PART D: SCIENCE BASE
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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OVERVIEW OF QUESTIONS ADDRESSED
This section addresses two major questions related to ethanol and health:
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)?
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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QUESTION 1: AMONG PERSONS WHO CONSUME FOUR OR FEWER ALCOHOLIC BEVERAGES
PER DAY, WHAT IS THE DOSE-RESPONSE RELATIONSHIP BETWEEN ALCOHOL INTAKE AND
In middle-aged and older adults, a daily intake of one to two alcoholic
beverages is associated with the lowest all-cause mortality.
Compared with nondrinkers, adults who consume one to two alcoholic beverages
per day appear to have lower risk of coronary heart disease (CHD).
Compared with nondrinkers, women who consume one alcoholic beverage per
day appear to have a slightly higher risk of breast cancer.
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
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:
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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QUESTION 2: WHAT IS THE RELATIONSHIP BETWEEN CONSUMING FOUR OR
FEWER ALCOHOLIC BEVERAGES DAILY AND MACRONUTRIENT PROFILES, MICRONUTRIENT
PROFILES, AND OVERALL DIET QUALITY?
A daily intake of one to two alcoholic beverages is not associated with
inadequate intake of macronutrient or micronutrients, or with overall dietary
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
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
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
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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,
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
*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
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Biometry and Epidemiology (August 2003).
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Table D8-1. The Relationship Between Moderate Alcohol Consumption and Mortality
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