Alcohol Alert From
Moderate drinking is difficult to define because it means different things to different people. Theterm is often confused with "social drinking," which refers to drinking patterns that are acceptedby the society in which they occur. However, social drinking is not necessarily free of problems. Moderate drinking may be defined as drinking that does not generally cause problems, either forthe drinker or for society. Since there are clearly both benefits and risks associated with lowerlevels of drinking, this Alcohol Alert will explore potentially positive and adverse effects of"moderate" drinking.
It would be useful if the above definition of moderate drinking were bolstered by numericalestimates of "safe" drinking limits. However, the usefulness of quantitative definitions ofmoderate drinking is compromised by the likelihood that a given dose of alcohol may affectdifferent people differently. Adding further complexity, the pattern of drinking is also animportant determinant of alcohol-related consequences. Thus, while epidemiologic data are oftencollected in terms of the "average number of drinks per week," one drink taken each day mayhave different consequences than seven drinks taken on a Saturday night (1).
Despite the complexity, numerical definitions of moderate drinking do exist. For example,guidelines put forth jointly by the U.S. Department of Agriculture and the U.S. Department ofHealth and Human Services (2) define moderate drinking as no more than one drink a day formost women, and no more than two drinks a day for most men. A standard drink is generallyconsidered to be 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof distilled spirits. Each of these drinks contains roughly the same amount of absolute alcohol--approximately 0.5ounce or 12 grams (3).
These guidelines exclude the following persons, who should not consume alcoholic beverages:women who are pregnant or trying to conceive; people who plan to drive or engage in otheractivities that require attention or skill; people taking medication, including over-the-countermedications; recovering alcoholics; and persons under the age of 21 (2). Although not specificallyaddressed by the guidelines, alcohol use also is contraindicated for people with certain medicalconditions such as peptic ulcer.
The existence of separate guidelines for men and women reflects research findings that womenbecome more intoxicated than men at an equivalent dose of alcohol (4). This results, in part,from the significant difference in activity of an enzyme in stomach tissue of males and femalesthat breaks down alcohol before it reaches the bloodstream. The enzyme is four times moreactive in males than in females (5). Moreover, women have proportionately more fat and lessbody water than men. Because alcohol is more soluble in water than in fat, a given dosebecomes more highly concentrated in a female's body water than in a male's (6).
Since the proportion of body fat increases with age, Dufour and colleagues recommend a limit ofone drink per day for the elderly (7). Benefits of Moderate Drinking
Psychological benefits of moderate drinking. A review of the literature (8) suggests that lowerlevels of alcohol consumption can reduce stress; promote conviviality and pleasant and carefreefeelings; and decrease tension, anxiety, and self-consciousness. In the elderly, moderate drinkinghas been reported to stimulate appetite, promote regular bowel function, and improve mood (7).
Cardiovascular benefits of moderate drinking. There is a considerable body of evidence that lowerlevels of drinking decrease the risk of death from co ronary artery disease (CAD). This effect hasbeen demonstrated in a broad range of older epidemiologic studies (9). More recently, Boffettaand Garfinkel (10) found that white American men who reported in 1959 that they consumed anaverage of fewer than three drinks per day were less likely to die during the next 12 years thanmen who reported abstinence. This finding was due primarily to a reduction in CAD. In a similarstudy using a wide range of ethnic groups, De Labry and colleagues (11) found that rates ofoverall mortality were lowest for men who consumed fewer than three drinks per day over a 12-year period.
Similar results have been obtained with female subjects. Stampfer and colleagues (12) analyzeddata on middle-aged women and determined that consumption of approximately one drink perday decreases the risks of coronary heart disease. Razay and colleagues (13), using a randompopulation sample, found consumption of up to two drinks per day to be associated with lowerlevels of cardiovascular risk factors in women. In postmenopausal women, the apparentprotective effect of alcohol may be explained in part by an alcohol-induced increase in estrogenlevels (14).
Various researchers have suggested that moderate drinking is not protective against CAD,arguing that higher mortality among abstainers results from including among them people whohave stopped drinking because of ill health. Higher mortality among these "sick quitters" wouldexplain the comparative longevity of moderate drinkers (15,16,17). However, studies
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investigating the "sick quitter" effect do not support that conclusion; including "sick quitters" inthe abstinent category cannot completely explain the apparent protective effect of moderatedrinking against CAD (10,18,19,20). Risks of Moderate Drinking
There are risks that might offset the benefits of moderate drinking. Research shows that adverseconsequences may occur at relatively low levels of consumption (1).
Stroke. A review of epidemiologic evidence concludes that moderate alcohol consumptionincreases the potential risk of strokes caused by bleeding, although it decreases the risk ofstrokes caused by blocked blood vessels (21).
Motor vehicle crashes. While there is some evidence to suggest that low blood alcoholconcentrations (BACs) bear little relationship to road crashes, impairment of driving-related skillsby alcohol has been found to begin at 0.05 percent BAC or lower, with rapidly progressingdeterioration as the BAC rises (22). A man weighing 140 pounds might attain a BAC of 0.05percent after two drinks.
Interactions with medications. Alcohol may interact harmfully with more than 100 medications,including some sold over the counter (23). The effects of alcohol are especially augmented bymedications that depress the function of the central nervous system, such as sedatives, sleepingpills, anticonvulsants, antidepressants, antianxiety drugs, and certain painkillers. There is aconsequent increased danger of driving an automobile after even moderate drinking if suchmedications are taken (24). In advanced heart failure, alcohol may not only worsen the disease,but also interfere with the function of medications to treat the disease (25).
Cancer. Although most evidence suggests an increased risk for certain cancers only among theheaviest drinkers, moderate drinking may be weakly related to female breast cancer. In onestudy (26), breast cancer was approximately 50 percent more likely to develop in women whoconsumed three to nine drinks per week than in women who drank fewer than three drinks perweek. Although evidence concerning large bowel cancer is conflicting, one study suggests thepossibility of a weak relation to consumption of one or more drinks per day (27).
Birth defects. Several ongoing studies are exploring the fetal risks associated with low levels ofalcohol consumption. In one study (28), chil dren whose mothers reported consuming anaverage of two to three drinks per day during pregnancy were smaller in weight, length, andhead circumference and had an increased number of minor physical anomalies when examined atintervals through the age of 3. In addition, mothers' self-reported consumption of as few as twodrinks per day during pregnancy was found to be related to a decrease in IQ scores of 7-year-oldchildren (29).
The question of whether moderate drinking is a risk factor for the fetus is not altogether settled,because mothers' self-reports of alcohol consumption may be underestimates (30). However,animal research provides additional evidence for adverse fetal effects from low levels of drinking. Nervous system abnormalities occurred in monkeys whose mothers were exposed weekly to lowdoses of alcohol. An effect occurred at a maternal BAC as low as 0.024 percent (31). A 120-pound woman might attain this BAC after one drink. Similarly, low prenatal alcohol dosesproduced biochemical and physiological changes in rat brains (32,33).
Shift to heavier drinking. Recovering alcoholics, as well as people whose families have alcoholproblems, may not be able to maintain moderate drinking habits (2). Once a person progressesfrom moderate to heavier drinking, the risks of social problems (for example, drinking anddriving, violence, trauma) and medical problems (for example, liver disease, pancreatitis, braindamage, reproductive failure, cancer) increase greatly (34). Moderate Drinking--A Commentary by NIAAA Director Enoch Gordis, M.D.
As noted in this Alcohol Alert, drinking at "moderate levels" (up to two drinks a day for men andone drink a day for women) has both benefits and risks. Therefore, it should not be surprisingthat there are questions about what advice to give to individuals about using alcohol.
Research aimed at more clearly defining the circumstances that increase risk and the categoriesof individuals who are at risk for alcohol-related problems will help individuals and theprofessionals who advise them to make more informed decisions concerning alcohol use. Betterunderstanding of the biological mechanisms involved in the cardioprotective aspects of moderatealcohol use also could lead researchers to find alternate ways to provide the same protection.
Current advice to individuals should acknowledge that there are tradeoffs involved in eachdecision about drinking: reducing risk of developing coronary artery disease, for example, may beoffset by risk of developing another alcohol-related health condition. In general, if an individual isdrinking "moderately" and does not fit into one of the special risk categories discussed in theAlcohol Alert, there is no reason to recommend anything different. Similarly, individuals who arenot yet drinking (young adults who have recently turned 21, for example), and not at special risk,
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can be told that "moderate drinking" will probably not be harmful. (Abstinent individuals,however, should not be advised to begin to drink two drinks a day solely to protect againstcoronary artery disease.) Finally, those who are at higher risk (because of a family history ofalcoholism, for example) must be made aware of the tradeoffs involved in decisions to drink.
Selected issues of Alcohol Alert related to "Moderate Drinking" may be of interest to readers:"Alcohol and Aging" (no. 2), "Alcohol and Women" (no. 10), and "Fetal Alcohol Syndrome" (no. 13). See p. 4 for instructions on ordering copies. References
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Alcohol and mortality in British men: Explaining the U-shaped curve. Lancet 2(8623):1267-1273, 1988. (18) KLATSKY, A.L.; Armstrong, M.A.; & Friedman, G.D. Risk of cardiovascular mortality in alcohol drinkers, ex-drinkers and nondrinkers. American Journal of Cardiology 66:1237-1242, 1990. (19) JACKSON, R.; Scragg, R.; & Beaglehole, R. Alcohol consumption and risk of coronary heart disease. British Medical Journal 303:211-216, 1991. (20) RIMM, E.B.; Giovannucci, E.L.; Willett, W.C.; Colditz, G.A.; Ascherio, A.; Rosner, B.; & Stampfer, M.J. Prospective study of alcohol consumption and risk of coronary disease in men. Lancet 338(8765):464-468, 1991. (21) CAMARGO, C.A., Jr. Moderate alcohol consumption and stroke: The epidemiologic evidence. Stroke 20(12):1611-1626, 1989. (22) Council on Scientific Affairs. Alcohol and the driver. Journal of the American Medical Association 255(4):522-527, 1986. (23) SHINN, A.F., & Shrewsbury, R.P., eds. Evaluations of Drug Interactions. New York: Macmillan, 1988. (24) GILMAN, A.G.; Rall, T.W.; Nies, A.S.; & Taylor, P., eds. Goodman and Gilman's The Pharmacological Basis of Therapeutics. New York: Pergamon Press, 1990. (25) THOMAS, B.A., & Regan, T.J. Interactions between alcohol and cardiovascular medications. Alcohol Health & Research World 14( 4):333-339, 1990. (26) WILLETT, W.C.; Stampfer, M.J.; Colditz, G.A.; Rosner, B.A.; Hennekens, C.H.; & Speizer, F.E. Moderate alcohol consumption and the risk of breast cancer. New England Journal of Medicine 316:1174-1180, 1987. (27) KLATSKY, A.L.; Armstrong, M.A.; Friedman, G.D.; & Hiatt, R.A. The relations of alcoholic beverage use to colon and rectal cancer. American Journal of Epidemiology 128(5):1007- 1015, 1988. (28) DAY, N.L.; Robles, N.; Richardson, G.; Geva, D.; Taylor, P.; Scher, M.; Stoffer, D.; Cornelius, M.; & Goldschmidt, L. The effects of prenatal alcohol use on the growth of children at three years of age. Alcoholism: Clinical and Experimental Research 15(1):67-71, 1991. (29) STREISSGUTH, A.P.; Barr, H.M.; & Sampson, P.D. Moderate prenatal alcohol exposure: Effects on child IQ and learning problems at age 7 1/2 years. Alcoholism: Clinical and Experimental Research 14(5):662-669, 1990. (30) ERNHART, C.B.; Morrow-Tlucak, M.; Sokol, R.J.; & Martier, S. Underreporting of alcohol use in pregnancy. Alcoholism: Clinical and Experimental Research 12(4):506-511, 1988. (31) CLARREN S.K.; Astley, S.J.; Bowden, D.M.; Lai, H.; Milam, A.H.; Rudeen, P.K.; & Shoemaker, W.J. Neuroanatomic and neurochemical abnormalities in nonhuman primate infants exposed to weekly doses of ethanol during gestation. Alcoholism: Clinical and Experimental Research 14(5):674-683, 1990. (32) FARR, K.L.; Montano, C.Y.; Paxton, L.L.; & Savage, D.D. Prenatal ethanol exposure decreases hippocampal 3H-glutamate binding in 45-day-old rats. Alcohol 5(2):125-133, 1988. (33) SWARTZWELDER, H.S.; Farr, K.L.; Wilson, W.A.; & Savage, D.D. Prenatal exposure to ethanol decreases physiological plasticity in the hippocampus of the adult rat. Alcohol 5(2):121-124, 1988. (34) National Institute on Alcohol Abuse and Alcoholism. Seventh Special Report to the U.S. Congress on Alcohol and Health. DHHS Pub. No. (ADM)90-1656. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1990.
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