J Community Health DOI 10.1007/s10900-014-9849-3
ORIGINAL PAPER
Energy Drink Use in University Students and Associated Factors Bekir Bulut • Nazım Ercu¨ment Beyhun Murat Topbas¸ • Gamze C ¸ an
•
Ó Springer Science+Business Media New York 2014
Abstract The use of energy drinks is common among adolescents and young age groups. The purpose of this study was to determine energy drink consumption status in students at the Karadeniz Technical University in Turkey and the factors affecting this. The research was performed at the Karadeniz Technical University among a total of 2001 students attending the Administration Department, the Physical Education Department, the Psychological Counseling and Guidance Department and the Faculty of Medicine. The research data were collected using the supervised questionnaire method. The 53.5 % (n = 1070) of students had never tried energy drinks, 22.5 % (n = 450) had tried them once only, 1.5 % (n = 30) had used them for a time and then gave up, 21.1 % (n = 422) consumed occasionally and 1.4 % (n = 29) regularly. The risks of regular energy drink consuming were male gender [2.4 (1.8–3.2)] [OR (95 %CI)], studying at night [1.6 (1.2–2.2)], having friends consuming energy drinks [3.6 (2.6–5.0)], regular physical activity [1.9 (1.4–2.5)], being an alcohol drinker [2.4 (1.7–3.2)]. This study revealed that almost half of university students had experience of energy drinks and that approximately one-fourth still used them. It will be useful for these factors listed above to be borne in mind in the development of policies aimed at protecting young people from the health impacts of energy drinks. Keywords Energy drink University student Alcohol Physical activity
B. Bulut (&) N. E. Beyhun M. Topbas¸ G. C¸an Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey e-mail: [email protected]
Introduction Energy drinks refer to beverages that provide energy for the human body through the beneficial carbohydrate in them and that may contain functional substances, vitamins and minerals whose limits are set out in the product characteristics [1]. The contents of energy drinks vary according to brand and type, though these may include water, caffeine, taurine, glucuronolactone, B group vitamins, glucose, saccharose, inositol, guarana essence, ginseng, gingko biloba and carnitine [2, 3]. The basic component of energy drinks is caffeine. Caffeine-related supraventricular or ventricular tachyarrhythmias, vertigo, anxiety, tremor, seizures and mood swings, insomnia, headache, muscle spasms, vomiting, gastro-esophageal reflux and dehydration caused by their diuretic effect may be seen. Loss of menstrual cycle, post-menopausal vaginal bleeding, breast enlargement, mild diarrhea and constipation, and vomiting, headache and vertigo in epilepsy patients may be seen in association with other ingredients. Germany has kept records of energy drink-related events since 2012. Cases of liver damage, kidney failure, respiratory disorders, agitation, seizure, psychotic states, rhabdomyelosis, tachycardia, cardiac dysrhythmias, hypertension, heart failure and death have been reported in association with energy drinks. Seventeen cases of confusion, tachycardia and seizures, and two deaths, were reported from Ireland in 1999–2005 [4–7]. In the light of all these side-effects, the Turkish Ministry of Food, Agriculture and Animal Husbandry’s Food and Control General Directorate imposed a legal requirement for all products sold by permission of the Turkish Food Codex Administration Energy Drinks Decree to carry a warning stating they should not be consumed together with alcohol, nor by children, minors under the age of 18, the
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elderly, diabetics, people with high blood pressure, pregnant or breastfeeding women, or individuals with metabolic disease, kidney insufficiency or sensitivity to caffeine. It also stressed that these are not sports drinks, should not be consumed during or after intense physical activity and should not be consumed in excess of 500 ml a day [1]. The use of energy drinks is common among adolescents and young age groups. One study of adults in America determined that the 18–24 age group consumes 10.7 times more energy drinks than the 60 and over age group [8]. A study of children and adolescents in Italy showed that the prevalence among males of using energy drinks at least once increased by 66.9 % from school year 6 to school year 8 [9]. Another study involving adults in America reported that the 18–29 age group consumed 8.8 times more energy drinks than the 55? age group, and that consumption of energy drinks mixed with alcohol was 6.16 times higher in the 18–29 age group compared to the 55? age group [10]. The 18–24 age group appears to be at most risk of consuming energy drinks either alone or in combination with alcohol. Studies of university students in Turkey report levels of consumption of at least one energy drink of between 32.6 and 78 % [11–13]. Although Europe and Asia became acquainted with energy drinks in the 1960s, the energy drink market began to expand with the appearance of the a famous brand in Australia in 1987 and America in 1997, reaching $5.7 billion in 2006 [14, 15]. Companies wage aggressive marketing campaigns aimed at adolescents and young adults and using celebrities and sports personalities. Sales in the United States of America rose approximately 465 % from 1998 to 2003 [5]. The number of young people consuming energy drinks rose by 3 million in 3 years, and more than 30 % of adolescents were reported to use energy drinks in 2006 [4]. The consumption of energy drinks in Turkey is growing and is becoming a significant market. The Turkish energy drink market expands by an average 30–40 % every year, with an approximately 50 million cans consumed annually. Some 40 domestic and foreign firms are active in the market [16]. With approximately 30 % growth in 2011, the Turkish energy drink market has reached a level of $320 million. In 2011, 26.3 million liters of energy drinks were consumed in Turkey, rising to more than 30 million in 2012. Per capita consumption is 300 ml. The sector represents 0.3 % of the total non-alcoholic drink market in the country [17]. Energy drink manufacturers seek to give the impression that consumption will enhance performance, support mental alertness, increase stamina and energy, reduce fatigue, accelerate metabolism and improve general performance [6]. Energy drinks are generally consumed for these purposes. The purpose of this study was to determine energy drink consumption status in students at the Karadeniz Technical University (KTU) in Turkey and the factors affecting this.
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Materials and Methods This descriptive research was performed at the KTU between 15 November, 2012, and 14 March, 2013. The KTU is in Trabzon, a city on the Black Sea coast in the northeast of the country. The study was conducted among students attending the Administration Department, the Physical Education Department, the Psychological Counseling and Guidance Department and the Faculty of Medicine. Written permissions obtained from all departments and verbal consents got from students before the study. In selecting these departments, various factors that might affect energy drink consumption were considered. On that basis, the Administration and Psychological Counseling and Guidance departments, thought to contain young people with more spare time to devote to social activities compared to other departments, and therefore spending more time in social environments, the Physical Education Department, with young people engaged in greater physical activity compared to other departments, and the Faculty of Medicine, with young people attending a more intensive study program and having to work shifts in the final year, were included in the study. According to KTU Student Affairs Office figures, as of 09.10.2012, there were 2090 students in the Administration Department, 258 in the Physical Education Department, 593 in the Psychological Counseling and Guidance Department and 1123 in the Faculty of Medicine. Individuals declining to answer the survey and absent from class during lessons did not participate. Distribution of the 2001 students who completed the questionnaire properly was as follows: 695 (33.2 %) from the Administration Department, 147 (56.9 %) from the Physical Education Department, 455 (76.7 %) from the Psychological Counseling and Guidance Department and 704 (62.6 %) from the Faculty of Medicine. The participation rate for all students was 49.2 %. The research data were collected using the supervised questionnaire method. The questionnaire, prepared on the basis of the literature, consisted of 44 questions. The form was divided into three sections—‘‘personal information,’’ ‘‘habits and health status’’ and ‘‘information about energy drinks and consumption.’’ The first section involves personal information. This inquired into age, gender, faculty and department attended, year of course, height, weight, parents’ educational level and occupation, type of housing, total monthly expenditure and whether or not the subject had any gainful employment. The second section, concerning participants’ habits and health status, inquired into cigarette smoking status, alcoholic drink consumption status and frequency, physical activity, presence of any long-term disease diagnosed by a physician and any continuous medication use.
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The third section inquired into participants’ knowledge of energy drinks and energy drink consumption. This section sought to elicit information concerning energy drink consumption, level of consumption, reason for consumption if applicable, reason for first consumption, time of first consumption, number of cans consumed and on how many days in the previous month, last time such a drink was consumed, at what time of day most consumption takes place, whether consumption is combined with alcohol, the reason why, if applicable, whether or not the subject had read the warnings on energy drink cans, whether they felt a constant need to consume energy drinks, whether they thought energy drinks had created a dependency, whether their daily lives were adversely affected if they were unable to consume such drinks, what effects they felt after consumption, whether they would encourage others to drink them, whether they had friends who consumed such drinks and, if so, what effects they noticed in them. The final question asked those people who did not consume them the reason for this. The appropriate permission was obtained from the relevant faculties and departments. Questionnaires were administered by KTU 6th year students who had completed the Public Health internship or members of the KTU Faculty of Medicine Public Health Department teaching staff or research assistants. Once the individual administering the questionnaire had explained the aim of the study and the form contents, the forms were distributed to students and collected again as soon as they had been completed. Distributions of the data obtained were expressed as numbers and percentages. Individuals responding ‘‘I regularly use energy drinks’’ or ‘‘I sometimes use energy drinks’’ to the relevant question we regarded as ‘‘energy drink consumers.’’ Individuals replying, ‘‘I used to consume them but no longer do so,’’ ‘‘I only tried them’’ or ‘‘No, I have never used them’’ were included in the non-consumer group. Pearson’s Chi square test was used to compare qualitative data between the consumer and non-consumer groups. A logistic regression model (backward LR) was used to determine factors affecting energy drink consumption. Significance was set at p \ 0.05. Statistical analysis was performed on the SPSS 13.0 for Windows program.
Results Sociodemographic Characteristics, Individual Habits and Health Status Students’ various sociodemographic characteristics, habits and health status are presented in Table 1. Students’ ages ranged between 17 and 36, with a mean age of 21.1 ± 2.1. Participants were 57.4 % (n = 1,148) women; 32.4 % (n = 639) lived with their families. Mean monthly
expenditure was 330.4 ± 181.3 dollars/248.8 ± 136.5 euros (584.7 ± 320.9 TL). In terms of education level, 41.9 % (n = 834) of mothers were primary school graduates, while 35.6 % (n = 707) of fathers were college or university graduates; 35.2 % (n = 704) of students were from the Faculty of Medicine, 34.7 % (n = 695) from the Administration Department, 22.7 % (n = 455) from the Psychological Counseling and Guidance Department and 7.3 % (n = 147) from the Physical Education Department, with 70.7 % (n = 1,415) receiving daytime instruction. Of the students, 17.2 % (n = 336) used cigarettes and 20.8 % (n = 407) alcohol. Level of participation in regular sporting activity was 18.1 % (n = 358), with 5 % (n = 98) being qualified, active practitioners. BMI was 20–24.99 in 58.2 % (n = 1,119) of students, a chronic disease diagnosed by a physician was present in 13.2 % (n = 254), and 8.4 % (n = 158) regularly used medications. Energy Drink Use While 53.5 % (n = 1,070) of students had never tried energy drinks, 22.5 % (n = 450) had tried them once only and 1.5 % (n = 30) had used them for a time and then stopped. The level of those saying they used them occasionally was 21.1 % (n = 422), while 1.4 % (n = 29) said they used them regularly. Among the reasons cited by those not using energy drinks at the moment were lack of interest (38.5 %) (n = 596), fears they may be harmful to health (29.2 %) (n = 453) and the idea that they contain alcohol (9.5 %) (n = 147). The most common reasons for first experimentation among those who had used energy drinks at least once were curiosity (51.3 %) (n = 478), to enhance physical performance (15.0 %) (n = 140) and to overcome sleepiness (9.2 %) (n = 86). Energy drinks most frequently began being used in high school, and most commonly between the hours 18:00 and 23:59. The level of students using energy drinks and mixing these with alcohol was 28.1 % (n = 213). This figure was 35.9 % (n = 150) among those still using energy drinks and 40.7 % (n = 11) among those using them regularly. Of those participants who had used energy drinks at least once, 52.5 % (n = 489) noticed no effect, 19.1 % (n = 178) said they felt more energetic, 11.7 % (n = 109) felt less sleepy and 5.8 % (n = 54) reported increased muscle strength. The most common reasons for consuming energy drinks among those students using them regularly are given in Fig. 1, the most common reasons for starting in Fig. 2 and the most commonly encountered effects in Fig. 3. More than one in three of the students still using energy drinks (n = 151) did not read the warnings on the cans. Of
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J Community Health Table 1 Participants’ socio demographic characteristics, individual habits and health status Characteristics
n
Table 1 continued Characteristics
n
%
% Physical activity status (n = 1,976)
Age groups B20 21–24 C25
847
42.3
1,043
52.1
111
5.5
Gender Female
No sporting activity apart from day to day activity
914
46.3
Walking less than 1 km Walking more than 1 km
299 307
15.1 15.5
Regular sport
358
18.1
98
5.0
522
27.1
Qualified active sportsperson 1,148
57.4
853
42.6
20–24.99
1,119
58.2
At home with family
639
32.4
25–29.99
257
13.4
Living with a friend
501
25.4
C30
25
1.3
In state hostel
435
22.0
In private hostel
330
16.7
254
13.2
69
3.5
1,674
86.8
Male Accommodation (n = 1,974)
Alone Monthly individual expenditure (n = 1,912) B500 TL
Body mass index (n = 1,923) \20
Chronic disease status (n = 1,928) Yes No Regular medication use (n = 1,880)
1,018
53.2
Yes
501–1,000 TL
791
41.4
No
C1,001 TL
103
5.4
Illiterate
88
4.4
Literate
90
4.5
Primary school
834
41.9
Middle school High school
225 439
11.3 22.0
College/university graduate
316
15.9
Illiterate
15
0.8
Literate
25
1.3
Primary school
468
23.6
Middle school
224
11.3
High school
547
27.5
College/university graduate
707
35.6
Medicine
704
35.2
Administration
695
34.7
Psychological counseling and guidance
455
22.7
Physical education teaching
147
7.3
1,415 586
70.7 29.3
158
8.4
1,722
91.6
Mother’s education level (n = 1,992)
Father’s education level (n = 1,986)
Department
Study time Day Night Cigarette use (n = 1,958) Yes No Quit
336
17.2
1,560
79.7
62
3.2
Alcohol use (n = 1,954) Yes No Quit
123
407
20.8
1,447
74.1
100
5.1
Fig. 1 The most common reasons for consuming energy drinks among those students using them regularly (N = 29)
those still using energy drinks, 5.3 % (n = 23) thought they produced dependency in them, 3.7 % (n = 16) felt the need to consume energy drinks during the day and 3.5 % (n = 15) reported negative effects in their daily lives when they did not consume them during the day. Of those using energy drinks regularly, 29.6 % (n = 8) thought that energy drinks caused dependency in them, 22.2 % (n = 6) felt the need to consume them during the day and 18.5 % (n = 5) reported negative effects in their daily lives when they did not consume them during the day. The most frequent negative effects in students who had used energy drinks at least once in their lives were palpitations (3.4 %), sleeplessness (2.8 %) and headache
J Community Health Table 2 Bivariate analysis of factors affecting participants’ energy drink use Characteristics
Energy drink use status Non-user
User
No.
%
No.
% \0.001
Gender Female
998
86.9
150
13.1
Male
552
64.7
301
35.3
96
65.3
51
34.7
Administration
465
66.9
230
33.1
Medicine
586
83.2
118
16.8
Psychological counseling and guidance
403
88.6
52
11.4
1,131 419
79.9 71.5
284 167
20.1 28.5
517
80.9
122
19.1
1,014
76.0
321
24.0
\0.001
Department Physical education teaching
Fig. 2 The most common reasons for starting to consume energy drinks among those students using them regularly (N = 29)
\0.001
Time of instruction Day Evening Accommodation With family External
0.014
\0.001
Monthly individual expenditure (TL) B500
844
82.9
174
501–1,000
572
72.3
219
27.7
59
57.3
44
42.7
989
80.0
248
20.0
553
73.2
202
26.8
Middle school or lower
596
81.4
136
18.6
High school or above
942
75.1
312
24.9
[1,000
17.1
Mother’s education level Middle school or lower High school or above Father’s education level
Fig. 3 The most commonly encountered effects among those students using them regularly (N = 29)
Factors Affecting Energy Drink Use Bivariate analyses revealed that males, individuals studying at night, not living with their families, with high monthly expenditure, whose parents had a high level of education, who were gainfully employed, with a high BMI, engaged in regularly physical activity and cigarette and alcohol users consumed more energy drinks (Table 2). Table 3 shows the logistic regression model for students still using energy drinks. According to that model, males consumed energy drinks 2.4 (1.8–3.2) times more than women, individuals studying at night 1.6 (1.2–2.2) times
0.001
\0.001 1,497
78.3
414
21.7
44
56.4
34
43.6
\20
420
80.5
102
19.5
20–24.99
865
77.3
254
22.7
25–29.99
182
70.8
75
29.2
17
68.0
8
32.0
1,244
81.8
276
18.2 \0.001
283
62.1
173
37.9
1,277
81.9
283
18.1 \0.001
194
57.7
142
42.3
1,218
84.2
229
15.8 \0.001
220
54.1
187
45.9
Working
(1.8 %). Among those using energy drinks regularly the most frequent negative effects were sleeplessness (13.8 %), thirst (10.3 %) and vertigo (6.9 %).
0.001
Engagement in gainful employment Not working
p value
Body mass index
C30 Physical activity status No regular physical activity Regular physical activity
0.016
Cigarette smoking Non-smoker Smoker Alcohol use No Yes
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J Community Health Table 3 Logistic regression model of risk factors for consuming energy drink Variables in model
p
OR
95 % CI
Gender Female Male
Ref. \0.001
2.4
1.8–3.2
Time of instruction Day Night
Ref. 0.001
1.6
0.094
1.3
Cigarette use Non-smoker Smoker
1.2–2.2
Ref. 1.0–1.9
Friend using energy drinks No Yes
Ref. \0.001
3.6
2.6–5.0
Regular physical activity No Yes
Ref. \0.001
1.9
1.4–2.5
Alcohol use No Yes Monthly expenditure
Ref. \0.001
2.4
1.7–3.2
0.028
1.0
1.0–1.001
more than those studying in the daytime, those with friends consuming energy drinks 3.6 (2.6–5.0) times more than those with no such friends, those engaging in regular physical activity 1.9 (1.4–2.5) times more than others and those using alcohol 2.4 (1.7–3.2) times more than subjects not using it.
Discussion Our study revealed that 46.5 % of university students had used energy drinks at least once in their lives. Another 22.5 % were still using energy drinks, while 1.4 % were using them regularly. In one study of university students in Turkey, 48.3 % had used energy drinks at least once, while 33.0 % were still using them [11]. In another study of university students in Turkey, 78 % were reported as having tried energy drinks at least once [12], a figure higher than those cited in other studies. In that same study, 92 % of students said they were unaware of the difference between energy and sports drinks; this may explain the high level of experimentation with energy drinks. In another study of medical faculty students in Turkey, 32.6 % of participants had tried energy drinks at least once [13]. The figure for Medical Faculty students in our study was 41.6 %. At the most optimistic, one in every three young people in Turkey has encountered energy drinks.
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The level of those still using energy drinks in our study was 22.5 %. In one study of university students in America the level of subjects still using energy drinks was 52.1 % [18]. In another study, the level of participants using energy drinks more than once a month was 51 % [15]. A study of college students in Alaska reported a level of energy drink use over the previous 30 days of 66.3 % [19]. The reason for these higher levels of use in Western societies compared to Turkey may be that the energy drink companies entered those countries before Turkey, and those societies became acquainted with energy drinks earlier. These data must act as a warning as to how energy drink consumption in Turkey can change and guide policy makers regarding precautionary measures to be taken. The most common reasons for energy drink use given by the students in our study were to enhance physical performance, overcome fatigue and to wake up. Another study performed in Turkey cited the most common reasons as to feel more energetic, to concentrate while studying, to remain awake, for alcoholic cocktails to remain and for the taste [11, 12]. To combat sleepiness, to enhance energy and for mixing with alcohol at parties were the most common reasons cited in a study of college students in America [15]. The most common reasons cited in a study of physical education students in Argentina were to improve the taste of alcoholic drinks, to extend evening leisure periods and to enhance physical performance. [20]. Similar reasons for energy drink use emerge across the world. That similarity may be a factor facilitating the production of common solutions through international cooperation aimed at altering energy drink consumption behavior. Of the students in our study still consuming energy drinks, 28.2 % said they mixed them with alcohol. A study of college students in Canada determined that 23 % of subjects had mixed energy drinks with alcohol in the previous 30 days. In another study of college students, this time from North Carolina, the level was 24 % [21, 22]. Another study of college students in America cited a level of 34.7 % experimenting with adding energy drinks to alcohol, with 9.3 % of subjects continuing to do so [23]. Although the frequency of energy drink use is higher in Eastern countries than in Turkey, it is striking and surprising that the level of addition of energy drinks to alcohol stands at the same level in Turkey as in Western countries. Energy drink consumption in our study was 2.4 times higher among subjects using alcohol than those not using it. One study of university students in Turkey determined that subjects using alcohol consumed 2.5 times more energy drinks than those not using it [11]. Another study of university students in Turkey also reported that subjects using alcohol consumed statistically more energy drinks than those not using alcohol [12]. It is vitally important for alcohol use habits to be considered when precautionary measures aimed
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at preventing the negative effects of energy drinks are being taken. Measures might include warning posters at alcohol sales points and the training of staff working in them. Further studies focusing on the consumption of energy drinks with alcohol in Turkey appear to be needed. Males consumed 2.4 times more energy drinks than females in our study. One study of adults in America reported that men consumed 3.7 times more energy drinks than women [10], and another study of adults in America determined that men consumed 2.8 times more than women [8]. Two studies of university students in Turkey both reported that males consumed for energy drinks than females [11, 12]. Male gender may be said to be a common worldwide risk factor for energy drink consumption. The causes leading males to consume more energy drinks than women need to be carefully examined, and these causes must not be overlooked in proposing solutions. In doing that, the error of excluding women users from our target must also not be committed. Individuals studying at night consumed 1.6 times more energy drinks compared to those studying in the daytime. One study of physical education students in Argentina reported that daytime students consumed significantly more energy drinks compared to those studying at night [20]. This was attributed to individuals studying at night being otherwise occupied when energy drinks are most consumed. The result from our study may be attributed to students studying at night wishing to remain awake or improve their mental performance. These two opposed views are only a hypothesis, and we think that further studies are required on the subject. According to our study, students with friends who consume energy drinks also consume 3.6 times more such drinks than students with no such friends. Although we encountered no studies in the literature directly examining these parameters as we looked at the factors affecting energy drink consumption, one study of university students in Turkey revealed that 59.2 % of students were with one or more friends when they first experimented with such drinks [11]. ‘‘To join in parties’’ is cited as one of the main reasons for energy drink consumption in studies [15, 20]. In one study of adults in America, subjects describing their social lives as perfect consumed sports or energy drinks once or more a week 1.22 times more frequently than those describing their social lives as poor [8]. In the light of all these findings, it may be said that the effect of friends/ social group is a significant factor in acquiring the habit of energy drink consumption. The effect of such friends/ groups should not be overlooked in measures aimed at weaning young people from this habit. Moreover, in addition to measures directed toward the individual, widerranging interventions must be planned, also bearing in light this interpersonal interaction.
Students engaged in regular physical activities in our study consumed 1.86 times more energy drinks than those not engaging in such activity. A study of physical education students in Argentina reported that students attending a gym consumed more energy drinks than other students [20]. An American study determined that consumption of sports and energy drinks was 1.59 times higher among subjects taking part in physical activity lasting at least 10 min seven or more times a week compared to those taking part in physical activity twice a week or less [8]. Although not inquiring directly into physical activity, a study of university students in Turkey reported that students from the sports department consumed 9.2 times more energy drinks than students from the medical faculty [11]. Enhancement of physical performance is the main reason for energy drink consumption worldwide. Studies show that a rise in physical activity also leads to a rise in energy drink consumption. Energy drink companies’ advertizing and sales campaigns also emphasize this. These intensive campaigns and advertizing conceal the side effects of energy drinks and encourage society, and particularly the young, to concentrate on their effects on physical performance. The results from studies show how successful they are in this. Much clearly needs to be done with regarding to raising society’s awareness of the side effects of these drinks. Various side effects, including death, have been reported in the literature [4–7]. The most common side effects in a study of college students in America were unsteadiness and falls (29 %), headache (22 %) and palpitations (19 %) [15]. The most common side effects in our students regularly consuming energy drinks were sleeplessness (13.8 %), thirst (10.3 %) and vertigo (6.9 %). Consumers of energy drinks must bear these subjective symptoms in mind and not forget that there have been cases ending in death. The students most commonly consuming energy drinks in our study were those from the Physical Education Department (34.7 %). These were followed by Administration Department students at 33.1 %. The lowest level of consumption was among Psychological Counseling and Guidance Department students (11.4 %). Use among Medical Faculty students was 16.8 %. Similar to our study, another study of university students in Turkey reported that sports department students consumed 9.2 times more energy drinks than students in the faculty of medicine, and that art department students consumed 3.5 times more [11]. That study postulated that this difference might be due to sport department students engaging in more physical activity and to art department students spending more time in a social environment. We think this is reasonable. Physical education students spending more time in physical activity and administration students being present more
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frequently in social environments compared to other students may explain their higher levels of consumption. On the other hand, as stated above, students attending a gym consuming more energy drinks in a study from Argentina [20] and a 1.22-fold higher level of consumption or engaging in sport once a week or more among subjects content with their social lives in a study from America [8] supports our account of this interdepartmental difference.
9.
10.
11.
Conclusion 12.
This study revealed that almost half of university students had experience of energy drinks and that approximately one-fourth still used them. The factors affecting energy drink consumption were male gender, attending classes at night, engaging in regular physical activity, having friends who consume energy drinks and alcohol consumption. It will be useful for these factors to be borne in mind in the development of policies aimed at protecting young people from the health impacts of energy drinks.
13.
14.
15.
16.
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energy drinks among US adults: National Health Interview Survey, 2010. Journal of Academy of Nutrition and Dietetics, 113(1), 112–119. Gallimberti, L., Buja, A., Chindamo, S., Vinelli, A., Lazzarin, G., Terraneo, A., et al. (2013). Energy drink consumption in children and early adolescents. European Journal of Pediatrics, 172(10), 1335–1340. Berger, L. K., Fendrich, M., Chen, H.-Y., Arria, A. M., & Cisler, R. A. (2011). Sociodemographic correlates of energy drink consumption with and without alcohol: Results of a community survey. Addictive Behaviours, 36(5), 516–519. Attila, S., & C¸akır, B. (2011). Energy-drink consumption in college students and associated factors. Nutrition, 27(3), 316–322. Funda ˙Isc¸iog˘lu, Gu¨lden Ova, Yasin Duyar, Mustafa Ko¨ksal. ¨ niversite o¨g˘rencileri arasındaki enerji ic¸eceg˘i tu¨ketimi (2010). U ve bilinci aras¸ tırması. Akademik Gıda, 8(5), 6–11. Hidiroglu, S., Tanriover, O., Unaldi, S., Sulun, S., & Karavus, M. (2013). A survey of energy-drink consumption among medical students. Jounal of Pakistan Medical Association, 63(7), 842–845. Reissig, C. J., Strain, E. C., & Griffiths, R. R. (2009). Caffeinated energy drinks—A growing problem. Drug and Alcohol Dependence, 99(1–3), 1–10. Malinauskas, B. M., Aeby, V. G., Overton, R. F., CarpenterAeby, T., & Barber-Heidal, K. (2007). A survey of energy drink consumption patterns among college students. Nutrition Journal, 6(35), 41. http://www.gidaraporu.com/genclik-icin-tehlike_g.html. Accessed 10 Dec 2013. http://brandtalks.org/2013/04/turkiyede-enerji-icecekleri-pazarive-markalari-ne-durumda/. Accessed 10 Dec 2013. Spierer, K. D., Blanding, N., & Santella, A. (2014). Energy drink consumption and associated health behaviours among university students in an urban setting. Journal of Community Health, 39, 132–138. Skewes, M. C., DeCou, C. R., & Gonzalez, V. M. (2013). Energy drink use, problem drinking and drinking motives in a diverse sample of Alaskan college students. International Journal of Circumpolar Health, 72, 21204. Ballisteri, M.C., Corradi-Webster, C. M. (2008). Consumption of energy drinks among physical education students. Rev Latino-am Enfermagem. 16(especial): 558–64. Brache, Kristina., & Stockwell, Timothy. (2011). Drinking patterns and risk behaviors associated with combined alcohol and energy drink consumption in college drinkers. Addictive Behaviors, 36, 1133–1140. O’Brien, M. C., McCoy, T. P., Rhodes, S. D., Wagoner, A., & Wolfson, M. (2008). Caffeinated cocktails: Energy drink consumption, high risk drinking, and alcohol related consequences among college students. Academic Emergency Medicine, 15, 453–460. Marczinski, C. A. (2011). Alcohol mixed with energy drinks: Consumption patterns and motivations for use in US college students. International Journal of Environmental Research and Public Health, 8(8), 3232–3245.
ORIGINAL PAPER
Energy Drink Use in University Students and Associated Factors Bekir Bulut • Nazım Ercu¨ment Beyhun Murat Topbas¸ • Gamze C ¸ an
•
Ó Springer Science+Business Media New York 2014
Abstract The use of energy drinks is common among adolescents and young age groups. The purpose of this study was to determine energy drink consumption status in students at the Karadeniz Technical University in Turkey and the factors affecting this. The research was performed at the Karadeniz Technical University among a total of 2001 students attending the Administration Department, the Physical Education Department, the Psychological Counseling and Guidance Department and the Faculty of Medicine. The research data were collected using the supervised questionnaire method. The 53.5 % (n = 1070) of students had never tried energy drinks, 22.5 % (n = 450) had tried them once only, 1.5 % (n = 30) had used them for a time and then gave up, 21.1 % (n = 422) consumed occasionally and 1.4 % (n = 29) regularly. The risks of regular energy drink consuming were male gender [2.4 (1.8–3.2)] [OR (95 %CI)], studying at night [1.6 (1.2–2.2)], having friends consuming energy drinks [3.6 (2.6–5.0)], regular physical activity [1.9 (1.4–2.5)], being an alcohol drinker [2.4 (1.7–3.2)]. This study revealed that almost half of university students had experience of energy drinks and that approximately one-fourth still used them. It will be useful for these factors listed above to be borne in mind in the development of policies aimed at protecting young people from the health impacts of energy drinks. Keywords Energy drink University student Alcohol Physical activity
B. Bulut (&) N. E. Beyhun M. Topbas¸ G. C¸an Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey e-mail: [email protected]
Introduction Energy drinks refer to beverages that provide energy for the human body through the beneficial carbohydrate in them and that may contain functional substances, vitamins and minerals whose limits are set out in the product characteristics [1]. The contents of energy drinks vary according to brand and type, though these may include water, caffeine, taurine, glucuronolactone, B group vitamins, glucose, saccharose, inositol, guarana essence, ginseng, gingko biloba and carnitine [2, 3]. The basic component of energy drinks is caffeine. Caffeine-related supraventricular or ventricular tachyarrhythmias, vertigo, anxiety, tremor, seizures and mood swings, insomnia, headache, muscle spasms, vomiting, gastro-esophageal reflux and dehydration caused by their diuretic effect may be seen. Loss of menstrual cycle, post-menopausal vaginal bleeding, breast enlargement, mild diarrhea and constipation, and vomiting, headache and vertigo in epilepsy patients may be seen in association with other ingredients. Germany has kept records of energy drink-related events since 2012. Cases of liver damage, kidney failure, respiratory disorders, agitation, seizure, psychotic states, rhabdomyelosis, tachycardia, cardiac dysrhythmias, hypertension, heart failure and death have been reported in association with energy drinks. Seventeen cases of confusion, tachycardia and seizures, and two deaths, were reported from Ireland in 1999–2005 [4–7]. In the light of all these side-effects, the Turkish Ministry of Food, Agriculture and Animal Husbandry’s Food and Control General Directorate imposed a legal requirement for all products sold by permission of the Turkish Food Codex Administration Energy Drinks Decree to carry a warning stating they should not be consumed together with alcohol, nor by children, minors under the age of 18, the
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elderly, diabetics, people with high blood pressure, pregnant or breastfeeding women, or individuals with metabolic disease, kidney insufficiency or sensitivity to caffeine. It also stressed that these are not sports drinks, should not be consumed during or after intense physical activity and should not be consumed in excess of 500 ml a day [1]. The use of energy drinks is common among adolescents and young age groups. One study of adults in America determined that the 18–24 age group consumes 10.7 times more energy drinks than the 60 and over age group [8]. A study of children and adolescents in Italy showed that the prevalence among males of using energy drinks at least once increased by 66.9 % from school year 6 to school year 8 [9]. Another study involving adults in America reported that the 18–29 age group consumed 8.8 times more energy drinks than the 55? age group, and that consumption of energy drinks mixed with alcohol was 6.16 times higher in the 18–29 age group compared to the 55? age group [10]. The 18–24 age group appears to be at most risk of consuming energy drinks either alone or in combination with alcohol. Studies of university students in Turkey report levels of consumption of at least one energy drink of between 32.6 and 78 % [11–13]. Although Europe and Asia became acquainted with energy drinks in the 1960s, the energy drink market began to expand with the appearance of the a famous brand in Australia in 1987 and America in 1997, reaching $5.7 billion in 2006 [14, 15]. Companies wage aggressive marketing campaigns aimed at adolescents and young adults and using celebrities and sports personalities. Sales in the United States of America rose approximately 465 % from 1998 to 2003 [5]. The number of young people consuming energy drinks rose by 3 million in 3 years, and more than 30 % of adolescents were reported to use energy drinks in 2006 [4]. The consumption of energy drinks in Turkey is growing and is becoming a significant market. The Turkish energy drink market expands by an average 30–40 % every year, with an approximately 50 million cans consumed annually. Some 40 domestic and foreign firms are active in the market [16]. With approximately 30 % growth in 2011, the Turkish energy drink market has reached a level of $320 million. In 2011, 26.3 million liters of energy drinks were consumed in Turkey, rising to more than 30 million in 2012. Per capita consumption is 300 ml. The sector represents 0.3 % of the total non-alcoholic drink market in the country [17]. Energy drink manufacturers seek to give the impression that consumption will enhance performance, support mental alertness, increase stamina and energy, reduce fatigue, accelerate metabolism and improve general performance [6]. Energy drinks are generally consumed for these purposes. The purpose of this study was to determine energy drink consumption status in students at the Karadeniz Technical University (KTU) in Turkey and the factors affecting this.
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Materials and Methods This descriptive research was performed at the KTU between 15 November, 2012, and 14 March, 2013. The KTU is in Trabzon, a city on the Black Sea coast in the northeast of the country. The study was conducted among students attending the Administration Department, the Physical Education Department, the Psychological Counseling and Guidance Department and the Faculty of Medicine. Written permissions obtained from all departments and verbal consents got from students before the study. In selecting these departments, various factors that might affect energy drink consumption were considered. On that basis, the Administration and Psychological Counseling and Guidance departments, thought to contain young people with more spare time to devote to social activities compared to other departments, and therefore spending more time in social environments, the Physical Education Department, with young people engaged in greater physical activity compared to other departments, and the Faculty of Medicine, with young people attending a more intensive study program and having to work shifts in the final year, were included in the study. According to KTU Student Affairs Office figures, as of 09.10.2012, there were 2090 students in the Administration Department, 258 in the Physical Education Department, 593 in the Psychological Counseling and Guidance Department and 1123 in the Faculty of Medicine. Individuals declining to answer the survey and absent from class during lessons did not participate. Distribution of the 2001 students who completed the questionnaire properly was as follows: 695 (33.2 %) from the Administration Department, 147 (56.9 %) from the Physical Education Department, 455 (76.7 %) from the Psychological Counseling and Guidance Department and 704 (62.6 %) from the Faculty of Medicine. The participation rate for all students was 49.2 %. The research data were collected using the supervised questionnaire method. The questionnaire, prepared on the basis of the literature, consisted of 44 questions. The form was divided into three sections—‘‘personal information,’’ ‘‘habits and health status’’ and ‘‘information about energy drinks and consumption.’’ The first section involves personal information. This inquired into age, gender, faculty and department attended, year of course, height, weight, parents’ educational level and occupation, type of housing, total monthly expenditure and whether or not the subject had any gainful employment. The second section, concerning participants’ habits and health status, inquired into cigarette smoking status, alcoholic drink consumption status and frequency, physical activity, presence of any long-term disease diagnosed by a physician and any continuous medication use.
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The third section inquired into participants’ knowledge of energy drinks and energy drink consumption. This section sought to elicit information concerning energy drink consumption, level of consumption, reason for consumption if applicable, reason for first consumption, time of first consumption, number of cans consumed and on how many days in the previous month, last time such a drink was consumed, at what time of day most consumption takes place, whether consumption is combined with alcohol, the reason why, if applicable, whether or not the subject had read the warnings on energy drink cans, whether they felt a constant need to consume energy drinks, whether they thought energy drinks had created a dependency, whether their daily lives were adversely affected if they were unable to consume such drinks, what effects they felt after consumption, whether they would encourage others to drink them, whether they had friends who consumed such drinks and, if so, what effects they noticed in them. The final question asked those people who did not consume them the reason for this. The appropriate permission was obtained from the relevant faculties and departments. Questionnaires were administered by KTU 6th year students who had completed the Public Health internship or members of the KTU Faculty of Medicine Public Health Department teaching staff or research assistants. Once the individual administering the questionnaire had explained the aim of the study and the form contents, the forms were distributed to students and collected again as soon as they had been completed. Distributions of the data obtained were expressed as numbers and percentages. Individuals responding ‘‘I regularly use energy drinks’’ or ‘‘I sometimes use energy drinks’’ to the relevant question we regarded as ‘‘energy drink consumers.’’ Individuals replying, ‘‘I used to consume them but no longer do so,’’ ‘‘I only tried them’’ or ‘‘No, I have never used them’’ were included in the non-consumer group. Pearson’s Chi square test was used to compare qualitative data between the consumer and non-consumer groups. A logistic regression model (backward LR) was used to determine factors affecting energy drink consumption. Significance was set at p \ 0.05. Statistical analysis was performed on the SPSS 13.0 for Windows program.
Results Sociodemographic Characteristics, Individual Habits and Health Status Students’ various sociodemographic characteristics, habits and health status are presented in Table 1. Students’ ages ranged between 17 and 36, with a mean age of 21.1 ± 2.1. Participants were 57.4 % (n = 1,148) women; 32.4 % (n = 639) lived with their families. Mean monthly
expenditure was 330.4 ± 181.3 dollars/248.8 ± 136.5 euros (584.7 ± 320.9 TL). In terms of education level, 41.9 % (n = 834) of mothers were primary school graduates, while 35.6 % (n = 707) of fathers were college or university graduates; 35.2 % (n = 704) of students were from the Faculty of Medicine, 34.7 % (n = 695) from the Administration Department, 22.7 % (n = 455) from the Psychological Counseling and Guidance Department and 7.3 % (n = 147) from the Physical Education Department, with 70.7 % (n = 1,415) receiving daytime instruction. Of the students, 17.2 % (n = 336) used cigarettes and 20.8 % (n = 407) alcohol. Level of participation in regular sporting activity was 18.1 % (n = 358), with 5 % (n = 98) being qualified, active practitioners. BMI was 20–24.99 in 58.2 % (n = 1,119) of students, a chronic disease diagnosed by a physician was present in 13.2 % (n = 254), and 8.4 % (n = 158) regularly used medications. Energy Drink Use While 53.5 % (n = 1,070) of students had never tried energy drinks, 22.5 % (n = 450) had tried them once only and 1.5 % (n = 30) had used them for a time and then stopped. The level of those saying they used them occasionally was 21.1 % (n = 422), while 1.4 % (n = 29) said they used them regularly. Among the reasons cited by those not using energy drinks at the moment were lack of interest (38.5 %) (n = 596), fears they may be harmful to health (29.2 %) (n = 453) and the idea that they contain alcohol (9.5 %) (n = 147). The most common reasons for first experimentation among those who had used energy drinks at least once were curiosity (51.3 %) (n = 478), to enhance physical performance (15.0 %) (n = 140) and to overcome sleepiness (9.2 %) (n = 86). Energy drinks most frequently began being used in high school, and most commonly between the hours 18:00 and 23:59. The level of students using energy drinks and mixing these with alcohol was 28.1 % (n = 213). This figure was 35.9 % (n = 150) among those still using energy drinks and 40.7 % (n = 11) among those using them regularly. Of those participants who had used energy drinks at least once, 52.5 % (n = 489) noticed no effect, 19.1 % (n = 178) said they felt more energetic, 11.7 % (n = 109) felt less sleepy and 5.8 % (n = 54) reported increased muscle strength. The most common reasons for consuming energy drinks among those students using them regularly are given in Fig. 1, the most common reasons for starting in Fig. 2 and the most commonly encountered effects in Fig. 3. More than one in three of the students still using energy drinks (n = 151) did not read the warnings on the cans. Of
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J Community Health Table 1 Participants’ socio demographic characteristics, individual habits and health status Characteristics
n
Table 1 continued Characteristics
n
%
% Physical activity status (n = 1,976)
Age groups B20 21–24 C25
847
42.3
1,043
52.1
111
5.5
Gender Female
No sporting activity apart from day to day activity
914
46.3
Walking less than 1 km Walking more than 1 km
299 307
15.1 15.5
Regular sport
358
18.1
98
5.0
522
27.1
Qualified active sportsperson 1,148
57.4
853
42.6
20–24.99
1,119
58.2
At home with family
639
32.4
25–29.99
257
13.4
Living with a friend
501
25.4
C30
25
1.3
In state hostel
435
22.0
In private hostel
330
16.7
254
13.2
69
3.5
1,674
86.8
Male Accommodation (n = 1,974)
Alone Monthly individual expenditure (n = 1,912) B500 TL
Body mass index (n = 1,923) \20
Chronic disease status (n = 1,928) Yes No Regular medication use (n = 1,880)
1,018
53.2
Yes
501–1,000 TL
791
41.4
No
C1,001 TL
103
5.4
Illiterate
88
4.4
Literate
90
4.5
Primary school
834
41.9
Middle school High school
225 439
11.3 22.0
College/university graduate
316
15.9
Illiterate
15
0.8
Literate
25
1.3
Primary school
468
23.6
Middle school
224
11.3
High school
547
27.5
College/university graduate
707
35.6
Medicine
704
35.2
Administration
695
34.7
Psychological counseling and guidance
455
22.7
Physical education teaching
147
7.3
1,415 586
70.7 29.3
158
8.4
1,722
91.6
Mother’s education level (n = 1,992)
Father’s education level (n = 1,986)
Department
Study time Day Night Cigarette use (n = 1,958) Yes No Quit
336
17.2
1,560
79.7
62
3.2
Alcohol use (n = 1,954) Yes No Quit
123
407
20.8
1,447
74.1
100
5.1
Fig. 1 The most common reasons for consuming energy drinks among those students using them regularly (N = 29)
those still using energy drinks, 5.3 % (n = 23) thought they produced dependency in them, 3.7 % (n = 16) felt the need to consume energy drinks during the day and 3.5 % (n = 15) reported negative effects in their daily lives when they did not consume them during the day. Of those using energy drinks regularly, 29.6 % (n = 8) thought that energy drinks caused dependency in them, 22.2 % (n = 6) felt the need to consume them during the day and 18.5 % (n = 5) reported negative effects in their daily lives when they did not consume them during the day. The most frequent negative effects in students who had used energy drinks at least once in their lives were palpitations (3.4 %), sleeplessness (2.8 %) and headache
J Community Health Table 2 Bivariate analysis of factors affecting participants’ energy drink use Characteristics
Energy drink use status Non-user
User
No.
%
No.
% \0.001
Gender Female
998
86.9
150
13.1
Male
552
64.7
301
35.3
96
65.3
51
34.7
Administration
465
66.9
230
33.1
Medicine
586
83.2
118
16.8
Psychological counseling and guidance
403
88.6
52
11.4
1,131 419
79.9 71.5
284 167
20.1 28.5
517
80.9
122
19.1
1,014
76.0
321
24.0
\0.001
Department Physical education teaching
Fig. 2 The most common reasons for starting to consume energy drinks among those students using them regularly (N = 29)
\0.001
Time of instruction Day Evening Accommodation With family External
0.014
\0.001
Monthly individual expenditure (TL) B500
844
82.9
174
501–1,000
572
72.3
219
27.7
59
57.3
44
42.7
989
80.0
248
20.0
553
73.2
202
26.8
Middle school or lower
596
81.4
136
18.6
High school or above
942
75.1
312
24.9
[1,000
17.1
Mother’s education level Middle school or lower High school or above Father’s education level
Fig. 3 The most commonly encountered effects among those students using them regularly (N = 29)
Factors Affecting Energy Drink Use Bivariate analyses revealed that males, individuals studying at night, not living with their families, with high monthly expenditure, whose parents had a high level of education, who were gainfully employed, with a high BMI, engaged in regularly physical activity and cigarette and alcohol users consumed more energy drinks (Table 2). Table 3 shows the logistic regression model for students still using energy drinks. According to that model, males consumed energy drinks 2.4 (1.8–3.2) times more than women, individuals studying at night 1.6 (1.2–2.2) times
0.001
\0.001 1,497
78.3
414
21.7
44
56.4
34
43.6
\20
420
80.5
102
19.5
20–24.99
865
77.3
254
22.7
25–29.99
182
70.8
75
29.2
17
68.0
8
32.0
1,244
81.8
276
18.2 \0.001
283
62.1
173
37.9
1,277
81.9
283
18.1 \0.001
194
57.7
142
42.3
1,218
84.2
229
15.8 \0.001
220
54.1
187
45.9
Working
(1.8 %). Among those using energy drinks regularly the most frequent negative effects were sleeplessness (13.8 %), thirst (10.3 %) and vertigo (6.9 %).
0.001
Engagement in gainful employment Not working
p value
Body mass index
C30 Physical activity status No regular physical activity Regular physical activity
0.016
Cigarette smoking Non-smoker Smoker Alcohol use No Yes
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J Community Health Table 3 Logistic regression model of risk factors for consuming energy drink Variables in model
p
OR
95 % CI
Gender Female Male
Ref. \0.001
2.4
1.8–3.2
Time of instruction Day Night
Ref. 0.001
1.6
0.094
1.3
Cigarette use Non-smoker Smoker
1.2–2.2
Ref. 1.0–1.9
Friend using energy drinks No Yes
Ref. \0.001
3.6
2.6–5.0
Regular physical activity No Yes
Ref. \0.001
1.9
1.4–2.5
Alcohol use No Yes Monthly expenditure
Ref. \0.001
2.4
1.7–3.2
0.028
1.0
1.0–1.001
more than those studying in the daytime, those with friends consuming energy drinks 3.6 (2.6–5.0) times more than those with no such friends, those engaging in regular physical activity 1.9 (1.4–2.5) times more than others and those using alcohol 2.4 (1.7–3.2) times more than subjects not using it.
Discussion Our study revealed that 46.5 % of university students had used energy drinks at least once in their lives. Another 22.5 % were still using energy drinks, while 1.4 % were using them regularly. In one study of university students in Turkey, 48.3 % had used energy drinks at least once, while 33.0 % were still using them [11]. In another study of university students in Turkey, 78 % were reported as having tried energy drinks at least once [12], a figure higher than those cited in other studies. In that same study, 92 % of students said they were unaware of the difference between energy and sports drinks; this may explain the high level of experimentation with energy drinks. In another study of medical faculty students in Turkey, 32.6 % of participants had tried energy drinks at least once [13]. The figure for Medical Faculty students in our study was 41.6 %. At the most optimistic, one in every three young people in Turkey has encountered energy drinks.
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The level of those still using energy drinks in our study was 22.5 %. In one study of university students in America the level of subjects still using energy drinks was 52.1 % [18]. In another study, the level of participants using energy drinks more than once a month was 51 % [15]. A study of college students in Alaska reported a level of energy drink use over the previous 30 days of 66.3 % [19]. The reason for these higher levels of use in Western societies compared to Turkey may be that the energy drink companies entered those countries before Turkey, and those societies became acquainted with energy drinks earlier. These data must act as a warning as to how energy drink consumption in Turkey can change and guide policy makers regarding precautionary measures to be taken. The most common reasons for energy drink use given by the students in our study were to enhance physical performance, overcome fatigue and to wake up. Another study performed in Turkey cited the most common reasons as to feel more energetic, to concentrate while studying, to remain awake, for alcoholic cocktails to remain and for the taste [11, 12]. To combat sleepiness, to enhance energy and for mixing with alcohol at parties were the most common reasons cited in a study of college students in America [15]. The most common reasons cited in a study of physical education students in Argentina were to improve the taste of alcoholic drinks, to extend evening leisure periods and to enhance physical performance. [20]. Similar reasons for energy drink use emerge across the world. That similarity may be a factor facilitating the production of common solutions through international cooperation aimed at altering energy drink consumption behavior. Of the students in our study still consuming energy drinks, 28.2 % said they mixed them with alcohol. A study of college students in Canada determined that 23 % of subjects had mixed energy drinks with alcohol in the previous 30 days. In another study of college students, this time from North Carolina, the level was 24 % [21, 22]. Another study of college students in America cited a level of 34.7 % experimenting with adding energy drinks to alcohol, with 9.3 % of subjects continuing to do so [23]. Although the frequency of energy drink use is higher in Eastern countries than in Turkey, it is striking and surprising that the level of addition of energy drinks to alcohol stands at the same level in Turkey as in Western countries. Energy drink consumption in our study was 2.4 times higher among subjects using alcohol than those not using it. One study of university students in Turkey determined that subjects using alcohol consumed 2.5 times more energy drinks than those not using it [11]. Another study of university students in Turkey also reported that subjects using alcohol consumed statistically more energy drinks than those not using alcohol [12]. It is vitally important for alcohol use habits to be considered when precautionary measures aimed
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at preventing the negative effects of energy drinks are being taken. Measures might include warning posters at alcohol sales points and the training of staff working in them. Further studies focusing on the consumption of energy drinks with alcohol in Turkey appear to be needed. Males consumed 2.4 times more energy drinks than females in our study. One study of adults in America reported that men consumed 3.7 times more energy drinks than women [10], and another study of adults in America determined that men consumed 2.8 times more than women [8]. Two studies of university students in Turkey both reported that males consumed for energy drinks than females [11, 12]. Male gender may be said to be a common worldwide risk factor for energy drink consumption. The causes leading males to consume more energy drinks than women need to be carefully examined, and these causes must not be overlooked in proposing solutions. In doing that, the error of excluding women users from our target must also not be committed. Individuals studying at night consumed 1.6 times more energy drinks compared to those studying in the daytime. One study of physical education students in Argentina reported that daytime students consumed significantly more energy drinks compared to those studying at night [20]. This was attributed to individuals studying at night being otherwise occupied when energy drinks are most consumed. The result from our study may be attributed to students studying at night wishing to remain awake or improve their mental performance. These two opposed views are only a hypothesis, and we think that further studies are required on the subject. According to our study, students with friends who consume energy drinks also consume 3.6 times more such drinks than students with no such friends. Although we encountered no studies in the literature directly examining these parameters as we looked at the factors affecting energy drink consumption, one study of university students in Turkey revealed that 59.2 % of students were with one or more friends when they first experimented with such drinks [11]. ‘‘To join in parties’’ is cited as one of the main reasons for energy drink consumption in studies [15, 20]. In one study of adults in America, subjects describing their social lives as perfect consumed sports or energy drinks once or more a week 1.22 times more frequently than those describing their social lives as poor [8]. In the light of all these findings, it may be said that the effect of friends/ social group is a significant factor in acquiring the habit of energy drink consumption. The effect of such friends/ groups should not be overlooked in measures aimed at weaning young people from this habit. Moreover, in addition to measures directed toward the individual, widerranging interventions must be planned, also bearing in light this interpersonal interaction.
Students engaged in regular physical activities in our study consumed 1.86 times more energy drinks than those not engaging in such activity. A study of physical education students in Argentina reported that students attending a gym consumed more energy drinks than other students [20]. An American study determined that consumption of sports and energy drinks was 1.59 times higher among subjects taking part in physical activity lasting at least 10 min seven or more times a week compared to those taking part in physical activity twice a week or less [8]. Although not inquiring directly into physical activity, a study of university students in Turkey reported that students from the sports department consumed 9.2 times more energy drinks than students from the medical faculty [11]. Enhancement of physical performance is the main reason for energy drink consumption worldwide. Studies show that a rise in physical activity also leads to a rise in energy drink consumption. Energy drink companies’ advertizing and sales campaigns also emphasize this. These intensive campaigns and advertizing conceal the side effects of energy drinks and encourage society, and particularly the young, to concentrate on their effects on physical performance. The results from studies show how successful they are in this. Much clearly needs to be done with regarding to raising society’s awareness of the side effects of these drinks. Various side effects, including death, have been reported in the literature [4–7]. The most common side effects in a study of college students in America were unsteadiness and falls (29 %), headache (22 %) and palpitations (19 %) [15]. The most common side effects in our students regularly consuming energy drinks were sleeplessness (13.8 %), thirst (10.3 %) and vertigo (6.9 %). Consumers of energy drinks must bear these subjective symptoms in mind and not forget that there have been cases ending in death. The students most commonly consuming energy drinks in our study were those from the Physical Education Department (34.7 %). These were followed by Administration Department students at 33.1 %. The lowest level of consumption was among Psychological Counseling and Guidance Department students (11.4 %). Use among Medical Faculty students was 16.8 %. Similar to our study, another study of university students in Turkey reported that sports department students consumed 9.2 times more energy drinks than students in the faculty of medicine, and that art department students consumed 3.5 times more [11]. That study postulated that this difference might be due to sport department students engaging in more physical activity and to art department students spending more time in a social environment. We think this is reasonable. Physical education students spending more time in physical activity and administration students being present more
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frequently in social environments compared to other students may explain their higher levels of consumption. On the other hand, as stated above, students attending a gym consuming more energy drinks in a study from Argentina [20] and a 1.22-fold higher level of consumption or engaging in sport once a week or more among subjects content with their social lives in a study from America [8] supports our account of this interdepartmental difference.
9.
10.
11.
Conclusion 12.
This study revealed that almost half of university students had experience of energy drinks and that approximately one-fourth still used them. The factors affecting energy drink consumption were male gender, attending classes at night, engaging in regular physical activity, having friends who consume energy drinks and alcohol consumption. It will be useful for these factors to be borne in mind in the development of policies aimed at protecting young people from the health impacts of energy drinks.
13.
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