722137

research-article2017
AJLXXX10.1177/1559827617722137American Journal of Lifestyle MedicineAmerican Journal of Lifestyle Medicine

vol. 11 • no. 6 American Journal of Lifestyle Medicine

Nicole D. White, PharmD, CDE

Alcohol Use in Young Adults With

Type 1 Diabetes Mellitus

Abstract: Although fewer individuals new environments, increased Effects of Alcohol on

with type 1 diabetes mellitus (T1DM) independence, and experimentation. It is Glucose Metabolism
drink alcohol, the potential and also a time where there may be
severity of harm associated with its increased access to alcohol, less parental Eighty percent of ingested alcohol is
consumption is higher in persons with monitoring, and an increased propensity metabolized in the liver, leading to an
diabetes. Alcohol use affects glucose for risky behavior.4 Because of the increase in the NADH:NAD ratio (NAD is
metabolism and results in various prevalence of alcohol consumption in nicotinamide adenine dinucleotide and
potential adverse effects both from this population and the potential risks NADH is its reduced form).5 This
acute ingestion and chronic ingestion associated with its use, it is important for so-called “redox shift” results in
in persons with T1DM. The purpose providers to discuss the effects of inhibition of gluconeogenesis. After the
of this article is to describe the effects
of alcohol on glucose metabolism
and diabetes control in persons with . . . it is important for providers to
T1DM and propose counseling pearls
for providers working with patients in discuss the effects of alcohol on
this population.
diabetes and develop strategies to
Keywords: type 1 diabetes mellitus;
alcohol; diabetic ketoacidosis; maintain good control and minimize
hypoglycemia
associated risks . . .

W
hile alcohol use tends to be
lower in patients with type 1 alcohol on diabetes and develop consumption of 48 g of alcohol
diabetes mellitus (T1DM) than strategies to maintain good control and (approximately 4 glasses), hepatic
in the age-matched general population, minimize associated risks for those gluconeogenesis has been shown to
rates of drinking in young adults with young adults who choose to consume it. decrease by about 45%.6
T1DM range from 19.3% to 26% in the The purpose of this article is to describe Gluconeogenesis is required to maintain
literature.1-3 Although fewer individuals the effects of alcohol on glucose glucose levels in the fasting state and
with T1DM drink alcohol, the potential metabolism and diabetes control in inhibition of gluconeogenesis may result
and severity of harm associated with its persons with T1DM and propose in hypoglycemia.
consumption is higher in persons with counseling pearls for providers working Glycogenolysis is also impaired by
diabetes. Early adulthood is a time of with patients in this population. alcohol.7 In a patient with normal

DOI: 10.1177/1559827617722137. From Pharmacy Practice, Creighton University School of Pharmacy and Health Professions, Omaha, Nebraska. Address correspondence to:
Nicole D. White, PharmD, CDE, Creighton University School of Pharmacy and Health Professions, 2500 California Plaza, Omaha, NE 68178; e-mail: nicolewhite@creighton.edu
For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright © 2017 The Author(s)

433
 American Journal of Lifestyle Medicine
glycogen stores, hepatic glucose output
has been shown to reduce by 12% after
ingestion of a moderate amount of
alcohol.7 This rarely causes
hypoglycemia. However, if glycogen
stores are depleted (as in malnourished
individuals, alcoholics, and potentially
persons consuming very low
carbohydrate diets or people who are
fasting or drinking without consuming
food), hepatic glucose production may
be significantly impaired by alcohol
ingestion and can lead to potentially
life-threatening hypoglycemia, especially
in patients with T1DM.
Short-Term Effects of
Alcohol in Diabetes
Moderate amounts of alcohol (1 g/kg),
when consumed with a meal, appear to
have limited effects on blood glucose
and insulin levels in patients with
T1DM.8 However, when alcohol is
consumed in a fasted state or several
hours after a meal, lower blood glucose
levels have been observed. Lange et al9
compared blood glucose levels and
incident hypoglycemia in 23 males with
type 1 diabetes following administration
of alcohol or mineral water.9
Consumption of just 1 L of beer several
hours after an evening meal resulted in
significantly lower blood glucose levels
and more episodes of hypoglycemia
compared with consumption of mineral
water. Interestingly, this finding was
significant between the hours of 7 am
and 11 am the morning following
administration of alcohol, suggesting
delayed hypoglycemia. Another study by
Turner et al10 supports this phenomenon.
The study followed 6 men with T1DM
from 5 pm to 12 pm the following day. The
men received regular insulin injections
before meals consumed at 6 pm and 8 am
as well as a basal insulin infusion
overnight. At 9 pm, 3 hours after the
evening meal, 0.75 g/kg of wine was
administered over the course of 90
minutes. Blood glucose, alcohol, and
insulin were measured throughout the
evaluation. There were no significant
differences in blood glucose in the
evening or overnight observation
434
periods. However, in the morning, fasting
and postprandial blood glucose levels
were significantly lower following
consumption of alcohol and 5 individuals
required treatment for hypoglycemia.
Analysis of registry data from more
than 30 000 young adults with T1DM
found higher alcohol use to be
associated with higher rates of severe
hypoglycemia (event requiring assistance
of another person to actively administer
carbohydrate, glucagon, or other
resuscitative actions) and diabetic
ketoacidosis (DKA).2 The registry
classified participants as abstainers,
low-risk drinkers (≤1 serving of alcohol
per day for women and ≤2 servings per
day for men) and at-risk drinkers (>1
serving per day for women and >2
servings per day for men). The rates of
severe hypoglycemia were similar
between low-risk and at-risk drinkers,
but were significantly higher in those
consuming alcohol than for those who
abstain from alcohol. At-risk drinkers
experienced DKA at a rate of 18.9
episodes per 100 patient years compared
with just 6.4 episodes per 100 patient
years for those abstaining from alcohol
and 7.5 episodes per 100 patient years
for those consuming moderate amounts
of alcohol (P < .001).
A study by Kerr et al11 found that
liberal intake of alcohol (approximately
4-5 drinks) is associated with increased
lactate and β-hydroxybutyrate levels in
patients with T1DM. Accumulation of
β-hydroxybutyrate causes ketosis and
may result in nausea, vomiting, impaired
mental function and potentially coma or
death. The study found a rise in ketones
despite uninterrupted insulin
administration in a controlled setting.
The authors cautioned risk of ketosis
may be more severe in less controlled
circumstances, especially as many of the
symptoms of DKA mimic symptoms of
extreme intoxication.
Effects of Chronic
Alcohol Consumption
on Diabetes Control
Moderate alcohol intake appears to
be associated with increased insulin
Nov • Dec 2017
sensitivity in young adults.12 However,
the relationship between alcohol and
insulin sensitivity appears to be
J-shaped, with increased insulin
resistance in both abstainers and in
heavy drinkers.13 Higher alcohol
consumption has also been associated
with worse glycemic control and poor
diabetes self-care.2,14 The same registry
analysis that found increased risk of
severe hypoglycemia and DKA in
at-risk drinkers, found the highest
HbA1c levels in this cohort as well,
even after adjustment for age, gender,
duration of diabetes and mode of
therapy.2 A study by Ahmed et al14
found that individuals with higher
alcohol consumption reported reduced
diabetes self-care behaviors, including
self-monitoring of blood glucose,
HbA1c testing, and adherence to
diabetes medications.
Discussion and
Conclusions
It appears that moderate alcohol intake
when combined with food, is a relatively
safe practice for individuals with T1DM.
Alcohol consumption without food,
should be avoided. While moderate
amounts of alcohol have been associated
with increased insulin sensitivity, heavy
drinking is associated with increased
insulin resistance, worse glycemic
control, poor diabetes self-care
behaviors, increased risk of severe
hypoglycemia, and increased risk for
DKA. Young adults should be advised to
drink alcohol responsibly. This includes
avoiding binge drinking and ingesting
carbohydrates while consuming alcohol.
Patients should be educated that alcohol
can reduce the awareness of
hypoglycemia and blood sugars should
be monitored more closely following
alcohol consumption. Patients should
also be informed to watch for delayed
hypoglycemia and that additional
carbohydrate intake or reductions in
insulin dose may be necessary to avoid
low blood glucose. Patients should be
advised to wear identification and inform
others of their diagnosis of diabetes and
the risk of hypoglycemia and DKA
 vol. 11 • no. 6
associated with alcohol use.
Hypoglycemia may be confused with
drunkenness, so additional vigilance may
be required by those accompanying an
individual with T1DM. Help should
always be secured when the status of the
individual with T1DM is in question.
Declaration of
Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article. AJLM
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