Prevalence of Wine Consumption in Type 2 Diabetics after a Dietary Nutritional Intervention from Primary Care

Carmen Celada Roldan; Jaime Lopez Diez; M Angeles Cerezuela; Faustino Rider; Almudena Tarraga Marcos; Pedro J Tarraga Lopez

Special Issue: Alcohol Addiction

Austin Diabetes Res. 2023; 8(1): 1027.

Prevalence of Wine Consumption in Type 2 Diabetics after a Dietary Nutritional Intervention from Primary Care

Carmen Celada Roldan¹*; Jaime Lopez Diez¹; M Angeles Cerezuela¹; Faustino Rider¹; Almudena Tarraga Marcos²; Pedro J Tárraga López²

¹Medico Familia Cartagena (Murcia), Spain

²Medico Bienestar Social Centro Base de Albacete, Spain

³Medico familia zona 5 de Albacete, Spain

*Corresponding author: Pedro Tarraga Lopez Medico familia zona 5 de Albacete, Spain. Email: [email protected]

Received: May 25, 2023 Accepted: June 27, 2023 Published: July 04, 2023

Summary

Introduction: At present there are changes in the lifestyle that have been modifying the nutritional culture, moving away from the Mediterranean diet (DMed), with a higher consumption of alcoholic beverages, a fact that together with the acquisition of a more sedentary lifestyle, has contributed to a significant increase in Cardiovascular Risk Factors (CVRF) such as obesity and type 2 Diabetes Mellitus (DM2), and consequently to a global increase in Metabolic Syndrome (MS) and Cardiovascular Diseases (CVD), which in the 21^st century continue to be the leading cause of morbidity and mortality. To reduce this pandemic and try to reduce alcohol consumption in patients with high cardiovascular risk, a multidisciplinary approach is required focused on the application of primary and secondary prevention strategies focused on nutritional education through the promotion of a healthy lifestyle from childhood and a healthier diet, such as the one included in the DMed. This dietary pattern, together with physical exercise, has been shown to contribute to the primary and secondary prevention of DM2.

Objective: To determine the initial adherence to the DMed, as well as the consumption of wine by sex, in patients with poorly controlled DM2 and to analyze the effects of a nutritional educational intervention from Primary Care on the consumption of wine, the degree of adherence to the DMed and the glycemic control.

Material and Methods: Descriptive observational study and quasi-experimental analytical study (before-after) in 93 patients diagnosed with type 2 diabetes mellitus with poor glycemic control (A1c≥7%), carried out in various health centers in Albacete and Cuenca between 2018 and 2019, in which the relationship between adherence to MedDM and CVRF is evaluated, before and after an educational intervention on MedDM. They are administered a data collection sheet that includes a MedD adherence survey (MEDAS-14) at baseline and at 6 months, after completing an education on MedD in Primary Care (PC) medical and nursing consultations).

The pre- and post-intervention variables were analyzed: age groups, sex, years of evolution of DM2, Body Mass Index (BMI), as well as Basal Glycemia (GB) and Glycosylated Hemoglobin (HbA1c). The main variable “MEDAS-14” is related to the rest of the variables. Specifically, item 8 assesses the consumption of more than or equal to 7 glasses of wine per week.

Results: Pre-intervention the score of the survey of adherence to the Mediterranean diet was relatively low (7.44±0.22 points), being in women (7.66 points) than in men (7.1 points). Of the 14 dietary items of the MEDAS-14, high compliance with the recommended intake of wine stands out (≥7 glasses/week, 69%), specifically there is a higher initial consumption in women (45%) than in men (28%). In general terms, despite the high consumption of olive oil, a large number of processed products are consumed (sweetened beverages, butter, commercial confectionery), with a low consumption of fruit, fish and nuts. Post-intervention, adherence to the DMED increased by 1.09±2.56 points (8.55 points). Men being those who present 0.4 points more (8.7 points) than women (8.4 points). The biggest changes have been in relation to the increase in the consumption of white meat, olive oil, nuts, vegetables and stir-fry. Just as a decrease in the consumption of processed foods and the weekly consumption of wine (down to 58%) is observed, specifically it has been higher in women, it has decreased by 11% (34.4%), maintaining itself in men (28%).

Conclusions: In diabetic patients with poor control, a nutritional educational intervention that promotes MedDM from PC improves adherence to said diet, increasing the consumption of healthy foods and decreasing harmful ones, thus optimizing metabolic control.

Keywords: Mediterranean diet; Type 2 diabetes; MEDAS-14; Item 8; Wine; Nutritional education

Introduction

Human nutrition has been essential in the evolution of man, modifying eating habits throughout history. Changes in lifestyle derived from a reduction in physical activity, work pressures, new forms of teleworking, widespread use of electronic devices and unlimited access to the food consumption market in developed countries have been modifying nutritional culture, transforming the habits of our traditional diet since childhood [1]. Likewise, the state of confinement COVID-19 has implied changes in the life habits and dietary profiles of the population [2].

The Mediterranean Diet (DMed) is classically defined as the eating pattern typical of the early sixties in the countries of the Mediterranean area (Greece, southern Italy and Spain) [3]. Its main characteristics are: a) high fat consumption, mainly in the form of olive oil; b) high consumption of whole grains, fruit, vegetables, legumes and nuts; c) moderate-high consumption of fish; d) moderate-low consumption of white meat and dairy products; e) low consumption of red meat and meat products, and f) moderate consumption of wine with meals. This pattern and the proportions of the different foods that compose it are graphically displayed in the form of a “food pyramid” [4].

Alcohol consumption is a culturally approved process in society and in different scenarios of human socialization this behavior has been present in the history of humanity [6], but when this consumption becomes frequent and excessive, the consequences are multiple (accidents, liver disease, neurological and psychiatric pathologies) increased the cardiovascular risk of patients who suffer from it, generating high socioeconomic costs and health resources. It has been pointed out that alcohol has diabetogenic effects in people with DM2 that include increased obesity, induction of pancreatitis, alterations in carbohydrate and glucose metabolism, presenting periods of hypoglycemia when alcohol is consumed excessively and there are long fasting periods, however it can also cause hyperglycemia when consumed in smaller quantities or to accompany food [7]. The ADA does not prohibit a person with DM2 from consuming alcohol, but it does not advise it either, it recommends limiting moderate consumption (one drink a day for women and two a day for men).

When analyzing the current situation in Spain, a country where there is a high prevalence of DM2 together with obesity (diabesity), two of the great epidemics of the 21^st century that increase CVD, being the first cause of morbidity and mortality worldwide and in Spain, derived from current lifestyles far from a Mediterranean lifestyle. For this reason, it was proposed to assess the effects of MedDM in the prevention of this disease [8].

It has been shown that an intervention with MedD is a very effective instrument in the prevention of T2DM in subjects with high vascular risk [9,10]. The American Diabetes Association [11], among its general recommendations, makes explicit reference to MedDM, mentioning the improvement in glycemic control and its cardiovascular benefits in patients with T2DM. Although, as we said, it has been systematically shown that MedD helps protect against cardiovascular, inflammatory and metabolic diseases, as well as numerous chronic degenerative diseases [12-15]; the protective effect of MD has been very different between the studies [16-18].

Consequently, many adherence scores of the MedMD are being created to determine the relationship between diet and health [19]. Therefore, this work planet, due to its ease of use, use the MEDAS-14 in diabetic patients with poor glycemic control to assess the degree of adherence to the DMed, objectify their consumption of wine and other variables.

Method

This is a multicenter study in which adult type 2 diabetic patients with poor glycemic control (HbA1c greater than 7%) from various health centers in Albacete and Cuenca participated during the period between June 2018 and September 2019. In the first stage, a descriptive observational study was carried out to determine the degree of adherence to the MedD, through the compilation of the MedD Adherence questionnaire (MEDAS-14) [20] (Figure 1) and anthropometric parameters (BMI, waist circumference) and glycemic biochemical parameters (GB, A1c). In a second stage, a quasi-experimental analytical study of the before-after type is carried out, relating the main variable "MEDAS-14" with the rest (IMC, GB, A1c) before and after the intervention.

Figure 1: MedD adherence test (MEDAS-14) from the PREDIMED study.

    
    
    Figure 1: MedD adherence test (MEDAS-14) from the PREDIMED study.

The Community Nutrition Program, framed in a monographic consultation for patients with poorly controlled DM2, developed a nutritional educational intervention carried out by nurses and PC doctors for 6 months, based on promoting health through the Mediterranean lifestyle ( DMed, physical exercise and smoking cessation) through discussion groups, theoretical-practical workshops and individual motivational interviews, to improve metabolic control in patients with DM2 (secondary prevention) and thus mitigate the appearance or aggravation of future complications and improve their quality of life.

The MEDAS-14 [20] questionnaire (Figure 1), administered at the beginning of the study and at 6 months, after carrying out an education on MedDM in the PC consultation, consisting of the assessment of adherence to the MedMD based on the validated 14-point score, also in British population. A score greater than or equal to 9 points is a good level of adherence, values less than or equal to 8 are considered poor adherence. During 6 months in the consultations they are given monthly appointments with weight and glycemia control, insisting on diet and lifestyles, referencing the foods of the DMed.

Item 8 (Do you drink wine? How much do you consume per week?) is the one that assesses alcohol consumption, specifically through weekly wine consumption (≥7 or more glasses per week = 1 point).

Statistic Analysis

The statistical analysis was performed with the statistical package SPSS^® (Statistical Package for Social Sciences) in its version 24.0. A descriptive analysis of the variables of interest was carried out, in which their distribution was observed in order to define cut-off points. To measure adherence to MedDM, the MEDAS-14 was assessed, classifying the participants into two categories: high adherence for a score ≥9, and low adherence if <9. The qualitative variables were presented through the frequency distribution of the percentages of each category while in the quantitative variables it was explored whether or not they followed a normal distribution using the Kolmogorov-Smirnov test, and indicators of central tendency (mean or median) and dispersion (standard deviation or percentiles) were given. The association between these factors was investigated using hypothesis contrast tests, with comparison of proportions when both were qualitative (Chi square, Fisher's exact test); comparisons of means when one of them was quantitative (Student's t test, ANOVA), and if they did not follow a normal distribution, the Mann-Whitney U test, Kruskall-Wallis and Friedman in the case of repeated measures. Linear regression tests were performed when the dependent variable was quantitative. In the case of qualitative variables, the Relative Risk (RR) was calculated for the different proportions and their CIs. The analysis was complemented with graphic representations. The statistical significance level for this study was p≤0.05.

Ethical Aspects

The study was carried out following the recognized Ethics Standards and the Standards of Good Clinical Practice. The data was protected from uses not permitted by persons unrelated to the investigation and confidentiality was respected regarding the Protection of Personal Data and Law 41/2002, of November 14, the basic law regulating patient autonomy and rights. And obligations regarding information and clinical documentation. Therefore, the information generated in this study has been considered strictly confidential, between the participating parties.

Results

Throughout the 12 months (6 months of intervention and 6 months of post-intervention), 93 diabetic adult patients participated, of whom 60% were women with a mean age of 64 +/- 9 years. The BMI at the beginning was 32kg/m² (grade I obesity), with a basal glycemia of 158mg/dl and a mean glycosylated hemoglobin of 7.88% (poor glycemic control). That is, the patients presented diabesity with poor metabolic control.

Pre-Intervention MEDAS-14 Score

The initial score of the MedD adherence survey (MEDAS-14) was 7.44±0.22 points (optimum ≥9 points), with initial adherence being higher in women (7.66 points) than in men (7.1 points).

Table 1 represents each of the MEDAS-14 items that were initially answered affirmatively according to gender.

Table 1: MEDAS-14 items answered affirmatively by sex. Source: self made.




  
    ITEMS MEDAS-14 
    MAN 
    WOMAN 
    TOTAL 
    p 
  
  
    1.Olive oil I 
    36,6% (n = 34) 
    47,3% (n = 44) 
    83,9% (n = 78) 
    NS 
  
  
    2. Olive oil II 
    25,8% (n = 24) 
    34,4% (n = 32) 
    60,2% (n = 56) 
    NS 
  
  
    3. Vegetable 
    29,6% (n = 27) 
    31,2% (n = 29) 
    (61,2% (n = 56) 
    < 0,033 
  
  
    4. Fruit 
    17,2%(n = 16) 
    37,6% (n = 35) 
    54,8% (n = 51) 
    < 0,053 
  
  
    5. Red meat 
    7,5% (n = 7) 
    36,6% (n = 34) 
    44,1% (n = 41) 
    < 0,000 
  
  
    6. Butter 
    3,2% (n = 3) 
    18,3% (n = 17) 
    21,5% (n = 20) 
    NS 
  
  
    7. Sugary drinks 
    7,5% (n =7) 
    12,9% (n = 12) 
    20,4% (n = 19) 
    NS 
  
  
    8. Wine 
    23,7% (n = 22) 
    45,2% (n = 42) 
    68,9% (n = 64) 
    NS 
  
  
    9. Legumes 
    32,3% (n = 30) 
    43% (n = 40) 
    75,3% (n = 70) 
    NS 
  
  
    10. Fish 
    19,4% (n = 18) 
    19,4% (n = 18) 
    38,8% (n = 36) 
    NS 
  
  
    11. Pastry 
    5,4% (n = 5) 
    21,5% (n = 20) 
    26,9% (n = 25) 
    < 0,015 
  
  
    12. Nuts 
    6,5% (n = 6) 
    11,8% (n = 11) 
    18,3% (n = 17) 
    NS 
  
  
    13. White meat 
    20,4% (n = 19) 
    29,1% (n = 27) 
    49,5% (n = 46) 
    < 0,0466 
  
  
    14. Sauté 
    19,4% (n = 18) 
    34,4% (n = 32) 
    53,8% (n = 50) 
    NS



Table 1: MEDAS-14 items answered affirmatively by sex. Source: self made.

There is initially a high consumption of the following foods: a) Olive oil (84%), using 2 or more tablespoons per day in 60% of the patients; b) Sugary drinks (80%) more than one a day; c) Butter, margarine or cream (79%) more than one serving (12g) per day; d) Non-homemade commercial confectionery (73%) more than 3 times a week; e) Legumes (75%) three servings (450g) or more per week; f) Wine (69%) three or more glasses per week; g) Vegetables or vegetables (61%) two or more servings per day. An average consumption of: h) Red meat (56%) more than one serving (100-150g) per day; i) Fruits (55%) three or more pieces a day; j) Stir-fried (54%) two or more times a week; k) Chicken, turkey or rabbit meat (50%). And a low consumption: l) Fish (39%) three servings (300-450g) or 12-15 pieces of shellfish weekly; m) Nuts (18%) one serving (30 g) per week.

Significant differences between sexes are observed in 5 items (3^rd, 4^th, 5^th, 11^th and 13^th): in women the consumption of fruits (38%), vegetables (31%) and white meat (29%) is higher, and in men the consumption of red meat (92.5%) and commercial confectionery (95%). In both sexes the consumption of nuts was equally low (22%).

Post-Intervention MEDAS-14 Score

The final score of the MedDM adherence survey (MEDAS-14) was 8.55±1.7 points, with adherence increasing more in men (8.7 points) than in women (8.4 points).

Table 2 shows each of the items of the MEDAS-14 questionnaire that were answered affirmatively after the nutritional intervention according to sex. Being statistically significant (p<0.005) 6 of the 14 items (item no. 4, 6, 7, 11, 12 and 14).

Table 2: Final MEDAS-14 items affirmative, by sex. Source: self made.




  
    ITEMS MEDAS-14 
    HOMBRE 
    MUJER 
    TOTAL 
    P 
  
  
    1.Olive oil I 
    34,4% (n = 32) 
    54,8% (n = 51) 
    89,2% (n = 83) 
    NS 
  
  
    2. Olive oil II 
    37,6% (n =35) 
    49,5% (n = 46) 
    87,1% (n = 81) 
    NS 
  
  
    3.Vegetable 
    31,2% (n = 29) 
    52,7% (n =49) 
    83,9% (n = 78) 
    NS 
  
  
    4.Fruit 
    17,2% (n = 16) 
    38,7% (n = 36) 
    55,9% (n = 52) 
    < 0,037 
  
  
    5. Red meat 
    24,7% (n = 23) 
    40,9% (n = 38) 
    65,6% (n = 61) 
    NS 
  
  
    6. Butter 
    18,3% (n = 17) 
    34,4% (n = 32) 
    52,7% (n = 49) 
    < 0,009 
  
  
    7. Sugary drinks 
    23,7% (n = 22) 
    20,4% (n = 19) 
    44,1% (n = 41) 
    < 0,013 
  
  
    8. Wine 
    23,7% (n = 22) 
    34,4% (n = 32) 
    58,1% (n = 52) 
    NS 
  
  
    9.Legumes 
    33,3% (n = 31) 
    51,6% (n = 48) 
    84,9% (n = 79) 
    NS 
  
  
    10.Fish 
    15,1% (n = 14) 
    24,7% (n = 23) 
    39,8% (n = 37) 
    NS 
  
  
    11.Pastry 
    24,7% (n = 23) 
    25,8% (n = 24) 
    50,5% (n = 47) 
    < 0,053 
  
  
    12.Nuts 
    22,6% (n = 21) 
    22,6% (n = 21) 
    45,2% (n = 42) 
    < 0,053 
  
  
    13.White meat 
    32,3% (n = 30) 
    52,7% (n = 49) 
    85%(n = 79) 
    NS 
  
  
    14.Sauté 
    36,6% (n = 34) 
    37,6% (n = 35) 
    74,2% (n = 69) 
    < 0,001



Table 2: Final MEDAS-14 items affirmative, by sex. Source: self made.

There is a high consumption of the following foods: a) Olive oil (89%) as the main fat for cooking, using 2 or more tablespoons per day in 87% of the patients; b) Legumes (85%) three servings (450 g) or more per week; c) Vegetables or vegetables (84%) two or more servings per day; d) Chicken, turkey or rabbit meat (85%); e) Stir-fried (74%) two or more times a week; There is an average consumption of: f) Wine (58%) three or more glasses per week; g) Fruit (56%) three or more pieces a day; Sugary drinks (56%) more than one a day; h) Non-homemade commercial confectionery (49.5%) more than 3 times a week; i) Butter, margarine or cream (47%) more than one serving (12 g) per day; j) Nuts (45%) one serving (30g) per week. There is a low consumption of: k) Fish (40%) three servings (300-450g) or 12-15 pieces of shellfish a week.

Comparison of Pre- and Post-Intervention Data

After 6 months of the nutritional educational intervention given from PC, adherence to the DMED has increased by 1.09±2.56 points (8.55 points). Men being those who present 0.4 points more (8.7 points) than women (8.4 points).

Figure 2 shows the evolution of adherence to the MedD in T2DM before and after the intervention. At a global level, the greatest changes have been in relation to the increase in the consumption of white meat (35.5%), olive oil (27%), nuts (26.9%), vegetables (22.7%), stir-fry (20.4%), legumes (9.6%), decreased consumption of butter (31.5%) and decreased consumption of carbonated beverages (23.7%), pastries (23.6%), red meat (21.5%) and wine (10.8%).

Figure 2: MEDAS-14 items overall evolution before and after the intervention. Source: self made.

    
    
    Figure 2: MEDAS-14 items overall evolution before and after the intervention. Source: self made.

Figures 3 and 4 show the evolution in adherence to the DMed according to sex: In women the consumption of white meat (23.6%), vegetables (21.5%), oil olive (15%), nuts (10.8%), legumes (8.6%), stir-fry (3.2%) and the consumption of butter (16%), wine (10 8%), carbonated drinks (7.5%), red meat (4.3%) and pastries (4.3%). In men, the consumption of stir-fry (17.2%), nuts (16.1%), olive oil (12%), white meat (12%), vegetables (1.6%) has increased ), legumes (1%) and the consumption of pastries (19.3%), red meat (17.2%), carbonated beverages (16.2%), butter (15%), unchanged wine consumption.

Prevalence of Wine Consumption in Type 2 Diabetics after a Dietary Nutritional Intervention from Primary Care

Summary

Introduction

Method

Statistic Analysis

Ethical Aspects

Results

Pre-Intervention MEDAS-14 Score

Post-Intervention MEDAS-14 Score

Comparison of Pre- and Post-Intervention Data

Discussion

Conclusions

References