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Section 8: Ethanol

INTRODUCTION

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.

OVERVIEW OF QUESTIONS ADDRESSED

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.

QUESTION 1: AMONG PERSONS WHO CONSUME FOUR OR FEWER ALCOHOLIC BEVERAGES PER DAY, WHAT IS THE DOSE-RESPONSE RELATIONSHIP BETWEEN ALCOHOL INTAKE AND HEALTH?
Conclusions
  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.
Rationale

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.

Cancer

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.

QUESTION 2: WHAT IS THE RELATIONSHIP BETWEEN CONSUMING FOUR OR FEWER ALCOHOLIC BEVERAGES DAILY AND MACRONUTRIENT PROFILES, MICRONUTRIENT PROFILES, AND OVERALL DIET QUALITY?
Conclusion

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

Rationale

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:

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

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.

SUPPLEMENTARY INFORMATION
Adverse Effects of Moderate Alcohol Consumption

The Committee also reviewed evidence regarding adverse effects of moderate alcohol consumption (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:

Situations Where Alcohol Should Be Avoided:

UNRESOLVED ISSUE
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.

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

SUMMARY

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

Sources:

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

Inclusion Criteria: Prospective, Case-Control, Cross-Sectional Studies; Human Subjects; Publication Dates 1997 and After

Citation Design Population Exposure Outcome Duration Results Statistics
Camargo et al., 1997 Prospective cohort 22,071 men in Physicians' Health Study, aged 40-84 years with no history of MI, stroke, transient ischemic attack, or cancer <1 drink/wk;
1 drink/wk;
2–4 drinks/wk;
5–6 drinks/wk;
7–13 drinks/wk;
>14 drinks/wk
all-cause mortality 10.7 years Multivariate RR (age >52 y) <1 drink/wk 1.00; 1 drink/wk 0.81(0.63–1.03);
2–4 drinks/wk 0.71 (0.57–0.89);
5–6 drinks/wk 0.88 (0.69–1.12);
7–13 drinks/wk 1.02(0.86–1.22);
>14 drinks/wk 1.63 (1.23–2.14)
95 percent confidence interval; P-value for association - linear p=0.04; non-linear p<0.001 RR of cause-specific mortality also provided. Cohort had exceptionally low mortality rate, only 34 percent of that expected in a general population of white men with same age distribution during a similar period.
Chyou et al., 1997 Prospective cohort 8,006 Japanese-American men living in Hawaii, between 45–68 years at initial examination in 1965–1968 occasionally; lightly; moderately; heavily overall mortality 22 years J-shaped pattern in risk for intake of alcohol; synergistic interaction between BMI and alcohol—Men with intermediate BMI (21.21–26.30 kg/m2) and drank occasionally to lightly (0.01–24.99 oz/mo) RR 1.00 (reference group); Men with lowest BMI (<21.21 kg/m2) and drank moderately to heavily (>25 oz/mo) RR 1.63 (1.33–1.99) Synergistic interaction between BMI and alcohol, p=0.0017; RR - 95 percent confidence interval Increase in risk due to the interactive effect of low BMI and high alcohol intake was stronger (and statistically significant) than when each of these risk factors was considered separately
Dawson, 2001 Prospective cohort 42,910 adults 18 years and older; data from 1988 National Health Interview Study linked with the National Death Index for 1988 through 1985 abstainers; infrequent drinkers; light; moderate mortality 7.5 year followup Relative to lifetime abstainers and infrequent drinkers, the risk of death from external causes increased directly with volume of intake. No evidence for reduced risk of death among light or moderate drinkers.
Dawson, 2000 37,682 U.S. adults age 25 years and older; data from 1988 National Health Interview Study linked with the National Death Index for 1988 through 1985 lifetime abstainers; past-year abstainers; light; moderate; heavy; very heavy all-cause mortality OR past-year abstainers 1.00; light 0.76 (0.68–0.84); moderate 0.84 (0.74–0.96); very heavy 1.17 (0.93–1.47) 95 percent confidence interval When lifetime abstainers used as reference, the protective effect of moderate drinking fell short of significance. When dependence was considered, light and moderate drinkers without dependence had a reduced mortality risk regardless of reference group.
Farchi et al., 2000 Prospective cohort 1536 males aged 45–65 in 1965 in Northern and Central Italy <12 g/d; 13–48 g/d; 49–84 g/d; 85–120 g/d; over 120 g/d age-adjusted life expectancy; total mortality 30 years Age-adjusted life expectancy (years+/-SE) <12 g/d–19.6+/-0.9; 13–48 g/d–20.9+/-0.5; 49–84 g/d–21.6+/-0.4; 85–120 g/d–19.4+/-0.6; over 120 g/d–20.6+/-0.2 Years+/-SE Taking smoking habit into account, longest survival was observed in non-smokers drinking 4-7 drinks daily. Stratifying for physical activity, the longest survival was in men engaged in heavy physical activity at work drinking 1-4 drinks per day.
Gaziano et al., 2000 prospective cohort 89,299 U.S. men from the Physicians' Health Study who were age 40–84 years in 1982 and free of known MI, stroke, cancer or liver disease rarely/never drinkers; 1 drink/wk; 2–4 drinks/ wk; 5–6 drinks/wk; 1 drink/d; > 2 drinks/d total mortality 5.5 years of followup RR of total mortality rarely/never drinkers 1.00; 1 drink/wk 0.74; 2–4 drinks/ wk 0.77; 5–6 drinks/wk 0.78; 1 drink/d 0.82; > or = 2 drinks/d 0.95 Total mortality significant at 95 percent CI, except >or= 2 per day (0.79-1.14) CVD mortality L-shaped with apparent risk reductions even at highest category of > or = 2 drinks per day; no clear harm or benefit for total or common site-specific cancers
Hoffmeister et al., 1999 Prospective cohort 15,400 representative sample of German population and 2,370 regional sample of the Berlin-Spandau, age 25–69 years 0 g/d; 1–20 g/d; 21–40 g/d; 41–80 g/d; >80 g/d all-cause mortality 7 years for Berlin-Spandau population All-cause mortality hazard ratio (HR) for men - 0 g/day 1.00; 1–20 g/d 0.51 (0.29–0.90); 21–40 g/d 0.90 (0.51–1.56); 41–80 g/d 0.93 (0.49–1.76); >80 g/d 0.44 (0.10–1.86); All-cause mortality hazard ratio (HR) for women - 0 g/day 1.00; 1–20 g/d 0.83 (0.47–1.47); 21–40 g/d 1.29 (0.61–2.72); 41–80 g/d 0.81 (0.25–2.65); >80 g/d 4.20 (1.23–4.30) 95 percent confidence interval 65 percent of men and 85 percent of women were light or moderate drinkers.
Jackson et al., 2003 Prospective cohort 112,528 U.S. men from the Physicians' Health Study, 1320 of whom reported a baseline history of stroke rarely or never drink; very light (<1 drink/d); light (1–6 drinks/wk); moderate (> 1 drink/d) total mortality 4.5 years RR rarely or never drink 1.00; <1 drink/d 0.88 (0.60–1.28); 1–6 drinks/wk 0.64 (0.48–0.85); > 1 drink/d 0.71(0.54–0.94) 95 percent confidence interval; p=0.03 for trend RR for cardiovascular mortality - very light 0.89 (0.58-1.36); light 0.56 (0.40-0.79); moderate 0.64 (0.46-0.99); p=-0.008 for trend
Keil et al., 1997 Prospective cohort 1071 and 1,013 women, age 45–65 years, from the Ausburg region of Germany nondrinkers; drinkers (further divided by grams of alcohol/d) total mortality 8 years Hazard rate ratio nondrinkers 1.00; drinkers 0.59 (0.36–0.97); For different alcohol groups - 20–39.9 g/d 0.46 (0.20–0.80); > 80 g/day 1.04 (0.54–2.00) 95 percent confidence interval Total mortality HRR showed U-shaped curve.
Maskarinec et al., 1998 prospective cohort 40,000 persons with Caucasian, Chinese, Filipino, Japanese, and native Hawaiian ethnicity none, low alcohol intake (1–7 drinks/wk); higher levels of intake (>7 drinks/wk) all-cause mortality 20 years Men and women with low alcohol intake (1–7 drinks/wk) had 20 percent reduction in total mortality. At higher levels of intake, women and Asian men experienced no mortality benefit.
Mukamal et al., 2001 prospective cohort 1,913 adults hospitalized with AMI between 1989 and 1994 in 45 U.S. community and tertiary care hospitals none; less than 7 drinks/wk; 7 or more drinks/wk; (1 drink = 15 g alcohol) all-cause mortality 3.8 years Hazard ratio (full model) abstainers 1.00; <7 drinks 0.79 (0.60–1.03); > 7 drinks 0.68 (0.45–1.05) 95 percent confidence interval, p=0.01 for trend
Muntwyler et al., 1998 Prospective cohort 5,358 men from Physicians' Health Study who reported a history of MI and provided information on alcohol intake rarely/never drinkers; 1–4 drinks/ month; 2–6 drinks/wk; 1 drink/d; > 2 drinks/ d total mortality 5 years Multivariate RR-age 65–84y rarely/never drinkers 1.00; 1–4 drinks/mo 0.84 (0.65-1.07); 2–6 drinks/wk 0.70 (0.54–0.91); 1 drink/day 0.81 (0.64–1.02); > 2 drinks/d 0.89 (0.55–1.47) 95 percent confidence interval Total mortality and alcohol association did not differ significantly by age classification (40-64 y vs. 65-84 y)
San Jose et al., 1999 Prospective cohort 18,973 residents in Eindhoven, Netherlands abstainers; light (1–14 units/wk); moderate (15–28 units/wk); excessive (> or =29 units/wk) mortality light or moderate drinkers had lower mortality than either abstainers or heavier drinkers
Simons et al., 2000 Prospective cohort 1,235 men and 1,570 women age 60 years and over living in Dubbo, New South Wales, first examined in 1988-89 zero consumption; 1–7 drinks/week; 8–14 drinks/wk; 15–28 drinks/wk, >28 drinks/wk (1 drink = 10 g alcohol) mortality 116 months Hazard ratio: Men (60–74 y.o.) - no consumption 1.00; 1–7 drinks/wk 0.68 (.49–.94); 8–14 drinks/wk 0.58 (.39–.85); 15–28 drinks/wk 0.62 (.40–.95) >28 drinks/wk 0.56 (.33–.96); Women (60+ y.o.) - no consumption 1.00; 1–7 drinks/wk 0.78 (.61–.99); 8–14 drinks/wk 0.66 (.45–.97); 15–28 drinks/wk 0.67 (.29–1.55) 95 percent confidence interval Any intake of alcohol was associated with reduced mortality in men up to 75 years and in women over 64 years. After almost 10 years follow-up, men taking any alcohol lived on average 7.6 years longer and women on average 2.7 months longer, than non-drinkers. Study also provides HR for pattern of alcohol intake.
Theobald et al., 2000 Prospective cohort 1,828 individuals age 18-65 years lifelong abstainers; ex-drinkers; <50 g/wk; <140 g/wk total mortality 22 years RR compared with intake of wine less than once a week or not at all – Intake of wine once a week or more 0.58 (0.40–0.84); RR compared to lifelong abstainers and <50 g - ex-drinkers 2.64 (1.56-4.49) 95 percent confidence interval
Thun et al., 1997 Prospective cohort 490,000 people (251,420 women and 238,206 men) age 30–104 in 1982 that were part of the Cancer Prevention Study II nondrinkers; less than daily (but at least 3/wk); remaining reported in units per day (i.e. 1/day, 2/day, etc); (1 drink = 12 g alcohol) all-cause mortality 9 years RR for 60-79 y.o. with low cardiovascular risk - nondrinkers 1.00; less than daily 0.8 (0.8–0.9); 1 drink/d 0.8 (0.8–0.9); 2 drinks/d 0.8 (0.8–0.9), 3 drinks/d 0.9 (0.9–1.0); > 4 drinks/d 1.0 (0.9–1.1); RR for 60–79 y.o. with high cardiovascular risk - nondrinkers 1.00; less than daily 0.8 (0.8–0.9); 1 drink/d 0.8 (0.8–0.8); 2 drinks/d 0.8 (0.8–0.8), 3 drinks/d 0.8 (0.7–0.9); > 4 drinks/d 0.8 (0.7–0.8) 95 percent confidence interval
Woo et al., 2002 Prospective cohort 2,032 Chinese subjects aged 70 years and older (mean age 80 years) abstinence; occasional (less than once to up to twice per week); regular (three of more times weekly) mortality 3 years OR abstinence 1.00; occasional 0.625 (0.41,0.95); regular 0.684 (0.44,1.07) 95 percent confidence interval - However not statistically significant after adjusting for age and baseline self-perceived health