ALCOHOLISM: CLINICAL AND EXPERIMENTAL RESEARCH
Vol. **, No. * ** 2015
Binge Drinking and Eating Problems in Russian Adolescents Andrew Stickley, Ai Koyanagi, Roman Koposov, Martin McKee, Adrianna Murphy, and Vladislav Ruchkin
Background: Binge drinking may be linked to problematic eating behavior, although as yet, little research has been conducted on this association. The objective of this study was to examine the relationship between binge drinking and eating problems in Russian adolescents. Methods: Data were drawn from the Social and Health Assessment, a cross-sectional school-based survey of 6th to 10th grade students (aged 12 to 17 years old) carried out in Arkhangelsk, Russia. Information was collected on various eating problems (worries about weight, feeling fat, excessive eating, fasting and excessive exercise, and purging behaviors) and binge drinking (5 or more drinks in a row). Logistic regression analysis was used to examine the relationship between binge drinking and eating problems. Results: Among the 2,488 adolescents included in the statistical analysis, nearly 50% of girls expressed worries about their weight, while 35.0 and 41.5% of adolescent boys and girls reported excessive eating, respectively. The prevalence of purging behaviors (vomiting/using laxatives) was, however, much lower among both sexes (females—2.6%; males—3.3%). In a regression model adjusted for demographic factors and depressive symptoms, among girls, binge drinking was associated with 5 of the 6 eating problems with odds ratios (ORs) ranging from 1.21 (upset about weight gain) to 1.68 (excessive eating). For boys, binge drinking was linked to feeling overweight (OR: 1.47, confidence interval [CI]: 1.20 to 1.81) and vomiting/used laxatives (OR: 4.13, CI: 1.58 to 10.80). Conclusions: Many adolescents in Russia report problematic eating attitudes and behaviors, and eating problems are associated with binge drinking. More research is now needed in this setting to better understand adolescent eating problems and their association with alcohol misuse, so that contextually suitable interventions can be implemented to reduce these behaviors and mitigate their potentially detrimental effects. Key Words: Adolescent, Binge Drinking, Eating Problems, Russia.
T
HE CHALLENGES OF adapting to complex physical, psychological, and emotional changes in adolescence are often associated with behaviors that confer considerable risk on those involved. One of the most obvious of these is the consumption of large quantities of alcohol (Windle, 1999), often termed “binge drinking,” commonly defined as consuming 5 or more drinks in a row (Hibell et al., 2004). Surveys from the United States and 36 European countries report that approximately 20 to 50% of adolescents engage in binge drinking (Hibell et al., 2012; Patrick et al., 2013), while a smaller group (around 10%) partake in “extreme” From the Stockholm Center on Health of Societies in Transition (SCOHOST) (AS, AK), S€ odert€ orn University, Huddinge, Sweden; Department of Human Ecology (AS), University of Tokyo, Tokyo, Japan; Regional Centre for Child and Youth Mental Health and Child Welfare (RK), UiT, The Arctic University of Norway, Tromsø, Norway; European Centre on Health of Societies in Transition (MM, AM), London School of Hygiene and Tropical Medicine, London, UK; and Department of Child and Adolescent Psychiatry (VR), Division of Neuroscience, Uppsala University, Uppsala, Sweden. Received for publication June 22, 2014; accepted November 25, 2014. Reprint requests: Andrew Stickley, PhD, Stockholm Center on Health of Societies in Transition (SCOHOST), S€ odert€ orn University, 141 89 Huddinge, Sweden. Tel.: +46-8-608-4689; Fax: +46-8-608-3040; E-mail: [email protected] Copyright © 2015 by the Research Society on Alcoholism. DOI: 10.1111/acer.12644 Alcohol Clin Exp Res, Vol **, No *, 2015: pp 1–8
binge drinking (10+ drinks) in the United States (Patrick et al., 2013). Public displays of drunkenness are, however, only the most visible manifestation of a spectrum of associated negative outcomes. Adolescent binge drinking has been linked to worse school performance (Miller et al., 2007) and to engaging in risky behaviors such as initiation of early sexual activity (Stolle et al., 2009) and use of illicit drugs (Miller et al., 2007). Binge drinkers also experience worse mood states (Bekman et al., 2013) and have a greater risk of engaging in suicidal behavior (Xing et al., 2006). A recent integrative review article has suggested that binge drinking might also be linked to another form of health risk behavior—disordered eating (Ferriter and Ray, 2011). Specifically, it has been argued that although many factors are associated with binge drinking and eating disorders, it is possible that common dispositional features such as neuroticism and urgency may underpin both binge drinking and binge eating with both behaviors possibly being used to cope with the high levels of negative affect that arise from such personality traits. It was also claimed that binging behaviors co-occur frequently (Ferriter and Ray, 2011). As yet, there has been comparatively little sustained focus on the relationship between binge drinking and different types of eating problem (i.e., concerns about weight, restricting food intake, excessive eating and purging behavior 1
STICKLEY ET AL.
2
(Lock et al., 2001)), although some research undertaken among adolescent school students has connected different types of eating problem to binge drinking. A study using data from 9th to 12th grade public and private school students in the United States linked disordered eating (fasting, using diet pills, or purging behavior) to higher odds of binge drinking among males and females (Pisetsky et al., 2008), while similar findings have been reported in Mexican female high-school students (Unikel et al., 2011). Binge eating and engaging in inappropriate compensatory behaviors (e.g., making oneself vomit/taking laxatives) were associated with a greater frequency of binge drinking in the past month among female school students in grades 7, 9, 11, and 13 in a study undertaken in Ontario, Canada (Ross and Ivis, 1999), while binge drinking has also been linked to fasting, the use of diet pills and purging behavior in normal weight and overweight high-school students in the United States (Eichen et al., 2012). Other research has cast doubt, however, on the existence of an association between binge drinking and eating problems. A study using data from the Swedish Twin Registry found that there was no association between suffering or having suffered from anorexia nervosa, bulimia, or binge eating disorder and binge drinking among adult females (Root et al., 2010), while a longitudinal study analyzing data from U.S. participants collected between 1996 (when the mean sample age was 12.0 years) and 2007 recorded no association between binge eating or overeating and starting to binge drink frequently (Sonneville et al., 2013). Nearly all of the research on the relationship between binge drinking and eating problems has been undertaken in North America. In an attempt to expand this research, this study will examine the relationship between eating problems and binge drinking among adolescents in Russia. Episodic heavy drinking, that is, binge drinking, has long been common in Russia, with evidence of associated negative health outcomes from the 19th century until the present day (Stickley et al., 2007, 2009). Recent research has also shown that binge drinking is commonplace among Russian adolescents (Stickley et al., 2013a) and is associated with an increased risk of engaging in a variety of negative health behaviors (Stickley et al., 2013b). However, this focus on risky health behavior has not included adolescent eating problems, which have been little researched to date in Russia or the other Eastern European countries. This may be related, in part, to the lack of attention given to this issue in the former Soviet bloc, where eating disorders were considered a bourgeois phenomenon and regarded as taboo (Boyadjieva and Steinhausen, 1996), a situation whose legacy is apparent in the limited awareness of eating disorders among family doctors and nonmental health medical professionals in Eastern Europe (Dolan, 1993). Despite this, it has been suggested that the changes that have occurred following the collapse of the communist system, such as the global spread of Western mass media and,
with it, the Western notion of an ideal body image to the former Soviet countries (Page et al., 2006-2007), may facilitate an increase in eating disorders in Russia (O’Keefe and Lovell, 1999). However, the few studies that have been undertaken so far in Russia have produced mixed results in terms of body size attitudes and behaviors related to them. One study found that Russian and (white) American adolescents were similar in terms of body size preference and the prevalence of dieting behavior, but that Russian adolescent females were much less worried about being overweight than their American counterparts (Stevens et al., 1997). In contrast, other research has highlighted the comparatively high levels of dissatisfaction with bodyweight among Russian (female) teenagers compared to girls in Helsinki (SarlioL€ahteenkorva et al., 2003) and that there is a high drive for thinness among Russian women (O’Keefe and Lovell, 1999). This has been backed by the finding from 1 study which showed that 10.4% of female undergraduate students aged 17 to 25 (n = 251) in Krasnodar, Russia, were dieting even though only 4.4% of them were overweight (O’Keefe and Lovell, 1999). Given the limited research on eating problems among Russian adolescents, the aim of the current study was 2-fold: (1) to determine the prevalence of eating problems among Russian adolescents and (2) to examine if there was a relationship between binge drinking and eating problems among adolescents in Russia. Such information is essential to formulate effective interventions to tackle these health risk behaviors. MATERIALS AND METHODS Study Participants The data used in this study were collected during the Russian Social and Health Assessment (SAHA). This was a schoolbased survey that was carried out in the northern Russian city of Arkhangelsk in 2003. The city, which has a population of 356,000 (Vserossiiskaya perepis’ naseleniya 2002 goda), is overwhelmingly Russian in ethnic terms (98%). The socioeconomic status of the population is close to the average in Russia, and there are only small interindividual differences in this measure (Sukhodolsky and Ruchkin, 2004). For the wider Arkhangelsk region, demographic indicators are also either near identical (birth and death rates) or close to (divorce rates) those seen across the country as a whole (Rosstat, 2003). Information was obtained from a representative sample of 6th to 10th grade students (aged 12 to 17 years old) in the public school system. These students came from randomly selected classes that were within randomly selected schools chosen from within each of the city’s 4 districts. The number of sampled adolescents was proportionate to the number of students in each district (i.e., 10% of all students in the specified grade age range in each district). Students completed the survey in their classrooms during a normal school day. Within the classes, 2 trained administrators oversaw the survey’s administration. The first administrator read all of the questions aloud while students followed along with their copies of the survey, reading the questions by themselves and then circling answers in booklets provided. The second administrator was available to provide help to individual students if requested. To minimize
BINGE DRINKING AND EATING PROBLEMS
problems with the classroom behavior of the students during the survey, the class teacher was also present. Prior to administering the survey, parents (for their children) and students were informed of their right to refuse to participate in the study. Written informed consent was given by all participants. The final study sample consisted of 2,892 adolescents (a 96.4% response rate), 42.4% of whom were boys. Ethical approval was obtained from within Russia (from the Northern State Medical University in Arkhangelsk) and the United States (from Yale University School of Medicine [protocol HIC#7092]). The research was carried out in accord with the principles laid out in the Declaration of Helsinki, 1975. Measures The data were obtained using the SAHA instrument. This had been used previously in several international studies and included new scales developed specifically for this survey and scales used previously with similar populations (Ruchkin et al., 2004). Binge Drinking. Participants were asked, “During the past 30 days, on how many days (if any) did you have 5 or more drinks of alcohol in a row, that is, within a couple of hours?” A drink was defined as a bottle or can of beer, a glass of wine or wine cooler, a shot of liquor, or a mixed drink. Those who engaged in binge drinking on at least 1 day were categorized as binge drinkers in this study. Eating Problems. Information on eating problems was obtained using an Eating Problems Scale developed by the SAHA Research Evaluation Team. This measured the occurrence of disordered eating symptoms during the previous 3 months. The scale included 4 statements on problematic attitudes (e.g., feeling fat) and behaviors (e.g., eating large amounts of food) that are similar to some items found in other eating disorder scales (e.g., Stice et al., 2000). Specifically, the statements were, “I worried a lot about how to stop gaining weight,” “I felt fat even when others told me I am too thin,” “I ate large amounts of food even when I didn’t feel hungry,” and “I felt very upset about my overeating or weight gain.” Response options to these statements were, “not true”, “somewhat true,” and “certainly true.” In this study, those who answered either “somewhat true” or “certainly true” were categorized as having experienced the symptom. In addition, there were 2 questions that enquired about how many times per week certain behaviors were undertaken to prevent weight gain. The first asked, “About how many times per week have you made yourself vomit or used laxatives to prevent weight gain?”, and the second asked, “About how many times per week have you fasted (skipped at least 2 meals in a row) or engaged in excessive exercise to prevent weight gain?” For both questions, the answers were dichotomized into those who had engaged in the behavior and those who had not. Cronbach’s alpha for the scale was 0.78. Control Variables. Information was also obtained on the age of the adolescents, on the level of education of their parents (parental education), and on the family structure. The parental education variable was dichotomized into those whose parents or guardians had graduated from university (high education) and those whose parents had less than a university education (low education). The highest education level was used if both parents were present. As many adolescents did not provide information on this variable, a third “missing” category was created to minimize the loss of cases from the statistical analysis. As regards family structure, adolescents were categorized as living in “intact” families if both biological parents were present in the household, “single parent” families if 1 biological parent alone was present, and “other” for any other type of household family living arrangement (e.g., where a biological parent and a step parent were living together).
3
Statistical Analysis Due to the small number of adolescents aged below 13 and above 17 years old, the analysis was restricted to those in the 13 to 17 age range. As some evidence suggests that the relationship between binge drinking and some aspects of disordered eating might be gender-specific (Eichen et al., 2012), separate analyses were undertaken for males and females. Chi-square tests were used to test the difference by sex for baseline characteristics with the exception of the depressive symptoms variable, which was tested using the Student’s t-test (Table 1). In Table 2, prevalence figures for binge drinking and the eating problems are presented for the different age groups to determine whether their occurrence varies across adolescence. The relationship between eating problems (dependent variable) and binge drinking (independent variable) was examined using logistic regression analysis (Table 3). Four regression models were constructed. In Model 1, the univariable relationship between each eating problem and binge drinking was examined. In Model 2, the relationship between each eating problem and binge drinking was examined while controlling for age. Model 3 was the same as the previous model but also controlled for the influence of the other demographic variables (parental education and family structure). In addition, as previous research has indicated that both binge drinking and eating problems might be associated with poorer mental health (Hudson et al., 2007; Palj€ arvi et al., 2009), a fourth multivariable model extended the analysis in Model 3 by examining whether the eating problems–binge drinking relation was affected by the presence of depressive symptoms in the past 30 days using data collected with a shortened version of the Center for Epidemiological Studies-Depression Scale (CES-D) (Radloff, 1977). As one of the questions on this scale is related to problematic eating, this item was removed to create a 9-item version (Cronbach‘s a = 0.82). Age and depression were entered into the regression analysis as continuous variables. The full results for all the variables in the fourth model are also presented in the Appendix. All regression analyses were adjusted for the clustering effect within schools. The results are presented as odds ratios (ORs) with 95% confidence intervals (CIs). The analysis was undertaken with Stata version 12.1 (Stata Corp, College Station, TX), with the significance level set at p < 0.05.
RESULTS After omitting those individuals who were outside the specified age range or had missing values for any of the control variables, the analytical sample consisted of 2,488 adolescents aged 13 to 17 years old (1,485 females and 1,003 males). The prevalence of binge drinking was almost the same among females (42.8%) and males (40.4%) (p = 0.245) (Table 1). Half of the adolescents had parents who were highly educated, while nearly two-thirds of them (65.1%) lived in intact families. The percentage of adolescents responding “somewhat/certainly true” was significantly higher among girls than boys (p < 0.001) for all of the eating problems except for vomiting/using laxatives to prevent weight gain where the prevalence of the behaviors was comparatively low (females 2.6%, males 3.3%). While nearly half of adolescent females (49.3%) worried about how to stop gaining weight and 44.7% felt fat (overweight), the corresponding figures among adolescent males were 13.7 and 12.8%, respectively. Similarly, while nearly 40% of females reported that they felt upset about overeating or weight gain, this figure was only
STICKLEY ET AL.
4
Table 1. Characteristics of the Study Sample Female
Male
Characteristic
Category
No.
%
No.
%
p-Value*
Binge drinking
No Yes 13 14 15 16 17 Low High Missing Intact Single Other Mean (SD) Not true Somewhat/certainly true Not true Somewhat/certainly true Not true Somewhat/certainly true Not true Somewhat/certainly true No Yes No Yes
850 635 133 415 453 327 157 405 772 308 972 364 149 6.2 751 731 820 662 865 613 890 591 1433 38 1010 461
57.2 42.8 9.0 27.9 30.5 22.0 10.6 27.3 52.0 20.7 65.5 24.5 10.0 4.0 50.7 49.3 55.3 44.7 58.5 41.5 60.1 39.9 97.4 2.6 68.7 31.3
598 405 110 334 304 168 87 295 474 234 647 246 110 4.6 860 137 869 127 648 349 879 119 950 32 876 100
59.6 40.4 11.0 33.3 30.3 16.7 8.7 29.4 47.3 23.3 64.5 24.5 11.0 3.7 86.3 13.7 87.2 12.8 65.0 35.0 88.1 11.9 96.7 3.3 89.8 10.2
0.245
Age (years)
Parental education Family structure Depressive symptoms** Worry about weight gaina Feeling fatb c
Excessive eating
Upset about weight gaind e
Vomited/used laxatives
Fasted/excessive exercisef
0.010
0.013 0.768
Vol. **, No. * ** 2015
Binge Drinking and Eating Problems in Russian Adolescents Andrew Stickley, Ai Koyanagi, Roman Koposov, Martin McKee, Adrianna Murphy, and Vladislav Ruchkin
Background: Binge drinking may be linked to problematic eating behavior, although as yet, little research has been conducted on this association. The objective of this study was to examine the relationship between binge drinking and eating problems in Russian adolescents. Methods: Data were drawn from the Social and Health Assessment, a cross-sectional school-based survey of 6th to 10th grade students (aged 12 to 17 years old) carried out in Arkhangelsk, Russia. Information was collected on various eating problems (worries about weight, feeling fat, excessive eating, fasting and excessive exercise, and purging behaviors) and binge drinking (5 or more drinks in a row). Logistic regression analysis was used to examine the relationship between binge drinking and eating problems. Results: Among the 2,488 adolescents included in the statistical analysis, nearly 50% of girls expressed worries about their weight, while 35.0 and 41.5% of adolescent boys and girls reported excessive eating, respectively. The prevalence of purging behaviors (vomiting/using laxatives) was, however, much lower among both sexes (females—2.6%; males—3.3%). In a regression model adjusted for demographic factors and depressive symptoms, among girls, binge drinking was associated with 5 of the 6 eating problems with odds ratios (ORs) ranging from 1.21 (upset about weight gain) to 1.68 (excessive eating). For boys, binge drinking was linked to feeling overweight (OR: 1.47, confidence interval [CI]: 1.20 to 1.81) and vomiting/used laxatives (OR: 4.13, CI: 1.58 to 10.80). Conclusions: Many adolescents in Russia report problematic eating attitudes and behaviors, and eating problems are associated with binge drinking. More research is now needed in this setting to better understand adolescent eating problems and their association with alcohol misuse, so that contextually suitable interventions can be implemented to reduce these behaviors and mitigate their potentially detrimental effects. Key Words: Adolescent, Binge Drinking, Eating Problems, Russia.
T
HE CHALLENGES OF adapting to complex physical, psychological, and emotional changes in adolescence are often associated with behaviors that confer considerable risk on those involved. One of the most obvious of these is the consumption of large quantities of alcohol (Windle, 1999), often termed “binge drinking,” commonly defined as consuming 5 or more drinks in a row (Hibell et al., 2004). Surveys from the United States and 36 European countries report that approximately 20 to 50% of adolescents engage in binge drinking (Hibell et al., 2012; Patrick et al., 2013), while a smaller group (around 10%) partake in “extreme” From the Stockholm Center on Health of Societies in Transition (SCOHOST) (AS, AK), S€ odert€ orn University, Huddinge, Sweden; Department of Human Ecology (AS), University of Tokyo, Tokyo, Japan; Regional Centre for Child and Youth Mental Health and Child Welfare (RK), UiT, The Arctic University of Norway, Tromsø, Norway; European Centre on Health of Societies in Transition (MM, AM), London School of Hygiene and Tropical Medicine, London, UK; and Department of Child and Adolescent Psychiatry (VR), Division of Neuroscience, Uppsala University, Uppsala, Sweden. Received for publication June 22, 2014; accepted November 25, 2014. Reprint requests: Andrew Stickley, PhD, Stockholm Center on Health of Societies in Transition (SCOHOST), S€ odert€ orn University, 141 89 Huddinge, Sweden. Tel.: +46-8-608-4689; Fax: +46-8-608-3040; E-mail: [email protected] Copyright © 2015 by the Research Society on Alcoholism. DOI: 10.1111/acer.12644 Alcohol Clin Exp Res, Vol **, No *, 2015: pp 1–8
binge drinking (10+ drinks) in the United States (Patrick et al., 2013). Public displays of drunkenness are, however, only the most visible manifestation of a spectrum of associated negative outcomes. Adolescent binge drinking has been linked to worse school performance (Miller et al., 2007) and to engaging in risky behaviors such as initiation of early sexual activity (Stolle et al., 2009) and use of illicit drugs (Miller et al., 2007). Binge drinkers also experience worse mood states (Bekman et al., 2013) and have a greater risk of engaging in suicidal behavior (Xing et al., 2006). A recent integrative review article has suggested that binge drinking might also be linked to another form of health risk behavior—disordered eating (Ferriter and Ray, 2011). Specifically, it has been argued that although many factors are associated with binge drinking and eating disorders, it is possible that common dispositional features such as neuroticism and urgency may underpin both binge drinking and binge eating with both behaviors possibly being used to cope with the high levels of negative affect that arise from such personality traits. It was also claimed that binging behaviors co-occur frequently (Ferriter and Ray, 2011). As yet, there has been comparatively little sustained focus on the relationship between binge drinking and different types of eating problem (i.e., concerns about weight, restricting food intake, excessive eating and purging behavior 1
STICKLEY ET AL.
2
(Lock et al., 2001)), although some research undertaken among adolescent school students has connected different types of eating problem to binge drinking. A study using data from 9th to 12th grade public and private school students in the United States linked disordered eating (fasting, using diet pills, or purging behavior) to higher odds of binge drinking among males and females (Pisetsky et al., 2008), while similar findings have been reported in Mexican female high-school students (Unikel et al., 2011). Binge eating and engaging in inappropriate compensatory behaviors (e.g., making oneself vomit/taking laxatives) were associated with a greater frequency of binge drinking in the past month among female school students in grades 7, 9, 11, and 13 in a study undertaken in Ontario, Canada (Ross and Ivis, 1999), while binge drinking has also been linked to fasting, the use of diet pills and purging behavior in normal weight and overweight high-school students in the United States (Eichen et al., 2012). Other research has cast doubt, however, on the existence of an association between binge drinking and eating problems. A study using data from the Swedish Twin Registry found that there was no association between suffering or having suffered from anorexia nervosa, bulimia, or binge eating disorder and binge drinking among adult females (Root et al., 2010), while a longitudinal study analyzing data from U.S. participants collected between 1996 (when the mean sample age was 12.0 years) and 2007 recorded no association between binge eating or overeating and starting to binge drink frequently (Sonneville et al., 2013). Nearly all of the research on the relationship between binge drinking and eating problems has been undertaken in North America. In an attempt to expand this research, this study will examine the relationship between eating problems and binge drinking among adolescents in Russia. Episodic heavy drinking, that is, binge drinking, has long been common in Russia, with evidence of associated negative health outcomes from the 19th century until the present day (Stickley et al., 2007, 2009). Recent research has also shown that binge drinking is commonplace among Russian adolescents (Stickley et al., 2013a) and is associated with an increased risk of engaging in a variety of negative health behaviors (Stickley et al., 2013b). However, this focus on risky health behavior has not included adolescent eating problems, which have been little researched to date in Russia or the other Eastern European countries. This may be related, in part, to the lack of attention given to this issue in the former Soviet bloc, where eating disorders were considered a bourgeois phenomenon and regarded as taboo (Boyadjieva and Steinhausen, 1996), a situation whose legacy is apparent in the limited awareness of eating disorders among family doctors and nonmental health medical professionals in Eastern Europe (Dolan, 1993). Despite this, it has been suggested that the changes that have occurred following the collapse of the communist system, such as the global spread of Western mass media and,
with it, the Western notion of an ideal body image to the former Soviet countries (Page et al., 2006-2007), may facilitate an increase in eating disorders in Russia (O’Keefe and Lovell, 1999). However, the few studies that have been undertaken so far in Russia have produced mixed results in terms of body size attitudes and behaviors related to them. One study found that Russian and (white) American adolescents were similar in terms of body size preference and the prevalence of dieting behavior, but that Russian adolescent females were much less worried about being overweight than their American counterparts (Stevens et al., 1997). In contrast, other research has highlighted the comparatively high levels of dissatisfaction with bodyweight among Russian (female) teenagers compared to girls in Helsinki (SarlioL€ahteenkorva et al., 2003) and that there is a high drive for thinness among Russian women (O’Keefe and Lovell, 1999). This has been backed by the finding from 1 study which showed that 10.4% of female undergraduate students aged 17 to 25 (n = 251) in Krasnodar, Russia, were dieting even though only 4.4% of them were overweight (O’Keefe and Lovell, 1999). Given the limited research on eating problems among Russian adolescents, the aim of the current study was 2-fold: (1) to determine the prevalence of eating problems among Russian adolescents and (2) to examine if there was a relationship between binge drinking and eating problems among adolescents in Russia. Such information is essential to formulate effective interventions to tackle these health risk behaviors. MATERIALS AND METHODS Study Participants The data used in this study were collected during the Russian Social and Health Assessment (SAHA). This was a schoolbased survey that was carried out in the northern Russian city of Arkhangelsk in 2003. The city, which has a population of 356,000 (Vserossiiskaya perepis’ naseleniya 2002 goda), is overwhelmingly Russian in ethnic terms (98%). The socioeconomic status of the population is close to the average in Russia, and there are only small interindividual differences in this measure (Sukhodolsky and Ruchkin, 2004). For the wider Arkhangelsk region, demographic indicators are also either near identical (birth and death rates) or close to (divorce rates) those seen across the country as a whole (Rosstat, 2003). Information was obtained from a representative sample of 6th to 10th grade students (aged 12 to 17 years old) in the public school system. These students came from randomly selected classes that were within randomly selected schools chosen from within each of the city’s 4 districts. The number of sampled adolescents was proportionate to the number of students in each district (i.e., 10% of all students in the specified grade age range in each district). Students completed the survey in their classrooms during a normal school day. Within the classes, 2 trained administrators oversaw the survey’s administration. The first administrator read all of the questions aloud while students followed along with their copies of the survey, reading the questions by themselves and then circling answers in booklets provided. The second administrator was available to provide help to individual students if requested. To minimize
BINGE DRINKING AND EATING PROBLEMS
problems with the classroom behavior of the students during the survey, the class teacher was also present. Prior to administering the survey, parents (for their children) and students were informed of their right to refuse to participate in the study. Written informed consent was given by all participants. The final study sample consisted of 2,892 adolescents (a 96.4% response rate), 42.4% of whom were boys. Ethical approval was obtained from within Russia (from the Northern State Medical University in Arkhangelsk) and the United States (from Yale University School of Medicine [protocol HIC#7092]). The research was carried out in accord with the principles laid out in the Declaration of Helsinki, 1975. Measures The data were obtained using the SAHA instrument. This had been used previously in several international studies and included new scales developed specifically for this survey and scales used previously with similar populations (Ruchkin et al., 2004). Binge Drinking. Participants were asked, “During the past 30 days, on how many days (if any) did you have 5 or more drinks of alcohol in a row, that is, within a couple of hours?” A drink was defined as a bottle or can of beer, a glass of wine or wine cooler, a shot of liquor, or a mixed drink. Those who engaged in binge drinking on at least 1 day were categorized as binge drinkers in this study. Eating Problems. Information on eating problems was obtained using an Eating Problems Scale developed by the SAHA Research Evaluation Team. This measured the occurrence of disordered eating symptoms during the previous 3 months. The scale included 4 statements on problematic attitudes (e.g., feeling fat) and behaviors (e.g., eating large amounts of food) that are similar to some items found in other eating disorder scales (e.g., Stice et al., 2000). Specifically, the statements were, “I worried a lot about how to stop gaining weight,” “I felt fat even when others told me I am too thin,” “I ate large amounts of food even when I didn’t feel hungry,” and “I felt very upset about my overeating or weight gain.” Response options to these statements were, “not true”, “somewhat true,” and “certainly true.” In this study, those who answered either “somewhat true” or “certainly true” were categorized as having experienced the symptom. In addition, there were 2 questions that enquired about how many times per week certain behaviors were undertaken to prevent weight gain. The first asked, “About how many times per week have you made yourself vomit or used laxatives to prevent weight gain?”, and the second asked, “About how many times per week have you fasted (skipped at least 2 meals in a row) or engaged in excessive exercise to prevent weight gain?” For both questions, the answers were dichotomized into those who had engaged in the behavior and those who had not. Cronbach’s alpha for the scale was 0.78. Control Variables. Information was also obtained on the age of the adolescents, on the level of education of their parents (parental education), and on the family structure. The parental education variable was dichotomized into those whose parents or guardians had graduated from university (high education) and those whose parents had less than a university education (low education). The highest education level was used if both parents were present. As many adolescents did not provide information on this variable, a third “missing” category was created to minimize the loss of cases from the statistical analysis. As regards family structure, adolescents were categorized as living in “intact” families if both biological parents were present in the household, “single parent” families if 1 biological parent alone was present, and “other” for any other type of household family living arrangement (e.g., where a biological parent and a step parent were living together).
3
Statistical Analysis Due to the small number of adolescents aged below 13 and above 17 years old, the analysis was restricted to those in the 13 to 17 age range. As some evidence suggests that the relationship between binge drinking and some aspects of disordered eating might be gender-specific (Eichen et al., 2012), separate analyses were undertaken for males and females. Chi-square tests were used to test the difference by sex for baseline characteristics with the exception of the depressive symptoms variable, which was tested using the Student’s t-test (Table 1). In Table 2, prevalence figures for binge drinking and the eating problems are presented for the different age groups to determine whether their occurrence varies across adolescence. The relationship between eating problems (dependent variable) and binge drinking (independent variable) was examined using logistic regression analysis (Table 3). Four regression models were constructed. In Model 1, the univariable relationship between each eating problem and binge drinking was examined. In Model 2, the relationship between each eating problem and binge drinking was examined while controlling for age. Model 3 was the same as the previous model but also controlled for the influence of the other demographic variables (parental education and family structure). In addition, as previous research has indicated that both binge drinking and eating problems might be associated with poorer mental health (Hudson et al., 2007; Palj€ arvi et al., 2009), a fourth multivariable model extended the analysis in Model 3 by examining whether the eating problems–binge drinking relation was affected by the presence of depressive symptoms in the past 30 days using data collected with a shortened version of the Center for Epidemiological Studies-Depression Scale (CES-D) (Radloff, 1977). As one of the questions on this scale is related to problematic eating, this item was removed to create a 9-item version (Cronbach‘s a = 0.82). Age and depression were entered into the regression analysis as continuous variables. The full results for all the variables in the fourth model are also presented in the Appendix. All regression analyses were adjusted for the clustering effect within schools. The results are presented as odds ratios (ORs) with 95% confidence intervals (CIs). The analysis was undertaken with Stata version 12.1 (Stata Corp, College Station, TX), with the significance level set at p < 0.05.
RESULTS After omitting those individuals who were outside the specified age range or had missing values for any of the control variables, the analytical sample consisted of 2,488 adolescents aged 13 to 17 years old (1,485 females and 1,003 males). The prevalence of binge drinking was almost the same among females (42.8%) and males (40.4%) (p = 0.245) (Table 1). Half of the adolescents had parents who were highly educated, while nearly two-thirds of them (65.1%) lived in intact families. The percentage of adolescents responding “somewhat/certainly true” was significantly higher among girls than boys (p < 0.001) for all of the eating problems except for vomiting/using laxatives to prevent weight gain where the prevalence of the behaviors was comparatively low (females 2.6%, males 3.3%). While nearly half of adolescent females (49.3%) worried about how to stop gaining weight and 44.7% felt fat (overweight), the corresponding figures among adolescent males were 13.7 and 12.8%, respectively. Similarly, while nearly 40% of females reported that they felt upset about overeating or weight gain, this figure was only
STICKLEY ET AL.
4
Table 1. Characteristics of the Study Sample Female
Male
Characteristic
Category
No.
%
No.
%
p-Value*
Binge drinking
No Yes 13 14 15 16 17 Low High Missing Intact Single Other Mean (SD) Not true Somewhat/certainly true Not true Somewhat/certainly true Not true Somewhat/certainly true Not true Somewhat/certainly true No Yes No Yes
850 635 133 415 453 327 157 405 772 308 972 364 149 6.2 751 731 820 662 865 613 890 591 1433 38 1010 461
57.2 42.8 9.0 27.9 30.5 22.0 10.6 27.3 52.0 20.7 65.5 24.5 10.0 4.0 50.7 49.3 55.3 44.7 58.5 41.5 60.1 39.9 97.4 2.6 68.7 31.3
598 405 110 334 304 168 87 295 474 234 647 246 110 4.6 860 137 869 127 648 349 879 119 950 32 876 100
59.6 40.4 11.0 33.3 30.3 16.7 8.7 29.4 47.3 23.3 64.5 24.5 11.0 3.7 86.3 13.7 87.2 12.8 65.0 35.0 88.1 11.9 96.7 3.3 89.8 10.2
0.245
Age (years)
Parental education Family structure Depressive symptoms** Worry about weight gaina Feeling fatb c
Excessive eating
Upset about weight gaind e
Vomited/used laxatives
Fasted/excessive exercisef
0.010
0.013 0.768
