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Joshua J. Neumiller, PharmD, CDE, CGP, FASCP, is an Assistant Professor of Pharmacotherapy in the College of Pharmacy, Washington State University, and co-owner of Pharmacy Advocates, LLC, Spokane, WA.
Chapter 4 Alcohol and Diabetes
Marion J. Franz, MS, RD, CDE
Effects of Alcohol on Glycemia and Other Metabolic Outcomes
Effects of Alcohol on Diabetes Complications
Alcohol: Triglycerides, HDL Cholesterol, Blood Pressure, and Weight
Guidelines for Consuming Alcohol
Highlights Alcohol and Diabetes
• Moderate alcohol consumption (~15–30 g/day; one to two drinks) has minimal acute or long-term effects on blood glucose levels in people with type 1 or type 2 diabetes. Studies on alcohol consumption report a U- or J-shaped association, suggesting benefit from moderate consumption.
• Moderate consumption of alcohol by people with type 2 diabetes is associated with reduced risk of and mortality from coronary heart disease and lower total mortality rates. The mechanism for this benefit is unclear but is likely related to improvements in insulin sensitivity with consumption of moderate amounts of alcohol.
• If individuals with diabetes choose to drink alcoholic beverages, daily intake should be limited to an average of up to one drink per day for adult women and up to two drinks per day for adult men and no more than three drinks in any single day for women and no more than four drinks in any single day for men. Insulin or insulin secretagogue users, to prevent hypoglycemia, should consume alcohol with food.
• There are no data to support recommending alcohol use to people with or without diabetes who do not currently drink. Abstinence is recommended for people with risks related to alcohol consumption. However, for the majority of people with diabetes who choose to consume alcohol in moderation, alcohol consumption does not need to be discouraged.
Alcohol and Diabetes
Alcohol consumption in the United States is common. It is estimated that 76% of men and 65% of women consumed alcohol at least once in the last year. A large number of individuals exceed the recommended upper limits of average intake. An estimated 9% of men consumed an average of more than two drinks per day and 4% of women consumed an average of more than one drink per day (Report of the Dietary Guidelines Advisory Committee [DGAC] 2010). Surveys of Kaiser Permanente Northern California adult diabetes patients reported that just over 50% currently consumed alcohol, 22% had never consumed alcohol (abstainers), and 28% were former drinkers (Ahmed 2008). In the Third National Health and Nutrition Examination Survey (NHANES III), adults with diabetes also reported drinking half the amount of alcohol as adults without diabetes (Mackenzie 2006). The lower prevalence of alcohol consumption by people with diabetes may be the result of the higher prevalence of former drinkers among people with diabetes compared with the general population (28 and 15%, respectively) (Ahmed 2006), or alcohol consumption may have been discontinued because of declining health, perceived risk of alcohol on diabetes management, or physician advice to limit alcohol intake. If people with diabetes choose to drink alcoholic beverages, they need to know what effect it can have on blood glucose control and the management of their diabetes and how to drink safely.
The alcohol in beverages is ethanol (ethyl alcohol, C2H5OH), which is the intoxicating molecule present in distilled spirits, wine, and beer. It is the byproduct of the oxidation of sugars for energy by yeast enzymes (fermentation). The term “alcohol” will be used in this chapter. One drink is commonly defined as 12 oz regular beer, 8 oz malt liquor, 5 oz wine, or 1.5 oz 80-proof distilled spirits, each of which contains ~15 g alcohol.
The American Diabetes Association (ADA) nutrition recommendations state: “If adults with diabetes choose to drink alcohol, daily intake should be limited to a moderate amount (one drink per day or less for women and two drinks per day or less for men). Abstention from alcohol should be advised for people with a history of alcohol abuse or dependence, women during pregnancy, and people with medical problems such as liver disease, pancreatitis, advanced neuropathy, or severe hypertriglyceridemia” (ADA 2008).
This chapter begins with a summary of the metabolism of alcohol from the 1999 book American Diabetes Association Guide to Medical Nutrition Therapy of Diabetes (Franz 1999) and then proceeds with reviews and updates on the evidence for effects of alcohol on glycemia and other metabolic outcomes, its effect on diabetes complications, and summarizes recommendations for the consumption of moderate amounts of alcoholic beverages.
A literature search was conducted using PubMed MEDLINE, and additional articles were identified from reference lists. Search criteria included the following: alcohol research in human subjects with diabetes, English language articles, and publication after the completion of the 1999 chapter on alcohol. The initial search of potentially relevant articles identified 957 articles, of which 934 articles were excluded because titles or abstracts did not meet inclusion criteria. A total of 37 articles were retrieved for more detailed evaluation. Fourteen of these articles are included and 18 were added from the review of reference lists, making a total of 32 articles that met inclusion criteria. A total of 28 primary studies (15 epidemiological/observational studies and 13 clinical trials), 1 meta-analysis, and 3 reviews are included in Tables 4.1 and 4.2. All studies in the meta-analysis and reviews published after publication of the 1999 book (Franz 1999) are included in the tables.
Alcohol is absorbed by a process of simple diffusion across the gastrointestinal mucosa of the stomach, duodenum, and jejunum and enters the portal circulation. It is one of the few substances that can be readily absorbed through the walls of the stomach into the bloodstream. With the ingestion of food, especially high-fat food, fewer alcohol molecules diffuse from the stomach. Ethanol does not require gastrointestinal digestion and may undergo first pass metabolism by gastric alcohol dehydrogenase (ADH). Adult men have greater gastric ADH activity then adult women; thus, alcohol bioavailability in men is reduced relative to that in women (Baraona 2001).
The primary mechanism by which the body disposes of alcohol is oxidation and use