Wardlaws Perspectives in Nutrition 10th Edition

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Chapter 8
Alcohol
Overview
Chapter 8 covers the production, metabolism, and health effects of alcohol. The chapter begins
with a discussion of the processes of fermentation and distillation that are used to produce alcohol. The
three pathways used to metabolize alcohol - the alcohol dehydrogenase pathway, the microsomal ethanol
oxidizing system, and the catalase pathway - and factors that affect alcohol metabolism, are explained.
Statistics regarding alcohol consumption among North Americans are provided with particular emphasis
on the perils of binge drinking on college campuses and underage drinking in general. Although there are
some health benefits of moderate alcohol consumption, these must be viewed in light of the many mental,
interpersonal, and physiological dangers of alcohol abuse and alcoholism. The interactions of alcohol
abuse and nutritional status are discussed and women are warned against drinking during pregnancy and
breastfeeding. Chapter 8 wraps up with a discussion of alcohol dependency and recovery from it.

Learning Outcomes
1. Describe the sources of alcohol (ethanol) and the calories it provides.
2. Define standard sizes of alcoholic beverages and the term moderate drinking.
3. Outline the process of alcohol absorption, transport, and metabolism.
4. Explain how alcohol consumption affects blood alcohol consumption.
5. Define binge drinking and describe the problems associated with it.
6. Discuss potential health risks and benefits of alcohol consumption.
7. Describe the effects of chronic alcohol use on the body and nutritional status.
8. List the signs of alcohol dependency and abuse.

Teaching Strategies, Activities, Demonstrations, and Assignments

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1. Assign students the Take Action activity at the end of the chapter, "Do You Know Why These Are
Alcohol Myths?" Have students discuss the myths they previously believed vs facts they now
understand.

2. Have students investigate alcohol use with the CAGE questionnaire. Have them complete the CAGE
questionnaire. Ask students to share observations they have made.

3. Have students, as groups, read and discuss the Case Study found in Chapter 8. After groups have
discussed the scenario, have them share their thoughts with the entire class.

4. Have students, as groups, brainstorm a variety of approaches to curb binge drinking on college
campuses and determine ways in which they could aid friends and family members who exhibit
alcohol abuse. After groups have thought of various approaches to curb binge drinking and ways in
which they could aid alcohol abusers, have them share their thoughts with the entire class.

5. Have students create a chart that summarizes the three metabolic pathways of alcohol metabolism.

6. Bring in containers that represent a standard-sized drink for beer, wine, and liquor. Have students
bring in their favorite drinking glass and compare their drink sizes to a standard-sized drink. After
comparing a standard-sized drink to the typical-size drink a student consumes, have them discuss
how their views have changed.

7. Have the students visit the website awareawakealive.org and choose one tool to present to the class
that they learned about through the website.

Lecture Outline
8.1 Sources of Alcohol
A. General
1. Common sources vary in alcohol and calorie content (see Table 8-1)
a. Beer
b. Wine
c. Distilled spirits
d. Liqueurs
e. Cordials
f. Hard cider
g. Ingredient in foods
2. Alcohol “proof” = twice the percentage of alcohol content
3. Standard drink provides ~14 g alcohol
a. 12 ounces of beer
b. 10 ounces of wine cooler
c. 5 ounces of wine
d. 1.5 ounce of hard liquor
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 4. Moderate alcohol intake
a. 1 drink/day for women
b. 2 drinks/day for men
B. Production of Alcoholic Beverages
1. Carbohydrate-rich foods are fermented by yeast, which convert simple sugars
(e.g., glucose or maltose) to alcohol and CO2 at room temperature
a. Malting is the process of allowing grain to sprout, which produces
enzymes that break down starch to simple sugars
b. First stage of fermentation is aerobic; yeast cells multiply and produce
small amount of alcohol
c. Second stage of fermentation is anaerobic
d. Fermentation ceases when alcohol content inactivates yeast
2. Alcohol maybe distilled by boiling and condensation to separate it from water
and concentrate it; used to produce hard liquor

8.2 Alcohol Absorption and Metabolism

A. Alcohol Absorption
1. Requires no digestion
2. Requires no specific transport mechanisms or receptors to enter cells
3. Rapid absorption by simple diffusion
a. 20% absorbed in the stomach
b. Remainder absorbed in the duodenum and jejunum
4. Rate of alcohol absorption is influenced by types and amounts of foods
consumed
a. Empty stomach leads to rapid absorption
b. High fat meal slows absorption
5. Alcohol is dispersed wherever water is distributed in the body
6. Alcohol diffusion through cell membranes causes damage to membrane proteins
B. Alcohol Metabolism: 3 Pathways
1. Alcohol cannot be stored; takes priority in metabolism as a fuel source
2. Metabolic pathways
a. Alcohol dehydrogenase (ADH) pathway metabolizes majority (90%) of
alcohol consumed at low or moderate levels
i. Alcohol dehydrogenase converts ethanol to acetaldehyde (toxic)
ii. Aldehyde dehydrogenase converts acetaldehyde to acetyl-CoA
(converted to carbon dioxide and water or used for fatty acid
synthesis)
iii. Cells lining stomach metabolize 10 - 30% of alcohol via ADH
pathway
iv. Liver is primary site for alcohol metabolism
b. Microsomal ethanol oxidizing system (MEOS) helps to metabolize
moderate to excessive amounts of alcohol
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 i. Occurs in the liver
ii. Also used to metabolize drugs and toxins; because alcohol
metabolism takes first priority, use of MEOS for alcohol
metabolism may increase risk for drug interactions and toxicities
iii. Like ADH pathway, produces acetaldehyde and then acetyl CoA,
but requires energy to function
iv. Increasing efficiency of MEOS with repeated exposure to
alcohol contributes to alcohol tolerance: increasing amounts of
alcohol are needed to produce the same effect
c. Catalase pathway
i. Minor contributor to alcohol metabolism
ii. Takes place in liver and other cells
3. ADH, MEOS, and catalase pathways metabolize nearly all alcohol consumed;
small percentage is excreted through lungs, urine, and sweat
4. Factors Affecting Alcohol Metabolism
a. Ethnicity
i. People of Asian descent have normal to high ADH activity, but
very low aldehyde dehydrogenase activity; buildup of
acetaldehyde leads to flushing, dizziness, nausea, headaches,
rapid heartbeat, and rapid breathing
b. Gender
i. Women produce less ADH in cells of stomach lining, leading to
30 - 35% more alcohol absorption from stomach directly into
bloodstream
ii. Smaller body size, higher body fat content, and less total body
water of women leads to greater concentration of alcohol in
blood and other tissues
c. Age: enzymes of ADH pathway decline with age
d. Alcohol content of beverage
e. Amount of alcohol consumed
f. Usual alcohol intake
i. Large amounts of alcohol on a regular basis activates the MEOS
pathway, thereby increasing alcohol metabolism and tolerance
5. Rate of Alcohol Metabolism
a. Social drinker, 150 lbs., normal liver function: metabolizes 5 - 7 g
alcohol/hour
b. When rate of alcohol consumption exceeds liver’s metabolic capacity,
BAC rises and symptoms of intoxication appear (see Figure 8-2)
c. BAC determined by measuring amount of alcohol excreted by the lungs,
which is directly related to BAC (breathalyzer test)
d. Acute alcohol intoxication (alcohol poisoning) can cause respiratory
failure, aspiration of vomit, and death
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 i. Confusion, stupor
ii. Vomiting
iii. Hypoglycemia
iv. Severe dehydration
v. Seizures
vi. Slow or irregular breathing and heartbeat
vii. Blue-tinged or pale skin
viii. Hypothermia
ix. Unconsciousness
e. Binge drinking is defined as having 4 or more drinks for females and 5 or
more drinks for males on a single occasion
8.3 Alcohol Consumption
A. Statistics
1. 65% of North American adults consume alcohol
a. 5.8% of women consume alcohol daily
b. 10.8% of men consume alcohol daily
c. 5% are excessive drinkers
i. >7 drinks/week women
ii. >14 drinks/week men
B. Drinking on college campuses
1. Young, white college students are largest drinking population in North America
2. Many drinkers are not of legal drinking age
3. Considered “rite of passage” into adulthood
4. Advertising targets college students
5. Drinks that combine alcohol and stimulants such as caffeine and guarana are
popular in college campuses
a. Lead to excess alcohol intake, as individuals are less able to judge their
degree of intoxication
6. Drinkers may be unaware of the harmful acute and chronic effects of alcohol
7. Binge drinking is associated with (see Table 8-4)
a. Vandalism
b. Violent crime
c. Traffic accidents and injuries
d. Sexual abuse
e. Suicide
f. Hazing deaths
g. Serious acute health risks
8. Poor habits contribute to lifelong problems

8.4 Health Effects of Alcohol

A. Guidance for Using Alcohol Safely

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 1. Non-drinkers should not start consuming alcohol because risks often outweigh
benefits, but moderate alcohol has some benefits
2. Recommendations for individuals who choose to drink alcohol
a. Drink alcohol sensibly and in moderation (up to 1 drink/day for women;
up to 2 drinks/day for men)
b. Some individuals should not consume alcohol
i. Unable to restrict alcohol intake
ii. Women who are or may become pregnant
iii. Anyone younger than the legal drinking age
iv. Use of medication that interacts with alcohol
v. Certain medical conditions
c. Alcoholic beverages should be avoided by individuals engaging in
activities that require attention, skill, or coordination
B. Potential Benefits of Alcohol Intake
1. Reduced anxiety and stress
2. Stimulation of appetite among elderly adults
3. Lowered risk of cardiovascular disease and overall mortality; may be due to
resveratrol in red wine
a. Decreased LDL
b. Increased HDL
c. Decreased platelet aggregation
4. Reduced risk of type 2 diabetes
5. Reduced risk of dementia
C. Risks of Excessive Alcohol Intake
1. Excessive alcohol consumption contributes to 5 of 10 leading causes of death in
North America
a. Heart failure
b. Cancer
c. Cirrhosis
d. Motor vehicle and other accidents
e. Suicides
2. Figure 8-5 summarizes effects of excessive alcohol on body
a. Cognitive deficits
b. Vasodilation and flushing of skin
c. Cancer of the oral cavity, throat, larynx, and esophagus
d. Heart muscle damage and resulting arrhythmias
e. Breast cancer
f. Irritation of the stomach lining and stomach cancer
g. Fatty infiltration of the liver, alcoholic hepatitis, cirrhosis, ultimate liver
failure, and liver cancer
h. Impaired pancreatic function, hypoglycemia, pancreatic cancer
i. Malabsorption of nutrients in the small intestine
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 j. Abdominal fat deposition and fluid accumulation (ascites)
k. Cancer of the colon and rectum
l. Osteoporosis
m. Intestinal bleeding
n. Depressed immune function
o. Sleep disturbances
p. Impotence
q. Nutrient deficiencies
r. High blood triglycerides
3. Cirrhosis of the Liver
a. Roles of liver
i. Nutrient storage
ii. Protein and enzyme synthesis
iii. Metabolism of protein, fats, and carbohydrates
iv. Detoxification
v. Drug metabolism
b. Progression of alcohol-induced liver disease
i. Steatosis (fatty liver); usually reversible
ii. Alcoholic hepatitis (inflammation of liver cells), leading to
nausea, poor appetite, vomiting, fever, pain, and jaundice;
usually reversible but frequently progresses to cirrhosis
iii. Cirrhosis (loss of functioning hepatocytes) leading to decreased
production of blood proteins, ascites, and poor nutritional status;
irreversible
c. Statistics
i. 50% chance of death within 4 years without liver transplant
ii. Cirrhosis develops in 10 - 15% cases of alcoholism
iii. Commonly associated with drinking equivalent of 6 standard
size drinks/day, but may be less, especially for women
d. Susceptibility to cirrhosis
i. Amount of alcohol consumed
ii. Duration of alcohol consumption
iii. Genetic factors
iv. Obesity
v. Diabetes
vi. Exposure to hepatotoxins
vii. Iron overload disorders
viii. Infections with hepatitis
e. Mechanisms for liver damage
i. Increased concentration of acetaldehyde may damage liver
ii. Accumulation of fat in liver cells causes inflammation and cell
damage
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 iii. Increased production of free radicals
f. Impact of nutritional status
i. Even with nutritious diet, alcoholism still causes liver damage
ii. Nutrient deficiencies increase vulnerability of liver to toxicity
D. Effects of Alcohol Abuse on Nutritional Status
1. General
a. Alcohol abusers tend to replace some or all of food with alcohol, a poor
source of nutrients
b. Protein-energy malnutrition can result
c. Micronutrient deficiencies result from poor intake and impaired
absorption or metabolism of nutrients
2. Water-Soluble Vitamins
a. Thiamin deficiency (Wernicke-Korsakoff Syndrome): alcohol is a poor
source of thiamin
i. Irreversible paralysis of eye muscles
ii. Loss of sensation in lower extremities
iii. Loss of balance with abnormal gait
iv. Memory loss
b. Niacin deficiency: alcohol metabolism requires large quantities of niacin
c. Vitamin B-6 deficiency: alcohol metabolism increases urinary excretion
of vitamin B-6
i. Increased risk of anemia
ii. Peripheral neuropathy
d. Vitamin B-12 deficiency: excessive alcohol intake can impair absorption
of vitamin B-12
e. Folate deficiency
3. Fat-Soluble Vitamins
a. Vitamins A, D, E, and K: chronic alcohol abuse damages liver and
pancreas, which impairs secretion of bile and enzymes that digest fat
b. Vitamin A: alcohol abuse decreases liver’s rate of breakdown and
excretion of vitamin A and decreases liver’s production of the protein
that transports vitamin A throughout the body; deficiency may lead to
night blindness
c. Vitamin K: decreased ability to synthesize vitamin K-containing
compounds for blood clotting
d. Vitamin D: decreased ability of liver to convert vitamin D to active form;
increased risk for osteoporosis
4. Minerals
a. Calcium: low intake and poor absorption due to decreased ability of liver
to convert vitamin D to active form
b. Magnesium: increased urinary excretion; leads to tetany

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 c. Zinc: decreased absorption and increased urinary excretion; leads to
changes in taste and smell, loss of appetite, and impaired wound healing
d. Iron: damage to gastrointestinal tissues causes bleeding, malabsorption,
iron deficiency
E. Alcohol Consumption During Pregnancy and Breastfeeding
1. Pregnancy
a. Slows nutrient and oxygen delivery to developing fetus; retards growth
and development, especially in the 12-to-16-weeks stage, when organs
are undergoing major developmental steps
b. Alcohol displaces nutrient-dense foods in maternal diet
c. Fetal alcohol spectrum disorders (see Figure 8-8)
i. Facial malformations
ii. Growth retardation (smaller than normal brain size)
iii. Birth defects
iv. Learning difficulties
v. Short attention span
vi. Hyperactivity
vii. Nervous system abnormalities
d. Fetal alcohol syndrome
i. Facial malformations
ii. Growth deficits
iii. CNS problems
e. Within minutes of consumption, alcohol reaches fetus through maternal
blood supply
i. Small size
ii. Immature metabolism
f. No safe level of alcohol consumption during pregnancy is known
g. Women planning pregnancy should avoid alcohol because first trimester,
when many women do not know they are pregnant, is time of highest
vulnerability
2. Breastfeeding
a. Reduces milk production
b. Decreases infant milk consumption
c. Leads to disrupted sleep patterns for infant
d. Alcohol consumption is not advised for breastfeeding mothers, but if
consumed, limit amount to 1 to 2 drinks and wait 2 hours before
breastfeeding
F. Global Perspective: Alcohol Intake Around the World
1. According to WHO, residents of Russia and Europe drink the most alcohol
2. Worldwide, nearly half of men and two-thirds of women do not drink. In the
U.S., only 36% abstain from alcohol consumption
3. Alcohol intake around the world is increasing
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 4. Worldwide, about 4% of deaths are attributed to alcohol intake. However, in
Russia more than half of the deaths of men aged 15 to 54 years are due to alcohol
5. Alcohol, typically wine, consumed with meals is a tradition enjoyed in
many cultures
6. Moderate alcohol intake may offer some health benefits
7. Risks increase when many alcoholic beverages are consumed in rapid succession,
resulting in alcohol poisoning and death

8.5 Alcohol Use Disorders: Alcohol Abuse and Alcoholism

A. General
1. Alcohol abuse (at least one of the following)
a. Failing to fulfill major responsibilities at work, school, or home
b. Drinking when it is physically dangerous (e.g., driving)
c. Having recurring alcohol-related legal problems
d. Having social or relationship problems that are worsened by alcohol
intake
2. Alcoholism (alcohol dependency)
a. Craving
b. Loss of control
c. Withdrawal symptoms (e.g., nausea, sweating, anxiety, shaking)
d. Tolerance
e. Unsuccessful attempts to cut down on alcohol use
3. Statistics
a. 1 in 3 Americans abuses or becomes dependent on alcohol over
a lifetime
b. 8.5% of U.S. population meet criteria for alcohol abuse or dependence
c. 30% of U.S. population is at high risk of developing alcohol-related
problems
B. Genetic Influences
1. Account for 40 - 50% of risk
2. May be due to genetic polymorphisms of enzymes of alcohol metabolism,
antioxidant enzymes, neurotransmitters or receptors, or immune factors
3. Those with family history of alcohol dependence should be alert for early signs
C. Effect of Gender
1. Men are at higher risk for alcohol dependency: 4 male:1 female
2. Women are more susceptible to adverse effects of alcohol due to smaller size,
lower body water content, and lower alcohol dehydrogenase in stomach
a. Liver disease
b. Heart muscle damage
c. Cancer
d. Brain injury
D. Age of Onset of Drinking
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 1. Underage alcohol consumption contributes to 4500 deaths/year in U.S.
2. 45% of youth who drink before age 14 develop alcohol dependence, compared to
10% of those who delay drinking until after age 21
3. 40% of high school youth report current alcohol consumption
E. Ethnicity and Alcohol Abuse
1. High use
a. Native American Indians
i. High rate of motor vehicle accidents and unintentional injuries
due to alcohol
ii. High rate of alcohol-related suicide and domestic abuse
iii. High rate of fetal alcohol syndrome
b. Alaska Natives
c. Native Hawaiian
2. Low use
a. Asian Americans
i. Uncomfortable side effects from low aldehyde dehydrogenase
activity
F. Mental Health and Alcohol Abuse
1. Alcohol abuse may aggravate or cause depression or anxiety disorders
2. People with mental health disorders may seek alcohol to self-medicate
3. Majority of suicides and interfamily homicides are alcohol-related
G. Clinical Perspective: Diagnosis and Treatment of Alcoholism
1. Two-phase problem
a. Problem drinking
b. Alcohol addiction
2. Signs of alcoholism (in addition to those listed in section 8.5)
a. Alcohol odor
b. Flushed face
c. CNS disorders (e.g., tremors)
d. Unexplained work absences
e. Frequent accidents
f. Falls or injuries of vague origin
g. Laboratory tests
i. Impaired liver function
ii. High triglycerides
iii. High uric acid concentration
3. Determining Whether a Problem with Alcohol Intake Exists
a. CAGE questionnaire (1 or more positive responses)
i. C: Have you ever felt you ought to cut down on drinking?
ii. A: Have people annoyed you by criticizing your drinking?
iii. G: Have you ever felt bad or guilty about your drinking?

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 iv. E: Have you ever had a drink first thing in the morning
(eye-opener) to steady your nerves or get rid of a hangover?
4. Recovery from Alcoholism
a. Behavioral therapy
i. Identify ways to compensate for the loss of pleasure from
drinking
ii. Total abstinence is the ultimate objective
iii. Co-existing mental health disorders must be treated
b. Medication
i. Naltrexone (ReVia): blocks craving for alcohol and pleasure of
intoxication
ii. Acamprosate (Campral): acts on neurotransmitter pathways to
decrease desire to drink
iii. Disulfiram (Antabuse): causes physical reactions (e.g., vomiting)
with alcohol consumption
c. Mutual-help programs
i. Alcoholic Anonymous
ii. Al-Anon for friends and family members
d. Recovery rates are 60% or higher for job-related alcoholism treatment
programs
e. Successful recovery depends on early detection and intervention

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