Drunkorexia: calorie restriction prior to alcohol consumption among college freshman.
Article Type: Clinical report
Subject: Weight loss (Risk factors)
Weight loss (Analysis)
Weight loss (Surveys)
Weight loss (Physiological aspects)
Weight loss (Health aspects)
Alcohol and youth (Risk factors)
Alcohol and youth (Analysis)
Alcohol and youth (Surveys)
Alcohol and youth (Physiological aspects)
Alcohol and youth (Health aspects)
Drinking of alcoholic beverages (Analysis)
Drinking of alcoholic beverages (Surveys)
Drinking of alcoholic beverages (Physiological aspects)
Drinking of alcoholic beverages (Health aspects)
Brain damage (Risk factors)
Brain damage (Analysis)
Brain damage (Surveys)
Brain damage (Physiological aspects)
Brain damage (Health aspects)
Medical research (Analysis)
Medical research (Surveys)
Medical research (Physiological aspects)
Medical research (Health aspects)
Medicine, Experimental (Analysis)
Medicine, Experimental (Surveys)
Medicine, Experimental (Physiological aspects)
Medicine, Experimental (Health aspects)
Compulsive eating (Risk factors)
Compulsive eating (Analysis)
Compulsive eating (Surveys)
Compulsive eating (Physiological aspects)
Compulsive eating (Health aspects)
Bulimia (Risk factors)
Bulimia (Analysis)
Bulimia (Surveys)
Bulimia (Physiological aspects)
Bulimia (Health aspects)
Body mass index (Analysis)
Body mass index (Surveys)
Body mass index (Physiological aspects)
Body mass index (Health aspects)
Authors: Burke, Sloane C.
Cremeens, Jennifer
Vail-Smith, Karen
Woolsey, Conrad
Pub Date: 08/01/2010
Publication: Name: Journal of Alcohol & Drug Education Publisher: American Alcohol & Drug Information Foundation Audience: Academic; Professional Format: Magazine/Journal Subject: Health; Psychology and mental health; Social sciences Copyright: COPYRIGHT 2010 American Alcohol & Drug Information Foundation ISSN: 0090-1482
Issue: Date: August, 2010 Source Volume: 54 Source Issue: 2
Product: Product Code: 8521217 Enzymology; 8000200 Medical Research; 9105220 Health Research Programs; 8000240 Epilepsy & Muscle Disease R&D NAICS Code: 54171 Research and Development in the Physical, Engineering, and Life Sciences; 92312 Administration of Public Health Programs
Accession Number: 236247802
Full Text: ABSTRACT

Using a sample of 692 freshmen at a southeastern university, this study examined caloric restriction among students prior to planned alcohol consumption. Participants were surveyed for self-reported alcohol consumption, binge drinking, and caloric intake habits prior to drinking episodes. Results indicated that 99 of 695 (14%) of first year students reported restricting calories prior to drinking, with 6% reporting this behavior to avoid weight gain and 10% to enhance alcohols effects; no significant differences were found between males and females. Based on the study findings, practical campus-based and student-centered education and prevention strategies are presented to explore solutions to reduce drunkorexia. Effective evidence-based behavior change brief interventions such as Motivational Interviewing and the Brief Alcohol Screening and Intervention for College Students (BASICS) program are presented and discussed.

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The misuse of alcohol and disordered eating are both major concerns on college campuses nationwide. Several studies have examined alcohol use among college students. In 2002, O'Malley and Johnston reviewed findings from several national data sets that examined alcohol use among college students including the College Alcohol Study, the Core Institute, Monitoring the Future, and the National College Health Risk Behavior Survey. Results of these national surveys are consistent, indicating that approximately 70% of college students report using alcohol in the past month, and about 40% report binge drinking (defined as 4 drinks for women and 5 for men in one sitting). In 2008, more than three-fourths of college students reported alcohol use in the past month (American College Health Association). Despite increased education and prevention efforts over the past 15 years, the misuse of alcohol does not appear to have changed much. In 2001, Hingson, Heeren, Zakocs, Kopstein, and Wechsler found that the frequency of binge drinking among college students had remained the same since 1993. Despite increased efforts to prevent alcohol misuse among college students, the prevalence of binge drinking remained fairly stable between 1993 and 2001, and the prevalence of frequent binge drinking (3 or more times in the past two weeks) increased from 19.7% to 22.8% (Wechsler, Lee, Kuo, Seibring, Nelson, & Lee, 2002). Additionally, the percentage of students that reported drinking on 10 or more occasions in the past 30 days increased 18.1% to 22.6%, and students who reported being drunk three or more times in the past 30 days increased 23.4% to 29.4%. To reach these conclusions about alcohol consumption patterns, Wechsler et al. (2002) examined four waves of data from the 1993, 1997, 1999, and 2001 College Alcohol Study. Compiled together, these studies indicate that the majority of college students use alcohol, and a large number (nearly half) participate in binge drinking episodes. Additionally, results suggest that students who are binge drinkers binge more frequently today than in the past (Ford, 2007).

Many college students engage in binge drinking and it appears that the majority of alcohol consumed is done so by students who engage in this behavior (Wechsler, Molnar, Davenport, & Baer, 1999). The College Alcohol Study (CAS) conducted at Harvard University found that "frequent binge drinkers," defined as those who engaged in binge drinking on three or more occasions in the past two weeks, constituted only 19% of the sample but consumed 68% of the 87,008 total drinks (Wechsler et al., 1999). In this study, frequent binge drinkers also consumed an average of 17.9 drinks in a week. In comparison, infrequent binge drinkers, defined as those who engage in binge drinking no more than two times in the past 2 weeks, comprised 24% of the sample and only consumed 23% of the total alcohol, averaging 4.8 drinks a week. This study is just one of many that demonstrates the ubiquitous nature of excessive alcohol consumption on college campuses.

First year college students have been identified as a high-risk population for engaging in the behavior of binge drinking (Larimer & Cronce, 2002). Research indicates that freshman are the most vulnerable to experience serious alcohol related problems in their first few months of school, a time during which they are likely to engage in high-risk drinking behaviors (Larimer & Cronce, 2002). Several studies have reported an increase in quantity and frequency of alcohol consumption among first year students (Baer, Kivlahan, & Marlatt, 1995; Bishop, Weisgram, Holleque, Lund, & Wheeler-Anderson, 2005; Grekin & Sher, 2006; Weitzman, Nelson, & Wechsler, 2003). Some factors that have been indentified for contributing to this increase are heightened academic rigor faced by first year students, college campus social norms promoting alcohol use, and a drastic decline in parental supervision during the transition to college life (Baer, 2002; Baer & Bray, 1999; Baer, Kivlahan, & Marlatt, 1995; Schulenburg & Maggs, 2002; Schulenburg et al., 2001). First year students also make up the majority of students attending parties at dorms and Greek houses where alcohol is most commonly consumed in the form of binge drinking on Thursday, Friday, and Saturday nights (Del Boca, Darkes, Greenbaum, & Goldman, 2004; Harford, Wechsler, & Seibring, 2002;).

Disordered Eating

Disordered eating is also a significant issue on college campuses. According to the National Eating Disorder Association (2006), approximately 20% of college students, both male and female, reported that they have had an eating disorder at some point in their lives. Studies have also discovered other subclinical disordered eating behaviors among college students that include binge eating, chronic dieting, fasting or purging to control weight, self-induced vomiting, and the use of diet pills or diuretics (Forman-Hoffman, 2004; Mints & Betz, 1988; Tylka & Subich, 2002.). Furthermore, the freshman year of college is marked by an increase risk in disordered eating and the perpetually rumored "freshman 15," a term used to describe weight gain thought to typically occur during this time period (Anderson, Shapiro, & Lundgren, 2003; Hoffman, Policastro, Quick, & Lee, 2006; Striegel-Moore, Silberstein, & Rodin, 1986). Therefore, while the general college student population may engage in extreme behaviors relating to weight control, freshman may be at an even greater risk for these behaviors due to the additional stress and environmental changes in this transition year.

The co-occurrence of eating disorders and alcohol misuse has been noted in many research studies (Dansky, Brewerton, & Kilpatrick, 2000; O'Brien & Vincent, 2003; National Center on Addiction and Substance Abuse at Columbia University [CASA], 2001). A 2001 CASA report, estimated that 30-50% of individuals with bulimia and 12-18% of individuals with anorexia either abuse or are dependent on alcohol. In addition, results indicated a distinct comorbidity between substance dependency and eating disorders with approximately 35% of people with alcohol or drug dependency also identified with an eating disorder. Among college students, studies have demonstrated an association between alcohol use and unhealthy eating patterns. This association extends beyond those clinically diagnosed with an eating disorder to include those with less severe disordered eating behaviors such as binge eating (Cooley & Toray, 1996; Krahn, Kurth, Gomberg, & Drewnowski, 2005; Anderson, Simmons, Martens, Ferrier, & Sheehy, 2006; Krahn, Kurth, Demitrack, & Drewnowski, 1992). Krahn et al. (1992) noted a positive relationship between dieting severity and frequency of alcohol consumption and binge drinking. Stewart, Angelopoulous, Baker, & Boland (2000) found similar results that indicated that higher levels of dietary restraint were associated with increased excessive drinking episodes and the likelihood of being classified as a binge drinker.

Among a population that is already at risk to suffer from serious alcohol related consequences, the restriction of calories or not eating prior to alcohol consumption, makes the use of alcohol even more dangerous. Studies among those who engage in disordered eating behaviors such as vomiting after eating, binge eating, caloric restriction, taking laxatives or stimulants for weight loss, etc. indicate a higher propensity to experience alcohol-related negative consequences, such as doing something regretted, engaging in forced intercourse, and blacking out (Anderson, Martens, & Cimini, 2005; Dams-O'Conner, Martens, & Anderson, 2005; Dunn, Larimer, & Neighbors, 2002; Krahn, Hurth, Gomberg, & Drewnowski, 2004; White, A, 2004). For women, the effects of not eating prior to alcohol consumption are a great concern, as women are already at increased risk of suffering serious alcohol related consequences due to differences between the sexes. Women generally weigh less, have less alcohol metabolizing enzymes (alcohol dehydrogenase), and typically have less total body water to dilute alcohol in the blood. Freeze et al. (1990) found that gastric alcohol dehydrogenase activities were 70-80% higher in nonalcoholic men than nonalcoholic women. These differences in alcohol metabolism make women more vulnerable than men to the development of cirrhosis, brain damage, and other health conditions resulting from alcohol misuse (National Institute on Alcohol Abuse and Alcoholism [NIAAA]; 1993). Regardless whether one is male or female, drinking on an empty stomach allows alcohol to get into the body faster, which raises blood alcohol levels and leads to increased risks for brain impairments (blackouts) and resultant negative health and behavioral consequences (White, 2004).

The term "drunkorexia" was coined by popular media in 2008 to describe the practice of restricting calories so more alcohol can be consumed without gaining weight (CBS News, 2008; Kershaw, 2008; Smith, 2008; Stopper, 2008). Drunkorexiajoins an increasing list of eating disorder diagnoses not recognized or condoned by the medical community, including "manorexia" (anorexia in men), "diabulimia" (diabetics using insulin restriction to purge), and even "bridorexia" (brides starving to fit into a certain size wedding dress).

Several studies explore the relationship between disordered eating behaviors and alcohol consumption, but few examine the eating motives among individuals engaging in these behaviors, and only one looks at the issue of restricting calories (Anderson, Simmons, Martens, Ferrier, & Sheehy, 2006; Giles, Champion, Sutfin, McCoy, Wagoner; 2009; Luce, Engler, & Crowther, 2007). Additional assessment of these behaviors on days proceeding nights of heavy drinking has yet to be explored, therefore there is a need for additional assessment of calorie restriction prior to alcohol consumption. This study examines the frequency of disordered eating behaviors specifically restricting caloric intake on days when heavy alcohol consumption was expected. The research questions for this study included: a) Do freshman students who have consumed alcohol in the past 30 days restrict their caloric intake on the days they choose to drink? b) Do freshman students who have binge drank in the past 30 days restrict their caloric intake on the days they choose to drink? c) Does race/ ethnicity impact one's behavior to restrict caloric intake on days when one chooses to drink? d) Does gender impact one's behavior to restrict caloric intake on days when one chooses to drink? e) Does BMI impact one's behavior to restrict caloric intake on days when one chooses to drink?

METHODS

During the Spring semester of 2008, undergraduate students enrolled in a required personal health course at a large southeastern university comprised the study population (N = 2,005). The survey was administered online and completed, at their convenience, by students outside of class for extra credit. Of the 2,005 students enrolled, 1,349 (67.3%) completed the online survey. Since this research focused on freshmen who used alcohol, results included only 692 respondents (70%) who met these criteria. The 20-item survey included 13 personal/demographic items, two items soliciting height and weight information, and two items inquiring about alcohol use. Because there is limited research pertaining to restricting food consumption before drinking, an established instrument was not available. Therefore, the researchers developed and included three items to explore this unique issue further. Content and face validity was established by consulting experts in the field.

Using a paired samples t test, instrument reliability was tested via test/retest method in a two-week interval during summer of 2008. A strong internal reliability was found with a correlation reliability of .86 (McDermott & Sarvela, 2003). Differences between age, gender, race/ethnicity, and BMI were analyzed using chi-square analysis to test for significance between each group.

RESULTS

Quantitative Results

The study population comprised of 692 first year college students who reported drinking in the last 30 days. Table 1 displays the demographics of freshman students studied. The age breakdown of the population with the majority of the respondents being 19 years of age (55%), followed by 18 year olds (44%) and 20 years of age (1%). The majority of the sample was female (68%, n = 473) and Caucasian (87%, n = 584). Almost all of the students sampled were full-time students and had never been married (99% and 98% respectively). Eighty-four percent (n = 495) live in a college dormitory or residence hall with 14% (n = 83) living in off-campus housing or an apartment. Six percent (n = 40) of respondents lived alone and 88% (n = 518) lived with a roommate or friend. Twelve percent (n = 72) of respondents were in a social fraternity or sorority. Seventy-two percent (n = 451) did not work, and 15% of those sampled worked with pay 10 hours or more a week.

Frequency analyses revealed that 83% of the total population of first year students (n = 945) drank alcohol in the past 30 days, with the mean number of drinking days being 3.17 (SD = 1.47). See Table 2 for the alcohol use patterns among first year student drinkers. Most respondents (26%) binged 6-9 days per month followed by 25% of respondents reporting binge drinking on 3-5 days, and 23% of the respondents binge drinking on 1-2 days (See Table 2). The mean number of days binge drinking occurred was 3.11 (SD = 1.76).

Chi-square analyses revealed significant differences between males and females ([chi square]= 18.80; p < .05) and ethnicities for respondents who drank alcohol in the past 30 days. Consistent with previous alcohol research, Caucasians reported drinking more frequently than black participants ([chi square]=1.06, p< 0.05), particularly for the 6-9 (27% versus 13%) and 10-19 (22% versus 13%) day ranges. Females reported using alcohol less frequently than males. The number of females that reported drinking was higher than males in all frequency categories during the past 30 days, with this difference becoming less pronounced as the frequency of drinking occasions increased (See Table 3).

Ninety-nine of 692 (14.2%) of first year students sampled restricted their caloric intake on days they knew alcohol consumption would occur. Of those first year students who engaged in this behavior, 70% (n = 70) were female and 29% (n = 29) were male. Thirty-nine first year students (72% females, 28% males) reported restricting calories before drinking to avoid gaining weight. Sixty-eight respondents (68% females, 32% males) reported restricting calories to feel alcohols' effects better.

Alcohol consumption was significantly different between students who reported restricting calories on days they knew they were drinking and those who did not engage in these behaviors ([chi square]=47.66, p<.01; See Table 4). The majority of students that restricted calories (30%) reported drinking 10-19 of the last 30 days, followed by 6-9 days (25%) and 3-5 days (23%). A Chi-square analysis also revealed statistical significance ([chi square]=36.86, p<.01) among first year students who reported binge drinking when restricting calories prior to drinking and the frequency of binge drinking occasions. Similar to current drinkers, some of the calorie restrictors (33%) reported binge drinking 10-19 days, followed by 6-9 days (23%). However, approximately one-fifth (21%) of binge drinking students that restricted calories reported binge drinking on more than 20 days in the past 30, which showed that, not only was restricting calories a problem, but binge drinking when doing so was also quite common.

Although significance was found (p < .01), the sample sizes for those in a sorority or fraternity (n = 72) and on an NCAA sports team (n = 42) were too small to test for significance. No significance was found for BMI, sex, ethnicity, and calorie restricting or non-restricting respondents.

Qualitative Results

Thirty-two students provided qualitative responses on why they restricted calories before drinking. Five themes emerged from these responses: a) Increased ability to drink, b) prevented being sick, c) forgot to eat, d) was not hungry, and e) lacked money. The two most common responses as to why calories were restricted before drinking were to prevent being sick and to increase their ability to drink more alcohol. Students indicated that they "did not want to throw up" or "so that I would not feel sick with the consumption of alcohol and food." Students also shared that they did not eat prior to drinking "so the food would not take up the beer room," because of "not being able to drink as much," and because "beer lasts longer that way." Only one student indicated that the reason for restricting calories prior to drinking was to account for the extra caloric content of alcohol.

DISCUSSION

The popular media has insinuated that drunkorexia is enough of a problem to justify its own pseudomedical diagnosis. Our findings suggest that the incidence of full blown drunkorexia may not be as widespread as portrayed by the media, but we did find that 99 out of 692 first year college student drinkers engaged in disordered eating and reported restricting calories prior to consuming alcohol. The fact that 99 students in our sample are engaged in this behavior illustrates that refraining from caloric intake prior to drinking is a college health issue. In addition, results revealed that more than three-quarters of the freshman population reported drinking (the highest percentage drinking 6-9 days a month) with over half reporting binge drinking episodes.

College students have already been identified as an at-risk group to suffer from problems associated with alcohol use. Furthermore, among college students, freshman have been found to be more susceptible to negative alcohol related consequences such as blackouts, motor vehicle accidents, and unwanted sexual activity. To what extent does calorie restriction prior to alcohol consumption further contribute to alcohol related problems? Findings from this study indicated that 14% of first year college students are restricting calories on days of planned alcohol consumption, and those who restricted calories were more likely to participate in binge drinking. This is a particular health concern, because not eating prior to alcohol consumption increases alcohol's toxicity and the subsequent health consequences such as brain and organ damage. Alcohol is also known for its vitamin (e.g., B-vitamins) and nutrient leaching qualities. By replacing food calories with alcohol calories students are more likely to suffer from other health problems related to nutritional deficits. College students also need to be aware that alcohol alters the body's normal metabolic processes and its ability to regulate blood sugar levels. By drinking on an empty stomach, students are more likely to suffer serious health consequences from alcohol induced hypoglycemia including traumatic brain injuries such as memory lapses and blackouts. Students should be informed that alcohol does not just kill the extra brain cells used to store memories, but it also kills brains cells (neurons) that are responsible for future learning and cognitive abilities. Students should be well aware that drinking inhibits the storage and formation of new memories and reduces cognitive functioning. Though not significant and reflective of the sample, frequencies revealed that primarily female freshman restricted calories when they knew they were going to drink. Of those who restricted calories, some did so to avoid gaining weight which may indicate disordered eating behavior associated with drinking among this sample. Our findings are lower than previous research which has shown 30-50% of individuals with bulimia and 12-15% of those with anorexia abuse are dependent on alcohol (Dansky et al., 2000; O'Brien & Vincent, 2003; CASA, 2001). It is important to note that there does not have to be a clinical diagnosis of an eating disorder, and the pathology of disordered eating may actually be problematic but not severe (Cooley & Toray, 1996; Krahn et al, 2005; Anderson et al., 2006; Krahn et al., 1992). In addition, more females than males (close to 70%) restrict calories to feel the effects of the alcohol better. Interestingly, no association was found between body mass index (BMI) and alcohol consumption patterns. The sample size was too small to enable us to draw conclusions about other campus groups, such as students in Greek organizations or on athletic teams, and their associations with high-risk alcohol consumption and in restricting calories. Future studies may want to focus on these groups to better assess their engagement in this behavior.

Our findings confirm previous research by Baer et al. 1995 ; Bishop et al., 2005; Grekin & Sher, 2006; Weitzman et al., 2003 who have reported an increase in quantity and frequency of alcohol consumption among first year college students. Binge drinking among college freshman may be a negative coping behavior to deal with pressures from college life including academic pressure, financial stress, and stressors of new found independence.

More qualitative studies are needed to further assess among all college students, not just those in their first year, the reasons for restricting calories. This study did begin to shed some light in this area with respondents sharing that they did not want to get sick or vomit, or they wanted to be able to drink more alcohol, or that food prohibited them from feeling the effects of alcohol. Regardless of the reason for engaging in this behavior, alcohol prevention programs and campus-based education need to be aware that this behavior exists.

This study was implemented in the spring semester of the academic year when students may have had varied exposure to campus wellness efforts. It is also possible that students were drinking less and experiencing less stress leading to drinking during their second semester. Research suggests that students may encounter greater stress during their first semester due to being away from home for the first time, living in a new environment or home, and increased responsibility (Burke, Wallen, & Rager, 2008). If implemented again, it is recommended to assess the fall semester of new freshman to control for these issues.

Future studies should examine calorie restriction prior to drinking among all college students including other high-risk populations such as athletes and students in Greek organizations. Incoming freshman should be educated about the increased health risks associated with calorie restriction prior to alcohol consumption. Health professionals should also be prepared to address concerns and questions about drunkorexia. While the merits of using this term are questionable, the media publicity accompanying it does afford college health professionals a "moment of gestalt" to promote healthy eating and responsible drinking behaviors.

Results of this study reiterate the continuing problem of risky drinking habits among college freshman. There are effective alcohol interventions available such as the Brief Alcohol Screening and Intervention for College Students BASICS (Dimeff, Baei, Kivlahan, & Marlatt, 1999). BASICS draws heavily from both cognitive-behavioral skills training and Motivational Interviewing (MI). MI can be used as a student-centered behavior change intervention strategy and has been clinically proven to be an effective tool for managing resistance and ambivalence toward change. Motivational Interviewing is a flexible intervention approach that has strong health behavior change theoretical ties to many popular theories such as the Transtheoretical Model. In practice, MI focuses on personal needs and positive motivations and has been shown to be particularly effective when students are in the precontemplative and contemplative stages of change (Rollnick, Miller, & Butler; 2008). The results of this study suggest a possible need for modifications to existing alcohol education and prevention programs to include important health information about the dangers of calorie restriction and drunkorexia.

Any correspondence regarding this article should be addressed to: Sloane C. Burke, Ph.D., CHES, Assistant Professor, Department of Health Education & Promotion, Carol Belk Building #3203, East Carolina University, Greenville, NC 27858, Office: (252) 737-1934; Fax: (252) 323-1285; Email: burkes@ecu.edu.

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Sloane C. Burke, Ph.D., Jennifer Cremeens, Ph.D., MSPH and Karen Vail-Smith

East Carolina University

and

Conrad Woolsey

Oklahoma State University
TABLE 1
Demographics (N = 692)

Characteristics

Age
  18                       44% (n = 304)
  19                       55% (n = 382)
  20                         1%  (n=6)
Gender
  Female                   68% (n = 473)
  Male                     31% (n = 217)
Ethnicity
  Caucasian                87% (n = 584)
  African American         8%  (n = 63)
  Hispanic/Latino          1%  (n = 11)
  Asian Pacific Islander   2%  (n = 19)
  Other                    2%  (n = 15)

TABLE 2
Alcohol use patterns among first year student drinkers

Frequency      Current Use   Binge Drinking
                 (N=692)        (N=588)

1-2 days           23%            17%
3-5 days           25%            20%
6-9 days           26%            25%
10-19 days         21%            22%
20+ days           5%             16%

TABLE 3
Frequency of alcohol use among first year students by ethnicity
and gender. *

                       1-2    3-5    6-9    10-19   20+
                       days   days   days   days    days

Ethnicity (%)
  Caucasians            21     25     27     22      5
  African Americans     49     25     13     13      0

Gender
  Male                  21     19     30     24      7
  Female                24     28     24     20      4

* Results limited to current drinkers.

** Latino, Asian Pacific Islander, American
Indian were too small to report.

TABLE 4
Alcohol use patterns among first year students reporting restriction
of calories on days they knew they were going to drink.

Frequency         Current Drinkers               Binge Drinkers
(days)
            Restrict     Non-       %     Restrict     Non
                       restrict   Diff.              restrict   Diff.

1-2           11%        25%       -14      10%        18%       -8
3-5           23%        26%       -3       13%        22%       -9
6-9           25%        26%       -1       23%        26%       -3
10-19         30%        20%       10       33%        20%       13
20+           11%         3%        8       21%        13%        8
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