The Diabetologist #24+25

during uncontrolled hyperglycemia and glycosuria.
Therefore, the micronutrient effect may depend on
the degree of glucose tolerance. Also, the micro
nutrient effect on insulin secretion is biphasic. Low
vitamin concentrations may stimulate insulin secretion,
and high concentrations may have an inhibitory
effect.53
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In human studies, dietary micronutrient amounts are
often unknown. To further confuse the micronutrient
role and diabetes, serum or tissue content of certain
elements -- copper, manganese, iron, and selenium
-- can be higher in people with diabetes than in control
subjects without diabetes. On the other hand,
serum ascorbic acid (vitamin C), B vitamins, and vitamin
D may be lower in individuals with diabetes,
whereas vitamins A and E have been reported to be
normal or increased.53
Regardless, micronutrients are intimately involved in
carbohydrate or glucose metabolism, insulin release,
and insulin sensitivity. Unfortunately, this information
is frequently extrapolated beyond what the research
supports. The ADA recommends that individuals
optimize food choices in meal plans to meet RDA
and DRI intakes for all micronutrients.11,53
ALCOHOL
Earlier studies in T1D subjects showed no acute
effect on blood glucose levels with moderate alcohol
intake with meals. Further studies reported
associations with late-onset hypoglycemia.54 Possible
causes include inhibition of gluconeogenesis,
reduced hypoglycemia awareness due to cerebral
effects of alcohol, or impaired counterregulatory responses
to hypoglycemia. A study with men with
T1D who consumed wine in the evening (0.75 g alcohol/kg
body weight; ~20 oz for a 70-kg individual)
resulted in hypoglycemia treatment being required
after breakfast.55 Growth hormone levels were significantly
reduced, but no other differences in insulin
or other hormone levels were reported. 55 Similarly,
in T1D adults, hypoglycemia (blood glucose 50 mg/
dl) resulted in lower peak growth hormone levels
compared to placebo; however, this study was also
associated with a decrease in insulin sensitivity.56
In a study similar to the men’s wine study, T1D individuals
drank either orange juice or vodka with their
evening meal. Continuous glucose monitoring data
showed that individuals who drank alcohol (0.85 g
alcohol/kg body weight) had more than twice as
many hypoglycemic episodes throughout the next
24 h than those who drank orange juice.57,58
In T1D subjects, both mild alcohol intoxication and
hypoglycemia (blood glucose ~43 mg/dl) were associated
with deteriorating reaction time and other cognitive
function tests, and total impairment was greater
when both were experienced together.59 The authors
emphasized that individuals must test blood glucose
levels before driving. They should not drive when mildly
hypoglycemic, even if asymptomatic.58
Elevated total ketone body concentrations are characteristic
of both diabetic ketoacidosis (DKA) and alcoholic
ketoacidosis (AKA). However, compared to
AKA, DKA is characterized by a higher glucose concentration
and lower β-hydroxybutyrate:acetoacetate
and lactate:pyruvate ratios. Hormonal profiles are similar
with decreased insulin levels and elevated levels
of counterregulatory hormones.60 T1D subjects who
liberally consumed alcohol at lunchtime had elevated
postprandial β-hydroxybutrate levels vs. suppressed
levels with placebo.61 The authors propose that
binge drinking may increase the risk of significant ketosis,
especially with erratic insulin administration, and
recommend that patient education materials highlight
these potential problems.58
Adolescents, in particular, must be instructed on alcohol
and its potential hypoglycemic effects, and on responsible
drinking. Adolescents who drive should be
instructed on blood glucose monitoring before driving
and on carrying a carbohydrate source with them at
all times in case hypoglycemia should occur.
In summary, moderate alcohol (one drink/day or less
for women and two drinks/day or less for men) consumption
appears to have minimal, if any, acute effects
on glucose levels and insulin need, but patients must
be aware of the occurrence of late-onset hypoglycemia,
likely due to alcohol-related growth hormone
reduction. Thus, alcohol should be consumed with
food.13 Also, patients should repeatedly self-monitor
blood glucose levels after drinking alcohol to assess
if hypoglycemia treatment is needed. The additive effect
of alcohol and hypoglycemia on cognitive function
highlights the urgency of avoiding alcohol when
planning to drive.58
CARBOHYDRATE COUNTING
Carbohydrate counting is a meal-planning method
based on the principle that all types of carbohydrate
(except fiber) are digested, with the majority being absorbed
into the bloodstream as glucose molecules.
The total carbohydrate consumed has a greater effect
on blood glucose elevations than the specific type
consumed. There are two main methods of meal planning:
an I:C ratio to adjust prandial insulin for variable
carbohydrate intake (physiological insulin regimen) or
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issue 24 - 25 < SEP./OCT. 2013