Friends and family, dancing and drinking, parties and presents?the holiday season is just around the corner! Many of us will enjoy the festivities and merriment, as will our patients. All of us will have decisions to make about healthy eating and drinking during the holidays, since the temptation to overindulge is perhaps greatest at this time of year. Yet, these decisions?especially concerning the use of alcoholic beverages?are vitally important for our diabetic patients throughout the year. How can we provide the best pharmaceutical care when counseling patients about diabetes and alcohol?
Before we can provide guidelines for responsible drinking, we must be aware of the specific risks and potential consequences of alcohol use for diabetics. These risks include both short- and long-term effects on the body, interactions with diabetic medications, and worsening of preexisting diabetic complications. Whereas alcohol use in moderation is prudent for most patients with diabetes, there are times when saying ?no, thanks? is the best decision.
Physiologic Effects of Alcohol in Diabetics
When alcohol is ingested, it moves quickly from the gastric contents and intestinal lumen into the bloodstream with minimal breakdown. Blood alcohol content is measurable within 5 minutes and peaks at 30 to 90 minutes. The liver metabolizes ethanol as a toxin through the alcohol dehydrogenase pathway. Absorption and breakdown rates are affected by many factors, such as gender, ethnicity, stomach contents, and body weight.
Alcohol and Blood Glucose
Under normal conditions, when blood glucose levels begin to decline, the liver converts stored carbohydrates into glucose for release into the bloodstream. This reaction avoids or slows the rate of hypoglycemia. When alcohol is ingested, however, conversion of carbohydrates into glucose for release becomes a secondary priority. The liver detoxifies alcohol until it is cleared, and it only then begins to assist in normalizing blood sugar. This scenario can quickly lead to hypoglycemia for the diabetic who ingests alcohol.
Alcohol and Diabetic Medications
Insulin and oral hypoglycemics mixed with alcohol may increase the risk of hypoglycemic reactions. Chlorpropamide and possibly other sulfonylureas may produce a disulfiramlike reaction with alcohol, leading to flushing, hypotension, nausea, tachycardia, vertigo, dyspnea, and blurred vision. Metformin should be avoided in patients with a history of chronic alcohol use because they may be more predisposed to lactic acidosis.
Alcohol and Exercise
Exercise depletes muscle glycogen stores, and they must be replenished with blood glucose. Because alcohol consumption prevents the liver from releasing glucose into the bloodstream, patients who exercise and ingest alcohol increase the risk of hypoglycemia.
Alcohol and Weight Gain
Alcohol is considered a substance with ?empty calories? due to its lack of nutrients, and it can adversely affect a diabetic who is concerned with weight loss. A single 12-oz beer contains approximately 150 calories, and a single 5- oz glass of wine or a 1.5-oz shot of 80- proof liquor contains about 100 calories. For diabetic meal-planning purposes, 1 drink equals 2 fat exchanges.
Alcohol and Diabetic Complications
For patients suffering from diabetic neuropathy, alcoholic beverages can increase the pain, burning, tingling, and numbness associated with this condition. This increase can even occur with moderate drinking (fewer than 2 drinks per week). Moderate drinking habits also may elevate blood triglyceride levels, already elevated in most diabetics. Heavy drinking (3 or more drinks per day) can worsen diabetic retinopathy. Finally, because diabetes and hypertension are often comorbid conditions, diabetics should be aware that alcohol use may raise blood pressure levels.
Guidelines for Alcohol Use
Now that we have considered the ramifications of alcohol use for the patient with diabetes, we should be prepared to provide the patient with useful guidelines concerning alcohol use and diabetes.
Questions for a Patient to Ask Himself or Herself
According to the American Diabetes Association (ADA), a diabetic patient should ask 3 questions before using alcohol: 1. Is my diabetes under control? 2. Does my health care provider agree that I am free from health problems that alcohol can make worse? 3. Do I know how alcohol can affect me and my diabetes? If the answers to all 3 questions are ?yes,? the ADA suggests that an occasional drink is acceptable. The recommendation for occasional drinking is the same for persons without diabetes: no more than 2 drinks a day for men and no more than 1 drink a day for women.
Other Tips to Share with Patients
Eat First Before Consuming Alcohol. Food may slow the rate of absorption and help to prevent hypoglycemic reactions.
Be Prepared for Low Blood Sugar Reactions. Have a high-carbohydrate snack ready for when the blood sugar level dips below 65 to 70 mg/dL. Remember that glucagon does not correct hypoglycemia related to alcohol use.
Monitor Your Blood Sugar Frequently! Bring your blood glucose monitor with you, and use it.
Carefully Check the Alcohol Level of What You Are Drinking. Make sure that mixed drinks are measured correctly, and be sure to account for added calories and carbohydrates in fruit juices, sodas, and other mixers. Check the proof of distilled spirits and the alcohol level of beers and wines. Also, consider drinking nonalcoholic beers or wines or virgin mixed drinks.
Remember That the Symptoms of Hypoglycemia and Intoxication Are Similar. Be sure that a responsible friend or family member is present to watch for signs such as dizziness, confusion, or shakiness that may indicate a low blood glucose level. This person should know how to help you check your sugar level and get you a high-carbohydrate snack if needed.
Eat a Snack Before Bedtime. Your blood sugar level can drop overnight even though you feel fine when retiring for the night. Set an alarm to wake you after a few hours? sleep so that you can check your level.
Choose Drinks That Are Low in Sugar and Alcohol. Light beers and dry wines are excellent choices. When using mixers, select ones that are sugar-free, such as club soda, seltzer, water, and diet soft drinks or tonic.
Know When to Say No to Alcohol
For some people with diabetes, not using alcohol at all is the best choice. Those with diabetic complications such as neuropathy, retinopathy, uncontrolled hypertension, or elevated triglyceride levels always should say no.
(Some considerations about not using alcohol apply to everyone. No one should drink and operate a motor vehicle or heavy machinery under the influence of alcohol. There are other medical conditions that may contraindicate the use of alcohol, such as liver disease, peptic ulcer disease, gastritis, pancreatitis, or pregnancy.)
After this review of the specific risks associated with drinking and diabetes, we should be better prepared as pharmacists to provide our diabetic patients with sound advice concerning the responsible use of alcohol. As the holiday season approaches, we should be able to tell our patients that they can enjoy themselves without fear if they know a few simple precautions to take. After all, the holidays are a celebration!
The author is senior assistant pharmacy officer with the US Public Health Service (PHS)/Indian Health Service, Whiteriver PHS Hospital, Whiteriver, Ariz. The opinions expressed in this article are those of the author and do not necessarily reflect the views of the USPHS or the Indian Health Service.