|Year : 2022 | Volume
| Issue : 2 | Page : 129-136
Prevalence, patterns, clinico-social, and behavioral factors associated with the consumption of sugar-sweetened beverages among undergraduate medical students of central India
Soumya Kanti Mandal, G Revadi, Darshan Parida, Anindo Majumdar
Department of Community and Family Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
|Date of Submission||27-Nov-2021|
|Date of Decision||08-Nov-2022|
|Date of Acceptance||15-Nov-2022|
|Date of Web Publication||31-Dec-2022|
Dr. G Revadi
Department of Community and Family Medicine, All India Institute of Medical Sciences, Saket Nagar, Bhopal - 462 016, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Excessive consumption of sugar-sweetened beverages (SSBs) in adolescents has become a global issue. As its link to obesity and noncommunicable diseases is clear, it is imperative to understand SSB consumption behaviors in the future health-care professionals. The objective of this study is to document the prevalence, patterns, and clinico-social and behavioral factors predicting high intake of SSBs among medical students.
Material and Methods: This cross-sectional study was conducted using a self-reported, web-based, questionnaire. All the students and interns who were part of a publicly funded premiere teaching hospital between October and November 2019 were included in this study. The semi-structured questionnaire enquired regarding socio-demographic, clinical details, amount, behavioral patterns, and money spent in connection with SSB consumption. Data were analyzed using IBM SPSS version 24.
Results: The mean age of participants was 19.3 ± 1.6 years, 71.7% being males. The current prevalence of SSB consumption was 90.5%. Furthermore, 49.9% and 29.1% of participants preferred soft drinks and sweetened fruit juice, respectively. Multivariate analysis showed that male gender (adjusted odds ratio [aOR]: 1.83, (1.03–3.25), current alcohol consumption (aOR: 4.09, 1.25–13.42), and recent (last week) consumption of a SSB predicted high intake of SSBs [aOR: 7.36, (3.41–15.87)] whereas, preference of energy/sports category of drinks predicted low intake of SSBs [aOR 0.10, (0.02–0.47)].
Conclusion: The consumption of SSBs among medical students was high. Targeted health education and behavior change interventions should be provided to males, alcohol users, and frequent consumers.
Keywords: Associated factors, consumption patterns, prevalence, sugar-sweetened beverage
|How to cite this article:|
Mandal SK, Revadi G, Parida D, Majumdar A. Prevalence, patterns, clinico-social, and behavioral factors associated with the consumption of sugar-sweetened beverages among undergraduate medical students of central India. Indian J Community Fam Med 2022;8:129-36
|How to cite this URL:|
Mandal SK, Revadi G, Parida D, Majumdar A. Prevalence, patterns, clinico-social, and behavioral factors associated with the consumption of sugar-sweetened beverages among undergraduate medical students of central India. Indian J Community Fam Med [serial online] 2022 [cited 2023 Feb 2];8:129-36. Available from: https://www.ijcfm.org/text.asp?2022/8/2/129/366557
| Introduction|| |
Globally, in 2016, more than 1.9 billion adults were overweight. Of these, over 650 million were obese. Not only adults, but adolescent obesity has also become a problem. In 2016, over 340 million in 5–19 years of age group were found to be overweight. Excessive consumption of sugar-sweetened beverages (SSBs) has been found to contribute to increase in the prevalence of obesity, tooth decay, and noncommunicable diseases (NCDs).,,, SSBs are any liquids that are sweetened with various forms of added sugars such as brown sugar, corn sweetener, corn syrup, dextrose, fructose, glucose, highfructose corn syrup, honey, lactose, malt syrup, maltose, molasses, raw sugar, and sucrose. Examples of SSBs include but are not limited to regular soda (not sugar free), fruit drinks, sports drinks, energy drinks, sweetened waters, and coffee and tea beverages with added sugar. SSBs have little nutritional value.
Since 1998, SSB sales in India have been increasing by 13% yearonyear exceeding 11 L/capita/year. According to a study based on the National Family Health Survey, round 4 (NFHS 4) data, in the Indian population, the highest amount of consumption of SSBs has been seen among adolescents. In other parts of the world also, adolescents and young adults were the highest consumer of SSBs. Among adolescents, being male, fast food consumption and watching TV were found to be associated with higher consumption of SSBs, but high physical activity is associated with low consumption. In another study, rural living environment, less knowledge of energy expenditure were found to be associated with higher consumption. Most of the undergraduate medical students are adolescents or young adults. If their health is not optimum, this will affect patient care. Furthermore, medical professionals consuming SSBs themselves would not be seen as ideal role models by their patients, who usually look up to their treating physician.
Due to the above-mentioned reasons, patterns of SSB consumption and associated clinico-social and behavioral factors are important to understand. Previous studies from India have analyzed secondary data, and also have studied few variables. In addition, we could not find any study conducted among medical students. The objectives of the present study were, thus, to document the prevalence and patterns of SSB consumption and to find out the clinic-social and behavioral factors predicting higher intake of SSBs among undergraduate medical students of a premiere tertiary care teaching hospital in central India.
| Material and Methods|| |
This cross-sectional study was conducted among all the undergraduate medical students and interns of a premier tertiary care teaching hospital in central India using universal sampling who were part of this institute between October and November 2019. Students who were on long-term leave due to any disease for at least 1 month during the study were excluded from the study.
A web-based self-administered questionnaire was developed using the Kobo Toolbox (Harvard Humanitarian Initiative), which is free for noncommercial use. The semi-structured questionnaire was developed in the English language having both closed and open-ended questions. It had questions regarding socio-demographic, clinical details, amount and patterns of SSB consumption, and the money spent for SSB consumption. We also asked the participants about the term “Sugar-Sweetened Beverage,” to see if he/she had ever come across this term in media/scientific articles/textbooks, which might have also influenced their consumption patterns.
The class representatives were briefed about the study and a link to the questionnaire, along with the electronic copies of participant information sheet and a copy of consent form were shared with them on WhatsApp (Facebook Corp), which is a mobile messaging application. The students were then asked to fill their responses in the next 20 min. At least two reminders were sent to students (absentees and nonresponders) through phone call, WhatsApp, or personal contact before marking him/her as nonresponder.
Current tobacco use: tobacco used in any form, either smoked or smokeless, in the last 1 month.
Current alcohol use: Any amount of alcohol consumed in the last 1 month.
Sufficient physical activity: Perceived self-reported amount of physical activity.
Enough sleep: Perceived self-reported amount of sleep.
SSB: liquids sweetened with various forms of added sugars such as brown sugar, corn sweetener, corn syrup, dextrose, fructose, glucose, highfructose corn syrup, honey, lactose, malt syrup, maltose, molasses, raw sugar, and sucrose. SSBs include but are not limited to regular soda (not sugar free), fruit drinks, sports drinks, energy drinks, sweetened waters, and coffee and tea beverages with added sugar. For the purpose of our study, we limited this definition to beverages which were sold in the market and purchased by people, and not homemade beverages, like coffee, tea, etc.
Current prevalence of SSB consumption: the number of participants who had consumed any form of SSB in the last 1 month out of total number of participants included in the study. Lifetime prevalence of SSB consumption: the number of participants who had ever consumed any form of SSB in their lifetime out of total number of participants included in the study.
High intake of SSB: consumption of ≥1 L of any form of SSB/participant/month.
Last/recent consumption of SSB: consumption of SSB in any form in the last week (7 days).
Education and occupation of parents were classified according to the Modified Kuppuswamy scale. For education, the original categories used for data collection were: profession or honors, graduate or postgraduate, intermediate or posthigh school diploma, high school certificate, middle school certificate, primary school certificate, and illiterate. For occupation, the categories used were: profession, semi-profession, clerical/shop owner/farmer, skilled, semi-skilled, unskilled, and unemployed. During analysis, some of these categories were clubbed together to re-categorize as the numbers were small in original categories to draw any meaningful conclusions. Per capita income was calculated by dividing total family income by number of family members. For the sake of analysis in this study, it was further categorized as 0–68.72 USD, 68.74–343.67 USD, and >343.68 USD. This was further recategorized into <68.74 and ≥68.74 USD for further analysis.
Data were exported from Kobo Toolbox to Microsoft Excel 2010 and analysis was performed using Statistical Package for Social Sciences version 24 (IBM Corp., Armonk, N.Y., USA). Proportions and means were calculated, along with 95% confidence interval and standard deviation, respectively. Chi-square test was used to compare proportions among groups and to test associations. Univariate logistic regression analysis was conducted to understand the predictors of increased SSB consumption, especially the socio-demographic and the clinical-related factors among the participants. Unadjusted odds ratio was calculated. The variables which had a P < 0.25 in univariate analysis were entered into the multivariate model. Multivariate logistic regression analysis was performed to find out the independent predictors of increased SSB consumption and adjusted odds ratio (aOR) were reported. P < 0.05 was considered to be statistically significant.
| Results|| |
A total of 358 responses were recorded out of 499 students who were sent the link to the questionnaire (28.3% nonresponse). Out of 358, one participant had missing data/inappropriate responses in most fields, so the total valid responses analyzed were 357 participants. None of the participants fit the exclusion criteria. Majority (71.7%) of the participants were male, were below 20 years of age (59.9%), had permanent residence in an urban area (72.8%), and belonged to a nuclear family (85.7%). The median (interquartile range [IQR]) per capita income per month was 183.29 (91.65–343.68) USD ranging from nil to 14663.8 USD. A total of three (0.8%) participants had a history of chronic disease namely diabetes, hypertension, and cardiovascular disease.
Out of 357, 111 (31.1%) participants had never heard the term “Sugar-Sweetened Beverage” previously. On asking what they understood by SSBs (question was asked before giving them the definition of SSBs), their responses ranged from “don't know” in 26 (7.3%) cases, to a maximum of five SSBs. Participants either mentioned the type of drink or a name of the brand of SSB. Among them, 297 (83.2%) had understood soft drinks as SSBs, 80 (22.4%) as energy/sport drinks, 176 (47.3%) as packaged fruit drinks, 138 (38.7%) mentioned packaged milk product-based drinks (such as “Lassi”) and milkshakes, while only two (0.6%) participants mentioned other types of beverages (alcoholic beverages and honey water) [Table 1].
|Table 1: Sociodemographic and clinical characteristics of the study participants (n=357)|
Click here to view
The lifetime prevalence of SSB consumption was 92.7% (331). The current prevalence was 90.5% as 323 had consumed SSBs in the last month. Median (IQR) consumption of SSBs was found to be 0.5 (0.2–1) L/participant/month, ranging from nil to 15 L/participant/month. Median (IQR) expenditure on SSBs in the last month was 1.37 (0.55–3.44) USD, ranging from nil to 137.47 USD. Average expenditure for buying SSBs in the last month was found to be 3.66% of the participant's per capita income. Most of the participants, i.e., 253 (76.4%) had consumed at least one of the SSBs within the last week [Figure 1]. In addition, out of those who had consumed SSBs, most participants, i.e., 178 (53.8%) preferred soft drinks [Figure 2].
|Figure 1: Frequency of SSB consumption among the study participants (n = 331). SSB: Sugar-sweetened beverages|
Click here to view
|Figure 2: Preference of participants with respect to type of sugar-sweetened beverage consumed (n = 331)|
Click here to view
High intake of SSBs among the participants. Those having a permanent residence in an urban area had 1.7 times higher odds of high SSB intake as compared to those hailing from rural areas (P = 0.034) [Table 2]. Furthermore, those who had consumed SSB in the last week (more recent use) had 6.7 times higher odds of high SSB intake as compared to those who had not consumed SSB within the last 1 week (P = 0.001) [Table 3]. The association of socio-demographic, clinical and behavioral factors with frequency of SSB consumption was also analyzed separately [Supplementary Table 1].
|Table 2: Univariate logistic regression analysis to determine the sociodemographic factors|
Click here to view
|Table 3: Univariate logistic regression analysis to determine the clinical and sugar-sweetened beverage consumption behavioral factors predicting participants' high sugar sweetened beverage intake (n=357)|
Click here to view
In this analysis, 'frequent consumers' were defined as last/recent consumption of SSB in any form in the last week (seven days), and'not frequent consumers' as those who consumed any form of SSB in the last month, last year or earlier. None of the variables were found to be significantly associated.
The variables included in multivariate analysis are age, gender, residence of the participants, father's occupation, alcohol intake, per capita income, last consumption of SSB, and type of SSB preferred. It was found that males had about 1.8 times higher odds of high SSB intake as compared to females (P = 0.04). Those who had current alcohol consumption had about 4.1 times higher odds of high levels of SSB intake as compared to those who had not currently consumed alcohol (P = 0.02). Similarly, those who had consumed an SSB in the last week had about 7.4 times higher odds of high SSB intake as compared to those who did not consume in the last week (P = 0.001). However, those who preferred to consume energy drinks/sports drinks had low amount of SSB intake (aOR: 0.1, P = 0.004) as compared to those who had consumed other drinks such as milk product-based packaged drinks [Table 4].
|Table 4: Multivariable logistic regression analysis to determine factors independently predicting high intake (≥1 L/month) of sugar-sweetened beverages among the participants|
Click here to view
| Discussion|| |
We found that the current (last 1 month) and lifetime prevalence of SSB consumption were 90.5% and 92.7%, respectively. The reported prevalence of SSB consumption among Chinese children and adolescents aged 6–17 years was around 67%, which is lower than our study. However, a study conducted in Ontario showed that about 81.4% of the adolescents aged 11–20 years had consumed an SSB in the last week, and another 12% had consumed energy drinks. This finding is similar to our study. The lower prevalence in Chinese adolescents can be ascribed to the lower age range when parental supervision is usually high. We found that the median (IQR) consumption of SSBs was found to be 0.5 (0.2–1) L/participant/month. Chinese adolescents had consumed around 0.61 servings/day (around 1.1 L/week). Whereas, a study from the USA reported much higher consumption of SSBs among adolescents, i.e., 4.5 L/week. High intake of SSBs can be due to many factors such as lack of legislative measures, proper social message, peer pressure, and cultural food habits. In addition, intelligent and aggressive marketing strategies by SSB manufacturing companies play a part.
We also found that 49.9% of the participants preferred soft drinks, followed by 29.1% who preferred sweetened packaged fruit juice. Similarly, Park et al. found that students consumed more of soft drinks than energy drinks, etc. Most (37%) of their participants preferred regular soda. They attributed these findings to the frequent use of fast-food restaurants and prolonged television viewing. About 50% of the participants in the study by Wang et al. did consume carbonated SSBs.
Third, we found that as compared to females, males had 1.8 times higher intake of SSBs. This fact has been reported in several studies.,, For instance, the aORs reported for males were 3.74 and 1.66 by Skeie et al. and Park et al., respectively. These studies were not conducted on medical students though. One possible reason might be that male medical students in India are usually outdoors for longer times as compared to females, due to cultural and safety reasons, which increases their chances of buying packaged SSBs.
The participants in our study, who had consumed SSBs in the last week, had 7.4 times high intake of SSBs. This may be attributed to negative symptoms experienced by participants by temporary stoppage/decrease in consumption, which might have led to an urge to have higher and higher amounts of SSBs due to its addictive tendency. Falbe et al. has reported that participants experienced headache, decreased satisfaction, low motivation to work, and inability to concentrate during SSB cessation phase.
Participants who currently consumed alcohol had higher odds of high SSB intake than those not consuming alcohol. Some studies had contrasting findings, the reason ascribed being that nondrinkers might prefer SSBs to alcohol. Bleich et al. too did find similar results. Cultural differences in type of alcohol preferences may partly explain our finding.
Participants who preferred energy drinks/sports drinks were less likely to consume high amounts of SSBs as compared to those consuming other type of SSBs. This may be because of the way they are marketed/advertised as elicited by a study by Bogart et al., with increase in advertisements resulting in increased consumption of SSBs.
Participants having permanent residence in an urban area consumed a higher amount of SSBs than those from rural areas, although this was not found to be statistically significant in multivariable analysis. Some previous studies have reported similar findings.,, However, one study from China did report that young children (aged 3–7 years) from rural area consumed more SSBs as compared to their urban counterparts. The lower age group and higher economic status of Chinese may be a factor, it being an upper middle-income country. Easy availability of different kinds of SSBs in urban areas and having a habitual urbanized lifestyle (unhealthy eating and drinking behaviors) as a part of their growing up, before getting into the medical course are possible factors.
We did not find any statistically significant association between high intake of SSBs and age, family type, parent's occupation and education, per capita income, tobacco use, physical activity, sleep and history of chronic disease. Skeie et al. too did not find any association between physical activity and SSBs consumed. Kenney and Gortmaker however, reported that increased SSB intake was associated with reduced physical activity. One study reported poor sleep quality with higher intake of SSBs.
So far, only few Indian studies have reported about SSB consumption. One study used secondary data from general population survey using only a limited number of variables. In addition, that study did not estimate the actual quantity of SSB consumed. It has been reported earlier that medical students are prone to develop NCDs.,,, To the best of our knowledge, this is the first study globally, reporting SSB consumption patterns and associated factors among medical students. Our sample size was also good. As data on the prevalence of SSB use among medical students were not available, we did not do a priori sample size calculation. However, taking 50% prevalence (as in pilot studies), 20% relative precision and α = 0.05, the minimum sample size required was 100. Since, the question on amount of SSB consumed in the last month was an open-ended question,; there could be an element of reporting bias. It is possible, that some would have entered their consumption in liters, even after instructing them to fill in milliliters, leading to underreporting. Our findings might not be fully generalizable to private medical institutes, where the socio-economic status of students and campus culture may be different. We did not assess other unhealthy dietary practices, for example, fast food intake, the information on semester, reasons for consumption, circumstances which led to the consumption, availability of the substance and place of consumption which might also influence SSB intake. Furthermore, we could not objectively assess sedentary behavior.
| Conclusion & Recommendations|| |
The prevalence of SSB consumption among medical students was high. Nearly half of the students preferred soft drinks, followed by sweetened packaged fruit juice (29%). Male gender, alcohol use in the last month and recent consumption of SSBs predicted high intake of SSBs. Behavioral change and legislative measures will help not only safeguard optimal health for future health-care providers but will also help prevent workforce shortage, excessive costs, and compromised quality of care leading to inefficient health systems.
Targeted behavioral health interventions should be given to male medical students, alcohol users and frequent consumers of SSBs. Individual counseling by psychologists/psychiatrists should be arranged by the administration of the respective institutes for high SSB consumers. Students should be encouraged to consume homemade healthy drinks and abstain from taking alcohol. Legislation banning the sale of SSBs within a certain radius of educational institutions should be brought in.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Malik VS, Schulze MB, Hu FB. Intake of sugar-sweetened beverages and weight gain: A systematic review. Am J Clin Nutr 2006;84:274-88.
Malik VS, Popkin BM, Bray GA, Després JP, Willett WC, Hu FB. Sugar-sweetened beverages and risk of metabolic syndrome and type 2 diabetes: A meta-analysis. Diabetes Care 2010;33:2477-83.
Yang Q, Zhang Z, Gregg EW, Flanders WD, Merritt R, Hu FB. Added sugar intake and cardiovascular diseases mortality among US adults. JAMA Intern Med 2014;174:516-24.
Sohn W, Burt BA, Sowers MR. Carbonated soft drinks and dental caries in the primary dentition. J Dent Res 2006;85:262-6.
Basu S, Vellakkal S, Agrawal S, Stuckler D, Popkin B, Ebrahim S. Averting obesity and type 2 diabetes in India through sugar-sweetened beverage taxation: An economic-epidemiologic modeling study. PLoS Med 2014;11:e1001582.
Mathur MR, Nagrath D, Malhotra J, Mishra VK. Determinants of sugar-sweetened beverage consumption among Indian adults: Findings from the National family health survey-4. Indian J Community Med 2020;45:60-5.
] [Full text]
Singh GM, Micha R, Khatibzadeh S, Shi P, Lim S, Andrews KG, et al
. Global, regional, and national consumption of sugar-sweetened beverages, fruit juices, and milk: A systematic assessment of beverage intake in 187 countries. PLoS One 2015;10:e0124845.
Park S, Blanck HM, Sherry B, Brener N, O'Toole T. Factors associated with sugar-sweetened beverage intake among United States high school students. J Nutr 2012;142:306-12.
Wattelez G, Frayon S, Cavaloc Y, Cherrier S, Lerrant Y, Galy O. Sugar-Sweetened beverage consumption and associated factors in school-going adolescents of new caledonia. Nutrients 2019;11:452.
KoBoToolbox | Data Collection Tools for Challenging Environments. KoBoToolbox. Available from: https://kobotoolbox.org/
. [Last accessed on 2020 Jul 17].
Wani RT. Socioeconomic status scales-modified Kuppuswamy and Udai Pareekh's scale updated for 2019. J Family Med Prim Care 2019;8:1846-9.
] [Full text]
Gui ZH, Zhu YN, Cai L, Sun FH, Ma YH, Jing J, et al.
Sugar-Sweetened beverage consumption and risks of obesity and hypertension in Chinese children and adolescents: A National cross-sectional analysis. Nutrients 2017;9:1302.
Sampasa-Kanyinga H, Hamilton HA, Chaput JP. Sleep duration and consumption of sugar-sweetened beverages and energy drinks among adolescents. Nutrition 2018;48:77-81.
Skeie G, Sandvær V, Grimnes G. Intake of sugar-sweetened beverages in adolescents from troms, norway-the tromsø study: Fit Futures. Nutrients 2019;11:211.
Wang YC, Bleich SN, Gortmaker SL. Increasing caloric contribution from sugar-sweetened beverages and 100% fruit juices among US children and adolescents, 1988-2004. Pediatrics 2008;121:e1604-14.
Bjelland M, Lien N, Grydeland M, Bergh IH, Anderssen SA, Ommundsen Y, et al
. Intakes and perceived home availability of sugar-sweetened beverages, fruit and vegetables as reported by mothers, fathers and adolescents in the HEIA (HEalth In Adolescents) study. Public Health Nutr 2011;14:2156-65.
Falbe J, Thompson HR, Patel A, Madsen KA. Potentially addictive properties of sugar-sweetened beverages among adolescents. Appetite 2019;133:130-7.
Park S, Pan L, Sherry B, Blanck HM. Consumption of sugar-sweetened beverages among US adults in 6 states: Behavioral risk factor surveillance system, 2011. Prev Chronic Dis 2014;11:65.
Bleich SN, Wang YC, Wang Y, Gortmaker SL. Increasing consumption of sugar-sweetened beverages among US adults: 1988-1994 to 1999-2004. Am J Clin Nutr 2009;89:372-81.
Bogart LM, Cowgill BO, Sharma AJ, Uyeda K, Sticklor LA, Alijewicz KE, et al
. Parental and home environmental facilitators of sugar-sweetened beverage consumption among overweight and obese Latino youth. Acad Pediatr 2013;13:348-55.
Ramírez-Vélez R, González-Ruíz K, Correa-Bautista JE, Meneses-Echávez JF, Martínez-Torres J. Demographic and socioeconomic differences in consumption of sugar-sweetened beverages among colombian children and adolescents. Nutr Hosp 2015;31:2479-86.
Hearst MO, Pasch KE, Laska MN. Urban versus. Suburban perceptions of the neighbourhood food environment as correlates of adolescent food purchasing. Public Health Nutr 2012;15:299-306.
Yu P, Chen Y, Zhao A, Bai Y, Zheng Y, Zhao W, et al
. Consumption of sugar-sweetened beverages and its association with overweight among young children from China. Public Health Nutr 2016;19:2336-46.
Kenney EL, Gortmaker SL. United States adolescents' television, computer, videogame, smartphone, and tablet use: Associations with sugary drinks, sleep, physical activity, and obesity. J Pediatr 2017;182:144-9.
Nyombi KV, Kizito S, Mukunya D, Nabukalu A, Bukama M, Lunyera J, et al
. High prevalence of hypertension and cardiovascular disease risk factors among medical students at Makerere university college of health sciences, Kampala, Uganda. BMC Res Notes 2016;9:110.
Adams-Campbell LL, Nwankwo MU, Omene JA, Ukoli FA, Young MP, Haile GT, et al
. Assessment of cardiovascular risk factors in Nigerian students. Arteriosclerosis 1988;8:793-6.
Aslam F, Mahmud H, Waheed A. Cardiovascular health – Behaviour of medical students in Karachi. J Pak Med Assoc 2004;54:492-5.
Bertsias G, Mammas I, Linardakis M, Kafatos A. Overweight and obesity in relation to cardiovascular disease risk factors among medical students in Crete, Greece. BMC Public Health 2003;3:3.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]