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8/3/2019 Alcohol and Diabetes3
http://slidepdf.com/reader/full/alcohol-and-diabetes3 1/22
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
8/3/2019 Alcohol and Diabetes3
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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
8/3/2019 Alcohol and Diabetes3
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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?
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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.
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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
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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?
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Association of Alcohol and Association of Alcohol and
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
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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
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Association of Alcohol and Association of Alcohol and
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?
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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.
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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
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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.
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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?
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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
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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?
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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.
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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.
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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.
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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?
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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
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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
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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