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U.S. Department of Health and Human Services

Nutrition and Your Health:
Dietary Guidelines for Americans

U.S. Department of Agriculture


Section 8: Ethanol


The hazards of heavy ethanol (alcohol) intake have been known for centuries. Heavy drinking increases the risk of liver cirrhosis, hypertension, cancers of the upper gastrointestinal tract, injury, and violence (USDA, HHS, 2000). A recent analysis found that alcohol use is the third leading actual cause of mortality in the United States, after tobacco use and poor diet and/or inactivity (Mokdad et al., 2004). The health consequences of consuming lesser amounts of alcohol are less often a focus of research or government recommendations.

In 1999–2001, 6 in 10 U.S. adults were current drinkers, 95 percent consuming light-to-moderate amounts (i.e., less than 7 drinks per week for women and less than 14 drinks per week for men) (Schoenborn et al., 2004) and 5 percent consuming more. Approximately 35 percent of adult Americans do not drink alcohol, with one in four being a lifelong abstainer (NIAAA, 1997). From a historical perspective, multiple sources suggest that fewer Americans consume alcohol today as compared to 50 to 100 years ago (See Figure D8-1).

The 2000 Dietary Guidelines for Americans defined moderate alcohol consumption as the consumption of up to one drink per day for women and up to two drinks per day for men (USDA, HHS, 2000). One drink is defined as 12 oz of regular beer, 5 oz of wine (12 percent alcohol), or 1.5 oz of 80-proof distilled spirits. The Committee largely agreed with these earlier Guidelines. This section examines a few specific questions to potentially modify the earlier work. The focus remains the health consequences of consuming moderate amounts of alcohol.

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This section addresses two major questions related to ethanol and health:

  1. Among persons who consume four or fewer alcoholic beverages per day (with a subsearch for persons age 65 and older), what is the dose-response relationship between alcohol intake and (1) total mortality and (2) several major causes of death (i.e., cardiovascular disease, cancer, and trauma)?

  2. Using recent national data, what is the relationship between consuming four or fewer alcoholic beverages daily and (1) macronutrient profiles, (2) micronutrient profiles, and (3) overall diet quality?

The search strategies used to find the scientific evidence related to these broad questions appears in Part C. Tables summarizing the findings from the searches appears in Appendix G-3.

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  1. In middle-aged and older adults, a daily intake of one to two alcoholic beverages is associated with the lowest all-cause mortality.

  2. Compared with nondrinkers, adults who consume one to two alcoholic beverages per day appear to have lower risk of coronary heart disease (CHD).

  3. Compared with nondrinkers, women who consume one alcoholic beverage per day appear to have a slightly higher risk of breast cancer.

  4. Relationships of alcohol consumption with major causes of death do not differ for middle-aged and elderly Americans. Among younger people, however, alcohol consumption appears to provide little, if any, health benefit; alcohol use among young adults is associated with a higher risk of traumatic injury and death.


These conclusions are supported by the State of the Science Report on the Effects of Moderate Drinking (NIAAA, 2003), an extensive review of the literature conducted by scientific staff of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and reviewed by 14 outside experts. In addition to recognizing the apparent mortality benefit of moderate alcohol consumption among middle-aged and older adults, the report concludes, "Except for those individuals at particular risk…, consumption of [up to] 2 drinks a day for men and 1 for women is unlikely to increase health risks" (NIAAA, 2003, p 30). Individuals at particular risk include persons who cannot restrict their drinking to moderate levels, children and adolescents, persons taking prescription or over-the-counter medications that can interact with alcohol, and individuals with special medical conditions (e.g., liver disease).

Conclusion #1 was further substantiated by 17 papers from the Committee systematic review of the scientific evidence examining the relationship between moderate alcohol consumption and mortality for those age 65 and older (See Table D8-1). These findings are primarily from prospective cohort studies, and they are largely consistent with findings from studies of adults under age 65. Moreover, the Committee found no evidence that moderate alcohol consumption adversely affects cognitive functioning as one ages.

More specific evidence on the relation of alcohol intake to health concerns is summarized in the discussion below:

Total Mortality

Studies conducted around the world consistently show that alcohol has a favorable association with total mortality among middle-aged and older adults. A meta-analysis on all-cause mortality using approximately 50 studies demonstrated an inverse association between moderate drinking and total mortality under all scenarios (Gmel et al., 2003). On average, the relative risk of all-cause mortality associated with moderate drinking was approximately 0.80. The J-shaped curve, with the lowest mortality risk occurring at the level of one to two drinks per day, is likely due to the protective effects of moderate alcohol consumption on CHD (Marmot, 2001; Mukamal, 2003) and ischemic stroke (Reynolds et al., 2003), the first and third leading causes of death in the United States, respectively.

The Committee found weak evidence that purported changes in body composition with age support lowering the drinking limit for older men to one drink per day (NIAAA, 2003). A discussion with experts at NIAAA indicated that body composition of the elderly may be less relevant now because, as Americans are aging better, many are losing less lean body mass. In addition, elderly drinkers' level of impairment at any given blood alcohol concentration does not differ from that of younger drinkers (NIAAA, 2003).

Coronary Heart Disease

An inverse association between light-to-moderate alcohol consumption and CHD morbidity and mortality has been demonstrated in a variety of populations and is independent of many other cardiac risk factors, including age, sex, race/ethnic group, smoking habits and body mass index (Corrao et al., 2004, 2000; Marmot, 2001; Mukamal and Rimm, 2001). On average, the relative risk of CHD associated with moderate drinking is between 0.50 and 0.80. The largest potential benefits are found among women age 55 or older, men age 45 or older, and those at risk for heart disease. At younger ages, potential reductions in CHD are probably offset by increases in traumatic death (e.g., Andreasson et al., 1988).

The totality of the evidence does not support beverage-specific effects of certain types of alcohol. While laboratory findings have suggested that red wine might have additional health-promoting compounds, this finding is not consistently translated into the epidemiologic data. For example, Keil and colleagues (1997) present evidence of lower total mortality and CHD rates among moderate drinkers in a beer-drinking population; other population studies have found the largest reductions among those consuming largely distilled spirits (Rimm et al., 1996).

These conclusions were reached and supported by evidence in the NIAAA's State of the Science Report (NIAAA, 2003) and by many other recent studies. Although the CHD risk reduction probably is causal (Rimm et al., 1999), several other factors can reduce the risk of CHD (and other chronic diseases) independent of alcohol consumption, including a healthy diet, physical activity, avoidance of smoking, and maintenance of a healthy weight.


Although immoderate alcohol intake has been linked to a various types of cancer (Corrao et al., 2004), moderate intake (i.e., up to one drink per day for women, up to two drinks per day for men) is not associated with most major cancers (NIAAA, 2003).

Breast cancer is a likely exception. Compared with nondrinkers, women who consume 1 drink per day appear to have an approximately 10 percent increase in the risk of breast cancer (NIAAA, 2003). Several meta-analyses suggest a linear dose-response relationship between the amount of alcohol intake and breast cancer risk (e.g., Smith-Warner et al., 1998). However, at the lower levels of intake (e.g., 2 drinks per week), the increase is sufficiently small that it is difficult to ascribe the finding to an effect of alcohol per se. The alcohol-breast cancer association may be of particular significance to women with a family history of breast cancer and those on hormone replacement therapy. Epidemiologic evidence indicates that the relative effect of moderate alcohol consumption on breast cancer risk may be small at the individual level but substantial at the population level.

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A daily intake of one to two alcoholic beverages is not associated with inadequate intake of macronutrient or micronutrients, or with overall dietary quality.


Ten papers from the Committee's systematic review of the scientific evidence provided data useful to the conclusion that the consumption of one to two alcoholic beverages per day is not associated with macronutrient or micronutrient deficiencies:

  • Seven cross-sectional studies (Barefoot et al., 2002; D'Avanzo et al., 1997; de Castro and Orozco, 1990; Jacques et al., 1989; Rosell et al., 2003; Schroder et al., 2002; Tremblay et al., 1995

  • Three clinical trials (Foltin et al., 1993; Orozco and de Castro, 1991; Tremblay et al., 1995)

At the Committee's request, U.S. Department of Agriculture's Center for Nutrition Policy and Promotion used a modeling process described in Appendix G-2 to examine the relationship of moderate alcohol consumption with nutrient intakes and diet quality of participants in the National Health and Nutrition Examination Survey (NHANES) 1999–2000. The analysis demonstrated that

  • Energy and nutrient intakes generally increased with increasing amounts of alcohol

  • Among women, the Healthy Eating Index increased with increasing amounts of alcohol.

  • Among men, the highest Healthy Eating Index was found among men who consumed an average of two drinks per day.

Nonetheless, alcoholic beverages supply calories but few nutrients. The energy contribution from alcoholic beverages varies widely. Specifically, some alcoholic beverages, such as dessert wines and mixed drinks, provide almost three times as many calories as do the standard drink portions: 12 oz. of beer, 5 oz. of wine, or 1.5 oz. of distilled spirit (see Part E, Table E-3 for a list of selected alcoholic beverages and their calorie content).

For those who choose to drink an alcoholic beverage, it is advisable to consume it with meals to slow alcohol absorption. Data suggest that the presence of food in the stomach can slow the absorption of alcohol (Jones et al., 1997) and thereby mitigate the associated rise in blood alcohol concentration.

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Adverse Effects of Moderate Alcohol Consumption

The Committee also reviewed evidence regarding adverse effects of moderate alcohol consumption (NIAAA, 2003).

  • Trauma. According to the NIAAA report (2003), studies on relationships of alcohol with injuries from falls and with violence and/or abuse frequently do not distinguish between moderate and excessive drinking. Studies of acute effects of alcohol show that even moderate-dose consumption compromises brain performance in terms of error detection, processing speed, and response time. Low levels of drinking and blood alcohol content below 0.08 percent increase the risk of driving-related accidents. Thus, there are compelling temporary reasons not to drink alcohol, such as when planning to drive, operate machinery, or take part in activities that require attention, skill, or coordination.

  • Hepatic effects. Alcohol abuse is the leading cause of liver-related mortality in the United States, accounting for at least 40 percent, and perhaps as many as 90 percent, of cirrhosis deaths (CDC, 1993; Vong and Bell, 2004). Lower levels of alcohol intake can result in liver function abnormalities short of cirrhosis. For example, moderate alcohol consumption may potentiate the carcinogenic potency of other hepatotoxins (NIAAA, 2003).

  • Young age. Children or adolescents should not consume alcohol. Alcohol consumption increases the risk of traumatic injury, which is the number one cause of death in this age group. Animal data on alcohol-related structural changes in the brain, while less compelling, illustrates why drinking is inappropriate for adolescents (Land and Spear, 2004; Markwiese et al., 1998). "Designer drinks" (i.e., newer alcohol products that tend to target young adults) are of recent concern because of their possible effect on underage drinking.

  • Pregnancy (including the first few months of pregnancy—often before the pregnancy is recognized). Moderate drinking during pregnancy may have behavioral or neurocognitive consequences in the offspring. Heavy drinking during pregnancy can produce a range of behavioral and psychosocial problems, malformations, and mental retardation in the offspring (NIAAA, 2003).

  • Breastfeeding. The level of alcohol in breast milk mirrors the mother's blood alcohol content. Low or moderate alcohol consumption does not enhance lactational performance and actually may decrease infant milk consumption. Recent data indicate that alcohol consumption while breastfeeding has adverse effects on the infant's feeding and behavior (NIAAA, 2003).

  • Other conditions. The NIAAA review also provides documentation that alcohol consumption should be avoided by individuals who cannot restrict their drinking to moderate levels, individuals taking medications that can interact with alcohol, and persons with specific medical conditions, such as liver disease (NIAAA, 2003).

Reasons Not To Drink Alcoholic Beverages

Abstention is an important option; approximately one in three American adults does not drink alcohol. Moreover, studies suggest adverse effects at even moderate alcohol consumption levels in specific individuals and situations, as described above.

People Who Should Not Drink:

  • Individuals who cannot restrict their drinking to moderate levels

  • Children and adolescents

  • Individuals taking prescription or over-the-counter medications that can interact with alcohol

  • Individuals with specific medical conditions (e.g., liver disease)

Situations Where Alcohol Should Be Avoided:

  • Women who may become pregnant or who are pregnant

  • Women who are breastfeeding

  • Individuals who plan to drive, operate machinery, or take part in other activities that require attention, skill, or coordination

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What Is The Relationship Between Consuming Four Or Fewer Alcoholic Beverages Daily And Obesity?

Available data on the relationship between alcohol consumption and weight gain/obesity are sparse and inconclusive. There are contradictory findings at the higher end of the spectrum (i.e., 3 to 4 drinks per day) that may relate to fundamental limitations of the cross-sectional study design. At moderate drinking levels (i.e., up to one drink per day for women, up to one drink per day for men), there is no apparent association between alcohol intake and obesity.

Ten observational papers from our systematic review of the scientific evidence provided data useful to this conclusion.

  • Cross-sectional (Barefoot et al., 2002; Dorn et al., 2003; Gavaler and Rosenblum, 2003; Lahti-Koski et al., 2002; Rosell et al., 2003; Sherwood et al., 2000)

  • Case control (Andersson and Rossner, 1996)

  • Prospective cohort (Hoffmeister et al., 1999; Sherwood et al., 2000; Vahtera et al., 2002; Wannamathee and Shaper, 2003)

In summary, although prospective data are limited, there is no apparent association between consuming one or two alcoholic beverages daily and obesity.

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A daily intake of one to two alcoholic beverages is associated with the lowest all-cause mortality and a low risk of CHD among middle-aged and older adults. Among younger people, however, alcohol consumption appears to provide little, if any, health benefit; alcohol use among young adults is associated with a higher risk of traumatic injury and death. Thus, the Committee recommends that if alcohol is consumed, it should be consumed in moderation, and only by adults. Moderation is defined as the consumption of up to 1 drink per day for women and up to 2 drinks per day for men; and 1 drink is defined as 12 oz of regular beer, 5 oz of wine (12 percent alcohol), or 1.5 oz of 80-proof distilled spirits. A number of situations and conditions call for the complete avoidance of alcoholic beverages.

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Figure D8-1. Historical Perspecitve of per Capita Ethanol Consumption in the United States

Figure D8-1. Historical Perspecitve of per Capita Ethanol Consumption in the United States - Click to view text only versiond

*Gallons of ethanol, based on population age 15 and older prior to 1970 and on population age 14 and older thereafter


Alcohol Epidemiologic Data System. Nephew, T.M.; Williams, G.D.; Yi, H.; Hoy, A.K.; Stinson, F.S., and Dufour, M.C. Surveillance Report #62: Apparent Per Capita Alcohol Consumption: National, State, and Regional Trends, 1970–2000. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism, Division of Biometry and Epidemiology (August 2003).

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Table D8-1. The Relationship Between Moderate Alcohol Consumption and Mortality (age 65+)

Table D8-1. The Relationship Between Moderate Alcohol Consumption and  Mortality (age 65+) - click here to view table Select icon to view table

Table of Contents

A. Executive Summary

B. Introduction

C. Methodology

D. Science Base
  • Section 1. Aiming To Meet Recommended Intakes of Nutrients
  • Text
  • Tables
  • Section 2. Energy
  • Section 3. Discretionary Calories
  • Section 4. Fats
  • Section 5. Carbohydrates
  • Section 6. Selected Food Groups
  • Section 7. Fluid and Electrolytes
  • Section 8. Ethanol
  • Section 9. Food Safety
  • Section 10. Major Conclusions

    E.  Translating the Science into Dietary Guidance
  • Text
  • Tables and Figures
  • F.  Research Recommendations

    G. Appendices
  • Glossary
  • Description of USDA Analyses
  • Summary Tables from Systematic Review
  • IOM Tables
    (Institutes of Medicine tables referenced in the 2005 Dietary Guidelines Advisory Committee Report are available at
  • History of Dietary Guidelines
  • Summary of Recommendations
  • Biographical Sketches of DGAC Members
  • Acknowledgements

    Read Public Comments