Sunday, November 10, 2013

Libations and IBD

Alcohol, Crohn's, and Ulcerative Colitis

Alcohol, more specifically ethyl alcohol (or ethanol), is a result of sugar fermentation.  Humans are believed to have consumed alcohol since prehistoric times.  Primarily a central nervous system depressant, alcohol has several sought-after psychoactive properties which have led to its recreational consumption in beverages and inclusion in recipes.  More specifically, small amounts of alcohol are found to produce short term euphoric effects, including increased self confidence and more relaxed social interactions.  In cooking, alcohol’s ability to evaporate quickly and act as a solvent for flavors that are not water-soluble are valuable assets, and the flair added to “flaming” dishes makes for dramatic presentation.

Alcohol use, like many other substances, has both positive and negative effects on those with IBD.  In general, the effects of moderate consumption of alcohol have been shown to have minimal negative and potential positive health effects.  The amount that is considered “moderate” varies per person and is a factor of gender, genetics, and size.  For an average woman, one-to-one and a half servings a day are considered moderate, whereas a large man may have two or two and a half servings at the moderate consumption level.  While most individuals with Crohn’s and Ulcerative Colitis are told to avoid alcohol, and they will self-report digestive problems after consumption, the number of individuals with IBD that drink is similar to the population at large.(1)

As a primary positive factor, a lower risk of coronary artery disease has been correlated with regular, small amounts of alcohol consumption.  With respect to IBD, moderate consumption has been shown to be correlated with lower C-Reactive Protein levels, one of the key markers associated with inflammation in the disease.(2)  Though there is a correlation, there is no direct evidence that there is a positive impact on intestinal inflammation, just systemic markers of inflammation (there is no negative impact shown either).  There is little evidence that minimum to moderate amounts of alcohol have any long-term negative effects on IBD outcomes.  In fact, consumption of smaller amounts of alcohol has been shown to have a protective effect against developing Ulcerative Colitis (odds ratio = .57).(3)

While moderate consumption has been shown to have minimal impact, higher consumption levels, both acute and chronic, have serious negative consequences.  The well-known acute impacts of consumption that are non-GI specific include impaired judgment, vomiting, slowing of cardiac function, and an altered level of consciousness (to include coma and death at the highest levels).  The effects of high level chronic consumption are additionally severe – including liver disease, coronary disease, and dependency-related issues.

While light-to-moderate consumption may show no evidence of impact on disease progression, moderate-to-heavy consumption has been shown to have an impact.  Ulcerative Colitis sufferers are more like have a relapse (Odds Ratio = 2.7) if they are in the top third of the IBD population in alcohol consumption v. the bottom third. (4) Additionally, because of intestinal permeability issues associated with IBD, there is a potential higher likelihood for co-morbid cirrhosis of the liver to develop in those who consume heavy amounts of alcohol. (5)

Despite the general rules, there are some specific circumstances where alcohol consumption is contraindicated for those with IBD.  Originally, metronidazole (Flagyl) was reported to have a deadly disulfiram-like reaction when alcohol was consumed while taking the drug.  The original reports have largely been dismissed at this point, though the possibility of multi-drug interactions still exist.(6,7)  Immunomodulators like methotrexate have an increased risk of liver damage, and alcohol consumption can increase this risk.  Additionally, drugs like Zantac and Tagamet can increase absorption leading to a higher blood alcohol level. (8)

Alcohol is not only in the things we drink – it can be in everything from cough medicines to mouth wash.  Alcohol is frequently used in cooking also – there is an unfounded assumption that alcohol burns off quickly (because of a quicker evaporation than water) .  The real story is more complicated – the smaller the pot, the less evaporates.  Additionally, the lower the temperature the less evaporates.  A table from the USDA (below) shows the evaporation for everything from flambé to simmering at various cooking times (uncovered).

Percentage Alcohol
Alcohol, overnight evaporation
Alcohol added to hot liquid
Alcohol 15 minutes cooking
Alcohol 30 minutes cooking
Alcohol 1 hour cooking
Alcohol 1.5 hours cooking
Alcohol 2 hours cooking
Alcohol 2.5 hours cooking

Bottom Line

·         Light consumption of alcohol is likely to have no negative effect on Crohn’s and Ulcerative Colitis progression
·         Heavy consumption of alcohol can have a serious impact on IBD and general health
·         If you are on medications, multi-drug interactions can be exacerbated by alcohol.  Talk to your doctor and ask them to show you the research on your particular meds!
·         Alcohol can and does appear in non-drink form in cough syrups, mouthwash, and many dishes in restaurants.  Cooking does not generally remove much of the alcohol content.

1.       Swanson, Garth R., Shahriar Sedghi, Ashkan Farhadi, and Ali Keshavarzian. "Pattern of alcohol consumption and its effect on gastrointestinal symptoms in inflammatory bowel disease." Alcohol 44, no. 3 (2010): 223-228.
2.       Albert, Michelle A., Robert J. Glynn, and Paul M. Ridker. "Alcohol consumption and plasma concentration of C-reactive protein." Circulation 107, no. 3 (2003): 443-447.
3.       Nakarnura, Yosikazu, and Darwin R. Labarthe. "A case-control study of ulcerative colitis with relation to smoking habits and alcohol consumption in Japan." American journal of epidemiology 140, no. 10 (1994): 902-911.
4.       Jowett, S. L., C. J. Seal, M. S. Pearce, E. Phillips, W. Gregory, J. R. Barton, and M. R. Welfare. "Influence of dietary factors on the clinical course of ulcerative colitis: a prospective cohort study." Gut 53, no. 10 (2004): 1479-1484.
5.       Keshavarzian, A., E. W. Holmes, M. Patel, F. Iber, J. Z. Fields, and S. Pethkar. "Leaky gut in alcoholic cirrhosis: a possible mechanism for alcohol-induced liver damage." The American journal of gastroenterology 94, no. 1 (1999): 200-207.
6.       Williams, Caroline S., and Kevin R. Woodcock. "Do ethanol and metronidazole interact to produce a disulfiram-like reaction?." The Annals of pharmacotherapy34, no. 2 (2000): 255-257.
7.       Visapaa, J. P., Jyrki S. Tillonen, Pertti S. Kaihovaara, and Mikko P. Salaspuro. "Lack of disulfiram-like reaction with metronidazole and ethanol." The Annals of pharmacotherapy 36, no. 6 (2002): 971-974.

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