One drink too many? How US health officials rethought alcohol limits

Federal dietary guidelines long recommended limits on alcohol consumption for Americans: one drink daily for women, two for men. But last spring, health officials seriously considered a dramatic redefinition of moderate drinking for men, according to two people with knowledge of the process who spoke anonymously because they feared reprisals.

The officials proposed lowering the cap for men to one drink a day, the recommended limit for women. That suggestion, contained in a draft document written in March and obtained by The New York Times, went nowhere.

When Robert F. Kennedy Jr., the health secretary, and other officials unveiled the new guidelines this month, they included a vague directive telling Americans only to “limit” alcohol. Even the long-established caps for men and women were gone.

Details regarding the internal document, put together by officials at the Department of Health and Human Services, were first reported by Reuters.

The proposal stipulated that both men and women should “limit consumption to one standard drink or less per day.”

“Even moderate drinking can carry health risks,” the document said. “For example, the risk of certain types of cancer increases even at less than one standard drink per day, regardless of the type of alcohol consumed.”

The advice never became a formal draft recommendation, and the team working on the document was disbanded. Some were terminated last spring, and others were reassigned.

In response to questions about what happened to individualized limits for men and women, Andrew Nixon, a spokesperson for Health Department, said the process was lawful and transparent, adding, “The dietary guidelines were based on rigorous scientific review and independent oversight.”

There has been a vigorous scientific debate in recent years about the benefits and risks of moderate drinking. Two reports commissioned by the government evaluated the research on health impacts; one of the reports was withdrawn and never submitted to Congress.

The alcohol industry has steadfastly supported the long-standing caps for men and women, and has opposed any changes to the formula. Indeed, industry representatives frequently note the safe thresholds recommended in previous guidelines.

“The spirits sector’s long-standing position has been that the definition of moderate drinking is helpful to consumers, and that the guidance should not change unless there is a preponderance of scientific evidence to do so,” Amanda Berger, senior vice president for science and research at the Distilled Spirits Council, said in a recent statement.

She pointed to a report on drinking by the National Academies of Science, Engineering and Medicine, or NASEM, that Congress commissioned, noting that it clearly defined “moderate alcohol consumption as one drink per day for women and two drinks per day for men.”

Last year, Congress stipulated that the NASEM report should be the only alcohol-related study used to inform the dietary guidelines.

That report concluded that moderate drinking was linked to lower all-cause mortality and lower cardiovascular mortality, compared with never drinking. But drinking was also associated with a higher risk of female breast cancer. The report based its conclusions on studies from around the world.

Dr. Ned Calonge, an epidemiologist at the University of Colorado Anschutz Medical Campus who led the NASEM panel on alcohol, said the new guidelines directing men and women simply to drink less were in line with the report’s findings.

“There are a lot of reasons people drink alcohol,” Calonge said. “What we’re saying is, health shouldn’t be one of them. Doctors should not recommend that people drink alcohol for any reason.”

But the other government report, called the Alcohol Intake and Health report, concluded that the risk of death began rising even at one drink daily, for both men and women, in the United States.

That report was commissioned by HHS during the Biden administration, but it became a target of scathing criticism in Congress and ultimately was withdrawn by the Trump administration.

Still, in remarks at a news briefing introducing the new dietary guidelines this month, Dr. Mehmet Oz, administrator of the Centers for Medicare and Medicaid Services, seemed to note a shift in the scientific consensus.

There has been a “general move away from two glasses for men and one glass for women — there was never really good data to support that quantity of alcohol consumption,” he said.

In the 1980s, the dietary guidelines said all adults could have one to two servings of alcohol a day, except during pregnancy. The separate recommendations for men and women, introduced in 1990, were based on the fact that men and women are biologically different.

But the idea that men could drink more was never rooted in solid scientific evidence, some experts have said, and it may have been influenced in part by paternalistic attitudes toward women.

The biological differences are real enough: Men are taller and heavier than women on average, and women metabolize alcohol differently because they have both a higher percentage of body fat (alcohol is water-soluble) and lower levels of a liver enzyme that’s responsible for metabolizing alcohol.

But men are more likely to engage in risky behaviors when drinking, and they have higher rates of habits, like smoking, that compound the harms of alcohol, scientists say.

“Blood alcohol content depends on how large someone is,” said Jürgen Rehm, a senior scientist at the Center for Addiction and Mental Health in Toronto and an author of the alcohol intake study.

But that metric “mainly plays a role in acute events, like traffic accidents, and there are other processes and pathways for how alcohol impacts on mortality,” he said.

“Even at one drink a day, the risk is small, but it accumulates,” he added.

Even at lower levels of drinking, men are more likely to engage in impaired driving, commit violence or experience drownings and falls, scientists have found.

“Men drink more, binge-drink more and generally do dumber things when impaired,” said Tim Naimi, director of the Canadian Institute for Substance Use Research and another author of the alcohol report.

Men account for roughly three-quarters of alcohol-attributable deaths in the United States and Canada, Naimi continued, and they are responsible for a majority of “secondhand harms.”

Men have almost triple the number of emergency department visits for alcohol-specific diagnoses than women, according to national figures released Thursday, with nearly 4 million visits each year on average in 2021 and 2022. The figure for women is 1.37 million emergency room visits.

Among men, the risk of dying from something related to drinking starts to exceed 1 in 1,000 at 6 1/2 drinks a week, Rehm and his colleagues found. Among women, the threshold is roughly the same, more than 7 drinks a week.

At 8 1/2 drinks a week, the risk exceeds 1 in 100 for both men and women.

“For low levels of use, at the same level of use, men are at a similar risk of health harms from alcohol use compared to women,” according to the internal HHS document.

The overall death toll from alcohol, for both men and women, far exceeds that from drug overdoses. According to the Centers for Disease Control and Prevention, more than 178,000 U.S. deaths in 2020-21 were attributable to alcohol.

The figure includes deaths immediately linked to drinking — including those caused by alcohol poisoning and motor vehicle accidents — as well as those resulting from cancer and suicides.

Alcohol causes 8% of breast cancer deaths, for example, and nearly half of deaths in men who develop a certain type of esophageal cancer.

If all American adults poured themselves less than one drink per day, an estimated 17,000 alcohol-related cancer deaths could be prevented, the internal HHS document estimated.

In 2020, when the dietary guidelines were previously being revised, scientific advisers also wanted to make a universal recommendation of no more than one drink a day for all adults. The advice never made it into the final dietary guidelines then, either.

The guidelines released this month recommend only that Americans drink less for better health. “It would have been helpful to say clearly what is meant by this,” said Marion Nestle, a nutritionist who studies food policy.

“If research shows a reasonable limit is less than one a day, they should have said that — less than one a day, three to four drinks a week and don’t worry about it. It’s very simple advice.”

The findings of apparent cardiovascular benefits from moderate drinking have muddied the debate over what to tell men and women, Nestle said.

At this point, however, “nobody is going to suggest drinking to reduce your cardiovascular risk, except people in the alcohol industry,” she said.