Abstract

Alcohol is the most common substance used among adolescents. In the Philippines, there is a fluctuating trend in the percentage of adolescent current drinkers from a downward trend in 2008 to 2013 (21.7% and 18.6%, respectively), to an upward trend in 2015 to 2018 survey (14.9% to 16.8%, respectively). Health issues related to alcohol drinking are impaired brain development, physical inactivity, malnutrition, unwanted injuries and violence. Based on secondary data analysis from the 2018 ENNS conducted by the FNRI – DOST, the study aimed to determine if there is an association between alcohol drinking status of adolescents and factors such as socio – economic characteristics and nutrient intake. A total of 15, 991 adolescents from the 2018 ENNS was included in the study. Height and weight were used to determine nutritional status. For the drinking status, a structured questionnaire was used to disaggregate adolescent non – binge drinkers from binge drinkers. Food intake was collected on 2 non-consecutive days. Physical activity status was also included as variable in the study using a developed questionnaire based on the WHO STEPS Surveillance Manual. About 16.8 % of the adolescent population were current drinkers, from the current drinkers 4.0% were identified binge drinkers. Adolescent binge drinkers were mostly male (4.5%), were not enrolled in schools (12.4%), and belonged to urban households (4.1%). Majority of energy and nutrient intake were significantly higher among adolescent binge drinkers than non-binge drinkers. Using Chi-square, factors identified to be associated with binge drinking include sex, educational status, urbanity, physical activity and calcium & iron intake. Among overweight and obese adolescents, physical activity was also associated with binge drinking. Based on logistic regression, the likelihood of binge drinking was higher among males (OR: 3.81) and those who are not enrolled in schools (OR: 2.67). The result of this study can be a basis in strengthening existing laws such as P.D. 1619, R.A. 10643 (Graphics Health Warning Law), and other city ordinances that will served as a reference to avoid underage drinking.

1. Introduction

Adolescent ages 10 – 19 years old as defined by the World Health Organization (WHO) is the phase between childhood and adulthood where rapid and evident phases of human development takes place. Therefore, this is a period of life with specific health and development needs ¹. Important developments in different regions of the brain happen during these years. Decision making, organization, impulse control and planning area are developed during these years. Data shows that more than 1.1 million aged 10 – 19 years old died in 2016, or 3000 every day, mostly from avoidable or treatable causes. Among these health issues are mental depression, physical inactivity, nutrition and micronutrient deficiencies, and violence due to influence of drugs and alcohol ². Consumption of alcohol is one of the most common psychoactive substance used by adolescents, majority of this age group was influence by alcohol as early as 12 years old. In the Philippines, there is a fluctuating trend in the percentage of current drinkers among adolescents From a downward trend from 2008 to 2013 (21.7 % and 18.6 %, respectively), there was an upward trend in the percentage of adolescent current drinkers from 2015 to 2018 national nutrition survey (14.9 % to 16.8%, respectively) ³. Curiosity, peer pressure, and environmental factors such as easy access to alcoholic substances significantly contributes to the early engagement of alcohol drinking among adolescents. Consequences of underage drinking may vary from acute to chronic effect to an individual’s health. Short term impairment affects adolescent’s decision – making capacity, as a result, young people may engage in risk – taking behaviour that can lead to illness, injury, and even death brought by the influence of alcohol consumption ⁴. Alcohol consumption during adolescence has an effect on functional and structural changes in the brain that can be carried out into adulthood. Recent studies have demonstrated detrimental effects of early drinking on brain development that are associated with, for example, learning difficulties. Research has also shown that delaying the age at which young people take their first drink lowers their risk of becoming problem drinkers later in life. Strengthening the prevention of underage drinking is also a vital part to ensure optimum quality of life as stated in the Sustainable Development Goal (SDG 3, Good Health & Well Being).

Consuming the right kind and amount of food and beverages is an integral part in the quality of life of an individual and should be taught at a young age. Proper nutrition and hydration are important during adolescent years as this is the period where rapid growth spurt and physical changes in the body becomes evident in preparation towards adulthood.

2. Methodology

The needed variables in this study were culled out from the 2018 Expanded National Nutrition Survey (ENNS) conducted by the Department of Science and Technology – Food and Nutrition Research Institute (DOST – FNRI). The ENNS is a three – year rolling survey which expands data collection that started in 2018, 2019, and 2021 compared to other National Nutrition Surveys and updating surveys which has a six –months coverage. This survey utilized the new 2013 master sample (MS), developed by the Philippine Statistics Authority (PSA), as it’s sampling design. A two – stage cluster sampling design was used wherein the first stage was the selection of primary sampling units (PSUs), composed of Barangays/Enumeration Areas (EAs) or group of adjacent small barangays, followed by the selection of secondary sampling units (SSUs) composed of housing units/households. Each PSU is roughly composed of 100 – 400 households. A total of 40 provinces and highly urbanized cities (HUCs) were covered for the year 2018 while another 40 and 37 areas are expected to be surveyed for the following years ³.

The study was carried out in accordance with the Declaration of Helsinki & the ethical guidelines for biomedical research involving human subjects, and national guidelines for biomedical/behavioral research. The Ethics Committee of the Food and Nutrition Research Institute which composed of medical doctors, public health experts and spiritual leaders approved the survey protocol. All surveyed household members signed informed consent forms prior to the conduct of interviews.

A total of 17,155 adolescents were covered out of the 159,926 total individuals in the ENNS or about 19.7% of the individuals belonged to the adolescent age group. Data on socio economic characteristics, nutritional status, physical activity and dietary were used in this study.

Trained field researchers composed of nutritionist – dietitians and nurses conducted weight and height measurement to determine nutritional status of adolescents using BMI – for – age ⁵. Weight were measured using a 150-200 capacity digital weighing scale (SECA 874), standing height were collected using a Stadiometer (SECA 213).

Face – to – face interviews were done using an electronic data collection system (eDCS) to get information on alcohol consumption. The drinking status was comprised of three groups which include: 1) lifetime abstainers or people who never consumed alcohol; 2) former drinkers or people who have previously consumed alcohol but have not done so in the previous 12 months preceding the survey; and 3) current drinkers or people who were currently consuming during the survey period. Disaggregated groups were binge and non – binge drinkers; life time abstainers, former drinkers, and current drinkers who were not identified as binge drinkers were classified as non – binge drinkers. Binge drinking was defined as drinking 4 or 5 standard drinks in one sitting ^{2, 6}.

Physical activity was collected using a structured questionnaire adapted from the WHO – STEPS surveillance manual ⁷. Insufficient physical activity is defined as a person not meeting three or more days of vigorous activity for at least twenty minutes per day; or five or more days of moderate intensity activity or walking of at least thirty minutes per day.

A two – day, non – consecutive food recall was used to get the average food intake of adolescents. For the first day recall, each respondent was interviewed on their one – day food consumption. For the second day, only 50 % of the sampled households with an existing one – day recall were interviewed for a subsequent recall. For both days, a face – to – face interview was done in which respondents were asked to recall and report all food and beverage consumed during the previous 24 – hour period. Values were expressed in common household measurements such as cups, tablespoons, milliliter, etc. Other tools like measuring cups, spoons and a set of plastic circles (used for estimation of baked goods) and wooden matchbox (to estimate meat products) were also utilized to assist the respondents in the description of their food items consumed.

Statistical analysis was done using STATA version 15.1. Descriptive statistics such as count (N), proportion (%), standard error (SE), mean, and 95 % confidence interval (CI) were used to summarize the sample population. Chi square test of independence was used to identify association between drinking status to the different variables indicated. Factors associated to binge drinking were subjected to logistic regression to measure the value of the relationship between variables. A p-value <=0.05 was considered significant for all analysis performed. To account for the intercensal shifts in the population structure, sampling weights were balanced and post-stratified based on the population projection.

3. Results

Table 2 shows the general profile by drinking status of Filipino adolescents. A total of 15,991 adolescent aged 10 to 19 years old were included in the study, which was composed of mostly male respondents (n=8,122) and majority were enrolled in school institutions (n=14,766). In terms of urbanity, majority of the respondents comes from rural areas (n= 10,857). Majority of the household of the respondents were male – headed and were married. In terms of the educational attainment of the household head mostly are High school and elementary graduate (n =6,697 and n= 6,134, respectively), majority are working or with business (n=13,872). Among all the respondents, households with more than five members (n=8,895) were slightly higher than families with less than five members (n=7,006). Majority of the adolescent binge drinkers were between the age group of 18 to less than 20 years old.

Chi-square test results showed that sex, educational status, urbanity and age groups were associated with binge drinking (Table 8). Using logistic regression, males were almost four times more likely to be engage in binge drinking compared to female (OR: 3.81). As for the educational status, adolescents who are not enrolled were almost thrice more likely to be engaged in binge drinking compared to those enrolled in schools (OR: 2.67).

Stunting prevalence was slightly similar for both groups at 26.1 % for non – binge drinkers and 27.7 % for binge drinkers. For wasting, it was slightly higher among non – binge drinkers at 11.6 % compared to their counterpart at 6.7 %. In contrast, prevalence of overweight and obesity results showed that binge drinkers was slightly higher at 15.4 % compared to 12.6% for non – binge drinkers.

Using Chi-square test, the results showed no association among stunting, wasting, overweight and obese by drinking status among adolescents (Table 3). Using logistic regression, none of the stunting, wasting, or overweight/ obesity, showed to be a significant factor of adolescent drinking (Table 9).

Table 4 shows the association of nutritional status and physical activity of Filipino adolescents. Physical activity status among adolescents showed a highly significant association among stunting, overweight & obese groups (p – value = <0.000**). When disaggregated by nutritional status, physical activity was associated with binge drinking among the overweight/ obese adolescents (p - value = <0.000**) (Table 5).

Mean energy and nutrient intake showed that consumption were significantly higher among adolescent binge drinkers specifically on energy, protein, iron, calcium, total fat, vitamin C, carbohydrates, thiamine, riboflavin, niacin, and vitamin A (Table 6). Using Chi square, calcium and iron intake showed an association with adolescent binge drinking (Table 7). However, using logistic regression, none of the nutrient were identified as a significant factor of binge drinking. (Table 10)

4. Discussion

Adolescence involves a tedious process which extends over a significant period of a person’s life. This period is crucial that will determine an individual’s autonomy and maturity in preparation to adulthood. Major changes occur in terms of their physiological and psychological abilities that should be critically monitored by parents or caregivers to avoid unwanted occurrences through this period and other succeeding life stages ⁸. Adolescent alcohol drinking has been an interest among researchers as this usually is the starting point where other unhealthy lifestyles and health related risk factors may coincide ⁹. The objectives of this study was to determine the relationship between adolescent by disaggregated drinking status to different variables such as socio-economic characteristics, nutritional status, and nutrient intake.

Alcohol and Socio – economic characteristics

Socio –economic status is defined as the social standing or class of an individual or group. A combination of variables like education, income, occupation are carefully considered to determine the social class of an individual or households ¹⁰. For this study, one of the highlights of the results revealed that male adolescent drinkers are significantly higher than females. It is widely reported gender differences in the consumption of alcoholic beverages among males, the ratio of men consuming alcoholic beverages is three times more compared to women ^{11, 12, 13}. In addition, other key difference between sexes is that men produces more enzyme called alcohol dehydrogenase that is responsible for the breakdown of alcohol before reaching the blood stream, making them much more tolerant and more likely to consume a significantly higher amount of alcoholic beverages ¹⁴. Another highlight of this study is the wealth status of the adolescent, significant number of adolescents binge drinkers belonged to urban households. Several studies suggest that higher income among families have a greater possibility to engage in alcohol drinking because of their buying capacity and easy access compared to rural households ^{15, 16, 17}.

Alcohol and Nutritional Status

Nutritional status or the physiological state of an individual that is commonly determine by their stature (weight and height) is widely used to determine if there is a deficiency, excesses or imbalances on their current physiological state ¹⁸. In the same manner, measurement of weight and height was used in this study to determine current nutritional status of the target group. Results have showed that overweight and obesity were associated among adolescent binge drinkers based on the chi -square analysis. Heavy drinking has been greatly associated with higher risk of being overweight and obese ¹⁹. Alcohol is the only substance that provides positive energy to the body, approximately 7.1 calories per gram. This is an intermediate source of energy when compared to major macronutrients such as carbohydrates and protein which both provide 4 calories per gram, and fat which provide 9 calories per gram ²⁰. Moreover, similar studies suggest that binge drinking in young adulthood increases the risk of transitioning to an unhealthy weight class as heavy drinking relates to consuming high caloric content, and therefore may develop non-communicable diseases later in life ^{21, 22}.

Dietary intake

Adolescence is the second most rapid phase in terms of growth after infancy, thus nutrient intake is crucial to meet the needs of the body during this years for optimum development ²³. The results on energy and nutrient intake suggests that adolescent binge drinkers consumed much more macro and micronutrients compared to non- binge drinkers based on the 24 – hour food recall mean intake. In addition, alcohol gives an additional “empty” calories that contributes to the weight gain if an individual. The effect of alcohol on food and energy intake have been studied in several journal articles, pre – load ingestion of alcohol reported a higher consumption of food therefore giving a positive energy balance in the total energy intake of the drinker ^{24, 25}. Moreover, binge drinking have been directly linked to the brain’s reward system. Heavy consumption of alcohol triggers a gradual increase in the reward threshold, it signals the brain to crave for highly palatable foods that is usually have higher amount of fat, thus contributing to more energy intake that might lead to overweight or obesity ²⁶.

Physical activity and alcohol drinking

Consumption of alcohol can give a negative effect on being physical active because of how it affects the motor skills during exercise and the side effects on the brain functions including judgment that can lead to impaired performance whenever engaged in physical activity. Alcohol is a diuretic that can lead to dehydration, during exercise the body needs to be hydrated to maintain flow of blood through our bodies, which is needed for oxygen and nutrients to reach muscles and organs of the body ²⁷. The result of the study suggests those adolescents who are more engaged to binge drinking are more prone to physical inactivity. In a similar study on the relationship between adolescent drinking and physical activity interpreted the same results because of the after effect of alcohol such as hang over, headache, hypersensitivity to lights and sounds can give a significant impact on the attitude and ability to engage in exercise among adolescents ²⁸. Proper hydration and consuming the right kind and amount of food are the keys to maintain the body’s optimum performance whenever engaged to exercise or any other physical activity.

5. Conclusion

Adolescent binge drinking was associated with sex, urbanity, educational status, age group, wasting overweight & obesity, calcium & iron intake. Predictors of binge drinking identified, include age, gender, and educational status. The study results could be used as basis to review existing laws on integration of graphic health warnings on alcoholic beverages and moving up the legal drinking age to 21 years old.

6. Limitations of the Study

The study was culled out from the existing data set of the 2018 Expanded National Nutrition Survey, that is why there were certain limitations in trying to generate better results and analysis as compared to efficacy and controlled studies wherein inclusions and exclusions in the study were applied in the methodology and can generate equal groups. Since this is a national survey the population between adolescent non – binge and binge drinkers were uncontrolled but weighted factors were used to have a sound comparison between groups.

Acknowledgements

The authors would like to extend their sincerest gratitude to the local field researchers for their dedication in collecting the data for the ENNS and to the 39 provinces covered during the first year of the survey. To Ms. Charmaine A. Duante, Officer – in – charge of the Nutritional Assessment and Monitoring Division (NAMD) for approving the study variables and giving additional inputs for this study.

References