Meo SA, Ullah A. Alcohol Intake: A Risk to Develop Type 2 Diabetes Mellitus-Think Before to Drink. J Pak Soc Intern Med. 2020;1(1):

Correspondence: Sultan Ayoub Meo. Email: sultanmeo@hotmail.com / smeo@ksu.edu.sa

Alcohol is a toxic and psychotropic liquid consisting properties of dependence producing. Alcohol has been widely used in many cultures1, and has been considered as a part of social activities2. Alcohol intake is one of the major public health challenges facing modern society. The swift economic development and a rise in average socio-economic level increase the trends of alcohol intake. During the last three decades, there has been a rapid increase in alcohol production, importation, availability and consumption2.

The excessive use of alcohol is a global leading health problem and has social and economic burden in the societies. Abusing alcohol is reported to be amongst five topmost risk factors for ailments, disability and death globally. The detrimental alcohol use is a cause of more than two hundred illness and injurious conditions1,3. Alcohol intake can cause various health problems, impair various physiological functions and develop metabolic dysfunctions4,5.

Diabetes Mellitus (DM) is a most challenging health issue of the 21st century6. Worldwide, the incidence of diabetes mellitus has augmented dramatically. Diabetes mellitus is a multifactorial syndrome7,8, few ways of life and attitudes like low physical activities and diets contained with high fat lead to obesity and increase risk of type 2 DM8. A less attention have been given to observe alcohol consumption and risk of T2DM. Therefore, the present study was conducted to investigate the association between alcohol intake and prevalence of Type 2 diabetes mellitus.

In this study a descriptive approach was employed to explore the relationship between alcohol intake and new cases of T2DM among men and women. Prevalence of T2DM was selected as the outcome, the diagnostic criteria was followed as per international guidelines based on American Diabetes Association and World Health Organizations. Initially 52 articles were published between the period Jan 1970-June2019 on theprevalence and incidence of diabetes mellitus which were identified from “Pub-Med, Medline, EMBASE,Web of Science,and Scopus databases”. The relevant studies were explored through the keywords including “alcohol intake” “alcohol consumption” “prevalence”, “incidence”, “type-2 Diabetes Mellitus” “Diabetes Mellitus”. The relevance of studies was determined by the title and abstract of the article. After the eligible studies had been shortlisted, the appropriate characteristics and findings were recorded by an investigator and verified by another investigator, the inconsistency of appraisal was resolved through the feedback of the third investigator and majority decision was permitted where a publication was reviewed by a third investigator. The findings including sample size, age, gender, numbers, incidence, and length of follow-up were noted. The articles were carefully analyzed for the prevalence of T2DM among male and females, and data were recorded.

The present analysis was based on the prospective, case-cohort, longitudinal community based12 studies and explored all possible relations between alcohol intake and the prevalence of T2DM. The total number of participants were 182,422, among them males were 120243 (65.92%) and females were 62179 (34.08%) with age ranges 18-98 years and the median follow up period was about 9.0 years.

Inclusion and exclusion criteria: The inclusion criteria of literature was based on the population based studies from all over the worldin which documents contained information about “incidence”, “type 2 diabetes mellitus” and alcohol users both male and females. The study must be available in peer review journals mainly the journals indexed in pub med and ISI Web of Science. The articles such as brief communications, non-observational correspondence, review articles were not included and duplicate publications were also omitted. The articles were verified under pre-determined inclusion and exclusion standards. Fifty-two studies were analyzed, finally 12articles were selected in the analysis and discussion was added with related documents and remaining studies were excluded.

Ethics Statement: In this study the data associated to the incidence of T2DM was acquired from different databases, subjects or patients were not directly involved, and therefore ethical approval was not required.

Statistical Analysis: A pooled incidence of T2DM was measured using random and fixed model effects. An R-foundation for statistical computation was used to perform analysis and incidence of T2DM was recorded. The p-value less than 0.05 was considered a significant.

Initially 52 articles were published between the period Jan 1970- June 2019 on theprevalence of diabetes mellitus which were identified from “Pub-Med, Medline, EMBASE, Web of Science, and Scopus databases”. After the eligible studies had been shortlisted, the appropriate characteristics and findings of 12 studies were analyzed. The characteristics of 12 studies are presented in Table I and II. All these studies included of male and females. In these studies the average follow up period was 9years.The total sample size of these studies was 182422, number of males was 120243 (65.92%) and number of females was 62179 (34.08%).

Based on the random effect model the incidence of T2DM among men and women was recorded. The incidence of T2DM among male alcohol users was 7% with 95% confidence Interval 5% -11%. However, the incidence of T2DM among female alcohol users was 6% with 95% confidence interval was 5%-9%. The pooled incidence of T2DM was higher in males compared to females (Figure I, Table II).

The present study identified that alcohol intake is a risk to develop type 2 diabetes mellitus in male and females. The “International Diabetes Federation's Atlas, 201921 displays new statistics and demonstrated that global overall prevalence of diabetes is 9.3% showing that 463 million adult people are diabetics. However, in the present study we found the occurrence of T2DM among male alcohol users was 7% with 95% confidence Interval 5%-11% and among female alcohol users was 6% with 95% confidence interval was 5%-9%. The incidence of T2DM was higher in males compared to females (Table II).

Peng et al13 assessed the causality between alcohol intake, diabetes risk among 4536 participants. In this randomization, study authors identified that high alcohol intake was causally coupled to insulin resistance and increased risk of diabetes mellitus. Similarly, Lai et al22 conducted a study in Taiwanese population and established a link between frequency of alcohol intake and risk of diabetes. The study population was 43,000, with 9-year follow-up period, incidece of diabetes was 3650 (8.49%). The risk of diabetes was significantly higher among regular heavy drinkers.

Hodge et al23demonstrated the rising risk of DM in men who consumed ≥210 g alcohol during 03 days in a week compared with men who consumed no alcohol. Moreover, a study conducted on 1650 Japanese men without diabetes, identified that drinking more than three beverages per diem remarkably surged the danger of DM. In another community-based cohort of 12,261 participants, reported a significant higher risk of diabetes among men who consumed more than 21 beverages a week as compared to the men consumed ≤1 drink a week20. Further literature has reported that low consumption of alcohol is associated with lower risk of DM24 while substantial alcohol consumption had greater association with elevated risk of DM25.

Vancampfort et al26 conducted a meta-analysis and described the pooled prevalence of T2DM in people with alcohol use was 12.4%, higher T2DM prevalence was observed among male participants. Similarly, in the present study, we found high incidence of T2DM among males compared to female. Marques-Vidal et al27 investigated the association of alcoholintake on the incidence of T2DM and IFG. The authors recruited 4765 individuals, 2152 male and 2613 female with mean age of 52 years, followed for an average of 5.5 years. During the follow-up, 5.96% participants developed T2DM and 13.49% developed IFG. The overall findings demonstrates that alcohol consumption was positively associated with the risk of developing T2DM.Cullmann et al28assessed the association between alcohol and risk of developing pre‐diabetes and T2DM in men and women. The authors recruited 2070 men and 3058 women and identified that total alcohol intake increased the risk of pre‐diabetes and T2DM in men. In the present study we also identified that alcohol intake is associated with high incidence of T2DM among males compared to females.

Koloverou et al15conducted a prospective study and investigated the impact of alcoholintake on diabetes incidence. In this cohort, the authors selected 3042; among them 1514 were men with age range 18-89 years and 1528 were women 18-87 years old. The authors found high incidence of diabetes, which was 13.4% in men and 12.4% in women. In addition, Han et al9 investigated the relationship between alcohol use and risk of T2DM. In this longitudinal study authors invited 12,186 (M=5617; F=6569) adults, identified the incidence of T2DM among males was 6.69% and females was 5.19%, however the total incidence among both gender was 5.48%. This study demonstrated that alcohol consumption was significantly associated with increased risk of T2DM.Similarly, in the present study, we found that the incidence of T2DM among male alcohol users was 7% and in female alcohol users was 6%. The pooled incidence of T2DM was higher in males compared to females.

Mechanism how alcohol can cause Diabetes Mellitus:This study explain the liaison between alcohol intake and prevalence of T2DM.Although, it is hard to understand the mechanism and the risk with one another in complex ways in the development of T2DM, it may however be explained via various mechanisms. Liver is the main metabolic organ and considered as a victim of the harmful use of alcohol. Acute liver damage due to alcohol use may cause defects in glucose homeostasis and glucose control mechanism29. Moreover, excessive alcohol consumption contributes to increase blood glucose by increasing “2,3-butanediol and 1,2-propanediol” which decrease the use of glucose in skeletal muscle and increase insulin resistance30.Another mechanism which is also allied to develop T2DM among alcohol users that alcohol and its metabolites directly injure pancreatic acinar cells and elicit "necrosis-fibrosis" sequence that leads to atrophy, fibrosis, and chronic pancreatitis3. Alcoholics have repeatedly been found to have deregulation of the glucose metabolism by impaired insulin secretion, increased hepatic glucose production and decreased peripheral glucose utilization. The link between alcohol intake and T2DM identified in this study could be explained by these mechanisms, which are important for the better understanding of the pathophysiological basis of these mechanisms.

Strengths and Limitations: This study added in literature established the association between alcohol intake occurrence of type 2 diabetes mellitus (T2DM) amongst male and female alcohol users. Data was collected using very dependable and consistent sources like “Medline”, “Pub-Med”, “Web of Science”, “Scopus” and “EMBASE”. However, the limitations of this study are that the authors chose the homogeneous, cohort, randomized with large sample sized community studies following the standard conditions while authors confronted few procedural challenges as in different studies numerous methodological approaches were followed to find association among alcohol intake with T2DM. The other limitations of this study are that, we were unable to classify the drinking patterns, which may complicate the estimation of the relationship between alcohol and T2DM.

Conclusions: Alcohol intake is associated with increasing occurrence of T2DM. The pervasiveness of T2DMwas high among males compared to females. In spite of social, health and economic problems linked to detrimental alcohol consumption where this reality continued as a low priority in public health policies comparatively. It is suggested that a healthy lifestyle pattern should be adopted and alcohol control policies should be implemented on average and high-risk drinking patterns. Moreover, health educational awareness programs should be familiarized to highlight the hazardous effects of alcohol and its association with T2DM. Alcohol users must think before to drink.

Conflict of Interest: No conflict declared.

Acknowledgment: Thankful to the “Deanship of Scientific Research, King Saud University, Riyadh, Saudi Arabia for supporting the work through the Research Group Project (RGP-181)”.

Table I: Literature related to alcohol intake and prevalence of Type 2 Diabetes Mellitus

Table II. Distribution of male and female individuals and pooled prevalence of T2DM

Figure I. Pooled prevalence of type 2 diabetes mellitus among male and female alcohol users

Figure II. PRISMA Flow Diagram for the Selection of Studies with alcohol intake and prevalence of Type 2 Diabetes Mellitus

Literature search was performed by using the search term “Alcohol intake, Alcohol consumption and prevalence of Diabetes Mellitus”Records after limiting search results to Alcohol Intake, Alcohol Consumption and Incidence of T2DM (n=84)

Records identified through other sources (n=412)Records identified through Pub-Med (n = 764)Records identified through Web of Science (n=582)

Identification

Articles excluded for being no detailed analysis (n=22)Studies finally included in quantitative synthesis (n = 12)Full-text articles assessed for eligibility (n= 34)Records screened for Original Research Articles (n = 52)Records excluded (n=18)ScreeningEligibilityIncluded