Review of Evidence on Alcohol and Health (2025)
Chapter: Front Matter
Consensus Study Report
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COMMITTEE ON REVIEW OF EVIDENCE ON ALCOHOL AND HEALTH
BRUCE N. CALONGE (Chair), Associate Dean for Public Health Practice and Professor of Epidemiology, Colorado School of Public Health, and Professor of Family Medicine, University of Colorado School of Medicine
ANDREW W. BROWN, Associate Professor in the Department of Biostatistics, University of Arkansas for Medical Sciences
CARLOS A. CAMARGO, JR., Professor of Emergency Medicine, Medicine, and Epidemiology, Harvard University
PATRICIA A. CASSANO, Alan D. Mathios Professor in the Division of Nutritional Sciences, Cornell University
PATRICK M. CATALANO, Professor in Residence, Reproductive Endocrinology Unit, Harvard University
KATHRYN E. COAKLEY, Assistant Professor in the College of Population Health, University of New Mexico Health Sciences Center
LUC DJOUSSE, Associate Professor of Medicine and Nutrition, Harvard University
JO L. FREUDENHEIM, SUNY Distinguished Professor in the Department of Epidemiology and Environmental Health and Associate Dean for Faculty Affairs, School of Public Health Professions, University at Buffalo
REBECCA A. HUBBARD, Carl Kawaja and Wendy Holcombe Professor of Public Health, Professor of Biostatistics and Data Science, Brown University School of Public Health
MICHELLE K. MCGUIRE, Professor of Nutrition and Director of the Margaret Ritchie School of Family and Consumer Sciences, University of Idaho
IAN J. SALDANHA, Associate Professor of Epidemiology and Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
SUSAN M. SMITH, Harris-Teeter Dickson Foundation Distinguished Professor in Nutrition, University of North Carolina at Chapel Hill
LINDA G. SNETSELAAR, Professor in the Department of Epidemiology and Endocrinology/Metabolism, Colleges of Public Health and Medicine, University of Iowa
EDITH V. SULLIVAN, Professor in the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine
Study Staff
KATRINA BAUM STONE, Study Director
ALICE VOROSMARTI, Associate Program Officer
TAKYERA ROBINSON, Associate Program Officer (until November 2023)
SARAH PONCET LANDOLT, Research Associate
JENNIFER STEPHENSON, Research Associate
JENNIFER MOUSER, Senior Program Assistant (until June 2024)
ANDI REISER, Senior Program Assistant (until February 2025)
REBECCA MORGAN, Senior Librarian
ANN L. YAKTINE, Director, Food and Nutrition Board
Consultants
DEEPA HANDU, Academy of Nutrition and Dietetics
LISA MOLONEY, Academy of Nutrition and Dietetics
MARY ROZGA, Academy of Nutrition and Dietetics
Reviewers
This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.
We thank the following individuals for their review of this report:
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by ALFRED O. BERG, University of Washington, and CATHERINE E. WOTEKI, Iowa State University. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.
Contents
8 MATERNAL ALCOHOL CONSUMPTION DURING LACTATION
Research Gaps by Type of Health Outcome
A Committee Member Biosketches
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1 Appendixes E through J are available online at https://nap.nationalacademies.org/catalog/28582.
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Boxes, Figures, and Tables
BOXES
1-1 Overview of the Process to Develop the Dietary Guidelines for Americans
1-2 Background on Questions in the Statement of Task
1-4 Definition of Moderate Alcohol Consumption
2-1 Key Terminology Related to Systematic Reviews
2-2 Search Dates, Periods, and Description
2-3 Understanding the Forest Plot
8-1 Lactation Questions from the Statement of Task
FIGURES
TABLES
2-1 Inclusion and Exclusion Criteria
2-2 Search Details by Statement of Task Questions
2-3 Dietary Guidelines Advisory Committee Links with Alcohol Sections
4-1 Centers for Disease Control and Prevention and World Health Organization Categories for Weight
4-3 Risk of Bias of Included Studies Examining the Relationship Between Alcohol Intake and Weight
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Acronyms and Abbreviations
| ALDH | acetaldehyde dehydrogenase |
| AMSTAR | A Measurement Tool to Assess Systematic Reviews |
| AND | Academy of Nutrition and Dietetics |
| ASD | autism spectrum disorder |
| AUD | alcohol use disorder |
| AUDIT | Alcohol Use Disorders Identification Test |
| BAC | blood alcohol concentration |
| BMI | body mass index |
| CARDIA | Coronary Artery Risk Development in Young Adults |
| CDC | Centers for Disease Control and Prevention |
| CHD | coronary heart disease |
| CI | confidence interval |
| CVD | cardiovascular disease |
| DGA | Dietary Guidelines for Americans |
| DGAC | Dietary Guidelines Advisory Committee |
| DNA | deoxyribonucleic acid |
| DSM | Diagnostic and Statistical Manual of Mental Disorders |
| DXA | dual x-ray absorptiometry |
| GABAA | γ-aminobutyric acid |
| HDL | high density lipoprotein |
| HHS | U.S. Department of Health and Human Services |
| HR | hazard ratio |
| IARC | International Agency for Research on Cancer |
| ICD | International Classification of Diseases |
| kcal | kilocalorie |
| kg | kilogram |
| LDL | low density lipoprotein |
| MI | myocardial infarction |
| MACE | major adverse cardiovascular event |
| MMSE | Mini-Mental State Examination |
| MRI | magnetic resonance imaging |
| NESR | Nutrition Evidence Systematic Review |
| NHANES | National Health and Nutrition Examination Survey |
| NLM | National Library of Medicine |
| NIAAA | National Institute on Alcohol Abuse and Alcoholism |
| OR | odds ratio |
| oz | ounce |
| PedsQL | Pediatric Quality of Life Inventory |
| PRISMA | Preferred Reporting Items for Systematic Review and Meta-Analyses |
| RCT | randomized controlled trial |
| RR | relative risk |
| SR | systematic review |
| USDA | U.S. Department of Agriculture |
| WC | waist circumference |
| WHI | Women’s Health Initiative |
| WHO | World Health Organization |
Preface
The United States has a long and complex societal relationship with alcohol consumption. According to the National Institute of Alcohol Abuse and Alcoholism, well over half of Americans consume at least some alcohol every year, and more people over age 12 have used alcohol in the past year than any other drug or tobacco product. The acceptability of alcohol consumption by nonpregnant adults at levels deemed to be “moderate” or “responsible” is fairly ubiquitous, although there are faiths and cultures, even in the United States, in which total abstinence is supported and practiced. There were even two separate amendments to the U.S. Constitution related to alcohol for beverage purposes: one to prohibit the manufacture, sale, transportation, import, and export of alcohol and the other to repeal the first. For many, drinking alcoholic beverages is part of daily life and in many social scenarios, including watching sporting events, celebrating important life events and achievements, convening socially, as part of meals, and accompanying other activities pursued for entertainment and enjoyment. There is also a major economy revolving around alcoholic beverages, ranging from farming to provide ingredients, industry for manufacturing and packaging, distribution, sales, and marketing efforts that support consumer access, and the service industry that provides public and social settings for consumption.
Why do people drink alcohol? Many alcohol-containing beverages provide flavors and sensations that people enjoy—fine wine, craft beer, or distinct distilled spirits, which may be mixed with other flavored, often sweet ingredients. Alcohol has other characteristics that likely impact the decision to consume it, specifically the effect on how we act and respond in
social situations based on how alcohol may affect self-confidence, inhibition, stress/anxiety, mood, pleasure and enjoyment. Furthermore, there is a cultural sense of alcohol consumption as a rite of passage or a sign of adulthood that likely influences the decision to drink alcoholic beverages.
While very small doses of alcohol may not have noticeable effects, higher doses of alcohol can impact judgement, and the line between the two can be fine and not appreciated by the individual at a given moment. The harms of acute intoxication and habitual heavy drinking are well known, and, as with other drugs that are addictive, use at low levels carries a risk of increasing and excess use. Based on the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), over 20 percent of those who consume alcohol will develop an alcohol use disorder (AUD) sometime during their lifetime. AUD is the most common substance use disorder in the United States according to the National Institute on Drug Abuse, although this progression is likely dependent on drinking patterns and individual characteristics including ancestry/genetics.
Looking at the evidence for lower consumption levels, the health effects of alcohol are inconsistent with a mixture of both potential health benefits and health harms. There is a significant body of evidence that examines the health effects of moderate drinking, generally defined as daily consumption of less than or up to 1–2 drinks, each containing about 14 grams of alcohol. There are underlying physiologic reasons for both increased and decreased risk of disease at these levels. Beyond physiology, though, there may be other impacts that are more difficult to measure, but may also be associated with health outcomes, such as social connectivity. Joining others to interact “over a drink” in private and public settings is a common behavior that may well provide measurable social connectivity benefits. However, there are also potential harms related to alcohol and social connectivity. Evidence for this occurred during the COVID-19 epidemic when, along with increased stress, there was increased isolation that accompanied social distancing interventions. This perfect storm was temporally related to increased drinking, with alcohol sales increasing by almost 3 percent in the United States and research reports of increases in consumption.
Research on the health effects of moderate drinking is challenging. Currently there are no published clinical trials for most important health outcomes, so even the substantial evidence base noted above is challenged by threats of bias inherent in observational studies, especially residual confounding. Exposure measurement is challenged by the inherent bias of the under-reporting of alcohol consumption as well as by the lack of standardized cutoffs for exposure categories. There is variation due to drinking patterns, including binge drinking, and to different types of alcohol consumed such as wine, beer, and spirits. Finally, the comparison group used in alcohol studies has been identified as a major source of bias. This
is because categories of “nondrinkers” often include former drinkers, who may have stopped drinking for health reasons including AUD and whose past consumption levels and associated health issues may well exceed those included in moderate drinking exposure levels.
It is with this background and these challenges that the committee convened by the National Academies of Sciences, Engineering, and Medicine undertook this review of the evidence on alcohol and health to inform the next edition of the Dietary Guidelines for Americans (DGA). This evidence review is based on the more recent evidence published over the past 5 to 15 years and is intended to be considered in the context of previous reviews. We believe the result of this report will help inform the DGA and support the expansion of and improvements in research of the health effects of moderate drinking.
Ned Calonge, Chair
Committee on Review of Evidence on Alcohol and Health
