Medical compass: Reducing diabetes and associated health risks

In some patients, small amounts of wine may reduce cardiovascular risk

By David Dunaief, MD

Dr. David Dunaief

Our understanding of diabetes — its risks and treatment paradigms — is continually evolving and improving. This is good news, since the current rate of diabetes among the American adult population is 13%, while an additional 88 million American adults have prediabetes (1).

What is prediabetes? Typically, this is when fasting blood sugar (HbA1C) is between 5.7 and 6.4%.

Diabetes comes with a host of other health complications, including an increased risk of heart attack. However, cardiovascular risk and its severity may not affect men and women equally. In two trials, women with type 2 diabetes had a higher cardiovascular risk than men. In a retrospective study, women with diabetes were hospitalized for heart attacks at a higher rate than men, although both had substantial increases in risk, 162% and 96%, respectively (2).

What could reduce our risk of diabetes or its complications? Fortunately, we have options. These include improvements in diet, timing of blood pressure medication, and, oddly enough, modest wine consumption.

Best metformin diet for diabetes prevention

Too often in the medical community we are guilty of seeking drugs and ignoring lifestyle modifications or expecting patients to fail with them. It’s a disservice; lifestyle changes may be more effective in preventing this disease.

In a direct comparison study, diet and exercise outperformed metformin for diabetes prevention (3). This study was carried out over a period of 15 years with 2,776 participants at high risk of diabetes because they were overweight or obese and had high blood sugar.

There were three groups in the study: one received a low-fat, low-calorie diet with 15 minutes of moderate cardiovascular exercise; one took metformin 875 mg twice daily; and one was a placebo group. Diet and exercise reduced the risk of diabetes by 27%, while metformin reduced it by 18% compared to placebo, both reaching statistical significance. Note that while these are impressive results that testify to the use of lifestyle modification and metformin, the diet they used was not an optimal diet for diabetes.

Blood pressure medication schedule

Interestingly, taking blood pressure medication at night has a strange benefit, reducing the risk of diabetes (4). In one study, there was a 57% reduction in the risk of developing diabetes in those who took blood pressure medication at night rather than in the morning.

Sleep blood pressure control appears to be more predictive of diabetes risk than morning blood pressure or 48-hour ambulatory blood pressure. This study lasted nearly six years with approximately 2,000 participants.

The researchers used three blood pressure medications in the trial: ACE inhibitors, angiotensin receptor blockers (ARBs), and beta-blockers.

The first two have their effect on the renin-angiotensin-aldosterone system (RAAS) of the kidneys. According to the researchers, these had the most powerful effect on preventing diabetes. Additionally, when sleep systolic blood pressure (top number) was elevated one standard deviation above the mean, the risk of type 2 diabetes increased by 30%.

Interestingly, drugs that block the RAAS are the same drugs that protect kidney function in diabetic patients.

Can wine help?

Diabetic patients are often warned to limit or eliminate alcohol. An important part of the reasoning relates to how the body metabolizes alcohol and sugars. So the results of a study that showed small amounts of wine could have beneficial effects in reducing complications associated with diabetes in those with well-controlled sugars made waves throughout the medical community.

The CASCADE trial, a randomized controlled trial, shows that wine may have beneficial effects on the heart of well-controlled patients with type 2 diabetes by altering the lipid (cholesterol) profile (5).

Patients were randomized into three groups, each receiving a drink with dinner every night. One group received five ounces of red wine, another five ounces of white wine, and the control group drank five ounces of water. Those who drank red wine saw a significant increase in their HDL “good” cholesterol levels, an increase in apolipoprotein A1 (the main component of HDL), and a decrease in the ratio of total cholesterol to HDL levels. compared to water. alcohol consumption control arm. In other words, there were significant beneficial cardiometabolic changes.

White wine also had beneficial cardiometabolic effects, but not as significant as red wine. However, white wine significantly improved glycemic (sugar) control compared to water, unlike red wine. Additionally, poor alcohol metabolizers in a combined analysis of red and white wine groups had better glycemic control than those who drank water. This study lasted two years and involved 224 patients. All participants were asked to follow a Mediterranean-type diet.

Does this mean diabetic patients should start drinking wine? Not necessarily. This was a small study, and the participants were well-controlled type 2 diabetic patients who usually didn’t drink.

We need to reverse the trend of higher prevalence of diabetes. The good news is that we continue to learn what reduces the risk of diabetes and, for people with type 2 diabetes, what can improve cardiovascular risks.


(1) (4) Journal of Diabetes and Its Complications 2015;29(5):713-717. (3) Lancet Diabetes Endocrinol. Online September 11, 2015. (4) Diabetologia. Online September 23, 2015. (5) Ann Intern Med. 2015;163(8):569-579.

Dr. David Dunaief is a speaker, author, and local lifestyle medicine physician who focuses on the integration of medicine, nutrition, fitness, and stress management. For more information, visit