Alcohol
Abuse and Dependence — Nutrition on the Rocks
By Mary Anne Clairmont, RD
Today’s Dietitian
Vol. 7 No. 9 P. 44
What is flammable, edible, addictive, and an antiseptic,
protects against heart attack, may promote breast cancer, destroys
a human liver, and is 10,000 years old? Alcohol or ethanol is the
name of this chemical compound.
Alcohol is one of the most controversial consumables
in history. From “devil’s brew” to “nectar
of the gods,” alcoholic drinks have been blessed and cursed
since the dawn of time.
Alcohol triggers some of the best and worst health
consequences for drinkers. Whether drinkers reap positive or negative
results may be determined by the amount of alcohol they drink, genetics,
and the general health of the consumer.
Portion Size Matters
We cannot talk about “moderate” drinking if we do not
know the size of a drink. Drink size varies even among research
studies.1
In the United States one drink is usually considered
to be 12 to 14 grams of alcohol. This is equal to 11/2 ounces of
hard liquor such as rum or whiskey, 5 ounces of wine, or 12 ounces
of beer.2
The Effects of Alcohol on the Body
Alcohol is classified as a depressant. Nevertheless, it may act
as a stimulant or a depressant depending on the dose. Exhilaration,
talkativeness, loss of inhibitions, extreme mood swings, and displays
of excessive emotion all mark the stimulant phase. All occur at
lower doses. The initial stimulant effects are due to a release
of hormones from the adrenal glands brought about by alcohol stimulating
the glands as it is absorbed from the duodenum. Alcohol does not
directly act on the brain at low doses, but 20% of the alcohol consumed
can be directly absorbed through the walls of the stomach. Alcohol
dehydrogenase is the major enzyme responsible for breaking down
ethanol. One reason women tend to become intoxicated more quickly
than men is that they produce less alcohol dehydrogenase in the
stomach than men do. A stomach full of food will also slow down
the absorption process of alcohol. As the amount of ingested alcohol
increases, it will cross the blood brain barrier.
After it reaches the duodenum, alcohol is rapidly
transported to the liver via the blood vessels of the digestive
system. When it reaches the liver, it spreads throughout the hepatic
blood vessels to cover as much area of the liver as possible. Alcohol
is primarily metabolized by the alcohol dehydrogenase system in
the liver. Ethanol is oxidized to acetaldehyde by the enzyme alcohol
dehydrogenase. The liver is the only organ capable of manufacturing
enough alcohol dehydrogenase to oxidize alcohol.
Alcohol receives preferential treatment and is metabolized
while other nutrients must wait. Fatty acids that would normally
be metabolized by the liver must wait until the alcohol is fully
processed. In heavy drinkers, this leads to a fatty liver.
Alcohol can cause hypoglycemia shortly after drinking
and for eight to 12 hours after drinking. This is a major concern
for individuals with diabetes, reactive hypoglycemia, and other
disorders of carbohydrate metabolism. Hypoglycemia is a result of
increased sensitivity to insulin caused by alcohol metabolism.
Alcohol supplies 7 kilocalories per gram and comes
from a carbohydrate source. Alcohol is found in the fat exchange
group and is not used like a carbohydrate for fuel in the body.
Instead, it is metabolized like a fat.
In the second step of the metabolic reaction, acetaldehyde
is converted to acetic acid by the enzyme aldehyde dehydrogenase.
Under normal circumstances, acetaldehyde is metabolized rapidly
and usually does not accumulate or interfere with normal functioning.
However, when large amounts of alcohol are consumed, accumulation
of acetaldehyde may cause symptoms such as headache, gastritis,
nausea, and dizziness, which may contribute to a hangover. This
is also the foundation for the use of disulfiram in the treatment
of alcoholism. It prevents the production of aldehyde dehydrogenase
resulting in the accumulation of acetaldehyde, which makes the drinking
episode a repugnant experience. Adequate niacin and zinc are needed
for this system to operate properly in the first step, which changes
alcohol to acetaldehyde. Nicotinamide adenine dinucleotide (NAD)
is one of the enzymes crucial to detoxifying.
Countable Calories
In cases of heavy drinking and alcoholism, when the amount of alcohol
surpasses the abilities of the alcohol dehydrogenase system, ethanol
is metabolized into acetaldehyde by the microsomal ethanol oxidizing
system (MEOS). This is an alternate system used as an auxiliary
to the alcohol dehydrogenase system. While alcohol has 7 kilocalories
per gram when it is metabolized by the alcohol dehydrogenase system,
when the MEOS kicks in, this is not the case. The alcohol dehydrogenase
system produces adenosine triphosphate (ATP). The MEOS burns ATP
to function. It is difficult to predict how many calories will be
produced when an individual slips into the MEOS to metabolize alcohol.
The MEOS may use all the available calories from alcohol just to
sustain itself. If the individual with alcoholism does not eat,
he or she will become malnourished and cachexic despite drinking
many calories daily.
Acetaldehyde must be converted into acetic acid
and once again, the body needs alcohol dehydrogenase, NAD, and zinc.
Niacin supplementation can be helpful in boosting this process in
patients who are nutritionally depleted and who suffer from poor
liver function. Acetic acid is broken down into energy, water, and
CO2 through the Krebs cycle. The process requires adequate thiamin,
niacin, magnesium, pantothenic acid, iron, riboflavin, and manganese.
Alcohol may interfere with the absorption of the B vitamins, especially
folic acid and thiamin. Malnutrition causes high levels of acetic
acid to remain in and continue to circulate through the body. If
a required nutrient is missing for the Krebs cycle, it will not
begin until that nutrient is present. The body of a person with
alcoholism changes to accommodate the extra acid and he or she gradually
develops more mitochondria in his or her liver and muscles. This
is a physical adaptation and the individual will experience physical
cravings and withdrawal when he or she attempts to stop drinking.
When the Krebs cycle is delayed, glucose and energy are not produced
and hypoglycemia occurs.
Liver Disorders
NAD is expended to detoxify alcohol in the heavy drinker and this
affects fat metabolism. NAD is not available to break down fats
and the fat is deposited in the liver, arteries, and heart. There
will be insufficient protein available to move fat out of the body.
As the liver is exposed to more fat, it produces more cells and
this results in a fatty liver. The liver commonly becomes inflamed
and the result is alcoholic hepatitis. Signs and symptoms of alcoholic
hepatitis include vomiting, nausea, loss of appetite, fever, abdominal
pain and tenderness, jaundice, and mental confusion.
A healthy liver metabolizes nutrients and breaks
them down into molecules the body can use. The liver of a person
with alcoholism becomes debilitated from constantly removing toxins
and controlling the composition of the blood. In the United States,
excessive alcohol consumption is the single greatest risk factor
for cirrhosis. The type of alcohol is less important than the amount
consumed over a period of years. Even small amounts of alcohol can
be damaging if someone is infected with the hepatitis B or C virus.
As the disease progresses, the hepatic blood vessels become varicose,
which spreads to the esophagus and causes esophageal varices.
Once cirrhosis occurs, damaged liver tissue cannot
be repaired. In severe cases, the only chance for survival is a
transplant. In many situations, if individuals become sober and
begin to nourish their body, they can recover a significant portion
of liver function and health. It is important to not overfeed or
oversupplement patients with poorly functioning livers as they are
unable to metabolize large amounts of nutrients.
Nutritional Effects
Individuals with alcoholism suffer from nutritional attacks on two
fronts—consequences of using alcohol and its effects on the
body and mind and consequences of the lifestyle; for instance, deficient
dietary intake and haphazard eating habits.
Poor dietary intake is a leading cause of malnutrition
in individuals with alcoholism as well as substituting alcohol for
food. Metabolism and brain chemistry changes in people with alcoholism.
Wernicke-Korsakoff Syndrome
One of the most devastating effects of alcoholism and one that is
easily remedied is thiamin deficiency. Individuals with alcoholism
frequently substitute alcohol for other nutritious foods. Additionally,
alcohol increases the body’s requirements for B vitamins.
It interferes with thiamin absorption in the intestines and impairing
the body’s ability to store and use thiamin. To complicate
this situation, the intake of the person with alcoholism is usually
poor and deficient in multiple nutrients.
Wernicke’s encephalopathy is a disorder of
the brain caused by thiamin deficiency. It is common among individuals
with alcoholism. The symptoms are mental confusion, vision impairment,
stupor, coma, hypothermia, hypotension, and ataxia. With thiamin
supplementation, adequate nutrition, and hydration, this syndrome
may be reversible.
With Korsakoff’s amnesic syndrome the heart,
vascular, and nervous system are involved as well as the memory.
These two disorders are often believed to be different stages of
the same syndrome. Wernicke’s encephalopathy is believed to
be the acute stage and Korsakoff’s amnesic syndrome the chronic
stage. However, the prognosis is not as good for Korsakoff’s
amnesic syndrome. Patients often attempt to hide their poor memory
by confabulating. The patient will create detailed, believable stories
about experiences or situations to cover gaps in memory. This is
not usually a deliberate attempt to deceive because the patient
often believes what he or she is saying to be true.3
Thiamin supplementation up to 50 milligrams daily
is required to stop and potentially reverse some effects of these
syndromes.
Gastrointestinal Effects
Alcoholism causes damage to the pancreas. Glucose, insulin, and
glucagon production are interrupted. Continued drinking will result
in inflammation of the lining of the stomach, which can lead to
tears in the upper part of the stomach and lower part of the esophagus.
Alcohol irritates the stomach and causes gastritis. It interferes
with absorption of many nutrients.
Cardiovascular Effects
Heavy drinking can cause high blood pressure and cardiomyopathy.
These can put individuals at risk of heart failure or stroke.
However, moderate drinking may provide improved
glycolic control.4 Moderate drinking may also lower the risk for
heart disease, according to numerous studies.5
Nutrition for Recovery
People with alcoholism appear deficient in most nutrients but have
a special need for thiamin, B6, vitamin C, magnesium, and calcium
replenishment. Postmenopausal women with alcoholism are at higher
risk of osteoporosis and require calcium supplementation.
They often need additional vitamin K from foods or supplements due
to poor production by malfunctioning livers. Vitamin A can be toxic
to an individual with poor liver function. However, some people
may suffer from deficiencies of this vitamin and need supplementation.
In this case, a food source is a better choice and a supplement
should be used only as a last resort. Vitamin A supplements taken
with alcohol can be extremely toxic. Vitamin B12 may be low due
to gastric disturbances from drinking, especially if the patient
suffers from gastritis.
Primarily, the client with alcoholism needs a meal plan that contains
all the food groups. He or she needs to learn to eat regularly to
nourish the body as part of personal care. Getting all of his or
her nutrition from foods should be his or her ultimate goal rather
than relying on supplements, unless there is a preexisting medical
condition.
Difference Between Alcoholism
and Alcohol Abuse
Alcoholism, also known as alcohol dependence, is a disease that
includes four symptoms:
• Craving: A strong need, or compulsion, to
drink.
• Loss of control: The inability to limit
one’s drinking on any given occasion.
• Physical dependence: Withdrawal symptoms,
such as nausea, sweating, shakiness, and anxiety, occur when alcohol
use is stopped after a period of heavy drinking.
• Tolerance: The need to drink greater amounts
of alcohol in order to “get high.”
Alcohol abuse differs from alcoholism in that it
does not include an extremely strong craving for alcohol, loss of
control over drinking, or physical dependence. Alcohol abuse is
defined as a pattern of drinking that results in one or more of
the following situations within a 12-month period:
• failure to fulfill major work, school, or
home responsibilities;
• drinking in situations that are physically
dangerous, such as while driving a car or operating machinery;
• having recurring alcohol-related legal problems,
such as being arrested for driving under the influence of alcohol
or for physically hurting someone while drunk; and
• continued drinking despite having ongoing
relationship problems that are caused or worsened by the drinking.
Although alcohol abuse is distinguished from alcoholism,
individuals with both disorders suffer from many of the same effects.
— Mary Anne Clairmont, RD, is the nutritionist
at Fairmount Behavioral Health System and Take Two Nutrition, a
nutrition consulting company in Plymouth Meeting, Pa.
References
1. Dufour MC. What is moderate drinking? Defining “drinks”
and drinking levels. Alcohol Res Health. 1999;23:5-14.
2. Dietary Guidelines for Americans. U.S. Department
of Agriculture, U.S. Department of Health and Human Services. Available
at http://www.nal.usda.gov/fnic/dga/dguide95.html.
Accessed on August 12, 2005.
3. American Academy of Family Physicians. Available
at http://www.aafp.org. Accessed
August 10, 2005.
4. Kroenke CH, Chu NF, Rifai N, et al. A cross-sectional
study of alcohol consumption patterns and biologic markers of glycemic
control among 459 women. Diabetes Care. 2003;26:1971-1978.
5. Rimm EB, Williams P, Fosher K, et al. Moderate
alcohol intake and lower risk of coronary heart disease: meta-analysis
of effects on lipids and haemostatic factors. BMJ. 1999;319:1523-1528.
Asking the Right Questions
The CAGE Questionnaire
How can you tell whether your clientmay have a drinking
problem? Asking the following four questions can help you find out:
• Have you ever felt you should Cut down on
your drinking?
• Have people Annoyed you by criticizing your
drinking?
• Have you ever felt bad or Guilty about your
drinking?
• Have you ever had a drink first thing in
the morning (as an “Eye opener”) to steady your nerves
or get rid of a hangover?
One “yes” answer suggests a possible
alcohol problem. If your client answered “yes” to more
than one question, it is highly likely a problem exists. In either
case, it is important to discuss the answers to these questions.
You can help your clients determine whether they have a drinking
problem and, if so, recommend that they see a physician or certified
addiction professional.
— MAC
Adverse Effects of Alcoholism
Overindulgence in alcohol increases the risk of the following:
• liver disease;
• alcoholic hepatitis;
• cirrhosis;
• pancreatitis;
• fetal alcohol syndrome;
• elevated triglycerides;
• high blood pressure;
• stroke;
• heart failure;
• cancer; and
• injuries, domestic violence, and death.
— MAC
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