Energy drinks consumption and perceptions among University Students in Beirut, Lebanon: A mixed methods approach

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Abstract

Background

Energy drinks (ED) are caffeine- and sugar-rich beverages with other ingredients that are marketed for their energy-boosting and performance-enhancing effects. The consumption of these drinks, with and without alcohol, is dramatically increasing worldwide, despite the reported side effects and potential harms to consumers. Few studies, to date, have explored the perceptions and experiences of young adults towards these beverages.

Objective

The present study aimed to explore the consumption patterns and correlates of ED consumption, as well as the perceptions and experiences of university students in Lebanon towards these beverages.

Methods

A sequential explanatory mixed-methods approach was adopted. Data collection was conducted in two private universities in Beirut, Lebanon. A self-administered 36-item quantitative survey was first used to explore the prevalence and correlates of ED consumption among a convenience sample of university students (n = 226). The survey included questions related to socio-demographic characteristics, anthropometric measurements, and other lifestyle behaviors, including physical activity of university students. The subsequent qualitative phase consisted of focus group discussions (FGD) conducted to further examine the perceptions and experiences of university students towards ED. Descriptive statistics and logistic regression analyses were conducted using survey data, whereas the transcribed FGD were analyzed thematically.

Results

A total of 226 university students completed the survey. Results showed that 45% of survey respondents consumed ED at least once in their life ( ever consumers), among which 30% reported consumption of ED mixed with alcohol (AmED). Adjusting for socio-demographic and anthropometric characteristics, coffee and sports drinks consumption were significantly associated with ED (OR = 2.45, 95% CI = 1.20, 5.00, and OR = 4.88, 95%CI = 2.41, 9.88, respectively). In addition, physically active participants were 1.89 times (95%CI = 1.01, 3.51) more likely to consume ED compared to their inactive counterparts. During the qualitative phase, a total of six FGD were conducted with 29 university students, who reported consuming ED at least once per month. Three main themes were derived reflecting individual-, interpersonal/social- and environmental-level factors affecting ED consumption among university students. These themes were further supported by eight subthemes, including: perceived benefits of ED, experienced side effects, misinformation about content of ED, peer pressure and social image, as well as affordability and accessibility of ED.

Conclusion

Findings highlight the need for public health policies and programs to curb the growing public health phenomenon of ED consumption amongst university students. Such programs should consider the multi-level factors affecting ED consumption at the individual, interpersonal/social, and environmental levels, including educational campaigns on ED potential harms, regulating ED content and labeling, as well as restricting sales and marketing of these beverages, especially among young consumers.

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Most cited references 49

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Health effects of energy drinks on children, adolescents, and young adults.

Sara M. Seifert, Judith Schaechter, Eugene R Hershorin … (2011)

To review the effects, adverse consequences, and extent of energy drink consumption among children, adolescents, and young adults. We searched PubMed and Google using "energy drink," "sports drink," "guarana," "caffeine," "taurine," "ADHD," "diabetes," "children," "adolescents," "insulin," "eating disorders," and "poison control center" to identify articles related to energy drinks. Manufacturer Web sites were reviewed for product information. According to self-report surveys, energy drinks are consumed by 30% to 50% of adolescents and young adults. Frequently containing high and unregulated amounts of caffeine, these drinks have been reported in association with serious adverse effects, especially in children, adolescents, and young adults with seizures, diabetes, cardiac abnormalities, or mood and behavioral disorders or those who take certain medications. Of the 5448 US caffeine overdoses reported in 2007, 46% occurred in those younger than 19 years. Several countries and states have debated or restricted energy drink sales and advertising. Energy drinks have no therapeutic benefit, and many ingredients are understudied and not regulated. The known and unknown pharmacology of agents included in such drinks, combined with reports of toxicity, raises concern for potentially serious adverse effects in association with energy drink use. In the short-term, pediatricians need to be aware of the possible effects of energy drinks in vulnerable populations and screen for consumption to educate families. Long-term research should aim to understand the effects in at-risk populations. Toxicity surveillance should be improved, and regulations of energy drink sales and consumption should be based on appropriate research.

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Environmental interventions to reduce the consumption of sugar‐sweetened beverages and their effects on health

Peter von Philipsborn, Jan Stratil, Jacob Burns … (2019)

Background Frequent consumption of excess amounts of sugar‐sweetened beverages (SSB) is a risk factor for obesity, type 2 diabetes, cardiovascular disease and dental caries. Environmental interventions, i.e. interventions that alter the physical or social environment in which individuals make beverage choices, have been advocated as a means to reduce the consumption of SSB. Objectives To assess the effects of environmental interventions (excluding taxation) on the consumption of sugar‐sweetened beverages and sugar‐sweetened milk, diet‐related anthropometric measures and health outcomes, and on any reported unintended consequences or adverse outcomes. Search methods We searched 11 general, specialist and regional databases from inception to 24 January 2018. We also searched trial registers, reference lists and citations, scanned websites of relevant organisations, and contacted study authors. Selection criteria We included studies on interventions implemented at an environmental level, reporting effects on direct or indirect measures of SSB intake, diet‐related anthropometric measures and health outcomes, or any reported adverse outcome. We included randomised controlled trials (RCTs), non‐randomised controlled trials (NRCTs), controlled before‐after (CBA) and interrupted‐time‐series (ITS) studies, implemented in real‐world settings with a combined length of intervention and follow‐up of at least 12 weeks and at least 20 individuals in each of the intervention and control groups. We excluded studies in which participants were administered SSB as part of clinical trials, and multicomponent interventions which did not report SSB‐specific outcome data. We excluded studies on the taxation of SSB, as these are the subject of a separate Cochrane Review. Data collection and analysis Two review authors independently screened studies for inclusion, extracted data and assessed the risks of bias of included studies. We classified interventions according to the NOURISHING framework, and synthesised results narratively and conducted meta‐analyses for two outcomes relating to two intervention types. We assessed our confidence in the certainty of effect estimates with the GRADE framework as very low, low, moderate or high, and presented ‘Summary of findings’ tables. Main results We identified 14,488 unique records, and assessed 1030 in full text for eligibility. We found 58 studies meeting our inclusion criteria, including 22 RCTs, 3 NRCTs, 14 CBA studies, and 19 ITS studies, with a total of 1,180,096 participants. The median length of follow‐up was 10 months. The studies included children, teenagers and adults, and were implemented in a variety of settings, including schools, retailing and food service establishments. We judged most studies to be at high or unclear risk of bias in at least one domain, and most studies used non‐randomised designs. The studies examine a broad range of interventions, and we present results for these separately. Labelling interventions (8 studies): We found moderate‐certainty evidence that traffic‐light labelling is associated with decreasing sales of SSBs, and low‐certainty evidence that nutritional rating score labelling is associated with decreasing sales of SSBs. For menu‐board calorie labelling reported effects on SSB sales varied. Nutrition standards in public institutions (16 studies): We found low‐certainty evidence that reduced availability of SSBs in schools is associated with decreased SSB consumption. We found very low‐certainty evidence that improved availability of drinking water in schools and school fruit programmes are associated with decreased SSB consumption. Reported associations between improved availability of drinking water in schools and student body weight varied. Economic tools (7 studies): We found moderate‐certainty evidence that price increases on SSBs are associated with decreasing SSB sales. For price discounts on low‐calorie beverages reported effects on SSB sales varied. Whole food supply interventions (3 studies): Reported associations between voluntary industry initiatives to improve the whole food supply and SSB sales varied. Retail and food service interventions (7 studies): We found low‐certainty evidence that healthier default beverages in children’s menus in chain restaurants are associated with decreasing SSB sales, and moderate‐certainty evidence that in‐store promotion of healthier beverages in supermarkets is associated with decreasing SSB sales. We found very low‐certainty evidence that urban planning restrictions on new fast‐food restaurants and restrictions on the number of stores selling SSBs in remote communities are associated with decreasing SSB sales. Reported associations between promotion of healthier beverages in vending machines and SSB intake or sales varied. Intersectoral approaches (8 studies): We found moderate‐certainty evidence that government food benefit programmes with restrictions on purchasing SSBs are associated with decreased SSB intake. For unrestricted food benefit programmes reported effects varied. We found moderate‐certainty evidence that multicomponent community campaigns focused on SSBs are associated with decreasing SSB sales. Reported associations between trade and investment liberalisation and SSB sales varied. Home‐based interventions (7 studies): We found moderate‐certainty evidence that improved availability of low‐calorie beverages in the home environment is associated with decreased SSB intake, and high‐certainty evidence that it is associated with decreased body weight among adolescents with overweight or obesity and a high baseline consumption of SSBs. Adverse outcomes reported by studies, which may occur in some circumstances, included negative effects on revenue, compensatory SSB consumption outside school when the availability of SSBs in schools is reduced, reduced milk intake, stakeholder discontent, and increased total energy content of grocery purchases with price discounts on low‐calorie beverages, among others. The certainty of evidence on adverse outcomes was low to very low for most outcomes. We analysed interventions targeting sugar‐sweetened milk separately, and found low‐ to moderate‐certainty evidence that emoticon labelling and small prizes for the selection of healthier beverages in elementary school cafeterias are associated with decreased consumption of sugar‐sweetened milk. We found low‐certainty evidence that improved placement of plain milk in school cafeterias is not associated with decreasing sugar‐sweetened milk consumption. Authors' conclusions The evidence included in this review indicates that effective, scalable interventions addressing SSB consumption at a population level exist. Implementation should be accompanied by high‐quality evaluations using appropriate study designs, with a particular focus on the long‐term effects of approaches suitable for large‐scale implementation.

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Interventions to reduce consumption of sugar-sweetened beverages or increase water intake: evidence from a systematic review and meta-analysis.

B Sykes-Muskett, J. Hooson, J Cade … (2017)

A systematic review and meta-analyses were conducted to evaluate the effects of interventions to reduce sugar-sweetened beverages (SSB) or increase water intakes and to examine the impact of behaviour change techniques (BCTs) in consumption patterns. Randomized and nonrandomized controlled trials published after January 1990 and until December 2016 reporting daily changes in intakes of SSB or water in volumetric measurements (mL d-1) were included. References were retrieved through searches of electronic databases and quality appraisal followed Cochrane principles. We calculated mean differences (MD) and synthesized data with random-effects models. Forty studies with 16 505 participants were meta-analysed. Interventions significantly decreased consumption of SSB in children by 76 mL d-1(95% confidence interval [CI] -105 to -46; 23 studies, P < 0.01), and in adolescents (-66 mL d-1, 95% CI -130 to -2; 5 studies, P = 0.04) but not in adults (-13 mL d-1, 95% CI -44 to 18; 12 studies, P = 0.16). Pooled estimates of water intakes were only possible for interventions in children, and results were indicative of increases in water intake (MD +67 mL d-1, 95% CI 6 to 128; 7 studies, P = 0.04). For children, there was evidence to suggest that modelling/demonstrating the behaviour helped to reduce SSB intake and that interventions within the home environment had greater effects than school-based interventions. In conclusion, public health interventions - mainly via nutritional education/counselling - are moderately successful at reducing intakes of SSB and increasing water intakes in children. However, on average, only small reductions in SSBs have been achieved by interventions targeting adolescents and adults. Complementary measures may be needed to achieve greater improvements in both dietary behaviours across all age groups.

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Author and article information

Contributors

Malake Ghozayel: Role: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: VisualizationRole: Writing – original draftRole: Writing – review & editing

Ali Ghaddar: Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: SupervisionRole: Writing – review & editing

Ghada Farhat: Role: ConceptualizationRole: InvestigationRole: MethodologyRole: Writing – review & editing

Lara Nasreddine: Role: InvestigationRole: MethodologyRole: SupervisionRole: Writing – review & editing

Janine Kara: Role: Formal analysisRole: Writing – original draftRole: Writing – review & editing

Lamis Jomaa:

ORCID: http://orcid.org/0000-0002-3046-4581

Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SoftwareRole: SupervisionRole: VisualizationRole: Writing – original draftRole: Writing – review & editing

Catherine Haighton: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 30 April 2020

Publication date Collection: 2020

Volume: 15

Issue: 4

Electronic Location Identifier: e0232199

Affiliations

[1 ] Department of Nutrition and Food Sciences, Faculty of Agricultural and Food Sciences, American University of Beirut, Beirut, Lebanon

[2 ] Department of Biomedical Sciences, Lebanese International University, Beirut, Lebanon

[3 ] Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America

[4 ] Social and Behavioral Sciences Department, Yale School of Public Health, Yale University, New Haven, Connecticut, United States of America

Northumbria University, UNITED KINGDOM

Author notes

Competing Interests: The authors have declared that no competing interests exist.

* E-mail: lj18@ 123456aub.edu.lb

Author information

Lamis Jomaa http://orcid.org/0000-0002-3046-4581

Article

Publisher ID: PONE-D-19-21625

DOI: 10.1371/journal.pone.0232199

PMC ID: 7192412

PubMed ID: 32353017

SO-VID: 7d2ba680-241d-40e5-b6ed-0cb1d3677cf6

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 31 July 2019

Date accepted : 9 April 2020

Page count

Figures: 1, Tables: 3, Pages: 21

Funding

Funded by: Funding for this project was secured from the Department of Nutrition and Food Sciences, American University of Beirut

Award Recipient : Malake Ghozayel

This study received funding from the Department of Nutrition and Food Sciences at the American University of Beirut in support of graduate student thesis. There was no additional external funding received for this study.

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Data Availability Data cannot be shared publicly because of confidentiality and privacy concerns. The American University of Beirut Institutional Review Board (IRB) approved the study, and the consent document the IRB approved assured participants that their data would not be shared beyond the research team and as aggregated in publications. The de-identified data set for the qualitative or quantitative phases of the study may be made available to investigators who contact AUB in accordance with institutional policies. Please note that AUB policies require AUB investigators to retain custody of research data, unless NonDisclosure Agreements (NDA) have been signed prospectively with investigators/collaborators in other institutions. You can also contact AUB IRB office irb@ 123456aub.edu.lb for any additional inquiries related to human subjects' data for research purposes.

Energy drinks consumption and perceptions among University Students in Beirut, Lebanon: A mixed methods approach

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Most cited references 49

Health effects of energy drinks on children, adolescents, and young adults.

Environmental interventions to reduce the consumption of sugar‐sweetened beverages and their effects on health

Interventions to reduce consumption of sugar-sweetened beverages or increase water intake: evidence from a systematic review and meta-analysis.

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