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Gut, 1985, 26, 882-887
Diet and drinking habits in relation to the development
ofalcoholic pancreatitis
J S WILSON, L BERNSTEIN, C MCDONALD, A TAIT,
D MCNEIL, AND R C PIROLA
From the DepartmentofGastroenterology, Division ofMedicine, Prince Henry Hospital, Sydney, NSW,
Australia, and the Department ofStatistics, Macquarie University, North Ryde, NSW, Australia
SUMMARY To determine whether increased intakes of fat and protein or particular drinking
habits are associated with the development of alcoholic pancreatitis, a dietary study has been
conducted. Patients with clinically evident alcoholic pancreatitis were compared with individuals
with clinically evident alcoholic cirrhosis with respect to dietary and drinking habits before the
onset of clinical illness. There was no significant difference between the two groups regarding
intake of nutrients, drinking habits or type of alcoholic beverage consumed.
Although alcoholism is common in western society increasing the dietary protein content has been re-
(affecting 3-5% of men and 0-1% ofwomen)1 only a ported to increase pancreatic protease content'1'4
small minority of alcoholic individuals develop and possibly also lipase activity.10 Although the
clinical pancreatitis. Dietary factors and drinking mechanism of such dietary adaptation is unknown,
habits have been considered as possible determi- its occurrence may predispose the pancreas to
nants of individual susceptibility to alcoholic pan- autodigestion. (b) High fat diets appear to increase
creatitis. The study described in this paper was the severity of experimental pancreatitis in dogs'5
undertaken to determine whether patients with this and there is a report of pancreatitis developing
disease differed from suitable controls with regard spontaneously in dogs consuming large amounts of
to: (a) their consumption of fat and protein, (b) the fat.'6 In addition, Maki et al17 have reported that
type of alcoholic beverage consumed and the increases in dietary protein enhance the develop-
pattern of its consumption prior to the onset of ment ofexperimental pancreatitis in rats. (c) Several
clinical disease. dietary surveys of patients with alcoholic pancreati-
tis have been carried out. Sarles' group 89 have
DIET AND PANCREATITIS reported that patients with this condition consume
Malnutrition has traditionally been considered to be more fat and more protein than the normal popula-
an important association of alcoholic pancreatitis. tion. The use of normal controls in these studies was
Malnutrition (in the absence of alcoholism) is unfortunate as they differed from the index group in
associated with pancreatitis in parts of Africa, India, more than one variable - they did not have
and South-East Asia.2 In addition, Mezey et a13 pancreatitis and they were not alcoholic. In addi-
have reported that pancreatic hyposecretion in tion, it was not made clear whether the patients
alcoholics is caused by malnutrition and is reversed were interviewed about their dietary habits before
by feeding adequate diets. or after the onset of clinical disease. Pitchumoni et
On the other hand, there is experimental and al. 20 reported that patients with alcoholic pancreati-
clinical evidence to suggest that 'hypernutrition' tis consumed more fat than patients with alcoholic
may be a predisposing factor in this disease: (a) cirrhosis. Both study groups were alcoholic and both
Several investigators have been able to increase groups had consumed enough alcohol to result in
lipase content of the pancreas of experimental organ damage. The difference in fat intakes re-
animals by feeding high fat diets.49 Similarly, ported, however, may have been related to the 13
year average age difference between the two groups.
Address for correspondence: Dr R C Pirola, 1st Floor Clinical Sciences Bldg. DRINKING HABITS AND ALCOHOLIC PANCREATITIS
Prince Henry Hospital, Anzac Parade, Little Bay, NSW 2036, Australia. A survey of the literature reveals considerable
Received for publication 30 October 1984 geographic variation in patterns of alcohol consump-
882
Diet and drinking habits in relatioh to the development of alcoholic pancreatitis 883
tion in association with alcoholic pancreatitis. In normal 300 U/1) or features of moderate or ad-
France2' 22 and Sweden23 patients are reported as vanced chronic pancreatitis on a retrograde pan-
consistent heavy drinkers with little variation in creatogram (according to the criteria of Kasugai et
alcohol intake between one day and the next. In the a135), (iii) negative radiographic studies of the gall
United States,24 South Africa,25 26 Scotland,27 and bladder, normal serum calcium (in remission),
Australia,28 29 however, bout drinking is said to be fasting serum triglycerides less than twice the upper
more prominent in these patients. limit of normal and no relevant drug history.
The relationship of drinking bouts to attacks of
pancreatitis is controversial. Phillips, 24 Marks and (b) Alcoholic liver disease
Bank,25 Boyer and Mackay,28 and Imrie27 have Patients presenting with clinical evidence of alcoho-
reported that attacks of pancreatitis often coincide lic liver disease all admitted to drinking 80 g or more
with periodic drinking bouts. On the other hand, of alcohol per day and had alcoholic cirrhosis
Saint,3 " Mayday and Pheils,3' and Kager et a123 diagnosed by liver biopsy or (when deranged coagu-
could find no association between attacks of pan- lation precluded a liver biopsy) by the presence of
creatitis and the imbibition of larger than usual typical stigmata of chronic liver disease with ascites
quantities of alcohol. and/or oesophageal varices and with a normal serum
The type of beverage consumed appears to be iron or serum ferritin.
unimportant in relation to the development of
alcoholic pancreatitis. Wine, spirits, beer, and cider (c) Gall stone pancreatitis
have all been incriminated in reports from various All patients in this category possessed the following
countries.21-23 25 32-34 features: (i) typical attacks of acute abdominal pain
ofWith the exception of the reports of Sarles21 and and tenderness, (ii) a serum amylase greater than
Kager et a123 there are no published data to 1100 U/I (upper limit of normal: 300 U/1), (iii)
support the above claims. The drinking habits and evidence of gall stones on biliary radiology or at
the preferred alcoholic beverage of patients with laparotomy, (iv) normal serum triglycerides, (v)
alcoholic pancreatitis need to be documented and normal serum calcium (in remission), (vi) no re-
compared with those of a suitable control group levant drug or alcohol history.
before such factors can be accepted or dismissed as
contributing to the development of the disease. (d) Gall stones in the common bile duct without
pancreatitis
Methods All patients in this category had: (i) gall stones in the
common bile duct found at the time of biliary
STUDY GROUPS surgery or with endoscopic retrograde cholangiogra-
The dietary fat and protein intakes and the drinking phy, (ii) no clinical evidence of pancreatitis, (iii) a
habits of patients with clinically evident alcoholic normal serum amylase.
pancreatitis were compared with those of patients
with clinically evident alcoholic liver disease. This DIETARY INTERVIEWS
particular control group was chosen because these All patients were interviewed by a research dietitian
individuals had consumed enough alcohol to result who was unaware of their diagnosis. All interviews
in damage of an organ other than the pancreas. took place within two years of the onset of clinical
If dietary factors contribute to the development of disease. Information was recorded about the pa-
alcoholic pancreatitis, they may also play a role in tients' dietary and drinking habits during the six
other forms of pancreatic injury. Therefore, a study month period before the onset of symptoms. In
was also made of the dietary intakes of patients with other words, an attempt was made to study patterns
gall stone pancreatitis. In this instance, the control of fat, protein and alcohol intake in the premorbid
group comprised individuals with one or more gall state. Where possible, information about the pa-
stones in their common bile ducts but without tients' dietary habits was also obtained from rela-
pancreatitis. tives.
CRITERIA FOR ENTRY DATA ANALYSIS
(a) Alcoholic pancreatitis Comparisons of dietary data between index patients
Patients presenting with clinical evidence of alcoho- and their controls were made with multiple regres-
lic pancreatitis admitted to drinking 80 g or more of sion analysis using the following multiple regression
alcohol per day and manifested: (i) typical attacks of model:
acute abdominal pain and tenderness, (ii) either a y = Bo + Blxl + B2x2 + B3z
serum amylase greater than 1100 U/I (upper limit of
Bernstein, McDonald, Tait, McNeil, Pirola
884 Wilson,
where Table 1 Study groups
y is the response variable (lipid intake, protein MalelFemale
intake, caloric intake, etc) Number Age ratio
B(1 is a constant coefficients
B1, B2, B3 are regression Alcoholic pancreatitis 20 40+9 3-8
xi, x2, z are explanatory variables with Alcoholic cirrhosis 33 51 + 11 2-2
x = age Gall stone pancreatitis 15 59±19 0-5
x2 = sex (in the case of males the variable x2 is Gall stones in duct 31 61 ± 18 (-4
assigned the value 1 and in the case of common bile
females it is assigned the value 0) * Mean+standard deviation.
z = group (for the index group z= 1; for the
control group z=0). variable to be 300U/l). Of the remaining two, one had pancreatic
This model allows the response and the other had
related to the group while adjusting for sex and age, calcification shown radiologically
assuming the latter effect is linear. (No evidence for features of moderately advanced chronic pancreati-
nonlinearity was apparent in the data). tis on a retrograde pancreatogram (according to the
In the case of the index group, the equation criteria of Kasugai et al.35) In nine of the patients
reduces to: with alcoholic pancreatitis, a pancreatogram was
y = B(, + Blxl + B2X2 + B3 done and in four cases, this showed moderate or
advanced features of chronic pancreatitis. with
In the case of the control group, it becomes: Table 2 compares the diet of patients with
y = B(1 + Blxl + B2x2 alcoholic pancreatitis with those of patients
alcoholic cirrhosis. It can be seen that both groups
The difference between the two groups is there- were well nourished consuming, on average, appro-
fore B3, which will have an expected value of zero if ximately 11 000-14 000 alcohol free kilojoules
the null hypothesis is true. Estimates of B3 were (2000-3000 calories) per day. Patients with alcoholic
derived for the following response variables: pancreatitis exhibited higher intakes of protein, fat
lipid intake (g/day) (including saturated and monounsaturated fat) and
protein intake (g/day) carbohydrate. Alcohol intakes were similar between
alcohol free kilojoules (AFKj/day) the two groups. Although the differences for satu-
lipid intake as a percentage of AFKj/day rated fat, carbohydrate and alcohol free kilojoules
protein intake as a percentage of AFKj/day are all statistically significant (p<005 in each case),
alcohol intake (g/day). these differences should be adjusted for age and sex
Whether or not B3 was different from 0 was to obtain a valid comparison. mean
determined by Student's t test, giving a p value in Table 3 presents the age and sex adjusted
each case. differences (B3 values) of the response variables
Data about drinking habits (type of alcoholic exhibited in Table 2. When age and sex were taken
beverage; patterns of consumption) were compared
using the x2 test.
Table 2 Dietary composition ofgroups with alcohol
Results related disease
Data concerning the size, average age and male/ Alcoholic Alcoholic
female ratios for the four study groups are given in pancreatitis cirrhosis
Table 1. Patients with alcoholic cirrhosis were, on Protein (g/day) 109±9* 88±5
average, 11 years older than patients with alcoholic Protein (as per cent of AFKjt) 13±1 14+±04
pancreatitis and the group contained more women. Lipid (g/day) 148±15 115+8
The two with gall stone related disease had Lipid (as per cent of AFKj) 4(0+1 41+2
groups Polyunsaturated fat (g/day) 12+2 12+ 1
similar age and sex characteristics. Saturated fat (g/day) 70±7 52±4
It is of interest that although the protocol allowed Monounsaturated fat (g/day) 59+6 45+3
for the inclusion of patients with chronic pancreati- Cholesterol (mg/day) 591+71 529+46
Carbohydrate (g/day) 383+39 289±25
tis, all patients were clinically regarded as having Carbohydrate (as per cent of AFKj) 46±2 45±2
relapsing pancreatitis. All had had typical attacks of Alcohol (g/day) 147+17 150+14
acute abdominal pain and tenderness. In addition, AFKj/day 13 856+1289 10 651±731
during an attack, all but two had a serum amylase * Results expressed as mean+SEM.
greater than 1100 U/l (upper limit of normal t AFKj = alcohol free kilojoules.
Diet and drinking habits in relatidn to the development of alcoholic pancreatitis 885
Table 3 Ageandsexadjustedmean differences (B?) in Table 5 Ageandsex adjustedmean differences (B?) in
dietary composition between groups with alcohol related dietary composition between groups with gallstone related
disease disease
B* t valuet p value B* t value' p value
Protein (g/day) 8 (082 0 41 Protein(g/day) 1 (1-11 (1-91
Protein (as per cent of AFKj#) - 2 -1-6 0-12 Protein (as per cent of AFKj#) -(0 1 -0-13 0 90
Lipid (g/day) 19 1.1 0-27 Lipid (g/day) 13 0-56 0(58
Lipid (as per cent of AFKj) -(09 -0-36 0-72 Lipid (as per cent of AFKj) 2 (0-94 (0-35
Polyunsaturated fat (g/day) -0-4 -0(15 0-88 Polyunsaturated fat (g/day) 4 (0-74 0-46
Saturated fat (g/day) 11 1.3 0-21 Saturated fat (g/day) 1 (1-072 0(94
Monounsaturated fat (g/day) it) 1-3 0-20 Monounsaturated fat (g/day) 6 0(65 (1-52
Cholesterol (mg/day) -3( -(-34 0-75 Cholesterol (mg/day) 1(04 1 -2 (0-24
Carbohydrate (g/day) 8(1 2-0 0-046 Carbohydrate (g/day) 18 (1-36 (0-72
Carbohydrate (as per cent AFKj) 2 0-72 0 47 Carbohydrate (as per cent AFKj) -2 -(-81 (0-43
Alcohol (g/day) 12 0-68 0 50 AFKj/day 7(06 (1-4 (1-69
AFKj/day 1760 1-2 0-23
* See section on data analysis for derivation of B3.
* See section on data analysis for derivation of B3. t Student's t test. t AFKj/day = alcohol free kilojoules.
t Student's t test. t AFKj = alcohol free kilojoules.
into account, it can be seen that patients with drinkers with little variation in their alcoholic intake
from one day to the next. Seven of the pancreatitis
alcoholic pancreatitis consumed on average each 8 g group and nine of the cirrhosis group admitted to
more protein, 19 g more fat (mainly saturated and drinking more heavily on one or two days per week
monounsaturated fat), 80 g more carbohydrate, but this difference was not significant (Table 6).
approximately 1600 more alcohol free kilojoules and There were no exclusive binge drinkers in either
12 g more alcohol. With 47 degrees of freedom for group.
the t tests, only the carbohydrate comparison was The types of alcoholic beverage consumed by
statistically significant (p=0-046), a result which is patients with pancreatitis and cirrhosis are com-
not remarkable when 12 comparisons are made (see pared in Table 7. The predominant alcoholic bever-
O'Neil and Wetherill).36 Thus we may conclude that age in both groups was beer, a not unexpected
no differences are significant. finding in an Australian population. There was a
The dietary intakes of patients with gall stone slight tendency for those with cirrhosis to consume
pancreatitis are compared with those of patients less beer and more wine. For the purposes of
with gall stones in the common bile duct in Tables 4 statistical analysis, a contingency table was con-
and 5. There was no difference in any dietary
response variable studied. Table 6 Patterns ofalcohol consumption in patients with
The majority of patients with alcoholic pancreati- alcoholicpancreatitis and with alcoholic cirrhosis
tis and alcoholic cirrhosis were consistent heavy
Alcoholic Alcoholic
Table 4 Dietary composition ofgroups with gallstone pantcreatitis cirrhosis
related disease Regular, daily consumption 13 24
Heavier consumption on I or 2
Gallstones days per week 7 9
Gallstone in common RawX2=0 35; with Yates correction X2 =0-08 (p=0(78).
pancreatitis bile duct
Protein (g/day) 97+13* 99+11
Protein (as per cent of AFKjt) 14+1 14+1 Table 7 Types ofalcoholic beverage consumed bypatients
Lipid (g/day) 145+23 145±21 with alcoholic pancreatitis and with alcoholic cirrhosis
Lipid (as per cent of AFKj) 43±2 42+ 1
Polyunsaturated fat (g/day) 24+6 20±2
Saturated fat (g/day) 61 ± 1(0 66+11 Alcoholic Alcoholic
Monounsaturated fat (g/day) 54+8 53+8 pancreatitis cirrhosis
Cholesterol (mg/day) 557+100 533+78
Carbohydrate (g/day) of 335+65 317+25 Beer 68+9* 52+8
Carbohydrate (as per cent AFKj) 44±2 45+1 Spirits 26+9 20+6
AFKj/day 12 743+2041 12 495+1352 Wine 6+4 28+6
* Results expressed as mean+SEM. * Results are expressed as mean±SEM of percentages of total
t AFKj = alcohol free kilojoules. alcohol consumption.
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