Associations between adolescents’ energy drink consumption frequency and several negative health indicators

This is a self-archived version of an original article. This version may differ from the original in pagination and typographic details. Author(s): Title: Year: Version: Copyright: Rights: Rights url: Please cite the original version: CC BY 4.0 https://creativecommons.org/licenses/by/4.0/ Associations between adolescents’ energy drink consumption frequency and several negative health indicators © The Author(s) 2023. Published version Puupponen, Maija; Tynjälä, Jorma; Välimaa, Raili; Paakkari, Leena Puupponen, M., Tynjälä, J., Välimaa, R., & Paakkari, L. (2023). Associations between adolescents’ energy drink consumption frequency and several negative health indicators. BMC Public Health, 23, Article 258. https://doi.org/10.1186/s12889-023-15055-6 2023 Puupponenetal. BMC Public Health (2023) 23:258 https://doi.org/10.1186/s12889-023-15055-6 RESEARCH © The Author(s) 2023. 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The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Open Access BMC Public Health Associations betweenadolescents’ energy drink consumption frequency andseveral negative health indicators Maija Puupponen*, Jorma Tynjälä, Raili Välimaa and Leena Paakkari Abstract Background The purpose of this study was to identify how various negative health indicators are associated with energy drink consumption frequency among 13- and 15-year-old Finnish adolescents. Methods Data (N = 2429) from the nationally representative international Health Behaviour in School-aged Children study (2018) were analyzed via descriptive analysis and logistic regression analyses, with control for salient covariates. Relative risks (RR) were derived from the adjusted odds ratios. Results Even infrequent energy drink consumption was associated with various negative health indicators. Moreover, as compared to non-users, frequent energy drink consumers were more likely to report several health-compromising behaviors: current smoking (RR = 9.85, 95% CI: 5.68–16.02), current snus use (RR = 3.62, 95% CI: 1.80–6.85), canna- bis use (RR = 3.42, 95% CI: 1.69–6.52), alcohol consumption (RR = 3.08, 95% CI: 2.49–3.71), problematic social media use (RR = 2.53, 95% CI:1.68–3.72), short sleep (RR = 2.12, 95% CI: 1.69–2.60), skipping breakfast (RR = 1.87, 95% CI: 1.51–2.29), drunkenness (RR = 1.59, 95% CI: 1.11–2.23), inadequate tooth brushing (RR = 1.28, 95% CI: 1.05–1.54). In addition, frequent energy drink consumption was associated with perceived negative health indicators: feelings of insufficient sleep (RR = 1.56, 95% CI: 1.11–2.15), low self-rated health (RR = 1.48, 95% CI: 1.15–1.87), and multiple health complaints (RR = 1.31, 95% CI: 1.07–1.56). Conclusions Energy drink consumption, even infrequent, was associated with several negative health indicators, and the reporting of these increased with the frequency of energy drink consumption. The findings support the concerns of health authorities regarding the negative associations between energy drink consumption and health, even among persons as young as 13 years. There is evidence to support specific policy level actions, including restrictions on the sale of energy drinks to adolescents. This measure has been proposed in a Finnish government program, but implementation has yet to occur. Moreover, marketing of these beverages in platforms that are popular among adolescents (e.g., the social media) should be rigorously evaluated, and comprehensive interventions and actions implemented to ensure that adolescents, parents/guardians, and professionals working with adolescents (e.g., in schools) have a good understanding of the links between energy drink consumption and health. Keywords Energy drinks, Adolescent, Health behavior, Relative risk Background Adolescence is a rapid developmental phase characterized by major physical, psychological, and psychosocial changes [1]. It is accompanied by the initiation of several health behaviors, which often track forward to adulthood *Correspondence: Maija Puupponen [email protected] Research Centre for Health Promotion, Faculty of Sport and Health Sciences, University of Jyväskylä, Keskussairaalantie 4, 40600 Jyväskylä, FI, Finland Page 2 of 12 Puupponenetal. BMC Public Health (2023) 23:258 [2]. Adolescents’ energy drink consumption has raised concerns among health authorities in different countries and regions. Energy drinks contain high levels of caffeine along with other plant-based stimulants and ingredients [3, 4]. Mostly due to their stimulant content, there have been a number of statements concerning the inappropriateness for adolescents of energy drinks and their constituents in various regions, including Finland [5], Europe [3], and the United States [6]. Moreover, World Health Organization researchers [7] have viewed energy drinks as a significant future risk for public health. In line with these statements, mandatory labeling has been established in EU member states for products with added caffeine content [8]. The labels include a warning that energy drinks are not recommended for sensitive consumer groups such as children. Despite these statements, energy drink consumption among adolescents is extremely prevalent across Europe [4, 9], and energy drinks are widely available for adolescents worldwide, due to the fact that like most European countries, the United States does not restrict sales to adolescents [10]. The rationale for the recommendations is mainly based on the known adverse physiological effects; however, a growing body of literature has linked energy drink consumption to the use of other harmful substances including alcohol [9, 11–17], cigarettes [9, 11, 13–16, 18], e-cigarettes [16], cannabis, and various other drugs [11, 14]. It is also important to examine the extent to which energy drinks contribute to other unfavorable health behaviors among adolescents, with consequences such as insomnia and obesity [7], various health complaints [9, 13, 19], and mental health problems [15]. Previous studies have found associations between energy drink consumption and late bedtime [17, 19] and short sleep [14, 20]. In addition, consumption of these beverages has been linked to an unhealthy diet [16–18, 20], higher BMI [14], and lower BMI [12]. Moreover, energy drink consumption has been associated with sedentary behaviors such as higher video game use [18] and higher screen time [17, 20, 21]. It has been further linked both to lower physical activity [14, 21] and to higher physical activity [17]. In contrast, Larson etal. [18] found no association between energy drink consumption and physical activity. Despite the growing research evidence, studies on adolescents have mostly concentrated on dichotomous measures in comparisons involving energy drink consumption. Thus, some studies have compared consumption versus no consumption, without considering the consumption frequency, while others have included frequency comparisons, but have ruled out non-users. There is also inconsistency in the definitions of different consumer groups. For example, “more frequent consumption” has been specified as consumption of energy drinks more than once a month [11], or else four or more times during the previous week [15]. To conclude, only a few studies (e.g. [11, 12, 15, 19, 22]) on adolescents have compared the associations between energy drink consumption and health indicators, while also giving consideration to the consumption frequency. The studies in question all indicate that frequency should be taken into consideration. Furthermore, most of the studies to date have focused only on individual health behaviors, and have not included groups of behaviors within the same study. They have also failed to include certain specific behaviors that have received too little attention in the literature on energy drinks, such as tooth brushing and the use of snus (i.e., smokeless tobacco). Given that the knowledge on energy drinks in Finland is scarce, and that there are empirical gaps in the literature related to methodologies and specific indicators, there is a clear need to obtain more evidence on energy drink consumption, and its associations with various health indicators in different cultural contexts and countries. Studies on these lines would build knowledge to improve regulations worldwide [7]. By utilizing nationally representative data, we aimed to address the following two objectives. First of all, we aimed to describe the prevalence of various negative health indicators among different groups of energy drink consumers (categorized as frequent, infrequent, and no consumption) among 13- and 15-year-old adolescents. The indicators included health-compromising behaviors (i.e., inadequate tooth brushing, skipping breakfast, low physical activity, short sleep, problematic social media use, current smoking, alcohol consumption, drunkenness,current snus use, and cannabis use), and perceived unfavorable health indicators (i.e., low self-rated health, multiple health complaints, and feelings of insufficient sleep). Secondly, we wished to analyze whether consumption frequency played a role, and whether age and gender moderated the associations identified after control for salient covariates. Methods Design Cross-sectional data were collected from Finnish adolescents in 2018 as part of the international Health Behaviour in School-aged Children (HBSC) study, which aims to gain information on adolescents’ health and well-being within their social context [23]. The European Union NUTS classification (Nomenclature of Territorial Units for Statistics) was applied in the stratification of the sampling, which was based on the Finnish school register. The participating schools were selected from the national Page 3 of 12 Puupponenetal. BMC Public Health (2023) 23:258 school register using a cluster sampling method adjusted by province, the type of municipality, and the size of the school (via PPS, i.e., Proportion Probable Size). The school principals gave permission for school classes to participate in the study. Within each school, participating classes were randomly selected. Parents were informed, and some schools required active parental/guardian consent. Informed consent was obtained from all students involved in the study, and participation in the study was voluntary. The survey was carried out as an online questionnaire via Webropol software (Webropol Oy, Helsinki, Finland). The response rate of students within schools which promised to take part in the survey was 54.1%. Participants The nationally representative and anonymous data were obtained from a total of 2429 adolescents (13-year-olds, n = 1260; 15-year-olds, n = 1169) in 77 schools. The proportion of boys (n = 1218) and girls (n = 1211) was almost equal. Measures Sociodemographic characteristics included age, selfreported gender, and self-reported material family wealth, which was assessed via Family Affluence Scale III (FASIII) [24]. Energy drink consumption was measured by asking adolescents to respond to “How many times a week do you eat or drink the following…” with energy drinks comprising one item in a 5-item block. The response categories were: never, less than once a week, once a week, 2–4days a week, 5–6days a week, once a day every day, and every day more than once. For the analyses in the present study, responses were grouped into three categories: frequent consumption (i.e., weekly), infrequent consumption (i.e., less than weekly), and no consumption. Health indicators (i.e., health behaviors and perceived health indicators) and their negative values were measured by the items presented in Table1. Physical activity was evaluated according to the moderate-to-vigorous activity (MVPA) scale [25]. Sleep length was calculated from the time of going to bed to the time of waking up on school days. Problematic social media use was defined by using the 9-item Social Media Disorder (SMD) scale [26], and the risk level was categorized according to Boer etal. [27]. In the perceived health indicators, self-rated health was measured using a single item [28], and health complaints were measured via the HBSC-SCL symptom checklist [29]. We examined the associations by defining a cut-off point indicating the negative dimension of each health indicator; this was based on the risk levels used in the HBSC international report [23] and on national recommendations (e.g., on tooth brushing), with attention also to the distribution of the response. Statistical analysis Descriptive analysis (including percentages, confidence intervals, and p-values) was used to determine the prevalence of negative health indicators by energy drink consumption. This information was stratified by age, and also presented for the total sample. Logistic regression models were used to examine the associations between energy drink consumption frequency and negative health indicators; this was done via a separate model for each health indicator. Models were individually controlled for age, gender, family affluence, and a set of other covariates (health-compromising behaviors and multiple health complaints). This was done on a theoretical basis according to which health-compromising behaviors accumulate and co-occur (e.g. [30]). Pairwise multiple comparisons were performed for each model with the Šidák correction test. To test whether age and gender moderated the associations between energy drink consumption and negative health indicators, the following analyses were conducted: (i) two-way interactions were tested in all models; (ii) for those models showing a statistically significant interaction the adjusted effect for energy drink consumption was estimated; furthermore, (iii) separate models by gender and/or by age were formed (see also the results, and the tables in the Additional files3 and 4). Relative risks were derived from the adjusted odds ratios to provide a more accurate interpretation of the associations, using the following formula [31]: in which P0 indicates the prevalence of the outcome of interest (negative health indicator) in the reference group (no energy drink consumption). The analyses were carried out using Stata (version 16) [32]. The analyses were weighted by language group (Finnish and Swedish) and by grade level. Results Prevalence ofnegative health indicators amongenergy drink consumers Half of the adolescents who frequently consumed energy drinks reported brushing their teeth less than twice a day, and consuming alcohol over the past 30days (Table2). Moreover, in the category of frequent energy drink consumers, less than half reported multiple health complaints, two out of five reported skipping breakfast and having short sleep, one in three reported current smoking and low self-rated health, one in four reported feelings of insufficient sleep, while one in five reported low RR = OR ( 1−P 0) + ( P 0 ×OR ) Page 4 of 12 Puupponenetal. BMC Public Health (2023) 23:258 Table 1 Measures on health indicators and their negative dimension Question Indicator range Negative value of the indicator Health-related behaviors Brushing teeth: How often do you brush your teeth? 1 = More than once a day 2 = Once a day 3 = At least once a week but not daily 4 = Less than once a week 5 = Never Inadequate tooth brushing: < 2 times/day (i.e., all values except 1 = More than once a day) Eating breakfast: How often do you usually have breakfast (more than a glass of milk or fruit juice) on weekdays? 1 = I never have breakfast during the week 2 = One day 3 = Two days 4 = Three days 5 = Four days 6 = Five days Skipping breakfast: Eating breakfast 0–2 days/weekdays Physical activity: Over the past 7 days, on how many days were you physically active for a total of at least 60 min per day? 0 to 7 days Low physical activity: 0–2 days Sleep length: Difference between bedtime and wake-up time on weekdays Hours Short sleep: ≤ 7 h / day Social media use: During the past year, have you… 9 items on the following criteria: preoccupation, tolerance, withdrawal, persistence, displacement, problem, deception, escape, conflict; for example: … regularly found that you can’t think of anything else but the moment that you will be able to use social media again? 1 = No 2 = Ye s (Items were coded as 1 = Yes and 0 = No, and a sum score was computed) Problematic social media use: Sum score of ≥ 6 Smoking: How often do you smoke tobacco at present? 1 = Every day 2 = At least once a week, but not every day 3 = Less than once a week 4 = I do not smoke Current smoking: From every day to less than once a week (i.e., all values except 4 = I don’t smoke) Snus use: Do you currently use snuff/snus? (Question was only asked of 15-year-olds) 1 = Every day 2 = Every week, but not daily 3 = Less than once a week 4 = I don’t use snuff/snus Current snus use: From every day to less than once a week (i.e., all values except 4 = I don’t use snuff/ snus) Alcohol consumption: On how many days (if any) have you drunk alcohol? … In the last 30 days? 1 = Never 2 = 1–2 days 3 = 3–5 days 4 = 6–9 days 5 = 10–19 days 6 = 20–29 days 7 = 30 days (or more) Alcohol consumption: All values except 1 = Never Drunkenness: Have you ever had so much alcohol that you were really drunk? (Question was only asked of 15-year-olds) … In your lifetime? 1 = No, never 2 = Yes, once 3 = Yes, 2–3 times 4 = Yes, 4–10 times 5 = Yes, more than 10 times Drunkenness: Twice or more Cannabis use: Have you ever taken cannabis (for example marihuana)? … In your lifetime? (Question was only asked of 15-year-olds) 1 = Never 2 = 1–2 days 3 = 3–5 days 4 = 6–9 days 5 = 10–19 days 6 = 20–29 days 7 = 30 days (or more) Cannabis use: All values except 1 = Never Perceived health indicators Self-rated health: Would you say your health is…? 1 = Excellent 2 = Good 3 = Fair 4 = Poor Low self-rated health: Fair or poor Page 5 of 12 Puupponenetal. BMC Public Health (2023) 23:258 physical activity, with a similar proportion responding in a manner that categorized them as problematic social media users. Additional items for 15-year-olds regarding substance use indicated that out of the frequent energy drink consumers, less than half reported drunkenness, one in three reported current snus use, and one in four had used cannabis. In a comparison of age groups (see Additional file1: Table S5), among both frequent and infrequent consumers, 15-year-olds showed a higher prevalence of low physical activity, current smoking, and alcohol consumption. Among frequent consumers, 13-year-olds showed a higher prevalence of low self-rated health. Among nonconsumers, 15-year-olds reported a higher prevalence of low physical activity, short sleep, current smoking, alcohol consumption, and feelings of insufficient sleep. The overall prevalence of health-compromising behaviors and perceived negative health indicators among 13- and 15-year-olds can be found in Additional file2: TableS6. Associations betweenenergy drink consumption frequency andnegative health indicators Health-compromising behaviors The reporting of several health-compromising behaviors (such as short sleep, problematic social media use, current smoking, alcohol consumption,current snus useand cannabis use) increased even among infrequent consumers, as compared to adolescents who did not consume energy drinks(Table3). This was the case even after control for several salient covariates was applied. By contrast, infrequent energy drink consumers were less likely to report low physical activity than non-consumers. Frequent energy drink consumers were more likely than non-consumers to report all listed health-compro- mising behaviors, except for low physical activity. They were also more likely than infrequent consumers to report skippingbreakfast, short sleep, currentsmoking, and alcohol consumption. Age moderated the association between energy drink consumption and short sleep, and between energy drink consumption and alcohol consumption, and separate models by age were formed (Additional file3: TableS7). Infrequent energy drink consumption was associated with short sleep only among 13-year-olds as compared to 15-year-olds. Moreover, the increase in the frequency of energy drink consumption (from infrequent to frequent consumption) indicated a stronger association with short sleep and with alcohol consumption among 13-year-olds as compared to 15-year-olds. Perceived unfavorable health indicators As compared to non-consumers, frequent energy drink consumers were more likely to report low self-rated health, multiple health complaints and feelings of insufficient sleep, even after control for several salient covariates (Table4). Interactions were found regarding low self-rated health and multiple health complaints, and separate models by age and/or gender were formed (Additional file4: TableS8). Age moderated the association between energy drink consumption and low self-rated health, and between energy drink consumption and multiple health complaints. Frequent energy drink consumption was associated with an increased risk of reporting low self-rated health and multiple health complaints only among 13-year-olds as compared to 15-year-olds. As regards gender differences, both infrequent and frequent consumption of energy drinks were associated with an increased risk of reporting multiple health complaints only among girls. Table 1 (continued) Question Indicator range Negative value of the indicator Health complaints: In the last 6 months: how often have you had the following…? headache, stomach-ache, backache, feeling low, irritability or bad temper, feeling nervous, difficulties in getting to sleep, feeling dizzy 1 = About every day 2 = More than once a week 3 = About every week 4 = About every month 5 = Rarely or never (Items were coded as 1 = More than once a week or about every day and 0 = About every week or less, and a sum score was computed) Multiple health complaints: Sum score of ≥ 2 (i.e., two or more symptoms more than once a week) Sleep sufficiency: How often do you feel that you have slept sufficiently? 1 = Every or almost every morning 2 = 3–5 mornings a week 3 = 1–2 mornings a week 4 = Hardly ever Feelings of insufficient sleep: Slept sufficiently hardly ever Page 6 of 12 Puupponenetal. BMC Public Health (2023) 23:258 Table 2 Prevalence of health-compromising behaviors and perceived negative health indicatorsa by energy drink consumption among 13- and 15-year-olds a Only the percentage for the negative dimension is presented in the table b P-values for the groups of energy drink consumption c Statistically significant difference between the age groups among frequent consumers, Pearson’s chi-squared test d Statistically significant difference between the age groups among infrequent consumers, Pearson’s chi-squared test e Statistically significant difference between the age groups among non-consumers, Pearson’s chi-squared test 13-year-olds 15-year-olds Total Energy drink consumption Energy drink consumption Energy drink consumption Frequent Infrequent No consumption P-valuebFrequent Infrequent No consumption P-valuebFrequent Infrequent No consumption P-valueb Inadequate tooth brushing 53.6 [46.7–60.4] 42.2 [35.9–48.8] 26.3 [22.4–30.7] < 0.001 47.9 [41.7–54.1] 35.1 [30.4–40.2] 30.3 [25.4–35.7] < 0.001 50.3 [45.6–55.0] 38.3 [34.4–42.3] 28.1 [25.0–31.4] < 0.001 Skipping breakfast 33.9 [28.7–39.6] 20.7 [15.4–27.3] 13.4 [10.7–16.6] < 0.001 41.1 [35.2–47.2] 21.4 [16.7–27.1] 18.1 [14.5–22.4] < 0.001 38.1 [33.9–42.4] 21.1 [17.4–25.4] 15.5 [13.2–18.0] < 0.001 Low physical activity 15.7c [11.3–21.3] 6.8d [3.9–11.6] 10.3e [7.7–13.6] 0.019 25.9c [21.8–30.5] 17.9d [13.6–23.1] 20.4e [16.8–24.5] < 0.001 21.6 [18.3–25.4] 13.0 [10.1–16.5] 14.7 [12.4–17.4] < 0.001 Short sleep 39.8 [33.5–46.5] 20.7 [16.4–25.8] 11.1e [8.4–14.4] < 0.001 38.4 [32.7–44.4] 26.2 [21.3–31.8] 18.4e [14.9–22.4] < 0.001 39.0 [34.6–43.5] 23.8 [20.4–27.6] 14.3 [12.0–16.9] < 0.001 Problematic social media use 23.4 [17.2–31.0] 12.4 [10.4–19.9] 6.5 [4.4–9.5] < 0.001 18.5 [14.5–23.2] 12.8 [9.5–17.2] 5.7 [3.7–8.6] < 0.001 20.5 [17.0–24.6] 12.6 [9.8–16.2] 6.1 [4.6–8.2] < 0.001 Current smoking 20.8c [15.8–27.0] 3.2d [1.6–6.3] 0.6e [0.2–1.7] < 0.001 36.2c [30.1–42.7] 12.3d [8.5–17.4] 3.7e [2.1–6.5] < 0.001 29.8 [25.2–34.9] 8.3 [5.8–11.6] 1.9 [1.1–3.3] < 0.001 Alcohol consumption 37.3c [30.4–44.8] 13.0d [8.7–19.0] 6.1e [4.2–8.7] < 0.001 56.4c [49.0–63.6] 40.3d [33.6–47.5] 20.6e [15.7–26.5] < 0.001 48.5 [43.0–54.1] 28.2 [23.0–34.1] 12.3 [9.7–15.6] < 0.001 Drunkenness 45.2 [38.3–52.2] 26.0 [21.8–30.8] 12.4 [9.2–16.5] < 0.001 Current snus use 29.8 [25.0–35.0] 10.5 [7.3–15.0] 3.0 [1.9–4.8] < 0.001 Cannabis use 25.0 [19.8–31.0] 10.4 [7.1–14.8] 2.9 [1.7–4.9] < 0.001 Low self-rated health 37.0c [31.2–43.2] 18.5 [14.1–23.8] 13.3 [10.6–16.7] < 0.001 25.3c [19.7–31.8] 19.2 [14.7–24.7] 16.8 [13.5–20.7] 0.037 30.2 [25.7–35.2] 18.9 [15.6–22.7] 14.8 [12.7–17.3] < 0.001 Multiple health complaints 50.4 [42.9–57.9] 33.0 [28.0–38.4] 28.2 [23.5–33.4] < 0.001 42.5 [37.5–47.7] 39.0 [33.8–44.5] 34.6 [30.0–39.4] 0.080 45.8 [41.3–50.4] 36.4 [32.6–40.4] 31.0 [27.6–34.6] < 0.001 Feelings of insufficient sleep 26.0 [20.0–33.1] 10.3 [6.9–14.9] 8.5e [6.1–11.6] < 0.001 25.5 [21.0–30.6] 13.9 [10.6–18.0] 13.0e [10.1–16.6] < 0.001 25.7 [22.1–29.7] 12.3 [9.8–15.3] 10.5 [8.5–12.8] < 0.001 n(164–272) (251–383) (631–687) (287–332) (297–334) (458–501) (523–604) (548–614) (1089–1186) Page 7 of 12 Puupponenetal. BMC Public Health (2023) 23:258 Table 3 Health-compromising behaviors by energy drink consumption: adjusted odds ratios (aOR), 95% confidence intervals (CI), and corresponding relative risks (RR) and 95% confidence intervals (CI)a Interaction was found in the models for short sleep and alcohol consumption: adjusted effect presented. The interaction effect is presented in the Additional file3: TableS7 a Relative risks and their confidence intervals were derived from adjusted odds ratios b Models were adjusted for age, gender, family affluence, short sleep, low physical activity, current smoking, alcohol consumption, and multiple health complaints c Model was adjusted for age, gender, family affluence, short sleep, current smoking, alcohol consumption, and multiple health complaints d Model was adjusted for age, gender, family affluence, low physical activity, current smoking, alcohol consumption, and multiple health complaints e Model was adjusted for age, gender, family affluence, short sleep, low physical activity, alcohol consumption, and multiple health complaints f Model was adjusted for age, gender, family affluence, short sleep, low physical activity, current smoking, and multiple health complaints g Tested with pairwise multiple comparisons Inadequate tooth brushingb Skipping breakfastbLow physical activitycShort sleepdProblematic social media useb Current smokingeAlcohol consumptionfDrunkennessbCurrent snus usebCannabis useb Energy drinks No consumption 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 Infrequent consumption aOR 95% CI P-value 1.22 [0.94–1.58] 0.139 1.24 [0.89–1.72] 0.196 0.70 [0.50–0.99] 0.045 1.62 [1.24–2.12] < 0.001 2.23 [1.40–3.56] 0.001 3.15 [1.56–6.37] 0.002 2.28 [1.63–3.18] < 0.001 1.39 [0.85–2.28] 0.187 2.63 [1.27–5.43] 0.009 2.59 [1.22–5.49] 0.014 RR 95% CI 1.15 1.20 0.73 1.49 2.07 3.03 1.97 1.33 2.51 2.48 [0.96–1.36] [0.91–1.55] [0.54–0.99] [1.20–1.83] [1.37–3.08] [1.54–5.78] [1.51–2.51] [0.87–1.97] [1.26–4.79] [1.21–4.86] Frequent consumption aOR 95% CI P-value 1.44 [1.07–1.94] 0.016 2.22 [1.66–2.99] < 0.001 0.83 [0.55–1.26] 0.373 2.60 [1.91–3.54] < 0.001 2.81 [1.76–4.51] < 0.001 11.89 [6.25–22.59] < 0.001 4.34 [3.14–5.99] < 0.001 1.74 [1.13–2.70] 0.013 3.94 [1.85–8.37] < 0.001 3.68 [1.73–7.80] 0.001 RR 95% CI 1.28 1.87 0.85 2.12 2.53 9.85 3.08 1.59 3.62 3.42 [1.05–1.54] [1.51–2.29] [0.59–1.21] [1.69–2.60] [1.68–3.72] [5.68–16.02] [2.49–3.71] [1.11–2.23] [1.80–6.85] [1.69–6.52] Infrequent vs. FrequentgP-value 0.562 0.003 0.803 0.005 0.408 < 0.001 < 0.001 0.642 0.456 0.619 Page 8 of 12 Puupponenetal. BMC Public Health (2023) 23:258 Discussion Our results support the concerns highlighted in international scientific discussion regarding energy drink consumption among adolescents. Our findings add to the growing body of research clearly indicating that adolescents who consume energy drinks have a greater chance of reporting health-compromising behaviors and perceived negative health indicators than those who do not consume energy drinks. This was the case even among persons as young as 13years, and after control for possible confounders was applied. Hence, evaluation of the appropriateness of energy drinks for adolescents should go beyond a focus on the direct physiological effects of energy drinks. Our study responds to the global need to obtain knowledge on energy drinks, in order to update existing policies and construct new ones. The aim would be to reduce energy drink consumption, bearing in mind that most countries have no legal restrictions on their sale. In some European countries (such as Finland and the UK) the government has proposed restrictions on energy drink sales to children aged under 16 [9, 33]; however, implementation has yet to occur. Latvia and Lithuania have banned the sale of energy drinks to persons under the age of 18 ([34], see also [35]). One of the main outcomes of this study was that even infrequent consumption of energy drinks is associated with several negative health indicators, representing possible risk factors for adolescents’ health and well-being. Moreover, our results suggest that the reporting of several health-compromising behaviors significantly increased in parallel with energy drink consumption. While causal relationships cannot be established, the findings strengthen the evidence for a “frequency–response” relationship between the health-compromising behaviors assessed and energy drink consumption (e.g. [11, 15, 19]). The co-occurrence of energy drink consumption and negative health indicators is alarming, given that energy drink consumption per se has previously proven associations with adverse health effects among adolescents, due to their psychoactive ingredients, especially caffeine [36]. Moreover, considering the developmental period of adolescence, most of the health-compromising behaviors examined can themselves put adolescents at risk. One exception in our results was the association between energy drink consumption and low physical activity. In contrast with other health indicators, we found no association between frequent energy drink consumption and low physical activity, and in fact infrequent energy drink consumers showed a lesser likelihood of reporting low physical activity than nonconsumers. It can be suggested that – given our results and the lack of consensus in previous studies regarding the association between energy drink consumption and physical activity [14, 17, 18, 21] – this association requires further study. One particularly concerning finding in our study was the clear associations between energy drink consumption and substance use, in line with previous studies [11–18], with evidence also on the use of snus – a phenomenon that has received only limited attention in the literature on energy drink consumption. Leal & Jackson. Table 4 Perceived negative health indicators by energy drink consumption: adjusted odds ratios (aOR), 95% confidence intervals (CI), and corresponding relative risks (RR) and 95% confidence intervals (CI)d Interaction was found in the models for low self-rated health and multiple health complaints, adjusted effect presented. The interaction effect presented in the Additional file4: TableS8 a Models were adjusted for age, gender, family affluence, short sleep, low physical activity, current smoking, alcohol consumption, and multiple health complaints b Model was adjusted for age, gender, family affluence, short sleep, low physical activity, current smoking, and alcohol consumption c Tested with pairwise multiple comparisons d Relative risks and their confidence intervals were derived from adjusted odds ratios Low self-rated healthaMultiple health complaintsbFeelings of insufficient sleepa Energy drinks No consumption 1.00 1.00 1.00 Infrequent consumption aOR 95% CI P-value 1.20 [0.85–1.71] 0.299 1.15 [0.88–1.49] 0.306 0.97 [0.68–1.37] 0.846 RR 95% CI 1.12 [0.87–1.55] 1.10 [0.91–1.29] 0.97 [0.70–1.32] Frequent consumption aOR 95% CI P-value 1.61 [1.18–2.21] 0.003 1.52 [1.11–2.09] 0.010 1.67 [1.12–2.48] 0.011 RR 95% CI 1.48 [1.15–1.87] 1.31 [1.07–1.56] 1.56 [1.11–2.15] Infrequent vs. FrequentcP-value 0.251 0.166 0.010