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Can Red Wine Cut Cardiometabolic Risk Factors in Diabetes?

  • Authors: News Author: Deborah Brauser
    CME Author: Charles P. Vega, MD
  • CME / CE Released: 11/11/2015
  • Valid for credit through: 11/11/2016
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Target Audience and Goal Statement

This article is intended for primary care clinicians, endocrinologists, nurses, pharmacists, and other clinicians who care for patients with type 2 diabetes.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  1. Evaluate the overall cardiovascular benefit of alcohol consumption
  2. Analyze the outcomes of regular, moderate wine consumption on the cardiovascular risk profile and safety variables among adults with type 2 diabetes


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  • Deborah Brauser

    Journalist, | Medscape Cardiology


    Disclosure: Deborah Brauser has disclosed no relevant financial relationships.


  • Robert Morris, PharmD

    Associate CME Clinical Director, Medscape, LLC


    Disclosure: Robert Morris, PharmD, has disclosed no relevant financial relationships.

CME Author(s)

  • Charles P. Vega, MD

    Clinical Professor of Family Medicine, University of California, Irvine


    Disclosure: Charles P. Vega, MD, has disclosed the following financial relationships:
    Served as an advisor or consultant for: Lundbeck, Inc.; McNeil Pharmaceuticals; Takeda Pharmaceuticals North America, Inc.

CME Reviewer/Nurse Planner

  • Amy Bernard, MS, BSN, RN-BC

    Lead Nurse Planner, Medscape, LLC


    Disclosure: Amy Bernard, MS, BSN, RN-BC, has disclosed no relevant financial relationships.

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Can Red Wine Cut Cardiometabolic Risk Factors in Diabetes?

Authors: News Author: Deborah Brauser CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / CE Released: 11/11/2015

Valid for credit through: 11/11/2016


Clinical Context

The negative health effects of alcohol consumption, particularly in regard to heavy alcohol intake and addiction, are well understood. However, the deleterious effects of heavy alcohol consumption are counterbalanced by the potential health benefits of light to moderate alcohol intake. A systematic review and meta-analysis by Ronksley and colleagues, which was published in the February 22, 2011, issue of the BMJ, analyzed the potential cardiovascular benefits associated with drinking alcoholic beverages.[1]

A total of 84 studies were included in the meta-analysis. Alcohol consumption was associated with lower risks for incident coronary heart disease and coronary heart disease mortality, with the greatest impact noted at 1 to 2 alcoholic beverages per day. However, alcohol consumption did not significantly affect the risk for stroke or stroke mortality. The overall pooled adjusted risk for cardiovascular disease mortality in comparing alcohol drinkers vs abstainers was 0.75 (95% confidence interval, 0.70-0.80).

Routine consumption of moderate levels of alcohol has been demonstrated to provide a cardiovascular benefit for patients with type 2 diabetes in cohort studies, but there are few prospective clinical trials of alcohol consumption among adults with diabetes. The current study by Shai and colleagues uses a randomized design to address this issue.

Study Synopsis and Perspective

A glass of wine with dinner can improve lipid and glycemic control profiles in patients with type 2 diabetes mellitus, suggests a small but prospective randomized trial[2].

Findings from the Cardiovascular Diabetes and Ethanol trial (CASCADE)[3], which included 224 patients from two centers in Israel with controlled diabetes, showed that those who consumed 150 mL/day of red wine plus a Mediterranean diet had significantly higher levels of high-density lipoprotein cholesterol (HDL-C)and apolipoprotein(a)1 after 2 years compared with those who drank equal amounts of mineral water plus the healthy diet (the primary outcomes).

In addition, the group randomized to white wine intake had significantly decreased fasting plasma glucose levels vs the mineral-water group. Both wine groups also had significantly improved triglyceride levels.

Principal investigator Dr Iris Shai (Ben-Gurion University of the Negev, Beer Sheva, Israel) told heartwire from Medscape via email that long-term, large-scale multicenter trials are now needed to follow morbidity and mortality incidence rates.

"But for now, the results suggest modest beneficial effects of initiating moderate wine consumption, and red wine in particular" for this patient group, said Shai. However, "these benefits should be weighed against potential risks when translated into clinical practice."

The findings were published online October 13, 2015, in the Annals of Internal Medicine.

"Controversial" Research

"The risk/benefit balance of moderate alcohol consumption in persons with diabetes is controversial," write the investigators. They add that if wine does convey benefit, the question of which color is better has not been thoroughly examined.

As reported by heartwire , Shai presented results of an initial, 3-month feasibility trial at the 2007 European Association for the Study of Diabetes annual meeting.[4] The team examined 109 "teetotaler diabetics" and found that initiating moderate consumption of red wine significantly decreased fasting plasma glucose levels compared with the participants who continued to abstain from alcohol.

For CASCADE, the researchers sought to assess both the long-term effects and safety of alcohol intake in patients with diabetes, while also examining whether type of wine mattered.

The participants, considered "mostly abstaining" from alcohol at baseline, were enrolled starting in November 2009 and were randomly assigned to consume a 5-oz serving (150 mL) of provided red wine (n=73), white wine (n=68), or mineral water (n=83) every night for 2 years.

"Compliance with alcohol intake was tightly monitored, with patients returning their empty wine bottles and receiving their new supplies," reported Shai.

Exclusion criteria for the study population included intake of more than one alcoholic drink per week at baseline or a personal or family history of myocardial infarction, stroke, or addiction.

All participants underwent several tests, including continuous monitoring of changes in blood pressure, heart rate, and blood glucose levels, "and follow-up for the dynamic of atherosclerosis and fat by ultrasound and MRI [magnetic resonance imaging] tests," Shai noted. "Genetic analysis of alcohol dehydrogenase [ADH]" was also conducted and electronic questionnaires were filled out.

Ethanol's Role

At the end of 2 years, the red-wine group significantly increased their HDL-C levels by 0.05 mmol/L (2.0 mg/dL) (P<0.001) vs the water group and increased their apolipoprotein(a)1 level by 0.03 g/L (P=0.05). The red-wine group also decreased total cholesterol/HDL-C ratio by 0.27 (P=0.04).

There were no significant differences in lipid changes between the white-wine and water groups. However, the white-wine group did significantly decrease their fasting plasma glucose level by 1.0 mmol/L vs the water group (P=0.004) -- a result that was not found in the red-wine group.

Secondary outcomes included triglyceride levels, which were significantly more favorable for both the red-wine group (-0.1 mmol/L [-12.0 mg/dL], P=0.02) and the white-wine group (-0.09 mmol/L [-7.9 mg/dL], P=0.004) vs the water group.

Carriers of the ADH1B*1 allele ("slow ethanol metabolizers") in the combined wine groups had significant improvements in glycemic control vs those who carried ADH1B*2 homozygotes ("fast ethanol metabolizers"). This included lower fasting plasma glucose (P=0.01) and glycated hemoglobin (HbA1c) levels (P=0.02).

The ADH1B variants "may assist in identifying patients with [diabetes] for whom moderate wine consumption may be clinically beneficial," write the researchers.

There were no significant changes in blood pressure, liver function, adiposity, drug treatment, or adverse events/symptoms in any of the groups. However, both wine groups saw significantly improved sleep quality vs the water group (P=0.04).

Shai noted that the investigators had hypothesized that "because of the ethanol component," the wine groups would have similar cardiometabolic effects on all measures. So the between-group differences actually found were surprising.

"The provided wines were nearly equal in alcohol and caloric content, but the red wine had sevenfold higher levels of total phenols and four- to 13-fold higher levels of the specific resveratrol group compounds than the white wine," she said.

"The genetic interactions suggest that ethanol plays an important role in glucose metabolism, while red wine's effects additionally involve nonalcoholic constituents."

"An Option for Improving Risk"

"There hasn't been much randomized controlled trial evidence on the effects of alcohol done in this way," Dr William Yancy (Duke University Department of Medicine, Durham, NC) told heartwire .

However, he noted that the current study "just looked at interim or surrogate markers" and not actual outcomes, such as mortality. "I think it provides some interesting information for us to think about, but I don't know if it'll change our clinical recommendations."

In other words, "it's important to keep in mind while we do other research, although it'll be hard to do that kind of long-term research with the end points that you need. Until then, we'll use observational studies to try to answer the issues."

Yancy said that past observational studies have shown that moderate alcohol intake is associated with a lower risk for mortality. "So it's reasonable to say, 'if you're drinking in moderation, keep doing it.' Just like the data show that drinking excessively is not good -- and that message doesn't go away," he said.

"The biggest question we have is: do we advise people to initiate drinking if they don't already drink? This study speaks to that and gives some evidence that alcohol in moderation could be started and you'd see some improvement in their risks."

He added that seeing benefits from both types of wine, albeit with some differences, was interesting. "Red wine benefited HDL cholesterol and the white wine benefited blood sugar control. So it seems like either one could be an option for improving a patient's risk."

The study was funded by a grant from the European Foundation for the Study of Diabetes. Shai, the study coauthors, and Yancy have disclosed no relevant financial relationships.

Study Highlights

  • Adults between 40 and 75 years old with type 2 diabetes were eligible for study inclusion. Individuals who drank more than 1 alcoholic beverage per week; had a personal or family history of addiction; or who had a history of smoking, stroke, or myocardial infarction were excluded from study participation. Patients treated with more than 2 injections of insulin per day were also excluded, and all participants had a baseline HbA1c level between 6.4% and 9.9%.
  • All participants were encouraged to follow a Mediterranean diet during the trial, but there was no attempt to reduce daily caloric intake or change participants' exercise habits.
  • Participants were randomly assigned to one of 3 intervention groups: red wine, white wine, or mineral water. All groups were instructed to consume 150 mL of their randomly assigned beverage with dinner on a nightly basis.
  • Researchers followed multiple metabolic outcomes as well as liver enzymes and quality of life during 2 years.
  • 224 adults underwent random selection. The mean age of participants was 59.7 years, and 69% were men. The mean HbA1c level at baseline was 6.9%, and the mean daily ethanol intake was 2.3 g.
  • Beverage adherence rates at 2 years were 87%, 84%, and 84% in the mineral water group, white wine group, and red wine group, respectively.
  • At 2 years, participants in the red wine group experienced a significant increase in levels of HDL-C compared with the mineral water cohort (mean difference, 2 mg/dL; P <.001). There was also a slight but significant increase in apolipoprotein(a)1 levels in the red wine group vs the mineral water group. White wine had no effect on these variables.
  • Both white and red wine led to modest improvements in triglyceride levels compared with mineral water.
  • There were no other significant differences in other components of the lipid profile, including low-density lipoprotein cholesterol (LDL-C), in comparing the wine groups with the mineral water group.
  • In contrast, only white wine improved fasting glucose levels (average reduction, -17.2 mg/dL; P =.004) compared with mineral water. It also improved insulin sensitivity. Red wine had no significant effect on glucose metabolism compared with mineral water, and HbA1c levels remained stable during the study in all 3 treatment groups.
  • All 3 groups experienced mild and similar reductions in body weight and waist circumference during the 2-year study period. Wine had no significant effect on blood pressure.
  • There were no adverse events related to wine consumption. Quality of life was generally similar in all 3 treatment groups, but participants who received wine reported better sleep.
  • Study interventions did not generally influence participants' diabetes treatment, and liver enzymes remained stable during treatment.
  • The red wine group experienced a significant decrease in the number of variables associated with the metabolic syndrome compared with the mineral water group (-0.34; P =.049).
  • On subgroup analysis, only slow metabolizers of alcohol in the wine groups experienced improvements in glycemic control, whereas fast metabolizers experienced lower blood pressure during the study.

Clinical Implications

  • A previous meta-analysis by Ronksley and colleagues found that moderate alcohol consumption is associated with reductions in incident coronary heart disease and coronary heart disease mortality, but not stroke or stroke mortality.
  • The current study by Shai and colleagues demonstrates that moderate, regular wine consumption appears to be safe among adults with type 2 diabetes. Consumption of wine was associated with modest improvements in the lipid profile (red wine) and glucose metabolism (white wine).
  • Implications for the Healthcare Team: Patients with type 2 diabetes may have widely variable beliefs and practices when it comes to alcohol consumption. The current study provides reassurance that moderate alcohol consumption should not be harmful for these patients, but it does not dramatically improve the cardiovascular risk profile either.

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