Comments Regarding the guideline concerning Alcoholic Beverages in
Nutrition and Health: Dietary Guidelines for Americans

submitted to the
Dietary Guidelines Advisory Committee

December 17, 1998

Below you will find a copy of comments submitted to the Dietary Guideline Advisory Committee, by the Center for Science in the Public Interest, Alcohol Policies Project.  We encourage you to submit your own comments (preferably by January 15, 1999) concerning alcoholic beverages and the dietary guidelines to:

Ms. Shanthy Bowman, Ph.D.
Agricultural Research Service
Nutrient Data Laboratory
4700 River Road, Unit 89
Riverdale, Maryland 20737

Email: sbowman@rbhnrc.usda.gov

Table of Contents

1. Avoid wording in this guideline that would provide new marketing opportunities for the alcoholic beverage industry

2. The word "moderate" in this guideline is without meaning and should be replaced with a specific recommendation to consume no more than one drink per day

3. Include a caution on breast cancer risk

4. Include a special alert regarding alcohol and young people page 9

5. Delete the unnecessary sentence: "Alcoholic beverages have been used to enhance the enjoyment of meals throughout human history."

6. Highlight alternatives to alcohol consumption as a way of reducing CHD risk

7. Include a special caution regarding alcohol and the elderly page

8. Final Recommendations on revised wording

9. Notes

Introduction

Alcohol is the third leading cause of death in the United States but, in some situations, may provide a health benefit. Men and women who drink alcoholic beverages regularly have, in comparison with abstainers, higher death rates from cirrhosis, cancers of the mouth, larynx, pharynx, esophagus, and liver1; from colorectal cancer, breast cancer, hemorrhagic stroke; and from injuries, violence, poisoning and suicide. Alcohol causes birth defects and can cause inflammation of the pancreas and damage to the brain. Small amounts of alcohol, for some individuals, might benefit health; particularly for those who are at high risk for coronary heart disease.

As you consider revisions to the U.S. Dietary Guidelines for Americans we raise seven concerns for your attention. After we review these concerns, we conclude with recommendations for improvements in the wording of the section of the current guidelines which deals with alcoholic beverages. Principally, we urge the committee to avoid creating a document that could be interpreted as endorsing a generic message to the public to increase alcohol consumption or initiate drinking for health reasons.

1. The wine industry has exploited the 1995 Dietary Guidelines for Americans as a marketing tool to encourage the consumption of alcoholic beverages "as part of a healthy lifestyle." Unless the revised guidelines are carefully constructed, that industry can be expected to continue to encourage people, directly or indirectly, to either take up drinking or to increase their drinking for health reasons.

Vintners and wine marketers, as well as others in the alcoholic-beverage industry, used the last revision of the guidelines as a tool in their marketing efforts to increase the consumption of beverage alcohol. At the time the Guidelines were released, the Wine Institute revealed its aim of promoting wine as a health food:"We had a campaign of tenacity, working with contributions from the scientific community . . . We have taken [wine drinking] away from the shadows of the past, where the industry was seen as a 'sin industry' and into something that is part of a healthy diet."2

Spurred by spin from the wine industry, numerous stories in both the industry and general media portrayed the 1995 changes in the Guidelines' wording as a significant departure from past government policy on alcohol consumption, and as an official recognition that drinking is beneficial to health. That, of course, is not what the guideline says. But as this committee already recognized during its preliminary discussion in September, one needs to be concerned both with the actual wording of the guideline, and the way that its meaning will be interpreted -- or potentially distorted -- by industry, the media, and the public.

For that reason, we agree with Dr. Kumanyika, who, during the committee's discussion of the sodium guideline at its first meeting, noted that the guideline needed to be written so that the recommendations to the public have a big safety margin in them, in order to make certain that people do not misinterpret the Guidelines and consume less than they actually need.3

Later on that same day, in discussing the wording of the alcohol guideline, Dr. Kumanyika said, "And I think we should bend over backwards not to suggest that we actually have evidence that beginning to drink lowers risk because we just can't tell that."4

Consider wine marketers' plans as you choose language to reflect both the risks and potential benefits of alcohol consumption. Last year, the industry journal Impact summarized the marketing strategy of the vintners: "For wine advertisers, the challenge is to find marketable ways which showcase wine as a choice of a healthy lifestyle as well as a moderate self-indulgence."5

This strategy has been widely recognized and accepted. David Higgins, President of Brown-Forman Wine Group, which markets wines under the Fetzer and Jekel brand names, asserts: "Lowering prices isn't going to sell any more wine. We have to get consumers to drink more."6 One way to get consumers to drink more is to convince them that drinking is healthy. At least that's the view of Peter Kavanaugh, President & CEO of Schieffelin & Somerset Co. At last spring's Impact marketing conference he said that the wine industry needs to grow by persuading marginal drinkers to increase their consumption. According to Kavanaugh:

What the industry needs to concentrate on is the group of people who are looking for permission to enjoy beverage alcohol but whose consumption habits are becoming denormalized by societal pressures which cause them to overthink the appropriateness of their usage. The time for this is ripe. We even have the US government and health organizations endorsing the notion that responsible consumption of beverage alcohol correlates with wellbeing and increased longevity.7

The views of the spirits industry are much the same, although liquor interests have not been nearly so aggressive as the wine industry. Tony Greene, chairman of Guinness PLC, answered a rhetorical question about the future of the alcohol industry by suggesting that liquor marketers: "chang[e] the sentiment toward the spirits industry through educating consumers to the benefits of alcohol."8

The "drink for your health "strategy is working, driving wine sales higher. According to an NPD group (the ninth largest marketing research firm in the United States) annual report, Eating Patterns in America, alcoholic beverages have now replaced coffee as the beverage most likely to be consumed with dinner -- and wine is the most popular of the alcoholic beverages, consumed at more than 50% of meals in which an alcoholic beverage is consumed.

NPD's vice-president Harry Balzer attributes this to the link between alcohol and health. "Recent publicity about the healthy effects of moderate alcohol intake could be behind this trend. The fact that it's increasing among Baby Boomers and mature Americans leads me to believe that these consumers are motivated by what they feel are the medicinal benefits of having a drink with dinner, trying in effect to 'drink' themselves to better health."9

Industry observers have noted:

The '60 Minutes' story on the 'French Paradox' that first aired in 1991 is seen as a watershed for the industry. That year, red wine shipments jumped by 39%, and the industry has never looked back.

Subsequent reports supporting wine's health benefits have added to the momentum. Perhaps the most important was last year's change in the U.S. Dietary Guidelines for Americans, which for the first time acknowledged scientific evidence linking moderate alcohol beverage consumption with lower risk of heart disease.10

"The positive health reports are still having an influence on the market,"says Howard Jacobson, senior vice-president, marketing, for Canandaigua Wine Company Inc. "Marketers are trying to figure out a way to keep that message in the forefront. We're having difficulty because of federal regulations, but there's so much positive information coming out with various studies that it's hard to get away from."11

"A steady flow of public information about studies linking wine to health benefits has given a major boost to sales. 'These announcements are increasing consumption more than anything else,' says Stephanie Grubbs, marketing manager for Robert Mondavi Coastal, one of the Hot Brands [for 1997]. 'The country seems to be changing its opinion on wine.' "12

Mark Fedorchak, the Vice-President for Brand Development at Bonterra and Bel Arbor Fetzer Winery has said that the 1995 revision in the Dietary Guidelines was more important than the 60 Minutes broadcast in boosting wine sales.

The wine industry has used "health claims" as a marketing tool even in those instances where the scientific record has not supported its statements. In October 1997 CSPI released a report, Vintage Deception, which documented that, in its publications and its web site, the Wine Institute had exaggerated claims about the health effects of drinking wine, regularly omitted the cautions and qualifications made by the researchers whose work was cited, and suggested additional health claims based on unpublished laboratory studies.

On September 30 13, the Federal Trade Commission closed an investigation into health claims made by the Wine Institute about the relationship between wine consumption and breast cancer risk. The Wine Institute had claimed in its web site that wine consumption was not associated with an increase in breast cancer risk and might in fact reduce a woman's risk of contracting breast cancer. The FTC found that the weight of scientific evidence was contrary to the Wine Institute's claims.

In August, a group of researchers from the U.S. Centers for Disease Control and Prevention in Atlanta released a new study of alcohol consumption by pregnant women. They found that, after declining during the late 1980's, alcohol consumption by pregnant women in the United States (the primary cause of fetal alcohol syndrome) began to increase after 1991 (following the CBS '60 Minutes' report on the "French paradox"). The lead author hypothesized that the increased drinking by pregnant women might be due to the recent reports on the health benefits of moderate drinking, and to the heightened media attention given those reports.14

In our opinion, the Wine Institute, and possibly the other alcoholic beverage marketers, will take advantage of every possible opening to portray the consumption of alcoholic beverages as a "healthy choice" for consumers. The Wine Institute currently has an application pending before the Bureau of Alcohol, Tobacco and Firearms for permission to begin using the following statement on the labels of wine bottles: "To learn about the health effects of moderate wine consumption, send for the Federal Government's Dietary Guidelines for Americans."

We have opposed that request for several reasons: the Dietary Guidelines are not designed to provide a complete statement of the risks and benefits of alcohol consumption; and the current Guidelines do not mention some of the most troubling risks of moderate consumption, such as breast cancer risk. According to consumer research on the proposed label, few people would actually look at, or write for, the Guidelines on the basis of the label language.15 We believe that the proposed label statement would inaccurately imply to consumers that the health benefits to consuming wine are substantial and universal. Such a statement would serve to reinforce wine industry efforts to market wine as a "health food."

The wine industry worked very hard to portray the last revision of the Dietary Guidelines for Americans as a significant change in government policy on alcohol consumption and as a government endorsement of drinking. Unless the next revision is very carefully crafted, we can expect similar distortions of this advisory committee's current work.

In light of this marketing reality, we urge the advisory committee to consider revising the guidelines in ways that make such distortions as difficult and unlikely as possible.

2. The use of the word "Moderate" in the existing Dietary Guidelines for Americans is without meaning, and should be dropped.

As Dr. Stampfer recognized in his initial presentation to the Committee on the alcohol guideline "usually moderate is, you know, whatever the speaker does and more than that is excess."16

In fact there is direct consumer survey evidence to buttress the considerable anecdotal evidence of this view. When the Center for Substance Abuse Prevention (CSAP) of the Department of Health and Human Services did a study of a potential wine label referring to "moderate consumption " it concluded:

The word 'moderate' when associated with drinking has virtually no meaning. The subject's conception of moderate ranged from "1 or 2 drinks a month" to "a bottle of wine in an evening." Heavier drinkers' concept of moderate drinking involved much more drinking than did the concept of light or medium drinkers. The more one drinks, the more drinking one thinks is moderate. The average number of drinks per occasion that heavy drinkers thought was moderate was almost 6 (higher than the generally accepted definition of binge drinking.)17

The existing version of the Dietary Guidelines for Americans uses the word "moderate" or the phrase "in moderation" throughout the text, and features a box (Box 16) which defines moderation as "no more than one drink per day for women and no more than two drinks per day for men."

Unfortunately this solution works only for those people who read the complete version of the Dietary Guidelines. For the far greater number of people who have heard about the alcohol guideline through press reports, or through the public relations efforts of alcohol companies and their trade associations, the word "moderate" stands by itself without explication.

In a review of the literature on the risks and benefits of alcohol use, Dr. Mary C. Dufour, Deputy Director of NIAAA, says:

"Similarly, the terms 'abstainer,' 'light,' 'moderate,' 'heavy,' and 'heavier,' are commonly used to describe types of drinkers, although no standard definitions exist for these drinking levels . . . This definitional vagueness can lead to considerable confusion . . . For example, people who intend to drink for cardioprotection need to know at what level of alcohol consumption such benefits accrue (i.e., how many and what size drinks constitute 'moderate' drinking) and what additional risks are associated with that drinking level."18

Fortunately there is a better way to address the definitional issue. Rather than using the phrase "in moderation" and then defining it, the revised Guidelines could simply express what it means. We suggest that the alcohol guideline reflect an actual recommended maximum quantity of safe and healthful alcohol consumption.

What level of consumption should the Guidelines endorse?

Dr. Stampfer has already suggested an answer, in his response to a question posed by Dr. Grundy during his initial presentation to the committee on September 28:

DR. GRUNDY: What is the least amount of alcohol in grams you could take to give this beneficial effect? It seems like it is fairly low.

DR. STAMPFER: Yes, I think it is. It's lower for women than for men in terms of its metabolic effect and also in the epidemiologic studies such that even, say, a half a drink a day you could -- you could have a measurable effect for women.

In terms of grams, that would be about, you know, six grams of alcohol. For men, it seemed like somewhat higher levels. But even a drink a day is at a level where you would see substantial benefit for coronary disease.19

Of course, as the Dietary Guidelines for Americans has already recognized, alcohol is an unusual substance. On the one hand, it is a part of many people's diets. While providing little in the way of nutrients, it has a modestly protective effect for some people, at low levels of consumption, against the risk of coronary artery disease. Alcohol consumption also increases the risks for a variety of other diseases and conditions as it increases.

Alcohol is potentially addictive for approximately 10% of those who consume it. As a mind-altering substance, it puts people at risk for everything from domestic violence and auto accidents to diseases (such as HIV) that may result from unwise behavior due to intoxication.

Determining a reasonable recommended level of alcohol consumption requires finding an amount that provides substantial protective benefits (within a safety margin against consumers' tendencies to exceed recommended levels) while still insuring minimum risk for other diseases and conditions. A review of the evidence related to the principal benefits associated with moderate alcohol consumption will help make that assessment.

Coronary Artery Disease

By now, a wide variety of studies has been conducted on the effects of moderate alcohol consumption in protecting people against coronary artery disease. Although the findings vary somewhat as to the smallest amount one can consume while still enjoying the maximum benefit compared to abstainers, most of the studies show the largest protective effect at the level of one drink per day for men, and half a drink per day for women.

J. Michael Gaziano, the Director of Cardiovascular Epidemiology at Boston University Hospital, summarized the literature at last year's American Heart Association annual meeting: "If you drink half a drink per day, you're not likely to derive greater benefit from drinking two drinks per day."20

Likewise the study by Camargo et. al. of the relationship between moderate alcohol consumption and the risk for angina pectoris or myocardial infarction found the most marked effect at about one drink per day.21

Rimm et. al.'s study on the relationship between alcohol consumption and the risk for coronary disease in men found the protective effect continued to consumption levels of 50/g/day level (about four drinks per day). However, two-thirds of that protective effect had been reached by the level of 10-16/g/day (less than one to 11/4 drinks per day),22 and the higher levels of alcohol consumption significantly increase risks for other health problems.

Another leading study, by Klatsky et. al., found the maximum reduction in risk for coronary artery disease to occur between 1 and 2 drinks per day. The risk then plateaued until the level of 5 drinks per day, when it began to increase again.23 See Table 1 below.

Table 1. Relative risks of death in drinkers compared with risk of lifelong abstainers after adjustment for age, sex, smoking, and nine other 'risk factors'

Drinking Category Coronary artery
Disease
All Causes
(2430 Deaths)
Lifelong abstainers 1.0 1.0
Ex-drinkers 1.0 1.1
Drinkers (no. of drinks)    
> 1 per month (occasional) 0.8 0.9
1-2 per day 0.6 0.9
3-5 per day 0.6 1.0
> 6 per day 0.8 1.4
Source: Richard Doll, "One for the Heart", BMJ, December 1997, p. 1665 based on data from Klatsky et al.

In reviewing all the available literature on the relationship between alcohol use and heart disease in 1995, Dr. Enoch Gordis, the Director of NIAAA, concluded: "Some research suggests that the cardioprotective effects of alcohol can be achieved with as little as one drink every other day [1/2 a drink per day]. In other studies the levels are higher."24

All-Cause Mortality

Of course, heart disease is only part of the picture, and depending on the age and gender of the consumer it may be a minor one. Men and women who drink alcoholic beverages have, in comparison with abstainers, higher death rates from injuries, violence, suicide, poisoning, cirrhosis, certain cancers, hemorrhagic stroke, but lower death rates from coronary artery disease and thrombotic stroke.

To quote Enoch Gordis again:

"The odds of a 16 year old dying of a heart attack are infinitely smaller than the odds of his or her being killed in an alcohol-related traffic crash. Coronary heart disease impacts primarily in men age 45 and older and women age 55 and older (postmenopausal)."25

Despite the large role of CHD in premature death, the Dietary Guidelines for Americans must look at the impact of alcohol consumption on total mortality and morbidity rather than narrowly review the impact on coronary heart disease. When viewed in this light, the studies more clearly show that the maximum benefits from consuming alcohol can be reached at levels of about one drink (or less) per day for a man, and approximately half that for a woman.

Mary Dufour's review of the literature on all-cause mortality provides a balanced exposition of the variety of risk factors of alcohol consumption based on a person's age, gender, and personal history. In essence, her review concludes that the greatest decline in all-cause mortality occurs at one drink per day, and begins to rise after that.26

Similarly, Thun et. al.'s study of alcohol consumption and mortality among middle-aged and elderly U.S. adults found that the lowest level of all-cause mortality for both men and women occurred at the level of one drink per day, and rose thereafter.27

Likewise, Klatsky showed all-cause mortality troughing at levels between less than one drink per month and 1 to 2 drinks per day, and increasing thereafter. (See Table 1 above).

In a comprehensive review of 29 studies, Poikolainen found that the consumption associated with minimum mortality varied from less than a drink per day to five, with one being the most frequently reported.28

Finally it is worth noting that some researchers question the protective effects of drinking on "all-cause" mortality. In a comprehensive review of the literature released last January jointly by the University of California at San Francisco and the journal Addiction, a group of researchers looked at all the other characteristics of "long-term abstainers",; "non-drinkers and," light drinkers" and attempted to adjust for all possible confounding variables such as life-style, weight, smoking history, etc. This study concluded that there was no higher risk for premature death among abstainers than among light drinkers.29

Therefore, in the interest of defining a safe limit of alcohol consumption that maximizes health benefits and minimizes risks, we recommend that the current qualitative drinking recommendation of the Dietary Guidelines for Americans be revised to read: "If you choose to drink, limit your consumption to one drink per day."

3. Since the last revision of the Dietary Guidelines for Americans, new evidence has emerged linking moderate alcohol consumption and a woman's risk of contracting breast cancer. The current Guidelines fails to mention this risk and it should be revised to highlight this information.

The existing 1995 edition of the Dietary Guidelines for Americans contains one "catch-all" reference to cancer. The second paragraph reads: "However, higher levels of alcohol intake raise the risk for high blood pressure, stroke, heart disease, certain cancers, accidents . . ." among other maladies related to heavier drinking.

At least five studies published in the past two years, including one large pooled analysis of cohort studies involving 322,647 women, identify alcohol consumption as a positive risk factor for incidence of breast cancer.30,31,32,33,34 The relationship between alcohol consumption and cancer incidence appears to be linear, and manifests at consumption levels as low as one-half glass per day (6 to 8 grams of ethyl alcohol). Although the increased risk is modest (9% for each 10 g/day increase in consumption) it is stronger than the increased risk associated with several reproductive factors and a positive family history of breast cancer.35

Menstrual and reproductive factors are the most widely studied and understood risk factors for breast cancer. However, those factors are largely outside consumers' control. Consequently, the public health implications of those causes are limited. Among those factors which are within a consumer's control, diet and nutritional factors are of specific interest, since several studies have found that a diet rich in vegetables and fruit has a favorable impact on breast cancer risk, whereas consumption of alcohol increases risk for breast cancer.36

The new information about breast cancer risk is distinguishable from the other cancer risks known to be associated with alcohol consumption. Unlike the evidence related to other cancers,37 breast cancer risk occurs even at relatively low levels of consumption. Thus the existing language of the guideline which associates "certain cancers" with "higher levels of alcohol intake" is inadequate, and needs to be modified.

We recommend that the wording of the alcohol guideline be changed to read:

  • "Current evidence suggests that one to two drinks per day is associated with a lower risk for coronary heart disease in some individuals, and with an increased risk of breast cancer for women.

  • "However, higher levels of alcohol intake raise . . ."

4. Alcohol is a potentially addictive drug; approximately 10% of drinkers will either become addicted to alcohol or suffer serious drinking problems. The current Guidelines pay little more than lip service to this risk. Recent evidence strongly confirms that alcohol dependency may be related to the early use of alcohol. The earlier someone begins to drink, the greater the risk of eventual addiction. We recommend that the Guidelines be modified to address this risk more specifically.

It is widely accepted that alcohol is a potentially addictive drug, and that the causes of alcohol addiction are a complex interaction of genetic factors and personal history.

NIAAA research demonstrates that the age at which one begins to drink is an important causal factor. If one begins to drink before the age of fourteen, one has a 43% of becoming alcoholic later in life; if one waits until 18 the risk drops to 20%, and if one waits until 21 the risk drops to 10%.38 Although the mechanisms for this relationship are not currently understood, the study's authors hypothesize that alcohol consumption during puberty affects the way neural connections are developed in a young person's brain.

All states prohibit the purchase of alcoholic beverages by those under 21. Despite those laws, young people drink, and the prevalence of underage drinking is on the increase. According to the Monitoring the Future study,39 three-quarters of all 12th graders and 65% of all 10th graders report having drunk alcohol in the past year. In fact, the median age at which children begin to drink is now 13.6 years.40 After declining in the late 1980s, the percentage of young people who drink is also on the rise.

In an atmosphere where the consumption of alcohol is often seen as a "coming-of-age" rite, it is important to make clear that there are good public health reasons to discourage underage drinking.

We therefore recommend that the Dietary Guidelines for Americans be modified to include a cautionary note about the potentially addictive nature of alcohol consumption and the particular risks of initiating consumption during the adolescent and teen years.

5. The sentence in the current guideline that reads: "Alcoholic beverages have been used to enhance the enjoyment of meals by many societies throughout human history" is gratuitous, unnecessary, and irrelevant to the purposes of the guidelines and should be deleted.

The only purpose for that sentence, which (presumably) was added to the Guidelines at its last revision at the suggestion of the alcoholic-beverage industry, is to provide an opportunity for alcohol marketers to use the Guidelines to promote the consumption of their products.

Significantly, it is not paralleled by similar language in other guidelines. To be consistent one would expect that the guideline for sodium would read:

"Salt has been used to enhance the enjoyment of meals by many societies throughout human history."

Or that the guideline for sugars would contain a sentence reading:

"Sugar has been used to enhance the enjoyment of meals by many societies throughout human history."

Or that the guideline for dealing with fat, saturated fat, and cholesterol would contain a sentence reading:

"Fatty foods have been used to enhance the enjoyment of meals by many societies throughout human history."

All of those statements are true -- and none of them has a place in the Dietary Guidelines. To the extent that consumers need to be reminded of the obvious -- that eating and drinking are not only necessary for life, but potentially sources of pleasure -- that is already accomplished in the second paragraph of the introductory page of Dietary Guidelines for Americans, under the heading: "Eating is one of life's greatest pleasures."

We therefore strongly recommend deleting the sentence about "enhancing the enjoyment of meals" from the seventh guideline.

6. Low-risk alternatives to alcohol consumption to reduce the risk of heart disease.

The Dietary Guidelines for Americans already contains substantial information about ways other than consuming alcohol that will reduce a person's risk for CHD. Both the introductory sections and the second guideline ("Balance the food you eat with physical activity -- maintain or improve your weight") urge consumers to exercise. The third guideline points out that a high-fiber diet "may lower the risk of heart disease and some cancers." The fourth suggests that a diet low in saturated fat and cholesterol will reduce the risk of heart disease.

As Dr. Garza pointed out during the first day of the advisory committee's meetings in September, those alternative strategies may be preferable for those who do not want to accept the other risks attendant to alcohol consumption, such as the potential for addiction.41

We recommend that the alcohol guideline be revised to include the following sentence at the end of the second paragraph:

"Those who are concerned about coronary heart disease should pay attention to the alternative methods for reducing their risk, such as regular exercise and the reduction of cholesterol, which have been discussed in the preceding six guidelines."

7. Alcohol and the elderly

The intricate balance between the health risks and benefits involved in drinking alcohol are more complex for the elderly than they are for the overall population.

On the one hand, the benefits of consuming a small amount of alcohol as a way of reducing the risk of coronary artery disease may be more important for the elderly than for any other population group, because this is the group at greatest risk for CHD.

On the other hand, there are several risks that are heightened for the elderly. As Enoch Gordis has pointed out:

While the misuse of alcohol has serious repercussions at any age, its consequences may be even more serious in the aging individual whose systems are already undergoing a process of decline. Both episodic heavy drinking and chronic drinking appear to precipitate or aggravate a number of conditions that may be experienced in the later years. Among these are cardiovascular disease, stroke, diabetes, cognitive loss, falls and fractures, depression, isolation and suicide.42

Several factors distinguish the elderly population as potential consumers of alcohol:

(1) Because of their reduced body mass, alcohol is more quickly absorbed into the blood stream of elderly persons and a given amount of consumption will produce a higher blood alcohol concentration than it will in younger consumers.

(2) As the country's largest consumers of legal drugs, older persons are especially vulnerable to adverse alcohol/drug interactions. This is particularly true for older women, who consume medications at a rate more than twice that of older men.43,44,45,46

(3) In recent years, increasing attention has been paid to the phenomenon of "late onset alcoholism." It is now recognized that a group of people exist who have not shown problem drinking behavior in earlier life, but who become alcoholic later on.47

For all those reasons, we recommend that the Dietary Guidelines for Americans be revised to include a particular caution to elderly consumers. Any statements that assert the possible health benefits of alcohol consumption for the elderly should be carefully balanced with warnings about the heightened risks they also face.

CONCLUSIONS

We recommend to this committee that the title and content of the Seventh Dietary Guideline be changed to read as follows: (Note that the wording we suggest you change is in red, while the wording that would remain unchanged is in black)

If you choose to drink, limit your consumption of alcohol to one drink per day.

Alcoholic beverages supply calories but few or no nutrients. The alcohol in these beverages has effects that are harmful when consumed in excess. These effects of alcohol may alter judgment and can lead to dependency and a great many other serious health problems. If adults choose to drink alcoholic beverages, they should consume one drink per day or less.

Current evidence suggests that one to two drinks per day are associated with a lower risk for coronary heart disease in some individuals and with an increased risk of breast cancer for women. However, higher levels of alcohol intake raise the risk for high blood pressure, stroke, heart disease, certain cancers, accidents, violence, suicides, birth defects, and overall mortality (deaths). Too much alcohol may cause cirrhosis of the liver, inflammation of the pancreas, and damage to the brain and heart. Heavy drinkers also are at risk of malnutrition because alcohol contains calories that may substitute for those in more nutritious foods. Those who are concerned about coronary heart disease should pay attention to the alternative methods for reducing their risk, such as regular exercise and the reduction of cholesterol, which have been discussed in the preceding six guidelines.

Alcohol is a potentially addictive drug, and approximately 10% of those who choose to drink will develop alcoholism.

Who should not drink?

Some people should not drink alcoholic beverages at all. These include:

  • Children and adolescents. The risk of becoming addicted to alcohol is much higher for those who drink as teenagers.
  • Individuals of any age who cannot restrict their drinking to moderate levels. This is a special concern for recovering alcoholics and people whose family members have alcohol problems.
  • Women who are trying to conceive or who are pregnant. Major birth defects, including fetal alcohol syndrome, have been attributed to heavy drinking by the mother while pregnant. While there is no conclusive evidence that an occasional drink is harmful to the fetus or to the pregnant woman, a safe level of alcohol intake during pregnancy has not been established.
  • Individuals who plan to drive or take part in activities that require attention or skill. Most people retain some alcohol in the blood up to 2-3 hours after a single drink.
  • Individuals using prescription and over-the-counter medications, especially the elderly. Alcohol may alter the effectiveness or toxicity of medicines. Also, some medications may increase blood alcohol levels or increase the adverse effect of alcohol on the brain.

ADVICE FOR TODAY

If you drink alcoholic beverages, consume one drink or less a day, with meals, and when consumption
does not put you or others at risk
.

ENDNOTES:

1. Thomas DB, "Alcohol as a Cause of Cancer," Environmental Health Perspectives, Vol. 103, Supplement 8, November 1995, pp. 153-160.

2. Nolte, Carl. "Wine Institute wins in new guidelines: A drink with meals now called OK." San Francisco Chronicle,
January 4, 1996, page A4.

3. Transcript of the September 28, 1998 meeting of the Dietary Guidelines Advisory Committee, at pp. 179-180.

4. Transcript at page 215.

5. Impact, Sept 1, 1997, Vol. 27, No. 17, p. 5.

6. Impact, Sept. 1, 1998, Vol. 28, No. 16, p. 2.

7. Impact, April 15 & May 1, 1998, Vol. 28, p. 20. [Emphasis added]

8. DISCUS News Release, January 27, 1998. It is fair to note that the wine industry is alone in actively pursuing a "health claims" marketing strategy -- neither the beer makers nor the "hard liquor" industry make such claims, despite the fact that the positive impacts of alcohol consumption on the incidence of coronary artery disease seem due to ethanol, rather than to beverage consumed. The DISCUS press statement last January goes on to say: "America’s distillers do not recommend that consumers drink beverage alcohol for health reasons. Further, it is commonly known that alcohol abuse can cause serious problems, and there is a body of literature regarding the reported risks of beverage alcohol generally."

9. Press Release of the NPD group, September 21, 1998. Available on the Internet at http://biz.yahoo.com/bw/980921/npd_dinner_1.html.

10. "US Wine Market, Fueled by Varietals, Continues Its Historic Upward Climb," Impact, Aug. 15, 1997, Vol. 27, No. 16, pp. 1-2.

11. Ibid.

12. Impact, March 1-15, 1997, Vol. 27, Nos. 5 & 6, p. 3.

13. September 30, 1998 "Closing Letter" from the Division of Advertising Practices of the Federal Trade Commission, FTC Matter No. 982-3021, investigating health claims made by the Wine Institute in its web site.

14. Ebrahim SH, Luman ET, Floyd RL, Murphy CC, Bennett EM, and Boyle CA, "Alcohol Consumption by Pregnant Women in the United States During 1988-1995," Obstetrics & Gynecology, Vol. 92, No. 2, August 1998, pp. 187 - 192.

15. Lewis D. Eigen, et. al., "The Effect of Wine Labels on Public Perception," Main Findings, January 30, 1998, The Department of Health and Human Services, Center for Substance Abuse Prevention (hereinafter CSAP study), PHD752.

16. Transcript at page 202.

17. CSAP study, op. cit.

18. Mary C. DuFour, "Risks and Benefits of Alcohol Use Over the Life Span," Alcohol Health & Research World, 1996, Vol. 20, No. 3, p. 146.

19. Transcript at page 212.

20. J. Michael Gaziano, Speech in Orlando, Florida before the American Heart Association, November 12, 1997, reporting on a study of 4,797 physicians by himself, Charles Hennekens, Robert J. Glynn and Julie Buring.

21. Camargo, CA Jr., Stampfer, MJ, Glynn, RJ, Grodstein, F, Gaziano, JM, Manson, JE, Buring, JR and Hennekens, CH, "Moderate Alcohol Consumption and risk for angina pectoris or myocardial infarction in U.S. male physicians," Annals of Internal Medicine, March 1, 1997, 126(5): 372-5.

22. Rimm EB, Giovannucci EL, Willett WC, Colditz GA, Asscherio A, Rosner B, Stampfer MJ, "Prospective study of alcohol consumption and risk of coronary disease in men," Lancet, 1991;338;464-468.

23. Klatsky AL, Armstrong MA, Friedman GD, "Risk of cardiovascular mortality in alcohol drinkers, ex-drinkers, and non-drinkers," American Journal of Cardiology, 1990;66:1237-43.  Table 1, which follows was developed by Richard Doll in "One for the Heart", British Medical Journal, December 20-27, 1997, Vol. 315, pp. 1664-1668 based on the data from Kaltsky et. al.

24. "Alcohol and the Heart: The Trade-offs," paper presented by Enoch Gordis at the American Heart Association’s 22nd Science Writer’s Forum, Santa Barbara, California, January 15-18, 1995, p. 9.

25. Ibid, p. 10.

26. Bofetta P, and Garfinkel L, "Alcohol drinking and mortality among men enrolled in an American Cancer Society prospective study," Epidemiology, 1:342-348, 1990.

27. Thun MJ, Peto R, Lopez AD, Monaco JH, Henley SJ, Health CW and Doll R, "Alcohol Consumption and Mortality and Middle-Aged and Elderly U.S. Adults," New England Journal of Medicine, 1998; 337; pp. 1705-1764.

28. Poikolainen K, "Alcohol and Mortality: A Review," Journal of Clinical Epidemiology, 1995; 448: 445-65.

29. Fillmore KM, Golding JM, Graves KL, Kniep S, Leino EV, Romelsjo A, Shoemaker C, Ager CR, Allebeck P and Ferrer HP, "Alcohol Consumption and Mortality", Addiction; 1998; 93(2); 183-229.

30. Smith-Warner SA, Spiegelman D, Yaun S, van den Brandt PA, Folsom AR, Goldbohm RA, Graham S, Holmberg L, Howe GR, Marshall JR, Miller AB, Potter JD, Speizer FE, Willett WC, Wolk A, and Hunter DJ; "Alcohol and Breast Cancer in Women: A Pooled Analysis of Cohort Studies," Journal of the American Medical Association, February 18, 1998, Vol. 279, No. 7, pp. 535-540.

31. Viel J-F, Perarnau J-M, Challier B, & Faivre-Nappez I; "Alcoholic calories, red wine consumption and breast cancer among premenopausal women," European Journal of Epidemiology 13: 1997; pp 639-643.

32. Mezzetti M, LaVecchia C, Decarli A, Boyle P, Talamini R, and Francheschi S; "Population Attributable Risk for Breast Cancer: Diet, Nutrition, and Physical Exercise," Journal of the National Cancer Institute, Vol. 90, No. 5, March 4, 1998, pp. 389-394.

33. Bowlin SJ, Leske MC, Varma A, Nabca P, Weinstein A, & Caplan L; "Breast Cancer Risk and Alcohol Consumption: Results from a Large Case-Control Study," International Journal of Epidemiology, Vol. 28, No. 5, 1997, pp. 915-923.

34. Swanson CA, Coates RJ, Malone KE, Gammon MD, Schoenberg JB, Brogan DJ, McAdams M, Potischman N, Hoover RN & Brinton LA; "Alcohol Consumption and Breast Cancer Risk among Women under Age 45 Years," Epidemiology, May 1997, Volume 8, No. 3, pp 231-237.

35. Smith-Warner, et. al., op. cit.

36. Mezzetti, et.al., p. 389.

37. Esophageal cancer may also manifest at very low levels of consumption. See Launoy G, Milan CH, Faivre J, Pienkowski P, Milan CI and Gignoux G, "Alcohol, tobacco and oesophageal cancer: effects of the duration of consumption, mean intake and current and former consumption," British Journal of Cancer, 1997, 75(9), pp. 1389-1396; and Blot, WJ, "Esophageal Cancer Trends and Risk Factors," Seminars in Oncology, Vol. 21, No. 4 (August) 1994, pp. 403-410.

38. Grant, B.F., and Dawson, D.A. (For HHS); "Age at Onset of Alcohol Use and Its Association with DSM-IV Alcohol Use and Dependence," Journal of Substance Abuse, Vol. 9, pp. 103-110, 1997.

39. Monitoring the Future Study (1997), National Institute on Drug Abuse, Rockville, MD. Based on surveys carried out by the Institute for Social Research at the University of Michigan.

40. Public Health Service, Healthy People 2000: National Health Promotion and Disease Prevention Objectives, U.S. Department of Health and Human Services, Washington, D.C., 1990, p. 97.

41. Transcript at pp. 210-211.

42. Enoch Gordis, "Testimony before the House Select Committee on Aging," February 4, 1992, page 6.

43. Adams, WL, "Interactions between alcohol and other drugs," International Journal of Addictions, 30:1903-1923, 1995.

44. American Medical Association Council on Scientific Affairs, "Alcoholism in the Elderly," Journal of the American Medical Association, 275:797-801, 1996.

45. Smith JW, "Medical manifestations of alcoholism in the elderly," Internal Journal of Addictions, 30: 1749-1798, 1995.

46. Williams M, "Alcohol and the elderly: An overview," Alcohol Health and Research World, 8:3-9. 52, 1984.

47. Brennan PL and Moos RH, "Late Life Drinking Behavior: The Influence of Personal Characteristics, Life Context, and Treatment," Alcohol Health & Research World, Vol. 20, No. 3, 1996, pp. 197-204.

 

For more information call:

George Hacker at (202) 332-9110 Ext 343

Released: December 24, 1998