Editor’s viewpoint: Alcohol and diabetes: A risky cocktail?

‘I hate to advocate drugs, alcohol, violence or insanity to anyone, but they’ve always worked for me.’ – Hunter S Thompson

Diabetes is so unfair. It impinges on all of the pleasures of life without providing any light relief. To make matters worse, the advice given to people with diabetes about sex, drugs and rock and roll (i.e. lifestyle) can be confused and might reflect our own personal values rather than actual evidence. In terms of alcohol use in diabetes, for example, the advice might be ‘do the same as everyone else’ or ‘ask the dietitian’!

The combination of alcohol and insulin is recognised to have potentially disastrous consequences, as modest amounts of alcohol can impair the early warning symptoms of a low blood glucose level and augment the associated cognitive deficits (Cheyne et al, 2004). The risk of next-day hypoglycaemia ‘the morning after the night before’ is also increased in people with type 1 diabetes (Turner et al, 2001). On the other hand, epidemiological evidence suggests that moderate alcohol use is particularly beneficial in reducing the risk of vascular disease, which is highly relevant for the diabetes population (Ajani et al, 2000).

Although authoritative voices suggest an approach to alcohol for our patients that is similar to that for the general population, this could be perceived as a bit of a ‘cop-out’ given that binge drinking (defined as drinking more than 6 units at a time) is fast becoming a national pastime. Binge drinking is not always pre-planned and expecting individuals to make rational choices about food, blood glucose levels and insulin at 2 a.m. after eight bottles of alcopops may be naïve.

Individuals who abuse alcohol are also at increased risk of the potentially serious condition of alcoholic ketoacidosis. This occurs in those who drink excessively while eating little because of satiety, abdominal pain or emesis. The net result is a combination of relative insulin deficiency, elevated counter-regulatory hormone levels and volume depletion. The metabolism of alcohol ratchets up the formation of ketone bodies, aggravating the acidosis even though glucose levels may not be particularly high. It is probably under-recognised (Trevisan et al, 2004).

So what should be done? Diabetes Digest would be interested in receiving advice from readers for Simon, a thirty-something single man with long-standing type 1 diabetes (more than 10 years) who is controlled on multiple injections of short-acting analogue insulin with each meal and a long-acting basal analogue insulin taken last thing at night. He has reasonable early warning of hypoglycaemia and an average HbA_1c of 7.5%. Simon is off to Amsterdam on a stag weekend and expects to drink copious amounts of the local brew. This topic was not covered in the intensive education programme he attended last year.

We will publish a selection of responses and there may be a (non-alcoholic) prize for the most useful. Finally, a ‘just say no’ approach is unlikely to cut much ice in the clubbing culture of places such as Bournemouth.