Compensatory Eating Behaviors Related to Alcohol Consumption (CEBRACS)

Abstract

The Compensatory Eating Behaviors Related to Alcohol Consumption (CEBRACS) scale is a specialized, 21-item psychometric instrument designed to assess the frequency and nature of compensatory eating and weight-regulation behaviors engaged in before, during, or after alcohol consumption. Developed by J. Kevin Thompson, Courtney J. Rahal, J. B. Bryant, J. Darkes, and J. E. Menzel in 2012 at the University of South Florida, the scale captures the intersection between eating pathology and high-risk drinking behaviors—a phenomenon colloquially termed “drunkorexia.” The CEBRACS measures behaviors across a three-month retrospective timeframe using a 5-point Likert-type scale ranging from 1 (Never) to 5 (Almost all the time). Psychometric evaluation confirms a robust four-factor structure comprising: (1) Alcohol Effects (restricting food to accelerate or heighten alcohol intoxication), (2) Bulimia (purging via vomiting, laxatives, or diuretics), (3) Diet and Exercise (using low-calorie food/drink substitutions and physical exercise to offset alcohol calories), and (4) Restriction (skipping meals or fasting for an entire day to compensate for caloric intake). Across college and young adult populations, the CEBRACS demonstrates exceptional internal consistency (Cronbach’s α ranging from .79 to .92 across subscales, with total scale α exceeding .90), sound test-retest reliability, and robust convergent and discriminant validity with established measures of eating disorder symptoms (e.g., EAT-26, EDI-3), alcohol-related negative consequences, and hazardous drinking patterns (e.g., AUDIT). This comprehensive article provides an exhaustive review of the scale’s theoretical foundation, psychometric properties, structural validity, clinical utility, scoring instructions, and the authentic scale items.

Keywords

CEBRACS, drunkorexia, compensatory eating behaviors, alcohol consumption, disordered eating, binge drinking, alcohol-induced hypoglycemia, psychometrics, factor analysis, collegiate health, bulimic behaviors, dietary restriction

Authors

The Compensatory Eating Behaviors Related to Alcohol Consumption (CEBRACS) questionnaire was developed by a team of clinical psychologists and researchers specializing in body image, eating disorders, and substance misuse at the University of South Florida (USF), Tampa, Florida, USA:

• Courtney J. Rahal, Ph.D. – Department of Psychology, University of South Florida. Primary investigator in the initial psychometric operationalization and validation of the scale.
• J. Kevin Thompson, Ph.D. – Emeritus Professor of Psychology, Department of Psychology, University of South Florida. Internationally recognized authority on body image disturbance, eating disorders, and somatic dissatisfaction. Contact: [email protected] / [email protected].
• J. B. Bryant, Ph.D. – Department of Psychology, University of South Florida. Key researcher in epidemiological and behavioral surveys assessing collegiate drinking patterns and compensatory strategies.
• J. Darkes, Ph.D. – Department of Psychology, University of South Florida. Expert in alcohol outcome expectancies, substance misuse interventions, and campus health psychology.
• J. E. Menzel, Ph.D. – Department of Psychology, University of South Florida. Clinical researcher focusing on sociocultural influences on body image and comorbid eating and substance use phenotypes.

Purpose

The primary purpose of the CEBRACS is to provide a standardized, empirically validated self-report assessment to quantify behaviors where individuals modify their dietary intake or engage in extreme compensatory actions in conjunction with alcohol consumption. In emerging adulthood, particularly within university environments, the convergence of heavy episodic drinking (“binge drinking”) and intense sociocultural pressure to maintain a thin or athletic physique creates a volatile behavioral landscape. Prior to the development of the CEBRACS, clinical researchers lacked a nuanced measurement tool that could separate two distinct yet overlapping motivations driving compensatory behaviors around drinking:

1. Caloric Compensation (Weight-Control Motive): Engaging in caloric restriction, excessive exercise, or purging to prevent weight gain resulting from the high caloric density of alcoholic beverages (ethanol provides approximately 7.1 kcal/gram).
2. Intoxication Enhancement (Pharmacokinetic Motive): Restricting food consumption prior to or during drinking to accelerate gastric emptying, eliminate the “food buffer” in the gastrointestinal tract, and achieve a faster, more intense, or more economical state of intoxication.

Clinically, understanding the specific motivation behind these behaviors is critical. Caloric compensation is frequently rooted in body dissatisfaction, shape concerns, and subthreshold or clinical eating disorders (such as Anorexia Nervosa or Bulimia Nervosa). Conversely, the pharmacokinetic motive often correlates with substance use severity, sensation-seeking, and severe alcohol use disorders. Fasting before heavy drinking produces rapid spikes in Blood Alcohol Concentration (BAC), significantly elevating the risk of alcohol poisoning, blackouts, impaired risk assessment, sexual assault, and alcohol-induced hypoglycemia due to impaired hepatic gluconeogenesis. Therefore, the CEBRACS serves both epidemiological researchers mapping youth health trends and clinicians developing targeted harm-reduction and cognitive-behavioral interventions.

Psychological Construct

The psychological construct assessed by the CEBRACS is multidimensional, capturing maladaptive behaviors situated at the intersection of disordered eating and hazardous alcohol misuse. Unlike general eating disorder inventories that assess general dietary restriction or purging over broad contexts, the CEBRACS contextualizes these actions strictly within the temporal and motivational matrix of alcohol use.

The Four Empirical Dimensions

Factor-analytic investigations by Rahal et al. (2012) and Bryant et al. (2012) established that the 21 items of the CEBRACS resolve into four coherent behavioral dimensions:

• Alcohol Effects (7 items: 1, 3, 6, 7, 9, 12, 14): This subscale measures deliberate food restriction, skipping meals, or complete fasting before or during drinking specifically designed to alter alcohol pharmacokinetics. Individuals scoring high on this dimension intentionally eliminate stomach contents so ethanol enters the small intestine rapidly, leading to steep increases in arterial blood alcohol levels. Typical behavioral manifestations include eating nothing before a party so that fewer drinks are required to become intoxicated.
• Bulimia (6 items: 5, 8, 13, 15, 17, 19): This dimension encompasses radical, medically dangerous purging behaviors executed across all three temporal phases (before, during, and after drinking). Behaviors include self-induced vomiting, taking non-prescribed laxatives, and abusing diuretics to offset the caloric content of alcohol or eliminate alcohol-related calories already ingested. This subscale reflects severe compensatory pathology closely aligned with traditional bulimic symptomatology.
• Diet and Exercise (6 items: 2, 10, 11, 16, 18, 20): This factor evaluates non-purging, culturally normalized forms of energy balancing. It reflects efforts to mitigate the caloric impact of alcohol through intense exercise bouts (before or after drinking sessions), choosing low-calorie or light alcoholic beverages, consuming low-fat or low-calorie food while drinking, or eating smaller meals following an evening of alcohol consumption.
• Restriction (2 items: 4, 21): Distinct from the intoxication-focused fasting captured in the Alcohol Effects subscale, this factor assesses extreme, protracted caloric restriction explicitly pursued for energy compensation. It includes skipping meals prior to drinking to “bank” calories for anticipated alcohol intake, or fasting for an entire day or more after drinking to compensate for calories consumed while intoxicated.

The Temporal Spectrum of Behaviors

The construct is further organized across three distinct chronological phases relative to the drinking episode:

• Anticipatory Phase (Before Drinking): Proactive behaviors occurring hours or days before alcohol consumption, involving pre-planned dietary restriction, preemptive workouts, or prophylactic laxative usage.
• Concurrent Phase (While Under the Effects): In-the-moment behaviors executed during intoxication, such as continuing to fast, refusing snacks, choosing light beverages, or consuming diuretics while socializing at bars or parties.
• Post-Intoxication Phase (After Effects Have Worn Off): Reactive compensatory strategies enacted the following morning or days later, characterized by compensatory purging, post-drinking fasting, guilt-induced cardiovascular exercise, and radical caloric restriction.

Theoretical Framework

The CEBRACS is grounded in several integrative psychological and behavioral models that explain comorbidity between substance use and eating disturbances:

1. The Dual-Motive Behavioral Economic Framework

From a behavioral economic perspective, dietary restriction in the context of alcohol consumption represents a trade-off between competing rewards: caloric regulation (maintaining aesthetic physical standards) and pharmacological reward (achieving euphoria or peer conformity). Individuals operating within this framework view calories as a fungible “currency.” To consume alcohol without exceeding daily caloric allowances, they “trade away” nutrient-dense solid food. Furthermore, those seeking rapid intoxication discover that fasting reduces the financial cost required to attain drunkenness, optimizing perceived physiological utility at high bodily risk.

2. Transdiagnostic Cognitive-Behavioral Theory

According to Fairburn’s transdiagnostic cognitive-behavioral model of eating disorders, over-evaluation of shape and weight forms the core cognitive vulnerability driving severe dietary restraint and compensatory behaviors. When individuals who harbor these cognitive distortions enter environments where heavy alcohol intake is normative (such as college campuses), they encounter profound cognitive dissonance. Alcohol represents “empty calories” that threaten their strict energy balance. To resolve this conflict, the cognitive schema activates compensatory strategies (exercise, fasting, or purging) to neutralize the perceived caloric threat without necessitating social abstinence.

3. Alcohol Outcome Expectancies and Pharmacokinetic Reinforcement

Expectancy theory posits that behavior is mediated by anticipated outcomes. Individuals who hold strong expectancies that alcohol facilitates sociability, tension reduction, or sexual disinhibition are motivated to feel its effects as quickly as possible. The physiological realization that an empty stomach accelerates ethanol absorption creates a powerful operant conditioning loop: skipping food leads to near-instantaneous intoxication, which is reinforced socially and neurologically, cementing the habit of anticipatory fasting.

4. Objectification Theory and Sociocultural Pressures

Sociocultural theories, notably Fredrickson and Roberts’ Objectification Theory, emphasize how Western cultural standards subject young adults—particularly women, though increasingly men—to continuous self-surveillance and pressure to attain lean, muscular, or slender physiques. The desire to conform to these aesthetic ideals directly fuels the Diet and Exercise and Restriction dimensions of the CEBRACS when navigating peer-driven drinking cultures.

Validity

Extensive psychometric investigations have established strong empirical support for the validity of the CEBRACS across diverse samples.

Construct and Convergent Validity

In the seminal validation study by Rahal et al. (2012) involving undergraduate students, CEBRACS subscales demonstrated statistically significant, theory-consistent correlations with established psychometric batteries:

• Correlations with Eating Pathology: The Bulimia, Diet and Exercise, and Restriction subscales correlated moderately to strongly with the Drive for Thinness, Bulimia, and Body Dissatisfaction subscales of the Eating Disorder Inventory-3 (EDI-3), as well as the total score of the Eating Attitudes Test (EAT-26) (Pearson $r$ values ranging from $.35$ to $.62$, $p < .001$). Individuals with higher eating pathology scores reported significantly greater compensatory behaviors surrounding drinking events.
• Correlations with Alcohol Misuse: The Alcohol Effects subscale exhibited strong convergent validity with measures of heavy drinking, correlating significantly with the Alcohol Use Disorders Identification Test (AUDIT) ($r = .42$ to $.55$) and the Rutgers Alcohol Problem Index (RAPI). Furthermore, it correlated positively with peak blood alcohol concentrations and reported frequencies of binge drinking episodes.

Discriminant and Incremental Validity

Discriminant validity was established by demonstrating that the Alcohol Effects dimension diverged conceptually from general dietary restraint measures. While traditional eating disorder questionnaires capture food restriction driven entirely by fear of weight gain, regression models indicated that the Alcohol Effects subscale accounted for unique variance in alcohol-related negative consequences (such as physical injuries, academic impairments, and blackouts) even after controlling for total weekly alcohol consumption and general eating disorder pathology. This confirmed that the CEBRACS measures a distinct, clinically meaningful phenotype rather than merely reflecting generalized disordered eating or non-specific alcohol misuse.

Criterion and Predictive Validity

Prospective and cross-sectional studies have demonstrated that high scores on the CEBRACS predict elevated rates of alcohol-related harms. In particular, endorsement of items on the Bulimia and Alcohol Effects subscales prospectively predicts emergency room admissions, legal complications, unintended sexual encounters, and severe physiological distress following drinking occasions.

Reliability

The CEBRACS exhibits high reliability across varied demographic groups and academic environments.

Internal Consistency

In the initial psychometric validation by Rahal et al. (2012) ($N = 457$), internal consistency estimates using Cronbach’s alpha (α) confirmed high reliability across the four factors and the total instrument:

• Alcohol Effects Subscale: α = .90 – .92 (demonstrating outstanding item homogeneity).
• Bulimia Subscale: α = .82 – .85 (indicating strong consistency among diverse purging modalities).
• Diet and Exercise Subscale: α = .81 – .84.
• Restriction Subscale: α = .79 – .82 (acceptable to strong reliability, especially given this subscale consists of two items).
• Total CEBRACS Scale: α = .91 – .93.

Subsequent investigations across independent collegiate cohorts (e.g., Bryant et al., 2012) confirmed comparable coefficients, with McDonald’s omega (ω) hierarchical values mirroring alpha estimates, confirming that composite scores reflect a single overarching construct supported by distinct sub-dimensions.

Temporal Stability (Test-Retest Reliability)

Evaluations of test-retest reliability over a two- to four-week interval demonstrated intraclass correlation coefficients (ICCs) ranging from $.78$ to $.88$ across subscales. This indicates that while the behaviors are episodic and tied to social calendars, self-reported behavioral patterns remain stable over short-to-medium measurement intervals in non-treatment-seeking young adults.

Factor Analysis

The latent structure of the CEBRACS was originally identified through Exploratory Factor Analysis (EFA) and subsequently confirmed through Confirmatory Factor Analysis (CFA).

Exploratory Factor Analysis (EFA)

During scale development, Rahal et al. subjected an initial item pool of candidate behaviors to principal axis factoring with oblique (Promax) rotation, reflecting the theoretical expectation that compensatory dimensions would correlate. Examination of the scree plot and eigenvalues (> 1.0 criterion) revealed a four-factor solution that accounted for roughly 61% of the total variance:

• Factor 1 (Alcohol Effects): Factor loadings ranged from $.64$ to $.89$, capturing items where restriction was motivated by wanting to get drunker or feel effects faster (Items 1, 3, 6, 7, 9, 12, 14).
• Factor 2 (Bulimia): Factor loadings ranged from $.52$ to $.84$, capturing laxative, diuretic, and vomiting behaviors across all phases (Items 5, 8, 13, 15, 17, 19).
• Factor 3 (Diet and Exercise): Factor loadings ranged from $.45$ to $.78$, capturing exercise, diet drinks, and low-calorie food choices (Items 2, 10, 11, 16, 18, 20).
• Factor 4 (Restriction): Factor loadings ranged from $.68$ to $.85$, isolating extreme skipping of meals or full-day fasting for caloric compensation (Items 4, 21).

Confirmatory Factor Analysis (CFA)

Subsequent cross-validation studies using independent samples verified the four-factor correlated model. Goodness-of-fit indices demonstrated acceptable to excellent fit to the data:

• Comparative Fit Index (CFI): .94 – .96
• Tucker-Lewis Index (TLI): .93 – .95
• Root Mean Square Error of Approximation (RMSEA): .048 – .058 (with 90% confidence intervals below .065)
• Standardized Root Mean Square Residual (SRMR): .042 – .051

Alternative models, including a single-factor unidimensional model and an orthogonal four-factor model, exhibited substantially poorer fit, confirming that compensatory eating behaviors related to alcohol consumption operate as a correlated multidimensional construct.

Instrument / Measurement Tool

The practical administration, structural parameters, and scoring protocols of the CEBRACS are summarized below:

• Test Type: Standardized self-report rating scale / behavioral frequency questionnaire.
• Target Population: Emerging adults, university students, and clinical populations exhibiting co-occurring alcohol misuse and eating concerns. Suitable for ages 18 and older.
• Administration Format: Paper-and-pencil or secure digital survey platforms (e.g., Qualtrics, REDCap).
• Completion Time: Approximately 5 to 8 minutes.
• Number of Items: 21 items organized across three temporal instructional headers: BEFORE drinking (Items 1–6), WHILE under the effects of alcohol (Items 7–14), and AFTER effects from alcohol have worn off (Items 15–21).
• Recall Period: Past 3 months.
• Response Scale: 5-point Likert-type frequency scale:
  • 1 = Never
  • 2 = Rarely (about 25% of the time)
  • 3 = Sometimes (about 50% of the time)
  • 4 = Often (about 75% of the time)
  • 5 = Almost all the time
• Subscale Item Breakdown:
  • Alcohol Effects Subscale: Items 1, 3, 6, 7, 9, 12, 14 (7 items; raw score range: 7 to 35).
  • Bulimia Subscale: Items 5, 8, 13, 15, 17, 19 (6 items; raw score range: 6 to 30).
  • Diet and Exercise Subscale: Items 2, 10, 11, 16, 18, 20 (6 items; raw score range: 6 to 30).
  • Restriction Subscale: Items 4, 21 (2 items; raw score range: 2 to 10).
• Scoring Rules: All items are positively keyed (no reverse-scored items). Subscale scores can be derived either as sum scores (raw totals) or as mean scores (sum divided by number of items, maintaining the 1 to 5 metric for cross-subscale comparison). A Total CEBRACS Score is computed by summing all 21 items (range: 21 to 105) or taking the grand mean across all items.
• Clinical Interpretation: Higher scores denote greater frequency of high-risk compensatory behavior. Any endorsement above 1 (Never) on the Bulimia subscale (especially Item 19: self-induced vomiting) or Restriction subscale (Item 21: skipping an entire day) signals clinical risk requiring comprehensive evaluation for eating disorders and hazardous alcohol dependence.

Permissions & Fee and Test Year

The CEBRACS was developed and published in 2012. The copyright for the initial validation article is held by Elsevier Inc. on behalf of Eating Behaviors. However, the instrument itself was created for academic, scientific, and clinical assessment purposes.

Permissions & Access: The scale is generally available free of charge for non-commercial research, academic, and clinical screening uses. Researchers and clinicians wishing to employ the instrument in empirical studies or formal clinical protocols are encouraged to contact the senior author to request permission, obtain testing guidelines, and ensure proper scholarly attribution:

Contact Information:
J. Kevin Thompson, Ph.D.
Department of Psychology, University of South Florida
4202 Fowler Ave, PCD 4118G, Tampa, FL 33620-8200, USA
Email: [email protected] / [email protected]
Online archive: USF Body Image Research Group Measures

References

• Bryant, J. B., Darkes, J., & Rahal, C. (2012). College students’ compensatory eating and behaviors in response to alcohol consumption. Journal of American College Health, 60(5), 350–356. https://doi.org/10.1080/07448481.2011.630703
• Fairburn, C. G., Cooper, Z., & Shafran, R. (2003). Cognitive behaviour therapy for eating disorders: A “transdiagnostic” theory and treatment strategy. Behaviour Research and Therapy, 41(5), 509–528. https://doi.org/10.1016/S0005-7967(02)00088-8
• Fredrickson, B. L., & Roberts, T. A. (1997). Objectification theory: Toward understanding women’s lived experiences and mental health risks. Psychology of Women Quarterly, 21(2), 173–206. https://doi.org/10.1111/j.1471-6402.1997.tb00108.x
• Giles, S. M., Champion, H., Sutfin, E. L., McCoy, T. P., & Wagoner, K. (2009). Caloric restriction on drinking days: An examination of ‘drunkorexia’ among college students. Journal of American College Health, 57(6), 603–609. https://doi.org/10.3200/JACH.57.6.603-610
• Papas, M. A., & Martin, C. M. (2020). Compensatory eating behaviors in response to alcohol consumption: A systematic review. Addictive Behaviors Reports, 12, 100295. https://doi.org/10.1016/j.abrep.2020.100295
• Rahal, C. J., Bryant, J. B., Darkes, J., Menzel, J. E., & Thompson, J. K. (2012). Development and validation of the Compensatory Eating and Behaviors in Response to Alcohol Consumption Scale (CEBRACS). Eating Behaviors, 13(2), 83–87. https://doi.org/10.1016/j.eatbeh.2011.11.001
• Saunders, J. B., Aasland, O. G., Babor, T. F., de la Fuente, J. R., & Grant, M. (1993). Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption–II. Addiction, 88(6), 791–804. https://doi.org/10.1111/j.1360-0443.1993.tb02093.x

13. Items of the Scale (Questionnaire)