Drunkorexia: Disordered eating behaviors and risky alcohol consumption among adolescents

Unification of the food and alcohol disturbance literature: A systematic review

Food and alcohol disturbance (FAD) reflects the functional relationship between disordered eating and alcohol use. There are two motivations underlying FAD - to enhance the effects of alcohol and/or to compensate for alcohol-related calories. Yet, most FAD studies have failed to adequately measure the motives underlying these behaviors, leading to inconsistent and imprecise findings. The aim of the current systematic review was to thematically consolidate FAD research findings by motive, identify limitations of the existing literature, and highlight next steps for FAD researchers. Eighty-one publications, presenting data from 38,536 participants, were included in the current review. Prevalence rates for the caloric compensation and alcohol enhancement motives range from 5.6% - 88.7% and 4.7% - 81.7%, respectively. Alcohol use and disordered eating were the primary correlates of FAD for both motives, and alcohol-related consequences were positively associated with both FAD motives cross-sectionally. Major limitations of the literature include inconsistent operationalization and imprecise measurement of FAD. Primary recommendations include adopting the terminology of and operationalization of FAD presented here, ensuring attention to FAD motive in developing and testing research questions, and moving beyond cross-sectional studies. Findings from this review can be used to contribute to more rigorous and unified FAD research.

Social Anxiety and Drunkorexia Behaviors among Adolescents and Young Adults: The Moderating Role of Resilience

Background: Existing evidence showed that social anxiety represents a significant factor in eating disorders. However, to our knowledge, no prior study has examined the association between social anxiety and drunkorexia behaviors. Objectives: The present study aimed at exploring the relationship between social anxiety and drunkorexia behaviors, and investigating resilience as a moderator of this relationship. Participants were 333 adolescents and young adults aged 15-24 years (Mage=18.26, SDage= 1.55; 66% females) who completed an online survey. Results: The results indicated that drunkorexia behaviors were positively correlated to three dimensions of social anxiety; however, only fear of negative evaluation had a significant predictive effect. In addition, resilience only moderated the relationship between fear of negative evaluation and drunkorexia behaviors, such that youths reporting high fear of negative evaluation and low resilience showed greater drunkorexia behaviors, whereas youths reporting high resilience showed no correlation between fear of negative evaluation and drunkorexia behaviors. Conclusions: The findings highlight the importance of drunkorexia interventions and preventive measures aimed at strengthening youths' resilience and ability to effectively manage stress and social anxiety (i.e., fear of negative evaluation).

Food and Alcohol Disturbance in High School Adolescents: Prevalence, Characteristics and Association with Problem Drinking and Eating Disorders

Food and alcohol disturbance (FAD) is characterized by the association of alcohol use with compensatory behaviors such as restricting calories, physical activity and purging. Despite not being part of the current nosography, research has grown in the past 10 years, mostly on college students' samples. In this study, we aim to describe the prevalence, characteristics and association of FAD with problem drinking (PD) and eating disorder risk (EDR) in a sample of Italian high school students. Participants were 900 high school students (53.6% males; mean age = 16.22) that were administered standardized questionnaires. Students who screened positive for PD, EDR and both were, respectively, 17.3%, 5.9% and 1.3%. Approximately one out four students reported FAD behaviors, mostly to control weight and by restricting calories, with higher prevalence and severity among those who screened positive for PD. Purging behaviors were rare overall (15.5%), but significantly more frequent in participants who screened positive for both PD and EDR (41.7%). FAD was more strongly associated with alcohol use severity than with ED symptom severity across all subgroups. FAD behaviors appear to be common in the Italian high school population and more strongly associated with PD. Future studies should investigate FAD's impact on adolescents' functioning and possible early interventions.

French validation of the Compensatory Eating and Behaviors in Response to Alcohol Consumption Scale (CEBRACS) in a university student sample

PURPOSE

Food and Alcohol Disturbance (FAD) is characterized by the combination of problematic alcohol use and eating disorder symptoms to offset caloric intake associated with alcohol drinking and/or to enhance intoxication. The Compensatory Eating and Behaviors in Response to Alcohol Consumption Scale (CEBRACS) is a proven tool for measuring FAD, validated in English and Italian populations but never in the French population. The present study aims at validating a French version of the CEBRACS in a representative sample of university students and to determine its validity and reliability.

METHODS

2267 university students completed the CEBRACS and measures of eating disorders, alcohol consumption and exercise.

RESULTS

An exploratory factor analysis revealed a 4-factor structure: enhancement of the effects of alcohol, dietary restraint and exercise, purging and vomiting and extreme fasting. The internal consistency for these subscales ranged from good to excellent. Correlations between the CEBRACS and eating disorders, alcohol and exercise measures revealed a good concurrent validity. No gender differences were found in the CEBRACS scores. Participants with a CEBRACS total score > 21 points were at higher risk for developing eating disorders and alcohol-related problems.

CONCLUSIONS

These findings highlight the reliability and validity of the French version of the CEBRACS. The distinct factors identified in the CEBRACS allow to distinguish between participants with different motives for engaging FAD behaviour and thus to prevent future development of eating and/or alcohol use disorders. The CEBRACS seems to be a relevant scale to capture FAD behaviors and thus to prevent negative and deleterious consequences.

LEVEL OF EVIDENCE

Level III, evidence obtained from well-designed cohort or case-control analytic studies.

The Psychological Impact of the COVID-19 Pandemic on Alcohol Abuse and Drunkorexia Behaviors in Young Adults

The COVID-19 outbreak negatively affected young adults' psychological well-being, increasing their stress levels and symptoms of anxiety and depression, and potentially triggering health-risk behaviors. The present study was aimed at investigating the psychological impact of the COVID-19 pandemic on alcohol abuse and drunkorexia behaviors among young adults living in Italy. Participants were 370 emerging adults (63% women, 37% men; Mage = 21.00, SDage = 2.96, range: 18-30) who were recruited through an online survey between November 2021 and March 2022. Participants completed measures of alcohol abuse, drunkorexia behaviors, negative life experiences, and post-traumatic symptoms related to the COVID-19 outbreak. The results showed that the emotional impact and negative life experiences associated with the pandemic predicted both alcohol abuse and drunkorexia behaviors, albeit in different ways. Specifically, the number of negative life experiences during the pandemic and the tendency to avoid COVID-19-related negative thoughts positively predicted alcohol abuse; and the presence of intrusive thoughts associated with the pandemic significantly predicted the frequency of drunkorexia behaviors. Implications for research and clinical practice are discussed.

Eating disorder risk in rural US adolescents: What do we know and where do we go?

Adolescence is a vulnerable period for the development of eating disorders, but there are disparities in eating disorder risk among adolescents. One population that may be at increased risk but is vastly understudied, is adolescents residing in rural regions within the United States. Rural communities face many mental and physical health disparities; however, the literature on rural adolescent eating disorder risk is nearly nonexistent. In this paper we summarize the scant literature on disordered eating and eating disorder risk and prevalence among rural US adolescents. We also detail eating disorder risk factors that may have unique influence in this population, including socioeconomic status, food insecurity, healthcare access, body image, and weight stigma. Given the presence of numerous eating disorder risk factors, we speculate that rural adolescents may be a particularly vulnerable population for eating disorders and we propose critical next steps in research for understanding eating disorder risk among the understudied population of rural adolescents. PUBLIC SIGNIFICANCE: Rural adolescents may be at increased risk for eating disorders due to disproportionate burden of known risk factors, though this relationship remains understudied. We present a summary of the literature on prevalence and unique risk factors, proposing that this may be a high-risk population. We detail next steps for research to understand eating disorder risk in this population to inform future prevention, identification, and treatment efforts needed in this community.

An integrative model as a step toward increasing the awareness of eating disorders in the general population

Eating disorders (EDs) represent a contradictory chapter of clinical psychiatry, i.e., although they are associated with significant prevalence and risks in the long term (including vital risk, especially for anorexia nervosa), the therapeutic resources are minimal and based on low-quality data. Another contradiction arose in the last few decades, i.e., a variety of new EDs have been described, either by clinicians or signaled by mass media, but their systematic exploration is progressing very slowly. Entities like "food addiction," "orthorexia nervosa," or "emotional eating disorder" still require intensive exploration in order to find the most accurate diagnostic instruments, diagnosis criteria, prevalence data, vulnerability factors, and therapeutic approaches. This article is focused on integrating into a comprehensive model a variety of EDs not specified or loosely defined by the current international classifications of psychiatric disorders. This framework is intended as an instrument for stimulating clinical and epidemiological research, with potential favorable consequences for therapeutic research. The dimensional model suggested here includes four main categories that accommodate the already recognized EDs (i.e., anorexia nervosa, bulimia nervosa, and binge eating disorder) as well as ten EDs that still need intensive research to find their clinical and pathophysiological characteristics. More good-quality studies are urgently required regarding this topic, based on the mental and physical negative impact these EDs may have in the short and long term, especially in vulnerable populations (e.g., pregnant women, athletes, adolescents, etc.).

The Relationship between Binge Drinking and Binge Eating in Adolescence and Youth: A Systematic Review and Meta-Analysis

Adolescence and youth are critical periods in which alcohol consumption is usually initiated, especially in the form of binge drinking. In recent years, it is increasingly common to find adolescents and young people who also present binge behaviors towards unhealthy food with the aim of alleviating their anxiety (emotional eating) and/or because of impulsive personality. Despite the social and health relevance of this issue, it remains scarcely studied and more preventive research needs to be developed. Our meta-analysis study aimed to evaluate the relationship and co-occurrence of both binge behaviors during adolescence and young adulthood to clarify the link between binge drinking and eating. Selective literature search on different online databases was performed. We identified discrete but significant results regarding the direct association between binge drinking and binge eating in correlation coefficients and odds ratio. Future research should focus on the common psychological background and motives behind these problematic behaviors owing to their clinical implications for effective prevention and treatment.

Differences between preemptive and non-preemptive physical activity among 'drunkorexia'-positive college students

Objective: 'Drunkorexia' is characterized by compensating for alcohol-related calories using physical activity (PA). Drunkorexia is common on college campuses but little is known about the PA behaviors within the drunkorexia paradigm. Methods: First-year college students living on campus completed an online survey collecting drunkorexia, PA, and alcohol consumption data. A total of 127 participants reported engaging in drunkorexia behaviors. Results: Fifty-three participants were classified as preemptively physically active (e.g., PA and drink on Tuesday) compared to 74 as non-preemptively physically active. Preemptively physically active participants consumed more alcohol on Fridays and Saturdays than those non-preemptively physically active. Preemptively physically active participants engaged in significantly greater amounts PA. Females accounted for all significant differences between groups. Discussion: Among drunkorexia-positive participants, many made preemptive efforts to control their calories before consuming alcohol, which may predispose them to higher incidences of adverse outcomes such as alcohol poisoning, unwanted sexual advances, and death.

Relationship between college lifestyle variables, eating disorder education, and eating disorder risk

Objective: This study examined relationships between eating disorder risk (EDR), lifestyle variables (e.g., exposure to healthy eating media), and differences among male and female college students. Participants: College students (N = 323) completed survey questionnaires (Fall, 2016). Fifty-three participants retook the survey at a later time. Methods: Participants completed a survey measuring EDR using EDI-3 subscales and 10 college lifestyle variables. Female and male EDR and Time 1 and Time 2 EDR were compared. Relationships between EDR and college life-style variables were examined. Results: Exercise, fewer daily meals, less face-to-face interactions, more digital interactions, less exposure to healthy eating media, and having conversations about body image were associated with EDR risk. Male college students showed an increase in EDR over time. Conclusions: Several lifestyle factors predicted EDR in college females and males. These lifestyle factors are modifiable and may be addressed by colleges during orientation and within the campus environment.

"… because I'm so drunk at the time, the last thing I'm going to think about is calories": Strengthening the argument for Drunkorexia as a food and alcohol disturbance, evidence from a qualitative study

Objectives

Drunkorexia are inappropriate compensatory behaviours in response to alcohol consumption (restricting food intake, excessive exercise, and purging). Past (predominantly quantitative) research shows that Drunkorexia is prevalent in 18–26‐year‐olds, and has significant negative health‐related consequences. There is a debate whether Drunkorexia constitutes an eating or substance disorder, or a Food and Alcohol Disturbance (FAD). To further explore this, and understand underlying motivators, this study utilized qualitative methods.

Design

Qualitative interviews with ten participants (aged 18–26).

Methods

Interviews were analysed with Thematic Analysis.

Results

Three themes were developed: (1) Appearance concerns as motivators, (2) Drunkorexia behaviours to get value for money, and (3) “It’s just a pattern… something I’ve always done”: Drunkorexia as a routine. Results show that Drunkorexia is driven by appearance‐related concerns, such as, wanting to look better/slimmer, engaged in, in relation to an event, such as going out drinking, and carried out despite negative health‐related consequences. However, disregard for compensatory behaviours once drunk was also described, culminating in the consumption of high‐calorie food. This suggests that Drunkorexia is not a persistent pattern of maladaptive behaviour as found in eating or substance use disorders. Wanting value for money (i.e., feeling the maximum intoxication) was described as another reason for Drunkorexia engagement; thus showing that participants consider compensatory behaviours part of their routine of going out drinking.

Conclusions

These result support the view of Drunkorexia as a FAD, rather than an eating or substance use disorder, and show that 18–26‐year‐olds are an at‐risk group for Drunkorexia and its negative health‐related consequences.

Food and alcohol disturbance among young adults during the COVID-19 lockdown in Italy: risk and protective factors

PURPOSE

The COVID-19 lockdown measures have had a significant impact on risk behaviors as alcohol use and disordered eating. However, little is known about a serious health-risk-behavior named "food and alcohol disturbance" (FAD), characterized by engaging in dysfunctional eating on days of planned alcohol consumption. The aim of the present study was to investigate potential factors that may have put young adults at risk or protected against FAD during the COVID-19 lockdown.

METHODS

A sample of 447 young adults (280 females, 167 males; range 18-26) completed an online survey during the country's nationwide lockdown composed of self-reported measures assessing FAD behaviors, alcohol consumption, compensatory behaviors, eating and weight concerns, social support, emotion regulation strategies, and living arrangement.

RESULTS

Our findings showed that FAD was significantly and positively correlated to alcohol consumption, use of laxatives, self-induced vomiting, eating and weight concerns, and expressive suppression, and negatively correlated to social support and living with family. Hierarchical regression analysis revealed that alcohol consumption, eating concern, and expression suppression positively predicted FAD, while social support and living with family were negative predictors.

CONCLUSIONS

Our results suggest that during the COVID-19 lockdown, preoccupation with eating and the use of expressive suppression may have increased vulnerability to FAD; conversely, perceived social support and living with family may have been a source of protection against this dysfunctional behavior.

LEVEL OF EVIDENCE

Level V, descriptive study.

An examination of the role of social comparison orientation and social norms in drunkorexia engagement

Drunkorexia is a behavior pattern marked by calorie restriction and/or compensation in relation to alcohol consumption. The aim of the present study was to examine the role of social norms (descriptive, injunctive) and social comparison orientation (SCO; global, alcohol-specific, eating disorder-related) in drunkorexia engagement. Specifically, our research aimed to examine a possible interaction between norms and SCO; we hypothesized that the relationship between social norms and drunkorexia would be moderated by SCO in that the relationship would be stronger among those elevated on SCO. Data were collected from an undergraduate sample (n = 501); participants completed the consent form and questions/questionnaires via Qualtrics. The results indicated that the predictor variables examined were correlated with overall drunkorexia engagement. In the regression models, in terms of main effects, eating disorder-related SCO emerged as the strongest predictor of the drunkorexia dimensions as well as overall drunkorexia engagement. Descriptive norms emerged as the second strongest predictor in the models. Only one interaction was identified; eating disorder-related SCO moderated the relationship between descriptive norms and the bulimia drunkorexia dimension. The simple slopes analysis indicated that descriptive norms was positively predictive of the bulimia drunkorexia dimension only among individuals with average or elevated eating disorder-related SCO. Social comparisons made regarding one's body, eating, or exercise (eating disorder-related) and social norms are potentially important targets for drunkorexia prevention and/or intervention programs. Further research is needed to better understand risk factors for drunkorexia engagement in the college population.

Drunkorexia: is it really "just" a university lifestyle choice?

PURPOSE

The current study investigated the prevalence of compensatory behaviours (caloric restriction, increased exercise and bulimic tendencies) in response to alcohol consumption (also known as Drunkorexia) in students, non-students and previous students, as well as beginning to understand the presence of possible predictors of these behaviours (body esteem, sensation seeking).

METHODS

A volunteer sample of students, non-students and previous students (n = 95) completed the Compensatory Eating and Behaviours in Response to Alcohol Consumption Scale, a questionnaire which measures overall Drunkorexia engagement. The participants also completed the Body Esteem Scale for Adolescents and Adults Scale (BESAA) and the Brief Sensation Seeking Scale (BSSS) to investigate predictors of Drunkorexia.

RESULTS

The results indicated that there was no significant difference in Drunkorexia engagement and behaviours between students, non-students and previous students. It was also found that both low body esteem and high sensation seeking tendencies were significant predictors of Drunkorexia; specifically, the appearance esteem factor of the BESAA and the disinhibition factor of the BSSS.

CONCLUSIONS

Findings suggest that Drunkorexia is also present outside of student populations, and therefore, future interventions and research should include non-students in samples. In addition, findings support the idea that Drunkorexia cannot be classified solely as an eating disorder or a substance abuse disorder. As a result of this, further research should be conducted to fully understand why this complex behaviour exists.

EVIDENCE-BASED MEDICINE LEVEL

III (Evidence obtained from case-control analytic study).

Exploring the association between psychological distress and drunkorexia behaviors in non-clinical adolescents: the moderating role of emotional dysregulation

PURPOSE

Although drunkorexia seems to represent a new form of eating disorder, it shares several features with traditional eating disorders. However, very little is known about the association between drunkorexia and a widely studied correlate of eating disorders, such as psychological distress and about mechanisms underlying this association. The present study aimed to investigate the relation between symptoms of anxiety and depression and drunkorexia, and to explore the role of emotional dysregulation as moderator of this relationship.

METHODS

The sample was composed of 402 adolescents (222 females, 180 males; range 15-21) who completed self-reported measures: Drunkorexia Motives and Behaviors Scale, which assesses different behaviors and motivations associated with drunkorexia, Emotional dysregulation scale from the Eating Disorder Inventory-3, reflecting difficulties regulating emotions, and Anxiety and Depression scales from the Symptom CheckList-90 Revised, assessing general signs of anxious and depressive symptoms.

RESULTS

Anxious symptomatology resulted a significant statistical predictor of drunkorexia behaviors (β = .28, p = .001). Furthermore, emotional dysregulation moderated the relation between anxiety and drunkorexia; specifically, a positive relation was found both at medium levels (β = .22, p = .007) and at higher levels of emotional dysregulation (β = .38, p = .000), whereas at lower levels of emotional dysregulation, this association became nonsignificant.

CONCLUSIONS

Findings suggest that adolescents who experience both elevated anxiety and emotional dysregulation may be more likely to turn to drunkorexia to reduce their unregulated negative affect in the absence of more adaptive emotion regulation strategies. Implications for intervention and prevention programs are discussed.

LEVEL OF EVIDENCE

Level V, descriptive study.

Body image perception, smoking, alcohol use, indoor tanning, and disordered eating in young and middle-aged adults: findings from a large population-based Swedish study

BACKGROUND

Body image concerns may give rise to a multitude of risk behaviors, such as unhealthy weight control practices, disordered eating behaviors (e.g., compensatory purging or preoccupation with food), smoking, excessive alcohol intake, or sunbed use. However, the distribution of these risk behaviors across adulthood has rarely been studied.

METHODS

The aim of this study was to explore health risk behaviors as correlates of body image perception in a randomly selected study population of 30,245 individuals aged 30-66 in Stockholm, Sweden, utilizing data from the Stockholm Public Health Cohort. Bivariate correlations were explored and a hierarchic binary logistic regression analysis was performed.

RESULTS

The prevalence of body image discrepancy was higher among smokers and respondents displaying disordered eating behaviors. In contrast, alcohol and sunbed use were inversely correlated to body image discrepancy. Body mass index was the substantially strongest explanatory factor behind the observed variance in body image discrepancy, followed by loss-of-control eating. Notably, no major gender differences in body image perception were detected. Some unexpected patterns of association between variables other than body image perception, such as those between smoking, alcohol use, and sunbed use, were seen.

CONCLUSIONS

Overall, the patterns differ substantially from what has previously been found in adolescent and young adult samples, indicating that the synergy and aggregation of risk behaviors observed among younger individuals may not apply to adults aged 30-66.

Drunkorexia: An Examination of the Role of Theory of Mind and Emotional Awareness among Adolescents

This study aimed to investigate Theory of Mind (ToM) and emotional awareness in drunkorexia, an emerging behavior characterized by calorie restriction when drinking alcohol is planned. A sample of 246 adolescents (148 females, 98 males; range 17-20) completed self-reported measures assessing drunkorexia, ToM and lack of emotional awareness. Drunkorexia was negatively correlated with ToM abilities, with reading neutral emotions, and positively with lack of emotional awareness. ToM and lack of emotional awareness were also found to predict drunkorexia. Findings highlighted that adolescents who engage in drunkorexia may have difficulties in reading others' mental states and being aware of their emotions.

Examining the role of body esteem and sensation seeking in drunkorexia behaviors

PURPOSE

The purpose of the present study was to examine the role of body esteem (BE), sensation seeking (SS), and their interaction in drunkorexia, a behavior pattern marked by calorie restriction/compensation in the context of alcohol consumption. While previous research on drunkorexia has focused on a range of variables, the present study examined two novel variables and their potential interaction: body esteem (weight, appearance) and sensation seeking.

METHODS

A sample of college students (n =488) completed the Body Esteem Scale for Adolescents and Adults, the Brief Sensation Seeking Scale, and the Compensatory Eating and Behaviors in Response to Alcohol Consumption Scale, which measures overall drunkorexia engagement as well as four dimensions: alcohol effects, bulimia, dietary restraint and exercise, and restriction.

RESULTS

Moderated linear regression analyses indicated that SS and BE (weight, appearance) did not interact in predicting drunkorexia. Rather, only main effects were observed; SS, weight esteem (WE), and appearance esteem (AE) were significant in predicting overall drunkorexia engagement. In terms of the drunkorexia dimensions, AE was a significant predictor in the alcohol effects, dietary restraint and exercise, and restriction models. WE was significant in the dietary restraint and exercise model as well as the restriction model. SS was a significant predictor across all drunkorexia dimensions.

CONCLUSIONS

Our findings suggest that both elevated SS and lowered BE are associated with drunkorexia engagement. Implications for practice are discussed. Drunkorexia is a complex and multifaceted behavior pattern; therefore, further research is needed in this area of study.

LEVEL OF EVIDENCE

Level V (descriptive study).

Psychological characteristics and eating attitudes in adolescents with drunkorexia behavior: an exploratory study

PURPOSE

Drunkorexia represents an emerging phenomenon that is still understudied especially among adolescents. The present study aimed to investigate the relation between drunkorexia and psychological characteristics relevant and commonly associated with existing forms of eating disorders.

METHODS

The sample was composed of 849 adolescents (513 boys, 334 girls, 2 unknown; range 14-22) who completed a survey composed of Compensatory Eating and Behaviors in Response to Alcohol Consumption Scale and Psychological scales of the Eating Disorders Inventory-3.

RESULTS

Our findings highlighted that drunkorexia was associated with low self-esteem, personal alienation, interoceptive deficits, emotional dysregulation, and asceticism. Hierarchical multiple regression analysis indicated that difficulties with emotion regulation and ascetic tendencies were significant predictors of drunkorexia among adolescents.

CONCLUSIONS

Our findings suggest the importance for programs preventing drunkorexia to be focused on training adolescents in using more adaptive strategies to manage emotions and accepting both emotional and physical signals without feeling guilty or threatened.

LEVEL OF EVIDENCE

Level V, descriptive study.