Easy Ways To Stop Drinking

Alcohol Free Forever

This powerful guide walks you step-by-step through exactly what you need to do to free yourself from your alcohol addiction without going through AA meetings or expensive sessions. There are three main types of relaxation techniques you can practice when you feel upset and stressed. If you practice regularly, they will become part of your lifestyle and you may find yourself habitually more relaxed as a result. Part 2 will exercise Neuro Linguistic Programming to release thoughts and a technique of progressive muscle relaxation also negative situations. Because of the mind body connection, exercises to relax the body will also flow through the mind. Much of the stress we feel is because of our resistance to certain feelings or emotions. Alcohol Free Forever is a lifesaver ebook. This guide was extremely eye-opening and the daily emails make it extremely easy to quit and to establish a routine that did not involve alcohol. Read more here...

Alcohol Free Forever Overview

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Alcohol Dependency And Abuse

Alcohol use disorders involve four problem areas Alcohol dependence (alcoholism) refers to a repetitive pattern of excessive alcohol use with serious adverse consequences, often including lack of control, tolerance, and withdrawal. Alcohol abuse is a milder category that refers to continued drinking despite adverse consequences, in the absence of dependence (75). Data from the 2001 to 2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) showed that alcohol use disorders have an annual prevalence rate of 7.35 in the United States (76). As many as 5 out of 6 patients who meet diagnostic criteria for abuse or dependence go unrecognized in primary care settings (77). When diabetes and alcohol use disorders coexist, they represent a considerable clinical challenge. Alcohol-induced fasting hypoglycemia can occur 6 to 36 h after alcohol intake in the context of low food intake. Fasting depletes liver glycogen stores and alcohol impairs gluconeogenesis....

Drinking alcohol safely

Never drink alcohol without food, especially when you're taking glucose-lowering medication. The following people should not drink alcohol at all Alcohol adds calories without any nutrition. Alcohol has no vitamins or minerals, but you do have to account for the calories in your diet. If you stop drinking alcohol, you may lose a significant amount of weight. For example, a person who has been drinking three drinks a night and stops will lose 26 pounds in a year. Alcohol can cause cirrhosis of the liver and raises blood pressure. It also worsens diabetic neuropathy. Do you need any more reasons not to drink alcohol In addition to drinking alcohol in moderation, here are major ways you can improve the rest of your lifestyle

Alcoholism

When the portion of liver that detoxifies ethyl alcohol (the drinking kind) is hampered you are at risk for alcoholism. The other contributors to alcoholism are beryllium and ergot. Perhaps there are even more contributors. To prevent alcoholism, protect your liver from food molds, especially ergot. Add vitamin C to nuts, pasta cereals, grains and even alcoholic beverages Avoid fossil fuel pollution of your home by switching to all electric utilities.

Ending Alcohol Abuse

If you have diabetes and your blood glucose levels are on target, it is generally safe to drink alcohol occasionally. But if you drink too much or have trouble controlling how much alcohol you drink, you may have an alcohol abuse problem. Alcohol abuse is even more dangerous for people with diabetes. Many of the complications of diabetes including nerve damage, eye problems, high blood pressure, kidney disease, and heart disease can worsen with excessive alcohol use. Alcohol abuse is especially hard on the liver, where your body stores glucose. If your liver is damaged by alcohol, your blood glucose levels may become erratic, and you are more likely to have hypoglycemia. Long-term alcohol abuse can interfere with how you take care of your diabetes. Ending alcohol abuse can be very difficult, but it is crucial for many reasons, including your diabetes care. If you have a problem with alcohol, or think you might have, there is help available to you. Talk to your provider, or call your...

Overestimation of Carbohydrate Intake

One of the most common reasons for recurrent hypoglycemia is injecting too much insulin or taking too much oral medication for the amount of carbohydrates ingested. You may overestimate the amount of carbohydrate in the food or eat less than planned, or you may be delayed in eating after taking the insulin or medicine. For example, a number of times, I have had patients inject a dose of insulin in the car before they went to a restaurant. At the restaurant, the food did not come at the expected time, and so their glucose level went low. Another example is when patients are asked to fast for a lab test (such as a lipid profile) they do not realize that they should delay taking their insulin or diabetic medicine until after the test. Drinking alcohol in excess (see Chapter 8), especially on an empty stomach, can also cause hypoglycemia.

Coronary Heart Disease

Light to moderate alcohol consumption is associated with a similar reduction in CHD risk among diabetic and non-diabetic men and women (27,28). Among the mechanisms accounting for the risk reduction are increased circulating concentrations of HDL cholesterol, inhibition of blood coagulation and the presence of antioxidant substances which reduce oxidative damage (Table 13.2). However, it is also well established that alcohol increases plasma triglyceride. Alcoholic hyperlipaemia results primarily from increased hepatic secretion of VLDL and secondarily from impairment in the removal of triglyceride-rich lipoproteins from the plasma. Raised triglycerides are also a feature of the Table 13.2 Potential benefits of moderate alcohol intake Table 13.3 Risks of heavy alcohol intake metabolic profile of Type 2 diabetes, together with small dense LDL and low concentrations of HDL cholesterol. Hypertriglyceridaemia is an independent risk factor for coronary artery disease especially for people...

Endocrine Disturbances

Chronic alcoholism can also affect gonadal function and lead to testicular atrophy, gynaecomastia (enlargement of male breasts) and sterility. It is not known what the exact mechanism for these changes is, but it is thought to be a result of reduced liver function. This reduced liver function decreases the rate of metabolism of female sex hormones, thereby leading to an increased level of circulating oestrogens. A second mechanism is thought to be that alcohol reduces synthesis of testosterone (18). Testosterone synthesis involves many steps and some of the intermediates may be dependent on the NAD + NADH concentration ratio which, as has already been discussed, is affected by alcohol consumption.

Counting Alcohol as Part of Your Diet

You can see that the alcohol calories add up pretty quickly. You may even wonder why alcoholics are not often overweight. The answer is that alcohol becomes a staple of their diet, and they develop wasting diseases associated with inadequate intake of protein, carbohydrate, fat, vitamins, and minerals. In addition to the calories, alcohol plays other roles in diabetes. If alcohol is taken without food, it can cause low blood glucose by increasing the activity of insulin without food to compensate for it. Some alcoholics, even without diabetes, go to bed with several drinks in their systems and are unconscious the next morning because of very low blood glucose. They can have brain damage unless their bodies are able to manufacture enough glucose to wake them up.

Management Of Hypoglycaemia

By relatives or friends after minimal training. Paramedics can also use it at the patient's home or in an ambulance. The disadvantages are that it takes longer (approximately 10 minutes) than intravenous glucose to restore consciousness and does not work in patients who have deficient or absent hepatic glycogen stores (alcoholics or people with cachexia). Unfortunately, even where glucagon is available, relatives or friends may not use it. In one study (Muhlhauser et al., 1985b), 53 of 123 episodes of severe hypoglycaemia were treated by relatives or friends with glucagon, 30 by assisting physicians and 44 required hospital admission. When glucagon was available but not used, it was because those who knew how to use it were not present (20 cases) or were too anxious to do so (24 cases). In children with diabetes, Daneman et al. (1989) found that glucagon was used in only a third of households in which it was available - presumably because relatives were either too frightened or poorly...

How can you cope with stress

Since stress can affect the body and mind in so many ways, stress management is a very important part of any programme for coping with diabetes. It is clear that stress can affect certain aspects ofdiabetes, including blood sugar levels. Importantly, you can learn effective strategies that will help you to deal with it. Obviously smoking, alcohol abuse, the use of inappropriate drugs, and overeating are all common but poor coping strategies. True, these activities will distract you and perhaps delay the effects of the stress, but they can also hurt you and prevent you from coping with stress in a constructive way. So, what should you do

Fatty Liver Hepatitis And Cirrhosis

Chronic alcohol consumption can cause the deposition of excess triglycerol in the liver leading to a condition known as 'fatty liver'. This damage can lead to hepatitis and, if severe enough, to cirrhosis. The damage is thought to be due to the high concentrations of ethanal within the cell and if severe enough will result in cell death. Cell damage and death trigger an inflammatory response, i.e. infiltration of lymphocytes and activation of an immune response. If this is not treated it will lead to the formation of fibrous tissue and a severe reduction in the functioning of the liver.

Diabetes and Its Relationship to Pancreatic Carcinoma

A hospital-based case-control study revealed that cigarette smoking, family history of PC, heavy alcohol consumption (> 60 ml ethanol day) and diabetes mellitus are significant risk factors for PC. The significant synergy between these risk factors suggests a common pathway for carcinogenesis of the pancreas 58 .

Carbohydrate And Plasma Lipids

The elevation of blood lipid concentrations in response to large amounts of dietary sugars, particularly fructose and sucrose, has been recognised for many years. There are also many other variables that can influence postprandial TG concentrations, such as obesity, excessive alcohol consumption, genetic background and renal failure.

When should the treatment of hypertension in diabetic patients begin and in what way How long will the treatment last

Since hypertension in the diabetic individual is defined as the presence of BP levels > 130 80 mmHg, it is obvious that the therapeutic approach should begin when its values exceed these limits. Initially, for blood pressure levels of 130-139 80-89 mmHg, it is advisable for the first approach to be non-pharmaceutical, and to try to reduce the BP with lifestyle modification measures. These include an effort of body weight reduction in obese patients (with diet and exercise), reduction of salt and alcohol consumption, and smoking cessation. Weight loss is the most efficient of these measures, as regards the success of BP reduction (a loss of 10kg body weight usually produces a BP fall by 5-20mmHg). A reduction of dietary caloric consumption is very important, with fat restriction, mainly saturated animal fat, being the basic factor. Salt should be limited to less than 6g per day. Alcoholic beverages should also not exceed 2-3 glasses of wine (or equivalent alcohol quantity in other...

Nutritional Recommendations

The current European nutritional recommendations for people with diabetes (1999) state 'For those who choose to drink alcohol, intakes of up to 15 g for women and 30 g for men are acceptable' per day (4,5). This equates to one small (125 ml) glass of wine (12 abv) or 1.5 units for women per day and two small glasses of wine (12 abv) for men, which equates to 3 units. However, many wines have a higher alcohol content and many people would regularly drink a larger measure. The present consensus outlined in the European and American nutritional recommendations for people with diabetes concludes that there are benefits (unless medically contraindicated) from light to moderate alcohol intakes taken with a carbohydrate-containing meal. Moderate intakes of wine, especially red wine, which contains non-nutrient flavonoid and phenolic compounds, which have antioxidant properties, may confer greater benefit than consumption of spirits or beer (6). Much of the evidence from studies is based on...

The Irs As Risk Factor For

Prospective studies, now a decade old first suggested that hyperinsulinemia may be an important risk factor for ischemic heart disease. The Quebec Heart Study studied men who were 45 to 76 years of age and who did not have ischemia heart disease (13). A first ischemic event occurred in 114 men who were then matched for age, body mass index (BMI), smoking habits, and alcohol consumption with a control selected from among the 1989 men who remained free of ischemic heart disease during follow-up. Fasting insulin concentrations at base line were 18 higher in the case patients than in the controls. High fasting insulin concentrations were an independent predictor of ischemic heart disease in these men after adjustment for systolic blood pressure, family history of ischemic heart disease, plasma triglyceride, apolipoprotein B, low-density lipoprotein cholesterol, and high-density lipopro-tein cholesterol concentrations. Similarly, hyperinsulinemia was associated with increased all-cause and...

How does kidney transplantation differ in people with and without DM

A 64 year old woman without previous history of DM presents at the outpatient clinic with mild xerostomia, polyuria and polydipsia. She reports having dyslipidaemia and hypertension for a year, treated with cilazapril 5mg and amlodipine 10 mg daily. She is a smoker, has a moderate alcohol consumption, is obese (weight 80 kg 176.4 lb , height 1.62 m 5 ft, 4 in , BMI 31 kg m2), and has arterial pressure 170 80 mmHg otherwise her physical condition is unremarkable. Laboratory findings fasting blood glucose 112 mg dl (6.2 mmol L) urinalysis abundant WBCs and urine protein (+++). What would you initially recommend for the patient

Guidelines And Recommendations

Finally, while lifestyle measures for lowering blood pressure are beyond the scope of this chapter, it must be emphasised that attention to non-drug factors such as weight control, restriction of alcohol consumption, and adequate physical activity are even more important in diabetics than in hypertensive subjects without diabetes, and form an indispensable foundation for drug treatment.

Quantitative sensory testing

The limitations of QST are also clear. No matter what the instrument or procedure used, QST is only a semiobjective measure, affected by the subject's attention, motivation and cooperation, as well as by anthropometric variables such as age, sex, body mass and history of smoking and alcohol consumption (Gerr & Letz 1994 Gelber et al. 1995). Expectancy and subject bias are additional factors that can exert a powerful influence on QST findings (Dyck et al. 1998). Further, QST is sensitive to changes in structure or function along the entire neuroaxis from nerve to cortex it is not a specific measure of peripheral nerve function (Arezzo 2003).

What is the role and what are the principles of a proper diet in pregnancy

Avoidance of alcoholic beverages is also recommended, since there is evidence that even moderate alcohol consumption can be associated with foetal growth retardation, miscarriages and birth of small-for-gestation infants, as well as poor control of the mother's diabetes (hypoglycaemias, etc.).

Counterregulation During Hypoglycaemia

The potentially serious effects of hypoglycaemia on cerebral function mean that not only are stable blood glucose concentrations maintained under physiological conditions, but also if hypoglycaemia occurs, mechanisms have developed to combat it. In clinical practice, the principal causes of hypoglycaemia are iatrogenic (as side-effects of insulin and sulphony-lureas used to treat diabetes) and excessive alcohol consumption. Insulin secreting tumours (such as insulinoma) are rare. The mechanisms that correct hypoglycaemia are called coun-terregulation, because the hormones involved oppose the action of insulin and therefore are the counterregulatory hormones. The processes of counterregulation were identified in the mid 1970s and early 1980s, using either a bolus injection or continuous infusion of insulin to induce hypoglycaemia (Cryer, 1981 Gerich, 1988). The response to the bolus injection of 0.1 U kg insulin in a normal subject is shown in Figure 1.3. Blood glucose concentrations...

Practical Recommendations

Provided alcohol intakes are not contraindicated (see below), for most people with diabetes it is healthiest for men to drink 2-3 units and women to drink 1-2 units per day. Higher intakes, even taken occasionally, will have an impact on blood pressure and triglycerides and will increase the risk of hypoglycaemia and ketoacidosis. It is especially important that people with diabetes who are treated with insulin or sulphonylureas should eat a carbohydrate-containing meal and take their medication before drinking and have a bedtime snack (and long-acting insulin if prescribed) before going to sleep. They should also be aware that prolonged and severe hypoglycaemia can occur up to 36 h after binge drinking and this can be mistaken for intoxication. For those inclined to drink more

Nonpharmacological Treatment Of Hypertension In Diabetic Patients

The goal of treating hypertension in patients with diabetes mellitus is to prevent associated morbidity and mortality. Lifestyle modification, including weight management, diet, salt reduction, moderation of alcohol intake, increased physical activity and smoking cessation are the cornerstones of therapy. Weight loss in overweight individuals can improve control of both hypertension and diabetes mellitus. Many studies have shown that even modest reduction of body weight can improve BP and glycemic control. Reduction in weight may be associated with BP reductions because of reduction of insulin levels, sympathetic nervous system activity, and vascular resistance.

Preventing diabetic eye disease

Pregnant women must have their eyes screened as soon as pregnancy is diagnosed and again later in pregnancy. It is probably sensible to avoid oral contraceptives in women with marked background or proliferative retinopathy. Smoking should be stopped anyway, and excess alcohol intake is inadvisable.

Other Nutritional Factors

There are no firm epidemiological data with regard to the role of dietary protein in the etiology of type 2 diabetes. Although vegetarians present with lower rates of type 2 diabetes compared with persons who eat meat, it is impossible to disentangle the association of animal protein with the risk of type 2 diabetes from other dietary factors, such as saturated fat and fiber intake (11). The relationship between alcohol and other dietary variables similarly complicates attempts to evaluate a potential role for alcohol in the etiology of type 2 diabetes. In the Rancho Bernardo Study, increasing intakes of alcohol in obese men were associated with an increased risk of type 2 diabetes (33). On the other hand, moderate alcohol intake has been shown to be associated with enhanced insulin sensitivity (34,35).

Nonpharmacological interventions

A variety of lifestyle modifications reduce blood pressure and the incidence of hypertension (Ebrahim and Smith, 1998 He etal., 2000 Sacks etal., 2001 Whelton etal., 2002). Non-pharmacological interventions include weight loss in the overweight (He etal., 2000, Whelton etal., 2001), exercise programmes (Whelton etal., 2002), moderation of alcohol intake (Xin etal., 2001) and a diet with increased fruit and vegetables and reduced saturated fat content (Sacks etal., 2001), reduction in dietary sodium intake (Whelton etal., 1998 Sacks etal., 2001) and increased dietary potassium intake (He and Whelton, 1999) (Table 6.2). When adherence is optimal, systolic blood pressure is reduced by > 10mmHg (Sacks etal., 2001). Reductions are more modest in clinical practice (Ebrahim and Smith, 1998) and studies were not designed or powered to evaluate changes in overall or cardiac mortality. However, in long-term, large-scale population studies, even small reductions in blood pressure are...

Treatment Of Hypoglycemia

Fear of hypoglycemia is a real concern of patients receiving insulin therapy. Intensive glycemic goals may make this concern a reality because there is a threefold greater incidence of severe disabling hypoglycemia for patients striving to achieve near normal glycemic targets as compared to conventional insulin replacement therapy (4,6). Education regarding all aspects of diabetes care will be paramount in equipping the patient to prevent and treat hypoglycemia. Carbohydrate counting, insulin dosing, concomitant medications, alcohol intake, exercise, and even driving should be included in the discussion. Reducing iatrogenic hypoglycemia will involve the patient, their support system, and health-care provider. The health-care providers will take on the role of facilitator as they educate and empower the patient to achieve diabetes self-care practices that will reduce diabetes-related complications (acute and long-term). Education will help alleviate fear of hypoglycemia that may impede...

Management of hypertension

The role of sodium restriction is controversial. The INTERSALT Study showed that dietary sodium restriction can independently lower blood pressure and is additive with weight loss (Fagerberg et al., 1984). Studies have shown that moderate sodium restriction to 100 mmol (2300 mg) per day can reduce systolic pressure by 5 mmHg and diastolic pressure by 2-3 mmHg (Cutler et al., 1997). In addition, the response to antihypertensive therapy appears to be more effective in salt-restricted subjects. Physical activity, involving 30-45 min of brisk walking has been shown to lower blood pressure, as well as smoking cessation, and reduction of alcohol intake (Joint National Committee, 1997 Haire-Joshu et al., 1999 American Diabetes Association, 2002).

Environmental Risk Factors

Several studies have suggested that moderate alcohol intake may be associated with a reduced incidence of type 2 diabetes.82 For example, among 20000 male physicians in the USA, those consuming more than 24 drinks week had a lower incidence of type 2 diabetes over the subsequent 12 years than nondrinkers, and these relationships persisted after adjustment for body-mass index and other diabetes risk factors.83

Dietary treatment of diabetes

Dietary changes should modify, rather than totally change the patient's eating pattern. Total calorie intake should be restricted to that needed to achieve and maintain an agreed target weight. At least half the energy intake should be made up of carbohydrate, and from mainly complex carbohydrates, with a high fibre content. At least five portions, and preferably more, of fruit and vegetables should be consumed every day (a portion is 80 g but is most simply measured as one handful), refined carbohydrates in the form of sugary food and drinks should be reduced. Total fat intake should be reduced, and saturated (animal) fats replaced with monounsaturated and polyunsaturated fats commonly found in oily fish and green leafy vegetables (Royal College of General Practitioners, 1994). Dietary salt should be reduced, alcohol intake should be in moderation, and special 'diabetic' products which are high in calories are not to be recommended. Much can be achieved from a few simple dietetic...

Types of Neuropathy and Treatment

If you are experiencing a sudden drop in blood pressure when you stand up, there are several treatment options. If you drink alcohol or take medications, such as diuretics, ask your provider about stopping them. Other options include medications for low blood pressure, raising the salt content of your diet, or raising the head of your bed. However, low blood pressure in itself is not unhealthy. It only becomes a problem if it makes you dizzy or disoriented. Try to stand up more slowly and avoid staying still for long periods to prevent fainting. When you get up in the morning, sit on the edge of the bed before you stand up.

Nonalcoholic Steatohepatosis

Non-alcoholic fatty liver disease, has recently become increasingly recognized and may progress to end-stage liver disease. It is histologically indistinguishable from the liver damage that is secondary to alcohol abuse, but occurs in people with no history of alcohol excess. Non-alcoholic fatty liver disease has a wide spectrum of liver damage ranging from simple steatosis to steatohepatitis, advanced fibrosis and cirrhosis. The combination of steatosis, infiltration by mononuclear or polymorphonuclear cells (or both), and hepatocyte ballooning and spotty necrosis is known as nonalcoholic steatohepatitis (NASH). Non-alcoholic fatty liver disease is the most common cause of abnormal liver blood results among adults in the USA. It is particularly common in those with combined diabetes and obesity in a group of severely obese patients with diabetes, 100 were found to have mild steatosis, 50 had NASH and 19 had cirrhosis. Insulin resistance seems to be the most reproducible causative...

Case Study Lactic Acidosis

A 74 year old woman presents to the hospital with complaints of recent high blood glucose levels and a feeling of progressively deteriorating fatigue. Her family members report episodes of lethargy and intense sleepiness, as well as confusion during the previous week. The patient suffers from DM (for 12 years), hypertension, coronary heart disease, dyslipidaemia, heart failure and atrial fibrillation. An echocardiogram done three months before showed left ventricular hypertrophy, mitral regurgitation and an ejection fraction of 35 percent. Her medications include glimepiride, 6mg day digoxin, 0.125 mg day rami-pril, 10 mg day furosemide, 20 mg twice a day aspirin, 325 mg day and for the last two months metformin, with a gradual increase of the dose to 1700 mg day. She does not smoke or drink alcohol. Biguanides, and mainly fenformin, increase lactate production. Frequently, however, manifestation of lactic acidosis requires the additional presence of some other disease or condition,...

Which factors can affect the HbAc value

Any condition that reduces the duration of life of the red blood cells or their mean life-span (haemolytic anaemias or an acute haemorrhage), leads to falsely low HbA1c levels, regardless of the method used for its determination. Hypertriglyceridaemia, uraemia, elevated bilirubin and alcoholism have been reported to influence chromatography methods, resulting in falsely elevated HbA1c values. Haemoglobinopathies affect some of the methods regardless of their effect on red blood cells' life span. The results can be false elevations or false decreases, depending on the method used and haemoglobinopathy present. Ion-exchange chromatography methods are affected more, and immunoassays and affinity chromatography methods, less. Nevertheless, most abnormal haemoglobins are recognized during chromatography and their presence should be reported in the result. Fetal haemoglobin (HbF) co-chromatographs with HbA1 and consequently, when increased (as is the case mainly in homozygous b-thalassaemia...

Biomedical Risk Factors

Instances, the degree of hypoglycemia was profound, i.e., blood glucose levels typically fell below 1.5mmol l (27mg dl), persisted for an extended period of time, and were accompanied by coma or seizure, or an essentially flat (isoelectric) EEG. Moreover, most of the diabetic patients described in these case reports were older adults who may have also had some other conditions that could affect brain integrity (e.g., history of chronic alcohol abuse) or who may have manifested wildly fluctuating blood glucose levels (e.g., history of brittle diabetes). Although this form of profound hypo-glycemia can lead to extraordinary brain morbidity, it seems to be atypical, occurring remarkably infrequently in diabetic patients as a group, with even fewer published reports of such events occurring in children and adolescents.

Laboratory Criteria Of Coma Diabeticum

The criteria in clinical chemistry of a diabetic coma are summarized in Table 2 (8) approximately 15 of patients with diabetic ketoacidosis have glucose concentration in plasma < 350mg dL. In these cases one speaks of euglycemic diabetic ketoacidosis. This appears in situations in which gluconeogenesis appears to be disturbed, e.g., liver disease, alcoholism, prolonged fasting or in cases where insulin-independent glucose consumption is very high (i.e., in pregnancy). In cases where blood glucose levels are below < 16mmol L (240 mg dL) and there is only mild ketonemia a diabetic cause for an unclear coma is virtually excluded. In these cases one must look for other causes of coma, e.g., intracerebral bleeding, liver failure, intoxication, uremia, and hypoglycemic coma.

Charcot Neuroarthropathy

Common Feet Deformities

Charcot neuroarthropathy is a noninfectious progression of joint destruction characterized by pathological fractures and joint dislocations. Although it was initially described by Musgrave in 1704, its name was attributed to J.M. Charcot in 1868 (116). The disease involves joint destruction of accompanying common diseases that manifest with peripheral neuropathy, such as leprosy, tertiary syphilis, chronic alcoholism, and spina bifida (117). Diabetes mellitus is currently the primary cause of Charcot neuroarthropathy.

Hyperglycemia Causing Cardiac Conduction Defect

Hypoglycemia Schematic Diagram

Focal neurological lesions as a consequence of acute hypoglycemia are rare, as is severe brain damage, which probably requires several hours of exposure to profound hypoglycemia. These isolated events are usually associated with deliberate insulin overdose or excessive alcohol consumption. However, transient and reversible neurological deficits have increasingly been demonstrated in individual cases with sophisticated neuroimag-ing techniques (44, 45), indicating that functional changes within the brain may be commonplace, without leaving a permanent structural abnormality. Structural abnormalities of the brain that are observed in the survivors of exposure to profound hypoglycemia include cortical and hippocampal atrophies and ventricular dilatation. Such individuals either exist in a vegetative state or have evidence of profound cognitive damage. In patients with profound and protracted hypoglycemic coma, prognosis can be difficult to determine, but if serum markers of brain damage,...

Clinical Efficacy Of Metformin In Patients With Type Diabetes Mellitus

One study investigating individual cases of metformin-associated lactic acidosis showed that in these patients metformin should either have never been started or discontinued with the onset of acute illness (110). Thus, strict adherence to the exclusion criteria of metformin treatment renal (creatinine clearance < 60 mL min) and hepatic disease, cardiac (NYHA III-IV) or respiratory insufficiency, severe infection, alcohol abuse, history of lactic acidosis, pregnancy, use of intravenous radiographic contrast) should minimize the risk of metformin-induced lactic acidosis.

Risks Of Death From Hypoglycaemia

The risk factors that are commonly cited as increasing the risk of death from hypoglycaemia are often anecdotal, and may owe more to the prejudices of individual clinicians than to scientific evidence. Those suggested are detailed in Box 12.1 and include alcohol abuse and or inebriation (Arky et al., 1968 Kalimo and Olsson, 1980 Critchley et al., 1984 MacCuish, 1993), psychiatric illness or personality disorder (Shenfield et al., 1980 Tunbridge, 1981), self-neglect (Tunbridge, 1981), resistance to education (Shenfield et al., 1980), hypopituitarism following pituitary ablation therapy for proliferative retinopathy (Nabarro et al., 1979 Shenfield et al., 1980), and patients who have diabetes secondary to pancreatic disease (MacCuish, 1993). Alcoholism and or inebriation Another study from Norway of patients under the age of 40, identified 240 deaths from all causes and 16 cases that fulfilled the criteria of 'dead in bed syndrome' (Thordarson and Sovik, 1995). This represented 6.7 of...

Epidemiology Of Dyslipidemia In Type Diabetes

Dyslipidemia is common in patients with type 2 diabetes it is present at the time of diagnosis, and even in the pre-diabetic phase. It persists despite usual hypoglycemic therapy and its expression will be affected by genetic and lifestyle characteristics, such as gender, obesity, exercise levels, diet, alcohol intake, poor glycemic control, smoking, hypothyroidism, as well as renal and hepatic function. It is also affected by concomitant drugs and the presence of primary dyslipidemia, such as familial combined hyperlipidemia.

Dietary Modifications

And finally, the quality and quantity of certain beverages should be considered in dietary intake. As noted above, high fructose containing soft drinks and other beverages like fruit juices drinks, and sports drinks should be avoided. In addition, one should be moderate if alcohol is consumed as excess alcohol consumption leads to a variety of health problems, including increasing the risks of developing type 2 diabetes and cancer. Drinking green tea may also be beneficial for health. The quality of water should also be considered since many tap waters may contain cancer-promoting chemicals such as perchlorate (jet fuel) or toxic heavy metals such as lead.

Metformin and Sulfonylurea

Because they contain metformin, metformin and sulfonylurea combination products are not indicated with serum creatinines greater than 1.4 mg dL in women and 1.5 mg dL in men or creatinine clearances less than 60 mL minute, or in congestive heart failure, respiratory conditions prone to acidosis, chronic alcoholism, significant hepatic disease, or any history of significant hypoxia or lactic acidosis. The same restrictions for withholding this product before any studies using iodinated contrast materials, as discussed in the Subheading entitled The Biguanides, are applicable.

Implications For Future Epidemiological Research

Field if standardized definitions were developed and used in multiple investigations, although care should be taken to avoid protocols that would be burdensome to study participants, because these would increase the likelihood of bias because of unac-ceptably low participation rates. Also, measurement methods should be used which easily translate into clinical practice. Important potential confounding variables must be considered in future studies, including alcohol consumption in particular, height, and possibly nutritional factors as well. Further investigation of the association between hyperlipidemia and risk of neuropathy is warranted to examine the possibility that this complication may have, in part, a macrovascular etiology. Prospective studies of large cohorts of diabetic subjects would likely yield the best quality information concerning potential causative risk factors for diabetic neuropathy. Because of the low frequency of occurrence of diabetic focal neuropathies, the...

Erectile Dysfunction in Diabetes and Its Treatment

Pensation, the presence of microvascular complications (especially retinopathy) and neuropathy, high blood pressure and the drugs taken for that condition, smoking and alcohol abuse. The age factor is particularly important. The very earliest epidemiological studies showed that the incidence of impotence in diabetic males rose from 1.5 in the under-40s to 25 in the 40-60 age group. More recently, others have reported incidences rising from 15 in the under-40 group to 55 at 60. The trend revealed by the Wisconsin Epidemiologic Study in particular is highly significant (p< 0.0001), rising from 1.1 in the 21-30 age group to 47.1 among insulin-dependent diabetics over 43 years old. Klein himself confirms that significance when he analyses the duration of diabetes men with a more than 35-year history of the disease are 7.2 times more likely to present this complication than those with only a 10- to 14-year history. However, the link between erectile dysfunction and disease duration is...

Precipitating Factors

Unless related to omission of insulin therapy, DKA is usually precipitated by coexisting illness. The most common factor is infection ranging from trivial viral infections to full-blown septicaemia. Other precipitating factors are cardiovascular events (myocardial infarction, stroke), gastrointestinal disease, inflammatory diseases, pancreatitis, trauma and major surgery, alcohol abuse and drugs (e.g. glucocorticoids). All of these factors induce insulin resistance due to stress hormone responses. Furthermore, poor appetite and food deprivation will often lead the patient to take less insulin, erroneously of course. In this context gastrointestinal disease with nausea and vomiting poses a specific problem and it may be necessary to admit such

Modifiable Risk Factors

Hu et al. (39) published results from the Nurses' Heath Study including 84,941 female nurses followed from 1980 to 1996, and who were free of diagnosed cardiovascular disease and diabetes at baseline. During the 16 years follow-up 3300 new cases of type 2 diabetes were diagnosed. As shown in Figure 4 obesity was the single most important predictor of diabetes. Women whose body mass index was at least 35.0 km m2 had almost 40-fold risk of becoming diabetic compared to women whose body mass index was < 23.0 kg m2. Weekly exercised at least 7h wk reduced the risk of type 2 diabetes by 39 compared to women who exercise < 0.5h wk. Smoking of > 14 cigarettes day increased the diabetes risk by 39 , but alcohol intake > 10 g day reduced the risk by 41 . The study also indicated that a diet high in cereal fiber and polysaturated fat and low in saturated and trans fats and glycemic load reduced the risk of developing diabetes. A combination of several lifestyle factors, including low...

Contraindications

People with diabetes who should abstain from drinking alcohol include those with a history of alcohol abuse, pancreatitis, liver disease, gastritis and women during pregnancy. Also intakes should be restricted for those who have hypertriglyceridaemia, hypertension, neuropathy and frequent hypoglycaemia and hyperglycaemia. People with DM who also take antiepileptics and tranquillisers should seek advice from their doctor or pharmacist before drinking alcohol because of possible drug interactions.

Finding help

Alcohol abuse has numerous physical and mental consequences, including cirrhosis of the liver (when the liver loses its ability to function properly and you die of hemorrhage or liver failure) and degeneration of the brain (when you lose coordination and develop severe emotional instability). Alcohol also is a home wrecker. For the person with T1DM, alcohol abuse makes it impossible to control the blood glucose to prevent complications. The abuser takes in enormous quantities of empty (non-nutritious) calories and usually fails to eat good food. He fails to take his insulin either because he's drunk or because he forgets to take it when sober. All this is a prescription for diabetes disaster. How do you know if you have a serious problem with alcohol Here are the key tip-offs that suggest you need help with a drinking problem You can stop your heavy drinking, but you need help to do it. Only a small percentage of alcoholics stop on their own, but 90 percent of alcoholics who go...

Fourniers Gangrene

This is a syndrome of synergistic, polymicrobial, necrotizing fasciitis of the perineum, scrotum, and penis. The prevalence of coexisting diabetes ranges from 32 to 60 (45,46). Other predisposing factors include alcoholism, steroid use, cancer chemotherapy, and acquired imnunodeficiency syndrome (AIDS) (47).

Biguanides

The most common and troublesome side-effects of metformin include gastrointestinal discomfort, nausea, diarrhea, anorexia, and rarely a metallic taste (Dandona et al 1983). Starting therapy with 500 mg daily and increasing the dose gradually can attenuate these side-effects. The biguanide-associated malabsorption of vitamin B12 (cyanocobalomin) and folate is usually not a major clinical concern (Tomkin 1973 Bergman, Boman and Wilholm 1978). However, this should be borne in mind when prescribing for elderly subjects who have a relatively high incidence of atrophic gastritis and vitamin B12 deficiency. Although rare, the most dreaded side-effect is lactic acidosis, the incidence of which is approximately 9 per 100 000 persons per year in metformin users (Stang, Wysowski and Butler Jones 1999), almost 10 times lower than that associated with phenformin. Therefore, any clinical condition associated with or predisposing to lac-tate generation or decreased ability to clear lactate is a...

Hypoglycaemia

In the fasted state, hepatic gluconeogenesis is essential for the production of glucose and maintenance of the blood sugar level. Ethanol is a potent inhibitor of gluconeogenesis. The suppression of gluconeogenesis, even at relatively low alcohol intakes, with low serum insulin and high serum glucagon, results in a decreased ratio of NAD + to NADH which inhibits the entry of the precursors of gluconeogenesis (i.e. glycerol, lactate, alanine and other amino acids) into the hepatocyte (13). This can lead to severe and prolonged hypoglycaemia when large volumes of alcohol are ingested rapidly and may occur up to 36 h after alcohol ingestion. The major problem of alcohol ingestion in the person with diabetes is induction and masking of hypoglycaemia, causing hypogly-caemia unawareness. Hypoglycaemia most commonly occurs in the fasting state in people with Type 1 and Type 2 diabetes but also in non-diabetics, especially when hepatic glycogen stores are depleted or exhausted....

Insulin Sensitivity

Moderate alcohol consumption among healthy subjects may be associated with increased insulin sensitivity and a reduced risk of diabetes (28). Reaven and co-workers (33) found that light to moderate alcohol consumption is associated with enhanced insulin-mediated glucose uptake, lower plasma glucose and insulin concentrations in response to oral glucose in healthy men and women. For people with diabetes, light to moderate alcohol intakes with meals do not substantially alter the blood glucose concentration (34,35). However, heavy intakes may be associated with an increase in glucose intolerance. So the effect on insulin sensitivity depends on the amount of alcohol consumed (36).

Alcohol

Alcohol need not be restricted in individuals with type 1 diabetes as long as it is limited to no more than one daily serving for women and two for men. Alcohol in these amounts has little effect on glycemic control but does potentiate the glucose-lowering effect of insulin by reducing hepatic glucose production. Because patients with type 1 diabetes take insulin, they should take care to consume alcohol with food to prevent hypoglycemia. Moderate alcohol consumption has been associated with reduced cardiovascular disease risk in the general population, suggesting that alcohol may, in fact, be beneficial to some individuals at high risk (54).

Hypertension

The UK Prospective Diabetes Study underlined the importance of well-controlled hypertension for people with Type 2 diabetes to reduce the risk of microvascular complications. There is a direct empiric relationship between alcohol intake and blood pressure. Some researchers have found this relationship to be J-shaped (19), others U-shaped, but there is agreement that light to moderate drinkers have lower blood pressure than those who abstain and blood pressure rises steeply with heavier intakes. In heavy drinkers ingesting > 300 g or 30 units per week there is a four times greater risk of stroke than in non-drinkers (20), whereas moderate alcohol consumption, up to two drinks per day, is protective for ischaemic stroke (21). Alcohol consumption showed a clear positive correlation with the subsequent development of haemorrhagic stroke but did not show a correlation with the thromboembolic variety (22). Although blood pressure is important in thrombotic stroke, alcohol's metabolic...

Other interventions

Observational results increasingly support the role of cigarette smoking as a reversible risk factor for diabetes. Manson and colleagues recently reported results from the Physicians Health Study247, which found a dose-dependent increased risk for development of type 2 diabetes compared with never smokers. After adjustment for BMI, activity and alcohol consumption (but not dietary factors), the RR for smoking were 1.0 (CI 0.8-1.3) for 1-19.9 pack-years 1.3 (CI 1.0-1.6) for 20-39.9 pack-years, and 1.6 (CI 1.3-2.1) for 40+ pack-years (p < 0.001 for trend). The other Health Professional follow-up studies showed consistent elevations in diabetes risk248,249, as did the Zutphen Study145, a Japanese worker cohort250 and the Osaka Health Survey251. Three other prospective studies found no associations140,194,252. Each of these negative studies had fewer cases of incident diabetes than seen in the positive studies. Smoking cessation for diabetes prevention has not been evaluated in...

Maintenance

In most cases, a behaviour will have to be continued for several months before it becomes the new norm and the individual can become less vigilant. This time period can vary according to the behaviour and individual differences. For smoking, this may take a year or two, for controlled drinking several years. In the maintenance stage, all the principles and problems identified in the action phase still apply. However, it is inevitable that people will sometimes forget to keep the change going and maybe go 'off the rails' for several days. For individuals prone to 'all-or-nothing' thinking, this may precipitate a total relapse. It is therefore essential that preparatory work is done to define the difference between a lapse (a temporary phenomenon) and relapse (in which the attempt to change is abandoned). This is known as the 'abstinence volition effect' in Marlott and Gordon's116 Relapse Prevention Model (Figure 5.10), in which an individual interprets a slip as a relapse and in...

Special populations

Waiver or alteration of informed consent procedure is sometimes necessary in order to perform studies in 'special populations' these are prisoners, students or employees of the trial site, or persons who are legally incapable of giving informed consent, such as children and comatose, sedated or psychiatric patients. In addition, studies on women of child-bearing age, alcohol or drug dependent individuals and individuals with a family history of drug or alcohol problems must be handled separately. An IRB IEC may approve a consent procedure that does not include or alters some or all of the elements of informed consent

Vanadium

The verdict on vanadium's benefits to people with diabetes is still out, but if you want to get a bit more of it into your diet, have a glass of red wine a few times a week. Perhaps this practice is the explanation for the decreased occurrence of heart disease in the French compared to Americans, and as I explain in Chapter 5, heart disease is a major complication of T1DM. Anything you can do to lower your chances of heart disease is a step in the right direction. But remember, a person with T1DM needs to watch his alcohol intake like a hawk I discuss alcohol in the next section.

Obesity

Whether or not the consumption of alcohol constitutes a risk for weight gain and 'whether alcohol calories count' has been widely debated. Alcohol is utilised as an energy substrate by the body, contributing 7 kcal g to energy intakes, however, unlike other energy sources, there is no immediate storage mechanism in the body. The net efficiency of energy utilisation is lower from alcohol than for fat and carbohydrate and its thermogenic effect has been assessed as 15 from acute doses (38). Lieber (39), when proposing the microsomal ethanol oxidising system (MEOS) for metabolising alcohol, hypothesised that in heavy drinkers this is uncoupled and energy from alcohol is dissipated. There is no evidence that consuming alcohol under isoenergetic conditions, i.e. replacing carbohydrate or fat calories with alcohol calories, increases the risk of obesity. Indeed some researchers have found an inverse relationship between alcohol intake and BMI and adiposity, despite an increase in total...

Diabetes and alcohol

Most people with diabetes drink alcohol and it is perfectly safe to do so. However, it is important to be aware that if you are treated with insulin, alcohol makes the occurrence of a hypo more likely and this increased risk continues for some time after you stop drinking. When someone has a hypo a number of hormones are produced that make the liver release glucose into the bloodstream. If that person has drunk some alcohol, even as little as two pints of beer or a double measure of spirits, the liver will not be able to release glucose and hypo reactions will be more sudden and more severe. This effect may be compounded by the fact that alcohol alters your perception and you may be less aware of your hypo symptoms. Therefore, when you are under the influence of alcohol you are not in the best shape to react appropriately and quickly. Most alcoholic drinks also contain some carbohydrate, which tends to increase the glucose in the blood. The overall effect therefore of a particular...

Histology

The histological changes of NAFLD are similar to that produced by alcohol (31). Thus the diagnosis of NAFLD cannot be made by histological means alone and requires the clinical exclusion of excessive alcohol intake. The histological hallmark of NAFLD is hepatocellular triglyceride accumulation, which is predominantly macrovescicular, although may be mixed with microvescicular fat, which implies defective mitochondrial FFA oxidation. Steatohepatitis requires the presence of lobular inflammation, which is usually a mixed mononuclear neutrophilic infiltrate and is frequently associated with hepatocyte ballooning and less commonly Mallory's hyaline (32). Hepatocellular ballooning, disarray and fibrosis are typically predominant in zone three of the hepatic lobule. Fibrosis is typically pericellular and perisinusoidal giving a chickenwire appearance. Eventually, fibrotic septae form between the hepatic vein and portal tract and nodules may form heralding the onset of cirrhosis....

What About Alcohol

Should you count the carbohydrates in the alcohol you drink When you drink alcohol, it is metabolized (that is, broken down) by the liver, and there is less glucose production while the alcohol is being broken down. In people with diabetes who are on insulin, this can cause hypoglycemic reactions. It is therefore important that you drink alcohol with a meal rather than on an empty stomach. The recommended amount of alcohol is the same as for people without diabetes two drinks for men and one for women. One drink is defined as twelve ounces of beer, five ounces of wine, or one and a half ounces of distilled spirits. You generally do not need to

Alcohol Addiction

When we drink alcohol or put it on the skin (as in mouth-wash, tinctures, medicine) or produce it by fermentation in the intestines (Candida produces alcohol) a substance, salsol, is formed. Salsol reacts with beryllium. If the beryllium is in the pleasure center it reacts with it there. This reaction has the effect of activating the cells Now a large amount of pleasure-chemical can be released. The amount is larger than normal because so many clogged cells are activated together. This explains the alcohol high. In all the alcohol-addicted persons I studied, salsol was present, along with beryllium, on the receptor sites normally activated by glutamate (or NMDA or kainate). As we removed the beryllium we saw that the salsol also disappeared. The solution to alcoholism is to avoid ergot contaminated food and avoid beryllium inhalation. We also remove the brain beryllium using thioctic acid. Stopping the use of alcohol may save a life or career but does not correct the problem. Even...

Lifestyle

Patients with normal body weight do not have dietary restrictions with respect to carbohydrate intake, but even so they should monitor their carbohydrate intake and adjust the dose of short-acting insulin based on experience or a personalized calculation of carbohydrate insulin ratio. Both lean and obese patients should be advised to restrict saturated fats and trans-fats. The use of alcohol is not prohibited, but should be moderate. Binge drinking of alcoholic beverages can induce late hypoglycemia (51). Smoking should be discouraged at all times, and patients should be offered both mental and pharmacological support to quit.

Hyperglycemic crisis

The most common precipitating factor in the development of DKA or HHS is infection. Other precipitating factors include cerebrovascular accident, alcohol abuse, pancreatitis, myocardial infarction, trauma, and drugs (steroids, antipsychotics, thiazide diuretics, etc.). In addition, new-onset type 1 diabetes or discontinuation of or inadequate insulin in established type 1 diabetes commonly leads to the development of DKA, which may be recurrent in some patients with psychologic problems complicated by eating disorders.

Toxic Food

Benzopyrenes must be detoxified using the liver's valuable benzene-detoxification system. With so many benzene-polluted items, there is hardly enough detoxification capability to get it all taken care of. NAD enzymes (the N stands for niacin) come into play too. These are essential for alcohol detoxification. If you have consumed alcohol, like a can of beer, NAD enzymes must be shared between the alcohol in the beer and the benzene in the beer. It takes longer to detoxify both the benzene and alcohol. The time delay is a time of lowered immunity and facilitates a growth spurt for parasites and pathogens.

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