Kimberly A. Brown, MD

Why Alcohol Recommendations in the New Dietary Guidelines Fall Short

In this segment from the latest episode of 

Liver Lineup: Updates & Unfiltered Insights

, the conversation around the newly updated US Dietary Guidelines turns to one of their most debated and most limited areas: alcohol.

While the guidelines emphasize reducing ultra-processed foods, Kimberly Brown, MD, presses the panel on whether there was a similarly clear message when it came to alcohol consumption. According to guest Jessica Mellinger, MD, the answer is yes, but only in the broadest sense.

“The message on alcohol was pretty limited,” Mellinger explains. “It was basically: drink less.”

While she says she does not disagree with that recommendation, she notes that the guidance lacks specificity and clinical nuance, particularly for patients with liver disease or conditions known to increase alcohol-related risk. Compared with prior guidelines, which defined “moderate” drinking using sex-based thresholds, the updated recommendations remove specific quantities altogether, reflecting a growing body of evidence suggesting that even low levels of alcohol consumption are associated with adverse health outcomes.

Mellinger highlights cancer risk as one of the most consistent findings in the literature, noting that alcohol is a known carcinogen with measurable associations even at low intake levels. Although certainty diminishes at lower levels of consumption, the overall trend has been toward recommending less alcohol across populations. From a hepatology standpoint, she emphasizes that this shift aligns with what clinicians increasingly see in practice.

However, Mellinger views the updated guidance less as a comprehensive directive and more as a starting point for individualized clinical conversations. In her alcohol-associated liver disease clinic, discussions often extend well beyond quantity and frequency, focusing instead on how alcohol affects a patient’s health, relationships, and quality of life.

From her perspective, there is no safe level of alcohol consumption she can ethically recommend to patients with liver disease based on the available data. Rather than offering reassurance around low-level use, she encourages clinicians to meet patients where they are, exploring motivation, readiness for change, and realistic next steps toward reduction or abstinence.

Nancy Reau, MD, adds that important at-risk populations remain absent from the public-facing guidance. Beyond pregnancy, she notes that patients who have undergone gastric bypass surgery represent another growing group for whom alcohol use carries significant risk, yet they are not explicitly addressed.

Ultimately, the panel agrees that while “drink less” may be an appropriate population-level message, it leaves critical gaps for clinicians to fill.

Editors’ Note: Relevant disclosures for Reau include AbbVie, Gilead, Salix, Arbutus, and VIR. Relevant disclosures for Brown include Mallinckrodt Pharmaceuticals, Gilead, Salix, Intercept, Ipsen, and Madrigal. Relevant disclosures for Mellinger include GlaxoSmithKline. Van Jacobs reports no relevant disclosures.

Brooks A. New Dietary Guidelines Draw Criticism For High Fat Dairy, Protein Recommendations. HCPLive. January 8, 2026. Accessed February 9, 2026. 

https://www.hcplive.com/view/new-dietary-guidelines-draw-criticism-high-fat-dairy-protein-recommendations

AASLD. AASLD Raises Concern Over Removal of Evidence-Based Alcohol Guidance in 2025–2030 Dietary Guidelines for Americans. January 9, 2026. Accessed February 9, 2026. 

https://www.aasld.org/aasld-raises-concern-over-removal-evidence-based-alcohol-guidance-2025-2030-dietary-guidelines

Videos

In this segment of a Liver Lineup episode, experts discuss where the new US Dietary Guidelines miss the mark for alcohol recommendations.

Liver Lineup: Nutrition, Alcohol, and Liver Health in the New Dietary Guidelines

Liver Lineup: Updates and Unfiltered Insights

, hosts Nancy Reau, MD, and Kimberly Brown, MD, are joined by 2 experts from their respective institutions to unpack the implications of the newly released US Dietary Guidelines and what they mean for patients with liver disease. Amanda Van Jacobs, MS, RDN, a transplant dietitian at Rush University Medical Center, and Jessica Mellinger, MD, a transplant hepatologist at Henry Ford Health specializing in alcohol-associated liver disease, offer a nuanced, clinically grounded discussion that moves beyond headlines to practical patient care.

The conversation opens with a breakdown of what has changed in the most recent dietary guidelines, including the shift in visual messaging from the familiar “MyPlate” to a new inverted pyramid. Van Jacobs highlights one of the most consequential updates for hepatology: a substantial increase in recommended protein intake, a change with important implications for patients with cirrhosis, sarcopenia, and metabolic dysfunction-associated steatotic liver disease (MASLD).

At the same time, the panel grapples with internal inconsistencies in the guidelines, including the prominent placement of red meat, full-fat dairy, butter, and beef tallow alongside continued recommendations to limit saturated fat to < 10% of daily calories.

A major throughline of the discussion is the guidelines’ strongest and clearest message: reduce ultra-processed foods. Van Jacobs and Brown emphasize the need to educate patients on what “ultra-processed” actually means, distinguishing these foods from minimally processed options such as frozen vegetables or packaged nuts. The group underscores that without this context, visual guidelines risk being misinterpreted, leading patients to add recommended foods on top of an already calorie-dense, highly processed diet rather than replacing unhealthy staples.

Mellinger then turns the focus to alcohol guidance, which she describes as notably sparse. While the updated guidelines broadly recommend “drinking less,” they remove specific thresholds and fail to address liver disease directly.

Drawing on evidence from hepatology and oncology, Mellinger reinforces that there is no safe level of alcohol consumption she can recommend for patients with liver disease, and stresses the importance of individualized conversations that consider total health risk, not just cardiovascular outcomes.

Across nutrition and alcohol use, the panel converges on a shared conclusion: guidelines are a starting point, not a substitute for clinician-led education. Meaningful progress, they argue, will require clearer public messaging, earlier education, and systemic changes that address how food and alcohol are marketed, consumed, and understood.

Brooks A. New Dietary Guidelines Draw Criticism For High Fat Dairy, Protein Recommendations. HCPLive. January 8, 2026. Accessed February 4, 2026. 

AASLD. AASLD Raises Concern Over Removal of Evidence-Based Alcohol Guidance in 2025–2030 Dietary Guidelines for Americans. January 9, 2026. Accessed February 4, 2026. 

Podcasts

Reau and Brown are joined by Amanda Van Jacobs, MS, RDN, and Jessica Mellinger, MD, to discuss the new dietary guidelines through the lens of liver health.

Identifying the Missing Link in Viral Hepatitis Elimination Efforts

In this segment of Liver Lineup, Nancy Reau, MD, and Kimberly Brown, MD, revisit the ongoing challenge of meeting 

 elimination targets, despite the availability of curative and highly effective therapies. Referencing recent observatory data compiled through collaborations between the World Health Organization and the US Centers for Disease Control and Prevention (CDC), the discussion underscores a persistent disconnect between what is possible scientifically and what is happening in real-world clinical practice.

Reau frames the issue bluntly, asserting that viral hepatitis remains a set of diseases that can be cured or well controlled, yet health systems are still falling short of elimination goals. While Brown acknowledges that her institution still lags behind in certain aspects, she highlights a notable success with eliminating viral hepatitis within a closed dialysis population by implementing a strategy built on universal testing.

Of note, instead of relying on referrals or action from outside clinicians, patients were screened systematically, and those who tested positive were proactively contacted and treated. According to Brown, this model demonstrated that elimination is achievable when identification and treatment are tightly integrated, but it also revealed that relying on individual providers to initiate screening can be a major barrier.

Both experts agree that patient identification remains the central obstacle. Screening for hepatitis B and C often falls to primary care, while hepatologists are left to manage treatment once patients are referred. Reau notes that even in systems with robust screening programs in high-risk settings, such as emergency departments and urgent care centers, linkage to care can be difficult, particularly for patients who are not already established within the health system.

Reau also expresses frustration with referrals for abnormal liver enzymes that lack basic hepatitis B and C testing. While acknowledging that viral hepatitis is not the most common cause of abnormal liver chemistries, she emphasizes that standard screening remains widely recommended and should not be overlooked. The absence of this testing, she argues, reflects missed opportunities for diagnosis rather than thoughtful exclusion.

Brown echoes that screening has improved at her institution, noting that patients she sees with elevated liver enzymes are now routinely tested for hepatitis B and C, even when the ultimate diagnosis is MASLD. Together, the discussion highlights that meaningful progress toward hepatitis elimination will depend less on new therapies and more on systematic screening, proactive outreach, and closing persistent gaps in care delivery.

Editors’ note: Relevant Disclosures for Reau include AbbVie, Gilead, Salix, Arbutus, and VIR. Relevant disclosures for Brown include Mallinckrodt Pharmaceuticals, Gilead, Salix, Intercept, Ipsen, and Madrigal.

Manning J, Ward J, Hiebert-Suwondo L. Global Progress toward the Elimination of Hepatitis B: Country-Level Provisional Achievements of WHO Targets for Prevention, Care, and Reductions in Mortality. Presented at the American Association for the Study of Liver Diseases (AASLD) The Liver Meeting 2025. Washington, DC. November 7-11, 2025.

Ching Z, Hiebert-Suwondo L, Ward J. Global Progress Toward Hepatitis C Elimination: Monitoring Achievements of WHO Goals and Targets for Hepatitis C Prevention and Care. Presented at the American Association for the Study of Liver Diseases (AASLD) The Liver Meeting 2025. Washington, DC. November 7-11, 2025.

In this segment, Nancy Reau, MD, and Kimberly Brown, MD, discuss ongoing challenges with viral hepatitis elimination efforts and clinical shortcomings in screening.

Recognizing, Treating Alcohol as an Additive Risk Factor in MASLD

, hosts Nancy Reau, MD, and Kimberly Brown, MD, focus on one of the most challenging, and often underappreciated, aspects of managing 

metabolic dysfunction-associated steatotic liver disease (MASLD)

: accurately assessing and addressing alcohol use.

Reau highlights data examining patient reluctance to disclose alcohol consumption, using phosphatidylethanol (PEth) testing as an objective biomarker. Even at a relatively low cutoff, PEth identified alcohol use in a substantial proportion of patients who reported little or no drinking during clinic visits. Of note, many patients who stated they abstained entirely showed biochemical evidence of alcohol exposure, reinforcing a reality many clinicians recognize: self-reported alcohol use is often inaccurate, whether due to stigma, reluctance, or misunderstanding of what constitutes meaningful intake.

The conversation then turns to how PEth testing can be integrated into practice. Reau emphasizes transparency, explaining that she routinely tells patients when PEth is being ordered, framing it as a tool to support honest, nonjudgmental conversations about liver health.

Brown contrasts this with a more routine testing strategy, likening PEth to other standard laboratory assessments. For her, she says the value lies in using objective data to educate patients, showing that even amounts they perceive as minimal may still be harmful in the context of MASLD. She also notes the implications for clinical trials, pointing out that many study populations likely include patients with overlapping metabolic disease and alcohol use, given the limitations of self-reporting.

Both experts emphasize the clinical importance of another study discussed in the segment, which demonstrated that even modest alcohol consumption, including levels considered lower risk by public health standards, was associated with increased fibrosis in patients with MASLD. This risk was compounded by the presence of multiple metabolic factors, with alcohol acting as another “layer” of risk that accelerates disease progression.

Reau and Brown agree that for patients with MASLD, particularly younger individuals with decades of disease risk ahead, no amount of alcohol is truly safe, and addressing this openly is essential to long-term outcomes.

Daugherty T, Roepke E, Caviness D, et al. Real-world use of PEth in a MASLD Clinic. Presented at the American Association for the Study of Liver Diseases (AASLD) The Liver Meeting 2025. Washington, DC. November 7-11, 2025.

Duseja A, Verma N, De A, et al. Any amount of alcohol intake increases the risk of significant fibrosis and fibrotic MASH in patients with metabolic dysfunction-associated steatotic liver disease (MASLD) - Insights from 7189 patients from Indian Consortium on MASLD (ICOM-D). Presented at the American Association for the Study of Liver Diseases (AASLD) The Liver Meeting 2025. Washington, DC. November 7-11, 2025.

Nancy Reau, MD, and Kimberly Brown, MD, discuss the challenges of accurately assessing and addressing alcohol use in patients with MASLD.

Kimberly A. Brown, MD

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