Alcohol and the risk for latent autoimmune diabetes in adults: results based on Swedish ESTRID study

Association Between Alcohol Consumption and Disability Accumulation in Multiple Sclerosis

BACKGROUND AND OBJECTIVES

Previous studies have indicated that alcohol consumption is associated with multiple sclerosis (MS) disease progression. We aimed to study the influence of alcohol consumption habits on disease progression and health-related quality of life in MS.

METHODS

We categorized patients from 2 population-based case-control studies by alcohol consumption habits at diagnosis and followed them up to 15 years after diagnosis through the Swedish MS registry regarding changes in the Expanded Disability Status Scale (EDSS) and Multiple Sclerosis Impact Scale 29 (MSIS-29). We used Cox regression models with 95% confidence intervals (CIs) using 24-week confirmed disability worsening, EDSS 3, EDSS 4, and physical and psychological worsening from the patient's perspective as end points.

RESULTS

Our study comprised 9,051 patients with MS, with a mean age of 37.5 years at baseline/diagnosis. Compared with nondrinking, low and moderate alcohol consumption was associated with reduced risk of EDSS-related unfavorable outcomes (hazard ratios between 0.81 and 0.90) and with reduced risk of physical worsening. The inverse association was confined to relapsing-remitting MS and was more pronounced among women. High alcohol consumption did not significantly affect disease progression. The inverse relationship between low-moderate alcohol consumption and disability progression became stronger when we only included those who had not changed their alcohol consumption during follow-up (hazard ratios between 0.63 and 0.71). There were no differences in measures of disability at baseline between drinkers who continued drinking alcohol after diagnosis and those who later discontinued. Our findings speak against bias due to reverse causation.

DISCUSSION

Low and moderate alcohol consumption was associated with more favorable outcomes in relapsing-remitting MS, compared with nondrinking, while there was no significant influence of high alcohol consumption on disease outcomes.

Exploration of Immune Targets for Type 1 Diabetes and Latent Autoimmune Disease Immunotherapy

Type 1 diabetes (T1D) is an autoimmune disease that destroys pancreatic beta cells, which produce insulin in the islets of Langerhans. The risk of developing T1D is influenced by environmental factors, genetics, and autoantibodies. Latent autoimmune diabetes in adults (LADA) is a type of T1D that is genetically and phenotypically distinct from classic T1D. This review summarizes the accumulated information on the risk factors for T1D and LADA, and immunotherapy trials that offer insights into potential future combined therapeutic interventions for both T1D and LADA to slow the rate of islet cell loss and preserve beta cell function. Future research should also focus on improving intervention doses, conducting more thorough examinations of intervention responders, and/or combining minimally effective single-target immunotherapies to slow the rate of islet cell loss and preserve beta cell function.

Adult-onset autoimmune diabetes

Adult-onset autoimmune (AOA) diabetes pathophysiology starts with immune changes, followed by dysglycaemia and overt disease. AOA diabetes can occur as classic type 1 diabetes when associated with severe loss of insulin secretion. More frequently, it is diagnosed as latent autoimmune diabetes in adults, a slowly progressing form with late onset, a long period not requiring insulin, and it is often misdiagnosed as type 2 diabetes. As its clinical presentation varies remarkably and immune markers often lack specificity, it is challenging to classify each case ad hoc, especially when insulin treatment is not required at diagnosis. Proper care of AOA diabetes aims to prevent complications and to improve quality of life and life expectancy. To achieve these goals, attention should be paid to lifestyle factors, with the aid of pharmacological therapies properly tailored to each individual clinical setting. Given the heterogeneity of the disease, choosing the right therapy for AOA diabetes is challenging. Most of the trials testing disease-modifying therapies for autoimmune diabetes are conducted in people with childhood onset, whereas non-insulin diabetes therapies have mostly been studied in the larger population with type 2 diabetes. More randomized controlled trials of therapeutic agents in AOA diabetes are needed.

Lifestyle or Environmental Influences and Their Interaction With Genetic Susceptibility on the Risk of LADA

Background

LADA is a common form of diabetes described as a mix between type 1 and type 2 diabetes. Understanding of how genes and environmental factors interact in the development of LADA is central for future efforts to prevent the disease. This review aims to synthesize the literature on lifestyle factors linked to LADA risk and discuss their potential interaction with genetic susceptibility.

Findings

Current knowledge on environmental risk factors for LADA is primarily based on observational data from Scandinavian populations. Increasing evidence suggest that lifestyle factors promoting type 2 diabetes such as obesity, sedentariness, low birth weight and smoking, is implicated in the risk of LADA. Data from mendelian randomization studies support that the link between LADA and obesity, low birth weight and smoking is causal. Limited evidence indicates that dietary factors including consumption of red meat, coffee and sweetened beverages may increase the risk while consumption of alcohol and omega-3 fatty acids may reduce the risk. Several lifestyle factors, including smoking and obesity, seem to interact with human leukocyte antigen genes associated with autoimmunity, conferring much stronger effects on disease risk among those exposed to both factors.

Summary

Available studies suggest that lifestyle modification has the potential for prevention of LADA, particularly for individuals with high risk of disease such as those with genetic susceptibility. Research into risk factors of LADA is however limited, confirmations are warranted, many factors remain to be explored, and there is a need for intervention studies to assess causality.

Combined lifestyle factors and the risk of LADA and type 2 diabetes - Results from a Swedish population-based case-control study

AIMS

We investigated the risk of latent autoimmune diabetes in adults (LADA) and type 2 diabetes in relation to a healthy lifestyle, the proportion of patients attributable to an unhealthy lifestyle, and the influence of family history of diabetes (FHD) and genetic susceptibility.

METHODS

The population-based study included incident LADA (n = 571), type 2 diabetes (n = 1962), and matched controls (n = 2217). A healthy lifestyle was defined by BMI < 25 kg/m², moderate-to-high physical activity, a healthy diet, no smoking, and moderate alcohol consumption. We estimated odds ratios (OR) with 95% confidence intervals (CIs) adjusted for age, sex, education, and FHD.

RESULTS

Compared to a poor/moderate lifestyle, a healthy lifestyle was associated with a reduced risk of LADA (OR 0.51, CI 0.34-0.77) and type 2 diabetes (OR 0.09, CI 0.05-0.15). A healthy lifestyle conferred a reduced risk irrespective of FHD and high-risk HLA genotypes. Having a BMI < 25 kg/m² conferred the largest risk reduction for both LADA (OR 0.54, CI 0.43-0.66) and type 2 diabetes (OR 0.12, CI 0.10-0.15) out of the individual items.

CONCLUSION

People with a healthy lifestyle, especially a healthy body weight, have a reduced risk of LADA including those with genetic susceptibility to diabetes.

Alcohol as friend or foe in autoimmune diseases: a role for gut microbiome?

Alcohol is well known for promoting systemic inflammation and aggravating multiple chronic health conditions. Thus, alcohol may also be expected to serve as a risk factor in autoimmune diseases. However, emerging data from human and animal studies suggest that alcohol may in fact be protective in autoimmune diseases. These studies point toward alcohol's complex dose-dependent relationship in autoimmune diseases as well as potential modulation by duration and type of alcohol consumption, cultural background and sex. In this review, we will explore alcohol's pro- and anti-inflammatory properties in human and animal autoimmune diseases, including autoimmune diabetes, thyroid disease, systemic lupus erythematosus, rheumatoid arthritis, experimental autoimmune encephalomyelitis and multiple sclerosis. We will also discuss potential mechanisms of alcohol's anti-inflammatory effects mediated by the gut microbiome.

Effects of moderate red wine on cardiovascular risk factors in diabetics: a systematic review and meta-analysis of randomized controlled trials

Background: Diabetes mellitus is of major public health concerns; its incidence is continuously increasing. Diabetes mellitus is associated with a high risk of cardiovascular complications such as hypertension. Red wine has been reported to reduce cardiovascular risk factors. We quantified the effects of red wine on cardiovascular factors. Methods: We retrieved English-language articles published from January 1990 to April 2019. Cardiovascular risk factors were compared using means with 95% confidence intervals (95% CIs). Results: We identified five eligible randomized controlled trials. Diabetic patients who drank red wine exhibited significantly reduced systolic blood pressure (BP) (mean difference [MD] -1.33, 95% CI -1.81, -0.85) and diastolic BP (MD -1.31, 95% CI -1.80, -0.83) than those who did not. Compared to the observations for diabetics who did not drink red wine, the high-density lipoprotein (HDL) level was significantly higher in red wine drinkers (MD -0.24, 95% CI -0.39, -0.09). However, red wine had no effect on the body mass index (BMI) (MD -0.27, 95% CI -1.80, 1.25), the total cholesterol level (MD 0.13, 95% CI -0.17, 0.44), or the low-density lipoprotein (LDL) level (MD 0.08, 95% CI -0.21, 0.37). Conclusions: Red wine consumption significantly lowered BP and increased the HDL level in diabetics. Red wine had no significant effect on BMI or cholesterol and LDL levels. Given the heterogeneity of the studied populations and the lack of standardization and completeness across the published studies, caution is required while interpreting these findings.

[Features of the development of latent autoimmune diabetes in adults (LADA)]

The study of the sociomedical problems of diabetes mellitus led to the discovery of latent autoimmune diabetes in adults (LADA), a special form of the disease. The slow onset of the disease, the clinical signs of type 2 diabetes mellitus concurrent with the autoantibody pancreatic β-cell destruction mechanism that is characteristic of type 1 diabetes. Genetic factors play an important role in the genesis of the disease. Insulitis concurrent with intact or hypertrophic islets of the gland originally develops morphologically. Subsequently, the phenomena of islet atrophy and sclerosis are progressive. The disease is typical for young people (generally those aged 25-35 years) with normal body mass index, low blood C-peptide levels, with antibodies against β-cells, primarily to glutamate decarboxylase, being detected. Insulin preparations should be used to treat these patients.

Etiology and Pathogenesis of Latent Autoimmune Diabetes in Adults (LADA) Compared to Type 2 Diabetes

As the heterogeneity of diabetes is becoming increasingly clear, opportunities arise for more accurate assessment of factors influencing disease onset, which may lead to more efficient primary prevention. LADA - latent autoimmune diabetes in adults - is a common, hybrid form of diabetes with features of both type 1 and type 2 diabetes. This review aims to summarize current knowledge on the pathophysiological and etiological overlap and differences between LADA and type 2 diabetes, discuss similarities between LADA and type 1 diabetes and point at future research needs. Studies conducted to date show a clear genetic overlap between LADA and type 1 diabetes with a high risk conferred by variants in the human leukocyte antigen (HLA) region. In contrast, data from the limited number of studies on lifestyle factors available indicate that LADA may share several environmental risk factors with type 2 diabetes including overweight, physical inactivity, alcohol consumption (protective) and smoking. These factors are known to influence insulin sensitivity, suggesting that insulin resistance, in addition to insulin deficiency due to autoimmune destruction of the beta cells, may play a key role in the pathogenesis of LADA. Moreover, this implies that onset of LADA, similar to type 2 diabetes, to some extent could be prevented or postponed by lifestyle modification such as weight reduction and increased physical activity. The preventive potential of LADA is an important topic to elucidate in future studies, preferably intervention studies.

Environmental (Lifestyle) Risk Factors for LADA

BACKGROUND

In order to prevent diabetes it is important to identify common, modifiable risk factors in the population. Such knowledge is extensive for type 2 diabetes but limited for autoimmune forms of diabetes.

OBJECTIVE

This review aims at summarizing the limited literature on potential environmental (lifestyle) risk factors for LADA.

METHODS

A PubMed search identified 15 papers estimating the risk of LADA in relation to lifestyle. These were based on data from two population-based studies; one Swedish case-control study and one Norwegian cohort study.

RESULTS

Studies published to date indicate that the risk of LADA is associated with factors promoting insulin resistance and type 2 diabetes such as overweight, physical inactivity, smoking, low birth weight, sweetened beverage intake and moderate alcohol consumption (protective). Findings also indicate potential effects on autoimmunity exerted by intake of coffee (harmful) and fatty fish (protective). This supports the concept of LADA as being a hybrid form of diabetes with an etiology including factors associated with both insulin resistance and autoimmunity.

CONCLUSION

LADA may in part be preventable through the same lifestyle modifications as type 2 diabetes including weight loss, physical activity and smoking cessation. However, current knowledge is hampered by the small number of studies and the fact that they exclusively are based on Scandinavian populations. There is a great need for additional studies exploring the role of lifestyle factors in the development of LADA.

Alcohol Consumption, Diabetes Risk, and Cardiovascular Disease Within Diabetes

PURPOSE OF REVIEW

The purpose of the study is to examine and summarize studies reporting on the epidemiology, the risk of developing diabetes, and the cardiovascular effects on individuals with diabetes of different levels of alcohol consumption.

RECENT FINDINGS

Men consume more alcohol than women in populations with and without diabetes. Light-to-moderate alcohol consumption decreases the incidence of diabetes in the majority of the studies, whereas heavy drinkers and binge drinkers are at increased risk for diabetes. Among people with diabetes, light-to-moderate alcohol consumption reduces risks of cardiovascular diseases and all-cause mortality. Alcohol consumption is less common among populations with diabetes compared to the general population. Moderate alcohol consumption reduces the risk of diabetes and, as in the general population, improves cardiovascular health in patients with diabetes. Type of alcoholic beverage, gender, and body mass index are factors that affect these outcomes.

Adult-onset autoimmune diabetes: current knowledge and implications for management

Adult-onset autoimmune diabetes is a heterogeneous disease that is characterized by a reduced genetic load, a less intensive autoimmune process and a mild metabolic decompensation at onset compared with young-onset type 1 diabetes mellitus (T1DM). The majority of patients with adult-onset autoimmune diabetes do not require insulin treatment for at least 6 months after diagnosis. Such patients are defined as having latent autoimmune diabetes in adults (LADA), which is distinct from classic adult-onset T1DM. The extensive heterogeneity of adult-onset autoimmune diabetes is apparent beyond the distinction between classic adult-onset T1DM and LADA. LADA is characterized by genetic, phenotypic and humoral heterogeneity, encompassing different degrees of insulin resistance and autoimmunity; this heterogeneity is probably a result of different pathological mechanisms, which have implications for treatment. The existence of heterogeneous phenotypes in LADA makes it difficult to establish an a priori treatment algorithm, and therefore, a personalized medicine approach is required. In this Review, we discuss the current understanding and gaps in knowledge regarding the pathophysiology and clinical features of adult-onset autoimmune diabetes and highlight the similarities and differences with classic T1DM and type 2 diabetes mellitus.

Family history of type 1 and type 2 diabetes and risk of latent autoimmune diabetes in adults (LADA)

BACKGROUND

A family history of diabetes (FHD) is a strong predictor of diabetes risk, yet has rarely been investigated in latent autoimmune diabetes in adults (LADA). This study therefore investigated the risk of LADA and type 2 diabetes (T2D) in relation to FHD, taking into account the type of diabetes in relatives.

METHODS

Data from a population-based study were used, including incident cases of LADA [glutamic acid decarboxylase antibody (GADA)-positive, n=378] and T2D (GADA-negative, n=1199), and their matched controls (n=1484). First-degree relatives with disease onset at age<40 years and taking insulin treatment were classified as type 1 diabetes (T1D) or, if otherwise, as T2D. Odds ratios (ORs) were adjusted for age, gender, BMI, education and smoking. Cases were genotyped for high- and low-risk HLA genotypes.

RESULTS

Both FHD-T1D (OR: 5.8; 95% CI: 3.2-10.3) and FHD-T2D (OR: 1.9; 95% CI: 1.5-2.5) were associated with an increased risk of LADA, whereas the risk of T2D was associated with FHD-T2D (OR: 2.7; 95% CI: 2.2-3.3), but not FHD-T1D. In LADA patients, FHD-T1D vs FHD-T2D was associated with higher GADA but lower C-peptide levels, lower prevalence of low-risk HLA genotypes (5.0% vs 28.6%, respectively; P=0.038) and a tendency for higher prevalence of high-risk genotypes (90.0% vs 69.1%, respectively; P=0.0576).

CONCLUSION

The risk of LADA is substantially increased with FHD-T1D but also, albeit significantly less so, with FHD-T2D. This supports the idea of LADA as a mix of both T1D and T2D, but suggests that the genes related to T1D have greater impact. LADA patients with FHD-T1D had more T1D-like features, emphasizing the heterogeneity of LADA.

Increased seroreactivity to proinsulin and homologous mycobacterial peptides in latent autoimmune diabetes in adults

Latent Autoimmune Diabetes in Adults (LADA) is a slowly progressing form of immune-mediated diabetes that combines phenotypical features of type 2 diabetes (T2D) with the presence of islet cell antigens detected in type 1 diabetes (T1D). Heterogeneous clinical picture have led to the classification of patients based on the levels of antibodies against glutamic acid decarboxylase 65 (GADA) that correlate with clinical phenotypes closer to T1D or T2D when GADA titers are high or low, respectively. To date, LADA etiology remains elusive despite numerous studies investigating on genetic predisposition and environmental risk factors. To our knowledge, this is the first study aimed at evaluation of a putative role played by Mycobacterium avium subsp. paratuberculosis (MAP) as an infective agent in LADA pathogenesis. MAP is known to cause chronic enteritis in ruminants and has been associated with autoimmune disorders in humans. We analyzed seroreactivity of 223 Sardinian LADA subjects and 182 healthy volunteers against MAP-derived peptides and their human homologs of proinsulin and zinc transporter 8 protein. A significantly elevated positivity for MAP/proinsulin was detected among patients, with the highest prevalence in the 32-41-year-old T1D-like LADA subgroup, supporting our hypothesis of a possible MAP contribution in the development of autoimmunity.

Sweetened beverage intake and risk of latent autoimmune diabetes in adults (LADA) and type 2 diabetes

OBJECTIVE

Sweetened beverage intake is associated with increased risk of type 2 diabetes, but its association with autoimmune diabetes is unclear. We aimed to investigate sweetened beverage intake and risk of latent autoimmune diabetes in adults (LADA); autoimmune diabetes with features of type 2 diabetes.

DESIGN/METHODS

Data from a Swedish population-based study was used, including incident cases of LADA (n = 357) and type 2 diabetes (n = 1136) and randomly selected controls (n = 1371). Diabetes classification was based on onset age (≥35), glutamic acid decarboxylase autoantibodies (GADA) and C-peptide. Sweetened beverage intake information was derived from a validated food frequency questionnaire. ORs adjusted for age, sex, family history of diabetes, education, lifestyle, diet, energy intake and BMI were estimated using logistic regression.

RESULTS

Daily intake of >2 servings of sweetened beverages (consumed by 6% of participants) was associated with increased risk of LADA (OR: 1.99, 95% CI: 1.11-3.56), and for each 200 mL daily serving, OR was 1.15 (95% CI: 1.02-1.29). Findings were similar for sugar-sweetened (OR: 1.18, 95% CI: 1.00-1.39) and artificially sweetened beverages (OR: 1.12, 95% CI: 0.95-1.32). Similarly, each daily serving increment in total sweetened beverage conferred 20% higher type 2 diabetes risk (95% CI: 1.07-1.34). In type 2 diabetes patients, high consumers displayed higher HOMA-IR levels (4.5 vs 3.5, P = 0.0002), but lower HOMA-B levels (55 vs 70, P = 0.0378) than non-consumers. Similar tendencies were seen in LADA.

CONCLUSIONS

High intake of sweetened beverages was associated with increased risk of LADA. The observed relationship resembled that with type 2 diabetes, suggesting common pathways possibly involving insulin resistance.

Low birthweight is associated with an increased risk of LADA and type 2 diabetes: results from a Swedish case-control study

AIMS/HYPOTHESIS

Our aim was to investigate the association between birthweight and latent autoimmune diabetes in adults (LADA), a common diabetes form with features of both type 1 and type 2 diabetes.

METHODS

We used data from the Epidemiological Study of Risk Factors for LADA and Type 2 Diabetes (ESTRID), a Swedish population-based study. Eligible for the analysis were 134 incident LADA cases (glutamic acid decarboxylase antibody [GADA] positive), 350 incident type 2 diabetes cases (GADA negative) and 603 randomly selected controls. We present ORs and 95% CIs for LADA and type 2 diabetes in relation to birthweight, adjusted for sex, age, BMI and family history of diabetes.

RESULTS

Low birthweight increased the risk of LADA as well as the risk of type 2 diabetes; OR per kg reduction was estimated as 1.52 (95% CI 1.12, 2.08) and 1.58 (1.23, 2.04), respectively. The OR for participants weighing <3 kg compared with ≥4 kg at birth was estimated as 2.38 (1.23, 4.60) for LADA and 2.37 (1.37, 4.10) for type 2 diabetes. A combination of low birthweight (<3 kg) and current overweight (BMI ≥ 25) further augmented the risk: LADA, OR 3.26 (1.69, 6.29); and type 2 diabetes, OR 39.93 (19.27, 82.71). Family history of diabetes had little impact on these estimates.

CONCLUSIONS/INTERPRETATION

Our results suggest that low birthweight may be a risk factor for LADA of the same strength as for type 2 diabetes. These findings support LADA, despite its autoimmune component, having an aetiology that includes factors related to type 2 diabetes.

Dietary patterns and the incidence of hyperglyacemia in China

OBJECTIVE

Epidemiological studies have examined associations between dietary patterns and the risk of type 2 diabetes. However, information on dietary patterns and the risk of type 2 diabetes in Chinese populations is scarce. The aim of the present study was to identify dietary patterns and examine their association with incident hyperglycaemia in Nanjing, China.

DESIGN

A community-based prospective cohort study. Dietary assessment was carried out using a validated eighty-seven-item FFQ. Dietary patterns were identified by exploratory factor analysis. Participants were categorized into tertiles of dietary factor score for each dietary pattern. The relationship between dietary patterns and hyperglycaemia risk was analysed using multivariable linear and Cox regression.

SETTING

Seven communities from two urban districts in Nanjing, China.

SUBJECTS

A total of 2900 of Chinese local residents aged 30 years or above, free of hyperglycaemia and other serious diseases, who participated in the baseline survey from June to September 2007 were followed up 3 years later from June to September 2010 for the development of hyperglycaemia. Fasting blood samples were collected at both baseline and 3-year follow-up surveys. Hyperglycaemia was defined as fasting plasma glucose concentration of ≥6·1 mmol/l or already taking oral hyperglycaemia agents for treatment of type 2 diabetes.

RESULTS

Five major dietary patterns were identified: (i) the 'condiments' pattern; (ii) the 'animal and plant protein' pattern; (iii) the 'healthy traditional' pattern; (iv) the 'fruits, eggs and juice' pattern; and (v) the 'alcohol, milk and tea' pattern. A total of 2093 (72·2 %) individuals completed the follow-up survey and the 3-year cumulative incidence of hyperglycaemia was 7·5 % (158/2093). A 1-unit increase in the score for the 'healthy traditional' pattern was associated with a decrease of 0·054 mmol/l in fasting plasma glucose (P=0·017), while a 1-unit increase in the 'fruits, eggs and juice' pattern score was associated with an increase of 0·050 mmol/l in fasting plasma glucose (P=0·023) by multivariable linear regression. For men, tertile 3 of the 'fruits, eggs and juice' pattern was associated with an 88 % greater risk (hazard ratio=1·88; 95 % CI 1·04, 3·54) of hyperglycaemia than tertile 1 of this pattern. Being in tertile 3 of the 'alcohol, milk and tea' pattern was associated with a 35 % greater risk (hazard ratio=1·35; 95 % CI 1·04, 2·16) relative to tertile 1 in women, while for the ''healthy traditional' pattern tertile 3 was associated with a 41 % lower risk (hazard ratio=0·59; 95 % CI 0·35, 0·99) compared with tertile 1. The 'condiments' and the 'animal and plant protein' patterns were not independently associated with hyperglycaemia.

CONCLUSIONS

Our findings suggest that modifying dietary patterns could reduce hyperglycaemia incidence in the mainland Chinese adult population.