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MARCH 8, 2016, 12:01 AM ET
Podcast available onlineat Adolescent Attitudes and Beliefs Regarding Caffeineand the Consumption of Caffeinated BeveragesPaige Turton, MScFN, RDy; Len Piche, PhD, RD; Danielle S. Battram, PhD, RD ABSTRACTObjectives: To explore adolescents' attitudes and beliefs toward the consumption of caffeinated bever-ages and factors influencing their caffeinated beverage choice and consumption patterns.
Design: Twenty focus groups were conducted with grades 9 to 12 secondary school students.
Setting: Two secondary schools in London, Ontario, Canada.
Participants: This study included 166 adolescents, 42% of whom were male and 72% of whom were ingrades 9 and 10.
Phenomenon of Interest: Adolescent views regarding caffeine and caffeinated beverages.
Analysis: Three researchers independently conducted inductive content analysis on the data using theprinciples of the immersion-crystallization method.
Results: Awareness levels regarding types of caffeinated beverages and their negative health effects werehigh in adolescents whereas awareness of other aspects of caffeine itself and recommended consumptionlevels were low. Adolescents also identified reasons for caffeine use, including providing energy, taste,accessibility, and image enhancement. Influences for caffeine use most noted by participants includedparental role modeling, media and advertising, and social norms.
Conclusions and Implications: Further education is needed to correct the misconceptions adolescentshave regarding certain aspects of caffeine. By gaining a deeper understanding of adolescents' caffeineuse, effective educational strategies may be developed to reduce its use and mitigate potential harms.
Key Words: adolescents, caffeine, caffeinated beverages, attitudes, focus groups (J Nutr Educ Behav.
2016;48:181-189.) Accepted December 5, 2015.
beverages regularly and at least 96% Because adolescents are consuming consume them occasionally.3,4 For more caffeine, and more caffeinated Caffeine is the most available and adolescents who consume caffeine, products are available in the market- widely used psychoactive substance in their estimated intake ranges from 60 place, there is reason to be concerned the world. It is also the only drug that to 800 mg/d, which suggests that a about the potential negative health ef- is legally accessible and socially accept- percentage of this population may fects of its use. Indeed, caffeine overcon- able for consumption by children and be overconsuming the substance.1,5 sumption and caffeine intoxication adolescents.1 Currently, adolescents Mitchell et al3 indicated that adoles- have resulted in serious health effects.7 are the fastest-growing population of cents in the 90th percentile consume Symptoms of caffeine intoxication in- caffeine users, with caffeinated beverage an average of 2.9 mg/kg body weight clude nervousness, anxiety, restlessness, consumption rates increasing consid- per day of caffeine, which exceeds insomnia, gastrointestinal upset, tremors, erably over the past decade.2 Recent Health Canada's6 current recommen- tachycardia, and in rare instances, studies have determined that 83.2% dation of 2.5 mg/kg body weight per death.8,9 The extent to which caffeine of adolescents consume caffeinated day for this age group.
intoxication occurs in adolescents iscurrently unknown; however, evenmoderate doses of caffeine (100–400mg) can result in nervousness and jitt- Division of Food and Nutritional Sciences, Brescia University College, Ontario, Canada eriness in children and adolescents.10-12 Conflict of Interest Disclosure: The authors' conflict of interest disclosures can be found online To date, the majority of published with this article on
research regarding caffeine has been † P. Turton was a graduate student and dietetic intern at the time this work was conducted.
conducted with adults, not adoles- Address for correspondence: Danielle S. Battram, PhD, RD, Division of Food and Nutri- cents.1 Furthermore, in-depth research tional Sciences, Brescia University College, 1285 Western Rd, London, Ontario N6G has not been done to discover adoles- 1H2, Canada; Phone: Telephone: (519) 432-8353, extension 28228; Fax: (519) 858-5137; cents' perceptions and understanding.
E-mail: Ó2016 Society for Nutrition Education and Behavior. Published by Elsevier, Inc. All rights investigated caffeine use, reasons for use, and expectancies in adolescents, they used a survey with predetermined Journal of Nutrition Education and Behavior  Volume 48, Number 3, 2016 Journal of Nutrition Education and Behavior  Volume 48, Number 3, 2016 responses, and therefore did not allow gators then attended these classes to day. The final 2 questions were: adolescents to freely express themselves.
explain the study to all eligible partici- ‘‘What advice would you give your Bunting et al14 explored adolescents' pants. Recruitment packages were peers and younger siblings about perceptions of caffeinated drinks thr- handed out to all students (n ¼ 230) caffeine?'' and ‘‘Where would you go ough focus group discussions; howev- with instructions to obtain informed, to get reliable information about er, they focused only on caffeinated written parental consent and, when caffeine?'' Focus groups were stratified energy drinks, not caffeine itself.
appropriate, students' assent for those by sex and grade level to capture poten- This limits their findings to only 1 interested in participating in the tial differences. For logistical reasons, 2 source of caffeine. Because only 10% study. Students were eligible to partic- focus groups included both males and of adolescents consume caffeinated ipate if they were in grades 9–12, females. Focus groups ranged from 15 energy drinks on a regular basis,3 a currently enrolled in a health class, to 60 minutes in duration. Although broader understanding of caffeine in and aged 13–18 years. In total, 177 stu- the intent was to conduct focus groups general, from all sources, is warranted.
dents agreed to participate in the until saturation was reached (12 focus Therefore, the aims of this study were study, which gave a response rate of groups), at the request of the schools, to investigate (1) adolescents' atti- 77%. Because focus groups were con- all students enrolled in a health and tudes and beliefs toward caffeinated ducted during a designated date and physical education class who wished beverages, and (2) factors influencing time, all students absent from their to participate in the study (and had pro- their caffeinated beverage choice and designated session (n ¼ 11) were vided consent or assent) could do so (20 removed from the study, which left a focus groups in total).
total of 166 participants.
All transcripts were audio recorded and transcribed verbatim by a profes- sional transcriber to ensure that all Focus Group Protocol and Data data were captured. To improve the A qualitative study design using focus trustworthiness of the data, a detailed groups as a means of data collection journal was completed by the moder- provided the framework for this study.
Focus group sessions took place during ator after each set of focus groups, to The researchers also chose the PRECEDE- a regularly scheduled class on a day pre- serve as an audit trail. Member checking PROCEED model for Health Promo- determined by the classroom teacher.
was conducted throughout the focus tion Planning and Evaluation to guide Each focus group was conducted by a group discussions to ensure that partici- this study because it includes a trained moderator and an assistant pant responses were understood and comprehensive diagnosis of the prob- moderator or note taker. Graduate stu- clarification was obtained as needed.
lem (PRECEDE; ie, social and environ- dents with an interest in adolescent Debriefing sessions also were conducted mental factors), while being mindful health were chosen to assist with this at the end of each focus group to discuss of collecting information for the study, because moderators who enjoy overall impressions and any concerns future implementation and evalua- interacting with adolescents increase with the session. These data provided tion of programming (PROCEED).15 the success of focus groups.16 The the researchers with the context for The authors obtained ethics approval moderator guided the focus group dis- each focus group. A brief demographic from the research ethics boards at cussions using a guide developed by questionnaire with questions about both Brescia University College and the researchers. Taking into consider- age, sex, grade level, caffeinated beverage Western University.
ation the population group, questions consumption patterns, and smoking were short, unambiguous, and open- habits was administered to partici- Sampling Methods and ended.17 The semi-structured nature pants upon completion of the focus of the interview guide ensured consis- group session. Because a detailed tency and flexibility as the discussion assessment of caffeine intake was not Upon the researchers receiving permis- unfolded within each focus group.18 the purpose of this study, a compre- sion from the local school board, 2 After the first day of focus groups hensive validated questionnaire was local high schools from different areas (n ¼ 4), the moderators and researchers not used; rather, questions were asked of the city were contacted by school met to discuss the guide and modifica- only to obtain a general understand- board personnel. Because income level tions were made to improve clarity.
ing of the frequency and types of was not an area of interest in this The final guide consisted of 8 ques- caffeinated beverages consumed. Par- study, these schools were selected tions. Four questions focused on ado- ticipants received a $10 iTunes gift randomly from the representative lescents' thoughts on caffeine: ‘‘What card for participation and partici- pool of schools contained within comes to mind when you hear the pating classes received a 90-minute middle-income neighborhoods. The word caffeine?'' ‘ What effects does interactive, educational lesson on investigators then contacted health caffeine have on the body?'' ‘‘Why do caffeine, delivered by the researchers you think students your age use after the focus groups were completed.
(n ¼ 5) at these schools, at which caffeine?'' and ‘‘What do you think in- time the purpose of the study was ex- fluences students your age to use plained. All teachers agreed to help re- caffeine?'' Two questions explored cruit students from their respective their knowledge regarding which bev- Using the principles of the immersion- classes and to aid in the logistics of erages contained caffeine and how conducting the focus groups. Investi- much caffeine is recommended each Journal of Nutrition Education and Behavior  Volume 48, Number 3, 2016 analysis to analyze and explore the Table 1. Characteristics of the Study Participants (n ¼ 166) dominant and recurrent themes arisingfrom the focus group data.20 All investi-gators coded the transcripts indepen- dently and then met to discuss their findings. Where coding discrepancies occurred, the group discussed and consensus until a common theme tem- plate was developed. Transcripts frommale and female focus groups as well as from different grade levels were coded separately to explore possible dif- ferences. Data were managed using Mi- Note: A sample size of 165 was used to calculate average age.
crosoft Word (version 14.0.0, MicrosoftCorporation, Santa Rosa, CA, 2010).
The demographic data were analyzed Awareness Level and of coffee) contained sugar. Only a few by simple descriptive statistics using participants (mostly older students in Microsoft Excel (version 14.0.0, Micro- Caffeine and caffeinated beverages.
grades 11 and 12) mentioned caffeine soft Corporation).
Overall, participants had a high level of awareness with regard to identifyingbeverages containing caffeine (eg, cof- Health effects of caffeine use. When fee, soft drinks, or energy drinks) participants were asked to state the po- (Table 2). Participants also were able tential effects of caffeine on the body, to identify other sources of caffeine the majority of responses were related Twenty focus groups (n ¼ 166) were (eg, chocolate, chocolate milk, and to perceived negative health effects.
conducted in 2 secondary schools in hot chocolate), noncaffeinated soft When further prompted by modera- London, Ontario between December, drinks, and herbal teas. Despite this tors, only a few positive effects were 2013 and May, 2014. Each group was awareness, however, there appeared mentioned. Participants had a high to be some confusion regarding which level of awareness regarding the risks (average, 8.3 participants). Table 1 lists caffeinated beverages contained the of consuming too much caffeine; the participant characteristics. With regard most caffeine. Although coffee and en- most cited effects were short-lived en- to caffeinated beverage consumption, ergy drinks were most often reported, ergy, elevated heart rate, insomnia, 4.8% of participants reported never some participants were unclear about and shakiness or jitteriness. Stunting drinking caffeinated beverages, 11.4% tea and soft drinks.
of growth also was noted as a domi- reported drinking caffeinated beverages No participant was able to state nant theme, but only by female partic- every day, 44.6% reported consuming Health Canada's current recommen- ipants. With regard to positive health caffeinated beverages 1–6 d/wk, and dation correctly as to the maximum effects, the most commonly stated 39.2% reported drinking caffeinated amount of caffeine to consume per ones included increased energy, wake- beverages once in a while. The most day; the majority of participants re- fulness, and improved focus or con- popular beverages consumed were ferred to the maximum amount in centration. When asked where they soft drinks (69.9%), coffee beverages cups of coffee rather than milligrams would go for reliable information, par- (such as lattes) (48.2%), tea (41.6%), of caffeine per day. Despite this, ticipants most often responded by coffee (22.3%), and energy drinks when asked what they would tell their saying the Internet (including com- pany Web sites) and their parents, fol- Supported by participant quota- caffeine, almost all participants stated lowed by their doctor or teachers.
tions, 3 important primary themes that moderation should be exercised emerged during data analysis: (1) a by their peers, whereas strict limits generally high level of awareness and and avoidance should be imposed on Reasons for Caffeine Use knowledge regarding caffeinated bev- their younger siblings.
Energy provision. The most common erages and their negative health effects When participants were asked, reason mentioned by participants for (Table 2), (2) reasons for caffeinated ‘‘What comes to mind when you hear consuming caffeinated beverages was the word caffeine?'' the majority re- the perceived outcome expectancy of (Table 3), and (3) key factors influ- sponded with an outcome expectancy alertness (Table 3). Caffeine was encing caffeinated beverage choice of caffeine, such as ‘‘energy'' or ‘‘hy- consumed in the morning, evening, and consumption patterns (Table 4).
per,'' or with a caffeinated beverage and during exams to stay awake for Secondary themes also are included in such as coffee. Most adolescents did class and to study. This energy provi- the respective tables. Sex and grade not understand what caffeine is, and sion, however, was strongly intercon- level differences were evident and are often equated it with sugar. Their nected with the type of beverage, such described subsequently where appli- perception was that most caffeine- as coffee and energy drinks. When containing drinks (with the exception asked how they would feel if caffeine Journal of Nutrition Education and Behavior  Volume 48, Number 3, 2016 Table 2. Representative Quotations Regarding Adolescents' Awareness Level and Knowledge of Caffeine Caffeine and caffeinated ‘‘Energy, like hyper.'' (grade 12 girl) ‘‘Coffee is the first thing you think of.'' (grade 10 girl)‘‘I would say, like a cup, like 1 serving.'' (grade 9 girl)‘‘Like, kids have enough energy as it is. They don't need to be drinking any coffee or whatever.'' Health effects of ‘‘Sugar rush.'' (grade 12 boy) ‘‘I would get really shaky.'' (grade 12 girl)‘‘Like, even more tired when you crash, so it's like you are kind of going backward by even drinking it in the first place.'' (grade 12 girl) ‘‘Completely messes with your blood sugar. Like, it spikes it and then you crash half an hour or an hour later.'' (grade 12 boy) ‘‘Like, coffee, everyone always says that if you drink too much it will stunt your growth.'' (grade 9 girl) were removed from these beverages, Taste. Taste was the second most beverages within a short walking dis- the majority of participants stated it common reason why adolescents tance of their schools. Having the would be problematic, particularly if chose to consume specific caffeinated ability to bring caffeinated beverages the beverage were purposefully being beverages. This was especially true for back into the school and classroom used for energy. Furthermore, a few soft drinks. Participants also stated also was mentioned as a reason for participants indicated that they co- that if caffeine were removed from consumption. Participants discussed nsumed some caffeinated beverages beverages that are consumed for taste, the lack of barriers, such as an age (eg, coffee) for the perceived energy, it would not alter their choice, unless limit, to purchase such beverages. In despite not liking its taste. There was the removal of caffeine affected the addition, some participants noted a significant sex difference in that only taste of the beverage.
that caffeine is accessible because it older male participants mentioned is present in the beverages they like consuming caffeine for energy during to drink, such as soft drinks and coffee sporting events, training, and social Accessibility. Accessibility was men- beverages (eg, iced cappuccino).
gatherings (eg, house parties). Finally, tioned throughout all of the focus combining caffeinated beverages and groups as a primary reason for alcohol was mentioned by a few male consuming caffeinated beverages. Par- Image enhancement. Although it was participants (grades 9–12) despite ticipants mentioned the close prox- a relatively minor secondary theme, their understanding of potential nega- imity of stores and restaurants and tive health effects.
the simplicity of obtaining caffeinated mature were mentioned, particularly Table 3. Representative Quotations Regarding Adolescents' Reasons for Caffeine Use ‘‘Getting through the day.'' (grade 10 girl)‘‘. For coffee and energy drinks, it's more like the energy boost in the morning or through the day kind of deal.'' (grade 12 boy) ‘‘I think that it defeats the purpose of energy drinks if you were to take the caffeine out, but other beverages, I think its fine.'' (grade 12 boy) ‘‘I don't really drink for the caffeine. I drink for the taste.'' (grade 9 girl)‘‘. I only drink coffee for the caffeine. That's all I drink with it. I don't like the taste.'' (grade 11 girl) ‘‘Because it's in what we drink.'' (grade 10 boy)‘‘It's in so much stuff that it gets to a point where you don't exactly care what it's in.'' (grade 10 boy)‘‘Very convenient. Very easy to find.'' (grade 12 boy)‘‘We can probably name 4 to 5 places on the corner within 100 feet or less that we could go get any type of caffeine .'' (grade 12 girl) ‘‘You can purchase it, like basically anywhere. So it's not really anything bad like alcohol. You don't have restrictions to buying it or using it.'' (grade 9 girl) Image enhancement ‘‘Like, we as teenagers, we want to grow up and we feel that coffee kind of seems like a more mature adult beverage, so we want to drink it.'' (grade 9 girl) ‘‘My mom and dad are coffee drinkers, so I would always want to try it to be like them, even though I didn't really like the taste, but now I find I am actually starting to accept the taste a little bit more.''(grade 9 student) Journal of Nutrition Education and Behavior  Volume 48, Number 3, 2016 Table 4. Representative Quotations Regarding Factors That Influence Adolescents' Caffeinated Beverage Choice and Consumption Patterns ‘‘If you see your parents drinking it, you are like, oh, it's not that bad because they are supposed to be a role model so it can't be that harmful, right?'' (grade 12 girl) ‘‘Like, if you see your parents drinking it, and it gets them through the day, then maybe if you are having a tired day, then you can do it, too, to help you get through the day.'' (grade 9 girl) ‘‘Say if we are going somewhere, my mom usually gets a (brand coffee), so then I have a choice to have one or not.'' (grade 10 boy) ‘‘I go to [coffee house] with her [mom] almost every day and so I feel like if I go with her I might as well grab a drink just since I'm there, right, I might as well.'' (grade 9 girl) ‘‘Also, most of us don't do our own grocery shopping. Our parents will buy the groceries for us, so it's kind of whatever is in the house that's available to eat or drink.'' (grade 12 girl) ‘‘I know that you get more drawn toward products that you do see advertised, like if I am going to get an energy drink, I am more drawn toward [common brands] because they are advertised so much. So I know that theyare the better choice of energy drink . because they have been advertised more.'' (grade 12 boy) ‘‘I think you also eat with your eyes, so if something looks appealing to you on the outside then you'll be more inclined to try it.'' (grade 9 girl) ‘‘If it is colorful and pretty looking, I get drawn toward that more because it will taste better because of the looks of it.'' (grade 12 girl) ‘‘Because like it's not really a taboo. It's like a social thing. You don't see people being ashamed of drinking caffeine, so it encourages you and tells you that it's not wrong.'' (grade 9 girl) ‘‘Just because your peers or your friends do it, so they might drink energy drinks, so you might just drink it purely because you think other people are drinking it, so why not, kind of thing.'' (grade 12 boy) ‘‘. People nowadays, if you ask them, do you drink coffee, and they say no, it's surprising now because it's just kind of expected, I guess.'' (grade 12 girl) by younger participants (grades 9 and participants mentioned that their par- to sell their products. This led to some 10). Drinking caffeinated beverages, discussion about the image often por- and in particular coffee, was seen as beverage to them directly or simply al- trayed by energy drink advertisements, something older adolescents and adults lowed free access to these beverages.
and how a specific product could boost do, and the ability to drink coffee Fewer participants stated that their sport performance. Finally, some par- without restriction by parents was parents had some control over what ticipants also mentioned the use of in- seen as a sign of being grown-up.
types of products were purchased and centives to influence their beverage available at home, although control choice and purchase, although this over the use of these beverages once was a minor theme.
Factors That Influence in the home was not mentioned.
Caffeinated Beverage Choice Social norm. Some participants men- and Consumption Patterns tioned social norms as a factor that Parent role modeling. Regardless of Media and advertising. Media and influenced their choice and consump- age or sex, when adolescents were advertising of caffeinated beverages tion of caffeinated beverages. Partici- asked what influences them to drink also emerged as major influencing fac- pants discussed how commonly these caffeinated beverages, parental role tors for caffeinated beverage use.
beverages are consumed by their peers modeling was the most commonly Although participants frequently men- and how it is perceived to be against mentioned response (Table 4). Adoles- tioned the use of catchy phrases, attrac- the social norm when one of their cents most often mentioned observing peers declines drinking them. Some their parents drinking caffeinated bev- (celebrities) as key ways by which com- erages (eg, coffee in the morning), panies promoted the appeal of their seeing their peers drinking a particular which implied that caffeine (coffee) products, adolescents appeared to beverage could encourage them to try was safe and acceptable for use. Ado- focus primarily on the frequency and it themselves.
lescents also stated that parents' pur- placement of advertisements on televi- chase of caffeinated beverages outside sion and in sport venues and how this the home (eg, fast-food outlet) was a affected their brand choice. Further- common routine before work and more, participants seemed to have school. Whether prepared at home or some awareness of the different mar- Adolescents provided a rich under- bought on the way to work or school, keting techniques used by companies standing of their overall attitudes Journal of Nutrition Education and Behavior  Volume 48, Number 3, 2016 and beliefs regarding the consump- that of the general adolescent popula- tion. The concept of increased aware- beverages. Guided by the PRECEED- ness not translating into better health have been shown to be effective in PROCEED model,15 participants not behaviors was previously observed in reducing sweetened beverage con- only identified a variety of intrinsic, adolescents with regard to healthy sumption in the US.32 Although a social, and environmental factors eating24 and is consistent with the School Food and Beverage Policy that contributing to their intake but also notion that although awareness of limits the type of beverages sold provided some key insights into po- health behaviors can be present, it is within the school environment exists tential program planning regarding only at a later age that health con- in Ontario,33 it does not address bever- caffeine use in this population. Over- sciousness develops and translates to ages purchased off-site and brought all, participants exhibited high aware- choosing healthier products.25 into the school environment.
ness regarding beverages that contain Participants identified many reasons Some younger adolescents (grades caffeine and the potential negative for consuming caffeinated beverages.
9 and 10) found that drinking caffein- health effects of caffeine overcon- The finding that these adolescents ated beverages, and in particular cof- sumption. However, these findings consume caffeinated beverages for the fee, made them feel mature. This is are in contrast to those previously outcome expectancy of providing en- consistent with findings from Bun- observed by both O'Dea21 and Bun- ergy is consistent with that previously ting et al,14 who found that adoles- ting et al,14 who found that youth as reported for both adolescents and cents and young adults value the well as adolescents and young adults young adults.13,14,26 Bunting et al14 image aspects of energy drinks even (aged 11–18 and 16–21 years, respec- found that energy seeking was a domi- above their functionality of providing tively) had a low level of awareness nant motivating factor for consuming energy. This concept of maturity was regarding the potential health risks energy drinks among 16- to 21-year- further demonstrated by participants' associated with energy drink con- olds; however, whereas participants in beliefs that these beverages (eg, coffee sumption. It is possible that owing to that study sought the pleasurable kick and energy drinks) should be limited their enrolment in a health class, par- of using energy drinks, the majority of ticipants in the current study had adolescents in the current study did younger siblings, and speaks to the in- higher levels of awareness. Although so to stay awake to study or to handle fluence of role modeling by older sib- caffeine and its health effects are ad- busy schedules. Furthermore, whereas lings and, more importantly, parents.
dressed in the current provincial Ludden and Wolfson13 found that In addition to the reasons why ado- Health and Physical Education curric- experimentation and fun were reasons lescents consume caffeinated bever- ulum for grade 10 and therefore were for caffeine use among high school stu- taught to the majority of partici- dents, this was rarely mentioned by some factors that influence their pants,22 when asked where they participants in the current study.
beverage choice and consumption.
would go for credible information When caffeine use was mentioned for Parental role modeling was consis- use at social gatherings by participants, tently mentioned by participants, source mentioned was the Internet it, too, was for the purpose of staying particularly with respect to the avail- rather than their teachers. Regardless, ability and accessibility of caffeinated there continues to be a lack of aware- Taste continues to be a dominant beverages both within and outside ness about caffeine, the amount found reason for caffeinated beverage choice the home. This is consistent with pre- in beverages, and the current recom- and is consistent with previous find- vious findings indicating that the mendations for safe consumption.
ings in children, adolescents, and home food environment has a strong Although participants' awareness young adults.14,26-28 Similarly, taste influence over children's beverage regarding the potential negative health tends to override awareness of the consumption patterns.34 Furthermore, effects of too much caffeine use may negative health effects of consuming parental role modeling practices are have been high, their caffeine con- such beverages.14,27 This is in contrast also known to influence children's sumption patterns were similar to to the idea that taste, too, could be eating behaviors and soft drink con- those previously reported in the litera- ignored if a beverage were being used sumption.31,35,36 In contrast to that ture. Based on findings from the specifically for energy provision. The observed in children,28 parental con- demographic questionnaire, 95% of removal of caffeine from beverages consumed for taste was not deemed mentioned by participants. In a quali- caffeinated beverages at least once in problematic by participants, unless tative study involving both parents a while, which is similar to that re- the taste was altered by its removal.
and adolescents, Bassett et al37 found ported by Temple et al.4 Furthermore, Although caffeine has been suggested that although adolescents have auton- the types of caffeinated beverages to be a flavor enhancer in soft drinks, omy over their food choices, parents consumed by participants (eg, soft this remains controversial.29,30 still exerted influence by control prac- drinks, coffee-type beverages, and en- Participants noted that accessibility tices (eg, controlling household food ergy drinks) were consistent with was a dominant reason for consuming supplies) and by coaching, coaxing, recent findings by Mitchell et al3 and and coercing. One could argue that Branum et al,23 which suggests that within and in close proximity to the although adolescents in the current despite the increased awareness, par- school environment. A negative corre- study did not acknowledge these con- ticipants appear to consume caffein- lation has been observed between trol practices, they were present, ated beverages at a level similar to accessibility and soft drink consump- because parents controlled the access Journal of Nutrition Education and Behavior  Volume 48, Number 3, 2016 of beverages in the home but also risk of not fitting in is enough to In particular, the current Health Can- when frequenting food outlets on the change behavior.
ada recommendation of caffeine in way to school.
Only students enrolled in a health milligrams per body weight did not Media and advertising also were and physical education class were appear to resonate with participants; common influences noted by partici- eligible to participate in this study.
therefore, presenting these recommen- pants, which is consistent with previ- Therefore, it is possible that these stu- dations in more relatable and under- ous literature involving energy drink dents may have been more interested standable ways (eg, common serving use in adolescents.14,21,38 Whereas in health (and may avoid caffeine) sizes) may be warranted to improve participants mentioned the attractive- and may have had a higher level of awareness within this population.
ness and appeal of certain products awareness regarding caffeine and its Because caffeine consumption was negative health effects. Although a strongly seen as an energy provider, erature),14,21 the primary focus was on comprehensive assessment of caffeine to reduce caffeine use effectively in the frequency and placement of adve- intake was not done, intake appears to adolescents, a broader educational rtisements and messaging implied by be similar to that found by Mitchell approach beyond caffeine may be beverage companies (eg, enhanced et al3 in the same age group, which needed and should include alternate sport performance). This, too, is co- suggests that the current sample did strategies to improve perceived energy nsistent with previous research that level, such as eating a healthy diet and has demonstrated the ability of media exposure to the health curriculum.
getting adequate sleep. Furthermore, to have an impact on the dietary Furthermore, although the sex distri- parents as role models and arbiters of habits of children.39 In contrast to chil- bution of the current study's sample adolescent intake were identified as a dren, however,28 participants appeared is representative of the school popula- key influence on participants' caffeine to have some media literacy regarding tion (M. Reagan, oral communication, use. Therefore, it would appear that the potential marketing strategies and 2015), it contained a higher propor- there is a continued need to include underlying intentions of advertisers.
tion of grade 9 and 10 students, which parents in educational strategies not The effect of media exposure and liter- limits the current study's findings to only to understand their continued acy on caffeinated beverage con- younger adolescents. The greater pro- influence on adolescents' beverage sumption patterns in adolescents is portion of grade 9 and 10 students is choices and consumption patterns currently unknown. However, Chang likely the result of more students be- but also to increase their awareness et al40 employed multivariate analysis ing enrolled in lower-level health clas- and knowledge with respect to the to demonstrate higher alcohol and to- ses, because students are required amount of caffeine deemed safe for bacco use among 10th graders with to take only 1 of these classes to grad- use by their children.
higher media exposure and lower me- uate. To ensure that the current In addition to education, partici- dia literacy for alcohol and tobacco, findings were transferable to all adoles- pants suggested some potential policy respectively. The modest media liter- cents, the researchers compared focus and environmental influences that acy observed in the current study's par- groups by grade level and identified may inform strategies to reduce caffeine ticipants is in contrast to that observed themes where appropriate. The num- intake among adolescents. Because soft by Bunting et al,14 who found that ber of participants per focus group drinks contribute to the amount of with respect to energy drinks, adoles- ranged from 3 to 12 and may have influ- caffeine in the adolescent diet,23 the cents had little media literacy. This enced responses; however, debriefing reduction or removal of caffeine from may be because participants in the cur- notes suggest that this was not a these beverages could be a means of rent study learned about media liter- concern. Finally, although not the decreasing caffeine intake. Further- acy in grade 9 as part of the health focus of this work, both high schools more, because accessibility beyond the were located in middle-income areas school environment was seen as a ma- Adolescents also noted that social neighborhoods, and therefore the jor influence on intake, advocating for norms were a common influence on findings may not be transferable to ad- policies regarding the built (and food) their caffeinated beverage choice olescents living in other income areas.
environment (eg, limit vendors selling and consumption patterns. This is caffeinated beverages around school findings by Bunting environments) may enhance and et al,14 who found that older adoles- complement existing policies in the cents and young adults (aged 16– schools. Finally, renewed interest in 21 years) were more conscious of advocating for policies regarding re- social image and peer group norms stricting advertising to children, in than were older individuals (aged Data emerging from this qualitative 22–35 years) with respect to energy study add to the existing body of pri- surrounding media literacy, appears drinks. The concept of social confor- marily quantitative knowledge con- mity has been reported among ado- cerning adolescents' perceptions of comprehensive educational strategies lescents with respect to healthy caffeine and caffeinated beverages.
and enhancing policies, it may be eating,41 which suggests that whereas Although awareness of certain aspects possible to decrease caffeine use in ad- direct peer pressure (eg, taunting or of caffeinated beverages was high olescents and mitigate the potential ridicule) may not have a significant among the current study's partici- health risks of caffeine overuse within role in choosing foods, the potential pants, some misconceptions remain.
this population.
Journal of Nutrition Education and Behavior  Volume 48, Number 3, 2016 prepubertal boys. Am J Psychiatry. 1981; of soft drink consumption in young adults: a qualitative analysis. Public This study was supported and funded 12. Rapoport JL, Jensvold M, Elkins R, Health Nutr. 2009;12:1816-1822.
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Guidelines für kardiovaskuläre Erk rankungen in der klinischen Praxis ( ESC / AGLA ) Dr. med. Karl Nüesch Kardiologie FMH Medical manager FH/EMBA Marktstrasse 11, 9435 Heerbrugg • Vortrag über die aktuellen Richtlinien • Fallpräsentation 1 • Fallpräsentation 2 • Diskussion

This Provisional PDF corresponds to the article as it appeared upon acceptance. Fully formatted PDF and full text (HTML) versions will be made available soon. Proteomics reveals multiple routes to the osteogenic phenotype in mesenchymal stem cells BMC Genomics 2007, 8:380 Kristin P Bennett () Charles Bergeron Scott L Vandenberg ()