alcohol and diabetes3

8/3/2019 Alcohol and Diabetes3

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Effects of Alcohol UseEffects of Alcohol Use

on the Incidence andon the Incidence and

Management of DiabetesManagement of Diabetes

Deborah Patrick Wubben, MD, MPHDeborah Patrick Wubben, MD, MPH

University of Wisconsin School of University of Wisconsin School of

Medicine and Public HealthMedicine and Public Health



ObjectivesObjectives

Prevalence of coPrevalence of co--occurring diabetes and alcoholoccurring diabetes and alcohol

abuseabuse

Association of alcohol and diabetes incidence Association of alcohol and diabetes incidence

Association of alcohol and heart disease Association of alcohol and heart disease

incidenceincidence

Effects of alcohol on longEffects of alcohol on long--term and shortterm and short--termterm

glycemic controlglycemic control Interactions of alcohol and antiglycemicInteractions of alcohol and antiglycemic

medicationsmedications



Prevalence of Diabetes andPrevalence of Diabetes and

Alcohol Abuse Alcohol Abuse How likely am I to encounter a patient withHow likely am I to encounter a patient with

diabetes and alcohol abuse in my primarydiabetes and alcohol abuse in my primary

care practice?care practice? How many adults with diabetes abuseHow many adults with diabetes abuse

alcohol?alcohol?

How many adults who abuse alcohol haveHow many adults who abuse alcohol have

diabetes?diabetes?



Prevalence of Alcohol Abuse inPrevalence of Alcohol Abuse in

Patients with DiabetesPatients with Diabetes Among patients Among patients

attending primaryattending primarycare clinics with DMcare clinics with DM

type 1 or 2,type 1 or 2,prevalence of prevalence of problem drinking wasproblem drinking was8.1%.8.1%.

Lower than other Lower than other clinic averages, butclinic averages, butsimilar to communitysimilar to communitysamples.samples.

VariableVariable OddsOdds

RatioRatio

BlackBlack 2.72.7

MaleMale 3.83.8

BlackBlack

MenMen

13.413.4

Spangler et al. J Fam Pract, 1993. 37(4): p. 370-5.



Prevalence of Diabetes amongPrevalence of Diabetes among

Patients who Abuse AlcoholPatients who Abuse Alcohol ??

DM prevalence in WisconsinDM prevalence in Wisconsin

All ages, 5.7% diagnosed, 2.3% undiagnosed, 8% total All ages, 5.7% diagnosed, 2.3% undiagnosed, 8% total

Ages 45 Ages 45--64, 8% diagnosed, 3.2% undiagnosed, 11.2%64, 8% diagnosed, 3.2% undiagnosed, 11.2%totaltotal

Higher rates among Blacks/Hispanics/clinic populationsHigher rates among Blacks/Hispanics/clinic populations

Among patients with co Among patients with co--occuring psychotic andoccuring psychotic andsubstance use disorders, 21% had diabetes.substance use disorders, 21% had diabetes.

Over 12 years, 41% died, compared to 10% of Over 12 years, 41% died, compared to 10% of those without diabetesthose without diabetes

Wisconsin Diabetes Surveillance Report, 2005

Jackson et al. Psychiatr Serv, 2007. 58(2): p. 270-2



Association of Alcohol and Association of Alcohol and

Diabetes IncidenceDiabetes Incidence Your patient¶s question:Your patient¶s question:

Doc, doesn¶t alcohol prevent diabetes?Doc, doesn¶t alcohol prevent diabetes?

Your question:Your question:

In adults, is the amount of alcohol useIn adults, is the amount of alcohol use

associated with diabetes incidence?associated with diabetes incidence?




Diabetes IncidenceDiabetes Incidence Definition of Alcohol ConsumptionDefinition of Alcohol Consumption

Best studies used nondichotomous categoricalBest studies used nondichotomous categoricalmeasuresmeasures

However, most studies only measured use atHowever, most studies only measured use atbaselinebaseline

Definition of DiabetesDefinition of Diabetes Best studies used objective, standard screeningBest studies used objective, standard screening

testtest

Study Design: Prospective CohortsStudy Design: Prospective Cohorts Many confounders that had to be controlledMany confounders that had to be controlled

BMI, family history of diabetes, race, SES, smoking,BMI, family history of diabetes, race, SES, smoking,prevalent CAD and cancer, diet and physical activityprevalent CAD and cancer, diet and physical activity



Incidence of Type 2 DM in MenIncidence of Type 2 DM in Men

by Alcohol Drinks/Dayby Alcohol Drinks/Day

0

0.5

1

1.5

2

2.5

3

3.5

4

N o n

d r i n k e

r s < 0

. 7

0 . 7 -

1 . 4

1 . 4 - 3 . 1

> 3 . 1

incidence/1000 years

Wei et al. Diabetes Care, 2000. 23(1): p. 18-22




Heart Disease IncidenceHeart Disease Incidence Your patient¶s question:Your patient¶s question:

Doc, doesn¶t alcohol prevent heart disease?Doc, doesn¶t alcohol prevent heart disease?

Your question:Your question:

In adults with diabetes, is the amount of In adults with diabetes, is the amount of

alcohol use associated with the incidence of alcohol use associated with the incidence of

heart disease?heart disease?



Adjusted Relative Risks of CHD Adjusted Relative Risks of CHD

among Patients with Diabetesamong Patients with Diabetes

0

0.2

0.4

0.60.8

1

None 0.1-

4.9

>5

Grams/day

Risk of CHD among Women

0

0.2

0.4

0.6

0.8

1

None <0.5 0.5-2 >2

Drinks/day

Risk of CHD among Men

Solomon et al. Circulation, 2000. 102(5): 494-99 Tanasescu et al. J Am Col Card, 2001. 38(7): 1836-42.



Mechanisms for the Association betweenMechanisms for the Association between

Alcohol and CHD:Alcohol and CHD:

the difference between a little and a lotthe difference between a little and a lotBlood

Pressure

Alcohol Use

Moderate

Heavy

Insulin

Sensitivity

HDL

Triglycerides

Platelet

Aggregation

Fibrinolytic

Activityo

q



Adjusted Mean Insulin Sensitivity Adjusted Mean Insulin Sensitivity

by Alcohol Drinks/Dayby Alcohol Drinks/Day

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

Insulin

Sensitivity

Never <0.5 0.5-

0.99

1-2.99 >3

Drinks/Day

model 1

model 2

Model 1: adjusted for demographic (clinic, sex, ethnicity, age) and

lifestyle (smoking, diet, physical activity) variablesModel 2: also adjusted for BMI and waist circumference

**

Bell et al. Diabetes Care 2000. 23: 1630-36.



Effects of Alcohol onEffects of Alcohol on

Glycemic ControlGlycemic Control Does alcohol use/abuse affect a patient¶sDoes alcohol use/abuse affect a patient¶s

longlong--term glycemic control?term glycemic control?



A1C by daily Alcohol Use among A1C by daily Alcohol Use among

Adults with DM Adults with DM

Ahmed et al. Journal of General Internal Medicine, 2008. 23(3): p. 275-282



Effects of Alcohol onEffects of Alcohol on

Glycemic ControlGlycemic Control Does alcohol use/abuse affect a patient¶sDoes alcohol use/abuse affect a patient¶s

shortshort--term glucose levels?term glucose levels?



HypoglycemiaHypoglycemia

Ethanol inhibits gluconeogenesisEthanol inhibits gluconeogenesis Oxidation of alcohol by dehydrogenases depletes NAD,Oxidation of alcohol by dehydrogenases depletes NAD,

a cofactor needed for entry of gluconeogenic precursorsa cofactor needed for entry of gluconeogenic precursorsinto the hepatocyteinto the hepatocyte

oo lactatelactate qq gluconeogenesisgluconeogenesis

After 48 g (4 glasses) of alcohol, gluconeogenesis After 48 g (4 glasses) of alcohol, gluconeogenesisdecreases about 45%decreases about 45%

If glycogen stores depleted, hypoglycemia occursIf glycogen stores depleted, hypoglycemia occurswithin 6 to 36 hourswithin 6 to 36 hours

Wiel.Diabetes Metab Res Rev

2004. 20: 263-67.



Alcohol consumption with meals Alcohol consumption with meals Potential of reactive hypoglycemiaPotential of reactive hypoglycemia

After carbohydrate After carbohydrate--rich meal plus alcohol, exaggeratedrich meal plus alcohol, exaggeratedinsulin response can cause hypoglycemia after 2 to 3insulin response can cause hypoglycemia after 2 to 3hourshours

Other studies have found only temporary postOther studies have found only temporary post--mealmeal

hyperglycemiahyperglycemia

Most studies show no effect on glycemic profileMost studies show no effect on glycemic profile Study of mineral water vs alcohol with a mealStudy of mineral water vs alcohol with a meal

Only difference wasOnly difference was mealmeal--induced insulin secretioninduced insulin secretionwithwith fasting glucose in patients with type 2 diabetesfasting glucose in patients with type 2 diabetes ± ±not clinically significantnot clinically significant

Koivisto et al. Diabetes Care, 1993. 16(12): 1612-4.



Alcohol Consumption without Food Alcohol Consumption without Food Type 1 DMType 1 DM

glucose values throughout the nightglucose values throughout the night

hypoglycemic episodes the next morning, can be prolongedhypoglycemic episodes the next morning, can be prolonged

Blunted nocturnal growth hormone response to hypoglycemiaBlunted nocturnal growth hormone response to hypoglycemia

Type 2 DMType 2 DM Study varied % of alcohol content in nonStudy varied % of alcohol content in non--alcoholic beer withalcoholic beer with

same carbohydratesame carbohydrate Glucose levels similar Glucose levels similar

oo Alcohol = Alcohol = oo Insulin levelsInsulin levels

Recovery from induced hypoglycemia was not affected byRecovery from induced hypoglycemia was not affected byalcohol in dietalcohol in diet--treated patientstreated patients

Normal counter Normal counter--regulatory hormone responses, but decreased peakregulatory hormone responses, but decreased peakglucagon responseglucagon response

Rasmussen et al. Metabolism, 2001.Rasmussen et al. Metabolism, 2001. 5050(4): p. 451(4): p. 451--77

Lange et al. Med Klin 1991. 86: 551-54.

Turner et al. Diabetes Care 2001. 24: 1888-93.

Christiansen et al. Eur J Clin Nutr 1993. 47:648-52.



Interactions of Alcohol andInteractions of Alcohol and

Antihyperglycemic Medications Antihyperglycemic Medications Are there any diabetes medications that Are there any diabetes medications that

have negative sidehave negative side--effects when combinedeffects when combined

with alcohol?with alcohol?



Antihyperglycemic Meds and Alcohol Antihyperglycemic Meds and Alcohol

SulfonylureasSulfonylureas

Possible increased risk of hypoglycemia if Possible increased risk of hypoglycemia if

drinking alcohol while fastingdrinking alcohol while fasting

MetforminMetformin

Possible increased risk of lactic acidosis withPossible increased risk of lactic acidosis with

heavy alcohol intake and/or liver diseaseheavy alcohol intake and/or liver disease



Summary of Summary of PossiblePossible Good Effects of Good Effects of

Moderate AlcoholModerate Alcohol

insulin sensitivity insulin sensitivity

HDL HDL

fibrinolytic activity fibrinolytic activity platelet aggregation platelet aggregation

blood pressure blood pressure

incidence of MI and death from CHD incidence of MI and death from CHD incidence of diabetes incidence of diabetes



Summary of Summary of PossiblePossible Bad Effects of HeavyBad Effects of Heavy

Alcohol in Patients with Diabetes Alcohol in Patients with Diabetes

insulin sensitivity insulin sensitivity Also inhibits insulin secretion Also inhibits insulin secretion

triglycerides triglycerides

free fatty acids, ketones, lactate ketoacidosis, free fatty acids, ketones, lactate ketoacidosis,and lactic acidosisand lactic acidosis

blood pressure blood pressure

risk of hypoglycemia risk of hypoglycemia

All the other known risks All the other known risks ± ± pancreatitis, cancers,pancreatitis, cancers,liver disease, psychiatric problems, addiction,liver disease, psychiatric problems, addiction,and shortened lifeand shortened life--spanspan

alcohol and diabetes3

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