Hypoglycemia

The consumption of alcohol is an established risk for hypoglycemia in patients with type 1 diabetes. It has been estimated that as many as one-fifth of severe hypoglycemic episodes are directly related to alcohol. Some researchers have reported an increase in risk of hypoglycemia in the morning hours, following evening consumption 12-16 hours prior. The exact mechanism of this observation is unknown, however it is thought that reduced cortisol levels play a role.

Both the British and American Diabetes Associations provide guidelines that recommend limiting alcohol consumption to no more than the equivalent of 2 servings of alcohol at one sitting.

The British and the US researchers teamed up to perform a controlled study to further examine both glucose control and hormonal responses through to midday following the consumption of alcoholic beverages in the evening. Six men with type 1 diabetes served as subjects. The mean age of the subjects was 33 years with the mean duration of diabetes being 13 years. All subjects had controlled diabetes with out complications, with the exception of background retinopathy. All subjects were being treated with a basal-bolus regimen of pre-meal regular insulin and bedtime NPH insulin. Subjects underwent detailed evaluation of their day-to-day glucose control for purposes of optimization of glycemic control prior to the initiation of the study.

The subjects were admitted to the study center for a 20-hour period beginning at 5:00 p.m. on two separate occasions. Subjects injected themselves with regular insulin at a dose of 70 percent their usual evening meal dose to reduce the likelihood of hypoglycemia between 6:00 and 9:00 pm. The subjects then ate a meal that provided 50 percent of calories from carbohydrate, 30 percent from fat, and 20 percent from protein. The carbohydrate content provided matched the average evening meal carbohydrate level given in the prestudy food diary. At 9:00, the subjects were given either dry, white wine or an equal volume of mineral Water (as a control) and were instructed to drink steadily over a 90-minute period. A volume was measured to provide 0.75 grams ethanol per kg body weight. Blood pressure and pulse were measured during drinking. At 11:00 p.m. an intravenous insulin infusion was initiated. A rate was chosen to provide a basal insulin level sufficient to maintain near-normoglycemia under the control conditions. No subcutaneous insulin was administered at bedtime. Upon waking in the morning, breakfast containing a carbohydrate content equivalent to the subjects' average breakfast was served. Blood samples were collected for immediate glucose analysis every 30 minutes while the subjects were awake and every hour while they were sleeping. Insulin, cortisol, glucagons and growth hormone were also regularly monitored. Subjects were then readmitted to perform the routine again, substituting either water or alcohol for the beverage that they had previously been tested for.

Blood ethanol reached a mean peak of 19.1 mmol/l and was undetectable in all subjects by 8:00 a.m. Fasting and postprandial blood glucose levels were significantly lower following consumption of wine than following consumption of mineral water. Five subjects required treatment for hypoglycemia after 10:00 am the morning following intervention with the alcohol. None of the subjects experienced hypoglycemia following consumption of Water. Growth hormone secretion was significantly reduced between midnight and 4:00 a.m. after consumption of wine. Levels of insulin or other hormones showed no differences between the control and intervention trials.

It appears that reduced nocturnal growth hormone secretion is responsible for predisposing type 1 diabetics to hypoglycemia after breakfast following an evening of excessive alcohol consumption.

B. Turner, E. Jenkins, D. Kerr, et al. The effect of evening alcohol consumption on next-morning glucose control in type 1 diabetes. Diabetes Care; 24: 1888-1893 (November, 2001) [Correspondence: Dr. Benjamin C. Turner, Diabetes and Endocrine Day Centre, 6/F North Wing, St. Thomas' Hospital, Lambeth Palace Rd., London, Sel 7EH U.K. E-mail: ben.turne@gstt.sthames.nhs.uk]

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