This study describes the patterns of energy drinks consumption and associated factors among University students in Palestine. A cross-sectional study was conducted at An-Najah National University in Nablus, West Bank-Palestine. The study included 279 students of three colleges: Medicine, Physical Education and Engineering. Data were collected using a 25-item self-administered questionnaire. Energy-drink consumption was significantly higher among male students, as 80.5% of energy-drink users involved in this study was males. It was higher among those with higher monthly expenditure. The most common cause for using energy drinks among users was to stay awake at night (68.6%), while most of those who never tried energy drinks in their lives didn’t do so because they thought energy drinks are unhealthy. About two thirds (64.4%) of the participants didn’t know the main constituents of energy drinks and about half (53.6%) stated that they knew that there might be side effects associated with the use of energy drinks. More than half of the current users (56.8%) consumed less than 1 bottle/day. Energy-drink usage is common among university students in Palestine and higher among males and those with higher monthly expenditure. Campaigns should be encouraged in order to spread awareness about the contents and possible side effects of energy drinks.

Keywords: energy drinks, consumption, university, students, Palestine

BMI, body mass index; WHO, world health organization

Energy drinks are carbonated drinks that contain large amounts of caffeine and sugar with additional ingredients, such as B vitamins, amino acids (e.g. Taurine) and herbal stimulants such as Guarana.^1–3 The term “energy drinks” refers to beverages that contain caffeine in combination with other ingredients such as Taurine, guarana, and B vitamins, and are purported to provide its consumers with extra energy.⁴ Regarding the history of the Energy Drinks; the Scottish Irn-Bru “Iron Brew” is considered to be the first energy drink produced in 1901, although not marketed as such. In the early 1960s, Japan started selling Lipovitan in small brown glass bottles. These bottles contained a concentrated amount of the drink which was equivalent to a full-sized can of the drink. Other drinks such as Gatorade were marketed to help improve performance in athletes.⁵ Athletes believe that energy drinks can be used to enhance their performance during training and competition due to their potentially ergogenic ingredients.⁶

Energy drinks entered the North American beverage market with exotic names, catchy slogans and expensive marketing campaigns and now occupy a significant portion of the industry. The first energy drink to hit the shelves in North America was Jolt Cola in 1985. At the time, it was basically marketed as a cola with high-caffeine and high-sugar contents. Jolt Cola’s original marketing strategy targeted students and busy professionals.⁷ The Red Bull energy drink was introduced to Europe in 1987 and to the United States in 1997 was the forerunner of the modern energy drink and remains the most recognizable brand in the industry.⁸ However, it has considerable competition in today’s marketplace; 500 new varieties of energy drink were introduced to the worldwide market in 2006.⁹ The worldwide sales of the drinks rose from $ 3.5billion in 2006 to $ 4.7billion in 2007.¹⁰

Many companies continue to introduce new drinks, hoping to capture a share of a growing consumer base. Responding to the influx of new products with which they must compete, manufacturers push the boundaries, producing drinks with increasingly complex combinations of medicinal ingredients, with ever higher levels of caffeine, served in larger sizes.⁹ A dose of caffeine 85-250mg may result in feelings of alertness, decreased fatigue, and eased flow of thought. Whereas, excessive caffeine uses 250-500mgresulted in restlessness, nervousness, insomnia, tremors, seizures and cardiovascular instability,^11–15 in addition, it leads to hypokalemia.^16,17 With the rising popularity of energy drinks and with more young people ingesting higher levels of caffeine, more serious health problems are now being reported. Today, energy drinks have become available everywhere, their manufacturers say that, in addition to providing a boost in energy, the drinks promote wellness through medicinal properties (they usually contain vitamins and/or ingredients like ginseng, guarana and Taurine). Whatever their intended use and purported benefits, consumers today consume energy drinks for a variety of reasons: to boost energy, keep awake at night, relief stress and other causes.¹⁰

Energy drinks are marketed with colorful descriptions and provocative names that make them sound fun and exciting. “Rockstar, Monster, Full Throttle, Throw Down and Sobe” are just a sampling of the inviting products that fill store shelves. Marketing slogans are developed to stimulate interest in a product and distinguish it from its competition: “Get spiked” “Party like a Rockstar” and “Feel the freak” are slogans representing the marketing strategies of energy drink companies. The language and images of such advertising are not directed at mature adults. If anything, the marketing of energy drinks removes all ambiguity about whom these products are meant to appeal to: teens and young adult’s.¹⁸ As a result, the consumption of energy drinks is likely to become even more common and socially acceptable.

Energy drinks drive their properties chiefly from sugar and caffeine. Several studies suggest an association between sugar-sweetened beverage intake and weight.^19,20 One way for people to reduce their intake of added sugars and help manage their weight is to reduce the amount of sugar-sweetened beverages they drink.²¹ Caffeine in energy drinks will provide the consumer the desirable effects of increased alertness, improved memory and enhanced mood. However, caffeine can have harmful physical consequences, including central nervous system, cardiovascular, gastrointestinal and renal dysfunction²² Energy drinks contain between 14 and 31mg of caffeine per 100ml.²³ Although their caffeine concentration (in milligrams per milliliter) may be similar to coffee, energy drinks are often packaged in significantly higher volumes, resulting in increased caffeine intake.²⁴ Many energy drinks would list the herbs as ingredients, but the caffeine in the herbs may not be listed as a separate ingredient. By law, caffeine does not have to be listed on labels unless it has been added to the product separately as a pure substance and so, consumers may be completely unaware of the amount of caffeine they are ingesting.²⁵

Various energy drinks are marketed with claims of performance enhancing effects although the existence and extent of such effects is subject to debate. Red Bull, for example, advertises several benefits of consumption including improved performance, endurance, concentration and reaction speed and increased metabolism.²⁶ Consumers may falsely believe that “more is better” and ingest multiple servings of these products. Since there are no restrictions on the sale of energy drinks, adolescents and children (who may be inexperienced and less tolerant to the effects of caffeine) may be at an increased risk for caffeine intoxication.¹⁸ Suspected deaths linked to energy drinks have been reported in Australia and Ireland, three people died in Sweden after drinking Red Bull: two had mixed Red Bull with alcohol and the third drank it after an exercise session. There is debate regarding whether the drinks caused these deaths, but as a result, some restaurants in Sweden have banned Red Bull in their establishments. The Swedish National Food Administration recommended that Red Bull not be mixed with alcohol or consumed after exercise. Norway sells Red Bull only in pharmacies because of its high level of caffeine. Due to health experts’ recommendations, France and Denmark have banned Red Bull altogether. In 2004, the European Union as a whole begin requiring Red Bull and other energy drinks to carry a health warning about their “high caffeine content”.²⁷

Although energy drinks have been sold worldwide for more than a decade, unfortunately only few studies have been published to test the effectiveness of these beverages on the physical or cognitive performance. There have been no reported or published studies about the exact situation of energy drink usage, patterns of consumption or side effects among young adults in Palestine. University students represent part of the society with high vulnerability to stress mainly derived from studying, exams and lifestyle (especially those who live away from their homes & families). And thus, have high tendency to consume energy-providing substances, adding that most of them don’t know about the adverse side effects of these drinks on their health. They are totally taken by the deceiving stimulating effects of energy drinks, causing them to feel less intoxicated than they actually are.^1,28 This study aimed to:

1. Determine the patterns of energy drinks consumption and their associations with socio-demographic characteristics (age, gender, faculty and economic status) and body mass index among a group of An-Najah National University students.
2. Find out the occurrence of adverse side effects among energy drink users.
3. Verify the relationship between energy-drink consumption and certain daily habits of drinkers, such as cigarette smoking, sports, breakfast and sleeping patterns.
4. Identify the main causes for using energy drinks and the occurrence of side effects amongst current energy drink users.

Study design and settings

A cross-sectional study was conducted at AN-Najah National University, Nablus and Palestine in the period between 8-2-2011 and 7-3-2011. A written approval for this study was obtained from the university IRB. In addition, a letter of approval to conduct this study was written by the dean of the faculty of medicine, which made it easier to acquire verbal approvals from deans of the other two faculties. A brief summary about the study and its objectives was provided at the top of the questionnaire’s first page along with a consent statement allowing the participant to freely choose whether to participate in the study or not. The questionnaires were anonymous.

An-Najah National University is considered to be one of the largest and highest ranked universities among all Palestinian universities. The number of students attending this university was 20,537 students in 2010 (according to “An-Najah National University Self Evaluation report” published in January, 2011), with a female presentation of 55%.²⁹ The attendants are distributed mainly on 18 different faculties: Science, Arts, Shari’a, Economics and Administrative Sciences, Engineering, Educational Sciences, Fine Arts, Agriculture, Pharmacy, Law, Veterinary Medicine, Information Technology, Medicine, Nursing, Optometry, Physical Education, Media and Faculty of Graduate Studies.

Population and sample

This study was conducted in 3 faculties, including the Faculty of Medicine, Faculty of Engineering and Faculty of Physical Education. Selection of faculties was based on the likelihood of energy drink use by the students. Students of these faculties are assumed to be more likely to use energy drinks in order to stay awake for studying due to high levels of academic stress; in order to work on projects for long periods of time; and to boost their performance in exercising and training, respectively. As the main purpose of the study is to determine the patterns of drinking and occurrence of side effects among energy-drink consumers, students of these faculties are predicted to be better informants than any others. A total of 300 students were randomly selected from the targeted faculties.

Instrument

Initially a focus group discussion of 8 students who were enrolled in a lecture was interviewed. Those students were asked open-ended questions regarding situations they use energy drinks in, frequency patterns and side effects from using energy drinks. Based on the focus group responses, and with the help of previous studies on energy drinks, a self-administered questionnaire consisted of 25 closed-ended questions was developed. The first section assessed personal and demographic information (age, gender, etc). The second section was concerned with daily behavior of participants including playing sports, smoking, feeding and sleeping habits. The third section evaluated energy drink consumption patterns among participants, causes of drinking and any adverse side effect that might have possibly been encountered

Measures

Age: Calculated by using the date of birth of each participant in relation to the date of filling the questionnaire.

The body mass index (BMI): Calculated by using the weight and height of participants, which were self-reported and then it was categorized based on the (WHO) international BMI classification of adult’s.³⁰

Monthly expenditure: The monthly household income was categorized by dividing them into quartiles using SPSS software as there was no reliable source determining household income categories in Palestine apart from a survey done in early 1996, according to the Palestinian Central Bureau of Statistics which could not be applicable to the current situation in Palestine.

Smoking: Categorized according to the recommendations of the World Health Organization (WHO) in which a heavy smoker is defined as that with a daily cigarettes consumption of more than 20 pieces per day.³¹

Sleeping: Sleeping hours were divided into 3 categories, with the normal average sleeping hours considered to be between 7 and 8 hours per day, according to a study in 2005.³²

The last section of the questionnaire consisted of 5 questions, with the first question categorizing the participants into 3 groups based on their use of energy drinks. Students who denied ever trying energy drinks were asked about the reasons for never using them, while those who ever used energy drinks were asked to determine the reasons for using them. Both (reasons for using and not using energy drinks) were determined based on the focus group held at the early beginning of this study and were further developed with the aid of a previous study on energy drink consumption done by the Department of Public Health at Hacettepe University Faculty of Medicine, Ankara, Turkey.³³

In addition, two questions were designed to be answered only by those who still used energy drinks, the first question assessing the amount of energy drinks consumed and the second one assessing the occurrence of any side effects that might have possibly been due to their use of energy drinks. The question regarding the side effects was developed based on different studies regarding side effects thought to be associated with energy drinks or any of its ingredients.

Data collection

The study included 279 students, who agreed to participate and fill the questionnaire, 8 refused to participate, stating that (they had no time to fill the questionnaire), another 13 did not turn the questionnaire back. The questionnaires were collected from students at the faculties of medicine, engineering and physical education. Within each faculty, classes were randomly chosen among a list of those containing students of that faculty and of different academic years. The faculty of medicine had the exception that students of every academic year attend separate classes, so the numbers of participants from each academic year was chosen based on the proportion of each specific year to the total number of students of that faculty. Participants were randomly chosen among students attending those classes who in turn filled the questionnaires anonymously. Data collection from the Faculty of Physical Education and the Faculty of Engineering was accomplished with the assistance of lecturers from both faculties under the guidance of the principal investigator

Data analysis

All data were entered, tabulated and analyzed using version 17 of SPSS software. Data were presented as frequencies and cross tabulations. Chi-square test was used to compare differences by socio-demographic characteristics. A significance level of p<0.05 was used.

Socio-demographic characteristics

Table 1 demonstrates social and demographic characteristics of participants. More than half (59.1%) of participants were males and 40.9% were females. The ages of participants ranged from 18 to 28years, with a mean of 20.8years and standard deviation of 2.15years (median 20.74years). Of the 279 participants, 99 were students from the faculty of Physical education, 91 from the faculty of Medicine, and 89 were from the faculty of Engineering. Regarding the Body Mass Index (BMI), the highest proportion of both males and females were in the normal range, only 14.3% of females were overweight compared to 30.9% of males. Most of the participants (n=265) were single, 12 were engaged and only 2 were married. The highest proportion shared residency with their families (81%), compared to 15.8% who lived together with other students and only 3.2% were living alone. The monthly income of the students’ families ranged from 1000 to 20000 NIS with a mean of 4345NIS and standard deviation of 2611 NIS. The students’ monthly expenditure ranged from 100 to 2200 NIS, with a mean of 683 NIS and standard deviation of 395 NIS.

Daily habits

Some aspects of daily habits of participants that might have an effect on energy drinks consumption were approached during this study. Table 2 presents the distribution of some of those daily habits. According to the participant’s reports, only 39 of them were smoking, 31 of which smoke less than one pack/day and only 8 were smoking more than one pack/day. There was a significant difference between males and females regarding smoking (p<0.001), the majority (95%) of smokers were males. More than half of the participants (51.6%) stated that they did sports irregularly, 29% did sports regularly and 19.4% didn’t do sports at all. Of the total participants, about one third (37.6%) confirmed having breakfast on a regular basis, half (51%) had it irregularly and 11.1% didn’t have breakfast at all. Regarding sleeping pattern, more than half (54.8%) of the participants had irregular sleeping patterns and 45.2% had a regular sleeping pattern, with the highest proportion (60.2%) of participants sleeping between 7 and 8 hours a day. It was noticed that the males were more likely to have irregular sleeping patterns than females.

Main reasons for using (or not using) energy drinks

Out of 279 participants 118 reported ever using energy drinks, while 161 denied ever using them. When asked about the reasons for never using them, 78.9% of non users reported that they thought that energy drinks are “unhealthy”, 70.2% stated that they did not have curiosity to try energy drinks and 61.5% said they did not need extra energy. Only 18% of non-users didn’t use energy drinks because they are expensive. On the other hand, the most common cause for using energy drinks among users was to stay awake at night (68.6%), followed by enjoying the taste and the need to concentrate during studying, exams and project which were chosen by 59.3% and 58.5% respectively. The least chosen reason was to imitate friends in 7.6% of users (Table 3).

Awareness of contents and possible side-effects of energy drinks

Of the 279 participants, 64.4% didn’t know the main constituents of energy drinks and 53.6% stated they knew that there might be side effects associated with the use of energy drinks.

Current energy-drink users

More than half of current users (56.8%) consumed less than 1 bottle/day (Table 4). Regarding side effects, 40.9% of current energy-drink users denied having any side effect associated with their energy drink use, the most common side effect faced by users was palpitations, encountered by 29.5%, while headache was the least to be encountered, in 9.1% of current users. The most common cause for using energy drinks among current users was enjoying the taste (84.1%), followed by the need to concentrate during studying, exams and projects (59.1%), while the least causes were to imitate friends and to relieve headache in 4.5% and 13.6% of current users, respectively.

Ever vs. never users

Table 5 shows the effect of socio-demographic characteristics on energy drink usage among participants. There was a significant difference in energy-drink consumption between males and females (p<0.001), as 80.5% of those who ever tried energy drinks were males. There was a relationship between monthly expenditure of participants and the use of energy drinks (p<0.05). Of the 62 participants who estimated their monthly expenditure by more than 1000 NIS, 58.1% have ever used energy drinks (n=36), while only 27.7% (n=13) of those who spent less than 400 NIS have. There was no significant difference in energy drink use in relation to the BMI, faculty, or average cumulative grade.

Effect of daily habits on energy-drink consumption

Among the daily habits assessed, the only one found to have a significant effect on energy-drink usage was cigarette smoking (p<0.05), as 61.5% of all smokers included in this study (n=24) have tried using energy drinks and 60.8% of non-smokers never used energy drinks in their lives. There was no significant difference in the use of energy drinks in relation to doing sports, having breakfast, sleeping pattern or average hours of sleeping (Table 6).

None.

The author declares no conflict of interest.

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