European Journal of Clinical Nutrition (1997) 51, 326±332
ß 1997 Stockton Press. All rights reserved 0954±3007/97 $12.00
Alcohol beverage drinking, diet and body mass index in a
cross-sectional survey
S MaÈnnistoÈ1, K Uusitalo1, E Roos1, M Fogelholm2 and P Pietinen1
1
National Public Health Institute, Department of Nutrition, Helsinki, Finland; and 2 the UKK Institute, Tampere, Finland
Objective: The study was carried out to determine the associations of alcohol beverage drinking with
macronutrients, antioxidants, and body mass index.
Setting: Dietary subsample of the 1992 Finmonica cardiovascular risk factor survey in Finland; a cross-sectional
study.
Subjects: 985 women and 863 men were drawn from the population register in the four monitoring areas. All
subjects were 25±64 y of age.
Methods: The mailed questionnaire included questions covering socioeconomic factors, physical activity,
smoking, and alcohol consumption. The diet was assessed using a three-day food record.
Results: The dietary differences between abstainers and alcohol consumers were more signi®cant than between
consumers of different alcoholic beverages. Among drinkers, fat intake as a percentage of energy was higher and
carbohydrate intake was lower than among abstainers. Those who preferred wine, however, had the highest
vitamin C intake; female wine drinkers also had the highest carotenoid intake. With the exception of those who
mainly preferred spirits, alcohol energy was not added to the diet but seemed to substitute food items both in men
and women. Despite the similar total daily energy intakes, daily energy expenditure, and physical activity index,
male drinkers were leaner than abstainers. In women, the proportion of underreporters of energy intake increased
with increasing alcohol consumption, and the association between alcohol and body mass index was similar to
that in men after the exclusion of underreporters.
Conclusions: Alcohol consumers were leaner than abstainers, and wine drinkers in particular had more
antioxidants in their diet.
Sponsorship: The Finnish Foundation for Alcohol Studies.
Descriptors: alcoholic beverages; alcohol intake; body mass index; diet; energy
Introduction
The U-shaped association between alcohol consumption
and coronary heart disease in both men and women is quite
well established (Doll et al, 1994; Fuchs et al, 1995). The
bene®cial effects of alcohol have been associated with
higher HDL/LDL cholesterol ratios and with the inhibition
of platelet aggregation. Moreover, the descending part of
the U-shaped curve may be the result of a higher number of
wine drinkers, and the ascending part a result of heavy
spirit-drinkers (Grùnbñk et al, 1995). In other words,
different effects of alcoholic beverages are possibly not
caused by the same main component (ethanol) but by other
characteristic components (Dorfman et al, 1985).
The `French Paradox' describes the phenomenon
observed in France, where a high intake of saturated fat
has not led to high mortality from coronary heart disease.
This ®nding has directed attention toward the possible
bene®cial effects of red wine (Renaud & de Lorgeril,
1992). Protective components in wine are not well established, but some evidence of the positive effects of ¯avonoids and phenolics have been presented (Kinsella et al,
1993). Although the Finnish diet (Pietinen et al, 1996) and
Correspondence: S MaÈnnistoÈ, National Public Health Institute, Department
of Nutrition, Mannerheimintie 166, 00300 Helsinki, Finland.
Recieved 16 August 1996; revised 11 December 1996; accepted 24
January 1997
patterns of alcohol consumption (Simpura et al, 1995) have
changed markedly during the last twenty years, Finland is
still exceptional among Western countries. This was supported by the ®ndings of Artaud-Wild et al (1993), who
concluded that the differences in cholesterol and saturated
fat intakes explained the differences in coronary mortality
in 40 countries but not in Finland and France. Further,
because drinking at meals is not common in Finland, the
mean number of drinking occasions per week remains far
below most other European countries and binge drinking is
common (Simpura et al, 1995).
There are also other lifestyle aspects related to alcohol
consumption. In some studies but not in all, alcohol consumers had lower body mass index (BMI) than abstainers,
despite their higher total energy intakes as reviewed by
Hellerstedt et al (1990) and Prentice (1995). Alcohol
consumers also smoke more than abstainers (Le Marchand
et al, 1988).
We have previously found that middle-aged men did not
substitute alcohol for food but added alcoholic beverages to
the diet, and that alcohol consumption in¯uenced daily
nutrient intakes only slightly (MaÈnnistoÈ et al, 1996). The
energy from alcohol increased body weight less than
expected, especially in daily alcohol users. However,
although that study of 27 215 men was substantial, it was
restricted to smoking men who were mainly spirit drinkers.
Thus women, young people, and those who mainly drink
wine or beer were excluded.
Alcohol, diet and BMI
S MaÈnnistoÈ et al
In this study we assessed whether selected indicators of
lifestyle (diet, obesity, smoking, physical activity) were
related to the type of consumed alcohol among 25±64 y old
adults. Because recent dietary studies have suggested that
daily energy intake is often under-reported compared to
estimated energy needs computed as a multiple of basal
metabolic rate (BMR) (Black et al, 1991), the results both
include and exclude underreporters of energy intake.
Subjects and methods
The subjects were participants in the dietary subsample of
the 1992 Finmonica risk factor survey, which followed the
WHO Monica protocol (WHO, 1988). A sample including
subjects aged 25±64 y, strati®ed by age and sex, were
drawn from the national population register in the four
Finmonica monitoring areas: the provinces of North Karelia and Kuopio in eastern Finland, the city of Turku and its
rural municipalities in southwest Finland, and the southern
cities of Helsinki and Vantaa. All subjects born between the
1st and 11th day of each month were chosen for the
subsample of the dietary survey. Of the eligible subjects
(2822), 76% came to the local health center, 1861 of whom
returned an acceptable three-day food record. The records
were checked by a nutritionist. Those records which had
less than three days or inadequate reporting of foods
consumed were excluded. Thus, the ®nal response rate in
the dietary survey was 61% of men and 71% of women
(Kleemola et al, 1994). Since six women and eight men
were excluded because of missing data on alcohol consumption, the ®nal data of this study included 985 women
and 862 men. Approval for the Finmonica risk factor
survey was given by the Ethics Committee of National
Public Health Institute.
The subjects ®lled in a self-administered questionnaire
covering questions on health, socioeconomic factors, physical activity, smoking, and alcohol intake. The ®rst alcohol
question dealt with alcohol consumption during the previous 12 months. The following questions concerned the
frequency and the average portion of beer, wine and spirits.
The consumption of red and white wine was not differentiated. The subjects were divided into four alcohol
consumption categories by ethanol intake (0 g, 0±100 g,
100±280 g and 280 g/week for men, and 0 g, 0±50 g, 50±
100 g and 100 g/week for women). Further, those subjects
who reported that on average at least 50% of their alcohol
intake was beer, wine, or spirits were classi®ed as beer,
wine or spirit consumers, respectively. The remaining
subjects were categorized as mixed drinkers.
A three-day food record was used to assess each subject's diet and alcohol intake over the following three days
after his or her visit to a health center. The discussion on
the adequate amount of food record days (Thompson &
Byers, 1994) and the history of the three-day food record in
this study have been reported elsewhere (Roos et al, 1995).
A blank diary was used for recording the dietary and
alcohol intake, and a 63-page picture booklet was used to
assess portion sizes. Individual daily energy and nutrient
intakes were computed using the food composition database of the National Public Health Institute. The nutrient
content of various alcoholic beverages were included in the
daily nutrient intake, but alcohol was excluded when the
percentage contribution of fats, carbohydrate, protein, and
sugar to total energy was calculated. To describe an
addition or a substitution of alcohol to the diet, we used
the alcohol consumption indicated by the food record. In
this paper the term `alcohol consumption' refers to absolute
alcohol intake, and alcohol consumers are all those subjects
who consumed alcohol, regardless of beverage type.
All physical activities, including activity at work (8 h),
on the way from home to work (self-reported time), during
leisure time (self-reported time), during sleep (8 h), and
during the rest of the day, were assigned an intensity unit
(MET) based on the rate of energy expenditure of each
activity (Ainsworth et al, 1993). One MET is de®ned as the
energy expenditure for sitting quietly for one hour. The
products of duration (h) and intensity (MET) were totaled
and divided by 24 h to obtain an average daily MET value,
that is, the daily physical activity index (Fogelholm et al,
1994). The estimation of daily energy expenditure was
calculated by multiplying the physical activity index with
BMR. We used FAO/WHO formulae to calculate the BMR
for each individual (FAO/WHO/UNU, 1985). Body mass
index (BMI), weight (kg) divided by the square of height
(m2), was used as the measure of adiposity, and the waistto-hip ratio was used as the measure of adiposity distribution. Waist circumference was measured midway between
the lower rib margin and iliac crest, and hip circumference
was measured at the widest circumference over the greater
trochanters.
The ratio of reported energy intake to estimated BMR
was calculated for all subjects. Those whose ratio was
below 1.28, according to the recommendation of FAO/
WHO/UNU (1985) were regarded as having implausibly
measured energy intakes for free-living persons, and were
classi®ed as energy underreporters. The detailed analysis of
underreporting based on this criteria has been reported
elsewhere (Hirvonen et al, 1997).
The adjusted mean nutrient intakes were obtained by the
analysis of covariance. The background variables used in
the models were age, area, smoking, education, energy
from food, and alcohol intake. Log-transformation and
geometric means were used as the values for vitamin C
and carotenoids since their distributions were skewed to the
right.
Results
Alcohol consumption and subject characteristics
Of the men, 8% were classi®ed as abstainers and 8% as
heavy drinkers, while the percentages for women were 18%
and 3%, respectively. The mean weekly alcohol consumption was 101 g (standard error 5.2 g) among men and 25 g
(1.7 g) among women (Table 1). Alcohol consumption had
a highly skewed distribution; the median of alcohol intake
was much lower than the mean consumption, and the
subjects in the highest alcohol decile consumed about
half of all reported alcohol (45% for men and 57%
for women). Men consumed four ®fths of the reported
alcohol.
Alcohol consumption was signi®cantly related to age,
living area, and smoking among both men and women.
Younger people consumed more alcohol than the elderly;
subjects living in the capital area consumed the most
alcohol; and regular smokers consumed more than twice
as much alcohol as non-smokers. In addition, also women
with more education than six years (62%) consumed twice
as much alcohol (30 g/d) as others (14 g/d) after adjusting
for age, area, physical activity, smoking, BMI and marital
status (P ˆ 0.0003).
The number of men was the greatest in the beer- and
spirit-drinking categories, while the majority of women
327
Alcohol, diet and BMI
S MaÈnnistoÈ et al
328
Table 1 Characteristics of alcohol consumption in men and women according to the questionnaire
Abstainers, %
Heavy drinkers, %a
Mean consumption, g/week
Median consumption, g/week
Proportion (%) of total consumption in the highest alcohol decile
Proportion (%) of those who consumed less than 1 drinkc per week
Proportion (%) of total consumption by sex
a
b
c
Men
(n ˆ 862)
Women
(n ˆ 985)
8
8
101 (5.2)b
52
45
22
78
18
3
25 (1.7)b
7
57
59
22
At least 280 g/week for men and 190 g/week for women.
Standard error.
One alcohol portion contains about 12 g alcohol.
were beer or wine drinkers (Table 2). Abstainers were
older, had fewer years of formal education, and they
smoked less than alcohol consumers. Male abstainers had
the highest BMI. When the data was analyzed by multiple
regression (including age, physical activity, education,
smoking, energy from food and alcohol intake), alcohol
had still explanatory power on BMI in women (P ˆ 0.05)
but not in men (P ˆ 0.33); R2 of the total model was 0.22
both in men and women. The proportions of current
smokers were the highest among male beer and spirit
drinkers, while female beer drinkers clearly smoked the
most. The differences in the waist-to-hip ratio between
categories were statistically signi®cant, but not practically
relevant. The physical activity index and daily energy
expenditures were similar among men in all groups,
whereas female spirit drinkers had the highest values and
wine drinkers had the lowest values. The reported alcohol
intake of men was higher in the questionnaire than in
the three-day food record, with the exception of mixed
drinkers. Women, however, reported lower alcohol consumption in the questionnaire compared to the food record.
The underreporting of energy intake increased with
alcohol consumption in women but not in men. The
proportion of underreporters was 40% among female
abstainers but increased to 57% among those who consumed at least 100 g of alcohol per week. Among men the
proportions were from 42±46% in all alcohol categories. As
Table 2 shows, male wine drinkers were more likely to
underreport their energy intake than those who preferred
other alcoholic beverages. Among women, the proportions
were quite similar between the type of alcoholic beverages.
The energy underreporters consumed more alcohol (108
g/week for men and 27 g for women), and they had a
higher BMI than non-underreporters.
Table 2 Characteristics of subjects by alcohol beverage drinking patterns (mean and standard error)
Alcohol consumers
Abstainers
Beer
Wine
Spirits
Mixed
P-value
Men
N
Agea
Years of educationb
Current smokers, %
Energy underreporters, %c
BMI, kg/m2
Excluding underreportersc
Waist-to-hip ratiob
Physical activity indexb
Daily energy expenditureb, kcald
Excluding underreportersc
Alcohol intake from the food record, g/week
From questionnaire
70
51 (1.3)
10 (0.4)
14
44
28.0 (0.4)
26.9 (0.6)
0.93 (0.008)
1.65 (0.03)
3005 (69)
3033 (95)
0
0
367
43 (0.6)
11 (0.2)
36
40
26.1 (0.2)
25.4 (0.2)
0.92 (0.004)
1.68 (0.01)
3035 (30)
3048 (39)
122 (9.0)
125 (8.7)
75
47 (1.3)
13 (0.4)
24
57
26.5 (0.4)
25.7 (0.6)
0.92 (0.008)
1.65 (0.03)
3025 (67)
3094 (101)
103 (16.4)
114 (18.0)
228
49 (0.7)
11 (0.2)
35
44
26.9 (0.2)
26.4 (0.3)
0.93 (0.005)
1.67 (0.02)
3086 (39)
3103 (53)
91 (10.8)
105 (10.5)
122
45 (1.0)
12 (0.3)
31
44
26.1 (0.3)
25.3 (0.4)
0.90 (0.006)
1.65 (0.02)
3019 (52)
2934 (71)
94 (13.5)
71 (8.8)
Ð
0.0001
0.0001
Ð
Ð
0.001
0.02
0.007
0.89
0.75
0.41
Ð
Ð
Women
N
Agea
Years of educationb
Current smokers, %
Energy underreporters, %c
BMI, kg/m2
Excluding underreporters
Waist-to-hip ratiob
Physical activity index
Daily energy expenditureb, kcald
Excluding underreportersc
Alcohol intake from the food record, g/week
From questionnaire
174
51 (0.9)
11 (0.2)
5
40
26.6 (0.4)
26.1 (0.4)
0.80 (0.005)
1.59 (0.02)
2247 (29)
2278 (37)
0
0
248
40 (0.7)
12 (0.2)
32
45
25.1 (0.3)
24.0 (0.4)
0.79 (0.004)
1.59 (0.01)
2229 (24)
2215 (33)
54 (5.0)
42 (3.5)
255
47 (0.7)
13 (0.2)
20
50
24.9 (0.3)
24.1 (0.4)
0.78 (0.004)
1.56 (0.01)
2181 (23)
2169 (32)
31 (3.9)
33 (4.2)
162
48 (0.9)
11 (0.2)
19
49
26.7 (0.4)
25.7 (0.5)
0.79 (0.005)
1.65 (0.02)
2362 (29)
2400 (41)
26 (6.6)
17 (4.3)
146
44 (0.9)
12 (0.3)
16
49
25.3 (0.4)
24.5 (0.5)
0.78 (0.006)
1.60 (0.02)
2267 (30)
2274 (43)
30 (5.1)
22 (2.4)
Ð
0.0001
0.0001
Ð
Ð
0.0001
0.0005
0.008
0.002
0.0001
0.0003
Ð
Ð
a
Area adjusted.
Age and area adjusted.
c
The ratio of reported energy intake to estimated BMR under 1.28 (FAO/WHO/UNU, 1985).
d
1 kcal ˆ 4.2 kJ.
b
Alcohol, diet and BMI
S MaÈnnistoÈ et al
329
Figure 1 Energy intake from food (white area) and alcohol (shaded
area), adjusted to age and area, by alcohol consumption among men
including underreporters. 1 kcal ˆ 4.2 kJ.
Figure 3 Energy intake from food (white area) and alcohol (shaded
area), adjusted to age and area, by alcohol beverage drinking among men
including underreporters. 1 kcal ˆ 4.2 kJ.
Figure 2 Energy intake from food (white area) and alcohol (shaded
area), adjusted to age and area, by alcohol consumption among women
including underreporters. 1 kcal ˆ 4.2 kJ.
Figure 4 Energy intake from food (white area) and alcohol (shaded
area), adjusted to age and area, by alcohol beverage drinking among
women including underreporters. 1 kcal ˆ 4.2 kJ.
Associations between alcohol drinking and diet
Among men, energy from food decreased with increasing
alcohol consumption (g/week), but there were no noticeable
differences in the total energy intakes between abstainers
and alcohol consumers, with (P ˆ 0.66) or without
(P ˆ 0.44) energy underreporters. This suggests that men
substituted alcohol for food (Figure 1). Among women,
alcohol consumers had signi®cantly lower total daily
energy intake (P ˆ 0.001) and energy intake from food
than abstainers (Figure 2). After the exclusion of underreporters, however, the total daily energy intakes between
the categories remained similar (P ˆ 0.27).
The association between energy intake and alcohol
consumption was the same when alcohol consumers were
divided into consumers of different alcoholic beverages.
Men and women both seemed to substitute alcohol for food,
except male spirit drinkers (Figures 3 and 4). Among men
there were no statistical differences in total daily energy
intakes between categories (P ˆ 0.67), but differences surfaced among women (P ˆ 0.01). When the energy underreporters were excluded, all categories, substituted alcohol
for food, except female spirit drinkers.
The differences in nutrient intakes were larger between
abstainers and alcohol consumers than between consumers
of different alcoholic beverages (Table 3). Among men, the
percentages of energy from fat (P ˆ 0.04) and protein
(P ˆ 0.007) were lower, and energy from carbohydrates
were (P ˆ 0.002) higher among abstainers than alcohol
consumers. The intake of vitamin C (P ˆ 0.02) was also
lower in male abstainers. Among women, the percentage of
energy from fat (P ˆ 0.02) was lower in abstainers, while
the intake of carotenoids was the highest in wine drinkers
and the lowest in beer-drinkers (P < 0.01). Only small
differences were found in dietary results when the energy
underreporters were excluded; the differences between the
percentages of energy from fat (P ˆ 0.09) and from protein
(P ˆ 0.16) leveled-off in men.
Discussion
Since the 1960s Finland has changed from a spirit-drinking
to a beer-drinking country. In particular, young and welleducated people have adopted new consumption patterns
favouring lighter alcoholic beverages (Simpura et al, 1995).
In 1992 the share of lighter beverages was 70% of the total
alcohol consumption, and the total alcohol consumption
was 7.2 litres per capita, calculated as ethanol (The Finnish
State Alcohol Company, 1993). The consumption not
included in the of®cial statistics was estimated to be
about 20% of the total alcohol consumption. About 10%
of men and 18% of women are abstainers (Simpura et al,
1995). In our study the proportion of abstainers was 8% of
men and 18% of women. Men and women consumed on
average 5.7 litres and 1.3 litres of absolute alcohol per year,
respectively. Surveys generally generate low estimates
(usually less than a half) of alcohol consumption compared
Alcohol, diet and BMI
S MaÈnnistoÈ et al
330
Table 3 Adjusted mean nutrient intakesa of women and men by alcohol beverage drinking
Alcohol consumers
Abstainers
Beer
Wine
Spirits
Mixed
P-value (all)
Men
Fat, E%b
Saturated fat, E%b
Protein, E%b
Carbohydrate, E%b
Sugar, E%b
Total carotenoids, mgc
Vitamin C, mgc
33.3
15.2
16.8
50.4
10.5
3080
88
35.3
15.8
17.1
48.3
9.7
3325
112
35.0
15.8
17.9
48.2
10.2
3452
134
36.0
16.2
17.9
46.7
9.8
3302
115
35.4
15.7
17.1
48.4
10.3
3636
113
0.04
0.37
0.007
0.002
0.59
0.64
0.02
Women
Fat, E%b
Saturated fat, E%b
Protein, E%b
Carbohydrate, E%b
Sugar, E%b
Total carotenoids, mgc
Vitamin C, mgc
33.5
15.2
16.4
50.1
10.5
4115
130
34.8
15.6
16.4
48.9
11.2
3630
137
34.3
15.3
16.6
49.1
11.0
4508
142
35.4
15.8
16.5
48.1
10.9
4008
135
35.0
15.6
16.3
48.7
11.2
4177
139
0.02
0.39
0.90
0.09
0.65
0.01
0.74
a
Values adjusted to age, area, smoking, education, energy from food and alcohol intake.
Alcohol was excluded when the percentage contribution of other energy nutrients to total energy was calculated.
c
Geometric means are shown. Log transformation was used for signi®cance test.
b
to of®cial statistics (Simpura et al, 1995). In addition to
underestimation, a majority of the high consumers of
alcohol do not usually participate in health surveys. In
our study, quite satisfactory overall response rates of 61%
of men and 71% of women were achieved. Nevertheless,
younger men living in the metropolitan area of Helsinki
(Kleemola et al, 1994), and women who consume an
above-average amount of alcohol had a lower response
rate than others (Roos et al, 1996).
There is a general agreement that the association
between alcohol intake and mortality is a J- or a Ushaped curve, as reviewed by Poikolainen (1995). The
bene®cial effects of alcohol relate to the inhibition of
platelet aggregation and to the higher ratio of HDL cholesterol to LDL cholesterol. There is less coherent evidence
of the relationship between types of alcohol beverages and
mortality from coronary heart disease as reviewed by
Rimm et al (1996). However, in the Copenhagen City
Heart Study the descending part of the U-shaped curve
could be explained by wine consumption while diseases,
injuries, and suicides of spirit drinkers explained the
ascending part (Grùnbñk et al, 1995). Flavonoids, some
phenolic substances, and tannin in red wine may
protect against coronary heart disease, mainly by decreasing oxidative tendencies in the metabolism (Kinsella
et al, 1993).
Little attention has been paid to the associations between
types of alcoholic beverages and diet, and the question
remains whether wine drinkers have a healthier diet than
others. In Western Australia wine was related to healthier
dietary choices among working men (Burke et al, 1995);
those who preferred wine consumed more fruit, vegetables,
and bread while meat, fried foods, eggs, and salt were
associated with a preference for beer. In our study, female
wine drinkers had a signi®cantly higher intake of carotenoids, and male wine drinkers had the highest intake of
vitamin C of all alcohol consumers. Forman et al (1995)
found that carotenoids were more ef®ciently metabolised
with than without alcohol. Further, red wine has been found
to increase the antioxidant capacity of serum within a
couple of hours after meals (Maxwell et al, 1994). It is
possible that pure ethanol and some components of wine
may prevent coronary heart disease, but our results indicate
that wine drinkers also have more antioxidants in their diet.
Wine drinkers tend to have higher education than abstainers
or spirit drinkers. However, the division of subjects according to their alcohol beverage drinking is very similar to the
division by education. The differences observed in diet
may, therefore, be more closely associated with educational
levels than with alcohol beverage drinking.
Among both men and women, the percentage of energy
from fat was signi®cantly higher in alcohol consumers than
in abstainers. Among male drinkers, the nonalcoholic
energy percentage derived from carbohydrates was lower
while the percentage derived from protein was greater, but
the associations with protein and fat leveled-off after the
exclusion of underreporters. Many other studies have
reported that alcohol consumers have lower carbohydrate
intake than abstainers (Le Marchand et al, 1989; Colditz et
al, 1991). Colditz et al (1991) suggested that the consumption of candy and sugar is inversely related to alcohol
intake, raising the possibility that sweet food items and
alcohol may be competitors in diet. Our study did not
support this observation because the percentages of energy
from sugar were quite similar between alcohol beverage
categories.
The results on the association between alcohol consumption and obesity are contradictory. Alcohol is the second
most energy-dense macronutrient and it is metabolized very
effectively. However, many epidemiological studies in
different populations support the hypothesis that high
alcohol intake may be associated with lower BMI (Hellerstedt, 1990; Prentice, 1995). These discrepancies have been
explained by energy wasting systems as MEOS (Lieber,
1991) or futile cycle (Prentice, 1995). Recent Finnish
laboratory experiments have shown that alcohol is partly
metabolized not only in the liver but also in the large bowel
by a bacteriocolonic pathway, in this case all energy from
alcohol may not become available for the human body
(Salaspuro, 1996). Opposite arguments have also been
presented. No noticed effect of alcohol has been observed
on thermogenesis and it was carbohydrate that was substituted by alcohol in experiences; the carbohydrate de®cit
can explain the noticed weight loss since glycogen binds
three times its weight of water. It can also be that some
other unmeasured lifestyle factors related to alcohol con-
Alcohol, diet and BMI
S MaÈnnistoÈ et al
sumption may offset the additional energy from the alcohol
(Prentice, 1995). Only few studies have reported anything
about the associations between types of alcoholic beverages
and body mass index. Beer drinkers were shown to gain
weight during a ®ve-week experiment in which they consumed 63 g alcohol per day (Belfrage et al, 1973), and in
Finland spirit drinkers were shown to be heavier than other
alcohol consumers (MaÈnnistoÈ et al, 1996).
In our study, male alcohol consumers had a lower body
mass index than abstainers although there were no differences between total energy intakes, physical activity index,
and daily energy expenditures. Thus, males seemed to
substitute alcohol for foods. The female alcohol consumers
also had a lower body mass index and substituted alcohol
for foods. Among females, the results including underreporters showed that total energy intake decreased with
increasing alcohol consumption, but after exclusion of
underreporters the differences in the total energy intake
between alcohol beverage categories disappeared. The
observed lower body mass index may be explained as a
contribution of the MEOS or other wasting system for
alcoholic energy. Spirit drinkers, however, were the heaviest among alcohol beverage categories; they tended to
add alcohol to the diet. In Finland, spirit drinkers represent
the traditional way of using alcohol, in which consumption
is concentrated on the weekends and at special occasions.
Many working-class men, for instance, have a habit of
buying a `Friday-night bottle' of spirits, which is consumed
without food and is mainly used to get drunk. It may be that
such drinking habits do not maintain wasting systems for
alcoholic energy (MaÈnnistoÈ et al, 1996).
The old dietary recommendations either do not address
alcohol intake (National Research Council, 1989) or they
advise limited use (The State Advisory Board on Nutrition,
1987). Because the available epidemiological evidences
clearly indicate that moderate alcohol consumption, in
comparison with abstinence, lowers the risk of coronary
heart disease, a new recommendation has been recently
published (Gaziano & Hennekens, 1995). The Royal Colleges of Physicians, Psychiatrists, and General Practitioners
have determined `sensible limits' of alcohol intake to be 21
units a week for men and 14 units for women. Jackson &
Beaglehole (1995) have also suggested that the subjects
most likely to bene®t from drinking small amounts of
alcohol are men over 40 and women over 50 y old who
are at high risk of coronary heart disease and at low risk of
alcohol-related injuries and diseases. In our study, alcohol
consumers were leaner than abstainers, and wine drinkers
in particular had the healthiest diet. Alcohol consumption
itself, or different characteristics of alcohol beverages, may
explain the `French Paradox', but the quality and quantity
of alcohol consumption can also be an indicator of education or lifestyle.
AcknowledgementsÐWe are grateful to PaÈivi Kleemola, M.Sc., for verifying the food records and analysing the baseline dietary data in the
Finmonica risk factor survey.
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