Effects of Alcohol Use on the Incidence and Management of Diabetes

Deborah Patrick Wubben, MD, MPH University of Wisconsin School of Medicine and Public Health

Objectives

 Prevalence of co-occurring diabetes and alcohol abuse  Association of alcohol and diabetes incidence  Association of alcohol and heart disease incidence  Effects of alcohol on long-term and short-term glycemic control  Interactions of alcohol and antiglycemic medications

Prevalence of Diabetes and Alcohol Abuse

 How likely am I to encounter a patient with diabetes and alcohol abuse in my primary care practice?

 How many adults with diabetes abuse alcohol?

 How many adults who abuse alcohol have diabetes?

Prevalence of Alcohol Abuse in Patients with Diabetes  Among patients attending primary care clinics with DM type 1 or 2, prevalence of problem drinking was 8.1%.

 Lower than other clinic averages, but similar to community samples.

Variable Black Male Black Men Odds Ratio 2.7

3.8

13.4

Spangler et al. J Fam Pract, 1993.

37

(4): p. 370-5.

Prevalence of Diabetes among Patients who Abuse Alcohol 

?

 DM prevalence in Wisconsin • • All ages, 5.7% diagnosed, 2.3% undiagnosed, 8% total Ages 45-64, 8% diagnosed, 3.2% undiagnosed, 11.2% total • Higher rates among Blacks/Hispanics/clinic populations Wisconsin Diabetes Surveillance Report, 2005  Among patients with co-occuring psychotic and substance use disorders, 21% had diabetes.

 Over 12 years, 41% died, compared to 10% of those without diabetes Jackson et al. Psychiatr Serv, 2007.

58

(2): p. 270-2

Association of Alcohol and Diabetes Incidence  Your patient’s question:  Doc, doesn’t alcohol prevent diabetes?  Your question:  In adults, is the amount of alcohol use associated with diabetes incidence?

Association of Alcohol and Diabetes Incidence    Definition of Alcohol Consumption   Best studies used nondichotomous categorical measures However, most studies only measured use at baseline Definition of Diabetes  Best studies used objective, standard screening test Study Design: Prospective Cohorts  Many confounders that had to be controlled • BMI, family history of diabetes, race, SES, smoking, prevalent CAD and cancer, diet and physical activity

Incidence of Type 2 DM in Men by Alcohol Drinks/Day

4 3.5

3 2.5

2 1.5

1 0.5

0 N on dr in ke rs <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

Association of Alcohol and Heart Disease Incidence

 Your patient’s question:  Doc, doesn’t alcohol prevent heart disease?  Your question:  In adults with diabetes, is the amount of alcohol use associated with the incidence of heart disease?

Adjusted Relative Risks of CHD among Patients with Diabetes

Risk of CHD among Women 1 0.8

0.6

0.4

0.2

0 None 0.1 4.9

>5 Grams/day

Solomon et al. Circulation, 2000.

102

(5): 494-99

Risk of CHD among Men 1 0.8

0.6

0.4

0.2

0 None <0.5 0.5-2 >2 Drinks/day

Tanasescu et al. J Am Col Card, 2001.

38

(7): 1836-42.

Mechanisms for the Association between Alcohol and CHD: the difference between a little and a lot Blood Pressure ↓ ↑ Insulin Sensitivity ↑ ↓ Platelet Aggregation ↓ ↑ Alcohol Use Moderate Heavy HDL ↑ ↑↑ Fibrinolytic Activity

 

Triglycerides ↑

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

Adjusted Mean Insulin Sensitivity by Alcohol Drinks/Day

Insulin Sensitivity 1.8

1.6

1.4

1.2

1 0.8

0.6

0.4

0.2

0 Never

* *

<0.5

0.5 0.99

1-2.99

Drinks/Day >3

Model 1: adjusted for demographic (clinic, sex, ethnicity, age) and lifestyle (smoking, diet, physical activity) variables Model 2: also adjusted for BMI and waist circumference

model 1 model 2

Effects of Alcohol on Glycemic Control  Does alcohol use/abuse affect a patient’s long-term glycemic control?

A1C by daily Alcohol Use among Adults with DM Ahmed et al. Journal of General Internal Medicine, 2008.

23

(3): p. 275-282

Effects of Alcohol on Glycemic Control  Does alcohol use/abuse affect a patient’s short-term glucose levels?

Hypoglycemia

 Ethanol inhibits gluconeogenesis   Oxidation of alcohol by dehydrogenases depletes NAD, a cofactor needed for entry of gluconeogenic precursors into the hepatocyte  lactate  gluconeogenesis  After 48 g (4 glasses) of alcohol, gluconeogenesis decreases about 45%  If glycogen stores depleted, hypoglycemia occurs within 6 to 36 hours Wiel.

Diabetes Metab Res Rev

2004. 20: 263-67.

Alcohol consumption with meals

 Potential of reactive hypoglycemia   After carbohydrate-rich meal plus alcohol, exaggerated insulin response can cause hypoglycemia after 2 to 3 hours Other studies have found only temporary post-meal hyperglycemia  Most studies show no effect on glycemic profile   Study of mineral water vs alcohol with a meal Only difference was ↑ meal-induced insulin secretion with ↓ fasting glucose in patients with type 2 diabetes – not clinically significant Koivisto et al. Diabetes Care, 1993.

16

(12): 1612-4.

Alcohol Consumption without Food  Type 1 DM   ↓ glucose values throughout the night ↑ hypoglycemic episodes the next morning, can be prolonged  Blunted nocturnal growth hormone response to hypoglycemia Lange et al. Med Klin 1991. 86: 551-54.

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

 Type 2 DM  Study varied % of alcohol content in non-alcoholic beer with same carbohydrate • Glucose levels similar •  Alcohol =  Insulin levels Christiansen et al. Eur J Clin Nutr 1993. 47:648-52 .

 Recovery from induced hypoglycemia was not affected by alcohol in diet-treated patients • Normal counter-regulatory hormone responses, but decreased peak glucagon response Rasmussen et al. Metabolism, 2001.

50

(4): p. 451-7

Interactions of Alcohol and Antihyperglycemic Medications  Are there any diabetes medications that have negative side-effects when combined with alcohol?

Antihyperglycemic Meds and Alcohol  Sulfonylureas  Possible increased risk of hypoglycemia if drinking alcohol while fasting  Metformin  Possible increased risk of lactic acidosis with heavy alcohol intake and/or liver disease

Summary of

Possible

Good Effects of Moderate Alcohol  ↑ insulin sensitivity  ↑ HDL  ↑ fibrinolytic activity  ↓ platelet aggregation  ↓ blood pressure  ↓ incidence of MI and death from CHD  ↓ incidence of diabetes

Summary of

Possible

Bad Effects of Heavy Alcohol in Patients with Diabetes  ↓ insulin sensitivity       Also inhibits insulin secretion ↑ triglycerides ↑ free fatty acids, ketones, lactate ketoacidosis, and lactic acidosis ↑ blood pressure ↑ risk of hypoglycemia All the other known risks – pancreatitis, cancers, liver disease, psychiatric problems, addiction, and shortened life-span