Background
Eating habits vary greatly from one person to another where inappropriate habits range from dieting to overeating [
1]. Generally, males have poorer and less healthy lifestyles than females [
2]. However, disordered eating habits, usually in attempt of weight control, are more common among female than among male adolescents, with the prevalence being 50.7 and 33.7%, respectively [
3]. Healthy weight is misconstrued among high school students thus, disordered eating behaviors are prominent among adolescents [
4,
5]. Not only have disordered eating patterns been linked to psychological issues [
6], Patton et al. suggested that dieting, for example, increases the risk of developing eating disorders in later stages of life [
7]. Furthermore, eating disorders include a spectrum of numerous disorders, the most common ones being anorexia nervosa and bulimia nervosa [
8]. Anorexia is a condition where people starve themselves whereas bulimia is a condition where they alternate between starving them and bingeing, proceeded by purging, i.e. removing calories from the body [
9]. Each eating disorder varies in terms of their prevalence in one gender. For example, anorexia is usually prevalent in females rather than males partly due to the pressures imposed by society’s standards in regards to women looking ‘thin’ and ‘slim’ [
10]. In contrast, women seem less likely to experience subthreshold binge eating disorder than men [
10,
11]; overweight and obesity are, hence, more common among males [
12].
Even though disordered eating habits have a huge impact on one’s psychology, it is important to investigate its effect on one’s dependency on smoking – cigarettes and water pipe – and alcohol in Lebanon. Not only do those with higher Body Mass Index (BMI) have a higher chance of consuming tobacco and smoking [
13,
14], but also, non-smokers have healthier eating behaviors than smokers. Furthermore, relationships were established between an increase in the amount of alcohol consumed and an increase in BMI [
15]. However, those who drank frequently but in smaller amounts had a lower BMI [
16]. In fact, the link between alcoholism and eating disorders, such as anorexia and bulimia nervosa, was found to be bidirectional [
17].
Most studies focus on the effect of disordered eating on females as they experience these behaviors more frequently than males. Disordered eating attitudes studied among females were associated with an increase in cigarette smoking [
18]. For example, those who practiced purging or dieting were more likely to drink alcohol and suffer the negative consequences of heavy drinking than women who did not engage in these eating behaviors [
19]. Additionally, women who suffered from disordered eating were at higher risk of involving themselves in heavy drinking [
20]. It was suggested that one of the main reasons behind the association of binge eating and alcohol drinking is that both behaviors serve as a coping mechanism, mainly avoidance [
21]. The focus of most studies on the aforementioned topic could be due to the difference between females and males in terms of compensatory behavior, thus leading to disordered eating practices to be underestimated among males.
Hence, it is important to further investigate this topic among males. Furthermore, it has been suggested that the eating behaviors of non-smoking males are as healthy as those of female smokers [
13]. In addition, males are more likely to smoke and drink than females. In Lebanon, waterpipe use was more prominent among males than females [
22]. The difference in gender habits could be due to the higher social acceptability of smoking in males compared to females, particularly in the patriarchal society of Lebanon. Conservative views might be held more strongly towards cigarettes than water pipe [
23,
24]. Furthermore, males were found to experience a higher consumption of alcohol than females in addition to being at higher risk of developing alcohol use disorder [
25,
26].
Not only is it a necessity to focus our study on males, but also on male adolescents in high school across Lebanon. Firstly, the engagement of people their age in disordered eating behaviors put them at higher risk of developing eating disorders and other health-risk behaviors [
27]. Smoking both cigarettes and water pipe in Lebanon among adolescents is on the rise. Around 35% of 13 to 15-year olds have already tried the water pipe [
28] with 19% of adolescents regularly using the waterpipe. Lebanon ranks the highest in terms of smoking frequency and intensity in the Middle East [
29]. Furthermore, adolescents tend to perceive water pipes as more appealing due to its different flavor options and their misconception of it being less harmful than cigarettes [
30].
Alcohol is another phenomenon posing a health concern worldwide as it is increasing among adolescents [
31]. Furthermore, in Lebanon, alcohol is more accessible to adolescents in comparison to other countries, due to its cheap price and the lack of law enforcement that prevents adolescents from purchasing alcohol [
32]. Lebanon has witnessed an increase of 48% between 2005 and 2011 in adolescents’ drunkenness [
33]; this might be due to several reasons including advertisement on social media combined with their feeling of power or ability to cope with stress in the presence of alcohol [
34,
35].
Furthermore, it is important to investigate the relationship between disordered eating and smoking and alcohol use within adolescents because alcohol and smoking and eating disorders are risk factors to other diseases as well. For example, high levels of alcohol accompanied by the acidic damage and nutritional deficit exhibited in people with disordered eating habits - due to induced vomiting - has been shown to increase risk of esophageal cancer [
36]. Smoking has also been established to be a risk factor for esophageal cancer [
37] and osteoporosis, which is often occurring with people with Anorexia Nervosa [
38].
While multiple studies have been done investigating how different factors – such us low earnings, weaker labor market attachments, genetic factors [
39], attachment styles [
40] and parental separation [
41] – are associated with smoking and alcohol consumption, few studies have been done to investigate the relationship between disordered eating and the prevalence of smoking and drinking among males. While the relationship might be bidirectional [
17,
42], our study aims to investigate how inappropriate eating habits play a role in one’s dependence on cigarettes, waterpipes, and alcohol in male adolescents. In addition, the establishment of this relationship has clinical implication for the selection of treatment methods for eating disorders; practitioners should know whether to focus on one’s dependence.
Methods
Study design and procedure
This was a cross-sectional observational study that enrolled 389 male students drawn from five Lebanese schools between October and December 2019. A list of the schools available in each Lebanese district was provided by the Ministry of Education and Higher Education; one school was chosen from each district using a simple randomization technique; the districts included the capital Beirut, Mount Lebanon, North, Beqaa, and South. A list of students was obtained from the designated school; all male students from grades 9, 10, 11 and 12 (13–17 years of age) at each school were asked to participate (total N = 500). Students were allowed to fill the questionnaires on a voluntary basis and the survey was administered in classrooms to avoid parents’ influence. Subjects who refused to complete the questionnaire were excluded. Any personal identification was removed from the questionnaire before coding began.
Minimal sample size calculation
According to the G-power software, and based on an effect size f2 = 4%, an alpha error of 5%, a power of 80%, and taking into consideration 4 factors to be entered in the multivariable analysis, the results showed that a minimal number of 304 was needed.
Data collection and measures
The data collection sheet used to retrieve data from the participants was established based on validated and standardized questionnaires [
22,
25‐
28]. The survey questionnaire was self-report, in Arabic, and distributed as a paper copy. Before use, the questionnaire was translated into Arabic (process involving two independent translations, synthesis of the two translations, back translations, review of the pre-final version and pretesting). The questionnaire included two sections. The first section collected demographic information, including participant’s age and socioeconomic characteristics. The second part was dedicated for the assessment of eating attitude and addiction (alcohol, nicotine and waterpipe addiction).
Eating Attitude Test (EAT-26): The EAT, validated in Lebanon [
43], was used for the assessment of disordered/inappropriate eating attitudes [
44]. It includes 26 questions scored from infrequently/almost never/never (0) to always (3). Scores ≥20 reflect probable disordered/inappropriate eating attitudes [
45] (α Cronbach in this study = 0.910).
For the assessment of alcohol addiction, the validated
Alcohol Use Disorders Identification Test (AUDIT) scale was used. This tool is composed of 10 items to assess alcohol use, drinking patterns, and alcohol-related issues, which can be administered by a clinician or self-administered [
46]. Scores ≥8 reflect high risk of alcohol use disorder (α Cronbach = 0.861). This scale was recently validated in Lebanon [
47].
The
Fagerström Test for Nicotine Dependence (FTND) is a six-item instrument used to screen for addiction to cigarette smoking. Items are scored as 0/1 for questions with a yes/no answer and 0–3 for multiple-choice items. Higher scores reflect more nicotine dependence [
48] (α Cronbach in this study = 0.874).
The
Lebanese Waterpipe Dependence Scale-11 (LWDS-11) test was used to assess waterpipe dependence [
49]. The LWDS-11 is composed of 11 items, measured on a 4-point Likert scale ranging from 0 to 3. The total scale is calculated by summing the 11 items. In this study, the Cronbach’s alpha was 0.908.
Statistical analysis
SPSS software version 25 was used to conduct data analysis. Since the LWDS, FTND and AUDIT scores showed a non-normal distribution, Spearman correlation was used to evaluate the association between continuous variables. A multivariate analysis of covariance (MANCOVA) was conducted taking the LWDS-11, FTND and AUDIT scores as a dependent variables and the EAT-26 score taken as the independent variable, after adjusting over other confounding variables: age, BMI and household crowding index. A partial eta squared of │0.01–0.05│indicated a small effect, │0.06–0.13│a moderate effect and > │0.14│ a large effect. A p < 0.05 was considered significant.
Discussion
This study aimed to investigate the relationship between inappropriate eating habits and one’s dependency on smoking – cigarettes and waterpipe – and drinking alcohol. It focused on a sample of males since few studies have investigated the effect of disordered eating habits in males. Furthermore, it focused on male adolescents since this age group is susceptible to drinking and smoking in Lebanon due to the lack of law implementation in addition to the misconception adolescents have in regards to perceiving different weight statuses [
50]. Our results found that 47.6% of the interviewed male adolescents experience inappropriate eating behaviors. A recent study found that the prevalence of disordered eating habits among females is 50.7% [
3]. The similarity in percentages highlights the importance of exploring the effect of this issue on different areas of male adolescents’ lives as well.
An increase in inappropriate eating habits was found to be correlated with waterpipe dependence in Lebanon; however, it had no relation with cigarette smoking. A study in Jordan also found that waterpipe-only smokers and dual smokers have unhealthy eating habits in comparison to cigarette-only smokers [
51]. While multiple studies carried out show an association between inappropriate eating habits and an increase in smoking tobacco [
52‐
54], a study in Jordan found that the prevalence of adolescents smoking only the waterpipe was 21.1% while those smoking only cigarettes was 6.7% [
55].
The results we established regarding Lebanese male adolescents with inappropriate eating habit showing a waterpipe dependence, but not a cigarette dependence might be due to the increased popularity of waterpipes. It is important to mention that waterpipes are perceived as more socially acceptable than cigarettes [
56,
57]. Waterpipe smoking among adolescents is a rising phenomenon in Lebanon and worldwide [
28,
55]. Hence, this should be further investigated especially since the engagement of adolescents in disordered eating at their age puts them at risk of developing eating disorder or other eating behaviors that are unhealthy.
Studies also suggest that mostly, people tend to consider waterpipe to be less harmful and/or addictive than cigarettes [
56]. However, one head of an unflavored waterpipe has actually been found to have the amount of nicotine found in 70 cigarettes [
57]. In addition, nicotine has been found to have a suppressing effect on one’s appetite [
58]. That could explain the relationship between waterpipe smoking and the manifestation of disordered eating habits, as adolescents strive to these measures in hope of losing weight. Not only has smoking tobacco been associated with increased physical inactivity [
59], but also waterpipe smoking has been found to be associated with an increased risk of developing a high BMI and obesity in adults in comparison to non-smoking [
60]. People seem to believe that these factors outweigh the consequences smoking - paired with disordered eating - has on one’s health, such as increasing risk of esophageal cancer, lung cancer or other cardiovascular diseases [
61,
62].
As for alcohol drinking, our studies suggest that more disordered eating behaviors were associated with the consumption of higher amounts of alcohol. Most studies have found similar results where inappropriate eating habits lead to negative health habits such as drinking and smoking, as aforementioned [
52‐
54]. However, a study suggested that males tend to want to be muscular and lean rather than lose weight [
63], as opposed to what females tend to achieve [
64]. Another study found that males who wanted to gain weight were more likely to engage in binge drinking and alcohol use than the males who wanted to lose weight [
65]. The relationship between alcohol use and disordered eating should be further investigated, as there could be several reasons behind the link. In addition, the link could be due to peer pressure and adolescents wanting to social conform within their groups by drinking, paired with having a well-perceived body shape [
54]. The term ‘drunkorexia’ has even been coined for the practice of dieting when drinking alcohol was planned, as means of decreasing the number of calories consumed within that day to prevent weight gain [
66]. Moreover, some studies found evidence where disordered eating and substance abuse – including alcohol and tobacco – had overlapping genetic underpinnings [
67]. In addition, the reason underlying the association between disordered eating and alcohol and/or tobacco consumption could be one’s way of coping with stress [
68], as both are avoidance mechanisms [
21] and adolescents would reduce their negative feelings through eating and/or drinking [
69].
Limitations and strengths
This study has some limitations; it faces is the focus on disordered eating behaviors in general instead of focusing on specific ones. Moreover, the association between the disordered eating patterns and drinking or smoking could have several underlying factors, such as depression or anxiety, so psychological factors should have been investigated. The scales used to assess smoking dependence are not validated in Lebanon. The sample enrolled in this study is small in size. A selection bias is possible because of the refusal rate. In addition, a sample of only 5 schools poses a limitation. A residual confounding bias is also possible since not all factors associated with alcohol and smoking dependence were taken into consideration in this study; of these factors are low earnings, weaker labor market attachments, and genetic factors. Finally, the data were self-reported as questionnaires were handed out to the participants. Hence, our study might exhibit some information bias due to a participant’s misinterpretation of a question decreasing the validity of his response. The results of this study cannot be generalized to the whole population; further larger studies taking all these limitations and tackling both genders are needed.
This study offers an added value in terms of the sample interviewed since most studies related to the effects of disordered eating on one’s life are focused on women. In addition to our sample being exclusively male, it focused on adolescent males since experiencing disordered eating at this age group increases risk of developing an eating disorder at later stages in life. This age group is also susceptible to misconceptions regarding weight status. Furthermore, our study focuses on the effects disordered eating has on unhealthy behaviors such as smoking and drinking. Hence, appropriate measures to prevent disordered eating and the incidence of smoking and drinking should be put into place.
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