Dr. Sadikot S.M
Consultant in Endocrinology, Diabetes and Metabolic Disorders,
Jaslok Hospital and Research Centre,
It would be so simple if one could simply tell all diabetics that they should abstain from alcohol. Unfortunately this is easier said than done. We have come a long way from time when "gin" was equated with "sin"! Today drinking has become an accepted social custom and many a diabetic considers having a drink or two as a part of his normal daily routine. Therefore, although it would be better for the diabetic to avoid alcoholic drinks, if he must have them , he must atleast understand the additional problems that he, as a diabetic will have to face, so that he will "drink" sparingly and sensibly!
First of all, although most alcoholic drinks do not have nutritive value in the sense that they do not have nutritive value in the sense that they do not contain vitamins, proteins or fats, they DO contain a large amount of calories which will have to be counted in the total number of calories that he is permitted per day. I feel that a diabetic should not get more than 5% of his total calories from alcohol. Therefore, it is essential that he should have an idea of the calorie content of his drinks. Although , I have given a table of the calorie content of some common drinks, there is such a variety in the types of alcoholic drinks available and even any one type of drink (say whisky),may come in different strengths, so that it may be better for the diabetic to calculate the calorie content of his usual drink himself. He can do this quite easily by using the formula: 0.8 x proof x number of ounces = colories
NOTE: The proof (strength) of the alcohol is often noted on the bottle. Some manufacturers, only give the alcohol percentage. The "proof " is double the alcohol percentage, i.e. 12% alcohol content means 24 proof. This is a better way of calculating the calories as drinks are usually measured by the ounce (peg) rather in grams. As a matter of interest 1 gram of alcohol gives seven calories
|Table 1: Calorie Content Of Common Alcoholic Drinks||Types Of Drink||Measure||Calories (Average)|
|Whiskey, gin, rum, vodka (80 proof)||30 ml||80 calories|
|Beer (6 - 7% alcohol)||650 ml||400 calories|
|Sweet wines (18% alcohol)||100 c.c||130 calories|
|Dry wines (18% alcohol)||100 c.c||90 calories|
Diabetics should avoid drinking beer. Although beers vary in their alcohol content, the more popular brands contain around 6 - 7% alcohol. Beers also have additional calories as they contain carbohydrates and it has been estimated that Indian beers, on an average, supply about 17 - 20 calories per ounce. Indian beers usually come in bottles and each contains 650 ml. Since most people usually finish the full bottle, this would mean a calorie intake of 400 - 500 calories which would be too excessive. There are some beers that are labeled as "diet" beers. Through they may contain less calories, they are not calorie free and for a diabetic, these may still be too many.
Wines, in addition to alcohol, also contain sugars which add to the calories. Although many of the "imported " wines have about 12% alcohol content, the more popular Indian wines have an alcohol content of 18% and consequently, that many more calories. It is said that "dry" wines are to be preferred to the sweeter varieties as they have less calories. One needs to be a little careful about this generalization, as sherry, a drink which is quite popular and which is thought of as a dry wine, contains around 30 calories per ounce!
Drinks like whisky, rum vodka, gin, feni, etc., should be taken with water soda or "on the rocks", rather than in the form of cocktails. Many of the mixtures used in the making of these cocktails are very rich in their calorie content. This not only needlessly adds to the amount of calories but also makes it almost impossible to calculate the number of calories in the drink. On an average, these drinks when taken with ice, water or soda supply around 80 calories per ounce(peg of 30ml) and therefore many patients may be allowed to have one to one and half peg of these drinks daily. This would supply around 80 - 120 calories and would come within 5% of the calories allowed in many diabetes diets. It is obvious that a patient who is on a low calorie diet so as to restrict his weight cannot take any alcoholic drink as even a peg these drinks would constitute more than the allowed percentage of daily calories.
A major aspect associated with the drinking is the habit of eating snacks along with the drinks, especially on social occasions. These snacks are often very rich in calories, fried, and full of proteins. The problem is that if you avoid the snacks, and drink on an empty stomach, the alcohol gets absorbed very rapidly and this can give a quick "high". If you do not eat the snacks you get, thus, quickly intoxicated, whilst if you do eat them, you are adding to the calories! This problem can be easily solved if you limit the snacks to a salad of raw vegetables like carrots, which is usually available.
One danger to the diabetic who drinks is that of low blood glucose levels which may be quite severe. The liver is the organ where "new" glucose is made and this helps to maintain the blood glucose levels so that they do not go into the hypoglycemic range. Alcohol , through certain mechanisms can stop the liver from making glucose and thus may precipitate hypoglycemia. It must be said that this usually occurs in a diabetic who is on insulin or oral agents who has imbibed a lot of alcohol and who has eaten very poorly, if at all ! Drinking may also mask the signs and symptoms of impending hypoglycemia so that the patient has no warning of the attack and may suddenly drop into coma! Therefore, it is essential that only a limited amount of alcohol should be taken and that an adequate meal should be eaten after the alcohol intake. It goes without saying that the calories supplied by the meal and the alcohol should be within the permitted limits.
Diabetics who are on sulfonylureas, especially chlorpropamide, may experience an acute reaction when they drink alcohol. Their face appears flushed and this may be accompanied by a severe choking sensation, nausea, vomiting, headache and even a significant drop in the blood pressure. As this reaction is similar to that observed after the use of Antabuse tablets the reaction is known as the Antabuse effect or the Chlorpropamide Alcohol flushing syndrome. It is not necessary that the full reaction should occur and it is plausible that may diabetics, on chlorpropamide, do experience some monor reactions like nausea or headache which are attributed to the alcohol itself rather than to the interaction of the drug with alcohol. At one time, it was thought that those patients who manifested this reaction were somehow protected from the long - term complications of diabetes, and in fact a test was devised to give the patient the drug and some alcohol and see whether he showed the reaction. If he did, it was felt that one may not need to control these patients optimally as they were protected from the long term ravages of diabetes. Before you start to test for the reaction, let me add that this theory has been given up quite a while back!
Diabetes taking biguanides like phenformin and metformin may have an additional problem with the use of alcohol. Studies have shown that when these drugs are taken by patients who have any problems with the liver or the kidneys, there is a dangerous rise in the level of blood lactate which leads to a very serious condition called lactic acidosis. Alcohol is known to damage the liver and many diabetics do have some nephropathy thus in these patients, biguandies may cause a severe attack of lactic acidosis. This condition has a mortality rate of around 50% even in the best of hands and in the most sophisticated hospitals! In any case, a diabetic who is on biguanide should never be taking alcohol in the first place. Biguanides are usually prescribed to overweight diabetics who are also on a weight reducing diets. As we have discussed previously, any diabetic on such a low calorie diet should not be allowed any alcohol as the calories from the alcohol would definitely constitute more than 5% of the total calories permitted for the day!
An excess intake of alcohol leads to neuropathy and this can be additive to the neuropathy caused by diabetes. Alcohol does damage the liver. Chronic and excessive alcohol intake may overwhelm the capacity of the liver to repair the damage caused by alcohol, and oral agents are contraindicated in patients who have evidence of liver dysfunction. Finally, it should be realized that although we have confined the discussion to the effect of alcohol as it relates specially to a diabetic, all the ill effects of excessive and chronic alcohol intake can and does occur in a diabetic as it may in a non diabetic!
Therefore, it the diabetic feels it a necessity to drink, he should take alcohol sparingly and sensibly!