Drunkorexia: Calorie restriction prior to alcohol consumption among college freshman

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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August, 2010
Volume 54(2), 17-35.
Drunkorexia: Calorie Restriction Prior to
Alcohol Consumption among College Freshman
Sloane C. Burke1, Jennifer Cremeens1, Karen Vail-Smith1, Conrad L. Woolsey2
East Carolina University1
Oklahoma State University2
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.
INTRODUCTION
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 which 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).

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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 who reported drinking on 10 or more occasions
in the past 30 days increased (18.1% to 22.6%) and student 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, only constituted 19% of the

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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 demonstrate 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, with this being a time that 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: First-year
students are faced with heightened academic rigor, 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

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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 which 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,” at 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 such 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

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disorders with approximately 35% of people with alcohol or drug dependency also being
identified to have 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, which 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 who 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 an
increased risk to suffer from serious alcohol related consequences due to differences

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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 as to whether one is male or female, drinking on an empty stomach allows
alcohol to get into the body faster, which raises blood alcohol levels higher 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). Drunkorexia joins 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
such 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

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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: 1) Do freshman students who have consumed alcohol in the past
30 days restrict their caloric intake on the days they choose to drink? 2) Do freshman
students who have binge drank in the past 30 days restrict their caloric intake on the days
they choose to drink? 3) Does race/ethnicity impact one’s behavior to restrict caloric
intake on days when one chooses to drink? 4) Does gender impact one’s behavior to
restrict caloric intake on days when one chooses to drink? 5) 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 by students outside of
class for extra credit at their convenience. Of the 2,005 students enrolled, 1,349 (67.3%)
completed the online survey. Since this research focused on first-year freshmen who
used alcohol, results included only the 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

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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 re-test
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
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 at all with 15% of those sampled working
with pay 10 hours or more a week.
Table 1: Demographics (N = 692)
Characteristics
Age
18
44% (n = 304)
19
55% (n = 382)
20
1% (n = 6)

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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)
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. The majority of 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 in the past 30 days (See Table 2). The mean number of days
binge drinking occurred was 3.11 (SD = 1.76).
Table 2: Alcohol use patterns among first year student drinkers
Frequency
Current Use
(N=692)
Binge Drinking
(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%
Chi-squared analyses revealed significant differences between males and females
(x2= 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 (x2=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 who reported drinking was higher than

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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).
Table 3: Frequency of alcohol use among first-year students by ethnicity and gender. *
1 - 2
days
3-5
days
6-9
days
10-19
days
20+
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.
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
Frequency
(days)
Current Drinkers
Binge Drinkers
Restrict
Non-
restrict
% Diff.
Restrict
Non-
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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in such behaviors (x2=47.66, p<.01; See Table 4). The majority of students who 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
(x2=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 who 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 size for those in a sorority
or fraternity (n = 72) and being on an NCAA sports team (n = 42) were both 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 regarding why they restricted
calories before drinking. Five themes emerged from these responses: 1) increased ability
to drink; 2) to prevent being sick; 3) forgot to eat; 4) not hungry; and 5) lack of 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, and because of “not being able to

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drink as much”, and “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 pseudo-medical 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 ¾ 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 alcohols’ toxicity and
the subsequent health consequences such as brain and organ damage. Alcohol is also

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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 bodies’ 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, witnessed by memory lapses and blackouts. Students should be informed that
alcohol does not just kill our extra brain cells used to store memories, but it also kills
brains cells (neurons) which are responsible for our 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 or 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

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too small to draw conclusions regarding other specific campus groups associated with
high-risk alcohol consumption, such as students in Greek organizations or on athletic
teams, and their engagement 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 these reasons among all
college students, not just those in their first year. This study did begin to shed some light
in this area with respondents sharing that they did not want to get sick or vomit, 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

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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 such a 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 and 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 pre-contemplative and contemplative stages of change (Rollnick,
Miller, & Butler; 2008). The results of this study, suggest a possible need for

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modifications to existing alcohol education and prevention programs to include important
health information about the dangers of calorie restriction and drunkorexia.
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