15 Moderate Consumption

of Alcohol

INTRODUCTION
Alcohol consumption, typically red wine, has been an integral part of most
Mediterranean dietary patterns, the main exception being Muslim populations.
Typically, wine is consumed daily in moderate amounts during unhurried meals. In
the United States, however, alcoholic beverages tend to be consumed erratically,
often with heavier weekend consumption and often not with meals. While wine con-
tinues to be a popular drink with everyday meals in most Mediterranean nations,
consumption of beer and distilled spirits gradually has been increasing.
Traditionally, alcohol was used in moderation, and alcoholism was rare; the con-
sumption of wine was not associated with alcohol abuse. Wine contains the same
vitamins and minerals found in grapes, but in such small amounts that the impact on
human nutrition is minimal. Wine does, however, contain phytochemicals that are
considered to provide health benefits, but red wine with skin extractions contains
greater amounts of these molecules than white wines. The alcohol calories of wine
do contribute to overall caloric intake, but other energy sources, such as fat, are typi-
cally the critical providers of dietary calories.
The key to achieving possible health benefits from alcohol consumption depends
on following the definition of moderate drinking. The 2010 Dietary Guidelines for
Americans defines moderate alcohol consumption as daily consumption of up to one
standard drink per day for women and up to two standard drinks per day for men.
Consuming large amounts of alcohol may contribute to excessive energy intake
and lead to obesity, disturb carbohydrate and glucose metabolism, induce pancre-
atitis, and impair liver function through excessive fat accumulation. Data from the
long-­running Nurses’ Health Study indicated that even low levels of alcohol con-
sumption were associated with a small increase in breast cancer risk. In addition,
alcohol consumption throughout adult life was independently associated with breast
cancer risk. Binge drinking is known to have serious health and social consequences.
Definitions of binge drinking range from having four to six or more alcoholic bever-
ages in one sitting, with women at the lower end of this range.
Drinking any type of alcohol should be avoided by some people, including chil-
dren, pregnant and lactating women, women who may become pregnant, individuals
who are unable to limit their alcohol intake, individuals on medications that can
interact with alcohol, and individuals with certain medical conditions. For those
who do not currently consume alcohol, it is not recommended to begin drinking
alcohol for the sole purpose of obtaining a possible health benefit as excessive

153
154 The Mediterranean Way of Eating

consumption clearly has adverse health effects. Individuals can follow other, more
important dietary recommendations to help reduce risks of type 2 diabetes, car-
diovascular diseases (CVDs), and other chronic diseases. Lifestyle behaviors, such
as engaging in regular physical activity and not smoking, also play a major role in
disease prevention.

APPLYING THE EVIDENCE ON ALCOHOL TO REDUCE RISK

OF TYPE 2 DIABETES
The relationship between alcohol consumption and type 2 diabetes has been a topic
of interest to researchers for a number of years. An association between alcohol con-
sumption and elevated glucose levels had been postulated and raised concerns that
alcohol intake may increase type 2 diabetes risk. This concern dissipated when data
from a large prospective cohort study of more than 85,000 women provided no sup-
port for the hypothesis that moderate alcohol consumption increased type 2 diabetes
risk. In fact, many studies show that light-­to-­moderate alcohol consumption is asso-
ciated with a lower risk of type 2 diabetes compared with zero alcohol consumption.
Alcohol likely acts through several different mechanisms in helping to decrease risk
of type 2 diabetes, including the slowing of glucose uptake from a meal.

Highlight: Many studies show that light-­to-­moderate alcohol consumption is asso-

ciated with a lower risk of type 2 diabetes compared with zero alcohol consumption.

Data from one study indicated that, in healthy men and women, light-­to-­moderate
alcohol consumption was also associated with enhanced insulin sensitivity. Findings
from a large study of men free from diabetes, CVD, and cancer who self-­selected for
moderate alcohol intake had reduced risk of type 2 diabetes. Another study exam-
ining alcohol consumption and incidence of type 2 diabetes found that moderate
alcohol intake in men and women was associated with reduced incidence of type 2
diabetes compared with very low alcohol intake. Binge drinking and high alcohol
intake, however, indicated an increased type 2 diabetes risk, especially in women.
Drinking patterns, in addition to amounts of alcohol consumed, also appear to
play an important role in the development of both type 2 diabetes and obesity. Data
collected and analyzed from more than 37,000 women and men who had never
smoked revealed that body mass index (BMI) was associated with how much alcohol
an individual consumed on the days the individual drank. Individuals who consumed
the smallest amount (one drink per drinking day) with the greatest frequency (3 to
7 days/­week) had the lowest BMI.

Highlight: Drinking patterns, in addition to amounts of alcohol consumed, also

appear to play an important role in the development of both type 2 diabetes and
obesity.
Moderate Consumption of Alcohol 155

Several reasons have been suggested concerning the association between a high
BMI and a high quantity of alcohol intake, including the following:

• Alcohol can be a significant source of calories.

• Liquid calories may not produce the same feeling of satiety as do calories
from solid foods.
• Drinking, especially in a social setting, may stimulate eating as well as
more drinking.

Results from another study of drinking patterns in relation to type 2 diabetes

risk among men found that consuming one to two alcoholic drinks per day was
associated with a 36% lower risk of type 2 diabetes compared with no alcohol con-
sumption. The type of alcoholic beverage—wine, beer, or distilled spirits—did not
change the results. Frequency of alcohol intake also was found to be inversely asso-
ciated with risk of type 2 diabetes. Alcohol consumption on at least 5 days/­week
appeared to offer the most protection, even when less than one drink per drinking
day was consumed.

APPLYING THE EVIDENCE ON ALCOHOL TO REDUCE RISK

OF CARDIOVASCULAR DISEASES
Substantial evidence from numerous types of studies indicates an inverse relation-
ship between moderate alcohol consumption and CVD risk. Findings from some
studies suggest that men and women who regularly consume one to two alcoholic
drinks a day (i.e., moderate drinkers) have a lower risk of heart disease compared
to nondrinkers. The benefit of moderate alcohol consumption is associated with a
lower risk of total mortality, CVD, CVD death, heart attack or myocardial infarc-
tion (MI), fatal MI, and coronary heart disease (CHD). Any potential heart benefit
gained from alcohol consumption rests strongly on moderate consumption. As stated
previously, excessive alcohol intake is associated with multiple well-­known adverse
health effects.

Highlight: Any potential heart benefit gained from alcohol consumption rests
strongly on moderate consumption.

A systematic review and meta-­analysis focused on alcohol consumption and

selected cardiovascular outcomes. Findings indicated that light-­to-­moderate alcohol
consumption, relative to nondrinkers, was associated with a reduced risk of several
cardiovascular outcomes, including CVD mortality, incident CHD, CHD mortality,
incident stroke, and stroke mortality. Data from the Spanish cohort of the European
Prospective Investigation into Cancer and Nutrition (EPIC) were analyzed to explore
the association between alcohol intake and CHD. Alcohol intakes that were moder-
ate to very high in men were all associated with a more than 30% lower rate of CHD.
Alcohol intake was also associated with reduced risk of CHD in women, but the
156 The Mediterranean Way of Eating

results were not statistically significant, possibly due to the lower number of coro-
nary events in women compared to men. Even though the highest levels of alcohol
intake in this study were still associated with a reduction in CHD risk in men, it
cannot be emphasized enough that excessive alcohol intake also is associated with
several other adverse health effects.
A cohort of 8,867 men of the Health Professionals Follow-­Up Study participated
in a prospective study investigating the association between alcohol consumption
and CHD risk in men with healthy lifestyles. The men were free of major illness and
reported engaging in healthy lifestyle behaviors. All participants had a BMI less than
25, exercised for 30 minutes or more per day, abstained from smoking, and followed
a diet high in fruits, vegetables, cereal fiber, fish, chicken, nuts, soy, and polyunsatu-
rated fat. Results indicated that even in men already at reduced risk for heart disease,
moderate alcohol intake, compared with abstention from alcohol, was associated
with lower risk for MI. Another study analyzed alcohol intake and risk of CVD pro-
spectively in large representative samples of the U.S. population using information
from the National Health Interview Survey. Findings of this report suggested that
light and moderate drinkers had significantly lower risk of death from CVD than did
alcohol abstainers and heavy drinkers. The risk reduction was similar among men
and women and among different age categories.
Results for a cohort study of over 1,300 men indicated that long-­term light alcohol
intake, less than or equal to 20 g per day, compared with no alcohol, lowered cardio-
vascular risk and all-­cause mortality risk and increased life expectancy. Men who
consumed modest amounts of wine each day compared with men who did not drink
alcohol had an increased life expectancy about 5 years longer.
Available evidence suggests that a regular and moderate intake of any type of
alcoholic beverage (i.e., wine, beer, or liquor) provides similar cardiovascular ben-
efits. The ethanol content of alcoholic beverages repeatedly has been shown to raise
slightly the blood concentrations of “good” high-­density lipoprotein (HDL) choles-
terol and to prolong clot formation, a benefit for most adults.

POTENTIAL ADVANTAGES OF RED WINE CONSUMPTION

COMPARED TO OTHER TYPES OF ALCOHOL
Little data exist that indicate one type of alcohol provides significantly greater health
benefits than another. Wine, however, has one advantage over other alcoholic drinks
because it contains several unique phenolic compounds, one class of phytochem-
icals. One phenolic compound in red wines is resveratrol, a polyphenolic phyto-
alexin. Phytoalexins are produced in certain plants as a defense against infection
by pathogenic micro­organ­isms. Resveratrol may also exhibit alexin-­like activity in
humans and has been reported to have cardioprotective benefits, as well as anti-
carcinogenic effects. A recent review summarized the cardiovascular effects and
molecular targets of resveratrol, noting that this unique compound stimulates endo-
thelial production of nitric oxide, reduces oxidative stress, inhibits vascular inflam-
mation, and prevents platelet aggregation. Red wines have much higher amounts of
resveratrol than do white wines because during the wine-­making process the reds
Moderate Consumption of Alcohol 157

have extended time for the extraction from the rich phenol-­containing grape skins.
Resveratrol, along with other flavonoid and nonflavonoid phenolic molecules, also
has antioxidant activities and continues to receive considerable research attention
because of its potential health benefits.

Highlight: Resveratrol, along with other flavonoid and nonflavonoid phenolic

molecules, also has antioxidant activities and continues to receive considerable
research attention because of its potential health benefits.

BOTTOM LINE
Alcohol consumption, especially of red wine, can be part of a healthy diet if used
in ways similar to those in most Mediterranean dietary patterns that use alcohol:
consumed mainly with a meal, especially a leisurely paced meal, and used regularly
in moderation.
Moderate alcohol consumption is considered as up to one standard-­size drink for
women and up to two standard-­size drinks for men daily or several times a week.
Refer to Box 15.1 for definitions of the standard sizes of different alcoholic beverages.
Findings from numerous studies suggest that light-­to-­moderate alcohol consump-
tion may offer some protection against the development of type 2 diabetes and CVDs.
Alcohol consumption, however, is associated with both health benefits and health
risks. Therefore, it is important to drink responsibly and, in some cases, to avoid
alcohol use altogether.

BOX 15.1
One standard drink is defined as containing approximately 0.6 fluid ounces
(14 g) of alcohol (ethanol), and equals

• 5 fluid ounces of wine (approximately 100 Calories)

• 12 fluid ounces of regular beer (approximately 144 Calories)
• 1.5 fluid ounces of 80-proof distilled spirits (approximately 96 Calories)