Propel founded by:

Use of caffeinated energy drinks and alcohol among secondary school students in Ontario, CanadaJessica L. Reid, David Hammond, Scott T. Leatherdale, Cassondra McCrory, Joel Dubin

CPHA: Public Health 2014May 28, 2014 | Toronto, ON

BACKGROUND

BACKGROUND: Energy Drinks

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80mg caffeine

160mg caffeine

246mg caffeine

220mg caffeine

BACKGROUND: Regulation & Recommendations

• Caffeinated energy drinks recently moved under Food & Drugs Act; Temporary Marketing Authorization from Health Canada while undergoing review

• Maximum caffeine amount: 400mg/L, not to exceed 180mg per single-serve container

• Health Canada “has not developed definitive advice for adolescents 13 and older because of insufficient data.”

• Recommendation for adolescents and children to limit caffeine consumption to 2.5mg/kg/day• For a 55kg (~120lb) adolescent, would be 137.5mg/day

• For a 80kg (~175lb) adolescent, would be 200mg/day 4

BACKGROUND: Energy Drink Use

• Increased consumption among young people

• 40% past-year use in grade 7-12 students in Ontario; 12% past-week use (OSDUHS, 2013)

• Concern about potential adverse effects of excessive caffeine consumption: • Effects on mood (irritability, nervousness, anxiety),

dizziness, headache, gastrointestinal disturbances, dehydration, sleep problems

• Effects on bone mineralization, arrhythmia, tachycardia, seizures, hemorrhage, hallucinations, death

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BACKGROUND: Energy Drinks and Alcohol

• Use of alcohol mixed with energy drinks (AmED) increasingly common among youth and young adults

• Concern about an increase in alcohol consumption and alcohol-related risk behaviour

• Studies of college/university-age students have found high use; little data for younger age groups

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BACKGROUND: Energy Drinks and Alcohol

• Use of alcohol mixed with energy drinks (AmED) increasingly common among youth and young adults

• Concern about an increase in alcohol consumption and alcohol-related risk behaviour

• Studies of college/university-age students have found high use; little data for younger age groups

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OBJECTIVES

• Objective: To examine the prevalence of consumption of caffeinated energy drinks among a large sample of high school students in Ontario, including socio-demographic and behavioural correlates, and relationship to alcohol use.

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METHODS: COMPASS

• COMPASS• Prospective cohort study, gr. 9-12 students in

Ontario• School-based, self-completed questionnaire• Assesses multiple youth health behaviours and

outcomes (e.g., obesity, healthy eating, physical activity, sedentary behaviour, tobacco use, alcohol and marijuana use, etc.)

• Baseline data collection: 2012/13• More info: www.compass.uwaterloo.ca

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METHODS: Sample

• 43 purposefully sampled Ontario secondary schools

• Total of 30,147 students enrolled in grades 9-12:

• 80.2% completed questionnaire

• 18.8% absent; 1% refusal (by parent or student)

• Students missing grade, sex, energy drink use questions excluded (n=542)

• This analysis: 23,631 grade 9-12 students

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METHODS: Outcome measures

Usual energy drink use:

Responses to week and weekend questions added to get weekly frequency of energy drink use (range: 0-7 days); also recoded into any weekly energy drink use (0=no days; 1=1-7 days)

Past-year alcohol mixed with energy drink (AmED) use:

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0=No1=Yes

0=No

METHODS: Alcohol use measures

Current alcohol use:

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Alcohol user

Non-user

METHODS: Alcohol use measures

Binge drinking:

Intensity of alcohol use: current alcohol use and binge drinking combined• Coded as 0=no drinking; 1=alcohol use, no binge drinking; 2=alcohol

use, occasional binge drinking; 3=alcohol use, monthly binge drinking; or 4=alcohol use, weekly binge drinking

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NoneOccasional

Monthly

Weekly

ANALYSIS

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• Generalized linear mixed effects models (SAS 9.3)• Accounts for student clustering within schools

• Separate models examining correlates of 3 outcomes: 1) any weekly energy drink use 2) frequency of energy drink use (# days/week)3) any use of alcohol mixed with energy drinks (last 12 mo.)

• Covariates: grade, sex, race, spending money, BMI, weight-related efforts, intensity of alcohol use

SAMPLE CHARACTERISTICS (n=23, 631)

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Characteristic %

Sex Female Male

49.8%50.2%

Race/Ethnicity White, Non-Aboriginal Off-reserve AboriginalOther/Mixed/Not stated

71.4% 5.3%23.3%

Spending money $0$1-20$21-100$100 or moreNot stated

15.7% 30.5%27.0%14.1%12.9%

BMI category UnderweightHealthy WeightOverweightObeseNot stated

1.4% 57.1%13.9% 6.3%21.3%

Weight-related efforts Lose weightGain weightStay the same weightNot trying to do anything

42.1%18.6%18.4%20.9%

SAMPLE CHARACTERISTICS (n=23, 631)

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Characteristic %

Alcohol use (past 12-month frequency) None Occasional (<once/month) Monthly (1-3 times/month) Weekly or more (≥once/week)

44.3%19.7%24.6%11.4%

Binge drinking (past 12-month frequency) None/Not applicable Occasional (<once/month) Monthly (1-3 times/month) Weekly or more (≥once/week)

60.6%16.0%17.3%6.2%

Intensity of alcohol use No alcohol use Alcohol use, no binge drinking Alcohol use with occasional binge drinking Alcohol use with monthly binge drinking Alcohol use with weekly binge drinking

44.6%15.2%16.3%17.7%6.3%

RESULTS: Usual Use of Energy Drinks

• 18.2% reported energy drink use in a “usual” week.

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Figure 1: Energy drink use (usual number of days per week) (n=23,631)

RESULTS: Correlates of Energy Drink Use

• Use of energy drinks associated (at p<0.01) with all socio-demographic and behavioural covariates.*

• Use more common among students who were:• Male (vs. female)• Grade 9 (vs. 10, 11, 12) • Off-reserve Aboriginal (vs. White or Other, non-Aboriginal)• Some spending money (vs. $0); >$100 (vs. all others)• BMI other than “healthy” or “overweight”• Trying to lose weight (vs. not trying to do anything)• Reported higher intensity of alcohol use

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*In a generalized linear mixed effects model, with covariates grade, sex, race/ethnicity, spending money, BMI, weight-related efforts, and intensity of alcohol use; school included as a random intercept.

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Grade 9

Grade 1

1Male

Whit

eOthe

r

Underw

eight

Overw

eight

Not sta

ted

Try to

lose

weig

ht

Try t

o main

tain

$1-20

> $10

0

Use, n

o bing

e

Binge m

onthl

y0

5

10

15

20

25

30

35

40

45

50

19.0

17.4

17.9

18.3

12.9

23.4

17.4

30.5

17.6

24.3

15.9 19

.024

.421

.4

17.4

23.5

16.9

15.9

13.2 17

.1 19.5

25.3

16.0

11.4 15

.2 17.0

28.3

42.5

% o

f res

pond

ents

repo

rting

ene

rgy

drin

k us

e

Use of energy drinks (any usual), by socio-demographic and behavioural variables (n=23,631)

RESULTS: Correlates of Energy Drink Use

RESULTS: Correlates of Energy Drink Use

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Use of energy drinks (any usual), by intensity of alcohol use (n=23,631)

No alcohol use

Alcohol use, no binge

Binge <monthly

Binge monthly Binge weekly0

5

10

15

20

25

30

35

40

45

50

11.4%15.2%

17.0%

28.3%

42.5%

% o

f res

pond

ents

repo

rting

ene

rgy

drin

k us

e

RESULTS: Correlates of Energy Drink Use

• Results for frequency (number of days per week) of energy drink use similar to those for “any” use

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RESULTS: Use of Alcohol Mixed with Energy Drinks

• Use of energy drinks mixed with alcohol (AmED) in the last 12 months was reported by 17.3% of the total sample (n=4,020)

• Among the 55.8% of students (n=12,853) who reported using alcohol in the last 12 months, 29.0% reported having used AmED

• Using AmED associated with race, spending money, and binge drinking*

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*In a generalized linear mixed effects model, with covariates grade, sex, race/ethnicity, spending money, BMI, weight-related efforts, and intensity of alcohol use; school included as a random intercept.

RESULTS: Correlates of AmED Use

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Use of alcohol mixed with energy drinks (any in last 12 month) among current alcohol users, by socio-demographic and behavioural variables (n=12,804)

Grade 9

Grade 1

1Male

Whit

eOthe

r

Underw

eight

Overw

eight

Not sta

ted

Try t

o los

e weig

ht

Try t

o main

tain

$1-20

> $10

0

Binge >

mon

thly

Binge w

eekly

0

10

20

30

40

50

60

24.3

24.6

30.4 33

.1

26.7 31

.3

27.7

34.4

32.6

27.7

28.7

29.7

28.4

29.5

28.7 33

.325

.7 27.7

23.6

24.3

30.1

35.9

29.3

10.0

22.5

39.3

62.7

% o

f alc

ohol

use

rs re

porti

ng u

sing

alc

ohol

+ C

ED

RESULTS: Alcohol mixed with Energy Drinks

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Use of alcohol mixed with energy drinks (any in last 12 month) among current alcohol users, by binge drinking (n=12,804)

No binge drinking

Binge > monthly

Binge monthly

Binge weekly

0

10

20

30

40

50

60

70

10.0%

22.5%

39.3%

62.7%

% o

f alc

ohol

use

rs re

porti

ng u

sing

al

coho

l + C

ED

• More likely to use AmED if less than monthly (OR=2.63; 2.11-3.28), monthly (OR=5.94; 4.81-7.33), or weekly (OR=14.75; 11.41-19.06) binge drinker (vs. none)

• Monthly (OR=2.26; 1.92-2.65) and weekly (OR=5.60; 4.51-6.96) more likely to use AmED than < monthly binge drinkers

• Weekly binge drinkers more likely to use AmED than monthly (OR=2.48; 2.03-3.04)

DISCUSSION: Summary

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• Use of energy drinks common, linked to student characteristics and strongly linked to alcohol consumption

• Use of alcohol mixed with energy drinks also fairly common

• Binge drinking had the strongest association with using alcohol mixed with energy drinks

DISCUSSION: Strengths and Limitations

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• Self-report questionnaires• May underestimate consumption (esp. alcohol)

• Sample of schools not probability based, but large number of schools/students and high participation within schools

• Correlational; cohort follow-up will examine relationships over time

CONCLUSIONS: Implications

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• Caffeinated energy drinks currently under review by Health Canada; possible new regulations

• Monitoring patterns of energy drink consumption among youth, including adverse events and risk behaviour

• Future studies should examine quantity of consumption, and context/reasons for use

ACKNOWLEDGEMENTS

• This project analysed data from the COMPASS study (PI: Scott Leatherdale), which was supported by a bridge grant from the Canadian Institutes of Health Research (CIHR) Institute of Nutrition, Metabolism and Diabetes (INMD) through the “Obesity – Interventions to Prevent or Treat” priority funding awards (OOP-110788; Leatherdale) and an operating grant from the CIHR Institute of Population and Public Health (IPPH) (MOP-114875; Leatherdale).

• Additional support was provided by the Propel Centre for Population Health Impact, a Canadian Institutes for Health Research New Investigator Award (Hammond), and a Canadian Cancer Society Research Institute Junior Investigator Research Award (Hammond).

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Propel founded by:

QUESTIONS?

Contact:Jessica Reid jl3reid@uwaterloo.ca(519)888-4567, x35620

aSeparate generalized linear mixed effects models for each outcome, with covariates grade, sex, race, spending money, BMI, weight-related efforts, and intensity of alcohol use; school included as a random intercept.bAdjusted for multiple comparisons (Bonferroni), α=0.01

Table 2: Estimates for all pair-wise comparisons from the modelsa for any energy drink use and frequency of energy drink use (n=22,861)