Abstract

This cross-sectional study aimed to analyze alcohol abuse in older adults with type 2 diabetes mellitus in primary health care. Household data were collected from March to October 2018 in the Family Health Strategy in Ribeirão Preto, São Paulo through face-to-face interviews with a form application. The pattern of alcohol consumption was estimated with the Alcohol Use Disorders Identification Test-C. A total of 338 older adults with type 2 diabetes mellitus participated, and 19.2% (95%CI 15.0-23.4) engaged in alcohol abuse. Among them, we observed a higher frequency of males (63.1%), aged 60 to 64 years (35.4%), economic class C (49.2%), 1-4 schooling years (53.8%), and multimorbidity (92.3%). There was a negative association between alcohol abuse and drug therapy adherence (PR = 0.55; 95%CI 0.36-0.86). The frequency of alcohol abuse and non-adherence to drug treatment among those with a high consumption pattern is troubling since it can lead to diabetes complications. Therefore, we underscore the importance of multidimensional elderly care and health education in primary care.

Key words:
Binge drinking; Health of the elderly; Diabetes mellitus; Delivery of health care; Public health surveillance

Introduction

Diabetes mellitus (DM) is one of the main non-communicable chronic diseases (NCDs), characterized by a multifactorial and complex etiology, with alterations in insulin production/secretion by pancreatic beta cells¹1 Rodacki M, Teles M, Gabbay M, Montenegro R, Bertoluci M. Classificação do diabetes. Diretriz Oficial da Sociedade Brasileira de Diabetes [Internet]. 2022. [acessado 2022 ago 3]. Disponível em: https://diretriz.diabetes.org.br/classificacao-do-diabetes
https://diretriz.diabetes.org.br/classif... . Brazil estimated 20.2% of people aged 60 or over with a medical diagnosis of this disease²2 Malta DC, Bernal RTI, Nogueira de Sá ACMG, Silva TMR, Iser BPM, Ducan BB, Schimdt MI. Diabetes autorreferido e fatores associados na população adulta brasileira: Pesquisa Nacional de Saúde, 2019. Cien Saude Colet 2022; 27(7):2643-2653. in 2019.

DM is a significant public health problem and a primary care-sensitive condition (PCSC)³3 Alfradique ME, Bonolo PF, Dourado I, Lima-Costa MF, Macinko J, Mendonça CS, Oliveira VB, Sampaio LF, Simoni CD, Turci MA. Internações por condições sensíveis à atenção primária: a construção da lista brasileira como ferramenta para medir o desempenho do sistema de saúde (Projeto ICSAP - Brasil). Cad Saude Publica 2009; 25(6):1337-1349.. Therefore, health promotion, screening, disease control, and disease prevention and rehabilitation actions are intended to occur in Primary Health Care (PHC)⁴4 Salci MA, Meirelles BHS, Silva DMGV. Primary care for diabetes mellitus patients from the perspective of the care model for chronic conditions. Rev Latino Am Enferm 2017; 25:e2882.. Brazil has care lines for NCDs, one aimed at DM. This initiative aims to implement strategies related to eating habits, regular physical exercise, medication use, and disease self-management⁵5 Ministério da Saúde (MS). Estratégias para o cuidado da pessoa com doença crônica: diabetes mellitus. Brasília: MS; 2013..

Alcohol consumption has become a concern in comprehensive care for people with DM in PHC, especially among older adults⁶6 Luis MAV, Garcia MVL, Barbosa SP, Lima DWC. O uso de álcool entre idosos atendidos na Atenção Primária à Saúde. Acta Paul Enferm 2018; 31(1):46-53.. Alcohol use can cause hypoglycemia or hyperglycemia, which can lead to complications. Furthermore, alcohol can interfere with the action of medications, leading to increased systemic blood pressure, liver cirrhosis, and falls. Other consequences can be listed as global behavior impairments and cognitive and intellectual functioning deficits⁷7 Schrieks IC, Heil ALJ, Hendriks HFJ, Mukamal KJ, Beulens JWJ. The effect of alcohol consumption on insulin sensitivity and glycemic status: a systematic review and meta-analysis of intervention studies. Diabetes Care 2015; 38(4):723-732.^,88 Mudd J, Larkins S, Watt K. The impact of excess alcohol consumption on health care utilisation in regional patients with chronic disease - a retrospective chart audit. Aust N Z J Public Health 2020; 44(6):457-461..

Alcohol is known to favor the development of acute and chronic DM-related complications⁶6 Luis MAV, Garcia MVL, Barbosa SP, Lima DWC. O uso de álcool entre idosos atendidos na Atenção Primária à Saúde. Acta Paul Enferm 2018; 31(1):46-53.

7 Schrieks IC, Heil ALJ, Hendriks HFJ, Mukamal KJ, Beulens JWJ. The effect of alcohol consumption on insulin sensitivity and glycemic status: a systematic review and meta-analysis of intervention studies. Diabetes Care 2015; 38(4):723-732.^-88 Mudd J, Larkins S, Watt K. The impact of excess alcohol consumption on health care utilisation in regional patients with chronic disease - a retrospective chart audit. Aust N Z J Public Health 2020; 44(6):457-461.. However, we should reflect on this practice and the possible impacts on the health-disease process to conduct harm reduction actions and favor DM control from a multidimensional perspective. Thus, this article aims to analyze alcohol abuse in older adults with type 2 DM (T2DM) in PHC.

Methods

This cross-sectional study was conducted in the Family Health Strategy (FHS) in Ribeirão Preto, São Paulo, from March to October 2018⁹9 Oliveira REM, Franco LJ. Glycemic control in elderly people with type 2 diabetes mellitus attending primary health care units. Primary Care Diabetes 2021; 15(4):733-736.. We included male or female older adults (age equal to or greater than sixty years) with a medical diagnosis of T2DM regardless of duration, in continuous use of medication to treat the disease, and registered with the FHS teams selected for the study. Older adults with cognitive impairment recorded in their health records, bedridden or dependent on caregivers, and a history of surgeries or hospitalizations in the three months before the survey were excluded, as were older adults who used medication to treat T2DM and interrupted the seven days preceding the interview to undergo diagnostic tests or some other medical advice.

The sample was calculated considering the frequency of older adults with T2DM and adherence to drug treatment at 50%¹⁰10 World Health Organization (WHO). Adherence to long-term therapies: evidence for action. Genebra: WHO; 2003.. We opted for an absolute tolerable error of 5% and a confidence coefficient of 95%. In the study planning, the FHS coverage was 22.4%, and we identified 2.766 registered older adults with T2DM¹¹11 Prefeitura de Ribeirão Preto, São Paulo. Secretaria Municipal de Saúde. Plano Municipal de Saúde 2014-2017 [Internet]. 2013. [acessado 2022 ago 3]. Disponível em: https://www.ribeiraopreto.sp.gov.br/files/ssaude/pdf/pms-rp-2014-2017.pdf
https://www.ribeiraopreto.sp.gov.br/file... . From this information, we calculated 338 participants. Random sampling by clusters was conducted in two stages. Initially, sixteen clusters were drawn among the forty-five groups (FHS teams). Then, the number of participants was listed proportionally to the frequency of older adults with T2DM through simple random sampling.

The dependent variable, alcohol consumption pattern, was measured by the Alcohol Use Disorders Identification Test-C (AUDIT-C)¹²12 Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med 1998; 158(16):1789-1795., validated in Brazil¹³13 Meneses-Gaya C, Zuardi AW, Loureiro SR, Marques JMA, Crippa JA. Is the full version of the AUDIT really necessary? Study of the validity and internal construct of its abbreviated. Alcohol Clin Exp Res 2010; 34(8):1417-1424., consisting of three items, each of which had five response options with 0 to 4 scores assigned. The final score was obtained on a scale ranging from 0 to 12 points. In men, a score of 4 or more is considered positive for alcohol abuse. In contrast, a score of 3 or more is considered positive in women.

The independent variables were gender (male and female), age group (60-64, 65-69, 70-74, 75-79, and equal to or greater than 80 years), economic classification (A, B, C, D/ E)¹⁴14 Associação Brasileira de Empresas de Pesquisa (ABEP). Critério de Classificação Econômica Brasil 2018. São Paulo: ABEP; 2018., schooling (0, 1-4, and equal to or more than 5 years of study), self-reported tobacco use (yes or no), multimorbidity being the simultaneous occurrence of two or more NCDs¹⁵15 Salive ME. Multimorbidity in older adults. Epidemiol Rev 2013; 35(1):75-83. (yes or no), self-reported cardiovascular disease (yes or no), self-reported dyslipidemia (yes or no), self-reported overweight/obesity (yes or no), emotional distress in living with T2DM¹⁶16 Gross CC, Scain SF, Scheffel R, Gross JL, Hutz CS. Brazilian version of the problem areas in diabetes scale (B-PAID): validation and identification of individuals at high risk for emotional distress. Diabetes Res Clin Pract 2007; 76(3):455-459. (yes or no), complications resulting from T2DM (yes or no), adherence to drug therapy¹⁷17 Ben AJ, Neumann CR, Mengue SS. Teste de Morisky-Green e Brief Medication Questionnaire para avaliar adesão a medicamentos. Rev Saude Publica 2012; 46(2):279-289. (yes or no), medications used for T2DM ( oral antidiabetic only, insulin only, oral antidiabetic and insulin), and blood glucose control established with glycated hemoglobin less than 8.0%¹⁸18 Almeida-Pititto B, Dias ML, Moura FF, Lamounier R, Vencio S, Calliari LE. Metas no tratamento do diabetes [Internet]. 2022. [acessado 2022 ago 3]. Disponível em: https://diretriz.diabetes.org.br/metas-no-tratamento-do-diabetes
https://diretriz.diabetes.org.br/metas-n... (yes or no). The smoking burden (packs/year) was calculated by the number of daily cigarettes consumed, divided by 20, and multiplied by the number of smoking years¹⁹19 Gouveia TS, Trevisan IB, Santos CP, Silva BSA, Ramos EMC, Proença M, Ramos D. Smoking history: relationships with inflammatory markers, metabolic markers, body composition, muscle strength, and cardiopulmonary capacity in current smokers. J Bras Pneumol 2020; 46(5):e20180353..

The database was investigated using the R software. The absolute and relative frequencies were presented in the exploratory analysis. Possible associations were verified using Pearson’s chi-square test. P-values lower than the adopted significance level (0.05) provided evidence of association. An association measure was presented with the respective 95% confidence interval (95%CI) and the p-value to estimate the strength of association between the dependent and independent variables. We calculated prevalence ratios (PR) using the Poisson regression method with robust variance, crude, and adjusted for gender and age group.

The Research Ethics Committee of the “Dr. Joel Domingos Machado” Health Center School, the Faculty of Medicine of Ribeirão Preto, University of São Paulo, approved the study under Opinion n° 2.487.864 and Presentation Certificate for Ethical Appreciation n° 82225317.0.0000.5414. The interviews were held after the participants had read and signed the Informed Consent Form. All ethical aspects were observed per Resolution n° 466 of 2012 of the National Health Council.

Results

Approximately 19.2% (95%CI 15.0-23.4) of study participants engaged in alcohol abuse. In this group, a higher frequency was observed among men aged 60 to 64 years, economic class C, with 1-4 schooling years, non-smokers, with two or more self-reported NCDs, having cardiovascular disease, using only oral antidiabetic, and non-adherent to drug therapy (Table 1). The mean tobacco use load among those who engaged in alcohol abuse and tobacco use was 43 packs/year (SD = 16.9).

In the AUDIT-C items, we found that 76.9% of older adults reported never consuming alcohol, while 5.6% consumed it four or more times a week (Figure 1a). We observed that 8.0% reported drinking four or five doses of alcohol on a normal day (Figure 1b). The frequency of consumption of five or more doses on a single occasion was 5.3% once a week (Figure 1c).

A negative association was found with adherence to drug therapy PR = 0.55 (95%CI 0.36-0.86) and use of oral antidiabetic and insulin PR = 0.45 (95%CI 0.21-0.96) in the PRs adjusted for gender and age of alcohol abuse among older adults with T2DM (Table 2).

Discussion

There are controversies in the scientific literature about the light and moderate consumption of alcohol to improve insulin sensitivity and blood glucose control⁷7 Schrieks IC, Heil ALJ, Hendriks HFJ, Mukamal KJ, Beulens JWJ. The effect of alcohol consumption on insulin sensitivity and glycemic status: a systematic review and meta-analysis of intervention studies. Diabetes Care 2015; 38(4):723-732.^,2020 Huang J, Wang X, Zhang Y. Specific types of alcoholic beverage consumption and risk of type 2 diabetes: a systematic review and meta-analysis. J Diabetes Investig 2017; 8(1):56-68.. However, the frequency of abusive consumption in the sample studied is of concern, especially due to the association with low adherence to drug treatment. The burden of diabetes in Brazil linked to alcohol abuse should guide clinical and public health actions focused on a multidimensional approach to older adults with T2DM in PHC²¹21 American Diabetes Association. Improving Care and Promoting Health in Populations: Standards of Medical Care in Diabetes-2022. Diabetes Care 2022; 45(Suppl. 1):S8-S16..

The 2019 National Health Survey conducted between August 2019 and March 2020 by the Brazilian Institute of Geography and Statistics in partnership with the Ministry of Health estimated that 3.8% (95%CI 3.3-4.3) of people who self-reported living with diabetes engaged in alcohol abuse²2 Malta DC, Bernal RTI, Nogueira de Sá ACMG, Silva TMR, Iser BPM, Ducan BB, Schimdt MI. Diabetes autorreferido e fatores associados na população adulta brasileira: Pesquisa Nacional de Saúde, 2019. Cien Saude Colet 2022; 27(7):2643-2653.. The study conducted with people aged 45 years or older with a medical diagnosis of diabetes in Belo Horizonte, Minas Gerais, showed that 17.7% (95%CI 11.1-24.2) of people assisted by the FHS engaged in alcohol abuse²²22 Silva SS, Mambrini JVM, Turci MA, Macinko J, Lima-Costa MF. Uso de serviços de saúde por diabéticos cobertos por plano privado em comparação aos usuários do Sistema Único de Saúde no Município de Belo Horizonte, Minas Gerais, Brasil. Cad Saude Publica 2016; 32(10):e00014615.. It should be noted that there are differences in the studied samples, and varying measurement techniques were used. However, a higher frequency was observed in this study.

Other important findings refer to the higher frequency of alcohol abuse among men aged close to 60 years with low income and education. In this setting, we highlight the relevance of providing comprehensive care for diabetes in PHC, valuing the social determinants that can influence the health-disease process²³23 Lang VB, Markovic BB, Vrdoljak D. The association of lifestyle and stress with poor glycemic control in patients with diabetes mellitus type 2: a Croatian nationwide primary care cross-sectional study. Croat Med J 2015; 56(4):357-365.. Some scientific evidence recommends health education and brief interventions to reduce alcohol consumption²⁴24 Pereira MO, Anginoni BM, Ferreira NC, Oliveira MAF, Varhar D, Colvero LA. Efetividade da intervenção breve para o uso abusivo de álcool na atenção primária: revisão sistemática. Rev Bras Enferm 2013; 66(3):420-428.. Therefore, we should reflect on the implementation process in PHC, and the clinical, humanistic, and economic results achieved through these strategies.

We noted that 20% of older adults who engaged in alcohol abuse used tobacco, and this characteristic requires attention, especially due to the known risk factor for cardiovascular diseases²⁵25 Gaidhane S, Khatib N, Zahiruddin QS, Bang A, Choudhari S, Gaidhane A. Cardiovascular disease risk assessment and treatment among person with type 2 diabetes mellitus at the primary care level in rural central India. J Family Med Prim Care 2020; 9(4):2033-2039.. Moreover, studies have highlighted that smoking can accelerate microvascular complications from diabetes caused by hyperglycemic harm to small blood vessels²⁶26 Strelitz J, Ahern AL, Long GH, Boothby CE, Wareham NJ, Griffin SJ. Changes in behaviors after diagnosis of type 2 diabetes and 10-year incidence of cardiovascular disease and mortality. Cardiovasc Diabetol 2019; 18(1):98.. Thus, we underscore the importance of encouraging tobacco cessation programs in PHC guided by actions according to people’s uniqueness in the behavioral sphere, drug treatment, and integrative and complementary practices by multidisciplinary teams²⁷27 Santos MDV, Santos SV, Caccia-Bava MCGG. Prevalência de estratégias para cessação do uso do tabaco na Atenção Primária à Saúde: uma revisão integrativa. Cien Saude Colet 2019; 24(2):563-572..

The multiple NCDs associated with T2DM, known as multimorbidity, were frequent among older adults engaging in alcohol abuse. One aspect to be analyzed by the health teams is the functionality level of older adults with T2DM and the possible limitations in their activities of daily living and leisure. Furthermore, alcohol’s hypoglycemic action can lead to body dysfunctions and increase the risk of falls. Thus, it is necessary to encourage disease self-management to avoid harm²⁸28 Melo LA, Lima KC. Fatores associados às multimorbidades mais frequentes em idosos brasileiros. Cien Saude Colet 2020; 25(10):3879-3888..

Non-adherence to drug therapy among older adults engaging in alcohol abuse is a warning sign in the studied sample. Notably, the responsible use of drugs prescribed for T2DM contributes to the control of the disease. In contrast, inappropriate or irregular use can lead to aggravating factors such as glycemic and metabolic changes²⁹29 Oliveira REM, Ueta JM, Franco LJ. Variables associated with adherence to the treatment of type 2 diabetes mellitus among elderly people. Diabetol Int 2021; 13(1):160-168.. In this sense, we suggest individual and collective actions in PHC, and we recommend elaborating and implementing unique therapeutic projects that involve the family and the community to help older adults manage medications and the periodic monitoring of community health workers and other professionals³⁰30 Khayyat SM, Mohamed MMA, Khayyat SMS, Hyat Alhazmi RS, Korani MF, Allugmani EB, Saleh SF, Mansouri DA, Lamfon QA, Beshiri OM, Abdul Hadi M. Association between medication adherence and quality of life of patients with diabetes and hypertension attending primary care clinics: a cross-sectional survey. Qual Life Res 2019; 28(4):1053-1061..

The present study’s design is a limitation. Moreover, the alcohol consumption frequency was underestimated in the sample since non-authentic reporting of behavioral aspects that influence health may occur in epidemiological surveys. However, this investigation shows the pattern of alcohol consumption in older adults with a high-impact disease and contributes to supporting discussions related to the topic. Thus, there is a need to improve brief and early interventions in PHC with a focus on diabetes education to reduce alcohol abuse in older adults and ensure better disease control with quality of life.

References

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