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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 6
| Issue : 4 | Page : 483-488 |
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Insights into patterns of knowledge, practices, and safety use of energy drinks: A cross-sectional observational study
Anmar Al-Taie1, Oritsetimeyin Arueyingho2
1 Department of Clinical Pharmacy, Faculty of Pharmacy, Istinye University, Istanbul, Turkey
2 EPSRC Centre for Doctoral Training in Digital Health and Care, University of Bristol, Bristol, United Kingdom
| Date of Submission | 02-Aug-2022 |
| Date of Decision | 02-Oct-2022 |
| Date of Acceptance | 06-Oct-2022 |
| Date of Web Publication | 15-Dec-2022 |
Correspondence Address:
Anmar Al-Taie
Department of Clinical Pharmacy, Faculty of Pharmacy, Istinye University, Istanbul
Turkey
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/bbrj.bbrj_240_22
Background: Energy drinks (EDs) are largely consumed by adolescents and sports youths without understanding safety precautions and associated side effects. The aim of this study was to assess the knowledge, practices, and safety use, including the occurrence of side effects of EDs among adolescents and sports youths in Kyrenia, Northern Cyprus. Methods: This was a descriptive, cross-sectional study conducted among adolescents and sports youths in Kyrenia province, Northern Cyprus, using a structured three-part questionnaire, consisting of 22 items to assess the knowledge, practices, and safety use of EDs. Results: The most common reported adverse effects were insomnia and palpitations (24%), diuresis (18.7%), headache (17.7%), and stress (15.6%). The study participants reported a statistically significant low knowledge about the ingredients of EDs (P < 0.0001) and side effects of EDs (P = 0.05). Although statistically nonsignificant, the study participants also reported a low knowledge about ED intake during the COVID-19 pandemic. Conclusions: There is still a lack of knowledge regarding ED consumption among the adolescents and sports youths in Northern Cyprus reported by low level of knowledge about the ingredients of EDs, their potential effects, and incidence of side effects along with correct consumption during the COVID-19 pandemic which creates a barrier to healthy dietary patterns.
Keywords: Adolescents, adverse effects, caffeine, COVID-19, energy drinks, knowledge
How to cite this article:
Al-Taie A, Arueyingho O. Insights into patterns of knowledge, practices, and safety use of energy drinks: A cross-sectional observational study. Biomed Biotechnol Res J 2022;6:483-8 |
How to cite this URL:
Al-Taie A, Arueyingho O. Insights into patterns of knowledge, practices, and safety use of energy drinks: A cross-sectional observational study. Biomed Biotechnol Res J [serial online] 2022 [cited 2023 Apr 1];6:483-8. Available from: https://www.bmbtrj.org/text.asp?2022/6/4/483/363575 |
| Introduction | |  |
The National Center for Complementary and Integrative Health defines energy drinks (EDs) as products indicated for improving physical performance, increasing energy, and enhancing mental alertness.[1] EDs, as functional beverages, are consumed before or during sporting activities to improve attention, supply energy and enhance physical performance.[2],[3]
It has been found that EDs are largely consumed by adolescents and youth people without understanding safety precautions and associated side effects.[4] Earlier studies have reported that EDs are usually consumed by approximately 30%–50% of adolescents and young adults, and they target adolescents and young adults as their primary market.[5],[6]
A lot of ED brands have been sold for decades in Europe. However, some were banned in Turkey due to their high caffeine content. There are over 26 different brands of EDs in Turkey, of which 15 are locally produced.[7] After some legislative changes in 2005, the only EDs marketed were required to have a maximum of 350 mg of caffeine and 400 mg of taurine.[8] However, legislation regarding the monitoring of ED sales, marketing, and consumption in Northern Cyprus appears to be vague even though most of the products sold in Turkey would be marketed on the island. A survey conducted in Istanbul, Turkey, revealed that 32.6% of the participants had consumed EDs at least once and 18.8% more than once. 11.8% of the study population affirmed that EDs helped them study, 16.8% highlighted its importance in improving sporting activities, and 2.3% confirmed that it helped relieve fatigue.[9] Similarly, another study conducted in Turkey revealed that more than 50% of the study participants had consumed an ED at least once, primarily for studying, maintaining physical activity, and combining with alcoholic drinks.[10] These studies, alongside other research articles, reveal that although youths and adolescents are targeted during the marketing of EDs, they do not understand the concepts and differences between sports drinks and EDs and their associated side effects.[11],[12] Thus, extensive health promotion programs must be conducted to increase awareness about the use of EDs, particularly among youths who are not necessarily into sports.
Several studies revealed that the COVID-19 pandemic might have negatively impacted the dietary habits of youths who were forced to work and study remotely. For example, a study revealed that remote examinations might have increased the consumption of EDs and reduced sleeping hours.[13] Therefore, the effects of the COVID-19 pandemic could also be extrapolated to Northern Cyprus. Since it has been established that the frequency of sporting activities is directly proportional to the intake of EDs along with the increased popularity of ED consumption among the young and sports, there are a significant need and an earnest interest in assessing the long-term safety of these drinks for preserving the health of this population by following the guidelines of healthy dietary patterns and being engaged into a regular physical activity routine. Although there is limited research on its intensity as it relates to sports, the aim of this study was to explore how knowledgeable athletes are about EDs, practices, and safety use, including the occurrence of side effects of EDs among adolescents and sports youths and how they might have consumed them during the COVID pandemic era among adolescents and sports youths.
| Materials and Methods | | |
Study design and sample size
This descriptive, cross-sectional study was carried out in Kyrenia province, Northern Cyprus, from January to April 2020 through a random sample selection of participants. A total of 198 participants were approached during this study; however, 158 participants completed the entire items of the questionnaire, giving a response rate of 79.8% based on the Cochran's sample size formula within ± 5% precision and a 95% confidence level for a large population whose degree of variability is not known. Inclusion criteria included adolescents and sports youths more than 18 years of age enrolled in gymnasiums and sporting centers in Kyrenia province, Northern Cyprus.
All participants were informed that participation was voluntary, and they were assured of their anonymity and confidentiality of response. The study aim was described in an introductory letter provided with the questionnaire, which demanded nearly 10 min. Those who dismissed participation or had incomplete response to the items of the questionnaire were excluded.
Statements of ethics
The study was approved by the Research Ethics Committee of Girne American University, Kyrenia, Northern Cyprus (2019-20/011).
Patient consent form
The participants who revealed readiness to participate in this study were supplied with written informed consent along with verbal information regarding the aim of the study.
Questionnaire design
The structured questionnaire was developed and customized to suit the objective of the study after an extensive and comprehensive literature review in a well-known database. The questionnaire underwent forwarding and backwarding bilingual translation from English into the Turkish language. The structured items of the questionnaire were assessed for rephrasing, reformatting, and relevance. Furthermore, several university academic experts from the faculty of pharmacy at Girne American University tested the final drafted questionnaire for face and content validity. In addition, a pilot part of the study was tested for around 5% of the sample size (n = 19) to process the questions' uncertainty and to figure out reliable data points which were excluded from the final statistical analysis. The final version of the questionnaire included 22 questions divided into three parts. The first part consisted of ten items and included participants' demographic characteristics (age, gender, education, presence of comorbid disease conditions, cigarette smoking, alcohol drinking, fast food intake, physical activity, sleep pattern, and average sleeping hours). The second part (four items) gathered data to assess the practical features of EDs by the participants (reasons for using EDs, intake of ED, occurrence of ED side effects, and reported side effects). The third part consisted of eight items which evaluated the participants' knowledge of ED consumption, including knowledge about consumption during the COVID-19 pandemic, and the respondents were given options to answer either “Yes” or “No.”
Statistical analysis
Statistical Package for the Social Science (SPSS) software for Windows (IBM Corp. Armonk,NY, USA) version 23.0 and Microsoft Office Excel 2013 were used for data analysis. Descriptive data were presented as numbers, percentages, and means (standard deviations) to describe the study population. A score of 1 was given to positive knowledge and attitude, while a score of 0 was given to negative knowledge and attitude toward every statement. Knowledge and attitude scores for individual statements were summed up and calculated to give the total attitude score of a participant. A cutoff level of less than 6 was set for negative knowledge and attitude and more than 6 for a positive one. A Chi-square test was applied to analyze the comparisons between proportions of the groups regarding the items of the questionnaire utilized for the assessment of the perceptions toward the level of knowledge and practices for proper use of patient information leaflets. The level of statistical significance was considered at P < 0.05.
| Results | | |
Regarding the sociodemographic characteristics of the study participants, the mean age of the respondents was 32.8 ± 10.5 years. More than half of the study participants were male (58.9%), and most of the respondents (41.1%) were in the age range between 18 and 30 years. Most of the study participants had a university-level qualification (44.5%). More than three-quarters of the study participants (79.1%) had no comorbid disease conditions, while more than half of the study respondents were neither cigarette smokers (62%) nor alcohol drinkers (69%). About the daily habits, almost half of the study participants (53.2%) reported having physical activity more than 60 min three times weekly, with 41.7% having a sleeping pattern of an average of 8 h/day. However, the same proportion of the respondents reported irregular sleep patterns (41.7%), as shown in [Table 1].
[Table 2] presents the practical patterns of ED followed by the study participants. Almost three-quarters of the study participants (74%) reported ED consumption to improve attention and enhance physical performance during sports activities, and 38.6% of the respondents reported the consumption of one ED can per day. On the other hand, 60.1% of the study participants reported having adverse effects following the consumption of ED. The most commonly observed adverse effects related to the intake of ED were recorded among the study participants as follows: an equal proportion of insomnia and palpitations (24%), diuresis (18.7%), headache (17.7%), and stress (15.6%). | Table 2: Practical characteristics of energy drink consumption by the study participants
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The study participants reported a statistically significant low level of knowledge about ED intake. This was observed in many fields, particularly knowledge about the ingredients of EDs (P < 0.0001), reason for taking EDs (P = 0.01), potential effects of EDs (P = 0.01), and knowledge about the side effects of ED (P = 0.05). Although statistically nonsignificant, the study participants also reported a low level of knowledge about ED intake during the COVID-19 pandemic, as shown in [Table 3].
When stratifying the participants' level of knowledge in consideration of the demographic characteristics, there was a statistically significant difference regarding age group (18–30 years; P = 0.02), male gender (P < 0.0001), educational level (university education; P = 0.001), and number of daily intakes of ED can (P = 0.004), as shown in [Table 4]. Similarly, when stratifying the occurrence of ED side effects in consideration of the demographic characteristics, there was a statistically significant difference regarding age group (18–30 years; P = 0.001), male gender (P < 0.0001), sleep pattern (regular; P < 0.0005), average sleeping hours (8 h; P = 0.004), number of daily intakes of ED can (P < 0.0001), fast food intake (P = 0.002), physical activity <3 times/week (P < 0.0001), and cigarette smoking ((P < 0.0001), as shown in [Table 5]. | Table 4: Correlation between demographic data with participants' knowledge of energy drink consumption
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 | Table 5: Correlation between demographic data with energy drink occurrence of side effects
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| Discussion | | |
In the present study, three-quarters of the study participants reported using EDs to improve attention and enhance physical performance, and 38.6% reported the consumption of one ED can per day. The trend of ED misuse appears to be increasing among this population and that the number of ED units ingested far exceeds the recommended maximum levels. The findings of the present study about ED consumption prevalence are higher than those found in studies by Seifert et al.[5] and by Kumar et al.[14] (5% and 17%, respectively) but lower than that reported by O'Dea[15] and Park et al.[16] (42.3% and 64.9%, respectively). Although there is a difference in prevalence of ED consumption reported by several studies, many youths are kept consuming ED against the recommendations of many health institutes, including those issued by the American Academy of Pediatrics. The study participants reported a low knowledge regarding the ingredients and adverse effects of EDs. Meanwhile, the respondents were also likely to be unaware about whether ED consumption could be useful as a right supplement during the COVID-19 pandemic. Furthermore, when stratifying the participants' knowledge about ED intake as well as the occurrence of ED side effects in consideration of the demographic characteristics, there was a statistically significant difference regarding age group within the range of 18–30 years, male gender, university education, and number of daily intakes of ED can. The findings of this study were in accordance with a retrospective observational study conducted in Australia to describe the epidemiology and toxicity of ED. The study found a poor knowledge of ED consumption among adolescents and young adults.[17] There is still a lack of awareness, education, and misconceptions regarding the proper nutrition intake during the COVID-19 pandemic among this population. The nutritional status represents a fundamental element to maintain a good health, and the importance of nutrition during COVID-19 pandemic is undeniable to improve both short and long-term prognoses. A competent nutritional supplementation can have potential protective and therapeutic roles to boost immunity. Several nutraceuticals, such as Vitamin C, Vitamin D, melatonin, zinc, and selenium, are being proposed as effective prevention and treatment options as they have antioxidant, anti-inflammatory, antithrombotic, antiviral, and immunomodulatory functions.[18]
Many adolescents and sports youths are unaware of the chemical composition in EDs, and thereby the potential for adverse effects remains ever-present. Because of a lack of knowledge and right information about consuming EDs, the participants wrongly perceived that these drinks are safe. The extent of the growing problem with ED consumption was observed by the detection of many adverse effects, such as insomnia, palpitations, diuresis, headache, and stress among the study participants. Furthermore, the incidence of these adverse effects was significantly reported among nonsmoker male youths within the age group (18–30 years), those with regular sleep pattern reaching 8 h/day, those consuming one can of ED daily, and those having fast food intake.
A variety of symptoms reported in the present study are related to the variable amounts of caffeine and consistent with the potential of caffeine stimulant misuse. EDs are beverages that contain varying amounts of caffeine along with a variety of other additives, such as guarana, a plant product that contains high amounts of caffeine. A typical can of ED may contain up to 300 mg of caffeine. Even a small dose of caffeine can induce tachycardia and agitation, while caffeine overdose can lead to seizures, psychosis, and cardiac arrhythmias.[17],[19] However, this amount may be higher than that listed on the beverage ingredients list, and many of these drinks neither display the exact amounts of their ingredients nor mention some of the main ingredients. Caffeine can enhance physical performance by increasing aerobic endurance, improving reaction time, and delaying fatigue. However, it can increase anxiety and trigger cardiac arrhythmias, while excessive caffeine consumption can cause tachycardia, vomiting, high blood pressure, sleep patterns, physiologic dependence, seizures, and death.[20],[21] Earlier reports found that taurine can cause coronary vasospasm and has similar physiological effects on the intracellular calcium concentration in smooth muscles.[22] Moreover, cohort studies that conducted the long-term safety of ED's ingredients are scarce and not sufficiently addressed to document the health problems and the toxicity of these ingredients. The findings of the present study are consistent with those conducted among university participants in the USA, and reported several adverse events, such as headache and heart palpitations after ED consumption.[23] A study by Gunja and Brown 19 also found that 87% of the adolescents and young adults after ED consumption experienced symptoms of palpitations, agitation, tremors, and gastrointestinal upset. A study showed an association between the intake of EDs and cardiac events among teens and recommended that this population should not exceed the consumption of more than 250 ml of these drinks per day.[24] Our findings suggest that there must be an earnest interest to improve awareness about the potential of health effects of ED and their long-term safety and by following the guidelines of healthy dietary patterns and being engaging in a regular physical activity routine.
To the best of our knowledge, this is the first study conducted to assess the knowledge, practices, and safety use, including the occurrence of side effects of EDs among adolescents and sports youths in Kyrenia, Northern Cyprus.
| Conclusion | | |
It is well observed from the findings of this study that many adolescents and sports youths in Northern Cyprus may be unaware, misinformed, and had a lack of knowledge about the nutritional contents and potential health effects of EDs. This was observed as a low level of knowledge about the ingredients of EDs, their potential effects, and incidence of side effects along with correct consumption during the COVID-19 pandemic which creates a barrier to healthy dietary patterns. These findings suggest that more efforts to improve education and more warranting review among this population along with regulation of the labeling and sale of these drinks are considered of high priority.
Limitations of the study
The present study has some limitations that must be pointed out. First, the study included adolescents and sports youths enrolled in Kyrenia province without the consideration of other provinces in other parts of Northern Cyprus. Second, the survey was self-reported, and this may have contributed to the inconsistent understanding of questions between participants and a recall bias. Third, the study did not report the brand names of the ED consumed by the study participants. Given these limitations into account, it is recommended that further prospective cohort studies be conducted to further evaluate the proper and safe use of EDs.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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