Table of Contents
Introduction
In the last 4 lessons I discussed the 3 primary macronutrients (protein, carbohydrate, and fat) as well as fiber, all of which are the building blocks of foods we eat. In this lesson I will discuss alcohol, the last macronutrient, and its impact on the dieting process as well as overall health.
Note: The impact of alcohol on health is controversial, and I discuss this in a lot of detail below to try to present a fair overview of the literature. For those who do not wish to read through all of this, you can get all the main points of this lesson by reading the:
- summary in the section of the short-term impact of alcohol on dieting and exercise
- 2020-2025 Dietary Guidelines for the Americas recommendation regarding alcohol intake listed at the beginning of the section of the long-term impact of alcohol on health
- summary in the section of the long-term impact of alcohol on dieting and health
- conclusion at the end
Short-term impact of alcohol on dieting and exercise
Considerations for short-term intake are much different than long-term intake. Short-term refers to within a single session. Binge drinking has negative impacts on health and I will not discuss this further as there is no controversy in the literature regarding this point. I will consider intermittent episodes of non-binge drinking here.
Impact on caloric consumption
A
A 2021 narrative review came to similar conclusions.(Fong, 2021) The authors note that while alcohol intake can lead to greater caloric consumption acutely this does not seem to influence long term weight gain, potentially due to various compensatory mechanisms such as increased physical activity.
Note: Alcohol has 7 kcal per gram, but many alcoholic drinks also have added sugar that further increase their caloric content. All of this counts if you are counting calories. Alcohol does have a relatively high thermic effect of feeding (more similar to that of protein than to carbohydrate or fat), but as most people consume relatively low amounts of alcohol this will not have a meaningful impact on dieting overall. Click here for a calculator to determine the caloric intake of different alcoholic beverages.
A 2016 study attempted to examine the impact of decreasing alcohol intake in an overall weight management behavioral intervention.(Kase, 2016) Among other things, generic advice was given to decrease alcohol consumption. Over a 1-year time span a decrease in alcohol consumption was not associated with weight changes overall. However, when looking at subjects who were determined to have a high level of behavioral impulsivity, alcohol reduction was associated with weight loss. It is possible that these individuals benefit most from alcohol reduction as this may decrease disinhibition (leading to less caloric consumption). It is also possible that decreased alcohol intake led to a decrease in the general expectancy that they will eat more calories when consuming alcohol, thus leading to fewer calories being consumed on occasions of alcohol intake.
Impact on exercise
A
Summary of the short-term literature
Thus, overall, there is no strong evidence in the literature that a low level of alcohol intake (consistent with the guideline listed below) will have a harmful effect on dieting and resistance training progress. This is also seen in longer term observational studies, with no association between alcohol intake and overweight/obesity in cohort studies and only a mild association (due to heavy alcohol consumption beyond the guideline discussed below) seen in cross-sectional studies.(Golzarand, 2021)
However, for individuals who are more prone to eating larger amounts of food with alcohol intake or who are more prone to take the mentality after consuming alcohol that they have “ruined” their dieting for the day and thus should do whatever they want and get back on track tomorrow, minimizing alcohol consumption would likely be helpful when actively dieting to lose weight.
Long-term impact of alcohol on health
The following note shows one set of guidelines for alcohol intake.
Note: Regarding alcohol intake, the 2020-2025 Dietary Guidelines for Americans recommends:
- 1 alcoholic drink-equivalent should be defined as containing 14 grams of pure alcohol (0.6 fluid ounces)
- This is equivalent to 12 fluid ounces of regular beer (5% alcohol), 5 fluid ounces of wine (12% alcohol), or 1.5 fluid ounces of 80 proof distilled spirits (40% alcohol).
- Females should consume no more than 1 drink daily and should especially avoid binge drinking (no more than 3 drinks in ~2 hours).
- Males should consume no more than 2 drinks daily and should especially avoid binge drinking (no more than 4 drinks in ~2 hours).
- People who do not currently drink alcohol should not begin drinking alcohol. Additionally, people should not drink alcohol if they are pregnant (or may be pregnant), younger than 21 years old*, recovering from alcoholism or unable to control the amount they drink, have certain medical conditions, or take certain medications that interact with alcohol.
Note: Of interest, there is not much research indicating a rationale for advising females to consume less alcohol than males, and some guidelines do not make a distinction by sex.(Wang, 2022)
The majority of the literature agrees with not going above these guidelines. However, there is significant controversy regarding whether alcohol intake within these guidelines provides a net health benefit or harm relative to abstaining from alcohol completely. There was even controversy when writing the 2020-2025 Dietary Guidelines for Americans regarding this specific point (see discussion here). I will attempt now to present a fair overview of this debate.
Review articles
In 2016 a consensus document specifically focusing on beer came to many of these same findings as the prior reviews.(de Gaetano, 2016) These authors also stated that unless there is concern for a high risk of alcohol-related cancer there is no reason to encourage healthy adults with regular light-to-moderate volume beer intake to decrease their consumption, but they additionally added that there is no evidence that adult abstainers who start drinking alcoholic beverages in moderation reduce their risk of chronic disease.
Note:
A 2018 review article discussed several prior studies and reviews indicating a benefit of low level alcohol intake on cardiovascular mortality and other health parameters.(O’Keefe, 2018) The authors noted that benefits are seen more frequently in middle-aged and older individuals than younger-aged, there are ethnic differences, and many benefits last <24 hours (which may help justify regular low level intake for sustained benefit rather than intermittent intake). They also stated that studies show it is difficult to predict who will be at risk for problem drinking once they begin and they cite the American Heart Association’s recommendation that nondrinkers should not be advised to start drinking.
A separate 2018 review came to similar conclusions.(Goel, 2018) The authors here also noted that benefits are more often seen as one’s age increases and the risks of developing drinking problems and binge drinking may outweigh the benefits for the younger population. They also found ethnic differences. They concluded that 1-2 drinks daily is not dangerous but abstainers should not be encouraged to start drinking as there is no way to predict if a person would only consume alcohol in moderation after starting.
Note: This is one of several topics in the field of nutrition where industry seems to exert some level of influence on research findings. While research sponsored by industry is not necessarily biased or untrustworthy, it is generally worth considering if the majority of the industry-sponsored research leans one way while non-industry-sponsored research takes a different point of view. See below for a more concrete example of the alcohol industry influencing research.
In 2019 another large review article on the impact of moderate alcohol consumption on cardiovascular disease (“CVD”) was published, echoing several of the findings discussed in the prior reviews.(Chiva-Blanch, 2019) The authors noted that women absorb alcohol differently due to lower body water, smaller stature, and lower gastric alcohol dehydrogenase content and that many studies have found sex-specific differences. Benefits for all-cause mortality (ACM) are typically only seen in white & Hispanic populations, not black/Indian/Chinese, and Asians seem to have a higher risk of hypertension & stroke at the same level of intake. Harmful effects of abusive or heavy intake, however, are the same throughout the globe. Findings from this review include:
- Moderate alcohol consumption seems to attenuate inflammation, decrease fibrinogen & fibrin D-dimer, increase tissue plasminogen activator & plasminogen concentrations, inhibit platelet reactivity, and increase HDL cholesterol.
- The risk of hypertension increases linearly with alcohol intake though <1-2 drinks daily with meals may not be detrimental.
- Low-to-moderate alcohol intake is associated with a decreased risk of heart failure and in people with CVD a lower incidence of ACM.
However, the authors mentioned that some data indicating benefits for ACM are only seen in generally older populations. They noted consumers who consider alcohol intake as healthy for CVD have been shown to consume 1.5x more alcohol than those who do not consider it healthy. They concluded stating it would be wise to suggest low-to-moderate alcohol consumption among current drinkers and to never recommend drinking in order to improve health.
A 2021 narrative review regarding the impact of alcohol on cardiovascular health highlighted much of the controversy, noting there is evidence of a negative impact of mild-to-moderate alcohol intake on some medical conditions as shown in their table reproduced below.(Stătescu, 2021)



The authors also highlighted differences in:
- race (light-to-moderate drinking is connected to lower risk of ACM in white individuals but not black individuals)
- ethnic origin (Italians experience improved health outcomes with low-to-moderate drinking while Chinese and Indians do not)
- genetic background
- type of alcoholic beverage (red wine may have greater health-promoting properties).
The authors acknowledged we need large randomized controlled trials. They recommended for individuals at high risk of CVD to minimize consumption and when consuming alcohol to consume wine at low-to-moderate intake.
A separate 2021 review of alcohol and cardiovascular health found some potential benefit at very low levels of intake (up to 1 drink daily) but also concluded there is a risk of harm for several conditions, there are many confounding factors in the literature, and an improvement in the overall body of evidence is needed to draw confident conclusions.(Roerecke, 2021)
In addition to all of the overview articles listed above, I will point out a handful of the more influential studies and then additional analyses that have been done in recent years.
Mendelian randomization analyses
In 2014 an important Mendelian randomization analysis was conducted.(Holmes, 2014) For a review of Mendelian randomization studies, particularly as it pertains to this analysis, please read through the following note prior to continuing. This can be a somewhat complicated concept and it is certainly not necessary to read through this note to understand the main point of this analysis discussed below.
Note: Mendelian randomization studies (some people prefer the term “genetic instrumental variable analysis”) essentially function as long-term randomized controlled trials. The idea is that a genetic variant is linked to a variable (ie, alcohol intake) which is then linked to an outcome (ie, coronary heart disease). For this analysis the authors looked at genetic mutations of ADH1B, which are known to be associated with decreased alcohol consumption. Thus, people with this mutation are “randomized” into a group that consumes less alcohol. Ideally this would be the only difference and thus if this group had different health outcomes it would be due to drinking less alcohol.
However, in practice there are other considerations, and this has led to some criticism of Mendelian randomization studies regarding alcohol intake. Some of these include:
- As this mutation alters the metabolism of acetaldehyde (a byproduct of alcohol breakdown in the body), if acetaldehyde directly influences any health benefits/harms then it will be unclear if health changes are due to different amounts of alcohol intake vs. different profiles of acetaldehyde metabolism.
- If this mutation associates with any other factors there can be confounding. As one example, this could occur if people who drink less alcohol are less likely to live a “party lifestyle” and are more likely to associate with other similar-minded individuals. Thus, there would be social differences between genetic carriers and non-carriers of the mutation and this could impact health outcomes.
- Any decrease in alcohol consumption due to this mutation would possibly extend to parental alcohol consumption prior to conception and possibly during pregnancy, which may substantially influence one’s health.
- If this mutation causes less alcohol consumption and moderate alcohol consumption is actually beneficial then this mutation may be associated with harm. However, if this mutation causes less binge drinking and binge drinking is detrimental then this mutation may be associated with benefit. Given potential competing factors, it can be hard to draw any definitive conclusion about what influences the actual health outcomes.
If curious,
This analysis was based on individual participant data from >260,000 people across 56 studies. The authors found that carriers of the variant allele consumed 17.2% less units of alcohol weekly, had an odds ratio of 0.70 of being in the top 1/3 of drinkers, had an odds ratio of 0.78 for binge drinking, and had an odds ratio of 1.27 of being abstainers from consuming alcohol. Thus, carriage of the variant allele was associated with all types of self-reported drinking behavior, which is important as this could then be used for analysis in individuals drinking amounts along the spectrum of low, moderate, and high alcohol quantities. The idea is that in any predefined bin of alcohol intake carriers would be drinking a lower amount of alcohol in that bin relative to non-carriers.
Their main finding was that for people who consumed alcohol, carriers had decreased odds (0.86) of coronary heart disease (“CHD”) compared to non-carriers. The same protective effect was seen at intakes of 0-6 units weekly, 7-20 units weekly, and ≥21 units weekly. Thus, as carriers consumed less alcohol in all of these different groups of alcohol intake, the fact that they had lower risk of CHD implies that alcohol increased the risk of developing CHD. Importantly, the risk was not decreased in abstainers, which implies the genetic variant itself did not provide protection from CHD.
In 2021 a SR of Mendelian randomization studies was published, including 24 such studies.(van de Luitgaarden, 2021) The authors noted a lot of heterogeneity in the methodology. Only one of these studies evaluated ACM, finding a detrimental effect of alcohol. However, 67% of the studies evaluating CVD and 75% of the studies evaluating diabetes found null effects. Thus, Mendelian randomization analyses provide variable results regarding the association of alcohol consumption with different health outcomes.
Concerns of abstainer bias
In
Note: Most prospective studies on alcohol intake and its impact on mortality have historically considered people who abstain from alcohol intake to be a control group. They have then compared low, moderate, and heavy alcohol intake to the abstainers (different studies have defined low, moderate, and heavy in different ways).
The potential issue here is that many people who are former drinkers have quit in part due to health problems related to their prior drinking. When they enroll in one of these studies they may still be placed in the control group as they are currently abstaining from alcohol intake. This will lead to the abstainer group having worse outcomes and thus people drinking a low level of alcohol may appear to have better health outcomes in comparison. To try to eliminate this “abstainer bias”, it is important to separate “lifelong abstainers” from “former drinkers”. One caveat is that lifelong abstainers may have other confounding factors (ie, be part of certain religions or communities that abstain from alcohol) that could then influence health outcomes in other ways.
The authors specifically looked at 87 prospective studies that considered the relationship between alcohol intake and ACM. They noted that historically studies showed a low level of drinking yielded better outcomes than not drinking at all. When looking at all 87 studies they found a protective effect of occasional and low volume alcohol drinking for ACM (relative risk of 0.84 and 0.86, respectively). However,
Note: A commentary on this study brought up concerns that most of the studies only assessed alcohol intake once while drinking patterns change over time and that in a US national survey >50% of people describe themselves as lifetime abstainers in follow-up after reporting drinking previously.(Rehm, 2016) The vast majority of large epidemiologic studies in the nutrition field only measure exposure level one time at baseline, and this is a common (and valid) criticism as many people will have exposure levels vary over time. This is discussed further below. The concern of people misremembering or simply lying about prior exposure is also a common occurrence in the nutrition field (ie, as mentioned in Lesson 2 many people misreport the number of calories they consume). While these two criticisms are valid, I do not believe either invalidates the findings of this study.
Perhaps a more appropriate criticism would be the concern of confounding lifestyle variables for lifetime abstainers These lifestyle factors would be very difficult to control for and may considerably influence the outcomes regarding ACM.
Subsequent studies
After
A 2018 article looking at this same NHIS data (and also data from the VA (Veterans Affairs)) found the lowest risk of death when drinking ~3 times weekly in the NHIS data and 2-3 times weekly in the VA data, with increased risk when drinking ≥5 days weekly.(Hartz, 2018) Of note, both of these data sets had alcohol measured only once and used in-person surveys (previously shown to yield underreporting of alcohol intake relative to anonymous surveys).
Additionally in 2018, a large analysis using data from 2016 looking at alcohol use globally across a large variety of health outcomes concluded that the optimal level of intake when looking at all health conditions is 0 drinks daily, though the authors found similar results with 1 drink daily.(GBD, 2018) The only health conditions for which they found a benefit of alcohol intake were ischemic heart disease and diabetes mellitus. For the majority of health outcomes they looked at they found increased risk of harm at any level of alcohol intake.
Another large study came out in 2018 that looked at almost 600,000 current drinkers across 83 studies.(Wood, 2018a) Here the authors excluded abstainers due in part to the various concerns noted above. Thus, they were attempting to determine for people who drink alcohol what level of intake is associated with the best outcomes. Of interest, ~71,000 of these participants from 37 studies had repeat measures of alcohol consumption and they calculated a regression dilution ratio of 0.50 (see note below for an explanation; similar to above this is a somewhat complicated concept and also is not necessary to understand the main points of the analysis).
Note: Regression dilution bias
By using repeat measurements over time, you can estimate the strength of this regression dilution, and then this can be applied as a correction factor.(Clarke, 1999) So, given a regression dilution ratio of 0.50, this implies that the regression coefficient relating health outcomes to baseline alcohol intake is ~1/2 the corrected regression coefficient relating health outcomes to alcohol intake throughout the study duration. Thus, the associations may be twice as strong as what studies that only consider baseline measurements indicate.
The authors found the lowest risk of ACM as well as CHD (not including myocardial infarction) with alcohol intake <100 grams weekly. The mean intake for the <100g intake group was 56 grams weekly (4 standard drinks). They found blood pressure and HDL cholesterol (the “good” cholesterol) increased with increasing alcohol consumption. For any given volume of weekly alcohol intake, they saw worse outcomes in people who drank less frequently (thus implying more potential binging). One commentary on this study noted that there were not worse numbers when drinking up to 200g weekly (14 standard drinks) in individuals who spread this out to ≥3 days weekly.(Thompson, 2018) The original authors caution in a response that <50% of the recorded deaths had drinking frequency information and there were wide confidence intervals when attempting to examine the hazard ratio for the association of binge drinking & disease outcomes, implying they do not have a complete enough data set to conclusively support that observation.(Wood, 2018b)
A 2019 publication used data from the Health and Retirement Study that examined elderly individuals over 15 years, separated lifetime abstainers from former drinkers, took measures of alcohol intake every 2 years (one of the few studies with repeat measurements), and considered many confounders.(Keyes, 2019) They found that occasional and low levels of alcohol intake had a hazard ratio of 0.81-0.93 for ACM relative to abstention. However, they also did not find an increased risk for heavy drinkers, which is not what has typically been seen previously; they attribute this to possible errors with self-reporting or reverse causation where people who are unhealthy decrease their alcohol intake. It is unclear to what degree this calls into question the overall results of the study.
A separate 2021 analysis of UK Biobank data found that among people who consume alcohol regularly(Jani, 2021):
- Predominantly spirits and beer/cider drinkers had higher health risks (including ACM, major adverse cardiovascular events, liver cirrhosis, and accidents/self-harm) than predominantly red wine drinkers.
- Splitting alcohol consumption over 3-4 days led to better health outcomes than 1-2 days (regarding ACM and major adverse cardiovascular events) or daily consumption (regarding liver cirrhosis).
- Consuming alcohol with meals led to better health outcomes than consuming alcohol in isolation.
- 90% reported a change in the amount of weekly alcohol units they consumed (on average there was a decease by 1.5 drinks over time)
- 48.6% had a change in the predominant type of alcohol they consumed
- 46.3% had a change in at least 1 aspect of their alcohol consumption pattern from baseline
- 40.5% had a change in frequency of consumption
- 31.8% had a change in their alcohol consumption pattern with respect to meals
When repeating the above analyses with this subset of individuals and considering their changes in alcohol consumption over time there was no consistent effect of alcohol type or consumption pattern with outcomes, though the confidence intervals were very large implying there were too few subjects to determine meaningful differences.
Thus, this data set further shows the potential peril of only including baseline alcohol intake measurements.
A 2021 analysis of dose-response relationships for alcohol use and various diseases using lifetime abstention as the reference group noted that most diseases have monotonic increasing relationships (meaning the risk continually increases as alcohol intake increases).(Rehm, 2021) The two exceptions seem to be ischemic diseases (such as heart attacks and stroke) and diabetes. For prevention of these diseases an intake of 10-20 grams daily may be optimal though the protective effect is greater in females than males.
Additional analyses of prospective cohorts have been done as well:
- Two cohort studies examined ethnic groups previously shown to have higher health risks with alcohol intake:
- A 2021 prospective cohort study of Chinese individuals found the lowest composite risk of mortality, CVD, and cancer with 1-25 grams of alcohol intake weekly (≤2 standard alcoholic drinks per week).(Zhang, 2021)
- A 2021 prospective cohort study of Korean adults found a dose-response relationship where increasing alcohol intake at any level associated with increased cancer mortality.(Ko, 2021)
- A 2021 analysis of 16 cohorts (15 European, 1 Australian) found that alcohol intake of ~5 grams daily (which is ~3 drinks weekly) was associated with a reduced risk of ACM, cardiovascular mortality and other causes of mortality other than mortality from cancer (no association was seen with cancer mortality at this level of intake).(Di Castelnuovo, 2021)
- A 2022 study evaluated alcohol consumption in a cohort of men when they were aged 50-54 years and determined how alcohol intake associated with the likelihood of them reaching age 90 years.(Brenn, 2022) 18.9% of the men who drank beer at most a few times a year reached age 90 years while only 11.9% of those who drank it more frequently reached age 90 years.
Lastly, a 2022 Mendelian randomization analysis using the UK Biobank data found that any level of alcohol intake increases the risk of hypertension and coronary artery disease.(Biddinger, 2022) The risk is only minimally increased when consuming up to 7 drinks weekly but increases considerably from that point upward, as shown in the figure below. Of interest, in this cohort individuals with light-to-moderate drinking levels have healthier lifestyle habits than those who abstain from alcohol, which would mask the harmful effect of alcohol consumption when comparing light-to-moderate consumers to those who abstain.



Alcohol and cancer
In 2014 a MA was published that attempted to synthesize all of the available evidence to determine a dose-response relationship of alcohol intake with site-specific cancer incidence.(Bagnardi, 2015) The authors presented data for the relative risk of light, moderate, and heavy alcohol intake, which they describes as consuming on average ≤12.5, >12.5 but ≤50, and >50 grams of alcohol per day, respectively. I have reproduced their figure for this data below.



They also presented dose-response curves for the site-specific cancer types; I have reproduced their figure for this data below.



A group of authors in 2021 published updated estimates of the global burden of cancer attributable to alcohol consumption.(Rumgay, 2021b) In this analysis the authors considered global alcohol consumption patterns in 2010 and subsequent cancer incidence in 2020, under the assumption there will be a ~10 year lag time between alcohol intake and cancer development. They also used relative risk numbers from the World Cancer Research Fund (“WCRF”) Continuous Update Project:
- Click here for the WCRF page on alcohol, if you download the available document you can find the specific relative risk numbers per 10 grams of alcohol intake on page 25.
- If curious, the reason I included the separate data above (despite the WCRF report being more recent) is because the report only provided the relative risks in a 10 gram per day increment, which is less informative than separating the risk based on light, moderate, and heavy intake if the risk is non-linear.
The authors combined the alcohol intake estimates with the cancer incidence and relative risk data to determine what percentage of the cancer cases could be attributed to alcohol consumption. They specifically focused on the cancer types with more confirmatory data regarding a causal impact of alcohol intake. I have reproduced their data below showing the number of cases of each type of cancer attributed to alcohol consumption as well as the population attributable fraction for each type of cancer below:
- Esophageal – 189,700 cases; population attributable fraction = 31.6%
- This means 189,700 cases were due to alcohol intake and almost 1/3 of cases of esophageal cancer were due to alcohol intake.
- Liver – 154,700; 17.3%
- Breast – 98,300; 4.4%
- Colon – 91,500; 8.1%
- Lip and oral cavity – 78,900; 20.2%
- Rectal – 65,100; 9.0%
- Pharyngeal – 39,400; 22%
- Laryngeal – 27,600; 15%
- Total – 741,300; 4.1%



Note: The above data does indicate alcohol consumption of any level will increase the risk of some types of cancers. However, as all of the data was observational, it is important to keep in mind that correlation does not necessarily mean causation. For example:
- Perhaps confounding factors that were not perfectly accounted for, such as smoking associated with alcohol intake, explain some of the increased risk of cancer.
- Several Mendelian randomization studies have not found associations between alcohol intake and cancer incidence, at least for some sites such as breast cancer.(Rumgay, 2021b) As discussed above Mendelian randomization studies are not perfect but this also indicates confounding factors may play a role.
- Perhaps people under-reported their level of alcohol consumption; this would make low levels of alcohol intake seem more harmful than it actually is. However, misclassification bias can also make it seem like alcohol intake is not harmful when it actually is, as has been shown in one study regarding breast cancer.(Pakzad, 2023)
- The abstainer bias mentioned above could be a factor here as well; this would make alcohol intake seem less harmful than it actually is.
- It is possible that having a small amount of wine in the context of a more healthy Mediterranean diet, potentially with more benefit if the wine helps to reduce stress, may provide health benefits that offset the relatively small increased risk of cancer with low alcohol intake.(Ursula, 2023)
Even though it is difficult to know exactly how much of an increased risk alcohol consumption contributes to cancer incidence, as alcohol is known to exert direct carcinogenic effects it is unlikely that there is no impact of alcohol consumption on cancer incidence given the above data. If this is a concern for you then you can consider decreasing your alcohol consumption accordingly.
Summary of the long-term evidence
- the total quantity of alcohol consumed
- alcoholic beverage choice
- the pattern of alcohol consumption
- whether alcohol is or is not consumed with meals
- changes in the above four variables over time
- the reference group considered and any confounding factors this may generate
- current non-drinkers may include people who have stopped drinking due to poor health
- lifetime abstainers may have other differing lifestyle factors that influence health outcomes
- genetic risk differences between different study groups
Given all of these variables and the conflicting results, it is not possible to state conclusively one way or another from the literature described above if a low level of alcohol intake yields superior health benefits to no intake at all, let alone if any such guidance would apply to all individuals equally. As summarized in a fairly recent overview of this controversy, large randomized trials would be the next step to try to determine the true health impact of low levels of alcohol consumption.
Large randomized trial?
It is clear that some studies fin
I have not come across any literature to suggest further randomized controlled trials are currently being planned. Without these trials it will be very difficult, if not impossible, to resolve the controversy alluded to above. A recent review article discussed the state of the literature, implying a large pragmatic trial may be the best way to move forward, where people are advised to decrease alcohol consumption and CVD endpoints are measured.(Hoek, 2022) They summarized the overall body of evidence in the figure below.



Sources of alcohol
Overall,
That said, there is some evidence that fermented alcoholic beverages (ie, beer and wine) may provide better health effects than distilled beverages (ie, liquors and spirits) due to fermentation yielding a higher concentration of bioactive compounds (ie, polyphenols).(Chiva-Blanch, 2019) These are typically most present in red wine > white wine > beer, while they are at much lower concentrations in liquors and spirits. Of note, specifically regarding polyphenols, strong evidence regarding a beneficial impact of their consumption is lacking (their consumption is thought to be beneficial but this has not been shown conclusively).(Visioli, 2020)
Nonetheless, wine intake has been associated with improved cardiovascular outcomes(Lombardo, 2023; Lucerón-Lucas-Torres, 2023), and beer itself has been shown to have several potential health benefits at low levels of intake.(de Gaetano, 2016; Spaggiari, 2020; Marcos, 2021) Given many confounding factors between lifestyles of people who prefer wine vs beer vs liquor it is difficult to draw firm conclusions; as indicated above some prospective cohort analyses indicate beer consumption is harmful regarding mortality risk.(Jani, 2021) For individuals who do choose to consume alcohol, until further evidence suggests otherwise, wine, particularly red wine, may be the alcoholic beverage of choice from a health perspective.
Conclusion
So
With the documented risk that initiating alcohol consumption may lead to progressively heavier consumption, and no overwhelming evidence of a net benefit at low intake levels, I agree with the authors of most of the reviews and the dietary guidelines listed above that alcohol intake should be kept at a low volume of intake for people who do consume alcohol (and should preferentially consume red wine, white wine, or beer, likely in that order of preference), binging should be avoided, and people who abstain should not be encouraged to begin consuming alcohol. For people who are dieting, if alcohol consumption triggers greater caloric intake then this should be minimized if possible.
Click here to proceed to Lesson 9
References
- Bagnardi V, Rota M, Botteri E, Tramacere I, Islami F, Fedirko V, Scotti L, Jenab M, Turati F, Pasquali E, Pelucchi C, Galeone C, Bellocco R, Negri E, Corrao G, Boffetta P, La Vecchia C. Alcohol consumption and site-specific cancer risk: a comprehensive dose-response meta-analysis. Br J Cancer. 2015 Feb 3;112(3):580-93. doi: 10.1038/bjc.2014.579. Epub 2014 Nov 25. PMID: 25422909; PMCID: PMC4453639.
- Biddinger KJ, Emdin CA, Haas ME, Wang M, Hindy G, Ellinor PT, Kathiresan S, Khera AV, Aragam KG. Association of Habitual Alcohol Intake With Risk of Cardiovascular Disease. JAMA Netw Open. 2022 Mar 1;5(3):e223849. doi: 10.1001/jamanetworkopen.2022.3849. PMID: 35333364; PMCID: PMC8956974.
- Brenn T, Løvsletten O. Mid-life alcohol consumption and survival to age 90 in men: The Tromsø Study 1979-1980 with follow-up to 2019. Scand J Public Health. 2022 Jul 25:14034948221111264. doi: 10.1177/14034948221111264. Epub ahead of print. PMID: 35876432.
- Chiva-Blanch G, Badimon L. Benefits and Risks of Moderate Alcohol Consumption on Cardiovascular Disease: Current Findings and
Controversies. Nutrients. 2019;12(1):108. Published 2019 Dec 30. doi:10.3390/nu12010108 - Clarke R, Shipley M, Lewington S, et al. Underestimation of risk associations due to regression dilution in long-term follow-up of prospective studies. Am J Epidemiol. 1999;150(4):341-353. doi:10.1093/oxfordjournals.aje.a010013
- Costanzo S, de Gaetano G, Di Castelnuovo A, Djoussé L, Poli A, van Velden DP. Moderate alcohol consumption and lower total mortality risk: Justified doubts or established facts?. Nutr Metab Cardiovasc Dis. 2019;29(10):1003-1008. doi:10.1016/j.numecd.2019.05.062
- Davey Smith G, Holmes MV, Davies NM, Ebrahim S. Mendel’s laws, Mendelian randomization and causal inference in observational data: substantive and nomenclatural issues. Eur J Epidemiol. 2020;35(2):99-111. doi:10.1007/s10654-020-00622-7
- de Gaetano G, Costanzo S, Di Castelnuovo A, et al. Effects of moderate beer consumption on health and disease: A consensus document. Nutr Metab Cardiovasc Dis. 2016;26(6):443-467. doi:10.1016/j.numecd.2016.03.007
- Di Castelnuovo A, Costanzo S, Bonaccio M, McElduff P, Linneberg A, Salomaa V, Männistö S, Moitry M, Ferrières J, Dallongeville J, Thorand B, Brenner H, Ferrario M, Veronesi G, Pettenuzzo E, Tamosiunas A, Njølstad I, Drygas W, Nikitin Y, Söderberg S, Kee F, Grassi G, Westermann D, Schrage B, Dabboura S, Zeller T, Kuulasmaa K, Blankenberg S, Donati MB, de Gaetano G, Iacoviello L. Alcohol intake and total mortality in 142 960 individuals from the MORGAM Project: a population-based study. Addiction. 2022 Feb;117(2):312-325. doi: 10.1111/add.15593. Epub 2021 Jul 8. PMID: 34105209.
- Estruch R, Hendriks HFJ. Associations between Low to Moderate Consumption of Alcoholic Beverage Types and Health Outcomes: A Systematic Review. Alcohol Alcohol. 2021 Dec 11:agab082. doi: 10.1093/alcalc/agab082. Epub ahead of print. PMID: 34897368.
- Evangelou E, Suzuki H, Bai W, Pazoki R, Gao H, Matthews PM, Elliott P. Alcohol consumption in the general population is associated with structural changes in multiple organ systems. Elife. 2021 Jun 1;10:e65325. doi: 10.7554/eLife.65325. PMID: 34059199; PMCID: PMC8192119.
- Fernández-Solà J. Cardiovascular risks and benefits of moderate and heavy alcohol consumption. Nat Rev Cardiol. 2015;12(10):576-587. doi:10.1038/nrcardio.2015.91
- Fong M, Scott S, Albani V, Adamson A, Kaner E. ‘Joining the Dots’: Individual, Sociocultural and Environmental Links between Alcohol Consumption, Dietary Intake and Body Weight—A Narrative Review. Nutrients. 2021; 13(9):2927. doi: 10.3390/nu13092927.
- GBD 2016 Alcohol Collaborators. Alcohol use and burden for 195 countries and territories, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016 [published correction appears in Lancet. 2018 Sep 29;392(10153):1116] [published correction appears in Lancet. 2019 Jun 22;393(10190):e44]. Lancet. 2018;392(10152):1015-1035. doi:10.1016/S0140-6736(18)31310-2
- Goel S, Sharma A, Garg A. Effect of Alcohol Consumption on Cardiovascular Health. Curr Cardiol Rep. 2018;20(4):19. Published 2018 Mar 8. doi:10.1007/s11886-018-0962-2
- Golzarand M, Salari-Moghaddam A, Mirmiran P. Association between alcohol intake and overweight and obesity: a systematic review and dose-response meta-analysis of 127 observational studies. Crit Rev Food Sci Nutr. 2021 May 17:1-21. doi: 10.1080/10408398.2021.1925221. Epub ahead of print. PMID: 33998940.
- Hartz SM, Oehlert M, Horton AC, et al. Daily Drinking Is Associated with Increased Mortality. Alcohol Clin Exp Res. 2018;42(11):2246-2255. doi:10.1111/acer.13886
- Hoek AG, van Oort S, Mukamal KJ, Beulens JWJ. Alcohol Consumption and Cardiovascular Disease Risk: Placing New Data in Context. Curr Atheroscler Rep. 2022 Jan;24(1):51-59. doi: 10.1007/s11883-022-00992-1. Epub 2022 Feb 7. PMID: 35129737; PMCID: PMC8924109.
- Holmes MV, Dale CE, Zuccolo L, et al. Association between alcohol and cardiovascular disease: Mendelian randomisation analysis based on individual participant data. BMJ. 2014;349:g4164. Published 2014 Jul 10. doi:10.1136/bmj.g4164
- Jani BD, McQueenie R, Nicholl BI, Field R, Hanlon P, Gallacher KI, Mair FS, Lewsey J. Association between patterns of alcohol consumption (beverage type, frequency and consumption with food) and risk of adverse health outcomes: a prospective cohort study. BMC Med. 2021 Jan 12;19(1):8. doi: 10.1186/s12916-020-01878-2. PMID: 33430840; PMCID: PMC7802201.
- Kase CA, Piers AD, Schaumberg K, Forman EM, Butryn ML. The relationship of alcohol use to weight loss in the context of behavioral weight loss treatment. Appetite. 2016;99:105-111. doi:10.1016/j.appet.2016.01.014
- Keyes KM, Calvo E, Ornstein KA, et al. Alcohol Consumption in Later Life and Mortality in the United States: Results from 9 Waves of the Health and Retirement Study. Alcohol Clin Exp Res. 2019;43(8):1734-1746. doi:10.1111/acer.14125
- Kimball SR, Lang CH. Mechanisms Underlying Muscle Protein Imbalance Induced by Alcohol. Annu Rev Nutr. 2018;38:197-217. doi:10.1146/annurev-nutr-071816-064642
- Ko H, Chang Y, Kim HN, Kang JH, Shin H, Sung E, Ryu S. Low-level alcohol consumption and cancer mortality. Sci Rep. 2021 Feb 25;11(1):4585. doi: 10.1038/s41598-021-84181-1. PMID: 33633295; PMCID: PMC7907072.
- Kosti R, Di Lorenzo C, Panagiotakos D, Sandeman G, Frittella N, Iasiello B, Teissedre P, Restani P. Dietary and lifestyle habits of drinkers with preference for alcoholic beverage: does it really matter for public health? A review of the evidence. OENO One. 2021;4:1-17. doi: 10.20870/oeno-one.2021.55.4.4757
- Kwok A, Dordevic AL, Paton G, Page MJ, Truby H. Effect of alcohol consumption on food energy intake: a systematic review and meta-analysis. Br J Nutr. 2019;121(5):481-495. doi:10.1017/S0007114518003677
- Lombardo M, Feraco A, Camajani E, Caprio M, Armani A. Health Effects of Red Wine Consumption: A Narrative Review of an Issue That Still Deserves Debate. Nutrients. 2023 Apr 16;15(8):1921. doi: 10.3390/nu15081921. PMID: 37111141; PMCID: PMC10146095.
- Lucerón-Lucas-Torres M, Saz-Lara A, Díez-Fernández A, Martínez-García I, Martínez-Vizcaíno V, Cavero-Redondo I, Álvarez-Bueno C. Association between Wine Consumption with Cardiovascular Disease and Cardiovascular Mortality: A Systematic Review and Meta-Analysis. Nutrients. 2023 Jun 17;15(12):2785. doi: 10.3390/nu15122785. PMID: 37375690; PMCID: PMC10303697.
- Marcos A, Serra-Majem L, Pérez-Jiménez F, Pascual V, Tinahones FJ, Estruch R. Moderate Consumption of Beer and Its Effects on Cardiovascular and Metabolic Health: An Updated Review of Recent Scientific Evidence. Nutrients. 2021 Mar 9;13(3):879. doi: 10.3390/nu13030879. PMID: 33803089; PMCID: PMC8001413.
- Mitchell G, Lesch M, McCambridge J. Alcohol Industry Involvement in the Moderate Alcohol and Cardiovascular Health Trial. Am J Public Health. 2020;110(4):485-488. doi:10.2105/AJPH.2019.305508
- Nova E, Baccan GC, Veses A, Zapatera B, Marcos A. Potential health benefits of moderate alcohol consumption: current perspectives in research. Proc Nutr Soc. 2012;71(2):307-315. doi:10.1017/S0029665112000171
- O’Keefe EL, DiNicolantonio JJ, O’Keefe JH, Lavie CJ. Alcohol and CV Health: Jekyll and Hyde J-Curves. Prog Cardiovasc Dis. 2018;61(1):68-75. doi:10.1016/j.pcad.2018.02.001
- Pakzad R, Nedjat S, Salehiniya H, Mansournia N, Etminan M, Nazemipour M, Pakzad I, Mansournia MA. Effect of alcohol consumption on breast cancer: probabilistic bias analysis for adjustment of exposure misclassification bias and confounders. BMC Med Res Methodol. 2023 Jul 4;23(1):157. doi: 10.1186/s12874-023-01978-6. PMID: 37403100; PMCID: PMC10318777.
- Poli A, Marangoni F, Avogaro A, et al. Moderate alcohol use and health: a consensus document. Nutr Metab Cardiovasc Dis. 2013;23(6):487-504. doi:10.1016/j.numecd.2013.02.007
- Poli A, Visioli F. Moderate alcohol use and health: An update a Consensus Document. BIO Web of Conferences. 2015;5. doi:10.1051/bioconf/20150504001
- Rehm J, Roerecke M, Room R. All-Cause Mortality Risks for “Moderate Drinkers”: What Are the Implications for Burden-of-Disease Studies and Low Risk-Drinking Guidelines?. J Stud Alcohol Drugs. 2016;77(2):203-207. doi:10.15288/jsad.2016.77.203
- Rehm J, Rovira P, Llamosas-Falcón L, Shield KD. Dose-Response Relationships between Levels of Alcohol Use and Risks of Mortality or Disease, for All People, by Age, Sex, and Specific Risk Factors. Nutrients. 2021 Jul 30;13(8):2652. doi: 10.3390/nu13082652. PMID: 34444809; PMCID: PMC8401096.
- Roerecke M. Alcohol’s Impact on the Cardiovascular System. Nutrients. 2021 Sep 28;13(10):3419. doi: 10.3390/nu13103419. PMID: 34684419; PMCID: PMC8540436.
- Rumgay H, Murphy N, Ferrari P, Soerjomataram I. Alcohol and Cancer: Epidemiology and Biological Mechanisms. Nutrients. 2021a Sep 11;13(9):3173. doi: 10.3390/nu13093173. PMID: 34579050; PMCID: PMC8470184.
- Rumgay H, Shield K, Charvat H, Ferrari P, Sornpaisarn B, Obot I, Islami F, Lemmens VEPP, Rehm J, Soerjomataram I. Global burden of cancer in 2020 attributable to alcohol consumption: a population-based study. Lancet Oncol. 2021b Aug;22(8):1071-1080. doi: 10.1016/S1470-2045(21)00279-5. PMID: 34270924; PMCID: PMC8324483.
- Spaggiari G, Cignarelli A, Sansone A, Baldi M, Santi D. To beer or not to beer: A meta-analysis of the effects of beer consumption on cardiovascular health. PLoS One. 2020 Jun 3;15(6):e0233619. doi: 10.1371/journal.pone.0233619. PMID: 32492025; PMCID: PMC7269243.
- Stătescu C, Clement A, Șerban IL, Sascău R. Consensus and Controversy in the Debate over the Biphasic Impact of Alcohol Consumption on the Cardiovascular System. Nutrients. 2021 Mar 25;13(4):1076. doi: 10.3390/nu13041076. PMID: 33806249; PMCID: PMC8066508.
- Stockwell T, Zhao J, Panwar S, Roemer A, Naimi T, Chikritzhs T. Do “Moderate” Drinkers Have Reduced Mortality Risk? A Systematic Review and Meta-Analysis of Alcohol Consumption and All-Cause Mortality. J Stud Alcohol Drugs. 2016;77(2):185-198. doi:10.15288/jsad.2016.77.185
- Thompson W. Risk thresholds for alcohol consumption. Lancet. 2018;392(10160):2167. doi:10.1016/S0140-6736(18)32197-4
- Trommelen J, Betz MW, van Loon LJC. The Muscle Protein Synthetic Response to Meal Ingestion Following Resistance-Type Exercise. Sports Med. 2019;49(2):185-197. doi:10.1007/s40279-019-01053-5
- Ursula F, Hammer C. Moderate wine consumption and cancer risk in context. BIO Web Conf. 56 04002. 2023. doi:10.1051/bioconf/20235604002
- van de Luitgaarden IAT, van Oort S, Bouman EJ, Schoonmade LJ, Schrieks IC, Grobbee DE, van der Schouw YT, Larsson SC, Burgess S, van Ballegooijen AJ, Onland-Moret NC, Beulens JWJ. Alcohol consumption in relation to cardiovascular diseases and mortality: a systematic review of Mendelian randomization studies. Eur J Epidemiol. 2021 Aug 22. doi: 10.1007/s10654-021-00799-5. Epub ahead of print. PMID: 34420153.
- Visioli F, Panaite SA, Tomé-Carneiro J. Wine’s Phenolic Compounds and Health: A Pythagorean View. Molecules. 2020 Sep 8;25(18):4105. doi: 10.3390/molecules25184105. PMID: 32911765; PMCID: PMC7570485.
- Wang CN, Liblik K, Haseeb S, Lopez-Santi R, Baranchuk A. Women and Alcohol: Limitations in the Cardiovascular Guidelines. Curr Probl Cardiol. 2022 Apr 8:101200. doi: 10.1016/j.cpcardiol.2022.101200. Epub ahead of print. PMID: 35398359.
- Wood AM, Kaptoge S, Butterworth AS, et al. Risk thresholds for alcohol consumption: combined analysis of individual-participant data for 599 912 current drinkers in 83 prospective studies [published correction appears in Lancet. 2018 Jun 2;391(10136):2212]. Lancet. 2018a;391(10129):1513-1523. doi:10.1016/S0140-6736(18)30134-X
- Wood AM, Kaptoge S, Paige E, Di Angelantonio E, Danesh J. Risk thresholds for alcohol consumption – Authors’ reply. Lancet. 2018b;392(10160):2167-2168. doi:10.1016/S0140-6736(18)32181-0
- Xi B, Veeranki SP, Zhao M, Ma C, Yan Y, Mi J. Relationship of Alcohol Consumption to All-Cause, Cardiovascular, and Cancer-Related Mortality in U.S. Adults [published correction appears in J Am Coll Cardiol. 2017 Sep 19;70(12):1542]. J Am Coll Cardiol. 2017;70(8):913-922. doi:10.1016/j.jacc.2017.06.054
- Zhang X, Liu Y, Li S, Lichtenstein AH, Chen S, Na M, Veldheer S, Xing A, Wang Y, Wu S, Gao X. Alcohol consumption and risk of cardiovascular disease, cancer and mortality: a prospective cohort study. Nutr J. 2021 Feb 1;20(1):13. doi: 10.1186/s12937-021-00671-y. PMID: 33522924; PMCID: PMC7852289.