The most familiar diet advice for people with high blood pressure is to cut down on salt. That “common knowledge,” however, is currently a hot scientific controversy. Though reducing salt intake does make a difference for some people, for many others it has no practical effect. Ask any two doctors what to do about salt, and you’re likely to get two different answers.
Given this confusion among even the experts, a “correct” decision is almost impossible to make. A wise one, however, remains a possibility—once you know the issues. Here’s what we can currently say with certainty, and what remains to be resolved.
There’s no question that a heart-healthy diet—low in saturated fat and other fats—can cut your overall risk of cardiovascular disease by reducing artery-clogging levels of blood cholesterol and helping you maintain an appropriate weight. It’s also possible that an increased intake of certain nutrients—and, possibly, a decrease in salt—may help keep blood pressure down.
Fortunately, there are two points about high blood pressure that the experts do agree on:
| • | Bringing high blood pressure under control saves lives. |
| • | Effective control of high blood pressure does not mean you have to eat a bland, highly restricted diet or start a perpetual round of visits to the doctor. |
High Blood Pressure: Take It Seriously
About 50 million Americans, or about one in four adults, have high blood pressure, also called hypertension. It has been called “the silent killer,” because it usually causes no symptoms until you are struck by one of its dangerous complications, including heart attack, stroke, heart failure, and kidney problems. Almost one-third of Americans don’t know they have high blood pressure until the damage to their cardiovascular system has already been done. That’s why it’s so important to have your blood pressure checked regularly, and to work with your doctor to lower it if it becomes too high.
Even mildly elevated blood pressure, left untreated, raises the risk of complications—especially if, like many people with mild hypertension, you have other cardiovascular risk factors such as high blood cholesterol, diabetes, or excess weight. Treatment to lower high blood pressure, usually with medication, has saved thousands of people from disability and death. Diet and other so-called “lifestyle measures” can play an important role, helping to control blood pressure with less medication or, in some instances, with no medication at all.
How Pressure Builds | ||
 As the arteries conduct oxygen-rich blood deeper and deeper into the tissues, their circumference steadily shrinks, ultimately ending at the arterioles. These tiny vessels, which feed blood into the network of capillaries supplying the individual cells, play a crucial role in maintaining your blood pressure. When their muscular walls tighten, there's less room inside and blood pressure rises. If the muscles relax, the available space increases and blood pressure falls.Some high blood pressure medications (the so-called ACE inhibitors) work by relaxing the walls of the arterioles. Others (diuretics) take the opposite approach, reducing the volume of blood the constricted arterioles must contend with. Diuretics do this by prompting the kidneys to wring salt and water from the bloodstream. If you are taking this type of medication, extra salt in your diet will counteract its effect. | ||
Blood Pressure Basics
Most cases of high blood pressure have no known cause. But it’s well known how blood pressure works, and why too high a pressure is risky.
Blood pressure is the force that the bloodstream exerts against the walls of the arteries as they carry blood from the heart to the rest of the body. (Blood returns to the heart through the veins.) At the end of each artery, tiny blood vessels called arterioles circulate blood to all the body’s tissues. The pressure inside these vessels varies as they open up (dilate) or clamp down (constrict)—in much the same way that water pressure inside a garden hose will go up or down depending on whether the nozzle is shut or open wide. Your blood pressure fluctuates in time with a number of factors, including emotional stress, bodily position, and time of day.
The body regulates blood pressure through a complicated system that involves the heart, kidneys, and many different substances in the bloodstream, including hormones and minerals such as sodium, potassium, magnesium, and calcium. For adults, normal blood pressure ranges from about 110/80 to as high as 140/90, measured in millimeters of mercury (mm/Hg), the standard unit on a blood pressure measuring device. The higher number is the systolic pressure, measured as the heart contracts; the second and lower number is the diastolic pressure, measured as the heart rests between beats.
Here is what hypertension experts recommend to physicians: Unless a patient’s blood pressure is very high, don’t make a diagnosis of hypertension until the reading has been elevated on three separate occasions. That’s because blood pressure can vary significantly from day to day. Treatment is usually recommended if blood pressure persists at 140/90 or above after several checkups.
Diet, Drugs, Or Both?
If you are diagnosed as having mild high blood pressure (140/90 to about 160/100), your doctor may suggest that you make certain lifestyle changes before starting medication, including eating less salt, getting more exercise, losing weight if you are overweight, and quitting cigarettes if you smoke. Such measures alone lower blood pressure to a safe level in about one out of four cases. Eventually, most people with high blood pressure will still need medication to control their condition, but in the meantime these non-drug methods will cut the risk of heart disease just as effectively.
In theory, doctors should recommend 6 to 12 months of lifestyle modification before prescribing medication to a patient with mild to moderately high blood pressure. After all, medication costs money, can cause side effects, and may need to be taken for life. Yet in practice, many physicians prescribe blood pressure-lowering drugs right away. Why? Because they believe that patients are more likely to stick with a regimen of pills than with “harder” changes such as diet, weight loss, and exercise. That is true for some people, but it may not be true for you. If your doctor recommends high blood pressure medication before you have tried these measures—and you feel willing and able to carry them out—let your doctor know.
The Great Salt Debate
“You’ve got high blood pressure? Uh-oh, no pretzels or potato chips for you!” Most Americans feel at least a twinge of guilt when they reach for the salt shaker. After all, everyone has heard that too much sodium (as in sodium chloride, or table salt) is a culprit in high blood pressure, and that cutting down on salt can keep pressure down.
There’s just one problem: Nutrition scientists aren’t so sure any more. Some researchers argue passionately that salt really is the villain. According to this camp, slashing the sodium from our current high-salt diets would practically wipe out high blood pressure, America’s most common chronic disease, in a single generation. Other scientists contend, just as ardently, that while research has shown some intriguing connections between sodium and blood pressure, there is nowhere near enough cause-and- effect evidence to justify a widespread salt shakeout, even for people with high blood pressure.
So what’s a pretzel lover to do?
At this point, moderation is still the best course. A moderate cutback on salt can be accomplished quite easily, and still leave your diet full of flavor. This kind of modest sodium restriction can’t hurt and may help if you have high blood pressure or are at risk of developing it. Whether or not a stricter reduction in sodium intake is necessary, or even wise, is another matter.
What We Know About Salt
Researchers know that sodium and blood pressure are interrelated; they just can’t agree on the implications.
Small amounts of sodium are essential to maintaining the body’s fluid balance. But no one on a typical American diet needs to worry about that. The body requires only about 500 milligrams a day to function; and a prudent daily maximum has been estimated at 2,400 (1,500 milligrams for people with conditions that put them at risk of developing high blood pressure). Americans, however, consume an average of 3,000 to 6,000 milligrams a day, and sometimes more! Normally functioning kidneys handle the excess by flushing out sodium and water, thus keeping a lid on blood volume (the space blood takes up in the vessels) and the resulting blood pressure.
Clearly, too much salt can raise blood pressure too high, at least in some people, based on the following evidence:
| • | Before the introduction of blood pressure-lowering drugs in the 1950s, dangerously high blood pressure was routinely treated with an extremely strict low-salt diet or a demanding weight-loss diet such as the so-called "Rice Diet." |
| • | Studies of laboratory animals have shown that those fed sodium-rich diets tend to have higher blood pressure and more strokes and related problems than animals on lower-salt diets. |
| • | Populations with a high sodium intake (usually, in more developed countries where foods are highly processed and preserved) have more cases of high blood pressure per capita than the populations of countries with low-salt diets, where people live mainly on fresh, unprocessed foods. |
So, the less salt, the better, right? Not necessarily. In a frustrating twist, scientists have failed to make a clear-cut connection between salt intake and blood pressure in specific individuals. Almost all Americans consume excess salt, but not all of us develop high blood pressure; and among those who do get hypertension, not all have a particularly salty diet. Some people with high blood pressure who switch to a low-salt diet see no effect on blood pressure, and a few even experience a rise in pressure. Thus, your uncle, the junk food lover, may live to a ripe old age with low blood pressure—while your aunt, the health food maven who wouldn’t touch a grain of salt, just might wind up with high blood pressure anyway.
It’s clear that some people are more sensitive to the effects of sodium on blood pressure than others are. These “salt-sensitive” individuals may retain more sodium in their bodies, leading to fluid buildup and, finally, to high blood pressure. Part of the puzzle may lie in genetics. African-Americans and people with a family history of hypertension are both more likely to be salt-sensitive, and are also at higher-than-average risk of hypertension. People over age 40 may also be more susceptible to the pressure-raising power of salt, possibly because the kidneys become less efficient at excreting salt as we get older.
One obvious solution would be to test everyone for sensitivity to sodium, and then recommend low-sodium diets only to those who would benefit. However, scientists have been unable to develop a simple and practical test for sodium sensitivity, in part because high blood pressure is affected by so many factors besides diet. Lacking this convenient shortcut, the only way to test yourself for sodium sensitivity is to cut back on sodium for several months, and see whether your blood pressure responds.
What’s Right For You?
Can you lower high blood pressure—or keep it from ever rising too high—just by restricting sodium?
That depends on several variables: personal salt sensitivity, how much your blood pressure is elevated, and how successfully you can really restrict sodium, which is present even in many of the salty-tasting commercially prepared foods. Many people find they can cut their salt intake approximately in half without too much difficulty, just by making simple and gradual substitutions in everyday food choices.
On average, this step reduces blood pressure by 3 to 4 points. However, results vary widely from one individual to the next. If you turn out to be salt-sensitive and your pressure is only a little too high, moderately restricting your sodium intake may do the job. But for many people, lowering blood pressure enough to make a difference may require dietary changes big enough to be burdensome, especially if you often dine out or depend heavily on packaged and convenience foods.
Special Salt Warning
For some people, there’s no question that salt restriction is worthwhile. For instance, a cut-back is definitely in order for people taking blood pressure-lowering medications called diuretics (“water pills”), such as hydrochlorothiazide (HydroDiuril), furosemide (Lasix) or amiloride (Moduretic). These drugs work mainly by helping the kidneys to flush out salt and water, which in turn helps reduce the amount of blood pushing against arterial walls; and a high-salt diet can counteract their effects. Other medical problems may also call for serious sodium restriction: They include heart failure, kidney (renal) disease, and other conditions that can cause fluid retention and swelling of the hands and feet.
Eat These High-Sodium Foods Sparingly When Cutting Back | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Cutting Back On Salt Without Losing Flavor
If you decide to try a moderate cutback in sodium, you’ll find that it’s one of the easiest health-boosting changes to make—if you do it with small, gradual adjustments. Scientists who research the human senses believe that a taste for salt, unlike a sweet tooth or a craving for fat, may not be inborn. So after “weaning” yourself from salty food, your tastes may actually change, making foods you once enjoyed seem unpleasantly salty.
A typical sodium-restricted diet calls for no more than 2,000 to 3,000 milligrams per day. There’s no need to be rigid or obsessive about numbers, however; if you pack away pizza and salted peanuts at a party, you can compensate by choosing low-salt foods the next day.
The first steps to a lower-sodium diet are to eat smaller portions of high-salt foods, choose alternatives to them when possible, and go easy on adding salt in cooking and at the table. Experiment with lemon juice, vinegar, wine, pepper, herbs, spices, onions, and garlic to add zest to your cooking. (For suggestions, see “Herbs and Spices: Your Allies for Healthier Meals.”)
Shop more carefully, choosing fresh foods instead of processed ones whenever possible. The lion’s share of sodium in the U.S. food supply is not added at the table or stove; more than one-third is added by food manufacturers, often to foods such as breakfast cereal and bread that may not seem salty. Thanks to public concern over salt, many traditionally high-sodium products such as crackers, canned soups, and tomato sauce are now available in lower-sodium versions. Some may taste unacceptably bland compared to the original, but others may surprise you.
Easy Trade-Offs | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
It's wise to keep sodium intake to no more than about 2,000 to 3,000 milligrams a day. Simple substitutions can make a big difference. For instance:
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One Step At A Time
Remember, the key to success is not to make big changes all at once. Try making one adjustment or substitution a week. Here are some suggestions:
| • | When choosing packaged foods, read labels and keep an eye on sodium content. (See box, "How Low is 'Low'?") |
| • | Ease up on the salt shaker—taste food before you salt it. Later, leave the salt shaker off the table. |
| • | Add little or no salt in cooking water for pasta, rice, and cereals. |
| • | If there are some foods, such as hard-boiled eggs or French fries, that you simply must eat with added salt, choose them less often and enjoy them, salted, when you do. |
| • | Instead of canned vegetables, choose fresh or plain frozen ones (without added sauce). |
| • | Choose fresh meat, poultry, and fish over canned and processed versions: for example, lean roast beef instead of a meat sandwich-spread or bologna. |
| • | Use smaller amounts of high-sodium condiments like ketchup, mustard, and soy sauce. |
| • | Use regular convenience foods in moderation and choose low-sodium versions whenever available. Items to be careful with include frozen entrées, canned soups, bottled salad dressings, and most dry instant mixes. |
| • | Reform your snacking: Choose low-salt crackers, plain pretzels, unsalted peanuts, fresh fruits and vegetable sticks, and plain air-popped popcorn more often than potato or tortilla chips, salted pretzels, or salted nuts. |
| • | If you eat out frequently, ask for sauce on the side or request that dishes be prepared without added salt. |
| • | At salad bars, go easy on salty additions such as dressing and bacon bits. |
Table salt is about 40 percent sodium by weight. Other common sodium-containing compounds include monosodium glutamate, the flavor enhancer; sodium bicarbonate, or baking soda, used in antacids; and various preservatives such as sodium citrate. It may be that salt, and not other sodium compounds, is the culprit in high blood pressure, but scientists aren’t sure. If you’re serious about sodium restriction, it wouldn’t hurt to watch intake of these other sources of sodium as well.
How Low is "Low"? | ||||||||||||||||||||||||||||||||||||||||
Here is how the Food and Drug Administration defines various terms and nutrition claims used on food labels:
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How Low Should You Go?
If moderate sodium restriction doesn’t seem to lower blood pressure, would a stricter cutback work?
You can’t count on it, say hypertension experts. It is certainly advisable to keep sodium intake reasonably low whether or not it actually brings down your blood pressure: Don’t chuck it all and go back to pickling everything. But many physicians who specialize in hypertension are reluctant to urge further salt restrictions on their patients, including those with high blood pressure. Here’s why:
| • | Blood pressure can usually be controlled without the inconvenience of a highly restricted diet if you follow your doctor's recommendations regarding medication and lifestyle changes, such as weight loss. |
| • | Many people find an extremely low-salt diet too difficult to follow for the long term, since it requires avoiding most convenience and fast foods. |
| • | Cutting out salt often means avoiding many highly nutritious foods such as meat, dairy products, canned beans, and grain foods including bread and muffins. The less variety in your diet, the greater your chance of nutritional shortfall. The net result may be a poorer diet if you don't plan food choices with extreme care. |
| • | Very low salt intake may be unwise for some people, including pregnant women, athletes, laborers, or others involved in heavy physical exertion, especially in warm climates where fluid losses due to perspiration are high. |
The bottom line: Ask your doctor before putting yourself on a super-low-sodium diet.
Stuck on Salt? Other Ways to Help Lower Blood Pressure | ||||||||||
Sodium reduction won't bring down high blood pressure for everyone, and it's not the top priority anyway. The following measures are just as important, or more so, in reducing elevated blood pressure:
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Replacing The Salt Shaker
So far, neither nature nor the food industry has come up with a perfect salt substitute for people who like to pour it on. Before you use a commercial salt substitute, read the label carefully. Some seasoning blends contain sodium as well as other ingredients. “Light” salt products may contain sodium diluted with fillers such as maltodextrin, a corn byproduct. Others contain only herbs, spices, or derivatives from vegetables, including seaweed. Some substitutes contain modest amounts of minerals that may be beneficial, such as calcium and magnesium (see below).
One ingredient to handle with care is potassium chloride, the chief component in some salt substitutes. It may leave a bitter or metallic taste, and should not be added to food during cooking. More importantly, potassium-containing substitutes can actually be dangerous if used along with:
| • | Potassium-retaining diuretics, including triamterene (Dyrenium, Dyazide) and amiloride (Midamor, Moduretic), which help the body conserve this mineral |
| • | Potassium supplements such as Micro-K, sometimes recommended for people taking diuretics that deplete potassium |
| • | ACE inhibitors such as benazepril (Lotensin) and captopril (Capoten), which can also cause blood potassium levels to rise |
The combination of any of these drugs with a potassium-based salt substitute could cause a harmful excess in your body. Potassium is vital to body functioning, and many people may not get enough of it. Too much of the mineral, however, can cause problems such as heart rhythm irregularities. If you are taking any sort of medication, check with your doctor before you start using any salt substitute that contains more than just herbal seasonings.
Other Changes To Consider
Who says there’s never any good news from the nutrition police? A major study sponsored by the National Heart, Lung, and Blood Institute has shown that adopting a diet low in fat and high in fruits, vegetables, and low-fat dairy foods can lower blood pressure as effectively as salt restriction—or even some blood pressure medications. (Cutting back on salt and making other lifestyle changes yields further dividends.)
The DASH Diet
The source of these findings is a clinical study dubbed “Dietary Approaches to Stop Hypertension” (DASH). The research was designed to determine the effects of a person’s total diet pattern, not the effects of individual nutrients within the diet. For eight weeks the 459 adult participants ate one of three diets: a control diet similar to a “normal” American diet; a diet high in fruits and vegetables; and a “combination” diet low in saturated and total fat, and high in fruits, vegetables, and low-fat dairy foods. At the end of the study, the combination diet produced the largest reductions in blood pressure, an average of 5.5 for systolic and 3 for diastolic. For participants who had hypertension, the diet reduced systolic blood pressure by 11.4 points and diastolic by 5.5. The reductions occurred in both men and women—and whites and minorities—within two weeks of starting the diet. For a majority of people with mild cases of hypertension, the DASH diet alone has proved sufficient to bring blood pressure back to normal.
While the research didn’t evaluate the impact of specific nutrients, it’s probably no coincidence that the DASH diet is rich in potassium, calcium, magnesium, and fiber. A number of studies have suggested that these nutrients have a beneficial effect on blood pressure, although the evidence is still too weak to justify taking them in supplement form. Here’s a closer look at the facts in their favor.
Potassium
Some scientists now believe that a shortage of this mineral, and not just an excess of sodium, may be an overlooked culprit in the high rates of hypertension that plague Western cultures. Higher potassium intake may also protect against stroke, independent of its effect on blood pressure. Other researchers suggest that it may be the ratio of sodium to potassium, rather than just levels of sodium or potassium alone, that regulates blood pressure, making lower sodium and higher potassium intake a good two-pronged strategy.
The recommended daily intake of potassium for an average adult is about 3,500 milligrams per day. Rich food sources of potassium include vegetables, fruits, meats, fish, and poultry. For most people, the safest and most enjoyable route is to include potassium-rich foods such as bananas, orange juice, beans, and potatoes in their daily diet. The official recommendation of at least five servings of fruits and vegetables daily will go a long way toward meeting this goal, and the DASH diet will take you even further. (See the nearby box for good sources of potassium.)
Good Sources of Potassium | ||||||
Ample potassium in the diet may help keep blood pressure from rising too high. For adults, the recommended daily intake of potassium is about 3,500 milligrams per day. People with certain medical conditions or those who take certain medications may need more, but ask your doctor before taking supplements. Among the best sources of potassium are the following foods:
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* Note that eating grapefruit or drinking grapefruit juice can interfere with certain blood pressure and heart medications, causing them to accumulate in the body and possibly reach toxic levels. Do not eat grapefruit if you are taking any of the following: felodipine (Plendil), nifedipine (Adalat, Procardia), nimodipine (Nimotop), nisoldipine (Sular).
Don’t, however, try to boost potassium intake by using supplements or potassium- containing salt substitutes unless your doctor specifically recommends it. Extra potassium is not a proven “treatment” for high blood pressure, although it may be prescribed for some people taking medications, such as diuretics, that cause excess potassium loss. Certainly, if your doctor prescribes a diuretic, you should ask whether you will need extra potassium.
Calcium And Magnesium
These two minerals play a closely linked role in blood vessel constriction, and may also help govern blood pressure. The first hint of this came from studies showing lower rates of cardiovascular disease in communities with hard water, which is exceptionally high in minerals. Studies in laboratory rats also suggest that adequate levels of dietary calcium and magnesium protect against high blood pressure.
This Diet Plan Puts the Lid on Pressure | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
The plan outlined below was the winner in a clinical test of "Dietary Approaches to Stop Hypertension" (the DASH study). It produced a significant reduction in blood pressure among those who tried it.Rich in fruits, vegetables, and low-fat dairy foods, this diet keeps saturated fat, total fat, and cholesterol to a minimum. It's moderately high in protein, and provides generous amounts of dietary fiber, potassium, calcium, and magnesium. The amounts shown below assume an intake of 2,000 calories a day. Depending on your caloric needs, your daily servings in each food group may vary.
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The results in human testing have been less conclusive, and no major health organization yet recommends magnesium or calcium supplementation as a preventive or treatment for high blood pressure. But many Americans get less than the recommended daily level of both minerals, so at the very least you should make sure you’re getting enough.
The official recommended daily intake of calcium is 1,000 milligrams for adults over 19 years old and 1,300 milligrams for adolescents; and many experts advise several hundred milligrams more than that, especially for pregnant, nursing, and post-menopausal women. To reach that goal, eat plenty of low-fat dairy products and other calcium-rich foods such as broccoli and salmon. Women, who may reap the added benefit of preventing osteoporosis (thinning of the bones), should also ask their doctors whether calcium supplements are advisable.
Up to three-quarters of the U.S. population gets less than the recommended amount of magnesium (about 400 milligrams a day). Those most likely to be deficient in magnesium include the elderly, diabetics, moderate or heavy drinkers, and people taking diuretics. Doctors use magnesium to treat heart rhythm abnormalities and it may even help prevent clogging of the arteries. High-magnesium foods include oats, bran, nuts, and legumes (beans and peas). Other good sources are fruits, vegetables, and fish. As for supplements, again—ask your doctor before taking them. They often cause diarrhea; and in any case, a varied diet offers benefits you can’t get from a pill.
Fiber
Although many scientists still doubt its validity, some research has suggested a link between increased fiber intake and reduced blood pressure. Given the well-known preventive benefits of fiber-rich foods for many other conditions, from heart disease to colon cancer, this is just one more reason to include fruits, vegetables, and whole grains in your daily diet.
Can Eating More Fat Help?
Wait a minute. Eat more fat to lower your blood pressure? Yes, this paradoxical strategy can work if you choose the right type of fat—namely olive oil and fish oil. The Archives of Internal Medicine reports that replacing some of the saturated fat in your diet with extra-virgin olive oil often lowers blood pressure by 5 points or more. In a separate study reported in the journal Hypertension, eating a daily serving of fish high in omega-3 fatty acids—including salmon, sardines, and tuna—lowered pressure by about 7 points; and combining a daily serving of fish with weight loss lowered it even further, by about 13 points. Researchers note that even salt restriction does not produce changes of this magnitude.
Can Cutting Down On Coffee Help?
Coffee has long been suspected of a host of harmful effects on the heart and other organs, and has been the object of extensive study. However, any evidence of potential harm is conflicting and not very strong. Some researchers have noted that blood pressure may rise in heavy coffee drinkers (more than about 5 cups a day), but more modest intake seems to make no difference. If you have hard-to-control high blood pressure and drink a great deal of coffee or other caffeinated beverages (including tea and some soft drinks), it may be worth cutting down or making at least a partial switch to decaffeinated brews. Some caffeine is also present in chocolate and cocoa products, and in many non-prescription medicines.
Can Cutting Down On Alcohol Help?
Heavy drinking and high blood pressure go hand in hand. It’s well proven that more than 2 ounces of hard liquor daily is associated with higher pressure, and more than 3 ounces with actual hypertension. Heavy drinking also boosts your risk of stroke and liver problems and, of course, carries with it the risk of addiction.
If you drink regularly, just cutting alcohol intake down or out can have a noticeable impact on too-high blood pressure. The usual recommendation is to limit daily alcohol intake to no more than 1 drink for women, 2 for men. (A drink equals an ounce and a half of liquor, 1 average glass of wine, or a standard can of beer.)
Is it better still to be a teetotaler? There’s no scientific evidence that the alcohol intake described above causes harm to most people. In fact, some studies suggest that modest alcohol intake may actually protect the heart, possibly by raising levels of HDL, or “good” cholesterol.
But when it comes to drinking, the risks are much better proven than the benefits. Alcohol is a source of nutritionally empty calories—a concern for people with high blood pressure who are watching their weight. Certain blood pressure and heart medications should not be mixed with alcohol. And some people should never drink: pregnant women and anyone with a personal or family history of alcoholism or any signs of liver disease.