Sherri Shafer, Registered Dietitian, Diabetes Management Part 6: Alcohol Considerations

Sherri Shafer, Registered Dietitian, Diabetes Management Part 6: Alcohol Considerations

November 5, 2019 0 By William Morgan


Hello.
We’re gonna talk about alcohol, how it
relates to somebody who uses insulin or
certain medications for
treating type 2 diabetes, and the risk for
low blood sugar.
So the objectives of this
module are to understand how
the alcohol can lead to hypoglycemia.
And to name three tips for reducing
that risk in patients who use insulin.
And to know the suggested limits for
how much women and
men should be drinking as a limit per
day and what counts as one drink.
People who take insulin, all types, are at
risk for hypoglycemia if they drink.
That risk is also for people who take
oral agents that stimulate insulin
production such as sulfonylureas-
glipizide, Amaryl.
This slide will explain how alcohol
impairs gluconeogenesis in orange
is the relative glucose concentration
both after eating and then between meals.
So for the first four hours,
you usually have glucose available
from the meal that you ate.
The highest blood sugar is one
to two hours after the meal.
By about the fourth hour,
you’re done digesting your food.
Then you switch to glycogenolysis and
gluconeogenesis.
And glucose is being
supplied from the liver
to keep the person’s blood sugar stable.
Imagine drinking alcohol
on an empty stomach.
Alcohol is processed in the liver.
Ethanol is converted to acetaldehyde
by alcohol dehydrogenase.
During that time, NAD is reduced to NADH.
Acetaldehyde is the toxic insult to
the brain and to the hepatocytes.
So the body wants to process
that further to CO2.
But my point here is that when alcohol
is being processed in the liver,
it takes priority and the liver is unable
to continue to release enough glucose.
Because NADH has to be disposed off.
And that will block other
pathways that need NAD.
So in the long run what that means is
that you synthesize more lipids and
triglycerides can go up
from drinking alcohol.
It also impairs gluconeogenesis
because you need available NAD
to do gluconeogenesis.
So exogenously administered insulin
will continue to push blood glucose
down despite falling serum glucose levels.
You can’t take that
insulin out once it’s in.
Now, if you had a person who did not
have diabetes, whose pancreas was
making the right amount of insulin,
that pancreas would turn on production and
off production as needed in very distinct,
short, little bursts.
And the person would not
get a low blood glucose.
Blood glucose drops because of
the insulin that’s on board in somebody
who’s injecting insulin.
It would be the long-acting insulins,
or it’d be the basal rates in the pump.
What about carbs and alcohol?
So many people think oh, alcohol’s
gonna raise my blood glucose level.
There’s absolutely no carbohydrate in
the hard alcohols like gin, vodka,
whiskey, scotch, bourbon.
Not even wine.
Juice, fruit juice, is converted
to alcohol when you ferment it.
There’s no carb residual,
less than one gram.
A beer because it does have barley,
malt and hops, has about 13 grams of carb
give or take in a 12 ounce beer, light
beer might only have five grams of carb.
But a mixed drink can have
significant amounts of carbohydrate.
You know, especially if you have fruit and
a little umbrella on top,
it’s probably got quite a bit of juice or
something.
Margaritas daiquiris all of those
things can have carbohydrate.
So what are the limits.
If an adult with diabetes
chooses to drink alcohol.
The American Diabetes Association
suggests that women
not have more than one drink a day and
men not more than two.
So what counts as a drink.
It’s a 12 ounce bottle of beer,
not a big red kegger cup.
It’s five ounces of wine,
not an eight ounce goblet.
And it’s one and a half ounces,
which is a shot glass of hard alcohol.
Each one of those is
an alcohol equivalent.
The only one there that I mentioned
that has carbohydrate is the beer,
has a little bit.
Don’t drink on an empty stomach.
You want to have some form of
carbohydrate if you’re having alcohol.
So it’s much safer to have that
glass of wine with your pasta,
to have that beer with your pizza.
If it’s a before dinner cocktail,
then look for crackers or
something to have with it, but
when do people actually drink?
The older generation gets the pre-dinner
cocktail that might be the martini,
it might be sipping on
wine while making dinner.
What if lunch was five or six hours ago?
There’s no carbohydrate
left over from lunch.
If you’re drinking in that time zone,
you’re using only the glycogen and
gluconial genesis from the liver.
And the minute you start drinking and your
liver’s processing that alcohol, you’re
impairing the release of glucose from
the liver, and you’re at risk for low.
What about the younger generation?
When do they drink?
When does a college-aged student drink?
Late at night, after school,
after studies, after everything is done.
Parties, clubs, night clubs,
all of those times are late at night, and
how much do they consume?
The more they consume,
the bigger the risk.
How many hours has it been since dinner?
How many drinks have they had?
How many hours will
gluconeogenesis be impaired?
Generally, one drink impairs you for
at least two hours.
So if somebody has three beers, two, four,
six hours or more their liver’s
impaired at releasing glucose.
That’s a significant amount
of time that you can be low.
What if you’re stumbling
because you are low and
somebody just saw you with a cocktail?
Are they going to come to your assistance?
Or, do they think you’re intoxicated.
What happens during sleep,
when you’ve had three or
four beers earlier in the evening,
and now it’s three AM, and
the alcohol is still in your liver and
pairing gluconeogenesis.
Do you feel your lows, when you’re asleep?
Not necessarily.
So there is a risk of
significant severe lows and
you can even die from low blood
sugar after heavy drinking.
So, what about glucagon?
Glucagon is a hormone.
People that inject insulin
should have a glucagon kit.
When administered, somebody else would
give it to them because they’re passed out
or having a seizure or something.
When administered, the way that it works
is the glucagon tells the liver to do
gluconeogenesis, glycogenolysis.
Glucagon injection isn’t going to work as
well if the liver is busy with alcohol.
The liver may have stored glycogen and
it can still release stored glycogen
when the liver’s dealing with alcohol.
It’s the gluconeogenesis that it can’t do.
Recovery from a severe low blood glucose,
in other words, is greatly impaired.
So drink responsibly.
That means limiting alcohol consumption.
Don’t drink on an empty stomach,
ever, if you’re an insulin user.
Carry a meter and
quick acting carbs to treat lows.
Don’t be unprepared.
Educate family and friends and the people
that you’re with on how to recognize if
you’re having a low blood glucose,
and what to do.
Calling 911, for example.
It’s important to keep
carbohydrate bedside,
and set an alarm if you find that, okay, I
did drink more than I know I should have.
Let’s set an alarm and wake up.
Set it on loud and
see what your blood sugar is doing.
Don’t sleep through severe hypoglycemias.
Don’t ever drive after drinking and
being on insulin.
Of course after drinking at all.
And it’s very important to
have a medical alert bracelet.
Somebody who’s down and out and
unconscious from a low blood sugar,
who’s been seen drinking could look like
somebody who’s intoxicated and passed out.
That concludes all of my
modules on managing diabetes.
And I hope that the carb counting,
or the carb portioning makes sense.
And how important it is for
people with diabetes to understand
the adjustments necessary for exercise,
and the precautions around alcohol, and
how to prevent and treat hypoglycemia.
As you can see, diabetes is a very complex
disease, and it can be very overwhelming.
And it really does take
a multi-disciplinary approach.
So it’s the person who has diabetes
who ultimately is their own
diabetes manager and
it’s the providers that help guide and
give information that can help that
person learn how to self manage.
The amount of time we spend with them in
a year is pretty minute, it’s their day to
day knowledge of managing that
will help them in the future.
So it’s important to involve dietitians,
nurses, pharmacists and
everybody in educating
the person with diabetes.
Whether that’s through one
on one consultations or
through diabetes management, education
classes there are many approaches.