The Dangers of Alcohol Use Disorder & Eating Disorders

Eating disorders and alcohol use disorders often co-occur, with individuals using both food and alcohol as coping mechanisms. Up to 41% of patients with bulimia nervosa also have alcohol use disorder. These conditions often reinforce each other, as alcohol may exacerbate disordered eating behaviors and vice versa. Treatment for both issues typically involves a comprehensive approach by offering strategies to manage both alcohol use and disordered eating.

Is Alcohol Use Common with Eating Disorders?

Co-occurring eating disorders and alcohol use disorder (AUD), colloquially known as “drunkorexia,” are exceptionally common, with a higher prevalence of AUD among patients with eating disorders and a greater rate of eating disorders in patients with alcohol use disorder.

The most common co-occurrence is observed in people with bulimia nervosa, with up to 41% of individuals suffering from both bulimia and alcohol use disorder, which is four times greater than in those with anorexia nervosa.¹

Both chronic alcohol use and eating disorders increase the risk of developing refeeding syndrome, a potentially life-threatening condition.² Both conditions also share a high mortality rate, underscoring the importance of effective treatment for each condition.

Restricting Food Before Drinking

Because alcohol consumption is a significant part of college life, holidays and milestones, many individuals with an eating disorder restrict their food intake to offset the calories from drinking alcohol.

While drunkorexia is often discussed in the context of college life, it’s not limited to college campuses. Studies show that up to 67% of people restrict food intake to offset the calories from alcohol.^3,4

When is Drinking Alcohol Problematic?

One way to identify if a patient frequently drinks too much is to track their alcohol intake. According to the National Institute on Alcohol Abuse and Alcoholism, alcohol consumption is categorized into three levels:⁵

• Moderate drinking: limiting alcohol intake to two drinks or less in a day for men or one drink or less in a day for women.
• Binge drinking: a pattern of drinking alcohol that brings blood alcohol concentration (BAC) to 0.08% or higher. For a typical adult, this pattern corresponds to consuming five or more drinks for men, or four or more drinks for women, in about two hours
• High intensity drinking: consumption of two or more times the sex-specific thresholds for binge drinking. This means ten or more standard drinks for men and eight or more for women
• Heavy drinking: drinking more than four drinks on any day or more than fourteen drinks per week for men and drinking more than three drinks on any day or more than seven drinks per week for women

Medical Complications of Substance Use & Eating Disorders

The combination of a substance use disorder (SUD) like alcoholism and eating disorders can be fatal. Eating disorders and SUDs are the two most lethal psychiatric disorders. Mortality from anorexia nervosa is six times higher than the general population, and when you combine it with alcohol use, the mortality jumps to nearly 12 times higher than those without SUD.⁶ The prevention and treatment of AUD in this patient group is of the utmost importance to reduce mortality.

Alcohol poisoning

Consuming a large amount of alcohol quickly can cause alcohol poisoning, which can suppress vital functions like breathing, heart rate and body temperature. These functions might already be compromised by malnutrition in individuals with eating disorders. 

Patients with eating disorders might also be prescribed psychiatric medications that can interact with alcohol, raising the risk of adverse effects or alcohol poisoning.

Refeeding syndrome

Individuals who consume excessive amounts of alcohol are at increased risk for refeeding syndrome for several reasons:

• Those with alcohol use disorder often replace nutrient-dense foods with alcohol, which contributes to weight loss and malnutrition^3,4,7 and is the main risk factor for developing refeeding syndrome when increased calories are introduced.
• People who consume excessive alcohol are at a higher risk of developing thiamine deficiency.⁸ Thiamine (vitamin B1) is a crucial cofactor in many metabolic pathways. When feeding is resumed, increased thiamine levels are necessary, as metabolic pathways may become dysregulated without enough vitamin B1, contributing to the clinical pentad observed in refeeding syndrome.
• Excess alcohol consumption can lead to magnesium loss, and additional magnesium decline during refeeding may contribute to refeeding syndrome.^2,9

Zinc deficiency

Zinc deficiency is often seen in patients with alcohol use disorder.¹⁰Low zinc levels may result from dietary deficiency, increased urinary loss, abnormal activation of specific zinc transporters or increased production of hepatic metallothionein. This can cause:¹⁰

• Skin lesions
• Impaired wound healing
• Slow liver regeneration
• Altered mental status
• Impaired immune system

Malnutrition

Alcoholism can disrupt normal nutrition, leading to malnutrition or deficiencies in essential macro and micronutrients.¹⁰ Those undergoing treatment for AUD have reported consuming as much as 50% of their total calories from alcohol.¹⁰

Heavy drinking has also been associated with a deficiency in:¹⁰

• Magnesium
• Selenium
• Thiamine (vitamin B1)
• Riboflavin (vitamin B2)
• Vitamin A
• Vitamin C
• Vitamin D
• Vitamin E
• Niacin
• Folate

Neurological issues

Chronic alcohol consumption can lead to neurological complications, including irreversible cognitive dysfunction (Korsakoff syndrome), Wernicke encephalopathy, alcoholic cerebellar degeneration and many others.^10,11

Blacking out

Drinking too much alcohol or drinking on an empty stomach can make a person get drunk faster, causing a rapid increase in blood alcohol levels. This can be very risky and may lead to a person blacking out (temporarily losing memory).

During a blackout, a person can still function normally, but because their inhibitions are lowered and they act more impulsively, they might engage in behaviors they usually wouldn't, such as drug use or driving.

Alcohol can also affect autonomic responses, including the gag reflex. A person who’s blacked out is at risk of vomiting while sleeping, and due to loss of reflex control, may choke or suffocate on their vomit.

Injury

Loss of coordination from alcohol use is also very common, increasing the risk of falling or injuring oneself, which can be especially dangerous for individuals with eating disorders who have low bone mineral density.

Dehydration

Excessive alcohol intake can lead to dehydration. Alcohol decreases the body's ability to retain water, which increases urine production. If insufficient water is consumed while drinking alcohol, it can result in dehydration. Dehydration may worsen existing complications of an eating disorder and malnutrition, such as:¹²

• Tiredness
• Headache or confusion
• Dizziness, weakness or light-headedness
• Hypotension
• Constipation and other gastrointestinal complaints
• Electrolyte complications

Treating Co-occurring Alcohol Use Disorder & Eating Disorders

Treating co-occurring alcohol use and eating disorders requires a comprehensive, multidisciplinary approach. Medical detox, nutritional support and evidence-based therapies like dialectical behavioral therapy are effective at addressing a person’s physical and mental health.

Alcohol detoxification

During alcohol detoxification (detox), alcohol is cleared from the body. Patients with AUD who have developed alcohol dependence face risks of experiencing both physiological and psychological symptoms of alcohol withdrawal, including serious symptoms such as:¹³

• Headaches
• Decreased appetite
• Anxiety or irritability
• Insomnia
• Heart palpitations
• Tachycardia
• Hypertension
• Tremors
• Confusion or delirium
• Hallucinations
• Seizures

Due to the dangers of alcohol withdrawal, patients should always undergo detoxification under medical supervision. This is especially important for patients with a co-occurring eating disorder because of the increased risk of cardiac complications.

Nutrition therapy

Considering the higher risk of malnutrition and refeeding syndrome in individuals who consume large amounts of alcohol, nutritional rehabilitation can be a vital part of treatment during detoxification and ongoing substance use recovery.

Psychotherapy for Alcohol Use Disorder & Eating Disorders

Process model of emotional regulation

Using the process model of emotional regulation, patients can understand how they process their feelings at any moment or during specific situations. This model helps patients recognize when emotional regulation is needed and encourages them to reevaluate their thoughts about a situation to affect their emotional response.

Symptoms of SUD and eating disorders increase when patients use maladaptive emotion regulation skills, such as rumination, suppression, and avoidance. Improving the ability to regulate emotions helps patients better manage and cope with their feelings effectively and appropriately.

Dialectical behavioral therapy

Dialectical behavior therapy (DBT) is a type of psychotherapy that emphasizes mindfulness, interpersonal skills, distress tolerance and emotional regulation. It is particularly effective for individuals who experience intense emotions. It can be an effective treatment for patients with co-occurring eating disorders and SUD, who may engage in disordered eating behaviors and substance use to manage overwhelming emotions.

Getting Help for Alcohol Use & An Eating Disorder

Both substance use disorder and an eating disorder can significantly impact your physical health, mental functioning and overall quality of life. Prioritizing withdrawal treatment and preventing refeeding syndrome are essential to ensure you can recover safely during eating disorder treatment.

References

1. Dansky, B. S., Brewerton, T. D., & Kilpatrick, D. G. (2000). Comorbidity of bulimia nervosa and alcohol use disorders: Results from the National Women’s Study. International Journal of Eating Disorders, 27(2), 180–190. https://doi.org/10.1002/(sici)1098-108x(200003)27:2
2. Da Silva, J. S. V., Seres, D. S., Sabino, K., Adams, S. C., Berdahl, G. J., Citty, S. W., Cober, M. P., Evans, D. C., Greaves, J. R., Gura, K. M., Michalski, A., Plogsted, S., Sacks, G. S., Tucker, A. M., Worthington, P., Walker, R. N., & Ayers, P. (2020). ASPEN Consensus Recommendations for Refeeding Syndrome. Nutrition in Clinical Practice, 35(2), 178–195. https://doi.org/10.1002/ncp.10474
3. Giles, S. M., Champion, H., Sutfin, E. L., McCoy, T. P., & Wagoner, K. (2009). Calorie restriction on Drinking Days: An examination of drinking consequences among college students. Journal of American College Health, 57(6), 603–610. https://doi.org/10.3200/jach.57.6.603-610
4. Bowden, J., Harrison, N. J., Caruso, J., Room, R., Pettigrew, S., Olver, I., & Miller, C. (2022). Which drinkers have changed their alcohol consumption due to energy content concerns? An Australian survey. BMC Public Health, 22(1). https://doi.org/10.1186/s12889-022-14159-9
5. Understanding alcohol Drinking Patterns | National Institute on Alcohol Abuse and Alcoholism (NIAAA). (n.d.). https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-drinking-patterns
6. Mellentin, A. I., Mejldal, A., Guala, M. M., Støving, R. K., Eriksen, L. S., Stenager, E., & Skøt, L. (2022). The impact of alcohol and other substance use disorders on mortality in patients with eating disorders: a Nationwide Register-Based Retrospective cohort study. American Journal of Psychiatry, 179(1), 46–57. https://doi.org/10.1176/appi.ajp.2021.21030274
7. White, B., & Sirohi, S. (2024). A Complex Interplay between Nutrition and Alcohol use Disorder: Implications for Breaking the Vicious Cycle. Current Pharmaceutical Design, 30(23), 1822–1837. https://doi.org/10.2174/0113816128292367240510111746
8. Subramanya, S. B., Subramanian, V. S., & Said, H. M. (2010). Chronic alcohol consumption and intestinal thiamin absorption: effects on physiological and molecular parameters of the uptake process. AJP Gastrointestinal and Liver Physiology, 299(1), G23–G31. https://doi.org/10.1152/ajpgi.00132.2010
9. Vanoni, F. O., Milani, G. P., Agostoni, C., Treglia, G., Faré, P. B., Camozzi, P., Lava, S. a. G., Bianchetti, M. G., & Janett, S. (2021). Magnesium Metabolism in Chronic Alcohol-Use Disorder: Meta-Analysis and Systematic Review. Nutrients, 13(6), 1959. https://doi.org/10.3390/nu13061959
10. Barve, S., Chen, S., Kirpich, I., Watson, W. H., & Mcclain, C. (2017). Development, Prevention, and Treatment of Alcohol-Induced Organ Injury: The Role of Nutrition. PubMed, 38(2), 289–302. https://pubmed.ncbi.nlm.nih.gov/28988580
11. Charness, M. (2025, August). Overview of the chronic neurologic complications of alcohol. UpToDate. https://www.uptodate.com/contents/overview-of-the-chronic-neurologic-complications-of-alcohol
12. Dehydration. (2025, July). Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/9013-dehydration
13. Hoffman, R., & Weinhouse, G. (2025, August). Management of moderate and severe alcohol withdrawal syndromes. UpToDate. https://www.uptodate.com/contents/management-of-moderate-and-severe-alcohol-withdrawal-syndromes