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. Author manuscript; available in PMC: 2009 Feb 1.
Published in final edited form as: Metabolism. 2008 Feb;57(2):241–245. doi: 10.1016/j.metabol.2007.09.007

Metabolic Effects of Alcohol in the Form of Wine in Persons with Type 2 Diabetes Mellitus

Anne E Bantle 1, William Thomas 1, John P Bantle 1
PMCID: PMC2238804  NIHMSID: NIHMS38900  PMID: 18191055

Abstract

Background

Moderate alcohol consumption is associated with reduced cardiovascular disease rates in non-diabetic populations. However, the effects of alcohol in people with diabetes are not well defined. Accordingly, we tested the hypothesis that alcohol would raise plasma HDL cholesterol or have other beneficial metabolic effects in persons with type 2 diabetes.

Methods

To assess acute effects of alcohol on plasma glucose and serum insulin, subjects were inpatients for two days during which they received, in random order, 240 ml wine or grape juice with their evening meal. To assess chronic effects of alcohol on fasting plasma lipids, subjects consumed, in random order, 120-240 ml wine daily for 30 days and abstained from alcohol for 30 days. Participants were 18 non-insulin treated type 2 diabetic volunteers.

Results

Acutely, 240 ml wine containing 24 g alcohol had no effect on plasma glucose or serum insulin. Chronically, wine consumption for 30 days (mean consumption 18 g alcohol/day) compared to abstinence for 30 days resulted, respectively, in mean ± SEM fasting plasma cholesterol 160±6 and 160±8 mg/dl (p=0.98), HDL cholesterol 47±3 and 46±3 mg/dl (p=0.87), LDL cholesterol 82±5 and 82±6 mg/dl (p=0.98), triglycerides 157±19 and 159±19 mg/dl (p=0.88), glucose 128±6 and 128±7 mg/dl (p=0.84) and serum insulin 14±2 and 17±3 μU/ml (p=0.03).

Conclusions

Moderate consumption of alcohol in the form of wine did not raise plasma HDL cholesterol. However, alcohol did not have any harmful metabolic effect and chronic consumption lowered fasting serum insulin. People with type 2 diabetes should not be discouraged from using alcohol in moderation.

Introduction

It is clear that some people should not consume alcohol. People who should abstain from alcohol include those with uncontrolled hypertension, hypertriglyceridemia, heart failure, liver disease, pancreatitis, porphyria, a strong family history of alcoholism, those who are pregnant and, of course, those who are not of legal age (1). For other people, the use of alcohol in moderation may not be harmful and may even confer health benefits. In both men and women, moderate alcohol consumption was associated with reduced mortality rates (2-4). Among male health care professionals, moderate use of alcohol was associated with reduced risk for angina pectoris (5), myocardial infarction (5,6), and stroke (7). In both men and women, moderate use of alcohol was associated with protection against congestive heart failure (8). The inverse association between alcohol consumption and cardiovascular disease was strongest in men with high plasma LDL cholesterol levels (9). Off setting, to some extent, the potential beneficial effect of alcohol for women is an association between moderate alcohol consumption and increased risk of breast cancer (10). However, in spite of the association with breast cancer, moderate alcohol consumption was associated with an overall reduction in mortality in women (4).

The association of alcohol with reduced health risks was not dependent on the type of alcohol containing beverage consumed or whether the alcohol containing beverages were consumed with meals (6). A meta analysis found evidence that all alcohol containing drinks (wine, beer and spirits) were associated with a lower risk of coronary heart disease and concluded that any benefit was associated with alcohol itself and not with other components of alcohol containing beverages (11). If alcohol does reduce cardiovascular risk, the reduced risk may be mediated by raised HDL cholesterol levels (1). However, other potential beneficial mechanisms have been proposed including anti-inflammatory and antithrombotic effects (1).

Alcohol also appears to have effects on carbohydrate metabolism. In both men and women, moderate alcohol consumption was associated with protection against development of type 2 diabetes mellitus (12-14). In a randomized, crossover trial in post-menopausal women, moderate alcohol consumption was associated with reduced fasting insulin and triglyceride concentrations and increased insulin sensitivity (15). The effects of alcohol in patients with diabetes have not been clearly defined. Moderate intake of alcohol by diabetic subjects does not acutely aggravate glycemia and may produce a modest decrease in plasma glucose (16). In patients with type 1 diabetes, excess alcohol may induce severe hypoglycemia (17). However, the effects on glycemia and lipemia of chronic consumption of alcohol by people with diabetes have not been reported. To address these issues, we studied both the acute and chronic effects of moderate alcohol intake by type 2 diabetic subjects. The hypotheses to be tested were 1) the use of alcohol in the form of wine with the evening meal would lower plasma glucose during the night and result in lower fasting plasma glucose the next morning and 2) the chronic use of alcohol in the form of wine would raise plasma HDL cholesterol.

Methods

Subjects

Eighteen subjects were recruited from the University of Minnesota outpatient clinics and from the community. Eligibility criteria were diagnosis of type 2 diabetes, age at least 40 years, hemoglobin A1c < 8.5%, constant dose(s) of oral diabetes medications (if any) and lipid lowering medications (if any) for at least one month, and ALT and AST less than two times the upper limit of normal. Exclusionary criteria were history of alcoholism or alcohol abuse, use of insulin in the previous 6 months, blood pressure > 150/90 mmHg, fasting plasma triglycerides > 400 mg/dL, heart failure, active liver disease, history of pancreatitis, history of porphyria, pregnancy or plans to become pregnant, and serum creatinine > 1.8 mg/dl.

Methods

To study the acute effects of alcohol, subjects were admitted to the General Clinical Research Center (GCRC) at the University of Minnesota for a two day inpatient stay. At 1700 hours on study day 1, blood samples were obtained for measurement of plasma glucose and serum insulin. Dinner providing 825 kcal (34% carbohydrate, 21% protein and 45% fat) was served at 1730 hours with, added to the meal, 240 ml of white wine or 240 ml of white grape juice. No bedtime snack was provided. Additional blood samples were obtained for plasma glucose and serum insulin every two hours until 0700 hours the next morning (8 samples total). Research procedures resumed at 1700 hours on study day 2 and were identical to procedures on day 1 except for the beverage served with dinner (white wine or white grape juice). The dinner on day 2 was otherwise identical to the dinner served on day 1. Treatment order was randomly assigned in a balanced way.

To study the chronic effects of alcohol, subjects consumed at least 120 but not more than 240 ml of wine daily for the one month and abstained from all alcohol for one month. Wine was consumed with dinner or between dinner and bedtime. After one month (28 - 32 days), subjects reported to the GCRC in the morning after a fast of 10 to 12 hours. Subjects were weighed and blood pressure was obtained twice in a seated position. Fasting blood samples were obtained for plasma lipids, plasma glucose, serum insulin, hemoglobin A1c, serum C-reactive protein and plasminogen. Subsequently, subjects originally assigned to wine were switched to abstinence and those originally assigned to abstinence were switched to wine. After another month (28 - 32 days), subjects again reported to the GCRC in the morning after a fast of 10 to 12 hours and outcome measures were obtained in the same way as before. Treatment order was randomly assigned in a balanced way. A selection of white and red wines was provided to subjects free of charge. Subjects kept diaries during both treatment periods to record daily wine consumption, consumption of other alcohol containing beverages and episodes of symptomatic hypoglycemia. The diaries were used to assess compliance, quantitate alcohol consumption and determine the frequency of hypoglycemia. Subjects who completed the study received a stipend of $500. The research protocol was approved by the University of Minnesota Institutional Review Board. Informed, written consent was obtained from all subjects.

All laboratory tests were performed in the University of Minnesota Hospital clinical laboratory. Plasma glucose was measured by glucose oxidase colorimetric reflectance spectrophotometry with an Ortho Clinical Diagnostics Vitros 950 Analyzer. Serum insulin was measured by chemiluminescent immunoassay with a DPC Immulite 2000 Analyzer. Blood hemoglobin A1c was measured by automated high performance liquid chromatography with a Tosoh A1c 2.2 Plus Glycohemoglobin Analyzer. Plasma cholesterol was measured by colorimetric reflectance spectrophotometry, plasma HDL cholesterol by colorimetric reflectance spectrophotometry after precipitation of non-HDL cholesterol with phosphotungstic acid and magnesium chloride and plasma triglycerides by colorimetric reflectance spectrophotometry, all with an Ortho Clinical Diagnostics Vitros 950 Analyzer. Serum C-reactive protein was measured by immunorate reflectance spectrophotometry with a high sensitivity Beckman Immage 800 Immunochemistry System. Blood plasminogen was measured by chromogenic (synthetic substrate) activity assay using a Stago STA Analyzer and Stachrome Plasminogen Kit 658. The normal range was 80 – 120%. Plasma LDL cholesterol was calculated according to the formula LDL cholesterol = total cholesterol – (HDL cholesterol + triglycerides/5) (18).

Biostatistical Methods

The acute (inpatient) phase was analyzed by comparing the two treatments at each time point separately, using a repeated-measures model with terms for sequence (wine-grape juice or grape juice-wine), subject and day. A Bonferroni correction for multiple comparisons was applied to the 8 comparisons of plasma glucose and serum insulin, so that p < 0.05/8 = 0.006 was required for a significant difference at the 5% level. The chronic (outpatient) phase was analyzed with a parallel model, and also with a model including gender effects. Occurrence of hypoglycemia during the two outpatient months was compared within subjects with McNemar's test. Statistical analyses were performed with SAS Version 9.1 (SAS Institute Inc., Cary, NC, USA) and graphics were drawn using R (R Foundation for Statistical Computing, Vienna, Austria; http://www.R-project.org). All results for continuous endpoints were reported as mean with standard error.

Results

Participants were 11 women and 7 men with mean (range) age 64 years (45-82 years), duration of diabetes 8 years (2-29 years), BMI 31.7 kg/m2(21.3-41.2 kg/m2), Hgb A1c 6.9% (5.5-8.4%), cholesterol 160 mg/dl (110-212 mg/dl), HDL cholesterol 43 mg/dl (23-71 mg/dl), LDL cholesterol 88 mg/dl (58-140 mg/dl), and triglycerides 143 mg/dl (44-369 mg/dl). Eleven subjects were taking metformin and a sulfonylurea, one was taking metformin and repaglinide, five were taking metformin alone, and one was taking no diabetes medication. Thirteen subjects were taking statin medications. Baseline consumption of alcohol containing beverages was <1 per week in 9 subjects, 1-7 per week in 8 subjects and 8-14 per week in 1 subject. After completing the acute study, one subject developed a cardiac problem requiring urgent cardiac catheterization and did not complete the chronic study.

As shown in Figure 1, alcohol had no acute effect on plasma glucose or serum insulin. After ingestion of 240 ml wine containing 24 g alcohol with dinner, plasma glucose and serum insulin were not different at any time point from 1900 to 0700 hours than after ingestion of grape juice with dinner. The greatest difference in plasma glucose values occurred at 1900 hours but the value of 148 mg/dl after wine was not significantly different from the value of 165 mg/dl after grape juice (p=0.21). In the acute study, there was no sequence (carry-over) effect.

Figure 1.

Figure 1

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Mean ± SEM plasma glucose (A) and serum insulin (B) values before and after consumption of grape juice or wine with dinner. To convert glucose to mmol/l, multiply by 0.05551; to convert insulin to pmol/l, multiply by 6.0.

During the 30 days of chronic wine consumption, mean daily consumption was 171 ml of wine containing 18 g alcohol (men 21 g alcohol, women 16 g alcohol) whereas during the 30 days of abstinence, mean daily alcohol consumption was < 0.1 g. At the end of the 30 day treatment periods, there was no significant difference between wine consumption and abstinence in values for fasting plasma cholesterol, HDL cholesterol, LDL cholesterol, triglycerides, plasma glucose, hemoglobin A1c, serum C-reactive protein, blood plasminogen, blood pressure, weight or episodes of mild hypoglycemia (Table 1). There was no episode of serious hypoglycemia during either treatment. Fasting serum insulin was 3 μU/ml lower after wine than after abstinence. In the chronic study, there was no sequence (carry-over) effect.

Table 1.

Mean ± SEM values after 30 days of daily wine consumption and 30 days of abstinence from alcohol.*

Wine Abstinence P-value
Fasting cholesterol (mg/dl) 160 ± 6 160 ± 8 0.98
Fasting HDL cholesterol (mg/dl) 47 ± 3 46 ± 3 0.87
Fasting LDL cholesterol (mg/dl) 82 ± 5 82 ± 6 0.98
Fasting triglycerides (mg/dl) 157 ± 19 159 ± 19 0.88
Fasting glucose (mg/dl) 128 ± 6 128 ± 7 0.84
Fasting insulin (μU/ml) 14 ± 2 17 ± 3 0.03
Hgb A1c (%) 6.7 ± 0.2 6.7 ± 0.2 0.63
C-reactive protein (mg/l) 0.32 ± 0.1 0.31 ± 0.1 0.87
Plasminogen (%) 114 ± 4 114 ± 3 0.98
Systolic BP (mmHg) 131 ± 3 130 ± 4 0.72
Diastolic BP (mmHg) 71 ± 2 72 ± 1 0.54
Weight (kg) 87.4 ± 3.9 87.4 ± 3.9 0.91
Episodes of hypoglycemia
(all subjects combined)		 4 8 0.50
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*

n = 17; to convert to mmol/l, multiply cholesterol by 0.02586, triglycerides by 0.0112 and glucose by 0.05551; to convert insulin to pmol/l, multiply by 6.0.

With 17 subjects, we had an 80% chance (power 0.80) to detect a true mean difference greater than 2.2 mg/dl in the primary endpoint, HDL cholesterol. Mean HDL cholesterol values for females were 52 mg/dl after wine and 50 mg/dl after abstinence whereas mean HDL cholesterol values for males were 40 mg/dl after both wine and abstinence. Thus, HDL cholesterol was higher in females than in males but did not change significantly with the treatments in either gender. When the subgroup of 5 subjects not taking statin medications was analyzed separately, there was no trend toward higher HDL cholesterol after wine consumption.

Conclusions

Our study did not demonstrate any acute effect of consumption of a moderate amount of alcohol in the form of wine with dinner on plasma glucose or serum insulin during the following evening and night. Although alcohol has been shown to inhibit hepatic gluconeogenesis in type 2 diabetic subjects, it does so without decreasing hepatic glucose output (19). Presumably, any decrease in gluconeogenesis is compensated for by increased glycogenolysis.

Our data also did not demonstrate any effect of chronic wine consumption on plasma HDL cholesterol or other plasma lipid fractions in type 2 diabetic subjects. Our study had an 80% chance of finding a true mean difference greater than 2.2 mg/dl in HDL cholesterol. It is possible that we did not have sufficient power to demonstrate an effect and that a larger study with more subjects might show an effect on HDL cholesterol. Most of our subjects were overweight or obese and it is possible that leaner diabetic individuals would have responded differently. Since most of our subjects were taking statin medications, it is also possible that statins blocked an effect of alcohol on HDL cholesterol. However, analysis of data from the five subjects not taking statins did not show a trend toward higher HDL cholesterol values with alcohol consumption.

It is possible that the amount of alcohol we used (mean 18 g daily) was too little to produce an effect on HDL cholesterol. In physically inactive men, consumption of 39 g alcohol daily from beer for three weeks raised HDL cholesterol (20) whereas in women, consumption of 35 g alcohol daily from wine for three weeks had no effect on HDL cholesterol (21). However, alcohol intake of more than 30 g (two drinks) daily has been associated with increased mortality (3,4) and probably should be considered excessive. The amount of alcohol we used slightly exceeded the maximum intake recommended for women with diabetes which is one drink per day (15 g alcohol) but was less than the maximum intake recommended for men with diabetes which is two drinks per day (30 g alcohol) (22).

Our data suggest that any cardioprotective effect of moderate alcohol intake in people with diabetes is not mediated by increased plasma HDL cholesterol. This raises the possibility that diabetes negates the potential HDL cholesterol raising effect of alcohol found in the general population. We also could not demonstrate any effect of alcohol on inflammation as measured by high sensitivity C-reactive protein or the fibrinolytic system as measured with a functional plasminogen assay.

We did find that fasting serum insulin was lower after chronic wine consumption than after abstinence. This is consistent with data in non-diabetic populations where alcohol intake was associated with reduced serum insulin and improved insulin sensitivity (15,23,24). Although our study was not designed to assess insulin sensitivity, the reduction in fasting serum insulin after 30 days of wine consumption suggests that alcohol may reduce insulin resistance in people with type 2 diabetes. The significance of this is uncertain, but this might be a mechanism whereby alcohol exerts a cardioprotective effect in people with diabetes.

In conclusion, our data demonstrate that moderate consumption of alcohol in the form of wine did not raise plasma HDL cholesterol in subjects with type 2 diabetes. However, alcohol did not have an adverse effect on body weight, blood pressure, lipemia or rates of hypoglycemia. Alcohol did lower fasting serum insulin when used chronically and, thus, might improve insulin sensitivity. People with type 2 diabetes should not be discouraged from using alcohol in moderation.

Acknowledgements

Supported by grant M01RR00400 from the Division of Research Resources, National Institutes of Health

Footnotes

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Trial Registration ClinicalTrials.gov Identifier: NCT 00167115.

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