There was a time when doctors told people with type 1 diabetes they couldn’t drink alcohol — along with a sizeable list of other diabetes “don’ts.” Thankfully, times have changed, and alcoholic beverages are back on the menu. But that said, alcohol presents a unique series of risks for those with diabetes, especially for people with type 1.

So how do you keep safe while toasting the town?

We’ve assembled a list of top tips from experts to help you safely enjoy moderate drinking.

But first, let’s review how alcohol affects the body, and the risks of one too many drinks…

Many alcoholic beverages have a roller coaster effect on blood sugar, first causing an upward surge in blood sugar levels, followed by a profound plunge many hours after drinking. This roller coaster is caused by the fact that many alcoholic drinks contain blood sugar-raising carbs, combined with the fact that alcohol — by itself — lowers blood sugar.

Carbs? What carbs?

Karen Ansel, a widely published author and master’s level registered dietitian, explains that while hard alcohol contains essentially no carbohydrates, “beer and wine, which are made from carbohydrate-containing ingredients, do supply some carbs,” as do most of the common “mixers.”

How does alcohol lower blood sugar?

Dr. Jeremy Pettus, a practicing endocrinologist in San Diego, California, a type 1 himself who gives talks on alcohol at the nationwide TCOYD diabetes education events, explains how alcohol lowers blood sugar: “When the liver is processing alcohol, it’s not producing sugar as it normally does.” He says he thinks of alcohol “almost working like a little bit of insulin, not unlike a gentle nudge in basal rate.”

Beware the morning after

A hangover headache is not the biggest concern for people with diabetes when it comes to a night of drinking. According to Ansel, the blood sugar-lowering effects of alcohol peak 8 to 10 hours after drinking, so a big drop in blood sugar the next morning can “really take a person by surprise.”

But isn’t it true that moderate alcohol consumption is actually good for your health?

While there is no definitive answer to this question relating to people with diabetes, Dr. David Kerr, Director of Research and Innovation at the prestigious Sansum Diabetes Research Institute in Santa Barbara, California, says a minor benefit is a possibility.

Kerr, who has conducted significant research in diabetes and alcohol, tells DiabetesMine: “There is old literature indicating some cardiovascular benefit to moderate alcohol intake for people with type 2 diabetes,” and that “given that type 1s also have significant cardiovascular risk, it seems reasonable to extrapolate they too would receive the same benefit.”

That said, drinking has a unique set of risks for people with type 1 diabetes. Chief among them are:

Drinking yourself into a coma — literally

Something that causes Dr. Kerr to lie awake at night is a “potentially lethal” side effect of alcohol on type 1s called alcoholic acidosis. More likely following binge drinking than at any other time, it can be thought of as DKA (diabetic ketoacidosis) without high blood sugar.

How is that possible? Apparently, the liver, with no glycogen in the system, turns on the production of a specific ketone that can trigger acidosis in the absence of elevated sugar. Kerr says he worries that in an emergency room, healthcare providers may find a binge drinker’s blood glucose normal, and therefore might will rule out DKA — missing the dangers here. So “binge drinking is a no-no” for people with diabetes, says Kerr, “that’s for sure.”

Interference with hypoglycemia recognition and response

Kerr also points out that drinking tends to blunt hypoglycemia (dangerously low blood sugar) awareness, especially drinking on an empty stomach. And hypos can be mistaken for drunkenness by outsiders. Either or both of these phenomenon can delay proper treatment of a hypo and are a “potential concern.”

The glucagon lifeboat has a hole in it

The good news, according to Dr. Pettus, is that the myth that rescue glucagon won’t work at all when you are drunk is just that, a myth. The bad news is that it won’t work as well as when you are sober. Still, something is better than nothing, so check to ensure your emergency glucagon isn’t expired, and carry it with you when you’re out drinking.

Booze has calories

One downside of drinking too much is gaining weight, which makes blood sugar harder to control in the long term. Dr. Kerr says “people don’t appreciate that there are calories in alcohol,” and that “people tend to underestimate the calorie content in drinks like wine.”

Dr. Pettus also points out that an additional challenge of determining carbs and calories in drinks is that there is no requirement for alcoholic beverages to have nutrition labels.

The American Diabetes Association (ADA) recommends that men with diabetes limit themselves to two drinks a day, and that women with diabetes limit themselves to one drink per day. These recommendations are the same as the USDA guidelines for people without diabetes. So what does that really mean?

How big is a drink?

One drink is defined as 12 ounces of beer, 5 ounces of wine, or 1 ½ ounces of distilled spirits. So guys can have two beers, two glasses of wine, or two shots per day. Ladies are limited to one beer, one glass of wine, or one shot.

Why are women supposed to drink less?

Ansel tells us that drink sizes for men and women vary for two reasons. “First, women are typically smaller than men, so their blood alcohol levels rise faster than men. But they also produce smaller amounts of the enzyme needed to metabolize alcohol, so a drink hangs out in a woman’s bloodstream longer than it would in that of a man.”

The serving size dilemma

Of course, one challenge for people with diabetes is that most bars and restaurants serve drinks that are larger than the official “standard” size, as defined by the National Institutes of Health (NIH).

A 16-ounce beer is a common size (versus the standard 12 ounce), as are both 6 and 9 ounce glasses of wine (versus the standard 5 ounce). And many mixed drinks contain two shots of spirits.

Is limiting yourself to one or two drinks realistic?

Aside from the fact that most “servings” are larger than the recommended serving, very few people — with or without diabetes — follow these limits. Remember that each round of drinks increases the complexity of balancing booze and blood sugar levels.

With regard to the calorie and carb content of the various classes of alcoholic beverages, Dr. Pettus points out:

  • Beer has the dual challenge of alcohol and carbs. Beers can run from a low of 95 calories and 5 carbs, up to 219 calories and 20 carbs — with 15 carbs being a typical average. The darker the beer, the higher the counts, with “good craft beers” being the highest. He notes that drinking a couple of beers has the same impact on blood sugar as eating a meal.
  • Wine, according to Pettus, is “more diabetes friendly” than beer, with a typical calorie count of 120, and 5 carbs. He says that while “beer tends to raise your blood sugar with all the carbs, wine tends to keep things a little bit more even.”
  • Spirits like whiskey have 69 calories and no carbs, at least when consumed “straight.” Either straight up, or with a sugar-free mixer, they are “the most diabetes-friendly drink to drink,” according to Pettus. Of course, if spirits are used in what he calls “foofy drinks,” the carb count can exceed most meals. For instance, a piña colada has 526 calories and a whopping 60+ carbs, similar to a Big Mac.

Pettus urges people with type 1 diabetes to have a “game plan” in place before going out on the town. He suggests having a good notion of the effects of drinks you like, and taking care of any diabetes “business” before you leave home. For example, if you’re on shots, take your basal insulin dose before heading out, and if you use a pump, be sure your infusion site is current.

He says, “You don’t want to deal with an infusion site change at 2 a.m.” after being out drinking. In light of the fact that most people aren’t going to stop at one or two drinks, he cautions PWDs to “be proactive against drunk you.”

Other tips for drinking safety include:

Wear your medic alert, and alert those you are drinking with

Even if you never wear medical alert jewelry, and you really should, make sure you add this life-saving bling to your party outfit. It can make the difference between landing in a jail cell and the ER if things go south for you. Also, ensure that at least one of your drinking buddies knows about your diabetes, and has some idea of what to do if you go low.

Make sure your mixers are sugar free

Ansel says, “Pure alcohol is practically carb free, so it doesn’t require insulin to provide energy. But once alcohol is combined with most mixers that all goes out the window, because these can all provide substantial amounts of carbohydrate.” She points out that soda, tonic water, and juice are all “carb heavy.”

Sansum’s Dr. Kerr also worries about the trend of using energy drinks as mixers, as these drinks are actually designed to prompt a rise in blood glucose from their sugar content. They also provide “a transient, but clinically significant, rise in blood pressure,” he notes.

Don’t drink alone (eat, too)

Kerr says to avoid what the Brits call “a liquid lunch” or “drinking your dinner” in the U.S. He says people with diabetes should always eat when drinking. Pettus concurs, joking that, “God made pizza and beer for a reason.”

How to nurse that one drink (or two)?

It’s always a good idea to sip slooooooowly on that first beer or glass of wine. If you’re indulging in cocktails, one tactic to stick to the recommended one drink is to start with a mixed drink using sugar free mixers, and then switch to a straight up mixer only.

Use a calorie-counting app to know what you’re putting in your body

Although nutrition labels aren’t required on alcoholic drinks, many carb-counting apps, such as Calorie King, can give you the breakdown on your alcohol of choice.

Bedtime snack

Pettus tells attendees to his talks that after an evening of drinking, if their blood sugars are under 180 mg/dL, they should consider eating a snack before bedtime that they won’t take any insulin for. This is important to guard against a nocturnal blood sugar drop.

One big question is: Do you take shots for your shots? We asked our experts.

Bolus for booze?

Ansel says, “If you count carbs, you’ll want to factor (your drink’s carbs) into your daily tally, just like any other beverage you’d consume.”

But how to factor it? Dr. Pettus says that to counter-act for the glucose-lowering effect of the alcohol, bolus at 50 percent of the carb count for beer, while taking nothing extra for wine.

Be alert that straight spirits — with no food — will lower blood sugar. He adds that you might need smaller boluses the next day, as the reach of alcohol’s lowering effect on blood sugar is lengthy.

Basal adjustment?

Pettus says that if you exceed the official drink limit, consider lowering your basal rate by 20 percent. But this tactic could lead to risk of alcoholic ketoacidosis, says Dr. Kerr: “Perhaps consider basal reduction for the morning after, but one must be ever-so-careful” with insulin reductions when it comes to alcohol, as it increases the risk of DKA, especially with high levels of alcohol consumption.

Insulin corrections?

If your sugar is too high following a night of drinking, Pettus says to limit bedtime corrections to 50 percent, bearing in mind the overnight glucose-lowering effect of the alcohol.

The key is not to overreact and “take a bunch of insulin” when your blood sugars are high following drinking, as the alcohol’s glucose production-blocking effect on the liver will cause whatever insulin you’ve taken to be supersized.

Glucose targets while drinking

Pettus says that it’s OK, and safer, to run a little high when thinking about glucose targets during or after drinking. His bottom line is that it’s better to permit some hyperglycemia (high blood sugar) while drinking, to avoid dangerous lows. “I’d rather have you at 200 mg/dL all night than at 30,” he says.

While Ansel says that drinking can be problematic for people who are on insulin, especially those with type 1 diabetes, it doesn’t mean that you can’t drink if you have T1D.

But she adds, “If you are on insulin or prone to hypoglycemia, it’s really important to discuss your drinking habits with your doctor or diabetes educator to make sure you have your blood sugar under control first.”

Kerr, on the other hand, insists that if done smartly, drinking is no riskier for type 1s than for people without diabetes. He says he would not advocate abstinence from alcohol, as long as it’s used in moderation.

And Pettus? Well, the title of his TCOYD talk is only half humorously titled, “How to be a Successful Drinker (with Diabetes).” In the description, he writes: “Yes, people with diabetes can drink alcohol despite what those 50-year-old textbooks or those 100-year-old doctors say! Cheers!!”