The problem exists, now what do we do?
The term, drunkorexia is not new in adolescent and college health literature. Drunkorexia is an idiomatic term coined by the media in 2008.1 Because the word is not readily recognized by the medical community and does not appear in the Diagnostic and Statistical Manual of Mental Disorders (DSM) V, controversy exists over its use.2 Drunkorexia is used in the literature (both scholarly and consumer publications) generally to describe a trend whereby a person restricts caloric intake before alcohol ingestion or in anticipation of alcohol ingestion. The motivation may be to avoid weight gain and/or to get intoxicated faster.3 Populations at greatest risk include college women.4 The literature recognizes the co-morbidity of alcohol abuse and disordered eating.3,5,6 A third correlational relationship has also been found with physical activity.1
Recent studies have examined the relationship of these variables in college students.1,3,4,6,7 Wilkerson and colleagues identified at-risk groups as Greek-affiliated students and those with weight loss intentions as behaviors of weight-conscious drinkers (BWCD).8 These studies were conducted at large universities, and the results may not be generalizable to a small Jesuit-affiliated university in the Northeast. Strategies employed to design interventions may be used as a guide, but knowing factors associated with the specific population on a particular campus may foster the success of future interventions.
What is known is that students on this relatively small campus of approximately 4000 undergraduates do consume alcohol and do engage in binge drinking behaviors. Programming efforts in this realm were directed throughout the past 2 to 3 decades by the Center for Health, Education, and Wellness (CHEW) and are addressed in first-year seminars and courses incorporating alcohol education. Other behaviors related to alcohol consumption have not been as clearly defined or investigated.
As a family nurse practitioner faculty member, my clinical practice in college health on campus includes consultation with the counseling center, in particular for students presenting with disordered eating. A multi-disciplinary approach generally is required, including a nutritionist in these instances to assist the student in maintaining their health while at school and not engage in risky eating behaviors. In the past few years, anecdotal reports of restricting calories prior to consuming alcohol were received during encounters with students. One student for whom an interdisciplinary approach was initiated, jogged several miles per day, restricted food intake, and drank nearly a fifth of liquor several days per week. Although the latter example is not generally the norm, the situation heightened awareness of extreme behaviors in relation to exercise, eating, and alcohol consumption for the healthcare providers.
To gain more information about the prevalence of intentionally restricting calories and/or increasing exercise before alcohol consumption or in anticipation of alcohol consumption, a research proposal was submitted in early 2016 to University’s Internal Review Board (IRB) and was subsequently approved. The purpose of the study was to determine the prevalence of behaviors associated with drunkorexia on campus to assist in the development of
appropriate programming and interventions to deter the unhealthy behavior in the university students.
Another objective of the study was to determine if the primary motivating factor to engage in altered eating and exercise behaviors before drinking alcohol was to avoid weight gain or to feel the effects of alcohol faster.
The intended sample was a cross-section of undergraduate students with a sample size of at least 150. Two graduate family nurse practitioner (FNP), nursing students, collected the data so as not to introduce bias as the primary researcher is known to some students as a faculty member and/or as a family nurse practitioner on campus. Data was collected on 2 dates, one in April and one in May 2016 by the 2 graduate student assistants in the common area of the student center. A university card swipe system from IT was used to record student participant identification numbers (attendance tracker) to be eligible for the incentive drawing for one of (2) $100 Visa gift cards.
The survey questions were uploaded on 2 android tablets. Data was retrieved in a file format by the student health service office manager and was only reviewed by the principal investigator (PI). Attendance records were only reviewed by the PI, and only the winners of the incentive were known to her. Frequencies and correlations of responses were analyzed. The time commitment for each student was 5-10 minutes.
The respondents were able to submit their name voluntarily at the end of the short survey to be entered into an incentive drawing for one of (2) $100 Visa gift cards. The survey questions were as follows:
- Do you intentionally restrict your calorie intake prior to consuming alcohol or in anticipation of consuming alcohol?
- Do you intentionally increase exercise before consuming alcohol or in anticipation of consuming alcohol?
- Do you intentionally restrict your calorie intake and/or increase exercise before consuming alcohol or in anticipation of consuming alcohol to prevent weight gain?
- Do you intentionally restrict your calorie intake and/or increase exercise before consuming alcohol or in anticipation of consuming alcohol to get drunk faster.
Of the 158 respondents, 40 males and 118 females, 21.5% indicated they intentionally restricted caloric intake, and 32.3% indicated they intentionally increased exercise before consuming alcohol or in anticipation of consuming alcohol. Weight gain (29.1%) was a greater motivating factor than to get drunk faster (10.8%). The sample participants were fairly evenly distributed among classes (freshman, sophomore, junior, senior) but the 19 and 20-year-olds were the most likely to respond “yes” to the behaviors. Although 74.7% of the participants identified as female, 20% (8) of the male participants responded affirmatively to intentionally restricting calories and 17.5% (7) males responded affirmatively to intentionally increasing exercise. Seven males indicated weight gain as a motivating factor and only five males reported to get drunk faster as a motivating factor. Refer to Tables 1 and 2.
The graduate assistant data collectors reported anecdotally that most students did not know the term, drunkorexia, or were not fully aware of the behaviors associated with the word. One freshman male was very surprised when he started the survey and remarked he never realized he engages in the specific behaviors before drinking alcohol.
Based on these specific results, this researcher met with the directors of CHEW and Student Health Services in August 2016 to discuss methods of disseminating the information to students in a meaningful way. The discussion centered on groups of interest such as athletes and the topic was to be introduced to the athletic department by the CHEW director at their next meeting after the semester began. It was also decided to enlist the peer educators on campus. Therefore, the primary researcher and the 2 graduate assistants met with 15 peer educators in October 2016 to educate them about drunkorexia and develop methods to disseminate the information. Most of the peer educators were unaware of the behaviors and the possible detrimental long-term effects of engaging in caloric restriction and extended exercising prior to consuming large quantities of alcohol. All agreed that the student body would benefit from raising awareness during the alcohol education presentations and in the “wellness wagon” sponsored by the peer educators in Spring 2017 semester. Included in the information would be where to seek help on campus.
Possible collaboration with Counseling Center and Student Health Services and the researcher regarding programming on a Body Image/Healthy Habit group was also discussed with the respective directors. Although at this time, no definitive plans are made for group sessions, dissemination of the topic was begun.
The results are only generalizable to the population at large of the university at which data was collected. However, it is essential to recognize that one of the student objectives of Healthy Campus 2020, is to, ‘Increase the proportion of students who report receiving information on alcohol and other drug use from their institution.’9 By disseminating the information of the study, hopefully, students will be motivated to identify ‘drunkorexia’ behaviors associated with alcohol use and motivated to change such behaviors. Knowledge of campus resources is an integral part of developing this motivation.
It is not enough to conduct studies and publish statistics but is imperative to disseminate information and educate about potentially harmful behaviors in college students. The topic of drunkorexia and possible detrimental consequences such as blackouts, possible injury and/or sexual assault plus physical well-being pervade the literature. Nurse Practitioners and other healthcare providers in primary care servicing young adults and college students need to be aware and alert to male and female patients presenting with symptomatology of caloric restriction and exercising prior to drinking alcohol. Astute history taking skills with sensitivity to disordered eating issues are necessary to elicit potentially detrimental health behaviors. A trusting relationship between college health care personnel and students is needed to assist in managing interventions. Appropriate referrals and consultations may be made once a student at risk is identified and an interdisciplinary interventional approach has begun.
- Barry AE, Piazza-Gardner AK. Drunkorexia: Understanding the co-occurrence of alcohol consumption and eating/exercise weight management behaviors. J Am Coll Health, 2012;60:236-243.
- Piazza-Gardner AK, Barry AE. Appropriate terminology for the alcohol, eating, and physical activity relationship. J Am Coll Health, 2013;61:311-313.
- Roosen KM, Mills JS. Exploring the motives and mental health correlates of intentional food restriction prior to alcohol use in university students. J Health Psychology, 2015;20:875-786.
- Eisenberg MH, Fitz CC. “Drunkorexia”: Exploring the who and why of a disturbing trend in college students’ eating and drinking behaviors. J Am Coll Health, 2014;62:570-577.
- Barry AE, Whiteman S, Piazza-Gardner AK, Jensen AC. Gender differences in the associations in body mass index, weight loss, exercise, and drinking among college students. J Am Coll Health, 2013;61:407-413.
- Rush CC, Curry JF, Looney JG. Alcohol expectancies and drinking behaviors among college students and disordered eating. J Am Coll Health. 2015(December 23); Epub ahead of print, PMID: 26700865.
- Burke SC, Cremeens J, Vail-Smith K, & Woolsey C. Drunkorexia: Calorie restriction prior to alcohol consumption among college freshman. J Alcohol and Drug Ed. 2010;54:17-34.
- Wilkerson, AH, Hackman, CL, Rush, SE, Usdan, SL, Smith, CS. “Drunkorexia”: Understanding eating and physical activity behaviors of weight-conscious drinkers in a sample of college students. J Am Coll Health, 2017;65:492-501.
- American College Health Association. 2012 Healthy Campus 2020. Available at: https://www.ACHA.org/HealthyCampus2020. Accessed February 14, 2018.