Note: Tables and figures
of the article can be accessed and seen in the PDF file.
Recently, Welcome and co-authors reported that alcohol
use reduces academic performance by about 7-12%. The
negative effect of alcohol use in this study was
apparent even at a non-regular use of alcoholic
beverages in small doses1. Regardless of the
enormous epidemiological data on students’ drinking
behaviors, the fact that alcohol use reduces academic
performance remains disputable2. Any
scientific data that will address this issue will be of
factors like stress, cognitive abilities, competency in
blood glucose maintenance might determine the level of
Decrease in the concentration of glucose leads to a
lowering of cognitive functions4. Glucose is
the main energy source for the brain (in anabolic, as
well as, in catabolic phase of metabolism)4-6.
The functional activity of the central nervous system
correlates with intensiveness of brain glucose
the nervous system, the liver is the main target organ
of the toxic effects of ethanol. The liver plays a
central role in maintenance of blood glucose homeostasis6,10.
might be assumed that intensive mental activities under
maximum stressed condition4,10,11, even in a
period of fasting, can cause hypoglycemia or even
hyperglycemia6 as a result of the increase in
the energy support for brain functions4-6,
and this might allow to finding some peculiarities in
blood glucose homeostasis control among alcohol users7-11.
therefore, test a model of students’ alcohol use
(involving the analysis of blood glucose homeostasis
control under long-term continuously stressed mental
activities of drinkers and non-drinkers) that might
define the pathogenetic mechanisms of alcohol use on
academic performance of students.
Methodology and Materials
Study population and location:
The study was conducted among male seniors of the
Belarusian State Medical University, Minsk, Belarus.
Firstly, this was based on the assumption that juniors
might not present any statistically significant
differences in academic performance between alcohol
users and the abstainers. Secondly, considering the dose
time dependent effect of alcohol confirmed in our later
study1 among male students, in which the
negative effect of alcohol use was only apparent after
the second school year. Thirdly, the seniors (especially
of fourth year) were much available for the study.
Sampling size and technique:
Twenty (20: 10 abstainers and 10 moderate alcohol users)
fourth year males medical students of the Belarusian
State Medical University, Minsk, were at random
explained the study aims and objectives one month before
the experiment. All students were told not to use
alcoholic beverages of any composition at least one week
before the study. Two weeks before the study, consent
forms were given to each of the 20 medical students to
approve their participation, 7 of them refused to
participate for unknown reasons. The medical students
who volunteered to participate were briefed on what they
should and should not take to ensure their daily calorie
intake of 2200-2600kcal/person/day. The students were of
simple daily diets with 3-4 times daily food intake
[maximum intake per person/day – not more than 400g of
glycemic carbohydrates e.g. of parboiled rice, 80-100g
of protein, including vegetable oil, spinach, carrots,
cornflakes, multi-fruit juice in the previous days
before the experiment]11,12.
randomly selected based on a screening survey conducted
in the Belarusian State Medical University. Out of 1499
respondents, 17.5% (262) students were problem drinkers
and 70.2% (1052) moderate drinkers and 12.3% (185) were
abstainers. The criteria used in the screening were
based on the following AUDIT scores: 1 through 7 –
moderate alcohol users; ≥8 – problem drinkers.
Abstainers had a zero (0) score1.
alcohol users were considered. On the average they use
40ml of absolute ethanol per month. They were told not
to exceed their normal alcohol intake, even before the
weeks prior to the experiment.
Abstinence for at
least a week before the experiment day. This was based
on the fact that acute effects of alcohol have been
greatly studied, however, its aftereffects (even after a
week’s interval of alcohol use is unknown). Besides,
significant differences in the intervals of alcohol use
among the moderate alcohol users might lead to different
variations in the blood glucose level.
No cases of chronic
alcohol intoxication, antisocial behavior, and
psychiatric anamnesis or multidrug use (two or more,
except for alcohol) during the period of study in the
university. Good daily regime – at least 6-7 hrs of rest
per day, 3-4 times daily food intake and good physical
Absence of hearing
and visual impairments as recorded in their medical
The Ethics and Research Committee of the Belarusian
State Medical University approved the study protocol.
All medical students confirmed their consent form on
participation on the day of the experiment.
General outline of the processes of the
The experiment was divided in three phases (phase I –
from 000 – 230 hrs; phase II -
from 230 – 400 hrs; phase III -
from 430– 600 hrs) and took 6.5
hrs of intensive mental work of increasing difficulty in
a condition of fasting. Mental work of increasing
difficulty involved two types of works – performing
standard tests (memory and attention tasks) by
determining the intellectual capacity (IC), as well as
mental work of increasing difficulty (filling of various
reading of texts
providing answers to the questions on the read texts).
Two texts were considered for use in the study. The
first text “Physiology of Bone Tissue”13 was
administered in the second phase, while the second text
“Physiology of Autonomic Nervous System”13
was used in the third phase. These two texts were
selected as intensive mental activities since they were
of significantly large page numbers and included
information that had been taught students in their first
to third school year syllabus.
tests on IC, results of blood glucose determination,
including all questionnaires filled by the participants
were marked and numbered by ordinal numbers as the study
rationale for using multiple memory tests and many
questionnaires in this study was to produce a maximum
stressed condition for the subjects. This was based on
the assumption that 2-4 hrs unstressed mental activities
might not show any significant differences in both the
blood glucose level and the mental activities between
alcohol users and non-alcohol users6,14. All
participants were confined during the study duration so
as to ensure no contamination in the experiment. They
were all subjected to standard mental activities of the
Flow of the processes
The phases and order in which the experiment was
conducted are described as follows:
Phase I (from 000 – 230
hrs of the experiment):
The 1st phase of the experiment was conducted
according to the following layout: The first 1/2 hrs
involved the 1st blood sampling, followed by
initial tests of Intellectual Capacity, IC on various
memory/attention tasks, as well as answering of the Big
Five Trait questionnaire and State Trait Anxiety
Inventory, and STAI.
next 1.5 hrs the participants answered on the following
questionnaires – AUDIT (Alcohol Use Disorders
Identification Test), MAST (Michigan Alcohol Screening
Test), CAGE (the Cut, Annoyed, Guilty and Eye
questionnaire), “General”, and Academic
Performance (results were filled from result cards).
last 1/2 hrs of the first phase involved the 2nd
blood sampling followed by the 2nd test of IC
on various memory/attention tasks, answering of the Big
Five Trait questionnaire, and STAI.
Phase II (from 230 – 430
hrs of the experiment):
As soon as the participants had finished answering on
the last questionnaires in the 1st phase, for
the next 1.5 hrs, they worked with the first text (a 20
page text on Physiology of Bone Tissue) with subsequent
performance of a control test exercise containing 43
last 1/2 hrs of the 2nd phase was meant for
the 3rd blood sampling, 3rd test
of IC on various memory/attention tasks and answering of
the Big Five Trait questionnaire, and STAI.
Phase III (from 430– 630
hrs of the experiment):
Immediately after filling the questionnaires on the 2nd
phase, participants started reading the second text and
subsequently performed a control test exercise that
followed it. This took 1.5 hrs.
last 1/2 hrs of the experiment was meant for the 4th
blood sampling, 4th test of IC on various
memory/attention tasks, answering of the Big Five Trait
questionnaire, and STAI.
Scoring Mechanisms of the various Questionnaires/Texts
used in the study
A total score of 3 or more was considered problematic
Any positive score of 2 through 4 is considered
clinically significant (problem drinking)1.
Is a highly reliable instrument for evaluation
of the state of anxiety. The result of the STAI was
conducted according to Spielberger and coauthors15,16.
(See Spielberger & Krasner, 1988 for details of STAI
scoring pattern). The test contains two subscales which
clearly differentiate between the temporary condition of
"state anxiety" (STAIS-Anxiety scale) and the more
general and long-standing quality of "trait anxiety" –
STAIT-Anxiety scale. The range of scores is 20-80. The
higher the score the greater the anxiety level.
The Big Five Trait
was modified according to John et al (2008) and
was meant for the determination of the degree of
intensity of neuropsychic stress, in the subjects17.
(See John et al 2008 for more information). An
average score somewhere at 30-40% is considered normal
The questionnaire on
contained 53 questions for determination of general
information (exception of name/surname) about the
subjects, sex, age, physical activeness, daily routine,
food regimen, religion.
All subjects entered their examination scores (including
resit examination scores) from examination cards for all
periods of study in the Belarusian State Medical
University into the questionnaire on “academic
performance”. The name of examinations were not stated,
but were coded by ordinal numbers in relation to the
semesters. The filling of examination scores was
controlled by one of the authors, M.O.W. The collected
data were used as objective criteria for academic
activities of the subjects. Two major criteria were
calculated: Grade Point Average (GPA) of examination
results for the 1st, 2nd, 3rd,
4th, 5th and 6th
semesters; success or effectiveness to sit for
examinations for the 1st time – 100%, 2nd
time – 50% and 3rd time – 25%. Analysis of
academic performances of students in Belarusian
institutions is determined on the 10-point scale. An
equivalent of this scale is the 100% scale. On the
10-point scale, a score of 1=10%; 2=20%; 3=30%; 4=40%;
5=50%; 6=60%; 7=70%; 8=80%; 9=90% and 10=100% . A
minimum score in examination caries a total of 1 point
on the 10-point scale. A maximum score is set at 10. A
score of 1, 2, and 3 is considered unsatisfactory with a
necessity of resit examination for that given
The control test
exercise on the first text “Physiology of Bone Tissue”
contained 43 questions, so results were calculated as
IC, ability to master the read text with the formula:
IC=100 (43–M) / 43, where M – sum of two numbers (number
of incorrect answers + number of questions without
The control test
exercise on the second text “Physiology of Autonomic
contained 46 questions. No student was able to finish
the second text and the questions that followed it. As a
result IC was calculated thus: IC=100 (Q–M) / Q, where Q
– number of questions with answers; M – number of
Blood glucose measurement:
Glucose concentration in the plasma of capillary blood
was measured as initial and in course of the experiment
(after 2, 4, and 6 hours of mental activities) in all
students using the glucometer – Bionime (RightestTM
GM100)18, with an accuracy up to 0.11mmole/L.
Blood sampling was done in volumes of 20 microliter from
the ring finger of the left hand by skin puncture with
disposable lancets under sterile conditions. The blood
test was performed by one of the authors, M.O.W.
Determination of mental
activity (Intellectual Capacity, IC on various tasks)
Standard tests for determining IC involved the
following: estimation of visual short-term memory,
auditory short-term memory and operative short-term
memory and processes of thinking, as well as conduction
of proof-correction tests on attention19-27.
Determination of auditory short-term
Auditory STM was determined using single-digit numeral
and two-digit vowel letters on increasing row from 3 to
10 numerals or letters, according to the following
The subjects were instructed to write down single-digit
numeral into the blank spaces of increasing row (from 3
to 10) provided, immediately after they were voiced by
one of the authors M.O.W. Subsequently, after the
numbers were voiced, the subjects were required to write
down the remembered ones in the sequence in which they
have heard it. The determination of auditory STM for
two-digit vowel letters was conducted the same way. The
time interval to completing the task for each row on the
average took 30-60 seconds. The first row, where any
incorrectly or not sequentially written numbers or
letters occur was considered a mistake with no
possibility of calculating the results of other rows
below. The number of correct answers was calculated
according to the formula: IC = 100 (A-M) / 10, where A –
number of answers to be written; M – number of mistakes
(incorrectly written numbers or letters).
Determination of visual short-term memory
Determination of visual STM was done according to the
following layout19,20,23-25 with
modifications. The subjects within 40 seconds were
introduced 10 two-digit numbers (any from 10th
to 99th) in different sequences. Subsequently
within 150 seconds after introduction of the numbers,
the subjects were supposed to have reproduced all
remembered numbers in unconditioned sequence. The number
of correct answers was calculated according to the
formula: IC = 100 (A-M) / 10, where A – number of
answers to be reproduced; M – number of mistakes
(incorrectly reproduced numbers).
Determination of thinking
Determination of thinking capacity was carried out using
simple arithmetic (on the level of simple logical
deduction with a single correct answer: addition and
subtraction). Operative memory calculation was carried
out according to the results of solved arithmetical
problems with a single-digit answer in the test
“arithmetical calculation”28,29 which was
carried out by the subjects within 20 seconds. The IC
and the speed of calculation according to the average
duration in accomplishing one problem (task) were
analyzed. IC = 100 (S–M) / P, where S – total number of
solved problems; M – number of mistakes (incorrectly
Determination of attention:
Attention was determined on the proof-correction test
using geometric tables21,26,27 (the table
contained 1600 symbols, where 200 symbols were needed to
be marked or configured correctly, and time of
completion of the test - not more than 5 minutes). The
Intellectual Capacity was calculated using the formula:
IC =100 (200–M) / 200, where 200 – number of symbols of
required configuration in the table; M – number of
mistakes (un-configured symbols or incorrectly marked
symbols). Visual Productivity Coefficient, VPC was
calculated thus: VPC = (0.5436*N–2.807*M) / Т, where N –
number of viewed symbols (maximum number = 1600); 0.5436
(bytes/symbol) – average volume of information that
equals one symbol; 2.807 (bytes/symbol) – loss of
information that equals one un-configured symbol or
incorrectly marked symbols; M – number of mistakes
(un-configured or incorrectly marked symbols); T – time
spent on the performance of the test in seconds (maximum
of 300 seconds).
Statistical calculations were performed using the SPSS
(The Statistical Package for the Social Sciences) 16.0
version for Windows. The probability value for
significance was set at p<0.05. All volumes of
alcohol used are given in values of pure ethanol. A
standard drink was set at 8g (10 ml) of absolute
ethanol. Results are reported and displayed as means and
standard error of means, M±m, as well as in percentages,
%. The Spearman rho, ρ was employed for correlation
analysis between the blood glucose level (independent
variable) and the effectiveness of mental activities
(total number of errors) and academic performance as the
All participants in this study were Christians. The
controlled diet intake for both groups and the body
weight were recorded (Table 1). The overall response
rate for the study was 65% (i.e. 13 out of 20 students
participated). According to the screening results 5
students were abstainers (non-alcohol users i.e.
controls – group № 1), while 8 were alcohol users (cases
– group № 2). The average statistical results of the
controls and cases according to the AUDIT, CAGE and
MAST, including volume of alcohol used are reported in
five percent (75%) of the alcohol users use alcohol once
a month, while 25% – twice per month. Six (6) students
reported non-alcohol use before entrance into the
moderate drinkers did not use alcoholic beverages of any
composition for 7-10 days before the experiment.
alcohol users, 37.5% cases of alcohol related injuries
were reported. The average volume of alcohol use was
reported as 23 ml/per session with 1.25 frequency of use
results of the Big Five Trait Questionnaire showed
increase in neuropsychological stress in course of the
experiment, especially after 4 hrs among the alcohol
users. Also, significant decrease in mood, activeness in
the second and third phases of the experiment among the
alcohol users was recorded.
The state anxiety (according to the STAIS-Anxiety scale
– the first subscale of the STAI), among the alcohol
users, the anxiety level increased by about 10%
immediately after 2hrs of intensive mental activities (р<0.05).
Increase of the trait anxiety (according to the STAIT-Anxiety
scale – the second subscale of the STAI) was noted only
after the 4th hr of the experiment (р<0.05).
level among the non alcohol users in both subscales
remained generally low in all phases of the experiment (р<0.05).
academic performance of the non-alcohol users was
significantly higher than that of the alcohol users. The
GPA and effectiveness to sit for examinations was
significantly reduced among the alcohol users. Reduction
of the GPA of group № 2 students (alcohol users) in
relation to the results of the 1st semester
was –1.26 points (р<0.05) on the second course and –1.38
points for third year of study. The effectiveness to sit
for exams by non-alcohol users on the 2nd and
3rd courses was by 10.9 % and 11.4 % (р<0.05)
respectively higher, compared to that of the alcohol
results in the tests on short term visual and short term
auditory memory in course of the experiment showed no
significant change in the Intellectual Capacity (IC) in
both groups. There was no significant difference in the
speed of calculation and the Visual Productivity
Coefficient (VPC) between non-alcohol users and alcohol
users in course of the experiment (Table 2). Among
students of both groups, there was significant increase
in the quantity of solved task on the test “arithmetical
calculation”, as well as number of configured symbols
and speed of viewing each symbol in the test “geometric
tables” (Table 2). However, increase in VPC by
+0.88±0.310 bytes/sec (р<0.05)
was noted only among the non-alcohol users after
the 6th hr of the experiment (Table 2).
result of intellectual capacity (i.e. effectiveness of
active attention) among abstainers was significantly
higher, compared to the alcohol users (Table 2). Some
similarities were also recorded. In the controls, the
intellectual capacity in the tests on attention and
operative memory under repeated condition remained
stable and high. Among the students of group № 2 the
effectiveness of mental work capacity was low in
relation to the expected value (100%). The number of
errors made on the “proof-correction test, using
geometric tables” among the students of the 2nd
group was 12.5 – 40.0 times (р<0.001)
higher in relation to the abstainers during the 1st,
2nd, 3rd, and 4th tests
(Table 2). The percentage increase in error commission
among students of the 2nd group after six
hours of mental work was 72% in relation to their
initial level (Table 2).
Evaluation of the ability of learning new materials by
the students, as well as reproduction of already learnt
materials in 1 – 3 courses of school years showed high
effectiveness among the abstainers (intellectual
capacity approximately 75 – 96 %) and lower than average
among the alcohol users (intellectual capacity 15 – 37
%). Reduction in the number of answers was noted among
group № 2 students, regarding the questions on
“physiology of autonomic nervous system”. The
correctness of answers (i.e. intellectual capacity)
among them was not more than 25%.
initial values of the blood glucose levels of abstainers
and alcohol users showed no statistically significant
difference (Fig. 1).
results of the blood glucose sampling showed increasing
glucose level (in relation to their initial value) among
abstainers (group № 1 or the controls) according to the
measure of increase in mental activities: +0.70 mmole/L
increase (р<0.001) in blood glucose concentration after
2 hrs, +1.40 mmole/L (р<0.001) after 4 hrs, +1.74 mmole/L
(р<0.001) after 6 hrs in relation to the initial level
among these students (Fig. 1). The increase in the blood
glucose level of alcohol users was observed only within
the first 2 hours of mental work (+0.45 mmole/L, р<0.05)
(Fig. 1). Thereafter, a fall in blood glucose level
after 4 hrs of work was observed. After 6 hours of work
blood glucose level among students of the group № 2
dropped by –0.89 mmole/L (р<0.05) in relation to its
level after 2 hrs of work, and by –0.80 mmole/L (р<0.05)
in relation to its level after 4hrs and had a tendency
to fall even in relation to its initial level (Fig. 1).
The rise of fatigue among students of the test group
after 4-6 hrs of mental work also testifies on the fall
in blood glucose level. At the end of the experiment
three students in the test group had symptoms of
Analysis showed negative correlation between blood
glucose level and total number of errors during the 4th
hour of work (ρ = –0.8, р<0.001). This correlation
increased slightly after 6th hr of the
experiment (ρ = –0.9, р<0.0001) (Table 3).
correlation analysis between glucose level (on fasting)
under intensive mental work and the academic performance
of students in different courses of study are reported
in table 4. Statistically, significant positive
correlation between the glucose level and the academic
performance (effectiveness to sit for examinations and
the GPA) was noted after the 4th and
especially the 6th hours of intensive mental
work, starting from the examination results of the 2nd
and 3rd courses of study in the university
(Table 4). Notably, the statistically significant values
were recorded for only the alcohol users and when they
were combined (i.e. for all 13 participants).
The results of this study suggest that the reduced
academic performance of students who use alcohol might
be related to the incompetency in blood glucose
regulation, which is accompanied by low cognitive
functions. This is the basis of the pathogenetic
mechanism of alcohol use on the academic performance.
Despite the small quantity and episodicity of alcohol
use by the alcohol users their academic performance, as
well as cognitive functions were significantly lower.
results of the blood sampling showed significant
increase in the glucose concentration among the
non-drinkers (group № 1 or the controls) according to
the measure of increase in mental activities. The
decrease in the blood glucose concentration after the
first two hours of mental activities had negative
effects on alcohol users. It therefore follows that
long-term intensive mental activities of students who
use alcohol (even in episodic and moderate doses) are
not accompanied by increase in the blood glucose level
and subsequently leading to inadequate energy supply for
brain functions. The result of this was the increase in
mistakes, decrease in mental work capacity, and even
rejection of performance of difficult tasks. A steady
increase in the blood glucose level is a necessary
physiological mechanism for adequate supply of energy
for brain functions under metal activities of increasing
difficulties: from questionnaires
answers to the questions on the read texts. Performance
of standard tests for the IC evaluation showed high
effectiveness among non-alcohol users throughout the 6.5
hr period of the experiment.
Therefore, alcohol use (even episodic, in small doses)
leads to negative effect on glucose homeostasis,
especially under a condition of long-term intensive
now, most studies have focused on the acute effect of
alcohol use, especially in alcoholics3,6,10,30-32.
Little is still known about the effects of alcohol even
after a week’s interval of moderate alcohol use.
Researchers have acknowledged the toxic effects of
ethanol, but little efforts have been made to show the
aftereffects of alcohol (even at moderate doses) on
glucose homeostasis control. The blood glucose
concentration is a direct predictor of the brain glucose
level, which in turn determines brain functions. On the
average the brain glucose concentration is about 30-50%
of the blood glucose concentration. As noted by de Galan
and co-authors, blood glucose level less than 3.5mmole/L
leads to symptomatic hypoglycemia6. In the
test group, as result of lowering of the blood glucose
concentration, leading to fast development of fatigue, 3
participants declined from continuing the tests on
physiology of autonomic nervous system (their blood
glucose level was <3.0 mmole/L).
increase in the state and trait anxiety of alcohol users
after 4 and 2 hours respectively, was evident of the
fact that state anxiety could transform into trait
anxiety with time, especially under stress.
Positive correlation noted (only on the 2nd
and 3rd courses, but not on the 1st
course) between the academic performance and blood
glucose level in course of the experiment indicates on
the dose-time dependent effect of alcohol use (75% of
alcohol users started using alcohol only in the
university) (Table 4). The absence of any statistically
significant correlation values between the academic
performance and blood glucose level among the abstainers
might be due to the very low sample size of only 5
before now, it has constantly reported by several
studies33-35 that alcohol in large doses
inhibits gluconeogenesis leading to hypoglycemia and
that the hypoglycemic effects of alcohol are as a result
of the shift in [NAD+]/ [NADH] ratio35.
Generally, determination of a safe dose of alcoholic
beverages is still a matter of discussion in the general
A major limitation to making general conclusions about
the results of this study is the small sample size
involved. Therefore, a more comprehensive
research on the effects of alcohol use (in various
doses) on glucose homeostasis control under varying
mental activities and state, putting into consideration
the academic performance of students in various levels
of study, as well as other factors that might
necessarily affect their academic success. Also,
research is needed on the phenomenon of increased error
commission that was associated with decrease in blood
The psychophysiological model presented in this study
defines the pathogenetic mechanisms of alcohol use on
academic performance of students.
use, even in episodic moderate doses by students leads
to disorders in cognitive functions (especially under
intensive mental activities), and subsequently a
reduction in academic performance.
Disorders in cognitive functions, precisely a decrease
in the effectiveness of thinking capacity and active
attention and development of fatigue (after 4 – 6 hours
of mental activities) are detected in students who use
alcoholic beverages, even after 7-10 days of alcohol use
in small doses.
Episodic alcohol use even in small doses is not safe, as
it results in glucose homeostasis disorders,
subsequently leading to decrease in cognitive functions.
detection of glucose homeostasis disorders in episodic
moderate alcohol users was possible in a condition of
6.5 hrs intensive mental activities.
procedures used in this study could well serve as a
model and a new method for early detection of alcohol
The results of this study suggest the necessity of
limiting time (by two or a maximum of 4 hours) on
continuous stressed mental activities of people
(students, lecturers and teachers, operators, drivers
etc) who use alcoholic beverages and the development of
complex measures, aimed at preventing menace of the rise
of symptomatic hypoglycemia.
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