Every five years, the United States produces a set of health recommendations entitled Dietary Guidelines for Americans. The document is authored jointly by the Departments of Agriculture (USDA) and Health and Human Services (HSS), which should cover the waterfront nicely. The USDA recently published a report on which the 2020 Guidelines will be based; comments are currently invited in the Federal Register.
Among its topics, Guidelines tells Americans how much alcohol they should consume—or whether they should drink at all. For those familiar with America’s temperance history, this can be a weighted topic.
The US, of course, banned the production, sale and commercial consumption of alcohol for 13 years, from 1920 to 1933. Among countries that have never prohibited alcohol are Italy, Greece, Spain, Germany, Japan and China. Indeed, the non-Muslim nations that have banned alcohol for substantial periods—Canada, Russia/Soviet Union, Finland, Iceland, Norway and the Philippines—can almost be counted on one hand.
The vacillating recommendations about alcohol in the US Guidelines over the decades make it a fascinating cultural document—especially since it is obligated to explain its advice in health terms. Let’s take a trip down memory lane.
“Alcohol has no net health benefit, is linked with many health problems, is the cause of many accidents and can lead to addiction. Its consumption is not recommended.”
“Alcoholic beverages have been used to enhance the enjoyment of meals by many societies throughout human history” [while] “current evidence suggests that moderate drinking … is associated with a lower risk for coronary heart disease in some individuals.”
The 2010 Guidelines’ alcohol section expert panel was headed by Eric Rimm, now director of the Harvard School of Public Health’s Program in Cardiovascular Epidemiology. The 2010 alcohol panel reported “strong evidence” that “the lowest mortality risk for men and women [occurs] at the average level of one to two drinks per day, [and] is likely due to the protective effects of moderate alcohol consumption on CHD [coronary heart disease], diabetes and ischemic stroke.”
The panel’s report further noted that “moderate evidence suggests that compared to non-drinkers, individuals who drink moderately have a slower cognitive decline with age.”
“If alcohol is consumed, it should be in moderation—up to one drink per day for women and up to two drinks per day for men … In comparison to moderate alcohol consumption, high-risk drinking is the consumption of 4 or more drinks on any day or 8 or more drinks per week for women and 5 or more drinks on any day or 15 or more drinks per week for men.”
“Excessive alcohol consumption … has no benefits.” [The implication that moderate drinking does have benefits was left unspoken.]
The Guidelines’ scientific panel for alcohol recommended reducing the amount of alcohol men should consume to one drink per day instead of two.
The New York Times article on the recommendations led by noting: “Can a daily drink or two lead to better health? For many years, the federal government’s influential dietary guidelines implied as much, saying there was evidence that moderate drinking could lower the risk of heart disease and reduce mortality … The 2010 guidelines mentioned that moderate drinking may even ‘help to keep cognitive function intact with age.’”
“This would suggest that there is a lot of new science on this topic, and there’s not.”
Not so, the new Guidelines background report “shows.” As one public health expert intoned in the Times piece, “the committee has finally gotten away from this idea that a small amount of alcohol is good for you. They’re really taking a stand and saying drinking less is always better,” indicating abstinence is the best policy.
The Guidelines’ push towards abstinence follows on the World Health Organization’s 2018 declaration that there is “no safe level of alcohol.”
Rimm responded to the new recommendations: “This would suggest that there is a lot of new science on this topic, and there’s not. It’s unfortunate because it’s going to create some confusion.”
I have reviewed these data for Filter. Hundreds of studies have found moderate drinkers to be healthier, and to live longer, than lifetime abstainers (after eliminating from the analysis those who have quit drinking for health reasons or due to alcohol use disorders). Such data never stop cropping up. Consider this 2017 report in the Journal of the American College of Cardiology, based on US government research involving a third of a million Americans:
Data were obtained by linking 13 waves of the National Health Interview Surveys (1997 to 2009) to the National Death Index records through December 31, 2011. A total of 333,247 participants ≥18 years of age were included …
Results: Compared with lifetime abstainers, those who were light or moderate alcohol consumers were at a reduced risk of mortality for all causes [such as heart disease and all forms of cancer].
Whatever WHO and the Guidelines tell us, they can’t erase regular findings that moderate drinkers are healthier and live longer.
We must question how public health bodies feel safe to ignore such persistent findings.
Such data, as with that 2017 report, come from large-scale government research and prestigious health agencies. Rimm and colleagues reported in 2010 that there was “strong evidence” that moderate drinkers had the “lowest mortality risk” (i.e., lived longest). I have long noted—from 1993 in the American Journal of Public Health to 2017 in Pacific Standard—that this conclusion is justified scientifically.
What about their reporting moderately strong evidence for the cognitive benefits of moderate drinking?
In 2000, Archie Brodsky* and I found in an article in Drug and Alcohol Dependence that the clearest psychological benefit** from alcohol (other than enjoyment) was reduced dementia/Alzheimer’s in middle-aged and older adults. As did Rimm et al., we based this conclusion on a series of research results.
So it was unsurprising when, in 2020, the Journal of the American Medical Association (JAMA) Network published a study of cognitive functioning and alcohol consumption:
In this cohort study of 19,887 participants from the Health and Retirement Study … when compared with never drinking, low to moderate drinking was associated with significantly better trajectories of higher cognition scores for mental status, word recall, and vocabulary and with lower rates of decline in each of these cognition domains. Meaning: Current low to moderate alcohol consumption among middle-aged or older adults may be associated with better total cognitive function.
JAMA is no fly-by-night operation. Once again, we must question how national and international public health bodies feel safe to ignore such persistent findings of benefits from sensibly consuming alcohol.
One popular criticism of data showing benefits from alcohol is that they are not the result of drinking, but occur because healthier people drink. Indeed, better-educated, economically better-off people are more often drinkers.
At a minimum, however, this finding removes the pall of the “no safe level of alcohol” meme. A group of privileged people—including, in my experience, an overwhelming majority of public health professionals—more often drink than those who are less privileged. Yet they comfortably maintain better health.
Thanks to their advantages, people who are wealthier and better-educated tend to do things that are both good for them—for example, they eat better and exercise more—and that are enjoyable.
Brodsky and I noted that the most reliable finding of a psychological benefit from alcohol is that people typically find drinking to be pleasurable. Is that something to be ignored or disparaged in the public health field, when many studies link happiness to longer life? Instead, as I wrote for Filter, encouraging positive, pleasurable substance use should be a drug policy project.
But if the many variables involved in comparing US socio-economic groups leave you unconvinced, we can turn to international examples.
Could it be that those presenting alcohol in the worst light overrepresent cultures that have the most harmful relationships with alcohol?
Studies of drinking among European countries have made an astounding discovery: There is less alcohol-related harm in countries that drink more! I detailed these results from the European Comparative Alcohol Study (ECAS)—the first systematic European comparison of drinking problems—as presented in the volume Alcohol in Postwar Europe:
Alcohol in Postwar Europe thoroughly supported with data that alcohol-related problems were lowest in Southern Europe and highest in the North, despite the much greater controls the latter imposed and the lower drinking ages and far greater consumption in the former.
Even more surprising was that alcohol-related mortality was also much higher in the North, due principally to the tendency in Temperance cultures to drink in heavy bursts, rather than regularly, but moderately. This leads to more accidents, violence, and suicide, and perhaps even to cirrhosis in Finland, Norway, Sweden—which consume the least alcohol—than in France, Italy Portugal, Spain, Greece, which consume the most.
ECAS found alcohol-related mortality was substantially higher in Northern than Southern Europe: 18 versus 3 such deaths per 100,000 for men, 3 versus 0.5 for women. There was an inverse relationship between alcohol consumption and alcohol-related mortality.
What makes these results doubly noteworthy is that Northern European countries are better-off economically as a group than Southern ones. Italian alcohol researcher Allaman Allamani described this as a cultural phenomenon:
In the Northern countries, alcohol is described as a psychotropic agent … It has to do with the issue of control and with its opposite—“discontrol” or transgression. In the Southern countries, alcoholic beverages—mainly wine-–are drunk for their taste and smell, and are perceived as intimately related to food, thus as an integral part of meals and family life.
Allamani went on to shed light on the continuing resistance to national differences like those revealed by ECAS:
Many European policies have been based on the brilliant and extensive studies carried out in Northern Europe and in North America. They put great emphasis on control and restriction measures. … As a consequence, alcohol studies and experiences are strongly influenced by both the Nordic and English-speaking countries. International agencies and WHO itself have possibly been influenced by this situation.
Could it be that those presenting alcohol in the worst light overrepresent cultures that have the most harmful relationships with alcohol? We surely have more to learn from cultures that navigate alcohol successfully and beneficially.
And perhaps the constantly yoyo-ing Dietary Guidelines for Americans should come with their own warning label attached: Consumption of this material may impair your ability to live well.
*Archie Brodsky is a member of the board of directors of The Influence Foundation, which operates Filter.
** We might debate whether reduced dementia/Alzheimer’s should be characterized as a psychological benefit or a physiological one. I note in this regard that (1) a persistent search has yet to identify reliable physiological markers of dementia/Alzheimer’s, and (2) among the best predictors of absence of cognitive decline are paid work engagement and life satisfaction, indicating a strong environmental and psychological component that might be labeled purpose and engagement.