Nutrition and Your Health:
Dietary Guidelines for Americans

Summary	Recommend you revise the definition of "moderate" to the equivalent of 3 or 4 beers per week. This sends a much better signal to people on what is "healthy."
Comments	By defining "moderation" as the equivalent of 2 beers per day, you are endorsing this quantity as acceptable. Inclusion of the words "or less" does not change this endorsement. Two beers a day may be what many Americans consume, but it is clear that the effects of this much alcohol for most people is just plain unhealthy.
Submission Date	9/23/2004 10:19:00 PM
Author	from Canal Winchester, OH

Summary	The Committee report states: One drink is defined as 12 oz of regular beer, 5 oz. of wine (12 percent alcohol), or 1.5 oz of 80-proof distilled spirits. It would be more useful to consumers if it included the information that defined each drink in terms of 0.6 fluid ounces of alcohol.
Comments	Clearly written consumer guidance on ethanol, with a comprehendible and consistent definition of a standard drink will assist dietitians and other health professionals in giving guidance about moderate and responsible consumption of alcohol for those adults who choose to drink. Given the importance of the definition of a drink in giving guidance for following the ethanol guideline, I propose two recommendations to make this statement more clear. First, the addition of the percent alcohol for wine that was added in the 2005 draft is extremely helpful, but propose that the percent alcohol should be stated for each type of beverage. Second, an additional important piece of information is that each of these standard drinks contains 0.6 fl oz of alcohol. There is a wide variety of alcohol beverages that have different percents of alcohol. Knowing that a ¡§standard drink¡¨ contains 0.6 fl oz of alcohol would allow the individual who consumes alcohol drinks to easily determine the amount of alcohol they are consuming so that they can follow the moderation guideline.
Submission Date	9/24/2004 4:05:00 PM
Author	from boston, ma

Summary	Standard drink definition should include amount of alcohol in each drink (0.6 fl ounces). Suggestion: 12 fl ounces of regular beer (5% alcohol); 5 fl ounces of wine (12% alcohol); 1.5 fl ounces of 80-proof distilled spirits (40% alcohol). Each standard drink contains 0.6 fl ounces of alcohol.
Comments	September 24, 2004 Ms. Kathryn McMurry HHS Office of Disease Prevention and Health Promotion Office of Public Health and Science STE LL100 1101 Wootton Parkway Rockville, MD 20852 FR Docket No. 04-19563, Department of Health and Human Services, Announcement of the Availability of the Final Report of the Dietary Guidelines Advisory Committee, a Public Comment Period, and a Public Meeting Dear Ms. McMurry: Thank you for providing the opportunity to comment on the Advisory Committee’s draft report of the 2005 Dietary Guidelines for Americans. These Guidelines are an important tool for consumers and the dietitians and other health professionals who advise them. As a professor in the Department of Family Medicine in the Graduate School of Medicine at the University of Tennessee, and past-president of the American Dietetic Association, I would like to thank the Committee for its efforts to provide useful and clear guidance on alcohol consumption. In general, the alcohol guideline provides evidence based information that will be helpful to dietitians and all health professionals in providing guidance to their patients. In counseling with patients, I am often asked, “What does moderation mean?” and “How much is a drink?” To effectively explain moderation, I need to be able to clearly communicate the meaning of a standard drink. The current definition in the proposed guideline is helpful. However, a clearer and more complete definition would better assist the dietitian in communicating the guidance on moderate and responsible consumption as defined in the alcohol guideline to their adult patients who choose to drink. The proposed 2005 guideline defines a standard drink as: One drink is defined as 12 oz of regular beer, 5 oz. of wine (12 percent alcohol), or 1.5 oz of 80-proof distilled spirits. The addition in the current draft of the percent alcohol for a serving of wine is an excellent revision to past Guidelines. However, to make this definition more complete and consistent, information on percent of alcohol by volume for each type of alcohol beverage (beer, wine and distilled spirits) should be included. Additionally, in counseling patients, dietitians address the fact that the alcohol content in different types of alcohol drinks may vary. Thus, the drink definition should also include information on the amount of alcohol in each standard drink (0.6 fl ounces). This information will provide a benchmark for quantification and assist consumers to better determine the number of standard drinks they are consuming. The additional clarifications I have suggested, as illustrated below, will provide consumers with the necessary information to most easily follow the recommendations set forth in the alcohol guideline. A standard drink is defined as: • 12 fluid ounces of regular beer (5 percent alcohol) • 5 fluid ounces of wine (12 percent alcohol) • 1.5 fluid ounces of 80-proof distilled spirits (40 percent alcohol). Each standard drink contains 0.6 fl ounces of alcohol. Once again I appreciate the opportunity to comment on the proposed 2005 Dietary Guideline’s guideline on alcohol. As a dietitian, I am committed to providing accurate and meaningful information to my patients regarding their diet and lifestyle. I think the suggested revisions will provide useful information to all health professionals in communicating their messages to their patients. Sincerely, Jane White, PhD, RD, FADA Professor, Department of Family Medicine Graduate School of Medicine University of Tennessee – Knoxville Knoxville, TN
Submission Date	9/24/2004 6:00:00 PM
Author	University of Tennessee – Knoxville

Summary
Comments	Alcohol risks listed do not include women with risk factors for breast cancer. The best studies are absolutely conclusive regarding the link, with the curve of risk never reaching zero even with only a very, very small alcohol intake.
Submission Date	9/27/2004 11:25:00 AM
Author	American College of Preventive Medicine

Summary	Health Professionals wishing to have the Dietary Guidelines provide additional information for patients so that they can more easily calculate the amount of alcohol they are consuming when they drink alcohol. This can be for patient self-education or in the context of working with a physician.
Comments	Ms. Kathryn McMurry HHS Office of Disease Prevention and Health Promotion Office of Public Health and Science STE LL100 1101 Wootton Parkway Rockville, MD 20852 RE: Federal Register Docket No. 04-19563, Department of Health and Human Services, Announcement of the Availability of the Final Report of the Dietary Guidelines Advisory Committee, a Public Comment Period, and a Public Meeting. Dear Ms. McMurry: Thank you for the opportunity to provide comments on the alcohol guideline in the proposed 2005 Dietary Guidelines for Americans. As physicians we regularly see patients who have various questions regarding drinking alcohol. We find that the alcohol guideline provides very informative, evidenced based information that will be helpful in providing guidance. We do wish to bring attention to one area where we believe the Dietary Guidelines can be improved even further. One scenario that repeatedly arises in patient interactions is, “Can I figure out how much I am drinking when I drink?” We are asking whether it could be possible to make a few changes that could provide even more useful information for physicians to communicate the guidance provided on consumption of alcohol? The current definition of a drink in the 2005 proposed Guideline is: “One drink is defined as 12 oz of regular beer, 5 oz. of wine (12 percent alcohol), or 1.5 oz of 80-proof distilled spirits.” To make this definition most clear, percent of alcohol by volume should be included for each type of alcohol drink. This would assist in helping patients calculate their total alcohol intake. Furthermore, the definition should also include a statement regarding the amount of alcohol in each drink. This additional information would provide the individual all necessary information to determine the amount of alcohol he or she is consuming so that they may follow the recommendations for moderation set forth in the proposed 2005 alcohol guideline. In addition and we believe of even greater importance, the guidelines could then be used to demonstrate to patients who are not drinking in a healthy manner, the amount by wish they might be misjudging their own alcohol intake due to lack of knowledge concerning equivalence of alcohol across types of drinks consumed. Some patients are uncomfortable discussing their drinking patterns with physicians and we believe that with the following changes, the dietary guidelines could be brought home from the physicians visit and used for self-education concerning this and many other topics of nutrition and health. We suggest the following drink definition: A standard drink contains 0.6 fluid ounces of alcohol. A standard drink is defined as: 12 ounces of regular beer (5 percent alcohol) 5 ounces of wine (12 percent alcohol) 1.5 ounces of 80-proof distilled spirits (40 percent alcohol). In discussions with patients we point out that there is a range of alcohol content in drinks and that they must therefore be aware of alcohol content they are consuming when they choose to drink. The Standard Drink is a helpful and easy way to help educate patients concerning total alcohol consumption. This is why we think it is important to include the amount of alcohol per standard serving in the 2005 Dietary Guidelines definition of a standard drink. Providing this information makes it straightforward for the health-conscious consumer to calculate the amount of alcohol they are consuming. This knowledge is key to making responsible decisions about drinking and following the Dietary Guidelines recommendations on moderation. We appreciate the opportunity to comment on the alcohol guideline in the proposed 2005 Dietary Guidelines. As physicians we are committed to providing patients with the most accurate and useful information for making prudent choices in their diet and lifestyle. We feel that our suggested revisions to the alcohol guideline will assist physicians and all health professionals in communicating to patients who choose to drink alcohol, the information most accurate and useful for making responsible decisions about drinking moderately. Please contact Howard Forman at hforman@aecom.yu.edu if you have any questions or would like more information. Sincerely, Stephen M. Kreitzer M.D. Internal Medicine, Pulmonary Medicine, Sleep Medicine Nava Bak M.D. Emergency Medicine Howard Forman Co-Chair, American Medical Association Action Team on Alcohol and Health
Submission Date	9/27/2004 11:33:00 AM
Author	from Bronx, NY

Summary	Supporting text should include alcohol consumption as a risk factor for breast cancer, as well as for high blood pressure and congestive heart failure if drinking is prolonged.
Comments
Submission Date	9/27/2004 1:18:00 PM
Author	ACS, ADA, AHA

Summary	Drink definition should include alcohol % for each type & add each drink contains 0.6 oz. The calorie table for alcohol is misleading & has inaccurate information. The recommendation to reduce alcohol consumption as a good weight loss strategy is not supported by the scientific literature.
Comments	September 27, 2004 Ms. Kathryn McMurry HHS Office of Disease Prevention and Health Promotion Office of Public Health and Science 1101 Wootton Parkway, Suite LL100 Rockville, Maryland 20852 Regarding: Federal Register Docket No. 04-19563; Department of Health and Human Services, Announcement of the Availability of the Final Report of the Dietary Guidelines Advisory Committee, a Public Comment Period, and a Public Meeting. Dear Ms. McMurry: The Distilled Spirits Council of the United States, Inc. (DISCUS) is a national trade association representing producers and marketers of distilled spirits and importers of wine sold in this country. We appreciate the opportunity to provide comments concerning the 2005 Committee report for the Dietary Guidelines for Americans that will be published by the Departments of Agriculture and Health and Human Services. These Guidelines provide an important public service to Americans and provide the basis for Federal nutrition policy and nutrition education activities. DISCUS and its members stand second to none in our concern about the abuse of beverage alcohol products. Throughout the decades, DISCUS and its members have developed, disseminated and supported numerous programs to reduce drunk driving; illegal underage drinking; and all forms of alcohol abuse. Many of these programs include the Dietary Guidelines alcohol guideline as a key message. DISCUS disseminates several thousand copies of the Dietary Guidelines at various venues throughout the year. Our commitment to combating alcohol abuse is longstanding and steadfast. Alcohol guideline We commend the Dietary Guidelines Advisory Committee’s commitment to provide evidenced based dietary guidance to consumers regarding beverage alcohol consumption. We strongly agree with the beverage alcohol guideline’s primary message concerning beverage alcohol consumption—“If you drink alcoholic beverages, do so in moderation.” This message has been the centerpiece of all editions of the Dietary Guidelines and of many education programs and efforts undertaken and supported by DISCUS and its members over the decades. In that regard, we will continue to incorporate the Dietary Guidelines into our programs and offer any help or assistance to the Department of Agriculture in its mandate to provide these guidelines to health professionals who provide nutrition and lifestyle advice to consumers. Standard drink definition It is essential that the evidence-based guidance on ethanol is supplemented with a complete and consistent definition of a standard drink. A clear understanding of a standard drink will assist the individual in following the alcohol guideline. We propose two recommendations to improve the clarity and completeness of the definition of a standard drink proposed in the 2005 Committee report. First, while the addition of the percent alcohol for wine that was added in the 2005 Committee report is extremely helpful towards a clearer definition, a further improvement would be that the percent alcohol should be stated for each type of beverage alcohol product. Second, an additional important piece of information is that each of these standard drinks contains 0.6 fl oz of alcohol. There is a wide variety of alcohol beverages that have different percents of alcohol. Knowing that a “standard drink” contains 0.6 fl oz of alcohol would provide an individual with necessary information to determine the amount of alcohol he or she is consuming, which is all about making responsible decisions about drinking moderately. The Committee report states: “One drink is defined as 12 ounces of regular beer, 5 ounces of wine (12% alcohol), or 1.5 ounces of 80-proof distilled spirits.” We suggest that the following definition would provide the most accurate and useful information to help consumers make responsible choices about beverage alcohol consumption: A standard drink contains 0.6 fluid ounces of alcohol. A standard drink is defined as: • 12 fluid ounces of regular beer (5 percent alcohol) • 5 fluid ounces of wine (12 percent alcohol); or • 1.5 fluid ounces of 80-proof distilled spirits (40 percent alcohol). The U.S. Department of Education’s Higher Education Center for Alcohol and Other Drug Abuse and Violence uses a similar definition (Please see Appendix 1). There can be a range of alcohol content in drinks. This is precisely why we think it is important to include the amount of alcohol per standard serving in the 2005 Dietary Guidelines definition of a standard drink. Providing this information makes it straightforward for the consumer to calculate the amount of alcohol they are consuming. This knowledge is key to enabling consumers to make responsible decisions about drinking in following the Dietary Guidelines recommendations on moderation. A guideline on moderate drinking Since the overwhelming majority of adult Americans who choose to drink do so responsibly and are at low risk for developing problems (NIH publication, 2000), a balanced discussion regarding moderate beverage alcohol consumption is of critical importance in formulating our nation’s nutrition and dietary policy, which is a stated goal of the Dietary Guidelines. Furthermore, the point has been made by the Committee that the Dietary Guidelines are intended for “healthy” Americans. “Healthy” adult Americans are those who either drink in moderation or choose to abstain. Therefore, the beverage alcohol guideline should start out with a statement that the overwhelming majority of adult Americans drink moderately or abstain. This statement emphasizes normative behavior and the expectations in our society for those adults that choose to drink (NIH publication, 2000). This also incorporates the Committee’s recommendation that language be added to state that abstention is an appropriate personal choice. DISCUS fully supports the right of an adult to abstain. Finally, the Departments of HHS and Agriculture should consider adding to the Dietary Guidelines NIAAA’s conclusion in its submission to the Committee: “Except for those individuals at particular risk (as are described in the current guidelines), consumption of 2 drinks a day for men and 1 for women is unlikely to increase health risks. As risks for some conditions and diseases do increase at higher levels of consumption, men should be cautioned to not exceed 4 drinks on any day and women to not exceed 3 on any day." (NIAAA, 2003, page 30) Calories Table E-3: Estimated Caloric Content of Alcoholic Beverages, is in some instances misleading to the consumer and in other cases incorrect. Although the majority of distilled spirits contain 100 calories, wine 100 calories and regular beer 150 calories per standard drink, there is certainly some variability in calories. Therefore, a general statement that some beers, wines and distilled spirits may have higher or lower calories may be helpful. The Dietary Guidelines, however, is not an appropriate vehicle to attempt to present an exhaustive list of drinks with associated calories. First, recipes for ingredients other than alcohol differ greatly depending on the individual making the drink, for example, regular soda vs. diet soda. Even though the Table states that calorie content may differ by recipe, recipes for many drinks are so varied that calories in a mixed drink could differ by 100 %. For this reason, it is not helpful to provide calorie estimates for mixed drinks, which include ingredients other than beverage alcohol. Second, the drink by drink approach is not only unhelpful, but unnecessary. We are not aware of any literature supporting the proposition that consumers are unaware that adding a mixer (such as juice) to beverage alcohol adds additional calories or, conversely, that adding a mixer (such as a no calorie soda) does not add extra calories. Finally, the Table lists “dark beer” as 165 calories. “Dark" beer is a category that contains many types of beer with different calories. For example, Guinness, which accounts for 95% of the Stout consumed in the United States, is probably among the best known of the “dark" beers. Guinness Stout has only 125 calories per serving. Obesity According to several studies over the past two decades, (For example see, Jequier, 1999; Cordain et al., 1997; Kahn et al., 1997; Mannisto et al., 1997; Istvan et al., 1995; Prentice, 1995; Liu et al., 1994; Colditz et al, 1991; Hellerstedt et al., 1990), the relationship between moderate alcohol consumption and obesity is unclear. For example, Lands (1995), in a review article concluded that the cumulative evidence of 31 separate studies does not support the concept that reduced alcohol consumption would help maintain a lower body weight. This conclusion was echoed in the NIAAA review of the literature submitted to the Committee (NIAAA, 2003), which stated that, “Thus far, the evidence on the relationship between moderate alcohol consumption and obesity remains inconclusive.” The NIAAA report goes on to state that “…there appears to be some protective effect of moderate consumption on two of the major sequelae of obesity, i.e., metabolic syndrome and diabetes.” The draft report states “The healthiest way to reduce calorie intake is to reduce one’s intake of saturated fat, added sugars and alcohol—they all provide calories, but don’t provide essential nutrients.” This may be misleading to those consumers who moderately consume beverage alcohol products and are interested in losing weight. First, much of the data shows that the extra calories from one or two drinks a day does not result in weight gain. Therefore, it is unclear whether calorie reduction by simply not consuming beverage alcohol will actually result in weight loss to the individual who has been moderately consuming. Certainly, given the ambiguities in the existing research literature, a clinical trial should be completed before the government recommends to the moderate consumer of beverage alcohol that they will lose weight by reducing their beverage alcohol consumption. Second, the literature shows that there may be some protective effect of moderate consumption of beverage alcohol on two major sequelae of obesity; metabolic syndrome and Type II Diabetes; particularly in overweight individuals (NIAAA, 2003). Thus, the recommendation to the moderate consumer of beverage alcohol to reduce alcohol consumption to reduce weight may not result in weight loss and may eliminate a potential protective effect for Type II diabetes and metabolic syndrome. Again, we urge that clinical trials be concluded before a recommendation is made that may be at best misleading to the individual attempting to lose weight, and at worst result in a potential increased risk of disease for some individuals. “Question 1: Among persons who consume four or fewer alcoholic beverages per day, what is the dose-response relationship between alcohol intake and health?” Conclusion 4. states, “Relationships of alcohol consumption with major causes of death do not differ for middle-aged and elderly Americans. Among younger people, however, alcohol consumption appears to provide little, if any, health benefit; alcohol use among young adults is associated with a higher risk of traumatic injury or death.” First, while mortality data indicate that there are few coronary deaths under the ages of 45 for men and 55 for women (NIAAA, 2003), there is a lack of scientific data to show whether or not potential benefits may accrue from exposure at an earlier age. In fact, most of the epidemiological data on risk reductions are from populations who have been drinking over several decades, not just at a point in time in their fourth or fifth decade. Thus, there does not appear to be scientific justification for the statement that moderate consumption provides little, if any, potential health benefit for younger adults (NIAAA, 2003, page 8). Second, we are aware of no data that support the statement that alcohol use among “young adults” is associated with a higher risk of traumatic injury or death and, certainly, none is provided in the draft. Furthermore, this statement is vague with respect to both age and alcohol consumption. The term young adult can refer to anyone from age 18-40. In addition, there is no qualification of the amount of beverage alcohol consumed. Taken to an extreme example, the individual can interpret that sentence to mean a 39 year old woman who consumes one drink per week is at increased risk for traumatic injury and death. Again, there is certainly no scientific data to support this statement. Meals versus Food We would like to again comment on the suggestion made by several Committee members over the past few editions of the Dietary Guidelines to consider changing consuming beverage alcohol with “meals” to “food.” Food is often consumed outside of what traditionally is considered a meal. Consumers may find themselves in social situations outside of regularly scheduled meal times where they may wish to consume a beverage alcohol product, such as having a cocktail at a reception or party where food is served, before dinner at home with a snack or hors d’oeuvres, or as an after dinner drink. The language in the 2000 Dietary Guidelines’ beverage alcohol guideline may create confusion among consumers inasmuch as the guideline suggests only consuming beverage alcohol with a meal. Moreover, there is no scientific evidence to suggest that consuming beverage alcohol only with meals is a more healthy choice. For example, in a study by Mukamal et al. (2003), the association of beverage alcohol consumption and cardiovascular disease was examined with consumption during meals as an independent variable. There were no differences in reduced risk of cardiovascular disease risk when beverage alcohol was consumed with meals versus not with meals. Clearly, the intent of the 2005 edition of the Dietary Guidelines is to encourage individuals to consume food when they are consuming a beverage alcohol product in order to slow down absorption. The food consumed with beverage alcohol, however, need not and should not be limited to food consumed only as part of a formal meal. Illegal underage consumption Research recommendation # 23 is: “Investigate the impact of banning alcohol advertising when and where it might increase underage drinking (e.g., during college sports events).” As stated earlier, the Distilled Spirits Council of the United States and its sister organization, The Century Council, have developed and implemented numerous programs over the decades aimed at reducing illegal, underage drinking. We all agree that underage drinking is unacceptable and is a complex societal problem that requires a sustained, collaborative commitment. The National Academy of Sciences (NAS) recently reviewed the scientific literature to develop a strategy to reduce underage drinking. The number one recommendation was a media campaign directed at parents. In reviewing the literature on advertising, NAS concluded that accumulated evidence does not demonstrate that advertising causes underage persons to consume beverage alcohol. The Department of Health and Human Services reached the same conclusion in their 1990 and 2000 Report to Congress (U.S. HHS, and NIAAA, 1990, 2000). It seems prudent to focus research recommendations on evidenced based factors. Finally, the data are clear that the majority of beverage alcohol consumed by underage persons is obtained through parents and other adults (NAS, 2003; FTC, 2003). A statement reminding adults not to provide beverage alcohol to underage consumers would appear to be warranted. Food Guide Pyramid There has been discussion about including beverage alcohol in the revised Food Guide Graphic that has been known as the Food Guide Pyramid for decades. The current preamble states: What's in this booklet for me? This booklet introduces you to The Food Guide Pyramid. The Pyramid illustrates the research-based food guidance system developed by USDA and supported by the Department of Health and Human Services (HHS). It goes beyond the "basic four food groups" to help you put the Dietary Guidelines into action. The Pyramid is based on USDA's research on what foods Americans eat, what nutrients are in these foods, and how to make the best food choices for you. The Pyramid and this booklet will help you choose what and how much to eat from each food group to get the nutrients you need and not too many calories, or too much fat, saturated fat, cholesterol, sugar, sodium, or alcohol. Indeed, the assumption would be that the Food Guide Graphic would offer guidance on all areas mentioned in the Dietary Guidelines. Many individuals only see the Food Guide Graphic and do not read the entire Dietary Guidelines and therefore, at this point in time, are left without the Guidelines’ message on beverage alcohol consumption. Additionally, this is a missed opportunity to reinforce messages on moderate and responsible consumption. Concern was raised by the Committee that the Food Guide Graphic is for all individuals greater than two years of age and that including alcohol in the Graphic may result in mixed messages for the underage. As the Food Guide Graphic will be revised to reflect the 2005 Dietary Guidelines, we think that it will be important to include beverage alcohol consumption so that a greater number of individuals will be exposed to the government’s guideline on beverage alcohol consumption. It has been mentioned repeatedly that one graphic may not be appropriate for all consumers and that there is a need for flexibility. Thus, there can be, as one suggestion, a version of the Food Guide Graphic for adults over the age of 21 so that they can benefit from a visual representation of the Dietary Guideline advice on how to make choices about beverage alcohol consumption in the context of an overall adult healthy diet. Conclusion The beverage alcohol guideline in the 2005 edition of the Dietary Guidelines for Americans will continue to assist adult Americans in making informed decisions for a healthy diet and lifestyle. For this reason, it is important that the statements in the alcohol guideline, as in all other guidelines in the Dietary Guidelines, are based on sound science. Furthermore, we feel that the revisions we have suggested to make the standard drink definition more complete and consistent will assist individuals in following the guidance for moderate beverage alcohol consumption as set forth in the 2005 Committee report. We thank you in advance for consideration of our comments. If you have any questions concerning our comments or if we can be of any assistance, please contact Monica Gourovitch, Ph.D. at Distilled Spirits Council of the U.S. (202.682.8837; mgourovitch@discus.org). Sincerely, Monica L. Gourovitch, Ph.D. Sr. VP, Office of Scientific Affairs Distilled Spirits Council of the United States CC: The Honorable Tommy Thompson The Honorable Ann Veneman Ms. Carole Davis References Colditz, G. A., Giovannucci, E., Rimm, E., Stampfer, M. J., Speizer, F. E., Gordis, E., Willett, W. Alcohol intake in relation to diet and obesity in women and men. (1991). American Journal of Clinical Nutrition, 54, 49-55. Cordain, L., Bryan, E. D., Melby, C. L., Smith, M. J. Influence of moderate daily wine consumption upon body weight regulation and metabolism in healthy free living males. (1997). Journal of the American College of Nutrition, 16(2), 134-139. Federal Trade Commission. (September 2003). Alcohol Marketing and Advertising, A Report to Congress. Hellerstedt, W. L., Jeffery, R. W., Murray, D. M. The association between alcohol intake and adiposity in the general population. (1990). American Journal of Epidemiology, 132(4), 594-611. Institute of Medicine, National Research Council of the National Academies. (September 2003). Reducing Underage Drinking A Collective Responsibility. The National Academies Press Washington, D.C. Istvan, J., Murray, R., Voelker, H. The relationship between patterns of alcohol consumption and body weight. (1995). International Journal of Epidemiology, 24(3), 543-546. Jequier, E. Alcohol intake and body weight: a paradox. (1999). American Journal of Clinical Nutrition, 69, 173-174. Kahn, H. S., Tatham, L. M., Rodriguez, C., Calle, E. E., Thun, M. J., Heath, C. W. Stable behaviors associated with adults' 10-year change in body mass index and the likelihood of gain at the waist. (1997). American Journal of Public Health, 87(5), 747-754. Lands, M. Alcohol and energy intake. (1995). American Journal of Clinical Nutrition, 62(5-suppl), 1101S-1106S. Liu, S., Serdula, M. K., Williamson, D. F., Mokdad, A. H., Byers, T. A prospective study of alcohol intake and change in body weight among US adults. (1994). American Journal of Epidemiology, 140(10), 912-920. Mannisto, S., Uusitalo, K., Roos, E., Fogelholm, M., Pietinen, P. Alcohol beverage drinking, diet and body mass index in a cross-national survey. (1997). European Journal of Clinical Nutrition, 151, 326-332. Mukamal, K. J., Conigrave, K, M., Mittleman, M. A., Camargo, C. A., Stampfer, M. J., Willett, W. C., Rimm, E. B. Roles of drinking pattern and type of alcohol consumed in coronary heart disease in men. (2003). The New England Journal of Medicine, 348, (2), 109-118. National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism and Department of Health & Human Services. (2003). State of the Science Report on the Effects of Moderate Drinking. Prentice, A. M. Alcohol and obesity. (1995). International Journal of Obesity, 19(5), S44-S50. U.S. Department of Health & Human Services, Public Health Service Alcohol, Drug Abuse, and Mental Health Administration, National Institutes of Health and National Institute on Alcohol Abuse and Alcoholism. (1990). Seventh Special Report to the U.S. Congress: Alcohol and Health (DHHS Publication No. (ADM) 90-1656). U.S. Department of Health & Human Services, Public Health Service, National Institute of Health and National Institutes of Health and National Institute on Alcohol Abuse and Alcoholism. (2000). 10th Special Report to the U.S. Congress: Alcohol and Health (DHHS Publication No. (ADM) 90-1656). U.S. Department of Health & Human Services, National Institutes of Health and National Institute on Alcohol Abuse and Alcoholism. (2000). The Physicians guide to helping patients with alcohol problems (NIH Publication No. 95-3769).
Submission Date	9/27/2004 4:58:00 PM
Author	Distilled Spirits Council of the U.S.

Summary	We recommend the definition of one drink of wine be retained as stated in the 2000 version of the Guidelines in Box 26 – What is Drinking in Moderation? Any changes made to the current definition would lead to inaccurate and misleading representations of the Guidelines’ moderation message.
Comments	September 27, 2004 Ms. Kathryn McMurry HHS Office of Disease Prevention and Health Promotion Office of Public Health and Science Suite LL100 1101 Wootton Parkway Rockville, MD 20852 Dear Ms. McMurry: Wine Institute is the public policy association of California wineries representing over 800 California wineries and affiliated businesses. These companies are responsible for 80 percent of the nation’s wine production. On behalf or our members, we are pleased to submit comments in response to the request for public input on the 2005 Dietary Guidelines Advisory Committee Report to the Departments of Health and Human Services and Agriculture. We agree that the 2005 Dietary Guidelines for Americans should represent a balanced approach to recommendations on the full range of nutrition, lifestyle and health issues. In particular, we support the Ethanol Subcommittee’s continued recommended advice to discourage excessive consumption and indicate that, even in moderation, there are individuals who should not drink. We are pleased that the main alcohol message has been maintained from the 2000 Dietary Guidelines: “If you drink alcoholic beverages, do so in moderation” and that the Committee has maintained the recommendation (advice) that, “For those who choose to drink an alcoholic beverage, it is advisable to consume it with meals to slow absorption. Data suggest that the presence of food in the stomach can slow the absorption of alcohol and thereby mitigate the associated rise in blood alcohol concentration.” While we support the majority of the findings in the Committee Report, we would like to provide additional comment in two important areas: • There should be no changes to the Drinking In Moderation Definition, especially with the “Count as a Drink” language regarding expressions of alcohol content for wine, because there will be extensive rulemaking by the Treasury Department’s Tax and Trade Bureau (TTB) in 2005 that will address several significant issues that are based on the language of the Dietary Guidelines. Language in the Dietary Guidelines should not be misused or misconstrued in any future regulatory action or rulemaking. • Messages relating to moderate drinking and weight gain and obesity for the public should clearly state that the scientific findings in this area are inconclusive and that alcohol, as well as other sources of discretionary calories, should be monitored closely for optimal health. I. MODERATE DRINKING DEFINITION In the 2000 version of the Dietary Guidelines for Americans, drinking in moderation is defined in Box 26 on page 36 - What is Drinking in Moderation?: The Advice For Today on page 37 goes one step further and recommends “Limit intake to one drink per day for women and two per day for men, and take with meals to slow alcohol absorption.” The Advisory Committee found this definition of moderate drinking as optimal for adults who choose to drink as a means to provide both beneficial effects on heart disease and all-cause mortality as well as reduce risks caused by heavy drinking. However, the Advisory Committee also states that, “The definition of moderation, including the size of one drink, requires emphasis. (Some investigators and apparently many individuals interpret ‘moderate drinking’ to cover higher levels of intake than shown in Table E-25. Many mixed drinks actually provide several servings of alcohol per drink.” (DG Advisory Committee Report, Part D, Section 8, page 3). In an apparent response to further define a moderate serving of each beverage, the Advisory Committee has added a “12 percent alcohol” qualifier to the definition of a serving of wine. Throughout the text of the Advisory Committee Report, one serving of wine is defined as “a 5-ounce glass of 12 percent alcohol.” (See Table E-25, below). Wine Institute believes that providing the public a frame of reference by including serving size information in ounces will assist wine, beer, and distilled spirits consumers in their awareness of alcohol consumption levels. We believe that direct serving size information in ounces about the product being consumed is relevant and, if truthful, accurate and specific, should be able to be included. However, within each category of drinks (wine, beer and distilled spirits) there is a range of products with different alcohol percent values. Unlike distilled spirits, wine is not a “mixed” drink. Consumers discriminate among the various wine products more by their broad product categories, and producers of wine do not target a particular alcohol level but a sensory style and taste. Even from a regulatory standpoint, the standards of identity for wine differ significantly from distilled spirits product standards. Table wine, for example, is defined as still wine between 7 and 14 percent alcohol by volume. While from a scientific or clinical standpoint it may make sense to qualify wine with a specific alcohol content, we do not believe that assigning an arbitrary value of 12 percent alcohol to wine provides the consumer with any additional useful information from which to make an informed decision. As the alcohol percent value of table wine varies between 7 percent and 14 percent and that for dessert wine is 14 percent and above, such a listing would not necessarily be truthful or accurate and could be misleading. We believe that the addition of a “12% alcohol” qualifier in the “Count as a Drink” language will be misinterpreted by some as the establishment of a “standard drink” size, which will eventually lead to a distortion and/or omission of the important moderation message. The Guidelines represent great efforts to explain moderate consumption to U.S. consumers, but they have also been misunderstood. We are seeing the moderation message giving way to a much broader interpretation that the Guidelines themselves have established the size of a “standard drink,” and there have been several regulatory actions that have been based on this contention. We have seen the “count as a drink” language stripped of its accompanying moderation context, with what remains being repackaged as a definition for a “standard drink.” We do not believe that this is what was intended by the authors of the Guidelines, and we are concerned that this misinterpretation and misuse, all pending the safeguards of future rulemaking, will raise serious social as well as political implications. While adding a “12% alcohol” qualifier to wine may appear to be minor and consistent with the “80 proof distilled spirits” language, we are concerned that such changes will result in an argument that these sizes equate to “standard drink” sizes and will become the basis for untruthful and misleading information on wine, beer, and spirits labels. Changes such as this will tend to bolster an argument that all alcoholic beverages are “equal,” a notion that Wine Institute disagrees with. It is an oversimplification to single out the ethyl alcohol property that all alcoholic beverages have in common, and then to conveniently boot strap this commonality into a graphic equation that all alcoholic beverages are equal but only in specific but differing quantities. There are three separate regulatory actions that are pending administrative rulemaking, all based in large part on the contention that the U.S. Dietary Guidelines have established standard serving sizes. Carbohydrate Labeling of Alcoholic Beverages Awaits Rulemaking On April 7, 2004, without the benefit and safeguards of the rulemaking process, the TTB published an Industry Circular that authorized the voluntary labeling of carbohydrate information for wine, beer, and distilled spirits . Citing the 2000 Dietary Guidelines , TTB in its Industry Circular uses the Dietary Guidelines “Count as a drink” language as a measure of a serving size: Accordingly, this ruling holds that the statement of average analysis must apply to a serving of the product, and that the serving must be 12 fl. oz. for malt beverages, 5 fl. oz. for wine, and 1.5 fl. oz. for distilled spirits. TTB indicates in this ruling that it will conduct a rulemaking on this issue in the future. To date, almost six months since the publication of this interim policy, Wine Institute still awaits the promised publication of a Notice of Proposed Rulemaking by TTB on this matter. The significance of this action, however, should not be lost. This is an instance where an administrative agency has taken information from the Dietary Guidelines, eliminated the notion of moderate consumption, and concludes that the “Count as a drink” volumes for alcoholic beverages are “standard drink” sizes. “Serving Facts Panel” Labeling of Alcoholic Beverages Awaits Rulemaking The issue of whether the Dietary Guidelines established a definition of a “standard drink” came to light again with TTB in early August, 2004. On August 5, 2004, and again without the benefit of rulemaking, TTB released what it referred to as a “Serving Facts White Paper” where the identical drink volume values were being used by TTB to permit not simply additional nutritional information, but a comparative “equivalency” graphic” showing illustrations of a beer, wine and spirits container: The beer and wine sectors of the alcoholic beverage industry, strenuously objected to both the process and the content of the “White Paper.” Wine Institute opposed the “White Paper” for many reasons, but we point out that the term “standard drink” used by TTB and attributed to the Dietary Guidelines does not appear anywhere within the 2000 version of the Dietary Guidelines. It should be noted that TTB did not move ahead on this version of the “Serving Facts Panel” white paper, but revised and reissued a second white paper on September 21, 2004. While this white paper removes the more onerous provisions embodied in the first version and is careful not to use the term “standard drink,” this second white paper maintains, without benefit of rulemaking, serving size information that is identical to the Guidelines’ “Count as a Drink” sizes. TTB states in this version of the white paper that it will be conducting a rulemaking in the future. National Consumer League / Center for Science in the Public Interest Rulemaking Petition Awaits Rulemaking Submitted to TTB in December of 2003, the rulemaking petition of the National Consumer League and the Center for Science in the Public Interest calls for uniform information on several label items: • Alcohol content • Standard serving size • Amount of alcohol in ounces and number of calories per serving • Number of standard drinks per container • Ingredient declaration • U.S. Dietary Guideline recommendations for moderate drinking The petitioners contend that more uniform alcohol information should be conveyed to consumers in a context where consumers can more easily understand how much alcohol they are consuming. They suggest that the serving sizes “prescribed” by the U.S. Dietary Guidelines should be used as the “standard serving size.” Additionally, the petitioners suggest that a consistent graphic, such as a beer mug or a glass of wine, be used to alert consumers to the statement. The sample label proposed in that petition looks like this: We urge the authors of the Dietary Guidelines 2005 version to allow for the completion of rulemaking before considering any changes to that portion of the Guidelines. II. CALORIES AND WEIGHT The issue of caloric content and association of alcohol with added sugar and solid fats in relation to discretionary calories and maintaining a healthy weight/weight gain is addressed both in Part A: Executive Summary and Part E: Translating the Science into Dietary Guidance. In the section “Control Calorie Intake to Manage Body Weight” (Part E page 7), the Advisory Committee states that, “Calories come from fat, carbohydrate, protein, and alcohol. The healthiest way to reduce calorie intake is to reduce one’s intake of added sugars, solid fat, and alcohol – they all provide calories, but they do not provide essential nutrients.” … “Table E-3 gives examples of how calories can be decreased by decreasing alcoholic beverage intake.” As we stated in our May 2003 submission to the Advisory Committee, “Given the current lack of consensus on the issue of moderate wine, beer and spirits consumption and its relationship to weight gain, Wine Institute recommends that the Committee provide more detailed discussion on the issue of moderate consumption of wine, beer and distilled spirits and its relationship to weight gain.” (WI Comment 2003, pages 6-7) The NIAAA review, State of the Science Report on the Effects of Moderate Drinking, concluded that the current scientific literature suggests that, “The data on the relationship between moderate alcohol consumption and weight gain/obesity are inconclusive. However, there is some evidence for reduced risk of diabetes and metabolic syndrome, which often co-exist with or develop from obesity.” (NIAAA 2003, page 29) An independent review commissioned by Wine Institute to review wine and alcohol and its effects on calories and body weight control since 1985 stated that, “At least 90 papers were published that have dealt directly or indirectly with alcohol consumption and body weight regulation. This renewed interest in how alcohol influences body weight stems, in part, from concern over dietary elements that may underlie the world-wide obesity epidemic. Although no universal consensus has been reached, a number of lines of evidence increasingly suggest that moderate alcohol consumption does not represent a dietary risk for developing obesity and may in fact promote certain metabolic changes which reduce the risk for overweight and obesity.” (Cordain 2003, page 2) In response to the scientific evidence presented, the Ethanol Subcommittee concluded that the relationship between consuming four or fewer alcoholic beverages daily and obesity was an “Unresolved Issue.” They state that, “The available data on the relationship between alcohol consumption and weight gain/obesity are sparse and inconclusive. There are contradictory findings at the higher end of the spectrum (i.e. 3 to 4 drinks per day) that may relate to fundamental limitations of the cross-sectional study design. At moderate drinking levels (i.e. up to one drink per day for women, up to one (sic?) drink per day for men), there is no apparent association between alcohol intake and obesity.” The Subcommittee concludes, “In summary, although prospective data are limited, there is no apparent association between consuming one or two alcoholic beverages daily and obesity.” Dietary Guidelines Advisory Committee Report, (Part 6, Section 8, page 6) Based on the Ethanol Subcommittee conclusion, we would like to recommend the statement made in Part E: Translating the Science into Dietary Guidelines be revised to read: “Calories come from fat, carbohydrate, protein, and alcohol. The healthiest way to reduce calorie intake is to reduce one’s intake of added sugars and solid fats. The findings on the relationship between moderate alcohol consumption and weight gain/obesity are inconclusive, however, it may be prudent to monitor consumption as it relates to the intake of discretionary calories.” CLOSING STATEMENTS We would like to commend the members of the Advisory Committee for their thorough review of the scientific literature and overall balanced recommendations on moderate alcohol consumption by healthy adults. On the issue of the Drinking In Moderation Definition, we strongly support the current definition of moderation (no more than 1 drink per day for women and no more than 2 drinks per day for men). We recommend the definition of one drink of wine be retained as stated in the 2000 version of the Guidelines in Box 26 – What is Drinking in Moderation? We believe that any changes made to the current definition would lead to inaccurate and misleading representations of the Guidelines’ moderation message to the public. Therefore, we recommend the addition of a clear and unambiguous statement in the guidelines that the “Count as a Drink” statements should not be interpreted as the establishment of a “standard drink,” and that the information is being provided to further explain the moderation message. As stated, there will be full and extensive industry and regulatory agency review accompanied by public comment for both serving size and serving facts labeling at the start of 2005. We would ask that any messages relating to moderate drinking and weight gain and obesity for the public clearly state that the scientific findings in this area are inconclusive and that alcohol, as well as other sources of discretionary calories, should be monitored closely for optimal health. We thank you for the opportunity to present additional information and recommendations on the Dietary Guidelines Advisory Committee Report. Sincerely, Robert P. Koch President and CEO cc: Secretary Tommy Thompson, HHS Secretary Ann Veneman, USDA
Submission Date	9/27/2004 5:30:00 PM
Author	Wine Institute

Summary	AIM appreciates the Committee's continued emphasis on moderation for those adults who choose to drink. However, recent research conclusions reveal that the wording on alcohol and calories needs further clarifications. We also suggest that moderate consumption with food should be emphasized.
Comments	This submission is made on behalf of Peter Duff, Chairman of AIM-Alcohol in Moderation. We would like DHHS and USDA to consider our earlier comments when reviewing the Dietary Guidelines Advisory Committee's report. Specifically, AIM would like the agencies to review and further consider AIM's original research submission, especially as it pertains to the question on alcohol and calories. Towards this end, we would like to underscore that the science to date does not support any message that implies that alcohol in moderation would lead to excess weight gain. May 18, 2004 Ms. Kathryn McMurry HHS Office of Disease Prevention and Health Promotion Room 738-G, 200 Independence Ave, SW Washington, DC 20201 Email: dietaryguidelines@osophs.dhhs.gov RE: Year 2005 Draft Edition of Dietary Guidelines for Americans Dear Ms. McMurry: The following comments are submitted on behalf of AIM (Alcohol in Moderation), an international non-profit education group dedicated to science and social responsibility related initiatives. Specifically, AIM is devoted to increase socially responsible behavior with respect to alcohol consumption by bringing scientifically based education messages to the public via websites and other programs. Our efforts are centered on governmental and public health messages from around the world. We work with a Social, Scientific and Medical Council of physicians, scientists, and experts in social policy in preparing and presenting information related to an ongoing debate on alcohol use and abuse. We appreciate the opportunity to make comments on the recommended wording of the 2005 Dietary Guidelines that will be published by the Departments of Agriculture and Health and Human Services. AIM has long acknowledged that these Guidelines represent an important foundation for nutrition education activities. In fact, the Dietary Guidelines for Americans have served as an important consumer education tool as part of AIM’s outreach efforts. These programs advocate moderate consumption as the only responsible option for those who choose to enjoy wine, beer and spirits as a component of a well-balanced diet and lifestyle. Towards this end, we are committed to continuing and expanding our educational outreach efforts with the upcoming 2005 Dietary Guidelines for Americans edition. First and foremost, we applaud the Advisory Committee’s effort and express our strong support for expanded wording intended to discourage abuse while indicating that moderate and responsible use of alcohol is an acceptable lifestyle choice, and encouraging the consumption of alcoholic beverages with food (which markedly decreases the risk of abuse). In our view, however, the Guidelines should more fully take into account the research facts presented by the National Institute of Alcohol Abuse and Alcoholism (NIAAA) in their December, 2003, submission. In particular, we agree that the Guidelines should be based on the “preponderance of scientific and medical knowledge current at the time of publication”. (1, 2) In light of the developing research consensus on moderate consumption, reflected in both published scientific research studies and official nutrition and public policy positions, we would like to respectfully ask you to consider the following additional points when finalizing the alcohol guideline wording: I. Provide a more positive opening of the guideline, underscoring that responsible consumption is the only acceptable choice for those adults who choose to drink In line with the emerging evidence on moderate versus abusive drinking, the Guidelines should give more weight to positive messages about moderation as part of a healthy diet and lifestyle. In fact, we believe that the currently proposed wording disproportionately focuses on reported risks of abusive consumption while not adequately addressing scientific findings with respect to moderation. This is especially warranted as the overwhelming majority of those who choose to drink consume alcohol moderately and responsibly. This is not only reflected on page 20 in the recent NIAAA submission (1) and in the NIH 2000 physician’s guide (3) but also in earlier reports by NIAAA on alcohol and health to the US Congress.( 4) Along those lines the recent NIAAA submission emphasizes that “the consequences of alcohol use must be evaluated in conjunction with its potential benefits.” It is stressed that alcohol’s apparent protective effect against coronary heart disease and other atherosclerotic diseases are significant, as these are the most common cause of death in the US. The submission also cites a 1994 study predicting that abstention among current drinkers would lead to significant increases in coronary heart disease death rates. Another recent review article by Dr. Arthur Klatsky from Kaiser Permanente, who has published dozens of scientific studies over the last two decades, also cautions that while non drinkers should not necessarily be encouraged to drink, current moderate drinkers with no health contraindications should not be discouraged from drinking.(5) These and other statements underscore the importance of a more balanced discussion on moderation and abuse when formulating the US nutrition and dietary policy, which is also a stated goal for the Dietary guidelines 2005 ( Fed. Reg., Vol.68, no 171. Sept 4, 2003). With these and other research and public health facts in mind, we firmly believe that it is important to open the Guidelines with an additional message that underscores the acceptable behavior of moderation while also stressing the consequences of abuse. In sum, we recommend the addition of a sentence before the current lead sentence that would underscore, “The moderate and responsible consumption of wine, beer and spirits as part of a well-balanced diet and lifestyle is the only acceptable option for adults who choose to enjoy consumption of alcoholic beverages. The overwhelming majority of adult Americans drinks moderately or abstains, depending on their lifestyle choice.” This could lead the reader directly to the definition of moderation, underscoring that heavy drinking and binge drinking are irresponsible, which would also be underscored by the next sentence of the guideline reading, “Alcoholic beverages are harmful when consumed in excess.” II Further expand discussions on moderation and stress both the consumption with food and/or meals to foster responsible drinking behavior even outside the traditional mealtime consumption. We fully endorse the emphasis on eating and meals and would suggest including an expanded wording that would underscore that consumption should “preferably occur with food and/or with meals to slow alcohol absorption.” You may also wish to point out that alcohol should be consumed slowly, preferably over several hours. Such messages would encompass a wider range of drinking occasions and would also address NIAAA’s statement that people should be given more detailed advice on what encompasses “moderation.” Along those lines, we would also like to recommend that the following NIAAA statement be included, “Except for those individuals at particular risk ( as described in the current guidelines), consumption of 2 drinks a day for men and 1 drink a day for women is unlikely to increase health risks. As risks for some conditions and diseases do increase at higher levels of consumption, men should be cautioned to not exceed 4 drinks on any day and women to not exceed 3 on any day.” This represents an important caution intended to prevent serious binge drinking behaviors. Furthermore, this more detailed approach is also in line with other governmental guidelines such as those of the UK and Australia that provide more specific guidance for the consumer. (6, 7) In fact, official guidelines such as the UK Sensible Drinking Guidelines and the Australian Alcohol Guideline are taking a more positive approach (as reflected in our recommendations I. and II). In addition, social scientists have underscored that such education messages emphasizing positive cultural norms reinforce and initiate the most responsible drinking behaviors in a given society. In fact, these points are directly and indirectly addressed in a Rutgers University monograph entitled, “Society, Culture, and Drinking Patterns Reexamined,” as well as the International Handbook on Alcohol and Culture published by Brown University Professor Dwight Heath. ( 8,9) III. Address scientific findings with respect to moderation and other aspects of health, including overall mortality and stroke (in line with the recent NIAAA submission). As the NIAAA submission attests, since 2000 scientific support of moderate consumption’s role as part of a healthy lifestyle has gotten stronger. Large-scale studies from the US and around the world have found moderate drinkers not only have a reduced rate of cardiovascular disease, but also have a reduced overall mortality rate. The largest study on alcohol consumption to date by Thun et al(add ref), based on nearly 500,000 Americans, reports that overall death rates were lowest among men and women reporting about one drink daily (approximately 20% lower than abstainers for both men and women). (10) The American Heart Association concluded in 1996, “The lowest mortality occurs in those who consume one or two drinks a day.” (11)These findings were also acknowledged in the NIAAA submission along with many other research findings including a 2003 meta-analysis based on more than 50 studies on the subject. (1) Therefore, we urge the Committee to consider expanding the discussions on the health effects of moderation by including the NIAAA statement:” The lowest total all-cause mortality occurs at the level of 1 - 2 drinks per day.” Along those lines we also suggest including a statement acknowledging the potential positive affects with respect to ischemic stroke and Type II diabetes, in line with the research findings presented by NIAAA in its appendix 2.(1) The suggested mentioning of potential stroke risk reductions is also in line with the National Stroke Association’s official statement, which states:” Current scientific data continue to show that moderate levels of alcohol consumption do not increase risk for heart failure, myocardial infarction or ischemic stroke, and in fact provide protective effects along a J-shaped curve.”(12) A meta-analysis published recently in the Journal of the American Medical Association by Reynolds, et al concluded, “Heavy alcohol consumption increases the risk of stroke while light or moderate alcohol consumption may be protective against total and ischemic stroke.” Another study suggested that alcohol may protect against reoccurring strokes, and others have confirmed these findings. (13,14) The inclusion of discussions on diabetes is also appropriate as recent studies continue to reveal a reduced risk of diabetes among moderate drinkers. These include a study by Davies, et al in 2003 and a recent study by Wannamethee, et al, which reported that light drinking cuts diabetes risk in women. (15-18) IV. Discussions on calories and obesity should not be misleading. While we agree that the guidelines should provide a general benchmark for outlining average calories for wine, beer and spirits, we would like to caution against a more detailed statement on moderate drinking and obesity. Numerous studies, as outlined in the NIAAA submission, suggest no clear association between alcohol and weight gain for men, and some studies indicate a slight reduction in weight gain for women. Specifically, we would like to urge you to fully consider NIAAA’s conclusion on the subject, which is as follows: “The data on the relationship between moderate alcohol consumption and weight gain/obesity are inconclusive. However, there is some evidence for reduced risk of diabetes and metabolic syndrome, which often co-exist with or develop from obesity.”(1) Experimental studies have suggested that alcohol calories are not efficiently utilized and therefore generally do not lead to weight gain. For example, a 1997 study published in the European Journal of Clinical Nutrition concluded, “Alcohol consumers were leaner than abstainers,” and this is a common finding in most epidemiologic studies everywhere. Furthermore, a 1998 study published in the American Journal of Clinical Nutrition suggests that alcohol’s consumption with food slows not only the absorption process, keeping alcohol blood levels low, but may also have a favorable effect on lipid profiles during the postprandial period. (19, 20) In line with many studies over the last two decades,, the relationship between moderate alcohol consumption and obesity is unclear. In line with the 2003 NIAAA conclusion, for example, Lands wrote in a 1995 review article, “Thus, alcohol seemed unable to contribute to the overall body mass of either men or women. In fact, the cumulative evidence of 31 separate studies does not support the concept that reduced alcohol consumption would help maintain a lower body weight. Also the National Health and Nutrition Examination Survey (NHANES) showed that moderate drinkers gained less weight, on average, than abstainers over a ten year follow up period (21-27) In light of these and other findings, we believe an overall cautionary and even warning message on alcohol’s calories would be misleading and is therefore unwarranted, especially if it would suggest in any way that individuals should reduce moderate consumption of beverage alcohol to decrease weight; scientific data are not present to support such a statement. V. The “Who should not drink section” should also be evidence-based and supported by science. In all of AIM’s education efforts, we stress the unacceptability of underage drinking and emphasize adherence to the laws regarding the purchase and possession age limitations in the US. Therefore, we support the Dietary Guideline’s Committee’s focus to reduce underage drinking problems. We are concerned, however, that the statement, “Risk of alcohol abuse increases when drinking starts at an early age,” is scientifically and culturally unwarranted. The issue is still a matter of debate, and indeed alcohol abuse rates are actually lower in many countries (such as Italy) where wine consumption begins early in life. It does appear that early abusers of alcohol and drugs may be more likely to be adult abusers, but studies have reported that it was drinking problems, rather than any drinking, that show the ability to predict later-life alcohol problems.(28,29)Other studies have shown that the age of first use of alcohol (as recalled at age 18) did not predict alcohol or drug use at either 20 or 30 years of age.(30) Another study concluded, “These results suggest the association between drinking onset and diagnosis is no causal, and attempts to prevent the development of alcohol dependence by delaying drinking onset are unlikely to be successful.”(31) More recent studies also conclude that much of the association can be accounted for by genetic vulnerability.(32,33) Recent reports by the Federal Trade Commission and the National Academy of Sciences point out that most alcohol beverages are obtained by underage persons through their parents and other adults.(34,35) Therefore, we strongly suggest to the Committee that it include wording that cautions parents to discourage their children from drinking and to discuss the subject of alcohol in detail with them. VI. The Food Guide Pyramid Graphics should include alcohol to help put the Dietary Guidelines into action, reinforcing the importance of moderation as the only choice. As the Food Guide Graphic will be revised to mirror the 2005 Dietary Guidelines, we would like to strongly recommend that alcoholic beverages will be included as an option for adults. We firmly believe that this would provide increased exposure to the government’s moderation message and the overall Guideline cautioning about abuse and the importance of only moderate consumption as part of an overall healthy and well-balanced lifestyle. The pyramid and accompanying booklet will help Americans get the needed guidance to choose a balanced diet and responsible decision-making skills as outlined in the Guidelines. This approach would provide an important venue to reinforce socially responsible behavior with respect to wine, beer, and spirits consumption. This approach is also in line with other dietary models and accompanying graphics. Specifically, we would like you to review and consider approaches presented in the Mediterranean, Latin-American, Asian, and Vegetarian Diet Pyramids. These concepts have been developed by leading experts from Harvard University of Public Health and other leading institutions. (36-40) In conclusion, we would like to reiterate that the developing research consensus on moderate versus abusive consumption should be fully reflected in the upcoming 2005 Dietary Guidelines for Americans. While we support the admonition against abusive behavior, and agree that for certain groups of individuals any consumption is inadvisable, we respectfully recommend through this submission that you re-examine the impressive and credible evidence suggesting that, for most people, moderate drinking is consistent with a healthy and well-balanced lifestyle. We are confident that the upcoming Guidelines will continue to assist Americans and other consumers around the world in making informed healthy diet and lifestyle choices. Towards this end, AIM will be committed to widely disseminating the 2005 Dietary Guidelines as a basis of our ongoing and expanded education initiatives. Thank you for your time and consideration. If you have any questions concerning our sub mission or if we can be of any assistance, please contact Elisabeth Holmgren, at our US office at (925) 934-3226 or at em-h@pacbell.net . Sincerely, Peter Duff Chairman AIM-Alcohol in Moderation Attachment I: References: 1. National Institute on Alcohol Abuse and Alcoholism, State of the Science Report on the Effects of Moderate Drinking, Submission to the Dietary Guidelines Advisory Committee, December 2003. 2. Dietary Guidelines Advisory Committee Meeting Announcement, September 4, 2003, Federal Register, 68 (171). 3. U.S. Department of Health & Human Services, National Institutes of Health and National Institute on Alcohol Abuse and Alcoholism 2000, The Physician’s Guide to Helping patients with Alcohol Problems, NIH Publication No. 95- 3796. 4. National Institute of Alcohol Abuse and Alcoholism, Ninth and Tenth Special Report to US Congress on Alcohol and Health, DHHS, 1997, 2000. 5. Klatsky A., Alcohol and Health: How Much is Good for You? Scientific American, February 2003. 6. United Kingdom Department of Health, Sensible Drinking, Report, 1995 at http://www.dh.gov.uk/AboutUs/fs/en 7. National Health and Medical Research Council, Australian Drinking Guidelines, 2000 at http://www.alcoholguidelines.gov.au/ 8. Pittman D J et al, Society, Culture, and Drinking Patterns Reexamined, Rutgers Center of Alcohol Studies, 1991. 9. Heath D, International Handbook on Alcohol and Culture, Greenwood Press: Westport, 1995. 10. Thun M. et al, Alcohol Consumption and Mortality among Middle-Aged and Elderly Adults, The New England Journal of Medicine, 1997; 337. 11. Pearson T and Nutrition Committee of the American Heart Association, Alcohol and Heart Disease, Circulation, 94 (11), 1996. 12. Gorelick P. et al, Prevention of first Stroke: A Review of Guidelines from the National Stroke Association, Journal of the American Medical Association, 1999; 281. 13. Sacco, R. et al, The Protective Effect of Moderate Alcohol Consumption on Ischemic Stroke, Journal of the American Medical Association, 281, 53-60, 19999. 14. Reynolds K, et al, Alcohol Consumption and Risk of Stroke: A Meta-Analysis, Journal of the American Medical Association, 289, 579- 588, 2003. 15. Davies MJ et al, Effects of Moderate Alcohol Intake on Fasting Insulin and Glucose Concentrations and Insulin Sensitivity in Postmenopausal Women, Journal of the American Medical Association, 287, 2003. 16. Wannamethee SG et al, Alcohol Consumption and the Incidence of Type 2 diabetes, Journal of Epidemiology and Community Health, Vol 56, 2002. 17. Wannamethee SG et al, Alcohol Drinking Patterns and Risk of Type 2 Diabetes Mellitus among Younger Women, Archives of Internal Medicine, 163, 2003. 18. Howard A et al, Effect of Alcohol Consumption on Diabetes Mellitus – A Systematic Review, Annals of Internal Medicine, Vol 140, No 3, 2004. 19. Howard A et al,, Effect of Alcohol Consumption on Diabetes Mellitus – A Systematic Review”, Annals of Internal Medicine, Vol 140, No 3, 2004.18. Mannisto S et al, Alcohol Beverage Drinking, Diet, and Body Mass Index in a Cross-Sectional Survey, European Journal of Clinical Nutrition, Vol 51, 1997. 20. Locher R et al, Ethanol Suppresses Smooth Muscle Cell Profileration in the Postprandial Stage: A New Antiathereosclerotic Mechanism of Ethanol? American Journal of Clinical Nutrition, Vol 67, 1998. 21. Liu S.et al, A Prospective Study of Alcohol Intake and Change in Body Weight among US Adults, American Journal of Clinical Nutrition, Vol 140, 1994. 22. Coldwitz G et al, Alcohol Intake in Relation to Diet and Obesity in Women and Men, American Journal of Clinical Nutrition, Vol 54, 1991. 23. Istvan, The relationship between patterns of alcohol consumption and body weight. International Journal of Epidemiology, 24 (3), 1995. 24. Jequier, E. Alcohol Intake and Body Weight: a Paradox, American Journal of Clinical Nutrition, 59, 1999. 25. Kahn, H.S., Stable behaviors Associated with Adults’ 10-year Change in Body Mass Index and the Likelihood of Gain at the Waist, American Journal of Public Health, 87, 1997. 26. Mannisto S, Alcohol Beverage Drinking, Diet, and Body Mass Index in a Cross- National Survey, European Journal of Clinical Nutrition, 1997 27. Lands, M. Alcohol and energy intake. American Journal of Clinical Nutrition, 26, 1995. 28. Fillmore F, Relationship between Specific Drinking Problems in Early Adulthood and Middle Age, Journal of Studies on Alcohol, 1975; 36:882-907 29. Labouvie, E et al, Age of First Use: Its Reliability and Predictive Utility. Journal of Studies on Alcohol, 58, 1997. 30. Grant, F et al, Age at onset of alcohol use and DSM-IV alcohol abuse and dependence: A 12-year follow-up. Journal of Substance Abuse, 12, 2001. 31. Guo, J et al, Developmental Pathways to Alcohol Abuse and Dependence in Young Adulthood, Journal of Studies on Alcohol, 61, 2000. 32. Mc Gue M et al, Origins and Consequences of first Drink, Alcoholism: Clinical and Experimental Research, 25 (7, 8), 2001. 33. Harford, T. Early Onset of Alcohol Use and Health Problems: Spurious Associations and Prevention. Addiction, Vol 98, 2003. 33. Anderson A et al, tracking Drinking Behavior from Age 15- 19 years, Addiction, 2003. 34. Federal Trade Commission: Alcohol Marketing and Advertising, A Report to Congress, 2003. 35. Institute of Medicine, National Research Council of the National Academies. Reducing Underage Drinking a Collective Responsibility, The National Academies Press 2003. 36. The Eat Wise Pyramid, released at the 2003 International Conference on the Mediterranean Diet, Boston, Oldways Preservation & Exchange Trust, 2003 37. The Healthy Traditional Mediterranean Diet Pyramid, released at the Intern. Conference on the Diets of the Mediterranean, San Francisco, Oldways, 1994. 38. The Healthy Traditional Asian Diet Pyramid, released at the International Conference on the Diets of Asia, San Francisco, Oldways PT, 1995. 39. 39. The Healthy Traditional Latin America Diet Pyramid, released at the Intern. Conference on the Diets of Latin America, El Paso, Texas, Oldways PT, 1996. 39.40. The Vegetarian Diet Pyramid, released at the International Conference on Vegetarian Diets, Austin, Texas, Oldways Preservation & Exchange Trust, 1997. AIMUS, 2004 May 18, 2004 Ms. Kathryn McMurry HHS Office of Disease Prevention and Health Promotion Room 738-G, 200 Independence Ave, SW Washington, DC 20201 Email: dietaryguidelines@osophs.dhhs.gov RE: Year 2005 Draft Edition of Dietary Guidelines for Americans Dear Ms. McMurry: The following comments are submitted on behalf of AIM (Alcohol in Moderation), an international non-profit education group dedicated to science and social responsibility related initiatives. Specifically, AIM is devoted to increase socially responsible behavior with respect to alcohol consumption by bringing scientifically based education messages to the public via websites and other programs. Our efforts are centered on governmental and public health messages from around the world. We work with a Social, Scientific and Medical Council of physicians, scientists, and experts in social policy in preparing and presenting information related to an ongoing debate on alcohol use and abuse. We appreciate the opportunity to make comments on the recommended wording of the 2005 Dietary Guidelines that will be published by the Departments of Agriculture and Health and Human Services. AIM has long acknowledged that these Guidelines represent an important foundation for nutrition education activities. In fact, the Dietary Guidelines for Americans have served as an important consumer education tool as part of AIM’s outreach efforts. These programs advocate moderate consumption as the only responsible option for those who choose to enjoy wine, beer and spirits as a component of a well-balanced diet and lifestyle. Towards this end, we are committed to continuing and expanding our educational outreach efforts with the upcoming 2005 Dietary Guidelines for Americans edition. First and foremost, we applaud the Advisory Committee’s effort and express our strong support for expanded wording intended to discourage abuse while indicating that moderate and responsible use of alcohol is an acceptable lifestyle choice, and encouraging the consumption of alcoholic beverages with food (which markedly decreases the risk of abuse). In our view, however, the Guidelines should more fully take into account the research facts presented by the National Institute of Alcohol Abuse and Alcoholism (NIAAA) in their December, 2003, submission. In particular, we agree that the Guidelines should be based on the “preponderance of scientific and medical knowledge current at the time of publication”. (1, 2) In light of the developing research consensus on moderate consumption, reflected in both published scientific research studies and official nutrition and public policy positions, we would like to respectfully ask you to consider the following additional points when finalizing the alcohol guideline wording: I. Provide a more positive opening of the guideline, underscoring that responsible consumption is the only acceptable choice for those adults who choose to drink In line with the emerging evidence on moderate versus abusive drinking, the Guidelines should give more weight to positive messages about moderation as part of a healthy diet and lifestyle. In fact, we believe that the currently proposed wording disproportionately focuses on reported risks of abusive consumption while not adequately addressing scientific findings with respect to moderation. This is especially warranted as the overwhelming majority of those who choose to drink consume alcohol moderately and responsibly. This is not only reflected on page 20 in the recent NIAAA submission (1) and in the NIH 2000 physician’s guide (3) but also in earlier reports by NIAAA on alcohol and health to the US Congress.( 4) Along those lines the recent NIAAA submission emphasizes that “the consequences of alcohol use must be evaluated in conjunction with its potential benefits.” It is stressed that alcohol’s apparent protective effect against coronary heart disease and other atherosclerotic diseases are significant, as these are the most common cause of death in the US. The submission also cites a 1994 study predicting that abstention among current drinkers would lead to significant increases in coronary heart disease death rates. Another recent review article by Dr. Arthur Klatsky from Kaiser Permanente, who has published dozens of scientific studies over the last two decades, also cautions that while non drinkers should not necessarily be encouraged to drink, current moderate drinkers with no health contraindications should not be discouraged from drinking.(5) These and other statements underscore the importance of a more balanced discussion on moderation and abuse when formulating the US nutrition and dietary policy, which is also a stated goal for the Dietary guidelines 2005 ( Fed. Reg., Vol.68, no 171. Sept 4, 2003). With these and other research and public health facts in mind, we firmly believe that it is important to open the Guidelines with an additional message that underscores the acceptable behavior of moderation while also stressing the consequences of abuse. In sum, we recommend the addition of a sentence before the current lead sentence that would underscore, “The moderate and responsible consumption of wine, beer and spirits as part of a well-balanced diet and lifestyle is the only acceptable option for adults who choose to enjoy consumption of alcoholic beverages. The overwhelming majority of adult Americans drinks moderately or abstains, depending on their lifestyle choice.” This could lead the reader directly to the definition of moderation, underscoring that heavy drinking and binge drinking are irresponsible, which would also be underscored by the next sentence of the guideline reading, “Alcoholic beverages are harmful when consumed in excess.” II Further expand discussions on moderation and stress both the consumption with food and/or meals to foster responsible drinking behavior even outside the traditional mealtime consumption. We fully endorse the emphasis on eating and meals and would suggest including an expanded wording that would underscore that consumption should “preferably occur with food and/or with meals to slow alcohol absorption.” You may also wish to point out that alcohol should be consumed slowly, preferably over several hours. Such messages would encompass a wider range of drinking occasions and would also address NIAAA’s statement that people should be given more detailed advice on what encompasses “moderation.” Along those lines, we would also like to recommend that the following NIAAA statement be included, “Except for those individuals at particular risk ( as described in the current guidelines), consumption of 2 drinks a day for men and 1 drink a day for women is unlikely to increase health risks. As risks for some conditions and diseases do increase at higher levels of consumption, men should be cautioned to not exceed 4 drinks on any day and women to not exceed 3 on any day.” This represents an important caution intended to prevent serious binge drinking behaviors. Furthermore, this more detailed approach is also in line with other governmental guidelines such as those of the UK and Australia that provide more specific guidance for the consumer. (6, 7) In fact, official guidelines such as the UK Sensible Drinking Guidelines and the Australian Alcohol Guideline are taking a more positive approach (as reflected in our recommendations I. and II). In addition, social scientists have underscored that such education messages emphasizing positive cultural norms reinforce and initiate the most responsible drinking behaviors in a given society. In fact, these points are directly and indirectly addressed in a Rutgers University monograph entitled, “Society, Culture, and Drinking Patterns Reexamined,” as well as the International Handbook on Alcohol and Culture published by Brown University Professor Dwight Heath. ( 8,9) III. Address scientific findings with respect to moderation and other aspects of health, including overall mortality and stroke (in line with the recent NIAAA submission). As the NIAAA submission attests, since 2000 scientific support of moderate consumption’s role as part of a healthy lifestyle has gotten stronger. Large-scale studies from the US and around the world have found moderate drinkers not only have a reduced rate of cardiovascular disease, but also have a reduced overall mortality rate. The largest study on alcohol consumption to date by Thun et al(add ref), based on nearly 500,000 Americans, reports that overall death rates were lowest among men and women reporting about one drink daily (approximately 20% lower than abstainers for both men and women). (10) The American Heart Association concluded in 1996, “The lowest mortality occurs in those who consume one or two drinks a day.” (11)These findings were also acknowledged in the NIAAA submission along with many other research findings including a 2003 meta-analysis based on more than 50 studies on the subject. (1) Therefore, we urge the Committee to consider expanding the discussions on the health effects of moderation by including the NIAAA statement:” The lowest total all-cause mortality occurs at the level of 1 - 2 drinks per day.” Along those lines we also suggest including a statement acknowledging the potential positive affects with respect to ischemic stroke and Type II diabetes, in line with the research findings presented by NIAAA in its appendix 2.(1) The suggested mentioning of potential stroke risk reductions is also in line with the National Stroke Association’s official statement, which states:” Current scientific data continue to show that moderate levels of alcohol consumption do not increase risk for heart failure, myocardial infarction or ischemic stroke, and in fact provide protective effects along a J-shaped curve.”(12) A meta-analysis published recently in the Journal of the American Medical Association by Reynolds, et al concluded, “Heavy alcohol consumption increases the risk of stroke while light or moderate alcohol consumption may be protective against total and ischemic stroke.” Another study suggested that alcohol may protect against reoccurring strokes, and others have confirmed these findings. (13,14) The inclusion of discussions on diabetes is also appropriate as recent studies continue to reveal a reduced risk of diabetes among moderate drinkers. These include a study by Davies, et al in 2003 and a recent study by Wannamethee, et al, which reported that light drinking cuts diabetes risk in women. (15-18) IV. Discussions on calories and obesity should not be misleading. While we agree that the guidelines should provide a general benchmark for outlining average calories for wine, beer and spirits, we would like to caution against a more detailed statement on moderate drinking and obesity. Numerous studies, as outlined in the NIAAA submission, suggest no clear association between alcohol and weight gain for men, and some studies indicate a slight reduction in weight gain for women. Specifically, we would like to urge you to fully consider NIAAA’s conclusion on the subject, which is as follows: “The data on the relationship between moderate alcohol consumption and weight gain/obesity are inconclusive. However, there is some evidence for reduced risk of diabetes and metabolic syndrome, which often co-exist with or develop from obesity.”(1) Experimental studies have suggested that alcohol calories are not efficiently utilized and therefore generally do not lead to weight gain. For example, a 1997 study published in the European Journal of Clinical Nutrition concluded, “Alcohol consumers were leaner than abstainers,” and this is a common finding in most epidemiologic studies everywhere. Furthermore, a 1998 study published in the American Journal of Clinical Nutrition suggests that alcohol’s consumption with food slows not only the absorption process, keeping alcohol blood levels low, but may also have a favorable effect on lipid profiles during the postprandial period. (19, 20) In line with many studies over the last two decades,, the relationship between moderate alcohol consumption and obesity is unclear. In line with the 2003 NIAAA conclusion, for example, Lands wrote in a 1995 review article, “Thus, alcohol seemed unable to contribute to the overall body mass of either men or women. In fact, the cumulative evidence of 31 separate studies does not support the concept that reduced alcohol consumption would help maintain a lower body weight. Also the National Health and Nutrition Examination Survey (NHANES) showed that moderate drinkers gained less weight, on average, than abstainers over a ten year follow up period (21-27) In light of these and other findings, we believe an overall cautionary and even warning message on alcohol’s calories would be misleading and is therefore unwarranted, especially if it would suggest in any way that individuals should reduce moderate consumption of beverage alcohol to decrease weight; scientific data are not present to support such a statement. V. The “Who should not drink section” should also be evidence-based and supported by science. In all of AIM’s education efforts, we stress the unacceptability of underage drinking and emphasize adherence to the laws regarding the purchase and possession age limitations in the US. Therefore, we support the Dietary Guideline’s Committee’s focus to reduce underage drinking problems. We are concerned, however, that the statement, “Risk of alcohol abuse increases when drinking starts at an early age,” is scientifically and culturally unwarranted. The issue is still a matter of debate, and indeed alcohol abuse rates are actually lower in many countries (such as Italy) where wine consumption begins early in life. It does appear that early abusers of alcohol and drugs may be more likely to be adult abusers, but studies have reported that it was drinking problems, rather than any drinking, that show the ability to predict later-life alcohol problems.(28,29)Other studies have shown that the age of first use of alcohol (as recalled at age 18) did not predict alcohol or drug use at either 20 or 30 years of age.(30) Another study concluded, “These results suggest the association between drinking onset and diagnosis is no causal, and attempts to prevent the development of alcohol dependence by delaying drinking onset are unlikely to be successful.”(31) More recent studies also conclude that much of the association can be accounted for by genetic vulnerability.(32,33) Recent reports by the Federal Trade Commission and the National Academy of Sciences point out that most alcohol beverages are obtained by underage persons through their parents and other adults.(34,35) Therefore, we strongly suggest to the Committee that it include wording that cautions parents to discourage their children from drinking and to discuss the subject of alcohol in detail with them. VI. The Food Guide Pyramid Graphics should include alcohol to help put the Dietary Guidelines into action, reinforcing the importance of moderation as the only choice. As the Food Guide Graphic will be revised to mirror the 2005 Dietary Guidelines, we would like to strongly recommend that alcoholic beverages will be included as an option for adults. We firmly believe that this would provide increased exposure to the government’s moderation message and the overall Guideline cautioning about abuse and the importance of only moderate consumption as part of an overall healthy and well-balanced lifestyle. The pyramid and accompanying booklet will help Americans get the needed guidance to choose a balanced diet and responsible decision-making skills as outlined in the Guidelines. This approach would provide an important venue to reinforce socially responsible behavior with respect to wine, beer, and spirits consumption. This approach is also in line with other dietary models and accompanying graphics. Specifically, we would like you to review and consider approaches presented in the Mediterranean, Latin-American, Asian, and Vegetarian Diet Pyramids. These concepts have been developed by leading experts from Harvard University of Public Health and other leading institutions. (36-40) In conclusion, we would like to reiterate that the developing research consensus on moderate versus abusive consumption should be fully reflected in the upcoming 2005 Dietary Guidelines for Americans. While we support the admonition against abusive behavior, and agree that for certain groups of individuals any consumption is inadvisable, we respectfully recommend through this submission that you re-examine the impressive and credible evidence suggesting that, for most people, moderate drinking is consistent with a healthy and well-balanced lifestyle. We are confident that the upcoming Guidelines will continue to assist Americans and other consumers around the world in making informed healthy diet and lifestyle choices. Towards this end, AIM will be committed to widely disseminating the 2005 Dietary Guidelines as a basis of our ongoing and expanded education initiatives. Thank you for your time and consideration. If you have any questions concerning our sub mission or if we can be of any assistance, please contact Elisabeth Holmgren, at our US office at (925) 934-3226 or at em-h@pacbell.net . Sincerely, Peter Duff Chairman AIM-Alcohol in Moderation
Submission Date	9/27/2004 7:38:00 PM
Author	AIM-Alcohol in Moderation

Summary	Keep alcoholic drinks to the bar/tavern in draft form, and encourage unpasteurized traditional soft drinks, herbal teas. Help eliminate alcoholism by encouraging complete hot meals first for all first.
Comments	Some of the Native American tribes made their own fermented drinks, mostly sour, with any alcohol being counteracted by the high quantity of B-vitamins in these indegenous drinks (example, pulque is undistilled, also unfermented in its traditional state, and not able to be transported very far - by distilling something similar to make Tequila, you develop the problems of severe intoxication). The Cherokees fermented a sour corn drink for visitors, releasing its nutrients to the highest advantage. Alcoholism is a plague killing many, and disabling many others. By returning even to the traditions of unpasteurized beer on the tap, we would have at least maintained the B-vitamins and kept the drunkenness to the taverns, minimizing its presence behind the wheels. Traditional drinks, including traditionally fermented ginger ale and native herbal flavored teas contain nutrients that strengthen constitution and also provide much less sugar than do the soft drinks of the convenience store.
Submission Date	9/27/2004 10:28:00 PM
Author	from Poplar, Montana

Summary	While we support the majority of the findings in the Committee Report, we would like to provide additional comment in two important areas: • There should be no changes to the Drinking In Moderation Definition, especially with the “Count as a Drink” language regarding expressions of alcohol content f
Comments	Wine Institute is the public policy association of California wineries representing over 800 California wineries and affiliated businesses. These companies are responsible for 80 percent of the nation’s wine production. On behalf or our members, we are pleased to submit comments in response to the request for public input on the 2005 Dietary Guidelines Advisory Committee Report to the Departments of Health and Human Services and Agriculture. We agree that the 2005 Dietary Guidelines for Americans should represent a balanced approach to recommendations on the full range of nutrition, lifestyle and health issues. In particular, we support the Ethanol Subcommittee’s continued recommended advice to discourage excessive consumption and indicate that, even in moderation, there are individuals who should not drink. We are pleased that the main alcohol message has been maintained from the 2000 Dietary Guidelines: “If you drink alcoholic beverages, do so in moderation” and that the Committee has maintained the recommendation (advice) that, “For those who choose to drink an alcoholic beverage, it is advisable to consume it with meals to slow absorption. Data suggest that the presence of food in the stomach can slow the absorption of alcohol and thereby mitigate the associated rise in blood alcohol concentration.” While we support the majority of the findings in the Committee Report, we would like to provide additional comment in two important areas: • There should be no changes to the Drinking In Moderation Definition, especially with the “Count as a Drink” language regarding expressions of alcohol content for wine, because there will be extensive rulemaking by the Treasury Department’s Tax and Trade Bureau (TTB) in 2005 that will address several significant issues that are based on the language of the Dietary Guidelines. Language in the Dietary Guidelines should not be misused or misconstrued in any future regulatory action or rulemaking. • Messages relating to moderate drinking and weight gain and obesity for the public should clearly state that the scientific findings in this area are inconclusive and that alcohol, as well as other sources of discretionary calories, should be monitored closely for optimal health. I. MODERATE DRINKING DEFINITION In the 2000 version of the Dietary Guidelines for Americans, drinking in moderation is defined in Box 26 on page 36 - What is Drinking in Moderation?: The Advice For Today on page 37 goes one step further and recommends “Limit intake to one drink per day for women and two per day for men, and take with meals to slow alcohol absorption.” The Advisory Committee found this definition of moderate drinking as optimal for adults who choose to drink as a means to provide both beneficial effects on heart disease and allcause mortality as well as reduce risks caused by heavy drinking. However, the Advisory Committee also states that, “The definition of moderation, including the size of one drink, requires emphasis. (Some investigators and apparently many individuals interpret ‘moderate drinking’ to cover higher levels of intake than shown in Table E-25. Many mixed drinks actually provide several servings of alcohol per drink.” (DG Advisory Committee Report, Part D, Section 8, page 3). In an apparent response to further define a moderate serving of each beverage, the Advisory Committee has added a “12 percent alcohol” qualifier to the definition of a serving of wine. Throughout the text of the Advisory Committee Report, one serving of wine is defined as “a 5-ounce glass of 12 percent alcohol.” (See Table E-25, below). Wine Institute believes that providing the public a frame of reference by including serving size information in ounces will assist wine, beer, and distilled spirits consumers in their awareness of alcohol consumption levels. We believe that direct serving size information in ounces about the product being consumed is relevant and, if truthful, accurate and specific, should be able to be included. However, within each category of drinks (wine, beer and distilled spirits) there is a range of products with different alcohol percent values. Unlike distilled spirits, wine is not a “mixed” drink. Consumers discriminate among the various wine products more by their broad product categories, and producers of wine do not target a particular alcohol level but a sensory style and taste. Even from a regulatory standpoint, the standards of identity for wine differ significantly from distilled spirits product standards. Table wine, for example, is defined as still wine between 7 and 14 percent alcohol by volume.1 While from a scientific or clinical standpoint it may make 1 27 USC 5041 states, in part, as follows: (a) Imposition There is hereby imposed on all wines (including imitation, substandard, or artificial wine, and compounds sold as wine) having not in excess of 24 percent of alcohol by volume, in bond in, produced in, or imported into, the United States, taxes at the rates shown in subsection (b), such taxes to be determined as of the time of removal for consumption or sale. All wines containing more than 24 percent of alcohol by volume shall be classed as distilled spirits and taxed accordingly. Still wines shall include those wines containing not more than 0.392 gram of carbon dioxide per hundred milliliters of wine; except that the Secretary may by regulations prescribe such tolerances to this maximum limitation as may be reasonably necessary in good commercial practice. (b) Rates of tax (1) On still wines containing not more than 14 percent of alcohol by volume, $1.07 per wine gallon; (2) On still wines containing more than 14 percent and not exceeding 21 percent of alcohol by volume, $1.57 per wine gallon; (3) On still wines containing more than 21 percent and not exceeding 24 percent of alcohol by volume, $3.15 per wine gallon; (4) On champagne and other sparkling wines, $3.40 per wine gallon; (5) On artificially carbonated wines, $3.30 per wine gallon; and (6) On hard cider which is a still wine derived primarily from apples or apple concentrate and water, containing no other fruit product, and containing at least one-half of 1 percent and less than 7 percent alcohol by volume, 22.6 cents per wine gallon. sense to qualify wine with a specific alcohol content, we do not believe that assigning an arbitrary value of 12 percent alcohol to wine provides the consumer with any additional useful information from which to make an informed decision. As the alcohol percent value of table wine varies between 7 percent and 14 percent and that for dessert wine is 14 percent and above, such a listing would not necessarily be truthful or accurate and could be misleading. We believe that the addition of a “12% alcohol” qualifier in the “Count as a Drink” language will be misinterpreted by some as the establishment of a “standard drink” size, which will eventually lead to a distortion and/or omission of the important moderation message. The Guidelines represent great efforts to explain moderate consumption to U.S. consumers, but they have also been misunderstood. We are seeing the moderation message giving way to a much broader interpretation that the Guidelines themselves have established the size of a “standard drink,” and there have been several regulatory actions that have been based on this contention. We have seen the “count as a drink” language stripped of its accompanying moderation context, with what remains being repackaged as a definition for a “standard drink.” We do not believe that this is what was intended by the authors of the Guidelines, and we are concerned that this misinterpretation and misuse, all pending the safeguards of future rulemaking, will raise serious social as well as political implications. While adding a “12% alcohol” qualifier to wine may appear to be minor and consistent with the “80 proof distilled spirits” language, we are concerned that such changes will result in an argument that these sizes equate to “standard drink” sizes and will become the basis for untruthful and misleading information on wine, beer, and spirits labels. Changes such as this will tend to bolster an argument that all alcoholic beverages are “equal,” a notion that Wine Institute disagrees with. It is an oversimplification to single out the ethyl a