Energy drinks: knowledge and practice among non-medical university students

Introduction

Beverages and drinks advertised as “energy drinks” contain different stimulants and are mainly marketed for the purpose of stimulating mental and physical functions of their consumers (1). Increased energy, improved sport performance and alertness are the main attractive points for energy drinks (EDs) consumers (2,3).

The first introduction of “Red Bull” was in April 1987 and this was followed by appealing advertisements to spread EDs all over the world. EDs gained popularity recently and especially among young adults and adolescents (3,4). EDs are caffeinated drinks which contain large amounts of sugars, carbohydrates, stimulants and other supplements (5). Ingredients like taurine, vitamin B combinations and herbal products are added to EDs to serve as energy enhancers (6).

Increased popularity, excessive consumption and rapid spread of EDs among young adults had negatively affected the individuals’ health and wellbeing (7). There are many concerns regarding the safety of EDs consumption, and different side effects are reported that affect many organs and body systems (8,9). Many studies (3,10–12) reported palpitation, tremor, insomnia, agitation, increased blood pressure, obesity, gastric upset and peptic ulcer as adverse effects of increased caffeine and EDs consumption. In a study conducted by Milazzo et al. (13) on Air Force personnel, about one percent of EDs consumers stated that they needed seeing a doctor or going to hospital due to side effects they were suffering as a result of EDs consumption.

With all these documented adverse effects, high consumption rates among the younger population and the huge advertisement campaigns of the ED companies, knowledge and awareness of the population about the risks of EDs is crucial (14).

The present study aimed to evaluate the awareness regarding EDs intake and their consumption in a sample of non-medical students at the University of Mosul in Mosul, Iraq.

Methods

A cross-sectional study was conducted among non-medical university students to assess students’ knowledge and consumption practice regarding EDs. An online self-administered questionnaire was distributed among the students from 13 to 20, October 2022. The present study was focusing on students studying at non-medical colleges in the University of Mosul and this was the criterion for the students to be included in the study. The participation in the current study was completely voluntary and this was cleared in detail to the participants on the front page of the questionnaire, which also included a description of the study and its aim.

The questionnaire was adapted from different published questionnaires (15–17). A three-page Google Form questionnaire was distributed online through social networking groups among students in different non-medical colleges at the University of Mosul. The first page consisted of questions to collect information about age, sex, home location and other personal characteristics of the participants. The second page contained questions to evaluate students’ knowledge about energy drinks (EDs ingredients, effects and other). The last page was used to assess EDs consuming patterns among students and to check students’ motives to drink or to avoid EDs. Details of the questions on each page are presented in the Results section.

Total EDs knowledge score was calculated by collecting the correct answers for the questions in the knowledge section, by giving one mark for each correct answer and zero mark for incorrect answers. Because the knowledge section consisted of 18 questions, the total EDs knowledge score could have varied between zero and eighteen. Depending on the total EDs knowledge score students were grouped into 2 groups, those having sufficient knowledge and those with insufficient knowledge (median split method was used for this purpose (18)).

Data from the completed questionnaires was cleaned and processed by using Microsoft Excel. The final statistical analysis was performed by using SPSS, version 28. P-value less than or equal to 0.05 was considered as indicator for the significancy of the results.

Results

A total of 1039 students from non-medical colleges participated in this study, with the majority (88.9%) being aged between 21 and 23 years. Female students were more than males in this study (59% females and 41% males) and 4^th class students were ranked first compared to other year groups. Slightly more than one-third of the sample admitted sleeping for more than 8 hours. Table 1 summarizes these socio-demographic characteristics of the study sample.

Table 1: Socio-demographic characteristics of the participants

The majority of respondents (83.3%) knew what energy drinks are but less than half of them were aware that EDs contain caffeine (43%) or that they could help staying awake (45.8%). Interestingly, 86.5% of the students recognized that EDs cannot improve mood. Most of the participating students (92.6%) admitted to knowing that EDs could have harmful effects on the body. These and the other responses of the students to the questions in the knowledge section of the questionnaire are presented in Table 2 along with the correct answer for each question.

Table 2: Responses of the participants to questions in the knowledge section

^a correct answer

Only 28% of the participating students in this study acknowledged practicing the habit of drinking EDs. Of those students who drink EDs (291 students), only 12.7% would consume EDs every day. More than one-third (36.4%) of the students prefer drinking EDs at nighttime and 45.8% favor Tiger over other brands of EDs (Table 3).

Table 3: Responses of the participants to the questions in the practice section

Helping with studying and staying awake were recorded as the main reasons for drinking EDs in this study just behind “no specific reason” (Figure 1). Only 31% of the consuming students reported experiencing side effects from drinking EDs (Figure 2). Insomnia, palpitation, nervousness and anxiety were the most common reported side effects while chest pain and sweating were the least reported (Figure 3)

Figure 1: Reasons stated by the students for drinking EDs (more than one answer was permitted per participant)

Figure 2: Students who experienced side effects from EDs

Figure 3: Individual side effects experienced by students from EDs

Figure 4 shows the reason given by those students who reported not using EDs for this practice. Not liking the taste and knowing the side effects came first while experiencing the side effects came last.

Figure 4: Reasons stated by the participants who did not drink EDs (bars are labeled by percentage, number)

The total EDs knowledge score for the students ranged between 1 and 17 with mean ± SD of 7.31 ± 2.62, and a median of 7. According to the median split method, those students who scored higher than the median were considered to have sufficient knowledge, and they constituted less than half of the sample (42.1%) as shown in Table 4.

Table 4: Distribution of students according to their level of knowledge of EDs.

Male students had significantly higher mean knowledge score than females, and those students with weekly income between 20 and 35 USD had significantly higher knowledge score than the other income groups. Consuming EDs was associated with significantly higher knowledge scores, while in the group of students who reported not drinking EDs, those who chose experiencing side effects previously as their reason not to drink had the highest mean knowledge scores (Table 5).

Table 5: Total knowledge score differences among the socio-demographic groups of the participants

¹One-Way ANOVA, ²Indipendent-Samples T test, ^§Significant results

Discussion

This study was conducted with the aim of assessing the level of knowledge of energy drinks among the students at non-medical colleges along with their practices with regard to these products. This segment of the society was targeted because most of the advertising campaigns of EDs are directed to the youth (19) claiming that EDs can enhance physical performance and sporting ability in addition to increasing focus and concentration for studying. Such campaigns deliberately fail to mention that EDs contain ingredients that could have harmful effects on the body and therefore studies like this are necessary.

The sample size in this study was significantly higher than that in a Polish study (16) which only included 131 students and higher than in an Italian study (15). Although there was a difference in the distribution of our responding students from different year groups in the non-medical colleges, the percentages in this study could be considered within the same range especially when compared to the Polish study where 1^st year alone constituted about 70% of the studied sample. The rather similar distribution of year groups in this study could help in generalizing its results and recommendation to all university students. The difference between the percentages of the 1^st year group and the 18-20 years old group could be due to the fact that the city of Mosul was occupied for 3 years by terrorist groups and many young people lost this period from their school years, putting older students in lower year groups in colleges.

Even though a significant fraction of the studied sample in this work admitted to knowing what EDs are, the proportion of those knowing the ingredients was rather low (about 30%), especially when compared to the Polish study (16) or the Italian study (15) where 78.6% and 75% respectively knew EDs' constituents. The same applies for the physiological effects of EDs where the knowledge of students in this study was lower than that in the Polish or Italian study. This difference in the knowledge could be attributed to the fact that the students in the two European studies were from medical colleges and that they study EDs in their curriculum.

The high percentage of students knowing what EDs are but with less knowledge about their ingredients or effects could be explained that those students have heard previously about EDs but did not bother to understand what they are and how they affect the body exactly. Also, the effect of this question on the total knowledge is negligible being only one question out of the 18 items which contributed to the total knowledge score. This negligible effect is confirmed by the higher proportion of students with inadequate than those with adequate knowledge.

The percentage of EDs consumers in this study was much lower than that in a study conducted in Kuwait (20) in which 58.3% of the young adult sample were drinking EDs. Such difference in consumption could be the result of the higher living standards and income of the Kuwaiti population compared to the Iraqi students, especially when about two-thirds of our participating students were spending less than 20 USD weekly. Nighttime consumption was very common in this study and is much higher than the 0% nighttime consumers in a Saudi study (3) which also surveyed non-medical students. The higher consumption at night may be due to gatherings with friends in cafes at this time and to the low level of knowledge recorded among our participants.

Having no specific reason was the most reported option for the question regarding the motivation behind drinking EDs in this study. This reason was not that popular in the Saudi study (3)  in which “to keep friends company” was the most preferred reason, and consuming EDs as study aids was not that popular in the Saudi study. Liking the taste was the most chosen reason the Kuwait study whereas drinking EDs while studying was not common as well (20).

The reasons reported by students who do not consume EDs in this study came similar to those in the Italian study  (15), where not liking the taste and knowing the side effects were the most common. A similar pattern for reasons presented by students for not drinking EDs was also observed in the Kuwaiti study (20).

With the low level of general knowledge regarding EDs and their effects, warning labels should be applied to these products before marketing in order to increase awareness of the society about harmful effects of the beverages and to give attention that these products are not suitable for patients with diabetes, hypertension, heart diseases, pregnant women and those below 18 years of age (20,21).

Conclusions

The popularity of energy drinks is increasing substantially, especially among the younger generation. Such an increase in consumption is not associated with proper knowledge regarding the effects of these beverages on health as demonstrated in this work. It was found that the general knowledge of the younger population regarding EDs is low, despite the finding that the knowledge is better among those who drink EDs. This should advise in favor of adding warning labels to these beverages and controlling their distribution.