Applied Evidence

Diabetes and alcohol use: Detecting at-risk drinking

J Fam Pract. 2011 December;60(12):E1-E6

Asking a simple question helps uncover at-risk drinking in patients with diabetes, and brief office interventions have proven effective in modifying behavior.

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References

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15. Howard AA, Arnsten JH, Gourevitch MN. Effect of alcohol consumption on diabetes mellitus. Ann Intern Med 2004;140:211-219.

16. Glasgow AM, Tynan D, Schwartz R, et al. Alcohol and drug use in teenagers with diabetes mellitus. J Adolesc Health 1991;12:11-14.

17. Turner BC, Jenkins E, Kerr D, et al. The effect of evening alcohol consumption on next-morning glucose control in type 1 diabetes. Diabetes Care 2001;24:1888-1893.

18. Richardson T, Weiss M, Thomas P, et al. Day after the night before. Influence of evening alcohol on risk of hypoglycemia in patients with type 1 diabetes. Diabetes Care. 2005;28:1801-1802.

19. Cheyne EH, Sherwin RS, Lunt MJ, et al. Influence of alcohol on cognitive performance during mild hypoglycaemia: implications for type 1 diabetes. Diabet Med 2004;21:230-237.

20. Lao B, Czyzyk A, Szutowski M, et al. Alcohol tolerance in patients with non-insulin-dependent (type 2) diabetes treated with sulphonylurea derivatives. Arzneimittelforschung 1994;44:727-734.

21. PDR Staff Physicians’ Desk Reference 2003. 57th ed. Montvale, NJ: Medical Economics Company; 2003.

22. Ramchandani N, Cantey-Kiser JM, Alter CA, et al. Self-reported factors that affect glycemic control in college students with type 1 diabetes. Diabetes Educ 2000;26:656-666.

23. Kyngas H. Compliance of adolescents with chronic disease. J Clin Nurs 2000;9:549-556.

24. Ahmed AT, Karter AJ, Liu J. Alcohol consumption is inversely associated with adherence to diabetes self-care behaviours. Diabet Med 2006;23:795-802.

25. Karter AJ, Ferrara A, Darbinian JA, et al. Self-monitoring of blood glucose. Diabetes Care 2004;23:477-483.

26. Chew LD, Nelson KM, Young BA, et al. Association between alcohol consumption and diabetes preventative practices. Fam Med 2005;37:589-594.

27. Johnson KH, Bazargan M, Bing E. Alcohol consumption and compliance among inner-city minority patients with type 2 diabetes mellitus. Arch Fam Med 2000;9:964-970.

28. D’Amico EJ, Paddock SM, Burnam A, et al. Identification of and guidance for problem drinking by general medical providers. Med Care 2005;43:229-236.

29. Roche AM, Parle MD, Stubbs JM, et al. Management and treatment efficacy of drug and alcohol problems: what do doctors believe? Addiction. 1995;90:1357-1366.

30. Aira M, Kauhanen J, Larivaara P, et al. Differences in brief interventions on excessive drinking and smoking by primary care physicians: qualitative study. Prev Med 2004;38:473-478.

31. Barry KL, Blow FC, Willenbring M, et al. Use of alcohol screening and brief interventions in primary care settings: implementation and barriers. Subst Abus 2004;25:27-36.

32. Smith PC, Schmidt SM, Allensworth-Davies D, et al. Primary care validation of a single-question alcohol screening test. J Gen Intern Med 2009;24:783-788.

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45. Fleming M, Brown R, Brown D. The efficacy of a brief alcohol intervention combined with %CDT feedback in patients being treated for type 2 diabetes and/or hypertension. J Stud Alcohol 2004;65:631-637.

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PRACTICE RECOMMENDATIONS

• Ask a question such as “How many drinks containing alcohol did you have on a typical day when you were drinking in the last year?” to ascertain a patient’s quantity of alcohol use. A

• Apply elements of the FRAMES approach to help patients curtail at-risk drinking—eg, use elevated HbA1c levels as evidence of a need to change behavior. A

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

There are enough challenges in controlling diabetes mellitus without the hindrance of undetected problematic alcohol use. The good news is that asking a single nonthreatening question can help you detect at-risk drinking—defined by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) as 5 or more drinks on one occasion or more than 14 drinks per week for men; and 4 or more drinks on one occasion or more than 7 drinks per week for women.^1,2 And, for patients who may be compromising their diabetes care and overall health through problem drinking, brief intervention techniques used in the office can enable them to reduce alcohol consumption significantly.

FAST TRACK

For further information on at-risk drinking, visit the National Institute on Alcohol Abuse and Alcoholism, athttp://www.niaaa.nih.gov/Pages/default.aspx.

When alcohol becomes a problem in diabetes care

Several studies have explored the long-term benefits of moderate alcohol use on glycemic control—with mixed results. A 2007 study found that diabetes patients who drink 1 glass of wine per day exhibited a lower fasting glucose level than abstainers after 3 months.³ There was no difference, however, on postprandial glucose levels. A 2008 study found that individuals who drank one to 2 glasses of wine per day for a month had lower fasting serum insulin levels relative to when they have abstained for a month,⁴ although levels of fasting plasma cholesterol, HDL cholesterol, glucose, and hemoglobin A1c (HbA_1c) remained unchanged relative to periods of abstinence.⁴

Furthermore, rates of coronary heart disease and CHD mortality in a meta-analysis were significantly lower in 3 categories of alcohol consumption (<6 g/d, 6 to <18 g/d, and ≥18 g/d) compared with abstinence.⁵ Nondrinkers also had a greater risk of total mortality compared with the lightest drinking group. Notably, however, the lower limit of the highest drinking category was only 1.5 drinks per day.

FAST TRACK

At-risk drinking for men is ≥5 drinks on one occasion or >14 per week; for women, ≥4 drinks on one occasion or >7 per week.

How big is the problem? In a study of insulin-treated patients seen for severe hypoglycemia, 17% had been drinking before the episode.⁶ In a primary care sample, 28% of randomly selected patients with type 2 diabetes met Diagnostic and Statistical Manual of Mental Disorders-IV criteria for a lifetime incidence of alcohol abuse and 13% met either current or lifetime criteria for alcohol dependence.⁷ Another study of primary care patients with diabetes⁸ found that 13.4% met NIAAA criteria for at-risk drinking; 11.1% of these at-risk drinkers met criteria for current alcohol dependence. (According to the NIAAA, the rate of at-risk/heavy drinking among US adults is 30%, and about one in 4 heavy drinkers meets the criteria for alcohol abuse or dependence.¹)

Detrimental effects with immoderate drinking. Individuals who engage in at-risk drinking, as defined by the NIAAA, are at increased risk for alcohol dependence⁹ and associated complications such as diabetic neuropathy and retinopathy,¹⁰ atherosclerosis,¹¹ and total and CHD mortality.^3,12 Heavy drinking also interferes with neuroendocrine, gastrointestinal, and sexual function,¹³ and its interaction with diabetes increases the risk for hepatocellular carcinoma after controlling for hepatitis B and C serology.¹⁴

Interference with diabetes control. Research examining the short-term effect of alcohol use has produced contradictory results, partly due to differences among studies, such as whether alcohol is administered with a meal and whether a fasting glucose level is measured.¹⁵ However, alcohol affects glycemic control and, when used excessively, can impair glucose production.^16,17 Alcohol may induce hypoglycemia,^10,18 and even small amounts may jeopardize diabetes control.¹³ In a study of patients with insulin-treated diabetes, alcohol use in the presence of mild hypoglycemia increased diastolic blood pressure or exacerbated hypoglycemia-related cognitive deficits.¹⁹ Another concern—in both the short and long term—is that alcohol interacts negatively with certain diabetes medications. It is more likely to induce hypoglycemia in the presence of sulfonylurea medications.¹⁰ Chlorpropamide decreases the rate of ethanol elimination from the blood.²⁰ And, in those taking metformin, excessive alcohol use elevates risk for lactic acidosis. ²¹

Diminished self-care. Alcohol use can interfere with self-care,^22,23 which is a crucial component of diabetes treatment.²⁴ It may lead to reduced eating¹⁶ or to decreased willingness to adhere to prescribed dietary regimens.¹³ It also impairs other self-care behaviors^13,15,25 such as self-monitoring blood glucose and showing up for medical appointments.²⁶ In a large, diverse sample of patients with diabetes,²⁴ heavy drinkers had the highest rates of morbidity. Importantly, alcohol and diabetes self-care behavior were significantly negatively associated. Studies of ethnic minority samples have yielded comparable results.²⁷