Diabetes and alcohol use: Detecting at-risk drinking
Asking a simple question helps uncover at-risk drinking in patients with diabetes, and brief office interventions have proven effective in modifying behavior.
Brief advice is a form of intervention that shows considerable promise in primary care.40-42 Two 10- to 15-minute sessions have led to significant reductions in the mean number of drinks and frequency of excessive drinking in the 7 days before a follow-up interview, as well as a reduction in binge drinking episodes in the previous 30 days.41,42
One study produced positive results with just a 5- to 10-minute counseling session involving advice for drinking goals delivered by primary care providers as part of a routine medical visit.43 This intervention led to significant decreases in alcohol use at a 6-month follow-up for high-risk drinkers compared with controls.43 Brief interventions additionally work within the time constraints of a busy primary care practice and are cost effective.
Some primary care providers think a specialist should conduct interventions and suggest that having a specialist immediately available would enable intervention.31 In fact, some research has supported the idea of special training. In a European study, primary care providers reported that more practical training, information about brief intervention studies, personal training, and lectures would facilitate interventions.44
Applying brief alcohol interventions to diabetes patients
Newer research has tested the efficacy of alcohol interventions with diabetes patients in the primary care setting. In one study,45 brief advice was given in 2 15-minute sessions and 2 5-minute follow-up telephone calls. Compared with controls, significantly more participants who received the intervention reduced heavy drinking from baseline to follow-up. One caveat is that patients with hypertension were included in the sample, making it difficult to determine the impact of the intervention on diabetes patients specifically.
In a small study of patients with diabetes exhibiting at-risk drinking,8 a single-session intervention based on motivational interviewing (MI) principles46 gave participants personalized feedback in relation to sex-based norms of drinking rates and HbA1c and triglyceride laboratory results. Patients were given information on the physiologic effects of alcohol on diabetes, the potential interactions between alcohol and diabetes medications, and the effect of alcohol on diabetes self-care behavior. They were asked to identify pros and cons of their drinking and to develop personal change goals. One of 2 PhD-level clinical psychologists trained in MI administered the single 50-minute intervention. By 1 month and continuing through to the 6-month follow-up, participants had reduced the proportion of drinking days, mean number of daily drinks, and proportion of heavy drinking days.
Ramsey and colleagues47 extended this work by comparatively examining a group of patients exhibiting at-risk drinking who received no intervention. The results favored the intervention group, with a medium-to-large effect size for the proportion of drinking days, a medium effect size for the reduction of mean number of daily drinks, and a small-to-medium effect size in the reduction of heavy drinking days. Furthermore, in the intervention group there was a trend toward better diabetes adherence behavior.
Implementing brief intervention in practice. Despite differences among interventions, the elements of brief interventions tend to be similar.48 Incorporating these elements in the primary care setting provides a useful framework that will likely prove beneficial. Specifically, brief interventions typically contain elements of the FRAMES (TABLE 2)46 acronym:
- Feedback about one’s drinking relative to others
- Responsibility for deciding to change
- Advice to change drinking
- Menu of options for implementing a change strategy
- Empathic listening
- Self-efficacy enhancement.
Decision-making models indicate that expectations about the effects of behavior change play a significant role in determining whether a decision to change is made.49 The perceived costs and benefits of changing drinking50,51 and positive52 and negative alcohol expectancies53,54 predict future alcohol use. For patients with diabetes who are at-risk drinkers, primary care appointments may provide “teachable moments” in which brief advice can have a significant impact—particularly when patients are told laboratory test results; advised about the sugar and carbohydrate content of alcohol; or given information regarding the effect of alcohol on diabetes, medications, and self-care behavior. Finally, primary care providers will also likely have knowledge of a patient’s comorbid conditions (eg, depression) that may relate to diabetes or alcohol use.
TABLE 2
How to implement the FRAMES approach in brief interventions46
| FRAMES elements | Sample statements |
|---|---|
| Feedback about one’s drinking relative to others | “Based on what you told me, you are drinking an average of 21 drinks per week, which puts you above the cutoff for at-risk drinking” or “According to what you told me, it looks like you are drinking more than 88% of men (or women) in the United States.” |
| Responsibility for deciding to change | “You’re in the best position to decide how you would like to make a change” or “Although reducing your drinking would be good for your health, it’s up to you to decide when you’re ready to make a change.” |
| Advice to change drinking | “Your test results indicate your HbA1c, an important measure of blood sugar, is elevated; making a change in your drinking will likely improve your blood sugar” or “I am concerned about the effect on your health of drinking alcohol while taking your diabetes medications. Making a change in your drinking is likely to protect you from complications.” |
| Menu of options for implementing a change strategy | “If it’s okay with you, I can share what has worked for others whose drinking is similar to yours. Some people alternate a drink containing alcohol with water or diet soda. Others will bring only a certain amount of money with them when they go to a bar.” |
| Empathic listening | “It sounds like this has been a concern" or "I know that change can be difficult.” |
| Self-efficacy enhancement | “I wonder if you could use some of the same strategies you used to lose 10 pounds last year?” or “It sounds like you have some ideas for how to make this happen.” |
