- Consumption also linked with substance abuse
It is necessary to educate young people in Sri Lanka about the harmful effects of using energy drinks, the consumption of which can also be linked with substance abuse.
These observations and recommendations were made in a research article on ‘Energy drinks consumption among undergraduate students at a Sri Lankan State university’ which was authored by D.K.M. De Silva (attached to the Colombo University's Nursing Faculty's Clinical Nursing Department), D.M.B.M. Dissanayake, P.K.I.S. Thilakarathna, G.L.S. Kumara, U.J.L. Shamen, W.D.D.S. Dharmasiri, A.G.M. Rozni and N.F. Minna (all seven attached to the above-mentioned Faculty), and D.L.N.L. Ubhayawardana and D.A.S. Elvitigala (both attached to the same Faculty's Basic Sciences and Social Sciences for Nursing Department), and which was published in the Sri Lankan Journal of Nursing's Fourth Volume's First Issue, in June of this year.
Energy drinks are categorised under non-alcoholic beverages (T. Lebacq, V. Desnouck, M. Dujeu, E. Holmberg, C. Pedroni and K. Castetbon's ‘Determinants of energy drink consumption in adolescents: Identification of sex-specific patterns’), containing a high concentration of caffeine (50-80 milligrams [mg] per single serving) (a German study – A. Galimov, R. Hanewinkel, J. Hansen, J.B. Unger, S. Sussman and M. Morgenstern's ‘Energy drink consumption among adolescents: Prevalence, correlates, and predictors of initiation’), added sugar, and other energy-stimulating agents such as herbal extractions, vitamin-Bs, amino acids [molecules that combine to form proteins], bioactive substances (L-carnitine, phenylalanine), and taurine (an amino acid containing sulphur and important in the metabolism of fats) (a United States [US] study – M.A. Heckman, K. Sherry and E.G. De Mejia's ‘Energy drinks: An assessment of their market size, consumer demographics, ingredient profile, functionality, and regulations’).
As commercially advertised, energy drinks can provide different benefits to their consumers, including physical energy, the enhancement of sports performances, the reduction of mental and physical stress, and boosting concentration, alertness, responsiveness, and body metabolism (C.J. Reissig, E.C. Strain and R.R. Griffiths's ‘Caffeinated energy drinks – A growing problem’). Because of the mentioned benefits, the energy drinks market is more often oriented toward youth (J.L. Harris and C.R. Munsell's ‘Energy drinks and adolescents: What’s the harm?’) and more prevalent among young adults in Western and Asian countries. In addition to this, youth and adolescents are particularly intrigued by energy drinks due to aggressive marketing, peer pressure, and the lack of knowledge of their potentially harmful effects (V. De Sanctis, N. Soliman, A.T. Soliman, H. Elsedfy, S.D. Maio, M.E. Kholy and B. Fiscina's ‘Caffeinated energy drink consumption among adolescents and potential health consequences associated with their use: A significant public health hazard’).
According to a Canadian study (C. McCrory, C.M. White, C. Bowman, N. Fenton, J.L. Reid and D. Hammond's ‘Perceptions and knowledge of caffeinated energy drinks: Results of focus groups with youth’) with adolescents and young adults (age 12-24 years), 73.6% had experience with energy drinks, and the male percentage of consumption was higher than females, while young adults who are between the ages of 20-24, showed the highest consumption prevalence, and out of them, 10.7% consumed four or more cans of energy drinks per day, while 48% consumed at least one can per day. On the other hand, Asia shares one of the biggest energy drinks markets. A Nepali study (R. Kushwaha, G.P. Rauniar, B. Koirala and N.K. Mandal's ‘Prevalence of substance use among undergraduate students in a Medical College’) using health science undergraduate students reported that 58.3% were energy drinks consumers, and that among them, the male proportion (75%) was higher than that of females.
The rapid growth in energy drinks sales among adolescents and young adults has, in turn, triggered potential adverse effects on their health, including cardiac symptoms (palpitation, tachycardia [an abnormally rapid heart rate]), neurological problems (F. Ali, H. Rehman, Z. Babayan, D. Stapleton and D.D. Joshi's ‘Energy drinks and their adverse health effects: A systematic review of the current evidence’), respiratory tract diseases, sleep disorders, and gastrointestinal symptoms. These adverse effects are more serious in adolescents and young adults since they are at a critical stage of physical and cognitive development (N. Yasuma, K. Imamura, K. Watanabe, D. Nishi, N. Kawakami and A. Takano's ‘Association between energy drink consumption and substance use in adolescence: A systematic review of prospective cohort studies’).
The prevalence is high and known health-related effects are considerable. Awareness regarding energy drinks-linked health events supports minimising the consumption rate. However, another US study (G. Kumar, S. Park and S. Onufrak's ‘Perceptions about energy drinks are associated with energy drink intake among youth’), a cross-sectional one focused on young adults (12-17 years of age) revealed that 19% believed that energy drinks are safe for youths. According to these data, many young people may be uninformed of or misinformed about the possible health consequences and nutritional value of energy drinks by their vendors.
Further, there is a potential risk that energy drinks consumption can lead to influence on substance use including alcohol, tobacco, and marijuana. Components in energy drinks are more likely to release pleasure-compensating neurotransmitters (e.g., dopamine and norepinephrine), which can directly act on the mesolimbic reward pathways of the brain, resulting in potential substance use and addiction. The afore-mentioned Nepali study reported that alcohol, cigarette, and marijuana consumption were higher among students who drank energy drinks more frequently compared to those who did not while among undergraduates who practice mixing alcohol with energy drinks, 73.3% use tobacco, and 42.1% use marijuana, with the same being positively correlated with substance use.
There is a considerable prevalence of energy drinks in our society as well. Adolescents and young adults are a vulnerable group with a high prevalence of energy drinks consumption in Asian countries.
Methodology
De Silva et al. conducted a descriptive study among undergraduate residential hostellers at the aforementioned University from March 2022 to January 2023. A total of 422 University hostellers were invited to participate, and a simple random sampling technique was used for enrollment. All undergraduate residential students at the University were eligible to be included, except undergraduate monks at the bhikku hostel.
An online, pre-validated and pre-tested, self-administered questionnaire constructed on Google Forms was utilised to collect the data. It consisted of close-ended questions.
Results
The questionnaire was distributed among 422 participants; 361 undergraduates (85.55%) responded. Of the total participants, 221/61.2% were females. The minimum age was 20 years, and the maximum age was 28 years, while the mean (the value obtained by dividing the sum of several quantities by their number - an average) age was 23.07 plus/minus (±) 1.43 years. Sinhalese and Buddhists were dominant among the participants, accounting for 90% and 87.5%, respectively. The majority of the respondents (97.2%) were unmarried. Nearly half were first-year undergraduates (154/42.7%).
Compared to the total number of responders, energy drinks consumers accounted for 112. This denoted that the prevalence of current energy drinks consumption among residential hostellers in the said University was 31%.
During the study period, 2.70% consumed energy drinks daily. From the remaining responders, 12/10.7% consumed energy drinks one-two times a week, four/3.6% consumed three-four times a week, 40/35.7% consumed one-two times a month, and the majority reported as infrequent consumers (less than one time for at least three months - 47.3%).
Hostellers take energy drinks for various reasons. The majority (78.8%) used energy drinks because of their taste. In addition, giving energy when tired (20.9%), helping with studying (10.2%), and making them feel better (10.7%) were reported as the main reasons.
Regarding the initial strategy of introduction to energy drinks among University hostellers, recommendations from friends (40.2%) was the most common strategy, while 25.9% indicated that they were introduced to energy drinks by advertisements. A minimum number of responders (13.4%) was initially introduced to the same at the selling stores.
Most of the responders (33.3%) did not need any special occasion to consume energy drinks – 27% of them consumed energy drinks while doing sports, and 23.4% consumed them while studying.
Age, gender, living with family members, the academic year, doing a part-time job, sexual activity, and the level of awareness regarding the health risks of energy drinks were identified as the significant associations with energy drinks consumption. Higher consumption rates were observed among males (59.8%) compared to females (40.2%) and students aged 23–25 years (57.1%). Students from single-parent families (11.6%) reported higher energy drinks consumption. Additionally, engagement in part-time jobs (25%) and being sexually active (24.1%) were associated with increased energy drinks consumption. The poor awareness of energy drinks' risks was associated with higher consumption (68.8%), while good awareness (25.9%) and excellent awareness (5.4%) showed lower rates.
Those who obtained a percentage mark (for the level of awareness) exceeding 80% were categorised as having excellent awareness, while 60% to 79% and less than 60% were denoted as having good and poor awareness, respectively. Over 85% of the responders had poor awareness levels, while 8.6% and 1.7% had good and excellent awareness, respectively.
Age, gender, the academic year, and energy drinks consumption were significantly associated with awareness. Awareness levels varied significantly by age, with students aged 23-25 years showing the highest percentage of good (48.4%) and excellent (50%) awareness compared to other age groups. Gender also showed a significant association, with males demonstrating higher, good awareness (67.7%) and excellent awareness (50%) compared to females. The academic year played a critical role, as second-year students had the highest percentage of good awareness (48.4%), while first-year and fifth-year students were more likely to exhibit excellent awareness (42.7% and 33.3%, respectively). Energy drinks consumption was strongly linked to awareness levels, with all participants with excellent awareness (100%) and the majority with good awareness (93.5%) being energy drinks consumers.
The majority of the responders consumed alcohol (13.6%), and only a few consumers (1.1%) used non-prescribed drugs. Energy drinks consumption has an association with subsequent substance use among undergraduate hostellers. Particularly, alcohol consumption was statistically significant with energy drinks consumption - 13.6% of consumers consume energy drinks and alcohol.
Similarly, cigarettes, tobacco, cannabis and marijuana consumption showed a significant association with energy drinks consumption. Energy drinks consumers, compared to non-consumers, were more likely to consume alcohol (13.6% versus 4.8%), cigarettes (21.4% vs. 2%), and other forms of tobacco (11.6% vs. 0.8%). Cannabis use was also significantly higher among energy drinks consumers (8% vs. 0.8%), as was marijuana use (8% vs. 0.8%). However, the association between energy drinks consumption and non-prescribed drug use was not statistically significant.
Discussion
More than one-third of the participants had never consumed energy drinks. Of the participants, 112 were currently consuming energy drinks, indicating a prevalence of consumption of 31% among undergraduate hostellers at the said University. According to a Lebanese study (M. Ghozayel, A. Ghaddar, G. Farhat, L. Nasreddine, J. Kara and L. Jomaa's ‘Energy drinks consumption and perceptions among university students in Beirut: A mixed methods approach’), university students have devised several ways to enhance their performance while studying, participating in sports, and coping with daily stressors, by using energy drinks. This alleged benefit of energy drinks may account for the large number of research participants who regularly use them.
Compared to other South Asian countries, the prevalence of energy drinks consumption among undergraduate hostellers was observed to be low in the current study. However, the differences in the population and sample sizes, in addition to the study design, may be the reasons behind the disparity in prevalence among the various studies.
Energy drinks consumption was cited by the survey participants for a variety of reasons, including the enjoyment of the taste, support for academic and athletic endeavours, while driving, and for sex enhancement. The primary motivation given by 64 respondents was the taste. The majority of energy drinks contain flavourings and sweeteners like glucose, which help to improve their taste. Furthermore, 20.9% and 10.2% of the people used energy drinks to get energy when they were tired and to help them study, respectively. This also potentially implies that the academic workload of undergraduates might increase the use of energy drinks.
Individuals initially encountered energy drinks through advertisements, personal recommendations from friends or relatives, or convenience stores. The most common methods of introduction were friends or family members and advertisements. It is not unexpected that commercials for energy drinks might lead people to start using them because they are so enticing. This implies that the drinking habits of these hostellers are heavily influenced by their close friends and family.
As observed by Lebacq et al., engaging in a physical activity increased the risk of energy drinks consumption among the young population, and having a single parent or lower family affluence was associated with energy drinks consumption. But surprisingly, the instant study revealed that there was no association between energy drinks consumption and the engagement in sport activities or having a single parent. According to the study results, most energy drinks consumers were living with both the parents.
This may be possible because people may have different reactions to energy drinks. Some may find them helpful for sports performance, while others may not. Further, in some sports or fitness communities, energy drinks are popular for their potential to boost energy and performance, while in others, the focus may be on healthier and more natural ways to improve physical performance.
Energy drinks consumption was associated with the level of awareness regarding the negative health effects of energy drinks.
This study revealed that nine out of 10 hostellers had comparatively poor awareness of the content of energy drinks, the maximum caffeine level, and whether it is associated with health-related risks. Among the respondents, 68.8% had poor awareness regarding health risks in energy drinks consumption, while 25.9% reported good awareness, and 5.4% had excellent awareness. As N. Gunja and J.A. Brown's ‘Energy drinks: Health risks and toxicity’ reported, little is known about the components, outcomes, and toxicity of energy drinks. When comparing other populations, this study sample also denoted a severe lack of awareness among the undergraduate hostellers.
This study found a significant association between gender and the awareness of the health risks associated with energy drinks consumption. Male participants had good awareness (67.7%) compared to females (64.2%). Studies have also shown an association between gender and energy drinks consumption and the knowledge of their health risks. For example, males are more likely to consume energy drinks and have more knowledge about their effects, contents, and side effects (H. Sampasa-Kanyinga, H.A. Hamilton and J.-P. Chaput's ‘Sleep duration and consumption of sugar-sweetened beverages and energy drinks among adolescents’). This is possible because peer groups and social circles can play a significant role in shaping awareness.
Further, this study found a statistical significance between the awareness of the health-related risks associated with energy drinks consumption and the academic year of the University students. The results indicate that first-year students had the highest levels of poor awareness. These findings differ from previous studies as according to some studies, students in later years or seniors have greater awareness. For instance, as per a Polish study (P. Cencek, E. Wawryk-Gawda, P. Samborski and B. Jodlowska-Jedrych's ‘Energy drinks – Consumption and awareness among students of the Medical University of Lublin’), medical and dental students at a medical university had a greater awareness of the health risks associated with energy drinks consumption in their later academic years than in their earlier academic years.
The current study also revealed that current energy drinks users consume various substances at different rates across the sample. It shows that 49 individuals consumed alcohol, while 29, 15, 11, 12, and four participants consumed cigarettes, tobacco (other than cigarettes), cannabis, marijuana, and non-prescribed drugs, respectively. Additionally, it showed a strong association between eventual drug usage and energy drinks consumption among undergraduate hostellers. According to the findings, alcohol consumption was associated with the use of energy drinks.
According to a cross-sectional Turkish study (A. Borlu, B. Oral and O. Gunay's ‘Consumption of energy drinks among Turkish University students and its health hazards’) conducted among undergraduates, the average regular consumer of energy drinks consumed alcohol-mixed energy drinks at a rate of 37.6%, and it was further reported that the subjects' regular and attempted energy drinks consumption situations were significantly associated with their alcohol consumption and smoking habits.
According to the findings of W.E. Leal and D.B. Jackson's ‘The role of energy drink consumption in the intention to initiate marijuana use among adolescents’, individuals who consume energy drinks are substantially more likely to desire to start using marijuana than those who do not. As D.A. Jackson, B.V. Cotter, R.C. Merchant, K.M. Babu, J.R. Baird, T. Nirenberg and J.G. Linakis's ‘Behavioural and physiologic adverse effects in adolescent and young adult emergency department patients reporting the use of energy drinks and caffeine’ observed among adolescents (13-17 years) and young adults (18-25 years) who visited the emergency department that young adults who use tobacco were more likely to consume energy drinks than young adults who did not.
A. Peacock, N. Droste, A. Pennay, P. Miller, D.I. Lubman and R. Bruno's ‘Awareness of energy drink intake guidelines and associated consumption practices: A cross-sectional study’ concluded that illicit drug users have consumed energy drinks at any point in their lifetime. However, these findings showed that non-prescribed drug use was not significantly associated with energy drinks consumption.
Limitations
This study has a few limitations. First, the reliance on self-reported data through an online questionnaire may have introduced response bias, as participants might have underreported or over-reported their energy drinks consumption and substance use behaviours. Second, the cross-sectional nature of the study limits the ability to establish causal relationships between energy drinks consumption, the awareness of adverse effects, and subsequent substance use.
Conclusions
Energy drinks use was shown to be greater among those who were between the ages of 23 and 25 years. They were in their first year at the University, were doing part-time jobs, and had lower levels of awareness as well. The majority of the hostellers had poor awareness regarding the health-related risks linked with energy drinks consumption. Long-term, this may raise their risk of harmful side effects or negative health impacts related to using energy drinks.
A considerable proportion of the hostellers consumed substances such as alcohol, tobacco, marijuana, and cannabis.