For individual use only. Duplication or distribution prohibited by law.
Nutrition
Perceptions About Energy Drinks Are Associated With Energy Drink Intake Among U.S. Youth Gayathri Kumar, MD; Sohyun Park, PhD; Stephen Onufrak, PhD Abstract Purpose. Energy drinks are growing in popularity among youth because of their stimulant properties. However, they can increase blood pressure and are associated with serious consequences such as cardiac arrest. This study examined the associations between energy drink perceptions and energy drink consumption among youth. Design. The design was a cross-sectional study using the YouthStyles Survey 2011. Setting. The online survey was administered at home. Subjects. Subjects were youths aged 12 to 17 years in the summer of 2011 (n ¼ 779). Measures. Energy drink consumption, perceptions about energy drinks, and sociodemographic and behavioral variables were measured. Analysis. Chi-square and multivariable logistic regression analyses were used. Results. Overall, 9% of youth drank energy drinks, 19.5% agreed that energy drinks are safe drinks for teens, and 12.5% agreed that energy drinks are a type of sports drink. The proportion of youth consuming energy drinks once per week or more was highest among youth aged 16 to 17 years and among those who are physically active three to six times a week. The odds for drinking energy drinks once per week or more was higher among youth who agreed that energy drinks are safe drinks for teens (odds ratios [OR] ¼ 7.7, 95% confidence intervals [CI] ¼3.6, 16.4) and among those who agreed that energy drinks are a type of sports drink (OR ¼ 5.0, 95% CI ¼ 2.4, 10.7). Conclusions. These findings suggest that many youth may be unaware or misinformed about the potential health effects and nutritional content of energy drinks. Efforts to improve education among youth about the potential adverse effects of consuming energy drinks are needed. (Am J Health Promot 2015;29[4]:238–244.) Key Words: Energy Drinks, Adolescents, Perceptions, Consumption, SugarSweetened Beverages, Prevention Research. Manuscript format: research; Research purpose: modeling/relationship testing; Study design: nonexperimental, observational; Outcome measure: behavioral; Setting: family; Health focus: nutrition; Strategy: education; Target population age: youth; Target population circumstances: general
Gayathri Kumar, MD, is with the Epidemic Intelligence Service, Office of Surveillance, Epidemiology, and Laboratory Services; and Sohyun Park, PhD; and Stephen Onufrak, PhD, are with the Division of Nutrition, Physical Activity and Obesity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Send reprint requests to Gayathri Kumar, MD, Epidemic Intelligence Service, Office of Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, 4770 Buford Highway, Atlanta, GA 30341; [email protected]. This manuscript was submitted August 20, 2013; revisions were requested October 3, 2013; the manuscript was accepted for publication October 28, 2013. Copyright Ó 2015 by American Journal of Health Promotion, Inc. 0890-1171/15/$5.00 þ 0 DOI: 10.4278/ajhp.130820-QUAN-435
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PURPOSE Energy drinks are the fastest growing segment of the beverage industry.1 They are marketed to improve energy, concentration, and athletic performance because of their high caffeine content and other additives.1–3 Caffeine content in energy drinks ranges from 50 mg to 505 mg per can or bottle.3 Although energy drinks may relieve fatigue and improve performance,4 their stimulating properties could also boost the heart rate and blood pressure, dehydrate the body, and prevent sleep.5 Furthermore, there is concern that adolescents sometimes believe that energy drinks are a type of rehydrating sports drink2; energy drinks have the potential to be harmful to the body during physical activity because of their dehydrating properties. Anecdotal reports of more serious consequences include seizures, cardiac dysrhythmias, and sudden death.1,6 Many countries have regulated energy drink consumption because of the adverse health effects associated with it. As an example, sales to children younger than 15 years are banned in Sweden, with labels warning against consuming these drinks after exercise or with alcohol.7 However, in the United States, energy drinks are classified as ‘‘natural dietary supplements,’’1 which are not subject to the same caffeine level limitations as in soft drinks, which are classified as food. Therefore, the safety of energy drinks is determined solely by manufacturers, and thus far there are no requirements for testing, warning labels, or restriction against sales or consumption by minors. Because of this, both the Institute of Medicine and the American Academy of Pediatrics have rec-
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For individual use only. Duplication or distribution prohibited by law. ommended against energy drink intake by youth and encourage efforts to educate parents and children about their potential health risks.2,8,9 Given that half of the energy drink market consists of adolescents and young adults,1 there is a great need to examine perceptions about energy drinks among these populations, as individual perceptions can influence behaviors (i.e., energy drink consumption). However, little is known regarding factors associated with energy drink consumption,10 and there is no literature to date on perceptions about energy drinks among U.S. adolescents between the ages of 12 and 17 years. Previous studies looking at associated factors have primarily targeted college age students and adults.11,12 It is of particular interest to examine energy drink consumption along with other poor dietary behaviors, such as reduced fruit and vegetable intake and increased fast-food consumption, because knowledge of these characteristics may inform public health interventions and education efforts designed to simultaneously reduce less desirable eating or drinking (e.g., energy drink consumption) and promote healthful eating. Studies have shown that increased overall sugarsweetened beverage consumption has been linked with increased fast-food restaurant use and reduced fruit and vegetable intake.10,13 Furthermore, assessing the association between energy drink consumption and physical activity is of interest given that adolescents may confuse energy drinks as a type of sports drink to be used prior to or during physical activity to enhance athletic performance.2 Therefore, the objectives of this study were to examine sociodemographic and behavioral factors associated with energy drink consumption among youth aged 12 to 17 years, to describe the sociodemographic and behavior factors associated with perceptions about energy drink safety and classification, and to model the associations between energy drink perceptions and energy drink consumption.
METHODS Design This cross-sectional study used data from the YouthStyles Survey conducted in the summer of 2011. The Youth-
American Journal of Health Promotion
Styles Survey is an online survey of U.S. youth between the ages of 12 and 17 years and is designed to assess health beliefs and behaviors surrounding important public health concerns. Participants include the children of adult participants who completed the HealthStyles Survey (administered in three parts, SpringStyles, SummerStyles, and FallStyles) in 2011. The sampling and data collection are conducted by Knowledge Networks, an online research firm that recruited an online research panel to provide a convenience sample of approximately 50,000 panelists. Sample The YouthStyles survey sample was obtained as detailed below. First, the SpringStyles survey was originally sent to a random sample of 14,598 adult panelists aged 18 and older, of whom 8,110 participants completed the survey (response rate of 56%). From the adult participants who completed the SpringStyles survey, a random sample of 1,614 adult panelists with children ages 12 to 17 were sent the SummerStyles survey. Children of these 1,614 adult panelists were sent the YouthStyles survey, and a total of 840 youth completed the YouthStyles Survey yielding a response rate of 52%. YouthStyles Survey data are weighted based on age, sex, race/ethnicity, household income, number of teenagers aged 12 to 17 years, parent education level, census region, metro status, and prior Internet access to match the U.S. Current Population Survey proportions.14 The analysis was exempt from the Centers for Disease Control and Prevention (CDC) Institutional Review Board process because personal identifiers were not included in the data provided to the CDC. Among the 840 youth who completed the survey, a total of 61 respondents were excluded because of missing data on energy drink intake (n ¼ 10), perceptions (n ¼ 14), or any of the behavioral variables (n ¼ 37), yielding a final analytic sample of 779 youth. Compared to those youth who were included in the study, those who were excluded did not differ in age, sex, race/ethnicity, annual household income, and parent education level.
Measures Energy Drink Consumption. The outcome of interest was energy drink intake, which was based on the following question: ‘‘During the past 7 days, how many times did you drink a can or bottle of energy drink like Red Bull, Monster, NOS, 5-hour Energy, or Full Throttle?’’ Response options were none, 1 to 2 times/wk, 3 to 4 times/wk, 5 to 6 times/ wk, 1 time/d, and 2 times/d. For analysis, two mutually exclusive categories were created: none and 1 time/ wk. The frequency of responses in the categories of 3 to 4 times/wk (9 or 1.1%), 5 to 6 times/wk (5 or .6%), 1 time/d (1 or.1%), and 2 times/d (2 or .3%) were too low to be considered as separate categories of their own. Hence, we dichotomized the categories into these two mutually exclusive categories based on the data distribution. Perceptions About Energy Drinks. The primary exposure variables were based upon participant response to two perception statements: (1) ‘‘Energy drinks like Red Bull, Monster, NOS, and 5-Hour Energy are safe drinks for teens’’ and (2) ‘‘Energy drinks, such as Red Bull or Monster, are a type of sports drink, such as Powerade or Gatorade.’’ Response options were ‘‘strongly disagree,’’ ‘‘somewhat disagree,’’ ‘‘neither agree nor disagree,’’ ‘‘somewhat agree,’’ and ‘‘strongly agree.’’ Three mutually exclusive categories were created for each perception variable: agree (strongly/ somewhat agree), neither, and disagree (strongly/somewhat disagree). Sociodemographic and Behavioral Variables. Mutually exclusive categories were created for each covariate. Sociodemographic variables included age (12–13, 14–15, and 16–17 years), sex, race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, and other/multiracial), parent education level (high school or less, some college, and college graduate), family annual income ($14,999, $15,000–$34,999, $35,000–$74,999, $75,000–$99,999, $100,000), and geographic region of country (Northeast, Midwest, South, and West). Behavioral variables included alcohol intake (never tried, have tried but not in last month, and have tried in last month), smoking
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For individual use only. Duplication or distribution prohibited by law. (not at all, some days, and every day), marijuana use (never tried, have tried but not in last month, and have tried in last month), vegetable and fruit consumption (none, 1–4, and 5 times/ d), non-diet soda consumption (none, 1, and 2 times/d), fast-food intake (none and 1 time/d), and physical activity for a total of at least 60 min/d (,3, 3–6, and 7 times/wk). Analysis Chi-square tests were used to examine the relationship between energy drink consumption and the sociodemographic and behavioral variables as well as to examine relationship between energy drink perceptions and sociodemographic and behavioral variables. A p value of ,.05 defined statistical significance. Two multivariable logistic regression models were fitted to estimate the adjusted odds ratios (ORs) and 95% confidence intervals for both of the perceptions associated with energy drink consumption, after controlling for other factors. The first model (model 1) controlled for sociodemographic variables (i.e., age, sex, race/ethnicity, family annual income, and parent education level). The second model (model 2) controlled for smoking, soda intake, and fast-food intake in addition to the aforementioned sociodemographic variables. Smoking, soda intake, and fast-food intake were selected based on the fact that these variables were consistently and significantly associated with energy drink intake and both of the energy drink perceptions. All statistical analyses were performed with the Statistical Analysis Software (SAS) version 9.3 (SAS Institute Inc., Cary, North Carolina).
RESULTS The final sample included 779 youth aged 12 to 17 years. About 8% of youth reported consuming energy drinks 1 time/wk and ,1% reported consuming energy drinks 1 time/d. Energy drink consumption significantly differed by age, alcohol intake, smoking, marijuana use, vegetable and fruit intake, non-diet soda intake, fast-food intake, and physical activity (Table 1, v2 tests, p , .05). The proportion of youth consuming energy drinks 1 time/wk was highest
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Table 1 Sociodemographic and Behavioral Characteristics of Respondents and Their Associations With Energy Drink Intake Among U.S. Youth (n ¼ 779)—YouthStyles Survey, 2011† Energy Drink Intake During the Past 7 d‡ Characteristic
None % 6 SE
1 Time/Wk % 6 SE
92.2 6 1.1
7.8 6 1.1
6 2.2 6 2.3 6 2.4
96.2 6 1.4 91.9 6 1.8 88.6 6 2.3
3.8 6 1.4 8.1 6 1.8 11.4 6 2.3
0.02
6 2.4 6 2.4
90.2 6 1.7 94.3 6 1.4
9.8 6 1.7 5.7 6 1.4
0.07
All % 6 SE
Total sample 100 Age 12–13 y 32.1 14–15 y 34.0 16–17 y 33.9 Sex Male 51.9 Female 48.1 Race/ethnicity White, non-Hispanic 60.6 Black, non-Hispanic 12.5 Hispanic 19.2 Other/multiracial 7.7 Parent education level High school or less 21.0 Some college 38.7 College graduate 40.3 Annual family income $14,999 8.5 $15,000–$34,999 15.9 $35,000–$74,999 33.0 $75,000–$99,999 19.4 $100,000 23.1 Geographic regions Northeast 18.5 Midwest 23.3 South 35.3 West 22.9 Alcohol intake Never tried 76.6 Have tried but not in the last mo 17.7 Had in last mo 5.7 Smoking status Not at all 97.1 Some days 2.2 Every day 0.8 Marijuana use Never tried 92.3 Have tried 6.1 Had in last mo 1.6 Vegetable and fruit intake None 7.9 1–4 times/d 65.4 5 times/d 26.7 Non-diet soda intake None 57.8 1 time/d 23.4 2 times/d 18.8 Fast-food intake None 71.0 1 time/d 29.0 Physical activity 60 min/d ,3 times/wk 46.3 3–6 times/wk 43.5 7 times/wk 10.2
6 6 6 6
2.5 2.0 2.2 1.1
6 2.0 6 2.4 6 2.3
91.4 93.4 95.2 88.3
6 6 6 6
1.3 3.8 2.3 4.5
93.0 6 2.5 91.0 6 1.9 92.9 6 1.6
8.6 6.6 4.8 11.7
p*
1.3 3.8 2.3 4.5
0.53
7.0 6 2.5 9.0 6 1.9 7.1 6 1.6
0.70
6 6 6 6
6 6 6 6 6
1.5 2.1 2.2 1.8 1.9
86.1 96.3 91.9 89.5 94.2
6 6 6 6 6
6.0 1.9 1.8 2.8 1.8
13.9 3.7 8.1 10.5 5.8
6 6 6 6 6
6.0 1.9 1.8 2.8 1.8
0.17
6 6 6 6
1.8 2.0 2.4 2.1
96.7 91.6 90.6 91.4
6 6 6 6
1.3 2.1 2.1 2.4
3.3 8.4 9.4 8.6
6 6 6 6
1.3 2.1 2.1 2.4
0.20
6 2.0
94.9 6 1.0
5.1 6 1.0
6 1.8 6 1.1
83.0 6 3.6 83.9 6 6.7
17.0 6 3.6 16.1 6 6.7
6 0.7 6 0.6 6 0.3
93.7 6 1.0 34.8 6 13.5 54.5 6 16.8
6.3 6 1.0 65.2 6 13.5 45.5 6 16.8
,0.0001
6 1.2 6 1.1 6 0.5
93.0 6 1.1 88.6 6 4.2 55.6 6 15.2
7.0 6 1.1 11.4 6 4.2 44.4 6 15.2
,0.0001
6 1.2 6 2.3 6 2.2
84.6 6 5.3 94.7 6 1.0 88.3 6 2.8
15.4 6 5.3 5.3 6 1.0 11.5 6 2.8
0.005
6 2.4 6 2.2 6 1.7
97.5 6 0.7 89.3 6 2.9 79.2 6 3.7
2.4 6 0.7 10.7 6 2.9 20.8 6 3.7
,0.0001
6 2.2 6 2.2
95.4 6 0.9 84.1 6 2.9
4.6 6 0.9 15.9 6 2.9
,0.0001
6 2.4 6 2.4 6 1.6
94.5 6 1.2 89.1 6 2.1 94.8 6 2.3
5.5 6 1.2 10.9 6 2.1 5.2 6 2.3
0.02
,0.0001
† Weighted percentage may not add up to 100% because of rounding. ‡ During the past 7 days, how many times did you drink a can or bottle of energy drinks like Red Bull, Monster, NOS, 5-hour Energy, or Full Throttle? * Chi-square tests were used to examine differences across categories for each variable.
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Table 2 Sociodemographic and Behavioral Characteristics of Respondent by Perceptions About Energy Drinks Among U.S. Youth (n ¼ 779)—YouthStyles Survey, 2011† Energy Drinks Are Safe Drinks for Teens‡
Total sample Age 12–13 y 14–15 y 16–17 y Sex Male Female Race/ethnicity White, non-Hispanic Black, non-Hispanic Hispanic Other/multiracial Parent education level High School or less Some college College graduate Annual family income $14,999 $15,000–$34,999 $35,000–$74,999 75,000–$99,999 $100,000 Geographic regions Northeast Midwest South West Alcohol intake Never tried Have tried but not in the last mo Had in last mo Smoking status Not at all Some days Every day Marijuana use Never tried Have tried Had in last mo Vegetable and fruit intake None 1–4 times/y 5 times/d Non-diet soda intake None 1 time/d 2 times/d Fast-food intake None 1 time/d Physical activity60 min/d ,3 times/wk 3–6 times/wk 7 times/wk
Disagree % 6 SE
Neither % 6 SE
Agree % 6 SE
58.8 6 2.3
21.6 6 1.9
19.5 6 1.8
62.3 6 3.7 61.1 6 3.8 53.3 6 4.5
22.2 6 3.0 18.2 6 2.8 24.6 6 4.0
15.6 6 2.5 20.7 6 3.1 22.1 6 3.5
53.1 6 3.3 64.9 6 3.3
24.7 6 2.9 18.3 6 2.5
55.6 67.4 63.2 59.3
20.9 23.8 20.6 26.4
6 6 6 6
2.7 7.6 6.3 7.0
6 6 6 6
2.1 6.8 5.3 5.9
Energy Drinks Are a Type of Sports Drink§ Disagree % 6 SE
Neither % 6 SE
Agree % 6 SE
70.6 6 2.1
16.5 6 1.8
12.9 6 1.4
0.31
69.7 6 3.3 69.0 6 3.7 73.2 6 3.9
16.4 6 2.4 17.0 6 3.3 16.0 6 3.3
13.8 6 2.5 14.0 6 2.3 10.8 6 2.6
0.89
22.1 6 2.4 16.7 6 2.7
0.04
66.6 6 3.1 75.0 6 2.8
17.8 6 2.6 15.1 6 2.3
15.6 6 2.1 9.9 6 1.8
0.09
23.5 8.8 16.3 14.3
2.3 3.9 4.5 4.5
0.22
69.5 75.4 77.0 56.4
16.3 14.2 14.2 27.5
14.2 10.4 8.8 16.1
1.8 4.2 2.8 5.0
0.34
6 6 6 6
p*
6 6 6 6
2.5 6.5 5.3 7.3
6 6 6 6
2.1 5.2 4.8 6.6
6 6 6 6
p*
61.6 6 4.9 55.9 6 4.0 60.2 6 3.5
19.5 6 3.7 23.2 6 3.5 21.3 6 2.8
18.9 6 3.6 20.9 6 3.1 18.6 6 2.7
0.88
73.0 6 4.2 68.5 6 3.7 71.5 6 3.1
14.2 6 3.2 19.4 6 3.4 14.9 6 2.4
12.8 6 3.0 12.1 6 2.2 13.6 6 2.3
0.71
54.0 65.4 58.7 53.8 60.3
6 6 6 6 6
9.0 6.5 3.8 4.9 4.7
22.1 19.8 23.5 18.6 22.6
6 6 6 6 6
7.2 5.0 3.3 3.4 4.4
23.9 14.7 17.7 27.6 17.1
6 6 6 6 6
6.9 4.4 2.6 4.8 3.4
0.58
55.7 69.3 67.1 76.3 77.3
6 6 6 6 6
9.0 6.5 3.6 4.2 3.5
23.9 19.5 17.5 12.4 13.7
6 6 6 6 6
7.5 5.7 3.1 3.1 2.9
20.4 11.2 15.3 12.4 9.0
6 6 6 6 6
6.6 3.8 2.5 3.1 2.0
0.26
57.8 61.1 55.7 62.0
6 6 6 6
5.4 4.6 4.1 4.8
25.6 18.5 25.2 16.1
6 6 6 6
5.0 3.3 3.6 3.0
16.6 20.4 19.0 21.8
6 6 6 6
3.4 3.7 3.1 4.1
0.52
70.1 75.1 68.6 69.6
6 6 6 6
4.6 3.8 3.8 4.7
17.3 14.8 17.5 16.0
6 6 6 6
3.9 3.3 3.1 4.0
12.6 10.1 13.9 14.4
6 6 6 6
2.8 2.2 2.7 3.1
0.93
62.8 6 2.6 48.3 6 5.6 38.2 6 9.8
22.2 6 2.2 14.2 6 3.2 37.1 6 10.8
15.0 6 1.8 37.5 6 5.5 24.7 6 7.6
,0.0001
70.2 6 2.5 72.3 6 4.6 72.0 6 7.7
18.4 6 2.2 10.3 6 2.9 10.6 6 4.8
11.5 6 1.5 17.4 6 3.8 17.4 6 6.1
0.12
60.2 6 2.4 12.0 6 6.5 20.5 6 12.2
21.6 6 2.0 24.9 6 13.2 21.5 6 13.6
18.3 6 1.8 63.1 6 13.8 58.0 6 16.2
,0.0001
71.6 6 2.1 39.4 6 13.9 37.5 6 15.7
16.5 6 1.8 15.1 6 11.4 19.8 6 12.8
11.9 6 1.4 45.6 6 14.4 42.7 6 16.9
0.0004
60.3 6 2.4 44.7 6 9.8 25.0 6 10.9
21.5 6 2.0 18.9 6 6.5 38.0 6 16.4
18.1 6 1.8 36.4 6 9.5 36.9 6 13.4
0.02
70.5 6 2.2 72.1 6 7.8 75.7 6 10.9
16.9 6 1.9 12.5 6 5.6 9.5 6 6.7
12.7 6 1.5 15.3 6 5.7 14.8 6 8.8
0.88
46.7 6 7.6 59.1 6 2.9 61.6 6 4.6
23.3 6 6.6 21.1 6 2.3 22.5 6 4.1
30.0 6 7.5 19.8 6 2.2 15.9 6 3.0
0.37
56.5 6 7.6 73.5 6 2.4 67.7 6 4.6
26.7 6 6.7 15.9 6 2.0 15.0 6 3.9
16.7 6 5.5 10.6 6 1.5 17.2 6 3.4
0.10
63.8 6 3.1 58.0 6 5.1 44.4 6 4.6
21.6 6 2.7 17.2 6 3.2 27.3 6 4.4
14.6 6 2.1 24.7 6 4.4 28.3 6 4.1
0.003
74.7 6 2.8 70.5 6 4.3 58.2 6 4.7
15.8 6 2.4 16.3 6 3.0 19.0 6 4.1
9.5 6 1.6 13.2 6 3.2 22.8 6 3.7
0.009
63.5 6 2.7 47.3 6 4.4
20.3 6 2.2 24.9 6 3.8
16.2 6 1.9 27.8 6 3.9
0.003
73.3 6 2.5 64.2 6 4.0
16.3 6 2.2 16.9 6 3.0
10.4 6 1.5 18.9 6 3.0
0.03
60.4 6 3.4 52.9 6 3.6 76.7 6 6.7
18.4 6 2.5 27.2. 6 3.2 12.8 6 6.0
21.2 6 2.7 19.9 6 2.8 10.5 6 3.5
0.02
69.1 6 3.2 71.7 6 3.1 72.9 6 6.7
17.4 6 2.7 16.2 6 2.5 13.9 6 5.6
13.5 6 2.1 12.1 6 2.1 13.2 6 4.2
0.96
† Weighted percentage may not add up to 100% because of rounding. ‡ Energy drinks like Red Bull, Monster, NOS, and 5-hour Energy are safe drinks for teens. § Energy drinks, such as Red Bull or Monster, are a type of sports drink, such as Powerade or Gatorade. * Chi-square tests were used to examine differences across categories for each variable, with p ,0.05 considered statistically significant.
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Table 3 Bivariate and Multivariable Analyses for Energy Drink Consumption by Energy Drink Perceptions Among U.S. Youth (n ¼ 779)— YouthStyles Survey, 2011†
Perceptions
None % 6 SE
Bivariate Analysis
Model 1 Multivariable Logistic Regression Analysis‡
Model 2 Multivariable Logistic Regression Analysis§
Energy Drink Intake During the Past 7 d
Energy Drink Intake 1 Time/Wk
Energy Drink Intake 1 Time/Wk
1 Time/Wk % 6 SE
Energy drinks are safe drinks for teens|| Disagree 96.6 6 0.7 3.4 6 Neither 92.6 6 2.2 7.4 6 Agree 78.4 6 3.9 21.6 6 Energy drinks are a type of sports drink# Disagree 94.0 6 1.1 6.0 6 Neither 96.5 6 1.5 3.5 6 Agree 76.7 6 5.1 23.3 6
p*
0.7 2.2 3.9
,0.0001
1.1 1.5 5.1
,0.0001
Adjusted Odds Ratio
95% Confidence Interval
Adjusted Odds Ratio
95% Confidence Interval
Reference 2.00 6.79¶
0.79, 5.09 3.12, 14.77
Reference 1.48 4.23¶
0.56, 3.90 1.93, 9.33
Reference 0.48 4.50
0.17, 1.39 2.08, 9.73
Reference 0.30 2.46
0.08, 1.20 1.09, 5.54
† Weighted percentage may not add up to 100% because of rounding. ‡ The multivariable logistic regression model included both perception variables and sociodemographic variables (i.e., age, sex, race/ethnicity, family annual income, and parent education level) in one model. Reference category included youth who did not drink any energy drinks. § The multivariable logistic regression model included both perception variables, sociodemographic variables (i.e., age, sex, race/ethnicity, family annual income, and parent education level) and behavioral variables (smoking, soda intake, and fast-food intake) in one model. Reference category included youth who did not drink any energy drinks. || Energy drinks like Red Bull, Monster, NOS, and 5-hour Energy are safe drinks for teens. ¶ Significant findings based on the 95% confidence interval (i.e., the confidence interval does not include 1). # Energy drinks, such as Red Bull or Monster, are a type of sports drink, such as Powerade or Gatorade. * p , 0.05 was considered statistically significant.
among youth aged 16 to 17 years; those who tried alcohol, but not in last month, and those who tried alcohol in the last month; those who smoked some days; those who used marijuana in the last month; those who did not consume fruits and vegetables; those who drank non-diet soda 2 times/d; those who ate fast food 1 time/d; and those who were physically active 3 to 6 times/wk (Table 1). Approximately 20% agreed that energy drinks are safe drink for teens, and 13% agreed that energy drinks are a type of sports drink (Table 2). Youth perceptions toward energy drink consumption differed by sociodemographic and behavioral characteristics (Table 2; v2 tests, p , .05). Among groups in which significant differences exist, the proportion of youth who agreed that energy drinks are safe drinks for teens was highest among males, youth who tried alcohol but not in last month, those who smoked some days, those who either had ever tried marijuana or used marijuana in the last month, those who drank non-diet soda 2 times/d, those who ate fast food 1 time/d,
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and those who are physically active ,3 times/wk. The proportion of youth who believed that energy drinks are a type of sports drinks was highest among youth who smoked some days, those who drank non-diet soda 2 times/d, and those who ate fast food 1 time/d (Table 2). Energy drink consumption significantly differed by youth perceptions about energy drinks. Consistent with findings from bivariate analysis, results of both multivariable logistic regression analyses showed that the odds for drinking energy drinks 1 time/wk was significantly higher among youth who agreed that energy drinks are safe drinks for teens (OR ¼ 6.8 vs. disagreed for model 1, and OR ¼ 4.2 vs. disagreed for model 2) as well as youth who agreed that energy drinks are a type of sports drink (OR ¼ 4.5 vs. disagreed for model 1, and OR ¼ 2.5 vs. disagreed for model 2) (Table 3).
DISCUSSION Our study reports that 8% of adolescents consume energy drinks weekly
and that only .17% of adolescents consume them daily or more frequently. Other studies reported energy drink consumption prevalence among adolescents varying from 5% daily to 42.3% biweekly.1,10,15–17 Each study differed in the time period for which the energy drink consumption was reported. One study conducted with the 2010 National Youth Physical Activity and Nutrition Study (NYPANS) data showed that 5% of U.S. high school students (n ¼ 11,209) reported drinking a can, bottle, or glass of energy drink 1 time/d.10 Although there is variation in prevalence of consumption across studies, it is clear that many youth are consuming energy drinks against the recommendations of the American Academy of Pediatrics. Sociodemographic and Behavioral Factors Associated With Energy Drink Consumption. Greater age of youth was the only sociodemographic variable associated with increased energy drink intake in the present study. This differs from the 2010 NYPANS study among U.S. high school students in which age was not
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For individual use only. Duplication or distribution prohibited by law. associated with energy drink intake, but being male and non-Hispanic black were associated with intake.10 In the present study, behavioral variables significantly associated with weekly energy drink consumption in bivariate analyses include use of alcohol, smoking, marijuana, vegetable and fruit, non-diet soda, fast foods, and physical activity. Some of these findings corroborate findings from other studies, such as the NYPANS 2010 study by Park et al.,10 that reported increased energy drink consumption with frequent fast-food restaurant use among high school–aged youth. Reduced vegetable and fruit consumption with increased energy drink consumption suggests that energy drink intake might be associated with less healthful dietary behaviors.18,19 The association between energy drinks intake and physical activity 3 to 6 times/wk suggests that youth may be using energy drinks as a method to boost physical performance, which is a current marketing strategy for energy drink beverages.1 Of note in this study is the association of energy drinks and other abused substances, such as alcohol, tobacco, and marijuana. Indeed, several studies, albeit in older populations, report that their survey populations coingest other substances such as alcohol with energy drinks.1,5,11,20–24 Similarly, our study suggests that energy drink intake may be more common among youth who engage in other risk-taking behaviors. Sociodemographic and Behavioral Factors Associated With Perceptions About Energy Drinks. Energy drink perceptions were significantly different by sociodemographic characteristics and behavioral factors in the present study. These findings suggest that youth who believe that energy drinks are safe are more likely to participate in other high-risk and unhealthy behaviors, possibly as a result of lack of awareness or education, peer influence, or deliberate risktaking behavior. Some psychologists and behavioral scientists have even suggested that given that risk-taking behaviors among adolescents can be influenced by a sense of invulnerability, sensation-seeking among youth, and strong peer influence, education efforts about these risk-taking behaviors may not always necessarily be effec-
American Journal of Health Promotion
tive.25,26 However, our findings suggest that many youth also wrongly perceive that energy drinks are safe; therefore, these youth may not have the right information about energy drinks to make informed choices in the future about consuming these drinks. Despite marketing strategies that tout physical performance enhancement with energy drinks,1 there is no association with physical activity for youth who believe that energy drinks are a type of sports drink in the present study. Association Between Energy Drink Consumption and Perceptions About Energy Drinks. Furthermore, energy drink consumption was significantly associated with energy drink perceptions among U.S. youth even after controlling for sociodemographic characteristics as well as smoking, soda intake, and fast-food intake in the present study. The odds of consuming energy drinks weekly was between 4 and 7 times higher if the youth agreed that energy drinks are safe, whereas the odds of consuming energy drinks was between 2.5 and 4.5 times higher if the youth agreed that energy drinks are a type of sports drink. These findings suggest that improved awareness among youth about energy drinks and their potential health effects has the potential to influence consumption. Limitations To the authors’ knowledge, this study is the first to report energy drink perceptions and their association with energy drink consumption among U.S. youth. There are several limitations to this study. First, the sample size for the YouthStyles Survey may not be large enough to detect differences in certain characteristics of energy drink consumers and perceptions. Second, findings may not be generalizable nationally because of selection bias associated with the use of a convenience sample from an online panel survey with a relatively low response rate. Third, it is possible that results of the YouthStyles Survey are biased given that the survey was administered at home where the presence of the youths’ parents could influence answer choices. For example the prevalence of smoking in the current sample was very low compared to estimates from the Youth Risk Behavior Survey, a paper-
SO WHAT? Implications for Health Promotion Practitioners and Researchers What is already known about this topic? Energy drinks are growing in popularity among youth because of their stimulant properties, despite the potential harms associated with consuming these drinks, such as elevated blood pressure and dehydration. Given that half of the energy drink market consists of adolescents and young adults, perceptions about energy drinks among these populations should be examined, although to the authors’ knowledge no literature to date on this topic exists. What does this article add? Overall, 8% of youth drank energy drinks, 20% of adolescents wrongly perceive that energy drinks are safe drinks for teens, and 13% of adolescents wrongly perceive that energy drinks are a type of sports drink. What are the implications for health promotion practice or research? The evidence from this study supports health promotion efforts to educate and make youth aware of the potential harmful health impact of consuming energy drinks. Possible promotion techniques include creating brochures/pamphlets on energy drink consumption that can be handed out directly to youth and parents, placing informational posters in schools and health care facilities, and conducting informational seminars/sessions about energy drinks directed at both youth and family members.
and-pencil survey that was administered in schools.27 Fourth, there is a risk of recall or reporting bias given that the YouthStyles data are selfreported. Lastly, given that this is a cross-sectional study, causality or the direction of the association cannot be determined. Conclusions Overall, 8% of youth drank energy drinks, 20% agreed that energy drinks are safe drink for teens, and 13% agreed that energy drinks are a type of sports drink. Energy drink intake was associated with the perceptions that energy drinks are safe drinks for teens and that energy drinks are a type of sports drink. Furthermore, factors asso-
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For individual use only. Duplication or distribution prohibited by law. ciated with energy drink intake include alcohol use, increased physical activity but not daily physical activity, and decreased vegetable and fruit consumption. Factors associated with the belief that energy drinks are safe drinks for teens include being male and use of alcohol, marijuana, and non-diet soda. Efforts to educate and make youth aware of the potential harmful health impact of consuming energy drinks among youth are needed. Acknowledgment The findings and conclusions in this presentation are those of the author and not necessarily the CDC.
References
1. Seifert SM, Schaechter JL, Hershorin ER, et al. Health effects of energy drinks on children, adolescents, and young adults. Pediatrics. 2011;127:511–528. 2. Committee on Nutrition and the Council on Sports Medicine and Fitness: sports drinks and energy drinks for children and adolescents: are they appropriate? Pediatrics. 2011;127:1182–1189. 3. Reissig CJ, Strain EC, Griffiths RR. Caffeinated energy drinks-a growing problem. Drug Alcohol Depend. 2009;99:1– 10. 4. Nawrot P, Jordan S, Eastwood J, et al. Effects of caffeine on human health. Food Addit Contam. 2003;20:1–30. 5. Atilla S, Cakir B. Energy-drink consumption in college students and associated factors. Nutrition. 2011;27:316– 322. 6. Starling S. Energy drinks safety questioned by German agency. Available at: www. beveragedaily.com/content/view/print/ 166290/. Accessed September 5, 2012. 7. Oddy WH, O’Sullivan TA. Energy drinks for children and adolescents. BMJ. 2009; 339:b5268.
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8. Institute of Medicine. Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth. Washington, DC: National Academies Press; 2007. 9. American Academy of Pediatrics. Kids should not consume energy drinks, and rarely need sports drinks, says AAP. Available at: http://www.aap.org/en-us/ about-the-aap/aap-press-room/pages/ Kids-Should-Not-Consume-Energy-Drinks,and-Rarely-Need-Sports-Drinks,-Says-AAP. aspx?nfstatus¼401&nftoken¼000000000000-0000-0000-000000000000& nfstatusdescription¼ERROR%3aþNoþ localþtoken. Accessed September 6, 2012. 10. Park S, Blanck H, Sherry B, et al. Factors associated with sugar-sweetened beverage intake among United States high school students. J Nutr. 2012;142:306–312. 11. Miller K. Energy drinks, race, and problem behaviors among college students. J Adolesc Health. 2008;43:490–497. 12. Berger LK, Fendrich M, Chen H, et al. Sociodemographic correlates of energy drink consumption with and without alcohol: results of a community survey. Addict Behav. 2011;36:516–519. 13. Park S, Sherry B, Foti K, Blanck HM. Selfreported academic grades and other correlates of sugar-sweetened soda intake among US adolescents. J Acad Nutr Diet. 2012;112:125–131. 14. US Bureau of the Census. Current Population Survey: 2010. Available at: http://www.census.gov/2010census/. Accessed on September 20, 2012. 15. Simon M, Mosher J. Alcohol, Energy Drinks, and Youth: A Dangerous Mix. San Rafael, Calif: Marin Institute; 2007. 16. Ballard SL, Wellborn-Kim JJ, Clauson KA. Effects of commercial energy drink consumption on athletic performance and body composition. Phys Sports Med. 2010; 38:107–117. 17. O’Dea JA. Consumption of nutritional supplements among adolescents: usage and perceived benefits. Health Educ Res. 2003;18:98–107.
18. Marshall TA, Eichenberger Gilmore JM, Broffitt B, et al. Diet quality in young children is influenced by beverage consumption. J Am Coll Nutr. 2005;24:65– 75. 19. Frary CD, Johnson RK, Wang MQ. Children and adolescents’ choices of foods and beverages high in added sugars are associated with intakes of key nutrients and food groups. J Adolesc Health. 2004;34: 56–63. 20. Peacock A, Bruno R, Martin FH. The subjective physiological, psychological, and behavioral risk-taking consequences of alcohol and energy drink co-ingestion. Alcohol Clin Exp Res. 2012;36:1–8. 21. Marczinski CA. Alcohol mixed with energy drinks: consumption patterns and motivations for use in US college students. Int J Environ Res Public Health. 2011;8:3232– 3245. 22. Gunja N, Brown JA. Energy drinks: health risks and toxicity. MJA. 2012;196:46–49. 23. Maulinauskas BM, Aeby VG, Overton RF, et al. A survey of energy drink consumption patterns among collect students. Nutrition. 2007;6:35. 24. Price SR, Hilchey CA, Darredeau C, et al. Energy drink co-administration is associated with increased reported alcohol ingestion. Drug Alcohol Rev. 2010;29:331– 333. 25. Irwin CE, Millstein SG. Biopsychosocial correlates of risk-taking behaviors during adolescence: can the physician intervene? J Adoles Health Care. 1986;7:82–96. 26. Steinberg L. Risk taking in adolescence: new perspectives from brain and behavioral science. Curr Dir Psychol Sci. 2007;16:55–59. 27. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance System: 2011 National Overview. Available at: http://www.cdc. gov/healthyyouth/yrbs/pdf/ us_overview_yrbs.pdf. Accessed September 20, 2011.
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Nutrition
Perceptions About Energy Drinks Are Associated With Energy Drink Intake Among U.S. Youth Gayathri Kumar, MD; Sohyun Park, PhD; Stephen Onufrak, PhD Abstract Purpose. Energy drinks are growing in popularity among youth because of their stimulant properties. However, they can increase blood pressure and are associated with serious consequences such as cardiac arrest. This study examined the associations between energy drink perceptions and energy drink consumption among youth. Design. The design was a cross-sectional study using the YouthStyles Survey 2011. Setting. The online survey was administered at home. Subjects. Subjects were youths aged 12 to 17 years in the summer of 2011 (n ¼ 779). Measures. Energy drink consumption, perceptions about energy drinks, and sociodemographic and behavioral variables were measured. Analysis. Chi-square and multivariable logistic regression analyses were used. Results. Overall, 9% of youth drank energy drinks, 19.5% agreed that energy drinks are safe drinks for teens, and 12.5% agreed that energy drinks are a type of sports drink. The proportion of youth consuming energy drinks once per week or more was highest among youth aged 16 to 17 years and among those who are physically active three to six times a week. The odds for drinking energy drinks once per week or more was higher among youth who agreed that energy drinks are safe drinks for teens (odds ratios [OR] ¼ 7.7, 95% confidence intervals [CI] ¼3.6, 16.4) and among those who agreed that energy drinks are a type of sports drink (OR ¼ 5.0, 95% CI ¼ 2.4, 10.7). Conclusions. These findings suggest that many youth may be unaware or misinformed about the potential health effects and nutritional content of energy drinks. Efforts to improve education among youth about the potential adverse effects of consuming energy drinks are needed. (Am J Health Promot 2015;29[4]:238–244.) Key Words: Energy Drinks, Adolescents, Perceptions, Consumption, SugarSweetened Beverages, Prevention Research. Manuscript format: research; Research purpose: modeling/relationship testing; Study design: nonexperimental, observational; Outcome measure: behavioral; Setting: family; Health focus: nutrition; Strategy: education; Target population age: youth; Target population circumstances: general
Gayathri Kumar, MD, is with the Epidemic Intelligence Service, Office of Surveillance, Epidemiology, and Laboratory Services; and Sohyun Park, PhD; and Stephen Onufrak, PhD, are with the Division of Nutrition, Physical Activity and Obesity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Send reprint requests to Gayathri Kumar, MD, Epidemic Intelligence Service, Office of Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, 4770 Buford Highway, Atlanta, GA 30341; [email protected]. This manuscript was submitted August 20, 2013; revisions were requested October 3, 2013; the manuscript was accepted for publication October 28, 2013. Copyright Ó 2015 by American Journal of Health Promotion, Inc. 0890-1171/15/$5.00 þ 0 DOI: 10.4278/ajhp.130820-QUAN-435
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PURPOSE Energy drinks are the fastest growing segment of the beverage industry.1 They are marketed to improve energy, concentration, and athletic performance because of their high caffeine content and other additives.1–3 Caffeine content in energy drinks ranges from 50 mg to 505 mg per can or bottle.3 Although energy drinks may relieve fatigue and improve performance,4 their stimulating properties could also boost the heart rate and blood pressure, dehydrate the body, and prevent sleep.5 Furthermore, there is concern that adolescents sometimes believe that energy drinks are a type of rehydrating sports drink2; energy drinks have the potential to be harmful to the body during physical activity because of their dehydrating properties. Anecdotal reports of more serious consequences include seizures, cardiac dysrhythmias, and sudden death.1,6 Many countries have regulated energy drink consumption because of the adverse health effects associated with it. As an example, sales to children younger than 15 years are banned in Sweden, with labels warning against consuming these drinks after exercise or with alcohol.7 However, in the United States, energy drinks are classified as ‘‘natural dietary supplements,’’1 which are not subject to the same caffeine level limitations as in soft drinks, which are classified as food. Therefore, the safety of energy drinks is determined solely by manufacturers, and thus far there are no requirements for testing, warning labels, or restriction against sales or consumption by minors. Because of this, both the Institute of Medicine and the American Academy of Pediatrics have rec-
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For individual use only. Duplication or distribution prohibited by law. ommended against energy drink intake by youth and encourage efforts to educate parents and children about their potential health risks.2,8,9 Given that half of the energy drink market consists of adolescents and young adults,1 there is a great need to examine perceptions about energy drinks among these populations, as individual perceptions can influence behaviors (i.e., energy drink consumption). However, little is known regarding factors associated with energy drink consumption,10 and there is no literature to date on perceptions about energy drinks among U.S. adolescents between the ages of 12 and 17 years. Previous studies looking at associated factors have primarily targeted college age students and adults.11,12 It is of particular interest to examine energy drink consumption along with other poor dietary behaviors, such as reduced fruit and vegetable intake and increased fast-food consumption, because knowledge of these characteristics may inform public health interventions and education efforts designed to simultaneously reduce less desirable eating or drinking (e.g., energy drink consumption) and promote healthful eating. Studies have shown that increased overall sugarsweetened beverage consumption has been linked with increased fast-food restaurant use and reduced fruit and vegetable intake.10,13 Furthermore, assessing the association between energy drink consumption and physical activity is of interest given that adolescents may confuse energy drinks as a type of sports drink to be used prior to or during physical activity to enhance athletic performance.2 Therefore, the objectives of this study were to examine sociodemographic and behavioral factors associated with energy drink consumption among youth aged 12 to 17 years, to describe the sociodemographic and behavior factors associated with perceptions about energy drink safety and classification, and to model the associations between energy drink perceptions and energy drink consumption.
METHODS Design This cross-sectional study used data from the YouthStyles Survey conducted in the summer of 2011. The Youth-
American Journal of Health Promotion
Styles Survey is an online survey of U.S. youth between the ages of 12 and 17 years and is designed to assess health beliefs and behaviors surrounding important public health concerns. Participants include the children of adult participants who completed the HealthStyles Survey (administered in three parts, SpringStyles, SummerStyles, and FallStyles) in 2011. The sampling and data collection are conducted by Knowledge Networks, an online research firm that recruited an online research panel to provide a convenience sample of approximately 50,000 panelists. Sample The YouthStyles survey sample was obtained as detailed below. First, the SpringStyles survey was originally sent to a random sample of 14,598 adult panelists aged 18 and older, of whom 8,110 participants completed the survey (response rate of 56%). From the adult participants who completed the SpringStyles survey, a random sample of 1,614 adult panelists with children ages 12 to 17 were sent the SummerStyles survey. Children of these 1,614 adult panelists were sent the YouthStyles survey, and a total of 840 youth completed the YouthStyles Survey yielding a response rate of 52%. YouthStyles Survey data are weighted based on age, sex, race/ethnicity, household income, number of teenagers aged 12 to 17 years, parent education level, census region, metro status, and prior Internet access to match the U.S. Current Population Survey proportions.14 The analysis was exempt from the Centers for Disease Control and Prevention (CDC) Institutional Review Board process because personal identifiers were not included in the data provided to the CDC. Among the 840 youth who completed the survey, a total of 61 respondents were excluded because of missing data on energy drink intake (n ¼ 10), perceptions (n ¼ 14), or any of the behavioral variables (n ¼ 37), yielding a final analytic sample of 779 youth. Compared to those youth who were included in the study, those who were excluded did not differ in age, sex, race/ethnicity, annual household income, and parent education level.
Measures Energy Drink Consumption. The outcome of interest was energy drink intake, which was based on the following question: ‘‘During the past 7 days, how many times did you drink a can or bottle of energy drink like Red Bull, Monster, NOS, 5-hour Energy, or Full Throttle?’’ Response options were none, 1 to 2 times/wk, 3 to 4 times/wk, 5 to 6 times/ wk, 1 time/d, and 2 times/d. For analysis, two mutually exclusive categories were created: none and 1 time/ wk. The frequency of responses in the categories of 3 to 4 times/wk (9 or 1.1%), 5 to 6 times/wk (5 or .6%), 1 time/d (1 or.1%), and 2 times/d (2 or .3%) were too low to be considered as separate categories of their own. Hence, we dichotomized the categories into these two mutually exclusive categories based on the data distribution. Perceptions About Energy Drinks. The primary exposure variables were based upon participant response to two perception statements: (1) ‘‘Energy drinks like Red Bull, Monster, NOS, and 5-Hour Energy are safe drinks for teens’’ and (2) ‘‘Energy drinks, such as Red Bull or Monster, are a type of sports drink, such as Powerade or Gatorade.’’ Response options were ‘‘strongly disagree,’’ ‘‘somewhat disagree,’’ ‘‘neither agree nor disagree,’’ ‘‘somewhat agree,’’ and ‘‘strongly agree.’’ Three mutually exclusive categories were created for each perception variable: agree (strongly/ somewhat agree), neither, and disagree (strongly/somewhat disagree). Sociodemographic and Behavioral Variables. Mutually exclusive categories were created for each covariate. Sociodemographic variables included age (12–13, 14–15, and 16–17 years), sex, race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, and other/multiracial), parent education level (high school or less, some college, and college graduate), family annual income ($14,999, $15,000–$34,999, $35,000–$74,999, $75,000–$99,999, $100,000), and geographic region of country (Northeast, Midwest, South, and West). Behavioral variables included alcohol intake (never tried, have tried but not in last month, and have tried in last month), smoking
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For individual use only. Duplication or distribution prohibited by law. (not at all, some days, and every day), marijuana use (never tried, have tried but not in last month, and have tried in last month), vegetable and fruit consumption (none, 1–4, and 5 times/ d), non-diet soda consumption (none, 1, and 2 times/d), fast-food intake (none and 1 time/d), and physical activity for a total of at least 60 min/d (,3, 3–6, and 7 times/wk). Analysis Chi-square tests were used to examine the relationship between energy drink consumption and the sociodemographic and behavioral variables as well as to examine relationship between energy drink perceptions and sociodemographic and behavioral variables. A p value of ,.05 defined statistical significance. Two multivariable logistic regression models were fitted to estimate the adjusted odds ratios (ORs) and 95% confidence intervals for both of the perceptions associated with energy drink consumption, after controlling for other factors. The first model (model 1) controlled for sociodemographic variables (i.e., age, sex, race/ethnicity, family annual income, and parent education level). The second model (model 2) controlled for smoking, soda intake, and fast-food intake in addition to the aforementioned sociodemographic variables. Smoking, soda intake, and fast-food intake were selected based on the fact that these variables were consistently and significantly associated with energy drink intake and both of the energy drink perceptions. All statistical analyses were performed with the Statistical Analysis Software (SAS) version 9.3 (SAS Institute Inc., Cary, North Carolina).
RESULTS The final sample included 779 youth aged 12 to 17 years. About 8% of youth reported consuming energy drinks 1 time/wk and ,1% reported consuming energy drinks 1 time/d. Energy drink consumption significantly differed by age, alcohol intake, smoking, marijuana use, vegetable and fruit intake, non-diet soda intake, fast-food intake, and physical activity (Table 1, v2 tests, p , .05). The proportion of youth consuming energy drinks 1 time/wk was highest
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Table 1 Sociodemographic and Behavioral Characteristics of Respondents and Their Associations With Energy Drink Intake Among U.S. Youth (n ¼ 779)—YouthStyles Survey, 2011† Energy Drink Intake During the Past 7 d‡ Characteristic
None % 6 SE
1 Time/Wk % 6 SE
92.2 6 1.1
7.8 6 1.1
6 2.2 6 2.3 6 2.4
96.2 6 1.4 91.9 6 1.8 88.6 6 2.3
3.8 6 1.4 8.1 6 1.8 11.4 6 2.3
0.02
6 2.4 6 2.4
90.2 6 1.7 94.3 6 1.4
9.8 6 1.7 5.7 6 1.4
0.07
All % 6 SE
Total sample 100 Age 12–13 y 32.1 14–15 y 34.0 16–17 y 33.9 Sex Male 51.9 Female 48.1 Race/ethnicity White, non-Hispanic 60.6 Black, non-Hispanic 12.5 Hispanic 19.2 Other/multiracial 7.7 Parent education level High school or less 21.0 Some college 38.7 College graduate 40.3 Annual family income $14,999 8.5 $15,000–$34,999 15.9 $35,000–$74,999 33.0 $75,000–$99,999 19.4 $100,000 23.1 Geographic regions Northeast 18.5 Midwest 23.3 South 35.3 West 22.9 Alcohol intake Never tried 76.6 Have tried but not in the last mo 17.7 Had in last mo 5.7 Smoking status Not at all 97.1 Some days 2.2 Every day 0.8 Marijuana use Never tried 92.3 Have tried 6.1 Had in last mo 1.6 Vegetable and fruit intake None 7.9 1–4 times/d 65.4 5 times/d 26.7 Non-diet soda intake None 57.8 1 time/d 23.4 2 times/d 18.8 Fast-food intake None 71.0 1 time/d 29.0 Physical activity 60 min/d ,3 times/wk 46.3 3–6 times/wk 43.5 7 times/wk 10.2
6 6 6 6
2.5 2.0 2.2 1.1
6 2.0 6 2.4 6 2.3
91.4 93.4 95.2 88.3
6 6 6 6
1.3 3.8 2.3 4.5
93.0 6 2.5 91.0 6 1.9 92.9 6 1.6
8.6 6.6 4.8 11.7
p*
1.3 3.8 2.3 4.5
0.53
7.0 6 2.5 9.0 6 1.9 7.1 6 1.6
0.70
6 6 6 6
6 6 6 6 6
1.5 2.1 2.2 1.8 1.9
86.1 96.3 91.9 89.5 94.2
6 6 6 6 6
6.0 1.9 1.8 2.8 1.8
13.9 3.7 8.1 10.5 5.8
6 6 6 6 6
6.0 1.9 1.8 2.8 1.8
0.17
6 6 6 6
1.8 2.0 2.4 2.1
96.7 91.6 90.6 91.4
6 6 6 6
1.3 2.1 2.1 2.4
3.3 8.4 9.4 8.6
6 6 6 6
1.3 2.1 2.1 2.4
0.20
6 2.0
94.9 6 1.0
5.1 6 1.0
6 1.8 6 1.1
83.0 6 3.6 83.9 6 6.7
17.0 6 3.6 16.1 6 6.7
6 0.7 6 0.6 6 0.3
93.7 6 1.0 34.8 6 13.5 54.5 6 16.8
6.3 6 1.0 65.2 6 13.5 45.5 6 16.8
,0.0001
6 1.2 6 1.1 6 0.5
93.0 6 1.1 88.6 6 4.2 55.6 6 15.2
7.0 6 1.1 11.4 6 4.2 44.4 6 15.2
,0.0001
6 1.2 6 2.3 6 2.2
84.6 6 5.3 94.7 6 1.0 88.3 6 2.8
15.4 6 5.3 5.3 6 1.0 11.5 6 2.8
0.005
6 2.4 6 2.2 6 1.7
97.5 6 0.7 89.3 6 2.9 79.2 6 3.7
2.4 6 0.7 10.7 6 2.9 20.8 6 3.7
,0.0001
6 2.2 6 2.2
95.4 6 0.9 84.1 6 2.9
4.6 6 0.9 15.9 6 2.9
,0.0001
6 2.4 6 2.4 6 1.6
94.5 6 1.2 89.1 6 2.1 94.8 6 2.3
5.5 6 1.2 10.9 6 2.1 5.2 6 2.3
0.02
,0.0001
† Weighted percentage may not add up to 100% because of rounding. ‡ During the past 7 days, how many times did you drink a can or bottle of energy drinks like Red Bull, Monster, NOS, 5-hour Energy, or Full Throttle? * Chi-square tests were used to examine differences across categories for each variable.
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For individual use only. Duplication or distribution prohibited by law.
Table 2 Sociodemographic and Behavioral Characteristics of Respondent by Perceptions About Energy Drinks Among U.S. Youth (n ¼ 779)—YouthStyles Survey, 2011† Energy Drinks Are Safe Drinks for Teens‡
Total sample Age 12–13 y 14–15 y 16–17 y Sex Male Female Race/ethnicity White, non-Hispanic Black, non-Hispanic Hispanic Other/multiracial Parent education level High School or less Some college College graduate Annual family income $14,999 $15,000–$34,999 $35,000–$74,999 75,000–$99,999 $100,000 Geographic regions Northeast Midwest South West Alcohol intake Never tried Have tried but not in the last mo Had in last mo Smoking status Not at all Some days Every day Marijuana use Never tried Have tried Had in last mo Vegetable and fruit intake None 1–4 times/y 5 times/d Non-diet soda intake None 1 time/d 2 times/d Fast-food intake None 1 time/d Physical activity60 min/d ,3 times/wk 3–6 times/wk 7 times/wk
Disagree % 6 SE
Neither % 6 SE
Agree % 6 SE
58.8 6 2.3
21.6 6 1.9
19.5 6 1.8
62.3 6 3.7 61.1 6 3.8 53.3 6 4.5
22.2 6 3.0 18.2 6 2.8 24.6 6 4.0
15.6 6 2.5 20.7 6 3.1 22.1 6 3.5
53.1 6 3.3 64.9 6 3.3
24.7 6 2.9 18.3 6 2.5
55.6 67.4 63.2 59.3
20.9 23.8 20.6 26.4
6 6 6 6
2.7 7.6 6.3 7.0
6 6 6 6
2.1 6.8 5.3 5.9
Energy Drinks Are a Type of Sports Drink§ Disagree % 6 SE
Neither % 6 SE
Agree % 6 SE
70.6 6 2.1
16.5 6 1.8
12.9 6 1.4
0.31
69.7 6 3.3 69.0 6 3.7 73.2 6 3.9
16.4 6 2.4 17.0 6 3.3 16.0 6 3.3
13.8 6 2.5 14.0 6 2.3 10.8 6 2.6
0.89
22.1 6 2.4 16.7 6 2.7
0.04
66.6 6 3.1 75.0 6 2.8
17.8 6 2.6 15.1 6 2.3
15.6 6 2.1 9.9 6 1.8
0.09
23.5 8.8 16.3 14.3
2.3 3.9 4.5 4.5
0.22
69.5 75.4 77.0 56.4
16.3 14.2 14.2 27.5
14.2 10.4 8.8 16.1
1.8 4.2 2.8 5.0
0.34
6 6 6 6
p*
6 6 6 6
2.5 6.5 5.3 7.3
6 6 6 6
2.1 5.2 4.8 6.6
6 6 6 6
p*
61.6 6 4.9 55.9 6 4.0 60.2 6 3.5
19.5 6 3.7 23.2 6 3.5 21.3 6 2.8
18.9 6 3.6 20.9 6 3.1 18.6 6 2.7
0.88
73.0 6 4.2 68.5 6 3.7 71.5 6 3.1
14.2 6 3.2 19.4 6 3.4 14.9 6 2.4
12.8 6 3.0 12.1 6 2.2 13.6 6 2.3
0.71
54.0 65.4 58.7 53.8 60.3
6 6 6 6 6
9.0 6.5 3.8 4.9 4.7
22.1 19.8 23.5 18.6 22.6
6 6 6 6 6
7.2 5.0 3.3 3.4 4.4
23.9 14.7 17.7 27.6 17.1
6 6 6 6 6
6.9 4.4 2.6 4.8 3.4
0.58
55.7 69.3 67.1 76.3 77.3
6 6 6 6 6
9.0 6.5 3.6 4.2 3.5
23.9 19.5 17.5 12.4 13.7
6 6 6 6 6
7.5 5.7 3.1 3.1 2.9
20.4 11.2 15.3 12.4 9.0
6 6 6 6 6
6.6 3.8 2.5 3.1 2.0
0.26
57.8 61.1 55.7 62.0
6 6 6 6
5.4 4.6 4.1 4.8
25.6 18.5 25.2 16.1
6 6 6 6
5.0 3.3 3.6 3.0
16.6 20.4 19.0 21.8
6 6 6 6
3.4 3.7 3.1 4.1
0.52
70.1 75.1 68.6 69.6
6 6 6 6
4.6 3.8 3.8 4.7
17.3 14.8 17.5 16.0
6 6 6 6
3.9 3.3 3.1 4.0
12.6 10.1 13.9 14.4
6 6 6 6
2.8 2.2 2.7 3.1
0.93
62.8 6 2.6 48.3 6 5.6 38.2 6 9.8
22.2 6 2.2 14.2 6 3.2 37.1 6 10.8
15.0 6 1.8 37.5 6 5.5 24.7 6 7.6
,0.0001
70.2 6 2.5 72.3 6 4.6 72.0 6 7.7
18.4 6 2.2 10.3 6 2.9 10.6 6 4.8
11.5 6 1.5 17.4 6 3.8 17.4 6 6.1
0.12
60.2 6 2.4 12.0 6 6.5 20.5 6 12.2
21.6 6 2.0 24.9 6 13.2 21.5 6 13.6
18.3 6 1.8 63.1 6 13.8 58.0 6 16.2
,0.0001
71.6 6 2.1 39.4 6 13.9 37.5 6 15.7
16.5 6 1.8 15.1 6 11.4 19.8 6 12.8
11.9 6 1.4 45.6 6 14.4 42.7 6 16.9
0.0004
60.3 6 2.4 44.7 6 9.8 25.0 6 10.9
21.5 6 2.0 18.9 6 6.5 38.0 6 16.4
18.1 6 1.8 36.4 6 9.5 36.9 6 13.4
0.02
70.5 6 2.2 72.1 6 7.8 75.7 6 10.9
16.9 6 1.9 12.5 6 5.6 9.5 6 6.7
12.7 6 1.5 15.3 6 5.7 14.8 6 8.8
0.88
46.7 6 7.6 59.1 6 2.9 61.6 6 4.6
23.3 6 6.6 21.1 6 2.3 22.5 6 4.1
30.0 6 7.5 19.8 6 2.2 15.9 6 3.0
0.37
56.5 6 7.6 73.5 6 2.4 67.7 6 4.6
26.7 6 6.7 15.9 6 2.0 15.0 6 3.9
16.7 6 5.5 10.6 6 1.5 17.2 6 3.4
0.10
63.8 6 3.1 58.0 6 5.1 44.4 6 4.6
21.6 6 2.7 17.2 6 3.2 27.3 6 4.4
14.6 6 2.1 24.7 6 4.4 28.3 6 4.1
0.003
74.7 6 2.8 70.5 6 4.3 58.2 6 4.7
15.8 6 2.4 16.3 6 3.0 19.0 6 4.1
9.5 6 1.6 13.2 6 3.2 22.8 6 3.7
0.009
63.5 6 2.7 47.3 6 4.4
20.3 6 2.2 24.9 6 3.8
16.2 6 1.9 27.8 6 3.9
0.003
73.3 6 2.5 64.2 6 4.0
16.3 6 2.2 16.9 6 3.0
10.4 6 1.5 18.9 6 3.0
0.03
60.4 6 3.4 52.9 6 3.6 76.7 6 6.7
18.4 6 2.5 27.2. 6 3.2 12.8 6 6.0
21.2 6 2.7 19.9 6 2.8 10.5 6 3.5
0.02
69.1 6 3.2 71.7 6 3.1 72.9 6 6.7
17.4 6 2.7 16.2 6 2.5 13.9 6 5.6
13.5 6 2.1 12.1 6 2.1 13.2 6 4.2
0.96
† Weighted percentage may not add up to 100% because of rounding. ‡ Energy drinks like Red Bull, Monster, NOS, and 5-hour Energy are safe drinks for teens. § Energy drinks, such as Red Bull or Monster, are a type of sports drink, such as Powerade or Gatorade. * Chi-square tests were used to examine differences across categories for each variable, with p ,0.05 considered statistically significant.
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For individual use only. Duplication or distribution prohibited by law.
Table 3 Bivariate and Multivariable Analyses for Energy Drink Consumption by Energy Drink Perceptions Among U.S. Youth (n ¼ 779)— YouthStyles Survey, 2011†
Perceptions
None % 6 SE
Bivariate Analysis
Model 1 Multivariable Logistic Regression Analysis‡
Model 2 Multivariable Logistic Regression Analysis§
Energy Drink Intake During the Past 7 d
Energy Drink Intake 1 Time/Wk
Energy Drink Intake 1 Time/Wk
1 Time/Wk % 6 SE
Energy drinks are safe drinks for teens|| Disagree 96.6 6 0.7 3.4 6 Neither 92.6 6 2.2 7.4 6 Agree 78.4 6 3.9 21.6 6 Energy drinks are a type of sports drink# Disagree 94.0 6 1.1 6.0 6 Neither 96.5 6 1.5 3.5 6 Agree 76.7 6 5.1 23.3 6
p*
0.7 2.2 3.9
,0.0001
1.1 1.5 5.1
,0.0001
Adjusted Odds Ratio
95% Confidence Interval
Adjusted Odds Ratio
95% Confidence Interval
Reference 2.00 6.79¶
0.79, 5.09 3.12, 14.77
Reference 1.48 4.23¶
0.56, 3.90 1.93, 9.33
Reference 0.48 4.50
0.17, 1.39 2.08, 9.73
Reference 0.30 2.46
0.08, 1.20 1.09, 5.54
† Weighted percentage may not add up to 100% because of rounding. ‡ The multivariable logistic regression model included both perception variables and sociodemographic variables (i.e., age, sex, race/ethnicity, family annual income, and parent education level) in one model. Reference category included youth who did not drink any energy drinks. § The multivariable logistic regression model included both perception variables, sociodemographic variables (i.e., age, sex, race/ethnicity, family annual income, and parent education level) and behavioral variables (smoking, soda intake, and fast-food intake) in one model. Reference category included youth who did not drink any energy drinks. || Energy drinks like Red Bull, Monster, NOS, and 5-hour Energy are safe drinks for teens. ¶ Significant findings based on the 95% confidence interval (i.e., the confidence interval does not include 1). # Energy drinks, such as Red Bull or Monster, are a type of sports drink, such as Powerade or Gatorade. * p , 0.05 was considered statistically significant.
among youth aged 16 to 17 years; those who tried alcohol, but not in last month, and those who tried alcohol in the last month; those who smoked some days; those who used marijuana in the last month; those who did not consume fruits and vegetables; those who drank non-diet soda 2 times/d; those who ate fast food 1 time/d; and those who were physically active 3 to 6 times/wk (Table 1). Approximately 20% agreed that energy drinks are safe drink for teens, and 13% agreed that energy drinks are a type of sports drink (Table 2). Youth perceptions toward energy drink consumption differed by sociodemographic and behavioral characteristics (Table 2; v2 tests, p , .05). Among groups in which significant differences exist, the proportion of youth who agreed that energy drinks are safe drinks for teens was highest among males, youth who tried alcohol but not in last month, those who smoked some days, those who either had ever tried marijuana or used marijuana in the last month, those who drank non-diet soda 2 times/d, those who ate fast food 1 time/d,
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and those who are physically active ,3 times/wk. The proportion of youth who believed that energy drinks are a type of sports drinks was highest among youth who smoked some days, those who drank non-diet soda 2 times/d, and those who ate fast food 1 time/d (Table 2). Energy drink consumption significantly differed by youth perceptions about energy drinks. Consistent with findings from bivariate analysis, results of both multivariable logistic regression analyses showed that the odds for drinking energy drinks 1 time/wk was significantly higher among youth who agreed that energy drinks are safe drinks for teens (OR ¼ 6.8 vs. disagreed for model 1, and OR ¼ 4.2 vs. disagreed for model 2) as well as youth who agreed that energy drinks are a type of sports drink (OR ¼ 4.5 vs. disagreed for model 1, and OR ¼ 2.5 vs. disagreed for model 2) (Table 3).
DISCUSSION Our study reports that 8% of adolescents consume energy drinks weekly
and that only .17% of adolescents consume them daily or more frequently. Other studies reported energy drink consumption prevalence among adolescents varying from 5% daily to 42.3% biweekly.1,10,15–17 Each study differed in the time period for which the energy drink consumption was reported. One study conducted with the 2010 National Youth Physical Activity and Nutrition Study (NYPANS) data showed that 5% of U.S. high school students (n ¼ 11,209) reported drinking a can, bottle, or glass of energy drink 1 time/d.10 Although there is variation in prevalence of consumption across studies, it is clear that many youth are consuming energy drinks against the recommendations of the American Academy of Pediatrics. Sociodemographic and Behavioral Factors Associated With Energy Drink Consumption. Greater age of youth was the only sociodemographic variable associated with increased energy drink intake in the present study. This differs from the 2010 NYPANS study among U.S. high school students in which age was not
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For individual use only. Duplication or distribution prohibited by law. associated with energy drink intake, but being male and non-Hispanic black were associated with intake.10 In the present study, behavioral variables significantly associated with weekly energy drink consumption in bivariate analyses include use of alcohol, smoking, marijuana, vegetable and fruit, non-diet soda, fast foods, and physical activity. Some of these findings corroborate findings from other studies, such as the NYPANS 2010 study by Park et al.,10 that reported increased energy drink consumption with frequent fast-food restaurant use among high school–aged youth. Reduced vegetable and fruit consumption with increased energy drink consumption suggests that energy drink intake might be associated with less healthful dietary behaviors.18,19 The association between energy drinks intake and physical activity 3 to 6 times/wk suggests that youth may be using energy drinks as a method to boost physical performance, which is a current marketing strategy for energy drink beverages.1 Of note in this study is the association of energy drinks and other abused substances, such as alcohol, tobacco, and marijuana. Indeed, several studies, albeit in older populations, report that their survey populations coingest other substances such as alcohol with energy drinks.1,5,11,20–24 Similarly, our study suggests that energy drink intake may be more common among youth who engage in other risk-taking behaviors. Sociodemographic and Behavioral Factors Associated With Perceptions About Energy Drinks. Energy drink perceptions were significantly different by sociodemographic characteristics and behavioral factors in the present study. These findings suggest that youth who believe that energy drinks are safe are more likely to participate in other high-risk and unhealthy behaviors, possibly as a result of lack of awareness or education, peer influence, or deliberate risktaking behavior. Some psychologists and behavioral scientists have even suggested that given that risk-taking behaviors among adolescents can be influenced by a sense of invulnerability, sensation-seeking among youth, and strong peer influence, education efforts about these risk-taking behaviors may not always necessarily be effec-
American Journal of Health Promotion
tive.25,26 However, our findings suggest that many youth also wrongly perceive that energy drinks are safe; therefore, these youth may not have the right information about energy drinks to make informed choices in the future about consuming these drinks. Despite marketing strategies that tout physical performance enhancement with energy drinks,1 there is no association with physical activity for youth who believe that energy drinks are a type of sports drink in the present study. Association Between Energy Drink Consumption and Perceptions About Energy Drinks. Furthermore, energy drink consumption was significantly associated with energy drink perceptions among U.S. youth even after controlling for sociodemographic characteristics as well as smoking, soda intake, and fast-food intake in the present study. The odds of consuming energy drinks weekly was between 4 and 7 times higher if the youth agreed that energy drinks are safe, whereas the odds of consuming energy drinks was between 2.5 and 4.5 times higher if the youth agreed that energy drinks are a type of sports drink. These findings suggest that improved awareness among youth about energy drinks and their potential health effects has the potential to influence consumption. Limitations To the authors’ knowledge, this study is the first to report energy drink perceptions and their association with energy drink consumption among U.S. youth. There are several limitations to this study. First, the sample size for the YouthStyles Survey may not be large enough to detect differences in certain characteristics of energy drink consumers and perceptions. Second, findings may not be generalizable nationally because of selection bias associated with the use of a convenience sample from an online panel survey with a relatively low response rate. Third, it is possible that results of the YouthStyles Survey are biased given that the survey was administered at home where the presence of the youths’ parents could influence answer choices. For example the prevalence of smoking in the current sample was very low compared to estimates from the Youth Risk Behavior Survey, a paper-
SO WHAT? Implications for Health Promotion Practitioners and Researchers What is already known about this topic? Energy drinks are growing in popularity among youth because of their stimulant properties, despite the potential harms associated with consuming these drinks, such as elevated blood pressure and dehydration. Given that half of the energy drink market consists of adolescents and young adults, perceptions about energy drinks among these populations should be examined, although to the authors’ knowledge no literature to date on this topic exists. What does this article add? Overall, 8% of youth drank energy drinks, 20% of adolescents wrongly perceive that energy drinks are safe drinks for teens, and 13% of adolescents wrongly perceive that energy drinks are a type of sports drink. What are the implications for health promotion practice or research? The evidence from this study supports health promotion efforts to educate and make youth aware of the potential harmful health impact of consuming energy drinks. Possible promotion techniques include creating brochures/pamphlets on energy drink consumption that can be handed out directly to youth and parents, placing informational posters in schools and health care facilities, and conducting informational seminars/sessions about energy drinks directed at both youth and family members.
and-pencil survey that was administered in schools.27 Fourth, there is a risk of recall or reporting bias given that the YouthStyles data are selfreported. Lastly, given that this is a cross-sectional study, causality or the direction of the association cannot be determined. Conclusions Overall, 8% of youth drank energy drinks, 20% agreed that energy drinks are safe drink for teens, and 13% agreed that energy drinks are a type of sports drink. Energy drink intake was associated with the perceptions that energy drinks are safe drinks for teens and that energy drinks are a type of sports drink. Furthermore, factors asso-
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For individual use only. Duplication or distribution prohibited by law. ciated with energy drink intake include alcohol use, increased physical activity but not daily physical activity, and decreased vegetable and fruit consumption. Factors associated with the belief that energy drinks are safe drinks for teens include being male and use of alcohol, marijuana, and non-diet soda. Efforts to educate and make youth aware of the potential harmful health impact of consuming energy drinks among youth are needed. Acknowledgment The findings and conclusions in this presentation are those of the author and not necessarily the CDC.
References
1. Seifert SM, Schaechter JL, Hershorin ER, et al. Health effects of energy drinks on children, adolescents, and young adults. Pediatrics. 2011;127:511–528. 2. Committee on Nutrition and the Council on Sports Medicine and Fitness: sports drinks and energy drinks for children and adolescents: are they appropriate? Pediatrics. 2011;127:1182–1189. 3. Reissig CJ, Strain EC, Griffiths RR. Caffeinated energy drinks-a growing problem. Drug Alcohol Depend. 2009;99:1– 10. 4. Nawrot P, Jordan S, Eastwood J, et al. Effects of caffeine on human health. Food Addit Contam. 2003;20:1–30. 5. Atilla S, Cakir B. Energy-drink consumption in college students and associated factors. Nutrition. 2011;27:316– 322. 6. Starling S. Energy drinks safety questioned by German agency. Available at: www. beveragedaily.com/content/view/print/ 166290/. Accessed September 5, 2012. 7. Oddy WH, O’Sullivan TA. Energy drinks for children and adolescents. BMJ. 2009; 339:b5268.
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8. Institute of Medicine. Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth. Washington, DC: National Academies Press; 2007. 9. American Academy of Pediatrics. Kids should not consume energy drinks, and rarely need sports drinks, says AAP. Available at: http://www.aap.org/en-us/ about-the-aap/aap-press-room/pages/ Kids-Should-Not-Consume-Energy-Drinks,and-Rarely-Need-Sports-Drinks,-Says-AAP. aspx?nfstatus¼401&nftoken¼000000000000-0000-0000-000000000000& nfstatusdescription¼ERROR%3aþNoþ localþtoken. Accessed September 6, 2012. 10. Park S, Blanck H, Sherry B, et al. Factors associated with sugar-sweetened beverage intake among United States high school students. J Nutr. 2012;142:306–312. 11. Miller K. Energy drinks, race, and problem behaviors among college students. J Adolesc Health. 2008;43:490–497. 12. Berger LK, Fendrich M, Chen H, et al. Sociodemographic correlates of energy drink consumption with and without alcohol: results of a community survey. Addict Behav. 2011;36:516–519. 13. Park S, Sherry B, Foti K, Blanck HM. Selfreported academic grades and other correlates of sugar-sweetened soda intake among US adolescents. J Acad Nutr Diet. 2012;112:125–131. 14. US Bureau of the Census. Current Population Survey: 2010. Available at: http://www.census.gov/2010census/. Accessed on September 20, 2012. 15. Simon M, Mosher J. Alcohol, Energy Drinks, and Youth: A Dangerous Mix. San Rafael, Calif: Marin Institute; 2007. 16. Ballard SL, Wellborn-Kim JJ, Clauson KA. Effects of commercial energy drink consumption on athletic performance and body composition. Phys Sports Med. 2010; 38:107–117. 17. O’Dea JA. Consumption of nutritional supplements among adolescents: usage and perceived benefits. Health Educ Res. 2003;18:98–107.
18. Marshall TA, Eichenberger Gilmore JM, Broffitt B, et al. Diet quality in young children is influenced by beverage consumption. J Am Coll Nutr. 2005;24:65– 75. 19. Frary CD, Johnson RK, Wang MQ. Children and adolescents’ choices of foods and beverages high in added sugars are associated with intakes of key nutrients and food groups. J Adolesc Health. 2004;34: 56–63. 20. Peacock A, Bruno R, Martin FH. The subjective physiological, psychological, and behavioral risk-taking consequences of alcohol and energy drink co-ingestion. Alcohol Clin Exp Res. 2012;36:1–8. 21. Marczinski CA. Alcohol mixed with energy drinks: consumption patterns and motivations for use in US college students. Int J Environ Res Public Health. 2011;8:3232– 3245. 22. Gunja N, Brown JA. Energy drinks: health risks and toxicity. MJA. 2012;196:46–49. 23. Maulinauskas BM, Aeby VG, Overton RF, et al. A survey of energy drink consumption patterns among collect students. Nutrition. 2007;6:35. 24. Price SR, Hilchey CA, Darredeau C, et al. Energy drink co-administration is associated with increased reported alcohol ingestion. Drug Alcohol Rev. 2010;29:331– 333. 25. Irwin CE, Millstein SG. Biopsychosocial correlates of risk-taking behaviors during adolescence: can the physician intervene? J Adoles Health Care. 1986;7:82–96. 26. Steinberg L. Risk taking in adolescence: new perspectives from brain and behavioral science. Curr Dir Psychol Sci. 2007;16:55–59. 27. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance System: 2011 National Overview. Available at: http://www.cdc. gov/healthyyouth/yrbs/pdf/ us_overview_yrbs.pdf. Accessed September 20, 2011.
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