participate, please click on the URL below.

https://www.surveymonkey.com/s/BHT5VFK

Thank You,

Jenna Iannello

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