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Prevalence and Predictors of Problem Drinking Among Primary Care Diabetic Patients John G

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Prevalence and Predictors of Problem Drinking Among Primary Care Diabetic Patients John G Prevalence and Predictors of Problem Drinking Among Primary Care Diabetic Patients John G. Spangler, MD, MPH; Joseph C. Konen, MD, MSPH; and K. Patricia McGann, MD, MSPH Winston-Salem, North Carolina Background. Alcohol abuse among patients with diabe­ with psychological stress and had a more highly nega­ tes mellitus is dangerous and complicates therapy, but tive affect than those without a drinking problem. De­ its prevalence and the factors that predict it are un­ pression, black race, and male sex were significantly as­ known. This study examined the prevalence of problem sociated with problem drinking (odds ratios = 8.42, drinking among a large number of primary care dia­ 2.70, and 3.80, respectively). Problem drinking did not betic patients, exploring its relation to age, race, sex, predict glycemic control but was associated with smok­ psychological factors, and other health behaviors. ing and less frequent glucose monitoring. Methods. Volunteers with insulin-dependent diabetes Conclusions. The prevalence of problem drinking mellitus and non-insulin-dependent diabetes mellitus among patients with diabetes mellitus appears lower were surveyed at three primary care practice sites. Pa­ tients completed a health risk appraisal designed to than among other medical outpatient populations and elicit alcohol use and other health practices, and two is in keeping with the prevalence found in communin' psychometric instruments: the Brief Encounter Psycho­ surveys. While the lack of association between problem social Instrument and the Affect Balance Scale. Fasting drinking and glycemic control in diabetic patients may blood glucose and hemoglobin A1C levels were also de­ be surprising, these data help define the characteristics termined. of this subgroup of diabetic patients and highlight the need for family physicians to intensify alcohol screen­ Results. Of 395 diabetic patients, 32 (8.1%) had a ing efforts in this population. drinking problem as defined by answering yes to the question “Have you ever had a drinking problem?” or Key words. Diabetes mellitus; alcoholism; blood glu­ reporting their last drink to be within 24 hours, or cose; health behaviors; models, psychological. both. Patients with a drinking problem coped less well ( / Ram Proa 1993; 37:370-375) Alcohol abuse affects about 10% of the general popula­ patients with diabetes mellitus is not only dangerous to tion1-3 and an even larger percentage o f medical clinic the patient, but also complicates diabetic therapy. Aside and hospitalized patient populations.4-7 The proportion from the adverse cardiovascular effects of alcohol of diabetic patients suffering from alcohol abuse is un­ abuse,8-9 its excessive use inhibits gluconeogenesis, mak­ known and may be more or less than that seen among ing diabetic patients prone to sudden and severe hypo­ patients with other medical problems. Alcohol abuse in glycemia10-11; induces transient hyperglycemia11-12; and predisposes patients to alcoholic ketoacidosis.12-13 Submitted, revised, A pril 16, 1993. Moreover, many studies have shown that certain behavioral and affective disorders are more common From the Departm ent of Fam ily and Community Medicine, The Bowman Gray School of Medicine o f Wake Forest University, W inston-Salem. Requests for reprints should be among heavy drinkers,2-14- 17 particularly anxiety, depres­ addressed to John G. Spangler, AID, M PH , Department of Family and Community Medicine, The Bowman Gray School o f Medicine of Wake Forest University, Winston- sion, psychosis, and antisocial personality'. Finally, alco­ Salem, N C 27517-1084. hol abuse often coexists with other high-risk behaviors © 1993 Appleton & Lange ISSN 0094-3509 370 The Journal of Family Practice, Vol. 37, No. 4, 1993 Problem Drinking and Diabetic Patients Spangler, Konen, and McGann such as cigarette smoking,18-19 not using seat belts,20 and patients: the Brief Encounter Psychosocial Instrument illicit drug use.2-21-22 (BEPSI), a five-item questionnaire with a 10-point Because o f the dangers associated with alcohol Likert-type scoring scale used to measure patient ability abuse, warning diabetic patients against excessive drink­ to cope with psychological stress28; and Derogatis’ Affect ing remains a standard o f good medical care.10 Although Balance Scale (ABS), a 4 0 -item questionnaire with a the prevalence and demographics o f alcohol abuse arc- 5-point Likert-type scale reflecting positive as well as well known in other populations,1-7 the prevalence and negative self-perceptions o f affect.29 After an overnight the predictors of problem drinking among diabetic pa­ fast, a venous blood sample was obtained from each tients are unknown. patient for glycosylated hemoglobin A 1C (normal values Using Cyr and Wartman’s definition of an alcohol ranging from 2.9% to 5.1%) and blood glucose deter­ problem,23 we studied the prevalence of problem drink­ mination. Finally, patients were asked their perception o f ing and factors associated with it in primary care diabetic their glycemic control over the past month using an patients. Our goal was to test three hypotheses: (1) 11-point Likert-type scale (0 = poor; 10 = excellent). demographic (age, race and sex) and psychological vari­ Health behaviors assessed in this study were exer­ ables would correlate with problem drinking among di­ cise, cigarette smoking, and blood glucose self-monitor­ abetic patients; (2) problem drinking would be associ­ ing. A cut-off level of greater than or equal to 600 kcal ated with adverse health behaviors among diabetic per week was selected as the definition o f exercise based patients, namely, smoking, lack o f daily self-monitoring on the type30 and intensity31 of patients’ self-reported of blood glucose, and lack o f exercise; and (3) problem physical activity. This level is approximately equivalent to drinking would be negatively associated with measured walking 2 miles three times a week and is the minimum and perceived diabetic glycemic control. quantity o f exercise for maintaining cardiovascular fitness as set forth by the American College o f Sports Medi­ cine.32 Smoking status was split into two groups, current Methods smokers and nonsmokers, the latter category including former and never smokers. Patients were also asked about Three hundred ninety-five patients over the age of 16 the frequency with which they checked their own blood years with insulin-dependent diabetes mellitus (IDDM, glucose, and these responses were dichotomized into “at n = 77) or non-insulin-dependent diabetes mellitus least daily” vs “not daily.” Hemoglobin A 1C levels were (NIDDM, n = 318) were recruited from a large family dichotomized into high and low levels (>7% and <7% , medicine ambulatory care unit, a university medical cen­ respectively). Blood glucose levels were also dichoto­ ter pediatric clinic, and a neighborhood community mized into high and low levels (> 1 4 0 mg/dL and <140 health center through a series o f mailed invitations as mg/dL, respectively). Perceived glycemic control was di­ described elsewhere.24 All cases met World Health Or­ chotomized into good and poor (> 5 and s 5 , respcctive- ganization (W HO) criteria25 for either IDDM or •y)- NIDDM. Statistical analyses were performed using the Cen­ We chose a screening tool for determining a drink­ ters for Disease Control and Prevention statistical pack­ ing problem based on its validity and case of incorpora­ age Epilnfo and the Statistical Packages for Social Sci­ tion into a busy clinical practice. Hence, we selected Cyr ences (version 2, 1988). “Ill” and “Well” ABS scores and Wartman’s23 two questions: “Have you ever had a were derived from the Likert-type responses to the anx- drinking problem?” and “When was your last drink?” icty/guilt/hostility/depression subscalcs and the joy/con- These authors define a drinking problem as an affirmative tentment/passion/vigor subscales, respectively. Using answer to the first question or a patient stating that he or these ABS scores, we created categories o f high negative she had a drink within the previous 24 hours, or both. and high positive affect corresponding to the upper decile Compared with the Michigan Alcoholism Screening Test of scores for the study population on the ABS “111” and (iMAST),26 these items have a sensitivity of detecting an ABS “Well” subitems, respectively. Patients with high alcohol problem o f 91.5% , a specificity of 89.7%, and a positive affect would thus have experienced joy, content­ positive predictive value of 69.4%.23 ment, passion, and vigor much more frequently in the Patients completed a series o f questionnaires before past month than patients without positive affect. Simi­ their appointments, including a modification of the larly, patients with high negative affect would have ex­ Healthier People Health Risk Appraisal,27 which elicited perienced anxiety, guilt, hostility, and depression much a history o f current or previous cigarette smoking and the more frequently in the past month. The BEPSI was duration, type, and frequency o f exercise. Two standard­ dichotomized into > 3 0 or < 3 0 , with the higher category ized psychometric instruments were also administered to indicating poor coping with psychological stress. 371 The Journal of Family Practice, Vol. 37, No 4, 1993 Problem Drinking and Diabetic Patients Spangler, Konen, and McGanu Table 1. Patient Characteristics, by Drinking Problem Status Patients with a Patients with No Drinking Problem* Drinking Problem Characteristic (n = 32) (n = 363) P Valued Age, y, mean ± SD 54 ± 12 53 ± 16 NS IDDM, % 16 20 NS Male, % 66 41 .01 Black, % 56 39 .052 Glycosylated hemoglobin, %, mean ± SD 7.3 ± 2.0 7.4 ± 2.1 NS Glucose, mg/dL, mean ± SD 225 ± 81 200 ± 88 NS Self-perceived good glycemic control, % 50 53 NS 'A drinking problem was defined as having had a drinking problem in the past and!or having had a drink within the last 24 hours.
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