Dietary Guidelines for Alcohol Consumption
Published by the US Office of Health Promotion and Disease Prevention, the 2015-2020 Dietary Guidelines for Americans defines “moderate drinking” as 1 drink per day in women and 2 drinks per day in men.5 Regardless of any comorbid conditions, the effects of alcohol consumption can include reduced inhibitions, motor impairment, respiratory distress, coma, and death.6
Type 1 and Type 2 Diabetes
Research published in Diabetes Care suggests that decreasing alcohol consumption can have a beneficial effect in type 2 diabetes;7,8 specifically, that it may result in decreased fasting insulin and hemoglobin A1c (HbA1c)7 and diabetes risk reduction in women.8 An abstract presented at the 2016 Annual Meeting of the Endocrine Society found that heavy alcohol consumption also had no impact on diabetes risk.9 In type 1 diabetes, however, alcohol has been associated with acute hypoglycemia, with even moderate alcohol consumption “predisposing patients to hypoglycemia after breakfast the next morning.”10 Researchers from Yale University School of Medicine and the Royal Bournemouth Hospital in the United Kingdom caution that people with type 1 diabetes should be made aware of this risk in order to take the appropriate preventative measures. The American Diabetes Association (ADA) supports emphasizing the importance of alcohol taken in moderation,11 encouraging people with diabetes to drink cautiously and regularly check blood glucose levels before, during, and up to 24 hours after drinking.
Osteoporosis and Bone Health
Regular alcohol consumption presents its own set of risks related to bone health and the development of osteoporosis. According to the US National Institute of Health (NIH) Osteoporosis and Related Bone Diseases National Resource Center, excessive alcohol consumption can interfere with the balance of calcium and vitamin D, as well as hormone deficiencies, lower testosterone in men, irregular menstrual cycles in women, and elevated cortisol, which increases bone breakdown.12 In addition, alcohol effects balance and gait — people with alcoholism fall more frequently than people without alcoholism.12 Specifically, hip and vertebral fractures have been linked to heavy alcohol consumption.12 According to the NIH, abstaining from alcohol is the best strategy to prevent alcohol-induced bone loss.12 However, a well-balanced diet, vitamin D supplementation, and exercise can all mitigate the effects of alcohol.12 This population can also consider a bone mineral density test as a way to detect osteoporosis before a fracture occurs.12
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Hypo- and Hyperthyroidism
Like diabetes, moderate alcohol consumption has been found to have a protective effect on autoimmune disorders13 — for example, decreasing a person’s risk of developing hypothyroidism. In addition, research published in Clinical Endocrinology found a link between alcohol consumption and risk reduction for Graves’ disease.14 However, other studies have identified multiple effects that alcohol has on the hypothalmopituitary axis — for example, suppression of thyroid function through cellular toxicity and a decrease in peripheral thyroid hormones.15 In 2015, Alcohol and Alcoholism16 published a study that explored the relationship between the thyroid axis and alcohol-seeking behavior in patients with alcohol dependence. The investigators identified correlations between thyroid stimulating hormone; free triiodothyronine; and the questionnaires used to measure alcohol cravings and anxiety, depression, and aggression, indicating that, if confirmed in larger samples, the thyroid axis “might represent a biomarker of alcohol craving and drinking.”
Alcohol Consumption in Pregnancy
The Centers for Disease Control and Prevention (CDC) cautions that there is “no known safe amount of alcohol use during pregnancy.”17 Drinking while pregnant can cause miscarriage; stillbirth; and a number of fetal alcohol spectrum disorders including low body weight, poor coordination, memory and attention issues, and learning disabilities, among others.17 A 2010 study from the International Journal of Environmental Research and Public Health reviewed long-term outcomes in children exposed to alcohol during pregnancy.18 The investigators noted that early detection of intrauterine alcohol exposure may “enable effective social and educational intervention programs,”18 providing appropriate support to both mothers and children.
Neurological Effects of Alcohol Use and Abuse
Neurological research has found that stroke mortality and alcohol consumption are related: a study published in the International Journal of Cardiology19 identified a J-shaped association between stroke morbidity and alcohol intake, while a study published in Stroke20 found that heavy drinking in midlife can “predominate over well-known risk factors” for stroke, including hypertension and diabetes until age 75. As a result, alcohol consumption should be considered an age-varying risk factor. In a similar manner, research has highlighted the negative consequences that binge drinking can have on neurodegeneration, including of the amygdala and prefrontal cortex.21 A meta-analysis published in Addiction Biology22 reviewed white matter volume in patients with alcohol use disorder. Study investigators recommend further research to examine the possibility of white matter recovery “with sustained abstinence.”
Is Alcohol Truly Cardioprotective?
Prevailing evidence suggests that light alcohol consumption can lower a person’s risk of developing cardiovascular disease (CVD). A 2014 scientific review23 published in the Journal of Cardiopulmonary Rehabilitation and Protection highlighted some lingering questions, including the impact of beverage type — beer, red wine, or hard liquor — on CVD risk reduction. Conversely, the American College of Cardiology recently highlighted results from a meta-analysis showing that regular, moderate, alcohol consumption can lead to an 8% increase in the risk for atrial fibrillation (AF) for every drink consumed per day,3 contrary to the perception of moderate intake as cardioprotective. Aleksandr Voskoboinik, MBBS, of the Alfred Heart Centre and the University of Melbourne in Melbourne, Australia, and colleagues reviewed the epidemiology and pathophysiology of AF, concluding that cardioprotective benefits don’t apply to patients with AF.4
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The Obesity Epidemic
The role of alcohol intake in the obesity epidemic is still unclear: according to a review published in Current Obesity Reports,24 the general consensus indicates that light drinking does not increase adiposity, while heavy drinking often results in weight gain. Mixed evidence suggests that drinking before meals may increase food intake, although available studies have only reported results relating to beer and wine consumption. In a similar manner, a study from the European Journal of Clinical Nutrition25 in more than 4700 adults found that after adjustment for age, energy intake, and regular physical exercise, both men and women who consumed more than 60 g and 30 g per day of alcohol, respectively, were more likely to be obese vs non-drinkers.
Mental Health and Substance Abuse
Excessive drinking does not necessarily equal alcohol dependence, according to the CDC.26 In conjunction with the Substance Abuse and Mental Health Services Administration (SAMHSA), data from more than 138,000 adults who responded to the National Survey on Drug Use and Health (NSDUH) in 2009, 2010, or 2011 were analyzed.27 According to the results, 90% of excessive drinkers did not meet Diagnostic and Statistical Manual of Mental Disorders (4th edition, DSM-IV) criteria for alcohol dependence. Robert Brewer, MD, MSPH, Alcohol Program lead at the CDC and one of the study’s investigators noted that while the results may be “contrary to popular opinion,” they “emphasize the importance of taking a comprehensive approach to reducing excessive drinking” through evidence-based strategies, screening, counseling, and treatment. Clinicians who are uncertain how the changes from DSM-IV to DSM-5 may affect the diagnosis of alcohol use disorders should reference the NIAAA comparison fact sheet.28
HIV and Hepatitis C
Although research has indicated that alcohol consumption can pose significant health risks in patients with HIV and hepatitis C (HCV),29 not much is known about patient perception of these risks. Multiple studies30-32 identified skewed perceptions in these patient populations regarding the potential consequences of continued alcohol consumption. For example, patients with HIV/HCV coinfection may underreport alcohol consumption during clinician interviews.32 Clinicians treating these patients may need to employ innovative rather than standard strategies to emphasize the benefits of a reduction in alcohol intake. Additional challenges have been identified in women living with HIV, many of whom report drinking to self-manage pain or emotions.31
Alcohol Use and Dependence in Young Adults
According to the CDC, alcohol is the most commonly used or abused drug in US adolescents and young adults.33 Multiple studies34-36 assess the benefits, harms, and efficacy of various interventional strategies used to reduce the frequency of and risks associated with underage drinking. One study34 found that when comparing direct strategies (eg, “space drinks out over time”) with indirect strategies (eg, “have a designated driver”), direct strategies resulted in less alcohol consumption while indirect strategies resulted in fewer alcohol-related consequences. Additionally, a meta-analysis of 185 studies36 found that while brief alcohol interventions result in modest but beneficial alcohol-related outcomes, such interventions can be beneficial based on their “brevity and low cost.”
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Managing Alcohol Use in Patients
Clinicians play an important role in the treatment of alcohol use disorders. A guide published by the NIAAA37 notes that regardless of the severity of a patient’s alcohol use, “most people with an alcohol use disorder can benefit from some form of treatment.” Clinicians can regularly screen patients for alcohol use disorder, and resources from the CDC38,39 and the NIAAA40 are available for everyday clinical practice.
According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), 87.6% of people age 18 and older in the United States have consumed alcohol at some point during their lifetime.1 Although some research indicates that alcohol consumption may have a beneficial effect on health,2 other research has found that even moderate alcohol consumption can lead to an elevated risk for developing cardiovascular disease (CVD), among other conditions.3,4
Compiled by Lauren Biscaldi
- Alcohol facts and statistics. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism. Updated January 2017. Accessed February 28, 2017.
- Millen B, Lichtenstein AH, Abrams S, et al; for the 2015 Dietary Guidelines Advisory Committee. Scientific report of the 2015 dietary guidelines advisory committee. 2015 Feb.Accessed March 1, 2017.
- Regular, moderate alcohol consumption may lead to afib [news release]. New York, NY: American College of Cardiology. Published December 5, 2016. Accessed February 28, 2017.
- Voskoboinik A, Prabhu S, Ling L-h, et al. Alcohol and atrial fibrillation. J Am Coll Cardiol. 2016;68(23):2567-2576. doi:10.1016/j.jacc.2016.08.074
- US Department of Health and Human Services and US Department of Agriculture. 2015-2020 dietary guidelines for Americans. 8th edition. December 2015. Accessed February 28, 2017.
- Overview of alcohol consumption. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism.Accessed February 28, 2017.
- Schrieks IC, Heil ALJ, Henddriks HFJ, Mukamal KJ, Beulens JWJ. The effect of alcohol consumption on insulin sensitivity and glycemic status: a systematic review and meta-analysis of intervention studies. Diabetes Care. 2015;35(4):723-732. doi:10.2337/dc14-1556
- Knott C, Bell S, Britton A. Alcohol consumption and the risk of type 2 diabetes: a systematic review and dose-response meta-analysis of more than 1.9 million individuals from 38 observational studies. Diabetes Care. 2015;38(9):1804-1812. doi:10.2337/dc15-0710
- Sams T, Karnchanasorn R, Feng W, Samoa R, Chiu KC. SAT-662: Alcohol consumption and the risk of type 2 diabetes mellitus. Presented at: ENDO 2016; April 1-4, 2016; Boston, MA.
- Turner BC, Jenkins E, Kerr D, Sherwin RS, Cavan DA. The effect of evening alcohol consumption on next-morning glucose control in type 1 diabetes. Diabetes Care. 2001;24(11):1888-1893. doi:10.2337/diacare.24.11.1888
- Alcohol. Arlington, VA: American Diabetes Association. Published September 30, 2013. Updated June 6, 2014. Accessed February 28, 2017.
- What people recovering from alcoholism need to know about osteoporosis. NIH Publication No. 16-7894. Bethesda, MD: NIH Osteoporosis and Related Bone Diseases National Resource Center. Published April 2016. Accessed February 28, 2017.
- Carlé A, Pedersen IB, Knudsen N, et al. Moderate alcohol consumption may protect against overt autoimmune hypothyroidism: a population-based case-control study. Eur J. Endocrinol. 2012;167(40):483-490. doi:10.1530/EJE-12-0356
- Carlé A, Pedersen IB, Knudsen N, et al. Graves’ hyperthyroidism and moderate alcohol consumption: evidence for disease prevention. Clin Endocrinol. 2013;79(1):111-119. doi:10.1111/cen.12106
- Balhara YPS, Deb KS. Impact of alcohol use on thyroid function. Indian J Endocrinol Metab. 2013;17(4):580-587. doi:10.4103/2230-8210.113724
- Aoun EG, Lee MR, Haass-Koffler CL, et al. Relationship between the thyroid axis and alcohol craving. Alcohol Alcohol. 2015;50(1):24-29. doi:10.1093/alcalch/agu085
- Alcohol use in pregnancy. Atlanta. GA: US Centers for Disease Control and Prevention. Updated July 21, 2016. Accessed February 28, 2017.
- Ornoy A, Ergaz Z. Alcohol abuse in pregnant women: effects on the fetus and newborn, mode of action and maternal treatment. Int J Environ Res Public Health. 2010;7:364-379. doi:10.3390/ijerph7020364
- Zhang C, Qin Y-Y, Chen Q, et al. Alcohol intake and risk of stroke: a dose-response meta-analysis of prospective studies. Int J Cardiol. 2014;174(3):669-677. doi:10.1016/j.ijcard.2014.04.225
- Kadelcová P, Andel R, Mukulik R, Handing Ep, Pedersen NL. Alcohol consumption at midlife and risk of stroke during 43 years of follow-up. Stroke. 2015;46:627-633. doi:10.1161/STROKEAHA.114.006724
- Stephens DN, Duka T. Cognitive and emotional consequences of binge drinking: role of amygdala and prefrontal cortex. Philos Trans R Soc Lond B Biol Sci. 2008;363(1507):3169-3179. doi:10.1098/rstb.2008.0097
- Monnig MA, Tonigan JS, Yeo RA, Thoma RJ, McCrady BS. White matter volume in alcohol use disorders: a meta-analysis. Addiction Biol. 2012;18(3):581-592. doi:10.1111/j.1369-1600.2012.00441.x
- Matsumoto C, Miedema MD, Ofman P, Gaziano JM, Sesso HD. An expanding knowledge of the mechanisms and effects of alcohol consumption on cardiovascular disease. J Cardiopulm Rehabil Prev. 2014;34(3):159-171. doi:10.1097/HCR.0000000000000042
- Traversy G, Chaput JP. Alcohol consumption and obesity: an update. Curr Obes Rep. 2015;4(1):122-130. doi:10.1007/s13679-014-0129-4
- Lourenço S, Oliveira A, Lopes C. The effect of current and lifetime alcohol consumption on overall and central obesity. Eur J Clin Nutr. 2012;66:813818. doi:10.1038/ejcn.2012.20
- Most people who drink excessively are not alcohol dependent [news release]. Atlanta, GA: US Centers for Disease Control and Prevention. Published November 20, 2014. Accessed February 28, 2017.
- Esser MB, Hedden SL, Kanny D, Brewer RD, Gfroerer JC, Naimi TS. Prevalence of alcohol dependence among US adult drinkers, 2009-2011. Prev Chronic Dis. 2014;11:140329. doi:10.5888/pcd11.140329
- Alcohol use disorder: a comparison between DSM-IV and DSM-5. NIH Publication No. 13-7999. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism. Updated July 2016. Accessed February 28, 2017.
- Younossi ZM, Zheng L, Stepanova M, Venkatesan C, Mir HM. Moderate, excessive or heavy alcohol consumption: each is significantly associated with increased mortality in patients with chronic hepatitis C. Aliment Pharmacol Ther. 2013;37(7):703-709. doi:10.1111/apt.12265
- Elliott JC, Aharonovich E, O’Leary A, Johnston B, Hasin DS. Perceived medical risks of drinking, alcohol consumption, and hepatitis C status among heavily drinking HIV primary care patients. Alcohol Clin Exp Res. 2014;38(12):3052-3059. doi:10.1111/acer.12570
- Cook RL, Cook CL, Karki M, et al. Perceived benefits and negative consequences of alcohol consumption in women living with HIV: A qualitative study. BMC Public Health. 2016;16:263. doi:10.1186/s12889-016-2928-x
- Roux P, Cohen K, Lascoux-Combe C, et al. Determinants of the underreporting of alcohol consumption by HIV/HCV co-infected patients during face-to-face medical interviews: the role of the physician. Drug Alcohol Depend. 2011;116(1-3):228-232. doi:10.1016/j.drugalcdep.2010.09.025
- Fact sheets – underage drinking. Atlanta, GA: US Centers for Disease Control and Prevention. Updated October 20, 2016. Accessed February 28, 2017.
- DeMartini KS, Palmer RS, Leeman RF, et al. Drinking less and drinking smarter: direct and indirect protective strategies in young adults. Psychol Addict Behav. 2013;27(3). doi:10.1037/a0030475
- Crewes FT, Vetreno RP, Broadwater MA, Robinson DL. Adolescent alcohol exposure persistently impacts adult neurobiology and behavior. Pharmacol Rev. 2016;68(4):1074-1109. doi:10.1124/pr.115.012138
- Tanner-Smith EE, Lipsey MW. Brief alcohol interventions for adolescents and young adults: a systematic review and meta-analysis. J Subst Abuse. 2015;51:1-18. doi:10.1016/j.jsat.2014.09.001
- Treatment for alcohol problems: finding and getting help. NIH Publication No. 14-7974. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism. Published 2014. Accessed February 28, 2017.
- CDC’s alcohol screening and brief intervention efforts. Atlanta, GA: US Centers for Disease Control and Prevention. Updated September 29, 2016. Accessed February 28, 2017.
- Centers for Disease Control and Prevention. Planning and implementing screening and brief intervention for risky alcohol use: a step-by-step guide for primary care practices. Atlanta, GA: US Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, 2014.Accessed March 1, 2017.
- Alcohol screening and brief intervention for youth: a practitioner’s guide. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism. Accessed February 28, 2017.