A Comparison of the Consumption of Sugar-Sweetened Beverages by College Students in Body Mass Index Groups

A COMPARISON OF THE CONSUMPTION OF SUGAR-SWEETENED BEVERAGES BY COLLEGE STUDENTS IN BODY MASS INDEX GROUPS

A master’s thesis submitted to the Kent State University College of Education, Health, and Human Services in partial fulfillment of the requirements for the degree of Master of Nutrition

Rahaf Al Hamad

May 2021

Thesis written by

Rahaf M. Al Hamad

B.S.Ed., University of Dayton, 2018

M.S., Kent State University, 2021

Approved by

______, Director, Master’s Thesis Committee Eun-Jeong (Angie) Ha

______, Member, Master’s Thesis Committee Natalie Caine-Bish

______, Member, Master’s Thesis Committee Tanya Falcone

Accepted by

______, Director, School of Health Sciences Ellen L. Glickman

______, Dean, College of Education, Health, and Human James C. Hannon Services

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AL HAMAD, RAHAF M., M.S., May 2021 Nutrition and Dietetics

A COMPARISON OF THE CONSUMPTION OF SUGAR-SWEETENED BEVERAGES BY COLLEGE STUDENTS IN BODY MASS INDEX GROUPS (149 pp.)

Thesis Director: Eun-Jeong (Angie) Ha, Ph.D.

The purpose of this retrospective, nonexperimental study was to compare the consumption of sugar-sweetened beverages (SSBs) by college students in BMI groups

(N=209). Data were collected from students enrolled in Science of Human Nutrition at a

Midwestern public university. More than half the students were women (73.2%) and freshmen (55.2%). The study involved a demographic survey, a three-day dietary log, and anthropometric measurements for data analysis. Descriptive statistics were used to examine demographics and types of SSBs. Analysis of covariance was used to analyze the association of SSB intake, calories derived from SSBs, and sugar derived from SSBs in students whose body mass index (BMI) classified them as underweight‒normal, overweight, and obese. Significance for the results was set at p-value < 0.05. Although the results revealed no significant differences between SSB consumption and BMI categories, they showed that approximately 65% of students consumed SSBs during the three-day period, suggesting the importance of the study.

ACKNOWLEDGMENTS

First and foremost, I thank my parents for always supporting my education and my dreams. I am blessed to have them as my parents. I would never have been able to attain my goals without their love and support.

I am grateful to Dr. Eun-Jeong Ha, my advisor, for her help and patience. I thank her for pushing me to go to the extra mile. I appreciate Dr. Natalie Caine-Bish for supporting me and believing in me. I am thankful for Professor Tanya Falcone, who enlightened me with her invaluable input. I appreciate her feedback and support. I also thank Dr. Ellen Glickman for supporting my research.

Finally, I deeply appreciate my siblings and friends who supported me and have been there for me when I needed them the most. I thank them for their support of my journey and encouraging me to achieve my goals.

TABLE OF CONTENTS Page ACKNOWLEDGMENTS ...... iv

LIST OF TABLES ...... viii

CHAPTER I. INTRODUCTION ...... 1 Statement of the Problem ...... 2 Purpose Statement ...... 3 Hypotheses ...... 4 Operational Definitions ...... 4

II. LITERATURE REVIEW ...... 5 Current Intake of Sugar-Sweetened Beverages in the General Population ...... 5 Trends in SSB Consumption Throughout the Life Span ...... 5 Added Sugar From SSBs Compared to Current Recommendation ...... 7 Main Components of SSBs ...... 8 Sugar ...... 8 Sucrose ...... 10 High Fructose Corn Syrup ...... 10 Other Ingredients ...... 11 Phosphoric Acid… ...... 12 Caffeine ...... 12 Types of Sugar-Sweetened Beverages ...... 13 Soft Drinks ...... 13 Water ...... 14 Sugar ...... 15 Acid ...... 17 Carbonation ...... 17 Colorings and Flavorings ...... 18 Caffeine Content ...... 19 Consumption Data ...... 20 Sport Drinks ...... 20 Types ...... 21 Carbohydrates ...... 22 Electrolytes ...... 23 Other Components ...... 25 Consumption Data ...... 25 Energy Drinks ...... 26 Sugar ...... 26 Caffeine ...... 27 Amino Acids ...... 28 v

Vitamins ...... 28 Plant-Based Stimulants ...... 29 Consumption Data ...... 30 Sweetened Coffee ...... 31 Composition ...... 32 Sugar ...... 32 Caffeine Content ...... 33 Consumption Data ...... 34 Sweetened Tea ...... 35 Composition ...... 36 Sugar ...... 36 Caffeine Content ...... 37 Consumption Data ...... 38 Lemonade ...... 38 Sugar ...... 39 Citric Acid ...... 39 Flavored Water...... 40 Sugar ...... 40 Consumption Data ...... 40 Metabolism ...... 41 Glucose Uptake ...... 42 Consuming Sugar in Liquid Form vs. Solid Form ...... 42 Relationship to Body Weight ...... 43 Sucrose Metabolism, Absorption, Excretion ...... 43 Fructose Metabolism, Absorption, Excretion ...... 45 Health Concerns Related to Sugar-Sweetened Beverages ...... 46 Obesity ...... 47 Type 2 Diabetes Mellitus ...... 51 Cardiovascular Disease ...... 53 Metabolic Syndrome ...... 55 Other Health Concerns ...... 57 Tooth Decay ...... 57 Reduced Bone Mineral Density ...... 58 Negative Effect on Gastrointestinal System ...... 60 Current Trends in Dietary Intake and Behavior in College Students ...... 60

III. METHODOLOGY ...... 64 Research Design...... 64 Participants ...... 64 Retrospective Data Collection Overview ...... 65

Questionnaires...... 65 Anthropometric Measurements ...... 66 SSB Intake ...... 67 Statistical Analysis ...... 67

IV. JOURNAL ARTICLE ...... 69 Methodology ...... 71 Research Design...... 71 Participants ...... 71 Retrospective Data Collection Overview ...... 72 Questionnaires...... 72 Anthropometric Measurements ...... 73 SSB Intake ...... 74 Statistical Analysis ...... 74 Results ...... 75 Discussion ...... 77 Sugar-Sweetened Beverages and BMI...... 78 Consumption of Sugar-Sweetened Beverages ...... 80 Soft Drinks… ...... 82 Sweetened Coffee… ...... 83 Sweetened Tea ...... 85 Sugar Intake and Caloric Intake From Sugar-Sweetened Beverages ...... 86 Limitations ...... 88 Implications...... 91 Conclusion ...... 93

APPENDIX ...... 94 APPENDIX A. SSB INTAKE DATA SHEET ...... 95

REFERENCES ...... 97

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LIST OF TABLES

Table Page

1. Best-Selling Soft Drinks ...... 16

2. Sugar Content in Sports Drinks ...... 24

3. Sugar Content in Energy Drinks ...... 27

4. Sugar Content in Sweetened Coffee ...... 33

5. Sugar Content in Sweetened Tea ...... 37

6. Sugar Content in Ready-to-Drink Lemonade ...... 39

7. Sugar Content in Flavored Water ...... 41

8. Demographic Characteristics of Midwest College Students Enrolled

in Three Sections of a Sophomore-Level Nutrition Class (N=209) ...... 76

9. Average Three-Day Intake of Sugar-Sweetened Beverages (fl oz)

in College Students Enrolled in Three Sections of a Sophomore-Level

Nutrition Class (N=209) ...... 76

10. Analysis of Covariance Examining Average SSB Intake, Average Calories

From SSBs, and Average Sugar Intake From SSBs Among BMI Categories

of College Students Enrolled in Three Sections of a Sophomore-Level Nutrition

Class (N=209)...... 78

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CHAPTER I

INTRODUCTION

The prevalence of overweight and obesity has continued to increase in the US in parallel with increased consumption of sugar-sweetened beverages (SSBs) and added sugars (Bray, 2003; Mokdad et al., 2001; Ogden et al., 2006); in addition, sweetened soft drinks are the main source of energy in the U.S. diet (Block, 2004). Increased intake of

SSBs, which include excessive sugar content and dietary energy that can result in weight gain and the risk of health comorbidities, often replaces nutrient-dense beverages like milk. According to the 2015 World Health Organization (WHO) Guideline recommendation on the intake of free sugars, a single can of sugar-sweetened soda contains approximately the upper limit of the recommended 25–50 grams per day.

Excess sugar consumption has been linked to weight gain, which can predispose individuals to diabetes, cardiovascular disease, and metabolic syndrome (Bray, 2003;

Gao & Bermudez, 2010; Mis, 2013). Considered a major source of added sugar in the diet, SSBs have been defined as drinks containing high sugar content in the form of table sugar or high-fructose corn syrup (Centers for Disease Control [CDC], 2017), including but not limited to the following drinks: sodas, sweetened coffee, sweetened tea, and sport drinks. The consumption of various types of SSBs has not been well studied in the literature; in fact, many researchers have neglected sweetened coffee (Park et al., 2015;

Marriott et al. 2019), focusing instead on soft drinks (Apovian, 2004; Dhingra et al.,

2007; Schulze et al., 2004). The expansion of the definition of SSBs to include new

drinks, such as flavored water, has shed light on the importance of conducting research studies that include all types of SSBs because they provide no nutritional value.

The consumption of SSBs has been associated with weight gain because of their high caloric density; furthermore, the consumption of sugar in liquid form has shown a weak satiety effect compared to consuming sugar in solid form (DiMeglio & Mattes,

2000). In addition, studies have shown that SSB consumption is linked to weight gain because of the higher lipogenic effect of fructose and more pronounced genetic predisposition to an elevated body mass index (BMI), an increased risk of obesity

(Mayes, 1993; Qi et al., 2012). Research has shown the link from the high intake of SSBs to higher energy intake, added sugars, and carbohydrates as well as a lower intake of fiber, orange juice, and low-fat milk (Gao & Bermudez, 2010). SSB consumption has increased worldwide particularly among young adults (Lundeen, Park, Pan, & Blanck,

2018), the prevalence of which demonstrates a pivotal concern because young adulthood is a time when people develop long-term habits and lifestyles that may influence their risk of chronic diseases and their relationship with weight gain (Crombie et al., 2009;

Hong et al., 2016; Racette et al., 2008; Vella-Zarb & Elgar, 2009; West et al., 2006).

Statement of the Problem

Research has shown that SSBs, the main source of energy in the American diet

(Block, 2004), promote positive energy balance with their high sugar content, low satiety effect, and incomplete compensation for energy, which can result in obesity (Mis, 2013).

Those found to consume the most calories from sugar-sweetened sodas of any age group are young adults and adolescents (Bleich et al., 2009; Nielson & Popkin, 2004).

Although added sugar has been widely known to have negative health outcomes, few individuals have been able to adhere to dietary recommendations for sugar intake and caloric intake, possibly leading college students to gain excessive body fat. The reduction of SSB consumption can potentially influence healthy dietary behaviors, leading to the reduction of the prevalence of obesity among young adults in the US (Nielsen & Popkin,

2004).

Various studies have been conducted on college students’ beverage consumption, but most of them have focused on specific drink types or broad consumption patterns

(Han & Powell, 2013; (Lundeen, Park, Pan, & Blanck, 2018; West et al., 2006). Limited studies have focused on overall SSB consumption among adults in relation to body-weight status (Bawadi et al., 2019; Gao & Bermudez, 2010). The introduction of more SSBs, such as caffeinated drinks, energy drinks, energy shots, and sports drinks, has increased the importance of studying college students’ intake because this stage of their lives is a critical period in developing long-term habits and a time when they are particularly vulnerable to weight gain (West et al., 2006).

Purpose Statement

The purpose of this study was to compare the consumption of SSBs in BMI groups of college students at a Midwestern public university.

Hypotheses

H1: The consumption of SSBs differs among college students grouped by body mass index (BMI) at a Midwestern public university.

H0: The consumption of SSBs does not differ among college students grouped by body mass index (BMI) at a Midwestern public university.

Operational Definitions

College students: Young adults ranging in age from 18 to 25 years

Sugar-sweetened beverages (SSBs): Drinks sweetened with added sugars

Body mass index (BMI): Individual’s weight in kilograms divided by the square of height in meters

CHAPTER II

REVIEW OF LITERATURE

Current Intake of Sugar-Sweetened Beverages in the General Population

In the US the consumption of sugar-sweetened beverages (SSBs) has decreased modestly since 2002 (Welsh, Sharma, Grellinger, & Vos, 2011), but intake levels have remained high. In fact, some groups exceed the recommendations of the Dietary

Guidelines for Americans (U.S. Department of Health and Human Services and U.S.

Department of Agriculture, 2015) and the World Health Organization (WHO; 2015) for no more than 10% of daily calories from all added sugar. Data from the National Health and Nutrition Examination Survey (NHANES) have shown that U.S. adults consumed an average of 145 kcal/day from SSBs, accounting for 6.5% of total calories between 2011 and 2014 with higher intake levels reported among younger age groups (Rosinger et al.,

2017). Among the 20 most populated countries, the US has been ranked second in

SSB-related deaths with an absolute death rate of 125 per million adults, or 25,000 total deaths related to SSB consumption in 2010 (Singh et al., 2015). One model demonstrated the role of SSB consumption in more than 180,000 global deaths in 2010, with 72.3% from diabetes and 24.2% from cardiovascular disease (Singh et al., 2015).

Trends in SSB Consumption Throughout the Life Span

During adolescence, a potential target for improving dietary intake is limiting the consumption of soft drinks (Jacobson, 1998; Ludwig et al., 2001; Rampersaud et al.,

2003; Troiano et al., 2000). Researchers have suggested that children who reduce their intake of SSBs along with other behavior modifications, such as increasing physical 5

activity and reducing screen time, may prevent excess weight gains that can lead to obesity (Berkey et al., 2003, 2004). Increased consumption of soft drink intake is associated with lower milk and fruit juice intake and with higher total energy intake

(Harnack et al., 1999). Girls who reported one daily serving of SSBs had a higher BMI during the year than those reporting none; furthermore, girls consuming two or three or more servings also gained weight compared with nondrinkers (Berkey et al., 2004).

NHANES III showed that the energy contribution from soft drinks was higher among overweight adolescents relative to adolescents with a normal weight (Troiano et al., 2000). Regular soda was the most heavily consumed (≥500 kcal/day) SSB type among adolescents and young adults and by 2007 to 2008 was the most prevalent SSB type in all age groups (Han & Powell, 2013). In addition, the prevalence of regular soda consumption decreased over time particularly among adolescents for whom the prevalence of sports or energy drink consumption tripled. The number of calories from sports or energy drinks increased to the largest extent among young adults (Han &

Powell, 2013). Sweetened beverages contributed an important proportion of energy to the total energy intakes of young adults: At least eight of 10 young adults drank sweetened beverages at a level of intake that placed those dietary factors among the main contributors of dietary energy in the diets of that population group (Gao & Bermudez,

2010). Some researchers have shown that the mean caloric intake from SSBs was 481 kcal per day among college students (Bawadi et al., 2019), but others have estimated the

daily caloric intake from the combined forms of SSBs averaged 543 ± 671 kcal/d among college students (West et al., 2006).

The daily SSB consumption among adults aged 18 to 55 was found to be high in the US and varied across states and subgroups. Among people in nine states surveyed in

2016, nearly one in three adults consumed SSBs one or more times per day (Lundeen,

Park, Pan, & Blanck, 2018). Adults with obesity had significantly higher odds of consuming SSBs one or more times per day than underweight or normal-weight adults.

The adjusted odds of drinking one or more SSBs per day were significantly higher among respondents aged 18 to 54 than those aged 55 or older.

Added Sugar From SSBs Compared to Current Recommendation

The Dietary Guidelines for Americans have suggested that less than 10% of total energy intake should come from added sugars (U.S. Department of Health and Human

Services and U.S. Department of Agriculture, 2015), whereas the Dietary Reference

Intake (DRI) recommends less than 25%. No DRI is available for the intake of added sugars (Trumbo et al., 2002). SSBs contribute more than one third (39%) of all added sugars consumed in the US and approximately 8% of total energy from added sugars in adolescents and adults, close to the 10% recommendation (Kit et al., 2013). According to the 2015 WHO guideline on the intake of free sugars, a single can of sugar-sweetened soda contains nearly the upper limit of the recommended 25–50 grams per day. Young adults and adolescents consume the most calories from SSBs of any age group, that is,

230 and 200 calories per day, respectively (Nielson & Popkin, 2004; Y. C. Wang et al.,

2008).

Main Components of SSBs

SSBs comprise ingredients that pose health concerns because the main ingredient found in them is sugar.

Sugar

Sugar is the most commonly used sweetener in the world. In the 17th and 18th centuries the New World produced large quantities of sugar at reduced prices (Galloway,

2000). Since then the use of sugar has been linked with industrialization and with the proliferation of processed foods and beverages with added sugar (Mintz, 1977). Between

1900 and 1967 an increase in sugar consumption was evident with an overall doubling in the US and the UK (Yudkin, 1967). By 1993 an estimated 110 million or more tons of sugar were produced worldwide (Mintz, 1986).

By the early 1970s, high-fructose corn syrup (HFCS), which had certain advantages over table sugar in regard to shelf life and cost, was introduced in the US (R.

J. Johnson et al., 2007). The composition of this sweetener resembles that of sucrose and is widely used to sweeten soft drinks, fruit punches, pastries, and processed foods. The combination of table sugar and HFCS has yielded a 30% increase in overall sweetener intake over the past 40 years, mostly in soft drinks (R. J. Johnson et al., 2007). Ingestion of these sweeteners accounts for approximately 150 lb. (67.6 kg) per person per year,

resulting in the consumption of more than 500 kcal per day (Elliot et al., 2002; R. J.

Johnson et al., 2007; U.S. Census Bureau, 2003).

Added sugars are extrinsic sugars and syrups included in foods and beverages during processing for preparation and include sugars naturally occurring in honey, syrups, and fruit juices but not the sugars present naturally in fruits or milk (Mis, 2013).

No upper safe limit of sugar intake has been agreed upon universally, but the WHO has suggested that intake of free sugars should be less than 10% of one’s total energy intake.

The notion that sugar might have detrimental health effects has been reiterated for decades, with claims that high intake may be associated with an increased risk of conditions as diverse as dental caries, obesity, cardiovascular disease, diabetes, gout, fatty liver disease, some cancers, and hyperactivity (Bristol et al., 1985; Burt & Pai, 2001; R. J.

Johnson et al., 2007; Milich et al., 1986; Te Morenga et al., 2013; van Baak & Astrup,

2009).

Sugars contribute to the intake of fructose, which can result in an increase of uric acid levels and in some individuals’ hyperinsulinemia, which has been indicated as a potentially important and independent predictor of obesity and metabolic syndrome (R. J.

Johnson et al., 2007). SSBs and other sources of dietary fructose have been shown to promote the deposition of liver, skeletal, and visceral fat and an increase in serum lipids independently of an effect on body weight (Silbernagel et al., 2011). The two common types of sugar used in SSBs are sucrose and high fructose corn syrup.

Sucrose

Sucrose is the most widely distributed disaccharide and most commonly used natural sweetener (Gropper et al., 2018). Organic sources of sucrose are found in cane and beet sugar, sorghum, and some fruits and vegetables (R. K. Murray et al., 2012).

Sucrose is a disaccharide consisting of two combined monosaccharides: glucose and fructose. Its structure is unique because of a glycosidic bond that involves the anomeric hydroxyl of both residues (Gropper et al., 2018). The linkage is ⍺ with respect to the glucose residue and β with respect to the fructose residue; therefore, it has no free hemiacetal or hemiketal function, and sucrose is not a reducing sugar. Before the body can use disaccharides, they must be hydrolyzed into monosaccharides in order to be absorbed from the gastrointestinal tract into the bloodstream (Gropper et al., 2018; R. K.

Murray et al., 2012). Sucrose is hydrolyzed slowly in acidic solution to its monosaccharides in a process called inversion (Ashurst et al., 2017).

High Fructose Corn Syrup

HFCS is defined as sweeteners made with corn-derived fructose and glucose. It is classified by the percentage of fructose contained in the final product: The Food

Chemicals Codex specifies that HFCS-55 must contain a minimum of 55% fructose

(Institute of Medicine of the National Academies, 2003). Along with fructose, HFCS contains maltose and glucose oligomers up to 5% in HFCS-55 (Hanover & White, 1993;

International Society of Beverage Technologists, 2014; Maxwell et al., 1984; Scobell et al., 1977; Wartman et al., 1976, 1980). Both total fructose and free fructose combined in

sucrose, in beverages, and in solid food may be considered as a precursor to fat because of the ease with which the carbon skeleton of fructose can form the backbone for triacylglycerols and be used for the synthesis of long-chain fatty acids (Teff et al., 2004).

HFCS has become a main alternative for sucrose in carbonated beverages, baked goods, canned fruits, jams and jellies, and dairy products (Hanover & White, 1993). The

US is the major user of HFCS in the world; however, it is now manufactured and used in many countries throughout the world (Vuilleumier, 1993). Between 1970 and 1990,

HFCS consumption has increased more than 1000%, far exceeding the changes in intake of any other food or food group (Bray et al., 2004). HFCS accounts for more than 40% of caloric sweeteners added to foods and beverages and is the predominant caloric sweetener in soft drinks in the U.S. According to one research study, the estimated consumption of HFCS among people in the US is equivalent to a daily average of 132 kcal for all people in the US aged 2 years and above, and the top 20% of consumers of caloric sweeteners ingest 316 kcal from HFCS per day (Bray et al., 2004). Numerous researchers have proposed that the increased use of HFCS in the US is associated with the rapid increase in obesity (Elliot et al., 2002; Gao et al, 2007; Havel, 2005; Lane &

Cha, 2009; Mayes, 1993; Teff et al., 2004; Wu et al., 2004).

Other Ingredients

The other common ingredients found in SSBs include phosphoric acid and caffeine.

Phosphoric Acid

Phosphoric acid has a strong effect on pH and is typically used to provide a specific taste profile to cola-type beverages. Its use is considered controversial because of its association with adverse health effects (Kregiel, 2015). Elevated levels of phosphorus in the blood, referred to as “hyperphosphatemia,” can lead to organ damage, especially the kidneys. Poor kidney function can raise serum phosphorus levels, which in turn lowers calcium levels, causing an increased risk of brittle bone disease. Moreover, elevated plasma levels of phosphorus and mineral abnormalities can individually and collectively contribute to vascular calcification and cardiovascular disease (Calvo &

Tucker, 2013; Calvo & Uribarri, 2013; K. J. Martin & González, 2011). The European

Food Safety Authority (2005) has declared the tolerable upper intake level of phosphorus to be 3000 mg/day for healthy individuals without causing negative effects. Some individuals have, however, reported mild gastrointestinal symptoms with supplemental intakes of more than 750 mg phosphorus per day. Phosphoric acid and its derivatives were permitted in the European Union prior to 2009 and have therefore been included in the program for reevaluation of food additives (European Food Safety Authority, 2013).

Caffeine

Caffeine from caffeinated beverages is popular with young adults, especially coffee, the primary source of caffeine. Caffeine intake alters the natural circadian rhythms, which can affect the sleep cycle; furthermore, caffeine intake can affect heart health and bone health, making the intake of caffeine controversial. It influences the

human body systems, including the nervous system, lipolysis process, respiratory system, heart health, and cognitive function (Heckman et al., 2010; Weinberg & Bealer, 2001), and has an impact on health depending on various factors, such as age, gender, medication, lifestyle, dietary habits, and the amount of caffeine consumed. Moderate caffeine consumption is associated with cognitive function improvement, such as increasing attention, memory, reaction time, wakefulness, and concentration (Lara,

2010). Excessive consumption of caffeine can cause anxiety, headaches, nausea, restlessness, jitters, insomnia, and heart palpitations and increase urinary output (Grosso et al., 2017), which can cause complications in individuals with kidney disease (Mahan et al., 2012). The consumption of caffeine in amounts over 400 mg/day for adults and over

300 mg/day for children and pregnant women is harmful and can cause toxicity.

Types of Sugar-Sweetened Beverages

SSBs are beverages sweetened with sugars, such as sucrose and HFCS, which can add calories. Examples of these beverages are soft drinks, sports drinks, energy drinks, sweetened coffees, sweetened teas, and lemonade (CDC, 2017).

Soft Drinks

Soft drinks are defined as carbonated or noncarbonated drinks that usually contain a sweetener and natural or artificial flavoring. Types of soft drinks include colas, flavored water, carbonated water, seltzer, sweet iced tea, fruit drinks, carbonated soft drinks, diet soft drinks, and fruit punch (Ashurst et al., 2017). Soft drinks can be classified by their components: regular, diet (no natural sugar, small amount of artificial sweetener),

low-calorie, flavored, caffeinated, and caffeine free. Diet, low-calorie soft drinks are not considered SSBs. Soft drinks consist of various ingredients, including water, sugars and sweeteners, acidity regulators, carbon dioxide, flavorings, colorings, and caffeine

(Tahmassebi & BaniHani, 2019).

Water

Water constitutes 90% of regular soft drinks, usually softened water, from which calcium and magnesium have been removed to eliminate any taste of chlorine residues

(Ashurst et al., 2017; Kregiel, 2015). Many soft drink companies have their own private water supply, which may or may not meet the water quality requirements enforced by the country where production occurs (Ashurst et al., 2017). Numerous branded products manufactured in various locations require water treatment to ensure product consistency.

Water treatment may include the removal of unstable iron, removal of sediment by sand filtration, softening by ion exchange, sterilization by addition of chlorine gas and its subsequent removal by filtration through active carbon (Ashurst et al., 2017). Water used in soft drinks must be safe for human consumption. To ensure that water meets the ideal specification to be used in soft drinks, microbiological quality, hardness, and freedom from toxic substances are measured. The ideal microbiological quality of water should be free from any microbiological contaminants, especially coliforms. Water used in soft drinks should not only lack any toxic substances, such as heavy metals, hydrocarbons, pesticides, herbicides, and dioxins, but also should exhibit low content of metals, such as iron, zinc, and copper, as well as low content in sodium, potassium, and

calcium. Water used in soft drinks should have a total solids content of less than 110 ppms.

Sugar

Regular soft drinks are approximately 1% to 12% sugar (Kregiel, 2015). In the form of sucrose, sugar is the standard carbohydrate in soft drinks. Sucrose is a disaccharide comprising two monosaccharides: glucose and fructose (Ashurst et al.,

2017). Sucrose, glucose, and fructose provide natural sweetness in soft drinks, independently or collectively. These three carbohydrates differ in relative sweetness.

Glucose is 20% less sweet than sucrose, and fructose is 25% sweeter than sucrose.

HFCS and sucrose are the most common sweeteners used in soft drinks. The nutrition labeling guidelines of soft drinks are regulated by the Food and Drug Administration

(FDA), which permits the use of the word “sugar” in soft drinks only in reference to sucrose (Food and Drug Administration [FDA], 2008). Soft drink manufacturers in the

US have almost completely replaced sucrose with HFCS (Ashurst, et al., 2017), which must be listed as an ingredient in soft drinks if used (FDA, 2008). The HFCS used in the

United States comprises 55% fructose (Ashurst et al., 2017).

In one study bottled samples of Coke, Sprite, and Pepsi tested at 95 to 100% of what was listed on the label (Ventura et al., 2011). Dr. Pepper and Mountain Dew samples had lower total sugar content compared to what was listed on the label with laboratory results of 87% and 92%, respectively, for the listed total sugar content.

Fountain drinks were also found to have a higher total sugar content compared to the

nutrition facts listed on the company websites with actual sugar contents of 101–128% of the listed information. In addition, the type of sugars listed in some soft drinks differed from the results of the laboratory assays. The laboratory results detected no sucrose in

Mexican Coca‐Cola, which listed “sugar” on the ingredients list but instead near equal amounts of fructose and glucose, suggesting the use of HFCS. Vitamin water listed only cane sugar and crystalline fructose as sweeteners in the ingredients, whereas laboratory analysis detected glucose in the drink. The fructose‐to‐glucose ratio in the HFCS used in soft drinks was shown to vary and but was nearly always higher than 55% with several major brands at 65% fructose.

According to the NHANES, soft drinks and fruit drinks were found to provide more than 40% of the “sugars” that are added to the diet (Marriott et al., 2010). Table 1 shows the best-selling soft drinks on the market with the amount of sugar they contain.

Table 1

Best-Selling Soft Drinks

Soft Drink Sugar (g/fl oz) Coco-Cola 39g/12 oz Pepsi-Cola 41g/12 oz Mountain Dew 46g/12 oz Dr. Pepper 40g/12 oz Sprite 38g/12 oz Fanta 48g/12 oz

Note. Adapted from Nutrition Value (2021).

Acid

In soft drinks, acid is added to balance the level of sweetness for a favorable taste

(Kregiel, 2015). Citric acid, the most common acid regulator used in soft drinks (Ashurst et al., 2017), is used to preserve soft drinks, improve the activity of beneficial antioxidants, and add aroma. Most commonly citric acid is combined with malic acid to provide strong flavor enhancement (Kregiel, 2015). Malic acid is considered slightly stronger than citric acid in terms of acidity, contributing a fuller, smoother fruit flavor

(Taylor, 2006). Phosphoric acid is considered the only inorganic acid used in food preparations. Its use in soft drinks provides astringent acidity that complements the dry character of cola drinks (Taylor, 2006). Phosphoric acid consumption has been associated with adverse health effects, such as high levels of phosphorus in the blood

(hyperphosphatemia), which causes organ damage mainly to kidneys and thus impairs phosphorus regulation (Kregiel, 2015).

Carbonation

Carbonation is the chemical process of carbon dioxide dissolving into liquid, forming carboxylic acids. The addition of carbon dioxide to soft drinks allows the drinks to be fizzy (Tahmassebi & BaniHani, 2019). The amount of carbonation in soft drinks varies from 1.5 to 5 g/l (Kregiel, 2015). The purpose of carbonation is to form acidity in soft drinks, which sharpens the flavor and taste and allows the natural preservation of soft drinks (Korzeniewska et al., 2005; Taylor, 2006).

Colorings and Flavorings

The purposes of using colorings in soft drinks are to make the product more appealing, to help correct for natural variations in color or changes occurring as a result of processing or storage, and to maintain the qualities by which the drink is recognized

(Kregiel, 2015). Colorings are categorized as follows: natural colorings, artificial colorings, and caramel. The common coloring used in soft drinks is caramel, which gives brown color to food and beverages. A health concern has arisen with the use of caramel color because it contains carcinogenic agents known as 4-methylimidazole (“Caramel

Color,” 2014). The FDA does not regulate the addition of caramel color; consequently, the amount of caramel color used in food or beverage is not reported.

Flavorings, found in comparatively small amounts in soft drinks (Gruenwald,

2009), are used to mimic the described flavor of the product. The many flavorings used in soft drinks fall into three main categories: natural, natural identical, and artificial

(Kregiel, 2015). Those in the natural category derive from natural sources by physical, enzymatic, or microbiological processes, and from byproducts of vegetable, animal, or microbiological origin (Ashurst et al., 2017). Flavoring components derived from chemical synthesis but are identical to substances found in nature are called natural identical. Artificial flavoring includes components derived from synthetic materials that include no natural substances. Flavorings for soft drinks contain a considerable amount of chemicals derived from chemical or natural sources dissolved in approved solvents. Some flavorings take the form of an emulsion when insoluble or slightly soluble products like

essential oils are emulsified into a water base, usually adding flavor and cloud to the beverage formulation. The chemicals in flavorings are often very reactive and susceptible to oxidation. Flavorings based on essential oils are the most unstable flavorings because of their vulnerability to auto-oxidation.

Caffeine Content

Caffeinated carbonated sodas that contain added caffeine are required to list caffeine as an ingredient but do not need to list the quantity (Kole & Barnhill, 2013). In

1980 the FDA, which regulated caffeinated soft drinks as foods (Reissig et al., 2009), proposed to eliminate caffeine from soft drinks because of health concerns associated with it (FDA, 1980). Soft drink manufacturers advocated the addition of caffeine to soft drinks for its capacity to enhance flavor (PepsiCo, Inc., 1981), but scientific research does not support that claim (Griffiths & Vernotica, 2000; Keast & Riddell, 2007). If caffeine had not been accepted as a flavor enhancer, then it would be considered a psychoactive ingredient, in which case soft drinks might have been regulated by the FDA as drugs (Reissig et al., 2009). Instead, the FDA approved caffeine as a flavor enhancer and established a limitation on the maximum amount of caffeine allowed in cola-type soft drinks to 0.02% caffeine, or 71 mg/12 fl oz (FDA, 2003).

A research study showed that caffeine concentration of the caffeinated carbonated sodas ranged from 18.0 to 48.2 mg/serving (McCusker et al., 2006). Caffeine content in soft drinks is not as high as it is in other beverages like coffee and energy drinks, but it has been a concern because of its high consumption, especially by younger populations.

A nationwide caffeine consumption survey found that 98% of children aged 5 to 18 years weekly consumed caffeine, derived mainly from carbonated beverages (Morgan et al.,

1982). Soft drinks were found to be the primary source of caffeine in youths ages 12‒15 years, among whom an average of 52.7 mg of caffeine was consumed daily; and approximately 19% of participants consumed 100 mg or more daily (Pollack & Bright,

2003).

Consumption Data

The leading source of added sugars in the U.S. diet is soft drinks (Nielsen &

Popkin, 2004). According to the NHANES, sweetened soft drinks are the main source of energy in the US. In 2017 an average of 628 eight-ounce servings of soft drinks were consumed per capita in the US (Kunst, 2019). The consumption of soft drinks has been a controversial public health and policy issue because of negative health repercussions.

Soft drinks have been banned from schools in several countries, including Britain and

France (Vartanian et al., 2007). In the US, soft drinks have been banned or severely limited in school systems in Los Angeles, Philadelphia, and Miami.

Sports Drinks

Sports drinks, which contain carbohydrates and electrolytes, are usually consumed before, during, and after exercise to prevent the risk of dehydration and hyponatremia and to help maintain blood glucose concentration and provide fuel for muscles (American Dietetic Association, 2009). The purpose of consuming sports drink is to allow body fluid balance and faster gastric emptying rate, compensate for any loss of

minerals, supply carbohydrates to help provide energy, and enhance performance

(Mitchell et al., 1988; Seiple et al., 1983).

Types

Prolonged heavy exercise can cause dehydration and carbohydrate depletion

(Costill, 1988; Lamb & Brodowicz, 1986). Carbohydrate-containing beverages are used to replenish body fluids in prolonged exercise; however, the optimal formulation of sport drinks continues to be questioned (Davis et al., 1990). Carbohydrate‒electrolyte beverages with greater than 2.5% and less than or equivalent to 10% carbohydrates are not likely to enter the vascular system more slowly than water, which will not weaken fluid replenishment.

The use of sports drinks is dependent on the intensity and duration of exercise.

For instance, fluid-replacing drinks were designed for use in activities of less than two hours in duration because they are absorbed quickly by the body. The three main types of sports drinks differ in water, electrolytes, and carbohydrates content (Diel & Khanferyan,

2018). First, isotonic drinks contain water, carbohydrates, and 4‒8 % electrolytes. These are recommended for use in intensive physical training. Second, hypotonic drinks contain

6% electrolytes, 2% carbohydrates, and 92% water. Third, hypertensive drinks contain

32% carbohydrates, 4% electrolytes, and water; this type includes a high concentration of digestible carbohydrates to rapidly restore energy reserves and has been recommended for use in highly intensive training.

Athletes usually look for sport drinks that provide adequate carbohydrates without causing gastrointestinal distress during training. Sports drinks can benefit athletes under certain conditions, but many sport drinks contain only sugars and have a low nutrient density (Dunford & Doyle, 2014). The advantages of sports drinks are as follows: They can provide carbohydrate, electrolytes (particularly sodium), sweet taste, rapid rate of absorption because of the sugar; and they are considered convenient. The disadvantages of sports drinks are that they can provide unwanted calories or excess substances. Many sports drinks are marketed to athletes to provide carbohydrates, vitamins, and electrolytes.

Carbohydrates

Carbohydrates play a major role in sports drinks in improving physical performance by delaying the depletion of muscle glycogen (Hao et al., 2014; Jeukendrup,

2014). Carbohydrate intake produces an antifatigue effect by maintaining high levels of glucose in the blood to support muscle energy production during physical activity and when muscle glycogen is low (Orrù et al., 2018).

Many sports drinks have been designed to contain a combination of glucose, fructose, sucrose, and maltodextrin‒glucose polymers added to provide less sweetness than sucrose or glucose in order to allow higher concentration of carbohydrates in the drink without making it too sweet to consume (Campbell, 2013). The type of carbohydrates in sports drinks did not significantly influence gastric emptying when the

concentration of carbohydrates was low. The amount of carbohydrates in sports drinks is typically between 6 and 15% (Coombes & Hamilton, 2000; Seiple et al., 1983).

Glucose polymers are chains of glucose longer than simple sugars but shorter than starches; their structure makes using them more preferrable than simple carbohydrates in sports drinks because they can be digested more rapidly (Seiple et al., 1983). Sports drinks that contain glucose polymers permit a higher concentration of carbohydrates up to

15% and increase the rate of gastric emptying and decrease the osmolality by minimizing the effect on osmo-receptors (Campbell, 2013; Seiple et al., 1983).

Simple carbohydrates supply energy and maintain fluid balance in sports drinks in a range of 5 to 10% carbohydrate concentration (Applegate, 1980; R. Murray, 1987). The absorption of fructose is slower than that of other carbohydrates; therefore, it does not promote as much fluid absorption (Coleman, 1988). Fructose plays no significant role in the increase of physical performance because of its slow metabolism and release by the liver to provide adequate amounts of glucose to the working muscle. The consumption of carbohydrate-loading drinks with a high concentration of fructose prior to an event can be beneficial because it can provide time for the body to produce adequate glycogen stores

(Coleman, 1988). See Table 2 for sugar content of sports drinks.

Electrolytes

The distribution of water throughout the body is regulated by osmolarity of extracellular fluid (ECF), which is influenced by certain electrolytes (Dunford & Doyle,

2014). For example, an increase in sodium in the ECF results in an increase in the volume

Table 2

Sugar Content in Sports Drinks

Sports Drink Brand Sugar Content Gatorade 34g/20 oz Powerade 34g/20 oz Bodyarmor 28g/16 oz Rebound Fx 8.5g/pack (12 g)

Note. Adapted from Nutrition Value (2021).

of water, whereas a decrease in sodium in the ECF results in a decrease in the volume of water. Electrolyte loss should be compensated to maintain long-term fluid homeostasis after physical activity. The compromise of electrolyte balance during exercise training or performance can cause dehydration, hyperkalemia, and hyponatremia, which explains the addition of electrolytes in sport drinks (Dunford & Doyle, 2014; J. Smith, 1992). Sweat comprises electrolytes, sodium, potassium, and chloride as well as small amounts of minerals that include calcium, iron, and magnesium (Dunford & Doyle, 2014).

Sports drinks are, therefore, generally formulated to provide for the replacement of the sodium, chloride, potassium, magnesium, and calcium lost through sweat (Orrù et al., 2018). Sport drinks contain approximately 25 to 200 mg of sodium and 30 to 90 mg of potassium per serving (240 mL [8 oz]; Committee on Nutrition and the Council on

Sports Medicine and Fitness, 2011). The purpose of sodium is to help stimulate thirst, resulting in voluntary consumption of more fluid, and to promote body water retention

(American College of Sports Medicine, 2007; Dunford & Doyle, 2014). If sodium stores are not met, individuals can experience nausea, vomiting, headache, loss of appetite,

muscular weakness, and leg and abdominal cramps (Williams, 1985). Chloride, which helps maintain osmotic pressure and acid-base balance, is an important component of gastric juice (Stachenfeld, 2014; Urdampilleta & Gómez-Zorita, 2014). The function of potassium is to help store and transport glycogen across the cell membrane. It also plays an important role in muscle contraction and nerve impulse conduction (Williams, 1985).

Magnesium is essential for bone formation and is a component of more than 300 enzymes

(Dunford & Doyle, 2014). Calcium is responsible for the mineralization of bone and teeth, muscular contraction, nerve conduction, and the secretion of hormones and enzymes (Dunford & Doyle, 2014; Williams, 1985).

Other Components

Sports drinks contain other components, including acids like citric acid, which is used to enhance flavor, and lactic acid, which is used to regulate the acidity of the beverage (Kregiel, 2015). Ascorbic acid is used as a preservative because of its antioxidant properties and colors, such as sunset yellow (Scotter & Castle, 2004).

Potassium sorbate is used to inhibit microorganism growth in the beverage, and sodium bisulfate is used to preserve flavor and color as well as to prevent bacterial growth

(Kregiel, 2015).

Consumption Data

Sales of sport drinks increased between 2010 and 2020, reaching $999.7 million in sales in the U.S. market (Statista, n.d). In 2015, Americans drank about 4.7 gallons of sports drink per capita. A research study of a nationally representative population of

students showed an increase in the consumption of sports drinks in students who lived in states that banned soda in school but still allowed the sale of SSBs in vending machines

(Taber et al., 2015). A total of 57.6% of high school students reported consuming at least one sports drink during the previous week; 31.8% consumed one to three sports drinks, and 11.9% consumed four to six sports drinks during the previous week (Cordrey et al.,

2018).

Energy Drinks

Advertised to boost energy, promote wakefulness, maintain alertness, and enhance mood and cognitive performance (Gunja & Brown, 2012), energy drinks are marketed to provide energy and promote weight loss through energy expenditure. The main components of energy drinks are caffeine, taurine, l-carnitine, carbohydrate, glucuronolactone (a naturally occurring glucose metabolite), vitamins, ginseng, guarana, yerba mate, and cocoa (Higgins et al., 2010; Seifert et al., 2011). Energy drinks are described below in terms of the sugar, caffeine, amino acids, vitamins, and plant-based stimulants they contain (Higgins et al., 2010).

Sugar

Added to energy drinks to provide rapid energy, sugar takes the form of either sucrose or HFCS (Higgins et al., 2010). As noted above, some discrepancy has occurred in ingredients listed in SSBs. Red Bull, for example, tested positive for fructose (1.9 per

10.9 g/100 ml of total sugar), but the ingredient list named sucrose and glucose as sweeteners (Ventura et al., 2011). The amount of sugar provided in one can (or 500 mL)

of an energy beverage is typically about 54 grams. A teaspoon of sugar weighs about 4 grams, so a typical energy beverage contains about 13 teaspoons, or just more than ¼ cup of sugar (Higgins et al., 2010). The American Heart Association has recommended limiting the amount of added sugars not to exceed 6 teaspoons of sugar for women and not to exceed 9 teaspoons of sugar for men (R. K. Johnson et al., 2009). See Table 3 for sugar content of energy drinks.

Table 3

Sugar Content in Energy Drinks

Energy Drink Brand Sugar Content

No Fear 33 g/237 mL Rockstar 31 g/237 mL Full Throttle 29 g/237 mL Amp 28 g/237 mL Red Bull 27 g/245 mL Note. Adapted from Nutrition Value. (2021).

Caffeine

Caffeine is the main stimulant in energy drinks, most containing between 70 and

200 mg of caffeine per 16-oz serving (Higgins et al., 2010). Additional amounts of caffeine can be added to energy drinks through additives, such as guarana, kola nut, yerba mate and cocoa (Babu et al., 2008; Heneman & Zidenberg-Cherr, 2011; Reissig et al.,

2009). Because the requirement to list caffeine content among these active ingredients is not enforced (Babu et al., 2008; Heneman & Zidenberg-Cherr, 2011), the actual caffeine

in a single serving may exceed the listed amount of caffeine in the energy drink (Cannon et al., 2001; Malinauskas et al., 2007).

Amino Acids

Taurine, the most abundant amino acid in the human body (Lourenço & Camilo,

2002), has various physiological functions, including neuromodulation, cellular membrane stability, and modulation of intracellular calcium levels (Brosnan & Brosnan,

2006; Huxtable, 1992, Timbrell et al., 1995). The concentration of taurine found in popular energy drinks is too low to deliver therapeutic benefits or adverse events

(Clauson et al., 2008). The average amount of taurine found in 80 different energy drinks is 753 mg/8 oz (Triebel et al., 2007), but researchers have not yet seen any adverse effects of a high intake of taurine (Brøns et al., 2004; Kendler, 1989; Mantovani, &

DeVivo, 1979; Sirdah et al., 2002; Zhang et al., 2004). Evidence showing that taurine positively affects physical and cognitive performance in humans is lacking (McLellan &

Lieberman, 2012).

Vitamins

B-vitamins, usually added to energy drinks, are water-soluble vitamins involved in important cellular processes (Depeint et al., 2006). B-complex is the grouping of the eight individual B-vitamins, most of which are involved in energy metabolism by functioning as coenzymes to physiological pathways like glycolysis, lipogenesis, and folate metabolism. For instance, vitamin B2 (riboflavin) acts as a coenzyme in carbohydrate metabolism; vitamin B3 (niacin) acts as a coenzyme in energy metabolism,

fat synthesis, and fat breakdown; vitamin B6 (pyridoxine) coenzymes aid in the utilization of carbohydrates, fats, and proteins; and vitamin B12 (cyanocobalamin) assists in folate metabolism and nerve function (Depeint et al., 2006; Wardlaw et al., 2014). Researchers have suggested that B-vitamins increase mental alertness and improve mood (Heckman et al., 2010). Because energy drinks contain high amounts of sugar, these vitamins are proclaimed as key ingredients to convert the added sugar to energy (Higgins et al., 2010); however, an adequate amount of B complex vitamins can be consumed through a balanced diet. Healthy, young individuals have no need for further supplementation

(Rosenbloom, 2007; Williams, 2004). Excess consumption of B-vitamins is excreted from the body through urine because B-vitamins are water soluble and are not stored by the body; therefore, excess amounts of B-vitamins in energy drinks have not been well rationalized (Heckman et al., 2010).

Plant-Based Stimulants

Energy drinks contain herbal supplements that include guarana and ginseng

(Higgins et al., 2010). Grown in Brazil, guarana is a rainforest vine containing caffeine and antioxidant properties (de Costa Miranda et al., 2009; N. Smith & Atroch, 2010). Its seeds are high in caffeine content, with 1 g of guarana being equivalent to about 40 mg of caffeine (Finnegan, 2003). Guarana is found to have therapeutic benefits, including the improvement of antioxidant activity, cognitive performance, and mental fatigue; it also helps induce lipid metabolism (Haskell et al., 2007; Kennedy et al., 2008; Lima et al.,

2005; Scholey & Haskell, 2008). The concentration of guarana found in popular energy

drinks is too low to achieve therapeutic benefits or adverse effects (Clauson et al., 2008); however, in emergency situations young adults have been admitted to the hospital because of caffeine overdoses after excessive consumption of guarana-based energy drinks (N. Smith & Atroch, 2010).

Ginseng, one of the best-known herbal supplements in the world, is used for disease prevention and treatment (Higgins et al., 2010). The proposed benefit of ginseng is that it increases energy, relieves stress, and increases memory by stimulating the hypothalamic and pituitary glands to secrete corticotropin. Athletes typically use ginseng for its alleged performance-enhancing attributes; however, a recent review showed that enhanced physical performance after ginseng administration remains to be demonstrated

(Bahrke et al., 2009). Side effects associated with ginseng use vary from hypotension, edema, palpitations, tachycardia, cerebral arteritis, vertigo, headache, insomnia, mania, vaginal bleeding, amenorrhea, fever, appetite suppression, pruritus, cholestatic hepatitis, mastalgia, euphoria, and neonatal death (Ballard et al., 2010). The concentration of ginseng found in energy drinks, however, is far below the amount expected to deliver therapeutic benefits or cause adverse effects (Clauson et al., 2008).

Consumption Data

In 2010 the energy drinks industry was valued at $6.7 billion with more than half its consumers adolescents and young adults (Heckman et al., 2010). Energy drink consumption reached approximately $2.98 billion in 2017 (Statista, n.d.). The global energy drink market has been predicted to reach $61 billion by 2021 (Research and

Markets, 2015). Energy drink consumption increased considerably after the launch of

Red Bull in 1997. Energy drink consumers were mostly athletes, but as the market grew and expanded, teenagers and young adults between 18 and 34 years old became the major consumers. Energy drink brands increased the use of digital media marketing to attract adolescents and young adults (Buchanan et al., 2017; Higgins et al., 2018). The

NHANES 2002‒2010 showed that 2.7% of U.S. adults consumed energy drinks (Bailey et al., 2014); a decade later the NHANES 2013‒2016 showed an increase in energy drink consumption by U.S. adolescents aged 12‒19 years and young adults aged 20‒39 years old; in fact, a significant increase occurred in the total caffeine intake from energy drinks for adolescents and young adults compared to nonconsumers (Vercammen et al., 2019).

According to the National Center for Complementary and Integrative Health (2021), approximately 25% of college students mix energy drinks with alcohol, and they tend to binge drink more than students who do not mix them. In addition, 42% of all energy drink-related emergency department visits are associated with mixing energy drinks with alcohol or drugs.

Sweetened Coffee

Sweetened coffee is a drink containing caffeine and a source of added sugar, the addition of which varies in form depending on the flavor preference and the type of beverage. The many types of sweetened coffee beverages varying from lattes, mochas, frappuccinos, and many more. Little research concerning sweetened coffee or specialty coffee drinks in particular has been conducted (An & Shi, 2017).

Composition

The composition of sweetened coffee is more complicated than coffee itself.

Coffee individually comprises a mixture of more than a thousand chemicals (Je et al.,

2009). The coffee bean includes many components. Among them are water, carbohydrates, fiber, proteins, free amino acids, lipids, minerals, diterpenes, chlorogenic acids, trigonelline, caffeine, alcohols, esters, hydrocarbons, aldehydes, ketones, pyrazines, furans, and sulphur compounds (Farah, 2012). In addition to the many components found in coffee alone, sweetened coffee usually includes a source of sugar that acts as a sweetening agent and a milk source that provides a thick and smooth texture. Aligned with the purpose of this paper, the focus of the next section is sweeteners used in coffee rather than components of coffee.

Sugar

Sucrose contributes not only to the flavor and quality of coffee but also up to 9% dry weight in Arabica coffee and approximately half of it in Robusta (Farah, 2012). The many sources of sugar in sweetened coffee vary with a range of flavorings and types of coffee. Approximately two thirds of coffee drinkers add sugar, cream, flavorings, or other calorie-rich additives to their drinks (An & Shi, 2017). The consumption of coffee with caloric add-ins was found to be associated with noticeable increases in daily energy intake (69 kcal), predominantly from sugar and fat (An & Shi, 2017). The CDC (2015) has advised individuals to rethink their drink when ordering at a coffee shop by excluding flavored syrups like vanilla or hazelnut that are sugar-sweetened and will add calories.

The CDC (2015) has also advised individuals to skip the whipped cream topping on coffee drinks, which adds calories and fat. Their recommendations include ordering a plain cup of coffee with fat-free milk and artificial sweetener, or black. Many coffee shops offer a wide variety of coffee drinks that exceed the daily recommended amount of sugar. In addition, coffee shops allow individuals to tailor the sweetness of their drinks to suit their preferences, so they can easily add more flavorings, contributing to greater sugar content. See Table 4 for sugar content of sweetened coffee.

Table 4

Sugar Content in Sweetened Coffee

Types of Sweetened Coffee Sugar Content

Dunkin Donuts’ Butter Pecan Swirl Frozen Coffee 97 g/16 oz Starbucks’ Mocha Cookie Crumble Frappuccino 46 g/12 oz Starbucks’ Salted Caramel Mocha 46 g/12 oz Dunkin Donuts’ Caramel Craze Signature Latte 39 g/16 oz Dunkin Donuts’ Salted Caramel Macchiato 31 g/16 oz Note. Adapted from Nutrition Value (2021).

Caffeine Content

The caffeine content in sweetened coffee beverages varies with beverage type, flavors used, and brewing method. Common beverage types of sweetened coffee that include frappuccino, latte, mocha, and macchiato have differing caffeine content.

According to Starbucks, macchiato (150 mg/8 fl. oz) has higher caffeine content than latte (135 mg/8 fl. oz), mocha (90 mg/8 fl. oz), and frappuccino (65 mg/8 fl. oz). Caffeine content in these drinks is interchangeable, depending on flavor, size, and any addition of espresso shots. The addition of flavors like cocoa to sweetened coffee can increase the

caffeine content of the drink because cocoa is considered a caffeine source. That caffeine content is determined by brewing methods is well known. Light roasted coffee (6.42 mg g−1) has higher content of caffeine than medium (5.77 mg g−1) and dark (2.63 mg g−1) roasted coffee (Król et al., 2020). Low to moderate doses of caffeine range from 50 to

300 mg, which can increase alertness, energy, and ability to concentrate; higher doses of caffeine (over 300 mg) have been shown to increase heart rate, insomnia, restlessness, and anxiety (Eskelinen & Kivipelto, 2010). According to the Dietary Guidelines for

Americans, a moderate amount of coffee is defined as three to five cups per day equivalent to an average of 400 mg of caffeine (U.S. Department of Health and Human

Services and U.S. Department of Agriculture, 2015).

Consumption Data

The growth of the coffee industry can be attributed to an increase in coffee demand and fresh trends (Adroit Market Research, 2019). Although research on consumption data for sweetened coffee is lacking, extensive research is available on consumption data for coffee drinkers in the US, where the number of coffee drinkers has increased from 57% in 2016 to 62% in 2017. According to Statista (2019), coffee consumption in the US was the highest in the age group 60 years and older (72%), followed by those 25 to 39 years of age (64%), those 40 to 59 years of age (62%), and finally those 18 to 24 years of age (47%). According to a report by the National Coffee

Association (2020), 63% of U.S. adults drink coffee daily. This National Coffee Drinking

Trends (NCDT) report showed a significant change in the quality of coffee rather than

quantity: Gourmet coffee achieved a new high of 61% in sales in 2019. The NCDT report included gourmet, espresso-based beverages, nonespresso-based coffee, and ready-to-drink coffee in its definition of gourmet coffee. According to data from

Information Resources, Inc., sales of iced coffee and cappuccino rose 6.4% to $2.87 billion and sales for cold brew coffee increased 18.1% with sales of $436 million in the year before this writing (Graybill, 2020). According to Adroit Market Research (2019), more than 50% of people in the US over the age of 18 drink coffee daily, which is equivalent to more than 150 million drinkers a day. Adroit Market Research also reported estimates that 30 million U.S. adults daily drink specialty coffee drinks (mocha, espresso, latte, cappuccino, mocha café, and coffee beverages) and that people in the US drink 400 million cups of coffee a day, resulting in the US ranking as the world’s leading coffee consumer.

Sweetened Tea

Sweetened tea is a beverage containing tea and a type of sweetener that can be natural or artificial. Sweetened tea with artificial sweetener is not considered an SSB.

Constant innovations in the tea industry have encouraged individuals to consume tea, for example, increased availability of a wide variety of teas as well as improved brewing methods and equipment (Rao & Ramalakshmi, 2011). These innovations have allowed the introduction of ready-to-drink (RTD) teas, which usually contain high sugar content

(Ivana & Merja, 2019; Rao & Ramalakshmi, 2011).

Composition

Tea is a mixture of polyphenols that provide protective effects against a variety of diseases (Mukhtar & Ahmad, 2000). RTD teas contain plant extracts, including green, rooibos, black, yerba mate extracts containing phenols (L. Wang & Bohn, 2012).

Sweeteners are added to RTD teas to improve the sensory profile of instant tea powder and to improve the taste of instant RTD tea, but the additives do not enhance the flavor profile (Dubey et al., 2020). The common ingredients found in iced tea are water, sugar or sweeteners, tea extracts, flavors, juices, acidity regulators, and antioxidants (Gasper &

Ramos, 2016). Iced tea can be mixed with flavored syrups that commonly include lemon, lime, strawberry, raspberry, passion fruit, peach, orange, and cherry (Koner et al., 2019).

Sugar

Findings have suggested that 33.4% of tea consumers drink tea with caloric add-ins, the most common of which include sugar or sugar substitute, honey, and whole or reduced-fat milk (An & Shi, 2017). In comparison to tea consumption without caloric add-ins, drinking tea with caloric add-ins was on average associated with an increase in daily total caloric intake by 43.2 kcal, caloric intake from sugar by 36.7 kcal, caloric intake from total fat by 3.7 kcal, and caloric intake from saturated fat by 2.1 kcal. A considerable proportion of tea consumers commonly use caloric add-ins to improve the flavor of their beverage possibly without taking into consideration its caloric and nutritional implications. An assessment of tea consumption with add-ins in relation to body weight status included speculation that the beneficial effect of tea consumption on

weight management was unsuccessful because of the use of add-ins (Bouchard et al.,

2010). The consumption of tea with caloric add-ins was found to be associated with evident increases in daily energy intake (43 kcal), predominantly from sugar (85% in tea add-ins) and fat (9% in tea add-ins) (An & Shi, 2017). See Table 5 for sugar content of sweetened tea.

Table 5

Sugar Content in Sweetened Tea

Types of Sweetened Tea Sugar Content

Starbucks’ Chai Latte 42 g/16 oz Dunkin Donuts’ Raspberry Sweet Tea 40 g/16 oz Dunkin Donuts’ Vanilla Spice 33 g/16 oz Starbucks’ Matcha Green Tea Latte 32 g/16 oz Starbucks Iced Peach Green Tea 23 g/16 oz

Note. Adapted from Nutrition Value (2021).

Caffeine Content

The caffeine content of sweetened teas can vary depending on the type of tea, tea leaf maturity, and brewing method used. In terms of tea type, black tea (~ 64‒112 mg/8 fl oz) is higher in caffeine content than Oolong tea (29‒53 mg/8 fl oz), white tea (32‒37 mg/8 fl oz), green tea (24‒39 mg/8 fl oz; Cabrera et al., 2006; Chin et al., 2008).

Research has also shown a difference of 20‒40% in caffeine based on the age of the tea leaves: Young tea leaves have higher caffeine content than older ones (Owuar &

Chavanji, 1986). Finally, brewed hot tea is higher in caffeine content than instant tea.

Iced and RTD teas have the least caffeine content (Cabrera et al., 2003).

Consumption Data

Tea is widely consumed in Western countries because of its overall health benefits. In the US the total consumption of tea reached 3.8 billion gallons in 2019.

According to the Tea Association of the USA (2020), over 159 million Americans have been estimated to drink tea daily. Tea industry global revenue, approximately $200 million in 2020, was expected to grow annually by 9.3% (Statista, 2020). According to

Information Resources, Inc., RTD tea sales amounted to more than $10 billion and accounted for almost 50% of the market share with $4 billion in sales in mass market and convenience outlets (Bolton, 2020). U.S. RTD tea production reached $6.6 billion in

2020 (IBIS World, 2020). Iced tea is the most consumed tea among Americans. In addition, individuals aged 22 to 38 years are most likely to consume tea in the US (Tea

Association, 2020).

Lemonade

Lemonade, a drink that contains diluted lemon juice and added sugar, may be freshly made at home; however, it is also available in ready-to-consume formulation at food stores. Commercially available lemonade formulations are usually designed to contain 15% real juice or less (Penningston et al., 2008).

Sugar

The added sugar found in lemonade beverages are typically in the form of sucrose. The average amount of sugar used in lemonade recipes that are made at home contain 200 grams of sugar in total and approximately 33 grams per serving. Most lemonade beverages, whether RTD or made at home from frozen concentrate or a powdered mix, contain about 100 to 120 calories in each 8-oz serving (Collins, 2016).

RTD lemonade beverages may contain higher amounts of sugar, depending on added flavors and sweeteners. See Table 6 for the sugar content of RTD lemonade.

Table 6

Sugar Content in Ready-to-Drink Lemonade

Lemonade Brand Sugar Content

Minute Maid Lemonade 28 g/240 mL Simply Lemonade 28 g/240 mL Tropicana Lemonade 28 g/240 mL Arizona Lemonade 24 g/240 mL Snapple Lemonade 23.5 g/240 mL Note. Adapted from Nutrition Value (2021).

Citric Acid

Citric acid (2-hydroxy-1,2,3-propanetricarboxylic acid) is a weak tricarboxylic acid naturally found in citrus fruits (Penniston et al., 2008). Existing as trivalent anion at the physiologic blood pH and to a lesser extent in urine, it is commonly used as a food additive that provides acidity and sour taste to foods and beverages. Lemons are rich in citric acid, comprising as much as 8% of the dry fruit weight (Muller et al., 1996). Citric

acid exists endogenously in the human body and is involved in intracellular glucose metabolism to produce adenosine triphosphate (ATP) in the citric acid cycle (Penniston et al., 2008). The gastrointestinal absorption of citric acid from dietary sources has been associated with a moderate increase in urinary citrate excretion (Kang et al., 2007; Seltzer et al., 1996; Penniston et al., 2007). RTD lemonade beverages contain more citric acid than powdered mixes prepared by mixing with water according to package instructions.

These beverages and those requiring mixing with water contain less than or equal to 6 times the citric acid of lemon and lime juice (Penniston et al., 2007).

Flavored Water

Flavored water is a drink that contains an array of additional ingredients, including natural and artificial flavors, sugar, sweeteners, vitamins, minerals, and other enhancements. In the literature, flavored water that includes vitamins, minerals, or infusions is also called functional water.

Sugar

The sugar content in flavored water varies depending on the type of drink. The typical amount of sugar found in flavored water has been estimated to be equivalent to 3 to 5 teaspoons of sugar per 8-ounce serving (Harris et al., 2011). See Table 7 for the sugar content of flavored waters.

Consumption Data

The flavored water market has gained popularity in recent years because the product has been marketed as a healthier alternative to soft drinks (Technavio, 2020). The

Table 7

Sugar Content in Flavored Water

Types of Flavored Water Sugar Content

Vitamin Water xxx Acai-Blueberry 32 g/ 20 oz Vitamin Water Revive 32 g/ 20 oz Vitamin Water Focus Kiwi-Strawberry 26 g/ 20 oz Tum-E Yummies Fruit Flavored Water 13 g/ 10.1 oz

Note. Adapted from Nutrition Value (2021).

flavored water industry has been estimated to see growth in the coming years as a result of innovation in ingredients, flavors, and proposed health benefits. Flavored water has been marketed to provide various health benefits that are not limited to hydration, such as the addition of collagen to enhance skin health and probiotics to preserve the gut microbiota. According to Euromonitor International, the global flavored waters market reached $ 6.5 billion in 2013 and reached $ 10.3 billion in 2018 (Malochleb, 2019). In the

United States, sales of flavored waters doubled from $ 1.3 billion to $ 2.5 billion from

2013 to 2018. According to Technavio, the flavored water market size has the potential to grow by $ 4.65 billion during 2020 to 2024 (Technavio, 2020).

Metabolism

The metabolism of SSBs is influenced by glucose uptake, the consumption of sugar in liquid form vs. solid form, and its relationship to body weight.

Glucose Uptake

Some of the dietary glucose taken up by the liver can be used for energy, stored as glycogen, or returned to the blood during nonfed periods (Gropper et al., 2018; R. K.

Murray et al., 2012). The remaining glucose passes into the systemic blood supply and is then allocated among other tissues, such as muscle, brain, kidneys, and adipose tissue.

The uptake of glucose in muscle and adipose tissue, especially following a high carbohydrate meal, is highly influenced by insulin and GLUT4, the activity of which is critical in normalizing blood glucose and thus preventing hyperglycemia. Elevated blood glucose levels cause the release of insulin by the β-cells of the pancreas into the bloodstream, where it circulates and binds with specific insulin receptors on cell membranes (Gropper et al., 2018). Insulin binding causes the translocation of GLUT4 to the cell surface and other important cellular responses. GLUT4 acts as an insulin-responsive transporter that is synthesized on the ribosomes of the rough endoplasmic reticulum and then transported to the golgi apparatus, where it is packed into

GLUT4 storage vesicles. Insulin, therefore, stimulates the cellular uptake of glucose, which leads to the conversion to storage forms in muscle and adipose tissue. In addition, insulin enhances the long-term uptake of glucose as a result of its actions on the enzymes, controlling glycolysis, glycogenesis, and gluconeogenesis (R. K. Murray et al., 2012).

Consuming Sugar in Liquid Form vs. Solid Form

Some research evidence has shown sugar consumed in liquid form rather than solid form produces overconsumption. HFCS in solid form has been suspected not to

produce the same overconsumption as it does in beverages (DiMeglio & Mattes, 2000).

Carbohydrates in liquid form elicit a weaker compensatory dietary response than the matched solid form. For instance, watermelon juice elicits a weaker compensatory response than watermelon (Mis, 2013). Researchers investigated the difference between consuming carbohydrates in liquid form versus solid form in regard to dietary response.

The results showed the total daily energy intake was 12.4% higher on the days the liquid form of carbohydrate was ingested because of a weak effect on satiety (Mourao et al.,

2007). Another study of short-term feeding trials in adults drinking SSBs and fruit juices before a meal showed 7.8% and 14.4% higher total energy intake, respectively, compared to drinking water (Daniels & Popkin, 2010). A possible explanation is that individuals do not compensate well for the calories they consumed with liquids by eating less food

(DiMeglio & Mattes, 2000; Raben et al., 2002).

Relationship to Body Weight

The human body undergoes different biochemical pathways to metabolize sucrose and fructose.

Sucrose Metabolism, Absorption, Excretion

The digestion of sucrose occurs in the mouth, stomach, or lumen of the small intestine (Gropper et al., 2018). Digestion takes place almost entirely within the microvilli of the upper small intestine via sucrase activity, and the resulting monosaccharides immediately enter the enterocytes with the facilitation of specific transporters. Sucrase is the enzyme located on the enterocytes to hydrolyze sucrose into

one glucose and one fructose residue. The resulting monosaccharides, together with small amounts of remaining disaccharides, can then be absorbed by the intestinal mucosal cells.

The metabolism of fructose is discussed in detail in the next section.

The cellular uptake of glucose is facilitated by a transport mechanism (GLUT4) that is insulin dependent in most tissues. Insulin is required for the activation of the insulin receptor, which causes an increase in the density of glucose transporters on the cell surface allowing the entry of glucose (Bray et al., 2004). Intercellular glucose is phosphorylated by glucokinase to form glucose-6-phosphate, from which the intracellular metabolism of glucose begins (R. K. Murray et al., 2012). Intracellular enzymes can strongly control the conversion of glucose-6-phosphate to the glycerol backbone of triacylglycerols through modulation by phosphofructokinase (PFK; Gropper et al., 2018).

The PFK reaction is an important site of regulation of glycolysis that allows the cell to metabolize glucose rather than converting it to another sugar or storing it as glycogen.

PFK is inhibited at normal intracellular concentrations of ATP and citrate (a product of the citric acid cycle and indication that energy needs are met). The inhibition by ATP is reversed by adenosine monophosphate, which indicates that the cell needs more energy (Gropper et al., 2018; R. K. Murray et al., 2012). Following digestion, glucose is absorbed in the intestine cell by active and facilitated transport. Some glucose is transported to the liver, but most of the glucose is transported into cells of different tissues, passing through the outer membrane of the cells by facilitated transport by way of

transporters. After absorption, glucose enters the portal circulation and is either transported to the liver or passed into general circulation (Bray et al., 2004).

Fructose Metabolism, Absorption, Excretion

The metabolism of fructose differs from that of glucose metabolism in several ways (Elliott et al., 2002; R. K. Murray et al., 2012). In contrast with glucose, fructose enters cells through a GLUT5 transporter that is not dependent on insulin (Gropper et al.,

2018). GLUT5 is not present in pancreatic β cells and the brain, which indicates limited entry of fructose into these tissues. Glucose generates “satiety” signals to the brain that fructose cannot provide because it is not transported into the brain. Intercellular fructose is phosphorylated to become fructose-1-phosphate (Mayes, 1993); then aldolase readily cleaves to fructose-1-phosphate to form trioses, which are the backbone for phospholipid and triacylglycerol synthesis (Gropper et al., 2018).

Fructose also provides carbon atoms for the synthesis of long-chain fatty acids; thus, it promotes the biochemical formation of triacylglycerols more efficiently than glucose (Elliot et al., 2002). Fructose undergoes more rapid glycolysis in the liver compared to glucose because it bypasses the main regulatory step that is catalyzed by

PFK (Gropper et al., 2018). In contrast to glucose, the enzyme responsible for fructose phosphorylation is fructokinase, which is not regulated like PFK by cytosolic citrate and

ATP. As a result, fructose metabolism forms more pyruvate than required for ATP formation. This causes fructose to flood the pathways in the liver, leading to increased lipogenesis, esterification of fatty acids, and secretion of very low-density lipoprotein

(VLDL), which may raise serum triacylglycerol and ultimately raise LDL cholesterol concentrations (R. K. Murray et al., 2012).

The hepatic metabolism of fructose favors de novo lipogenesis because of the ease with which the carbon skeleton of fructose can form the backbone for triacylglycerols and can be used for long-chain fatty acids synthesis (Teff et al., 2004).

Increased consumption of fructose, therefore, provides a relatively unregulated source of carbon precursors for hepatic lipogenesis. In contrast to glucose, fructose does not stimulate insulin secretion or enhance leptin production. Insulin and leptin are key afferent signals in the regulation of food intake and body weight; therefore, dietary fructose may contribute to increased energy intake and weight gain (Gropper et al.,

2018). Following digestion fructose is absorbed in the duodenum and jejunum by a nonsodium dependent process after which it enters the portal circulation and can be transferred to the liver; whereas fructose can be taken up and converted into glucose or passed into the general circulation (R. K. Murray et al., 2012).

Health Concerns Related to Sugar-Sweetened Beverages

Research has shown some health concerns associated with the consumption of

SSBs. Increased consumption of SSBs is related to obesity, type 2 diabetes mellitus, cardiovascular disease, metabolic syndrome, and other health concerns, including tooth decay, and reduced bone mineral density.

Obesity

Obesity is a complicated, chronic disease caused by an imbalance in energy expenditure and energy intake (Mahan et al., 2012). The excess energy is stored in fat cells that enlarge or increase in number in actions called hyperplasia and hypertrophy (Bray, 2003). The mass of the excess fat or the increased secretion of the fatty acids and peptides of the enlarged fat cells cause health repercussions associated with obesity, including a variety of diseases, such as diabetes mellitus, cardiovascular disease, metabolic syndrome, osteoarthritis, gallbladder disease, and some forms of cancer (Bray 2003). For more than 2,000 years, excess weight has had a deleterious effect on morbidity and mortality (Bray, 2003). The rising prevalence of overweight and obesity continues to increase in the US (Mokadad et al., 2001; Ogden et al., 2006). The epidemic of obesity has been linked to consumption of SSBs because of their promotion of positive energy balance by their high sugar content, low satiety effect, and incomplete compensation for energy (Mis, 2013).

Multiple studies have found an association between consumption of SSBs and obesity (Allison & Mattes, 2009; Berkey et al., 2004; Bray et al., 2004; Dhingra et al.,

2007; Malik et al., 2006; Nicklas et al., 2003; Schulze et al., 2004; Schwartz, 2003). The possible association between sweetened beverages and obesity could be the result of the excessive dietary energy intake provided by those liquid sources of energy (Gao &

Bermudez, 2010). As indicated above, satiety mechanisms are not as strongly regulated with the intake of liquid compared to solid foods (DiMeglio & Mattes, 2000). Another

potential association between SSBs and obesity is the amount of HFCS, which has been reported as a large proportion of all added sweeteners in the U.S. diet (Bray et al., 2004;

Bray, 2008). The metabolism of fructose decreases the production of insulin and leptin, which are two hormones involved in long-term regulation of energy homeostasis and body adiposity (Elliot et al., 2002; Teff et al., 2004). See Figure 1.

Figure 1

The Potential Association Between SSBs and Weight Gain and Obesity

In addition, fructose metabolism by the brain does not require the activation of the malonyl-CoA signaling pathway, which helps suppress food intake to prevent excessive weight gain (Lane & Cha, 2009). The findings of a cross-sectional study (Gao &

Bermudez, 2010) were consistent with the observations from cohort studies, including the prospective cohort analyses of the Nurses’ Health Study (Schulze et al., 2004) and the

Framingham study (Dhingra et al., 2007) as well an analysis in a Mediterranean cohort

(Bes-Rastrollo et al., 2006). Those studies reported that an excessive consumption of

SSBs was associated with an increased risk of weight gain. Higher intake of sweetened beverages in a sample of the U.S. population aged 20‒39 years was positively associated with obesity (Gao & Bermudez, 2010). Researchers reported that individuals who consumed six servings per day of sweetened beverages were twice more likely to have total and abdominal obesity than were those who did not drink the beverages.

Excessive intake of added sugars is another reason underlying the associations between the beverages and obesity (Drewnowski et al., 2004). Researchers found that 10 additional teaspoons of added sugars per day were associated with a 52% higher risk of obesity (Gao & Bermudez, 2010). In the US, half the added sugars consumed is in the form of HFCS, which happens to be a major sweetener in SSBs (Block, 2004; Guthrie &

Morton, 2000). A higher intake of fructose could stimulate long chain fatty acid synthesis and lead to hypertriglyceridemia (Mayes, 1993). Fructose has shown to reduce leptin production and increase insulin resistance and plasma uric acid production (Gao et al.,

2007; Havel, 2005; Wu et al., 2004). See Figure 2.

Figure 2

Effect of Fructose on Insulin Resistance

In addition, SSBs have been linked to obesity by gene–SSB interactions (Qi et al.,

2012). Individuals who consumed one or more servings of SSBs per day had genetic effects on body mass index (BMI) and obesity risk that were twice as high as those who consumed SSBs less than once per month. Data suggest that regular consumers of SSBs may be more susceptible to genetic effects on obesity or that persons with a greater genetic predisposition to obesity may be more susceptible to the detrimental effects of

SSBs on BMI. Excessive consumption of sweetened beverages and added sugars could affect diet quality because it may lead to the underconsumption of foods and drinks of high nutritional quality, leading to increased risk of obesity, type 2 diabetes mellitus, cardiovascular disease, and metabolic syndrome (Bray, 2003; Gao & Bermudez, 2010).

Type 2 Diabetes Mellitus

Type 2 diabetes mellitus (T2DM) is a chronic disease that involves a progressive insulin deficiency because of insulin resistance from the tissues (Mahan et al., 2012).

Insulin plays a crucial role in taking glucose and transferring it to the organs in the body.

When insufficient insulin comes from the pancreas, the result is the accumulation of high blood glucose in the blood. Insulin resistance is a condition in which cells fail to respond normally to insulin. Therefore, insulin resistance causes the increased need for insulin, leading to increased insulin production by the beta-cells, ultimately resulting in the pancreas losing its ability to produce insulin. Predisposing factors to T2DM include age, obesity, and lack of physical activity. According to the WHO (2016), T2DM has been estimated to be the seventh leading cause of mortality by 2030. The number of individuals with diabetes increased from 108 million in 1980 to 422 million in 2014.

Researchers have found that women who consumed one or more SSBs per day for eight years had an 83% greater risk of developing T2DM compared with those who consumed less than one SSB per month (Schulze et al., 2004). The potential association of high consumption of SSBs with an increased risk for T2DM development results from

SSBs providing excessive calories and large amounts of rapidly absorbable sugars (Malik et al., 2010). SSBs have been proven to rapidly raise blood glucose and insulin concentrations, and they are often consumed in large amounts, indicating their contribution to a high dietary glycemic load (Janssens et al., 1999).

Diets that have high glycemic load are known to induce glucose intolerance and insulin resistance particularly among overweight individuals (Schulze et al., 2004). High glycemic load diets can raise levels of inflammatory biomarkers (e.g., C-reactive protein), which are linked to the risk of T2DM (Liu et al., 2002). Cohort studies have indicated that a high dietary glycemic load increases the risk of developing cholesterol gallstone disease, which is associated with insulin resistance, metabolic syndrome, and

T2DM (Tsai et al., 2005). The endogenous compounds existent in SSBs, such as advanced glycation end products, produced during the process of caramelization in cola-type beverages may affect pathophysiological pathways related to T2DM and metabolic syndrome (Uribarri et al., 2007). In addition, SSBs may indirectly increase risk by promoting alterations in taste preferences and diet quality, resulting from frequent consumption of highly sweetened beverages (Brownell et al., 2009).

Evidence on fructose and T2DM has continued to grow, but minimal human studies have been conducted on fructose and T2DM; furthermore, the exact mechanism involving how fructose affects insulin secretion is still not completely understood.

Human studies have, however, shown that fructose together with another nutrient or compound can increase the likelihood of T2DM (Ang & Yu, 2018). The biochemical pathway of the ingestion of large amounts of fructose has suggested that increases of hepatic acetyl CoA led to increased production of VLDL and triglycerides, which is associated with T2DM (Stanhope et al., 2009). Fructose consumption elicits a low glycemic index and does not require insulin to be transported among cells (Tappy & Lê,

2010). Thus, the conversion of fructose to glucose increases the risk of T2DM; furthermore, fructose may also have a negative effect on blood glucose homeostasis by causing insulin resistance in the liver.

Scientific evidence has indicated that fructose can cause insulin resistance in humans (Ang & Yu, 2017). Human studies showing daily intake of fructose as high as

80 g (Hallfrisch et al., 1983), 110 g (Aeberli et al., 2013), 138 g (Stanhope et al., 2009), and approximately 250 g (Beck-Nielson et al., 1980) have suggested that fructose intake must be high to potentially cause insulin resistance (Sievenpiper et al., 2014). Many studies have shown the increase in insulin resistance upon consumption of fructose (Gao et al., 2007; Harrington, 2008; Havel, 2005; Hwang et al., 1987; Wu et al., 2004). In animal studies, the insulin resistance and obesity induced by long-term fructose feeding promotes hyperinsulinemia, which may lead to hypoglycemia or T2DM (Elliot et al.,

2002). Research findings have shown that fructose consumption may induce accumulation of visceral adipose deposition, indicative of a dysmetabolic state increasing risk of T2DM and cardiovascular disease (Després et al., 2008; Stanhope et al., 2009).

Cardiovascular Disease

Cardiovascular disease (CVD) is an array of interrelated diseases that include coronary heart disease (CHD), atherosclerosis, hypertension, ischemic heart disease, peripheral vascular disease, and heart failure (Mahan et al., 2012). Of all causes of death,

CVD is the leading cause of death in both men and women in the US, where one of every

2.9 deaths is attributed to CVD. According to national representative data, more than

50,000 cardiometabolic deaths in U.S. adults in 2012 were associated with high SSB consumption, causing SSBs to be the leading factor associated with cardiometabolic mortality in young and middle-aged adults (Micha et al., 2017). Excess SSBs were estimated to be the leading factor associated with cardiometabolic mortality between the ages of 25 and 64.

The effect of high amounts of SSB consumption on the causation of CVD can be attributed to several factors. One such factor, dependent on weight, is that excessive SSB consumption is linked to obesity, which is a risk factor for cardiometabolic outcomes.

The other factors associated with increased CVD risk, independent of weight, are the development of risk factors precipitated by adverse glycemic effects and increased fructose metabolism in the liver (Malik & Hu, 2015). The consumption of fructose and added sugars in SSBs are associated with high blood pressure and increased risk of cardiovascular disease in adolescents (Nguyen et al., 2009; Pollock et al., 2012; Welsh,

Sharma, Cunningham, & Vos, 2011). The harmful effects of high intake of SSBs have been repeatedly associated with increased risk of hypertension, coronary heart disease, and stroke as well as with adverse changes in lipid levels and inflammatory markers (de

Koning et al., 2012; Welsh et al., 2013). The American Heart Association has defined one component of an ideal cardiovascular diet as consisting of 450 calories or less per week of SSBs (Wersching et al., 2017).

Metabolic Syndrome

Metabolic syndrome (MetSyn) is considered a cluster of risk factors that precedes the development of T2DM and cardiovascular disease (Mahan et al., 2012). Its diagnosis is based on the presence of at least three of the following five risk factors: hyperglycemia, raised blood pressure, elevated triglyceride levels, low high-density lipoprotein (HDL) cholesterol levels, and central adiposity (Alberti et al., 2009). In the US 23% of adults were estimated to be diagnosed with metabolic syndrome (Beltran-Sanchez et al., 2013;

Saklayen, 2018).

Few prospective studies have been conducted on SSB intake in relation to the development of Met Syn possibly because of challenges in outcome assessment. A

Prevención con Dieta Mediterránea trial study found significant results indicating a positive association between SSBs and fruit juice with MetSyn among participants at high risk for CVD (Ferreira-Pego et al., 2016). Research studies investigating individual risk factors of MetSyn instead of its diagnosis have tended to be more consistent.

The Coronary Artery Risk Development in Young Adults study showed higher

SSB consumption was associated with a number of cardiometabolic outcomes that include high waist circumference, high low-density lipoprotein (LDL) cholesterol, high triglycerides, and hypertension (Duffey et al., 2010). A cohort study found that an increase in soda consumption by one serving per day was associated with a 1 cm increase in waist circumference over two years (Stern et al., 2017). The Framingham Third

Generation cohort study concluded that SSB intake was associated with a long-term

adverse change in visceral adiposity (Ma et al., 2016). A systematic review of five cohort studies investigating the association between SSB intake to vascular risk factors showed positive associations for blood pressure, triglycerides, LDL cholesterol, and blood glucose, and an inverse association for HDL cholesterol (Keller et al., 2015). The Health

Professionals Follow-up Study and Nurses’ Health Study cohorts support these findings, verifying associations between SSBs and higher plasma triglycerides, along with inflammatory cytokines and other cardiometabolic risk factors (de Koning et al., 2012;

Yu et al., 2018).

Growing evidence has indicated the role of SSBs in the development of hypertension (Jayalath et al., 2015; Kim & Ye, 2016; Xi et al., 2015). A meta-analysis comprising six cohort studies showed that an increase of a one serving per day in SSB intake was associated with approximately 8% higher risk of hypertension (Kim et al.,

2016). A meta-analysis of 39 randomized controlled trials demonstrated that higher intakes of dietary sugars or SSBs in comparison to lower intakes significantly raised triglyceride concentrations total cholesterol, LDL cholesterol, and HDL cholesterol (Te

Morenga et al., 2014). In addition, this meta-analysis showed a significant blood pressure-raising effect of sugars, particularly in studies ≥ 8 weeks in duration. Significant results in a two-week parallel-arm trial that showed consuming beverages containing

10%, 17.5%, or 25% of energy requirements from HFCS produced a significant linear dose–response increase in postprandial triglycerides, fasting LDL cholesterol, and 24-h mean uric acid concentrations (Stanhope et al., 2015). In a different study, results showed

an increase in uric acid after six months of consuming 1 L/day of sucrose-sweetened cola compared to isocaloric consumption of milk, water, or diet beverages; the change in uric acid correlated with changes in liver fat, triglycerides, and insulin (Bruun et al., 2015). A randomized crossover study among normal-weight healthy men showed that consumption of SSBs in small to moderate amounts for three weeks resulted in impaired glucose and lipid metabolism and promoted inflammation (Aeberli et al., 2011).

Other Health Concerns

The consumption of SSBs is associated with other health concerns that include tooth decay, reduced bone mineral density, and negative effect on the gastrointestinal system.

Tooth Decay

The effect of SSB consumption on oral health is associated with tooth decay. The proposed mechanism of SSBs causing tooth decay is that more frequent exposure to sugar between meals increases caries activity and higher decay-missing-filled (DMF) index than consuming sugar at meals (Ismail et al., 1984). Individuals who consume four or more soft drinks between meals are associated with 179% increase in odds of having a high DMF index. Carbonated drinks typically have a pH of 2 or 3 and can cause marked loss of tooth structure by erosion (Mishra & Mishra, 2010). The main component in SSBs responsible for the formation of dental caries is sugar. Considered the most cariogenic sugar—promoting the production of dental caries—sucrose is capable of forming glucans that enable bacterial adhesion to teeth and limit diffusion of acid and buffers in the plaque

(Bowen et al., 1997). The consumption of SSBs is, therefore, associated with increased risk of dental caries because of the high sugar content and acidity in SSBs that can result in enamel erosion over time (Ismail et al., 2009; Warren et al., 2009).

Reduced Bone Mineral Density

Numerous studies have been conducted to investigate the negative association of

SSBs, especially carbonated drinks, on bone mineral density (Goulding, 2007; Ogor et al., 2007; Root, 2002; Tucker et al., 2006; Vartanian et al., 2007; Wyshak & Frisch,

1994). Excessive consumption of carbonated beverages may negatively affect bone metabolism and predispose to fracture (Goulding, 2007; Root, 2002). Research evidence shows that increased cola beverage intake is associated with reduced bone mineral density, increased bone fracture risk at any age, and an increased risk of osteoporosis later in life (Wyshak & Frisch, 1994).

Some components existent in the cola beverage formulation, such as caffeine, phosphoric acid, caffeine, sugar, caramel coloring, carbon dioxide, and aluminum, may contribute to the association between cola beverage and bone metabolism disorders. Soft drinks contain high amounts of phosphorus with no calcium content (Vartanian et al.,

2007). High amounts of caffeine, phosphoric acid, and fructose in soft drinks were shown to interfere with calcium absorption and contribute to imbalances that lead to additional loss of calcium (Amato et al.,1998; Milne & Nielsen, 2000; Rapuri et al., 2001). The high caffeine and phosphorus content in colas may cause an increased acid load in the body,

which may influence the calcium/phosphorus ratio and bone mineral density (Ogor et al.,

2007).

A research study has shown women who consume soft drinks daily have lower bone mineral density than that of nonconsumers (Tucker et al., 2006). Another possible mechanism is that acidifying dietary constituents may adversely affect calcium metabolism and accelerate bone resorption (Buclin et al., 2001). The acid load characteristic of cola drinks may contribute negative effects on calcium and bone metabolism by causing an increase in bone resorption and calcium mobilization and decrease in 25-hydroxyvitamin-D production (Garcia-Contreras et al., 2000). In addition, high caffeine content in cola beverages has been associated with reduced bone mineral density and increased fracture risk (Hernández-Avila et al., 1993; Ohta et al., 1999).

Beverages with both phosphoric acid and caffeine increase urinary calcium excretion, and this may contribute to reduced bone mineral density (Tucker et al., 2006). Research evidence has shown significant increase in alkaline and acid phosphatases in serum, urine, and bone after five or seven months of Coca-Cola consumption (Hassan &

El-Komy, 2008; Serag, 2015). Long-term consumption of Coca-Cola caused an increase in bone resorption (as indicated by elevation of the calcium/creatinine ratio and minerals excretion in urine), resulting in increase in the bone formation as manifested by elevation of ALP activity in serum, urine, and bone (Hassan & El-Komy, 2008).

Negative Effect on Gastrointestinal System

Several findings have shown the effect of SSBs on the gastrointestinal system in existing studies conducted on humans (Ericson et al., 2020; Ramne et al., 2020;

Zhernakova et al., 2016). SSB consumption causing hyperglycemia may result in alteration of the gut-barrier function and increase the risk of enteric infection (Thaiss et al., 2018). Increased consumption of simple sugars (such as those found in SSBs) cause reduced bacterial gut diversity, activity, and gene expression, which may promote obesity and metabolic dysfunction (Greenblum et al., 2012; Ley et al., 2006; Turnbaugh et al.,

2008). Researchers have proposed that an increased consumption of sugar results in an unfavorable microbiota composition (Di Rienzi & Britton, 2020; Payne et al., 2012).

How sugar consumption effects the gut microbiota is unclear because of the absorption of sugars in the small intestine; therefore, they do not reach the colon (Ramne et al., 2020).

High intake of fructose, however, reaches the colon, which is proposed to affect the gut microbiota composition (Payne et al., 2012). Most of the studies involving the effect of sugar on the gut microbiota composition are animal studies (Do et al., 2018; Rosas-

Villegas et al., 2017; Ruiz-Ojeda et al., 2019).

Current Trends in Dietary Intake and Behavior in College Students

The burdens resulting from SSB intake are relatively unique because of their predominant proportional impact on the young. Throughout much of the world, intake at younger ages is far higher than later in life. Consequently, the proportional mortality attributed to SSBs is remarkably high among younger adults, exceeding one in 10 of all

diabetes and obesity-related deaths in nearly every region of the world. Younger adults comprise the largest proportion of the workforce in most countries, producing tremendous economic losses related to SSB intake in these age groups (Singh et al.,

2015).

College students develop dietary habits during college as they gain responsibility and control of their diets. During this crucial period, most college students are no longer dependent on caregivers to prepare their meals or buy their groceries. According to the literature, college plays an important role for young adults in terms of food choices and their relationship with weight gain (Crombie et al., 2009; Racette et al., 2008; Vella-Zarb

& Elgar, 2009). College students tend to gain more weight compared to those who do not attend universities (Mokdad et al., 1999). The relationship between college students and their eating behaviors is influenced by university characteristics, such as living arrangements (e.g., dormitory, off-campus, with parents) or academic schedules (e.g., classes, exams; Deliens et al., 2014; Irwin, 2004; Nelson et al., 2009).

The common barriers to healthy eating among college students (Sogari et al.,

2018) include time constraints, unhealthy snacking, convenience high-calorie food, stress, high prices of healthy food, and easy access to junk food. During this period, college students typically participate in excessive alcohol consumption and low levels of physical activity. Few young adults meet recommendations to consume at least two cups of fruit and two to three cups of vegetables daily (Larson et al., 2012). Because of time constraints, to purchase snacks, college students find themselves using vending machines,

which usually offer unhealthy snacks high in sugar. Overall SSB intake has been associated with vending machines and fast-food restaurants (Wiecha et al., 2006).

The major source of dietary sucrose and fructose is SSBs (Malik & Hu, 2015).

According to the CDC (2010), soft drinks are the main source of added sugars in the diet.

SSB consumption has been found highest among older adolescents or those completing their first or second year of college (CDC, 2010). Undergraduates reported that they consume significant amounts of SSBs (West et al., 2006), the increased consumption of which among college students has been linked to increased portion sizes (Nielson &

Popkin, 2004). Furthermore, SSBs contribute to an increase in postprandial blood glucose levels, decrease insulin sensitivity, and decrease satiety levels, leading to overeating

(Harrington, 2008). Higher intake of SSBs is associated with higher energy intake, lower intake of fiber, orange juice, and low-fat milk, added sugars and carbohydrates

(Bermudez & Gao, 2010). Frequent SSB consumption is linked to infrequent breakfast meals, low fruit and vegetable intake, and food insecurity (Sharkey et al., 2011).

Long-term (age 25 to 33 years) high consumers of SSBs demonstrated higher caloric intake; fewer of them were physically active, and a higher proportion regularly smoked when compared to long-term low consumers. In addition, high stability of SSB intake from early adulthood into later adulthood has been found (Kvaavik et al., 2005).

Following a healthy diet during young adulthood can help achieve optimal health and decrease risk of chronic diseases (Hong et al., 2016). According to the literature, consumption of a nutrient-dense diet in young adulthood helps protect against chronic

diseases and excess weight gain in the future (Archer et al., 1998; Brooks et al., 2006;

French et al., 2000; Ludwig et al., 1999; Pereira et al., 2002, 2005; Raitakari et al., 1994;

Steffen et al., 2005; Yoo et al., 2004). Factors that promote healthy behavior include improved food knowledge and education, meal planning, involvement in food preparation, and participating in physical activity (Sogari et al., 2018).

CHAPTER III

METHODOLOGY

Research Design

The research design of the current investigation was quantitative, nonexperimental, and retrospective. Research was extracted from preexisting data collected as part of homework assignments and class activities in three sections of a sophomore introductory-level nutrition course at a Midwestern public university.

Independent and dependent variables for analytical purposes included SSB consumption and BMI, respectively. Approval for the analysis of preexisting data was granted by the

Kent State University Institutional Review Board (IRB) after data collection was completed and students were assigned an identification number to maintain their anonymity.

Participants

Data obtained from 232 students were used to assess SSB consumption and BMI from three sections of Science of Human Nutrition. The students enrolled in this course during spring 2017 ranged from 18 to 24 years in age and pursued diverse majors, including nutrition, hospitality management, human development, other, and undeclared.

The exclusion criteria included ages younger than 18 and older than 25, incomplete surveys, unrealistic diets that were too high (over 5,000 kcal per day) or too low (under

500 kcal per day) in calories, missing caloric intake, and missing beverage intake.

Retrospective Data Collection Overview

The original data obtained from students was a part of their course requirements:

The questionnaires were considered class assignments and the dietary record was their course project; thus, students received credit for completing the questionnaires and dietary records. During the first class, the primary investigator instructed students on how to complete a four-day dietary record. Students also were provided time to complete the demographic, health perception and knowledge, lifestyle, and physical activity questionnaire. Once completed, the questionnaires were collected by trained research assistants, and the dietary record was sent home with students as a take-home assignment.

Students were given a week to complete the dietary record. During the second week, upon completion of dietary records, students were interviewed for 30 minutes by the researchers to validate their dietary record. To avoid education about nutrition-related topics that could influence their survey and dietary records responses, all data were obtained from the students by the end of the second week of the semester so that they had learned only about food safety and digestion in class.

Questionnaires

In the current study the elements of the survey that were of particular interest included demographic information, anthropometric measurements, and SSB consumption. The demographic questionnaire included birth date, age, weight, and height information collected with 23 other questions covering the following: gender, class standing, major, course load, GPA, any college-level nutrition level course, ethnicity, car

availability, mother’s highest education, father’s highest education, employment status, occupation, family’s annual income, individual’s monthly income, health insurance, blood cholesterol level, yearly physical exam, marital status, children (if any), current living arrangements, medical conditions, food restrictions resulting from medical conditions, and presence of food allergies.

Therefore, the current study included an examination of a three-day dietary record that included two weekdays and one weekend day, representative of typical intake.

Anthropometric Measurements

On the day of the anthropometric measurement, students were required to attend the assessment at sunrise and were instructed not to eat two hours before measurement and to wear lightweight clothing. Upon students’ arrival, they had a three-minute resting period before measuring their blood pressure three times and then averaging the readings.

Students’ height was measured to the nearest tenth, using Seca’s measuring rod with participants standing in bare feet. Students’ weight, body composition, and BMI (kg/m2 ) were measured using TANITA Bioelectrical Impedance Analysis (BIA) TBF-410, a body composition analyzer. The electrodes in the BIA machine were cleaned with alcohol pads between measurements to avoid inaccurate readings. BMI measurements were made after

consent in a closed area by researchers of the same gender to ensure privacy and comfort.

All the measurements were performed by trained research staff.

SSB Intake

SSB intake was obtained from students’ written food records using a beverage intake log created for the current study. It included rows for the types of SSBs: lemonade, soft drinks, fruit drinks, smoothies, sports drinks, energy drinks, sweetened coffee, sweetened tea, flavored milk, and other SSBs. The beverage intake log had columns labeled Day 1, Day 2, Day 3, 3-day total, and the average of the drink per day. Day 1 and

Day 2 were the two weekdays, and Day 3 was the weekend day. The average intake of each drink was calculated by dividing the number of fluid ounces per day by the number of total days (three). The beverages were calculated using fluid ounces per drink.

The beverage intake log, which was developed to measure consumption of SSBs among college students, appears in Appendix A. SSB consumption was measured by categorizing drinks as follows: lemonade, soft drinks, fruit drinks, smoothies, sport drinks, energy drinks, energy shots, sweetened coffee, sweetened tea, flavored milk, and flavored water.

Statistical Analysis

Statistical Package for the Social Sciences (SPSS), version 24, was used for statistical analysis. Descriptive statistics were used to analyze demographic information and consumption of SSBs. ANCOVA was used with BMI as the independent variable and average amount of SSB intake, average sugar intake from SSBs, and average calorie

intake from SSBs as the dependent variables. The variables were controlled by average caloric intake per day as a covariate. BMI was treated as a categorical variable, whereas average amount of SSB intake, average sugar intake from SSBs, and average caloric intake from SSBs were treated as continuous variables. BMI was categorized as underweight‒normal, overweight, and obese. The significance of the results was set at p-value < 0.05.

CHAPTER IV

JOURNAL ARTICLE

SSBs, which include excessive sugar content and dietary energy that can result in weight gain and the risk of health comorbidities, often replaces nutrient-dense beverages like milk. According to the 2015 World Health Organization (WHO) guideline on the intake of free sugars, a single can of sugar-sweetened soda contains approximately the upper limit of the recommended 25–50 grams per day.

Excessive sugar consumption has been linked to weight gain, which can predispose individuals to diabetes, cardiovascular disease, and metabolic syndrome

(Bray, 2003; Gao & Bermudez, 2010; Mis, 2013). Considered a major source of added sugar in the diet, SSBs have been defined as drinks containing high sugar content in the form of table sugar or high-fructose corn syrup (Centers for Disease Control [CDC],

2017), including but not limited to the following drinks: sodas, sweetened coffee, sweetened tea, and sport drinks. The consumption of SSBs has been associated with weight gain because of their high caloric density; furthermore, consumption of sugar in liquid form has shown a weak satiety effect compared to consuming sugar in solid form

(DiMeglio & Mattes, 2000). In addition, studies have shown that SSB consumption is linked to weight gain because of the higher lipogenic effect of fructose and more pronounced genetic predisposition to an elevated BMI and increased risk of obesity

(Mayes, 1993; Qi et al., 2012). Research has shown the link from high intake of SSBs to higher energy intake, added sugars, and carbohydrates as well as a lower intake of fiber, orange juice, and low-fat milk (Gao & Bermudez, 2010). SSB consumption has increased worldwide particularly among young adults (Lundeen, Park, Dooyema, & Blanck, 2018), the prevalence of which demonstrates a pivotal concern because young adulthood is a time when people develop long-term habits and lifestyles that may influence their risk of chronic diseases and their relationship with weight gain (Crombie et al., 2009; Hong et al., 2016; Racette et al., 2008; Vella-Zarb & Elgar, 2009; West et al., 2006).

Various studies have been conducted on college students’ beverage consumption, but most of them have focused on specific drink types or broad consumption patterns

(Han & Powell, 2013; (Lundeen, Park, Dooyema, & Blanck, 2018; West et al., 2006).

Limited studies have focused on overall SSB consumption among adults in relation to body weight status (Bawadi et al., 2019; Gao & Bermudez, 2010). The introduction of more SSBs, such as caffeinated drinks, energy drinks, energy shots, and sports drinks, has increased the importance of studying college students’ intake because this stage of their lives is a critical period in developing long-term habits a well as a time when they are particularly vulnerable to weight gain (West et al., 2006). In this study the exploration of

SSB consumption and its association with BMI during adulthood and its consequences has laid a foundation for evidence-based interventions aimed at college students to help

educate them and change their patterns of SSB consumption. The purpose of this study was to compare the consumption of SSBs in BMI groups among college students at a

Midwestern public university.

Methodology

Research Design

Independent and dependent variables for analytical purposes included SSB consumption and BMI, respectively. Approval for the analysis of preexisting data was granted by the

Kent State University Institutional Review Board (IRB) after data collection was completed and students were assigned an identification number to maintain their anonymity.

Participants

The exclusion criteria included ages younger than 18 and older than 25, incomplete

surveys, unrealistic diets that were too high (over 5,000 kcal per day) or too low (under

500 kcal per day) in calories, missing caloric intake, and missing beverage intake.

Retrospective Data Collection Overview

The original data obtained from students was a part of their course requirements, in which the questionnaires were considered class assignments and the dietary record was their course project; therefore, students received credit for completing the questionnaires and dietary records. During the first class, the primary investigator instructed students on how to complete a four-day dietary record. Students also were provided time to complete the demographic, health perception and knowledge, lifestyle, and physical activity questionnaire. Once completed, the questionnaires were collected by trained research assistants, and the dietary record was sent home with students as a take-home assignment.

Questionnaires

information collected with 23 other questions covering the following: gender, class standing, major, course load, GPA, any college-level nutrition level course, ethnicity, car availability, mother’s highest education, father’s highest education, employment status, occupation, family’s annual income, individual’s monthly income, health insurance, blood cholesterol level, yearly physical exam, marital status, children (if any), current living arrangements, medical conditions, food restrictions resulting from medical conditions, and presence of food allergies.

In the original investigation a four-day dietary record was collected. The current study, however, eliminated dietary intake recorded on Friday because preliminary data analysis showed that Friday intake fell between weekday intake and weekend day. The current study included an examination of a three-day dietary record that included two weekdays and one weekend day, representative of typical intake.

Anthropometric Measurements

between measurements to avoid inaccurate readings. BMI measurements were made after consent in a closed area by researchers of the same gender to ensure privacy and comfort.

All the measurements were performed by trained research staff.

SSB Intake

Statistical Analysis

and average amount of SSB intake, average sugar intake from SSBs, and average calorie intake from SSBs as the dependent variables. The variables were controlled by average caloric intake per day as a covariate. BMI was treated as a categorical variable, whereas average amount of SSB intake, average sugar intake from SSBs, and average caloric intake from SSBs were treated as continuous variables. BMI was categorized as underweight‒normal, overweight, and obese. The significance of the results was set at p-value < 0.05.

Results

The study included data from 209 of the 250 students enrolled in the three sections of Science of Human Nutrition. Data from 28 students were excluded, because they did not report their beverage intake at all. In addition, data from 13 students were excluded because of missing caloric intake, so sums were appropriately represented in the statistical analysis. This resulted in the exclusion of 41 students, and a final sample of

209 college students was used. Table 8 provides the demographic characteristics of the sample. A little more than two thirds of sample was female students. Approximately half the students were freshmen and a third were sophomores, followed by juniors and then seniors.

Table 9 shows the average three-day intake of consumption of fluid ounces of

SSBs among the study population. Soft drinks were the most consumed SSBs followed by sweetened coffee and sweetened tea in that order. The most popular SSB among college students was sweetened coffee, about a quarter of the students consuming it

Table 8

Demographic Characteristics of Midwest College Students Enrolled in Three Sections of a Sophomore-Level Nutrition Class (N=209)

Demographics Mean % (n) Age (years) 19.48 Sex Male 26.8% (56) Female 73.2% (153) Class Standing Freshman 55.2% (116) Sophomore 27.1% (57) Junior 10.5% (22) Senior 6.7% (14) BMI Groups Underweight‒Normal 54.1% (113) Overweight 26.8% (56) Obese 19.1% (40)

Table 9

Average Three-Day Intake of Sugar-Sweetened Beverages (fl. oz) in College Students

Enrolled in Three Sections of a Sophomore-Level Nutrition Class (N=209)

Mean (SD) %

Sweetened Coffee 5.73 (13.11) 24.2 Specialty Coffee 1.81 (9.58) 11.7 Coffee with add-ins 3.75 (19.86) 12.5 Soft Drinks 6.72 (17.6) 21.1 Cola Drinks 5.16 (29.2) 14.3 Noncola Drinks 2.25 (9.0) 6.7 Sweetened Tea 4.01 (10.57) 15.8 Sport Drinks 3.98 (11.35) 14.4 Lemonade 2.12 (6.05) 11 Flavored Milk 1.21 (4.63) 8.6 Fruit Drinks 1.48 (6.99) 6.2 Shakes .75 (3.39) 5.3 Smoothie .54 (3.09) 3.3 Energy Drinks .16 (1.30) 1.4 Flavored Water .14 (1.54) 1 SD = Standard Deviation

during the three-day period. The second most popular SSB was soft drinks with 21.1% of the students consuming soft drinks during the three-day period. The average SSB intake of the study population was 9.54 fluid ounces during the three-day period. The average water intake of the study population was 54.6 fluid ounces. The average caloric intake derived from SSBs was 99.83 calories, and the average total energy intake was 1998.81 calories, is approximately 5% of the average total caloric intake. The average sugar intake derived from SSBs was 20.56 grams.

Table 10 illustrates the results of the ANCOVA analysis of the underweight‒normal, overweight, and obese students and their average SSB intake, average caloric intake from SSBs, and average sugar intake from SSBs when controlled for average total caloric intake. Contrary to the initial hypothesis, no significant differences were detected in average SSB intake, average calories from SSBs, and average sugar from SSBs across BMI categories (p >.05).

Discussion

The purpose of this study was to compare the consumption of SSBs by college students in BMI groups at a Midwestern public university. The study showed no significant differences in SSB consumption across BMI categories; therefore, the null hypothesis was rejected. Because more than half the students were women (73.2%) and freshman (55.2%), the participant pool was not representative of the gender ratio of the university’s population, which is 66% female students and 34% male students.

Table 10

Analysis of Covariance Examining Average SSB Intake, Average Calories From SSBs, and Average Sugar Intake From SSBs Among BMI Categories of College Students

Enrolled in Three Sections of a Sophomore-Level Nutrition Class (N=209)

Underweight‒ Overweight Obese Normal (n=113) ( n =56) (n=40) Variable Mean (SD) Mean (SD) Mean (SD) p Average SSB 8.93 (9.34) 9.08 (19.09) 11.92 (14.56) .371 Intake (fl. oz)

Average Calories 103.42 (113.65) 71.12 (112.78) 129.88 (169.82) .078 from SSBs (kcal)

Average Sugar 20.33 (23.49) 16.56 (27.81) 26.82 (39.92) .170 from SSBs (g) Note. Model controlled for average caloric intake. SD = Standard Deviation.

Sugar-Sweetened Beverages and BMI

In the past decade, numerous studies have shown the association between the consumption of SSBs and weight gain (Bermudez & Gao, 2010; Bes-Rastrollo et al.,

2006; Dhingra et al., 2007). The potential association between SSBs and weight gain could be explained by the high caloric density of SSBs. This was supported by a study that showed an increase in the consumption of SSBs in parallel with an increase in total caloric consumption by an average of 358 calories per day, which was mainly from soda

(Schulze et al., 2004). Furthermore, consumption of sugar in liquid form has shown a weak satiety effect compared to consuming sugar in solid form (DiMeglio & Mattes,

2000). Multiple studies have shown that individuals who increased liquid carbohydrate consumption did not reduce their solid food consumption (Anand & Basiotis, 1998;

Berkey et al., 2004; R. K. Johnson & Frary, 2001; Kant, 2000; Kvaavik et al., 2005;

Rodriguez-Artalejo et al. 2003; Troiano et al., 2000). Studies have also suggested that

SSB consumption might be linked to weight gain because of the higher lipogenic effect of fructose and more pronounced genetic predisposition to an elevated BMI and increased risk of obesity (Mayes, 1993; Qi et al., 2012).

In this study, SSB consumption was higher compared to studies conducted one or two decades earlier than the current study. SSB consumption in college students is a concern because they are vulnerable to weight gain during this time in their lives (West et al., 2006). A meta-analysis showed that almost two thirds of students gained 3.5 kg (7.5 lbs.) weight during their first year of university attendance, and one in 10 students gained at least 6.8 kg (15 lbs.; Vadeboncoeur, 2015). Therefore, research findings suggest the first years of college are critical period to develop weight gain prevention efforts

(Lloyd-Richardson et al., 2009). In fact, college students are more prone to weight gain compared to those who do not attend university (Mokdad et al., 1999).

The results from the current investigation were inconsistent with several studies that showed significant association between increased consumption of SSBs with elevated risk of weight gain (Bermudez & Gao, 2010; Bes-Rastrollo et al., 2006; Dhingra et al., 2007; Schulze et al., 2004). Discrepancies in the research evidence on the question of SSBs and increased risk of weight gain or obesity could be explained by multiple reasons. First, various inconsistencies and methodological difficulties in research studies to measure beverage intake cause a challenge to fully evaluate the question and draw

definitive conclusions. The inconsistency in the literature might be accounted for by differences in SSB definition, sample size, survey administration, and methods of assessing weight status. Second, human studies are influenced by biases, which is apparently seen in studies with self-reported dietary intake (Bolton-Smith & Woodward,

1994; Poppitt et al., 1998). Third, this investigation involved body mass index as a screening tool to identify weight status, which is affected by other factors like physical activity, which was not controlled for in this study. Finally, an understanding of the effect of SSB consumption on weight status can be hindered by neglecting other influential factors that affect weight gain and obesity.

Consumption of Sugar-Sweetened Beverages

SSB consumption has not been thoroughly studied in the literature because many researchers have neglected sweetened coffee (Park et al., 2015; Marriott et al., 2019) and focused on soft drinks (Apovian, 2004; Dhingra et al., 2007; Schulze et al. 2004).

Previous researchers have focused on soft drinks because of this high sugar content and increased consumption during the early 2000s (Vartanian et al., 2007); however, soft drink consumption has steadily decreased in the past decade because of a shift to diet soft drinks (Welsh, Sharma, Grellinger, & Vos, 2011). Researchers who investigated overall sweetened beverages found that they contributed an important proportion of energy to the total energy intakes of young adults: At least eight of 10 young adults drank sweetened beverages at a level of intake that placed those dietary factors among the main contributors of dietary energy in the diets of that population group (Gao & Bermudez,

2010). These findings have suggested that a decrease in soft drinks consumption is not equivalent to a decrease in SSB consumption among young adults, but it might instead indicate young adults consume other SSBs.

In this study, SSBs were defined as drinks that are sweetened with added sugar; these include soft drinks, sport drinks, fruit drinks, energy drinks, smoothies, shakes, sweetened coffee, sweetened tea, lemonades, flavored milks, and flavored waters. The diverse definitions of SSBs in the literature have caused discrepancy in results designed to determine whether SSBs should be considered a health concern (Bleich et al, 2018;

Malik et al., 2013; Marriott et al., 2019; Mendez et al., 2019).

The current investigation showed that a little less than two thirds of students

(~65%) consumed SSBs during the three-day period with average intake of 9.54 fluid ounces, about 1.2 servings, slightly higher than results from other studies in which SSB consumption was examined among young adults (Bawadi et al., 2019; Kit et al., 2013).

According to the NHANES, 50.6% of U.S. adults consumed at least one SSB daily, but

Bawadi et al. (2019) reported that 60% of students consumed SSBs daily. Based on global survey data, adults over age 20 reported an average of 0.58 serving per day of

SSBs (Singh et al., 2015). In the United States, the average SSB consumption by young adults was 0.73 servings per day. The discrepancies among studies could be the result of variability in the definitions of SSBs and data collection. Few studies included all types of SSBs (Bleich et al., 2018; Malik et al., 2013; Marriott et al., 2019; Mendez et al.,

2019), and some used 24-hour recalls to examine SSB consumption (Bleich et al., 2018;

Marriot et al., 2019). The most consumed SSB among students was soft drinks, followed by sweetened coffee and sweetened tea. The results of both Bawadi et al. (2019) and

Singh et al. (2015) indicated that the prevalence is evident among young adults, raising a concern that increased SSB consumption might replace more nutritious beverages, such as water or milk (Zheng et al., 2015). In addition, SSBs are high in calories and sugar content, indicating that overconsumption of SSBs might increase the risk of weight gain, type 2 diabetes, fractures, and dental caries over time (Archer et al., 1998; Brooks et al.,

2006; French et al., 2000; Ludwig et al., 1999; Pereira et al., 2002, 2005; Raitakari et al.,1994; Steffen et al., 2005; Yoo et al., 2004).

Soft Drinks

The highest average of intake of SSBs in the current study was derived from soft drinks, which was equivalent to 6.72 fluid ounces during the three-day period. A study showed that one serving of soda (8 ounces) per day can result in a weight gain of 15 pounds or 6.75 kilogram in one year (Apovian, 2004). This suggests that, theoretically, students in this study can gain about 7.5 pounds or 3.4 kilograms in one year if they maintain their soft drink intake at the current level, possibly leading to substantial weight gain throughout their college years. About one fifth (21.1%) of the students in the current study reported soft drink consumption during the three-day period. This finding was lower than a previous study, which reported that 37% of college students consumed soft drinks daily (West et al., 2006). The discrepancy in the results could be attributed to differences in modes of survey administration and methods of data collection. The other

study included college students who volunteered to complete a demographic and semiquantitative food frequency questionnaire. In addition, previous research has shown that consumption of sugary soft drinks has steadily decreased in the past decade because of a shift to diet soft drinks (Welsh, Sharma, Grellinger, & Vos, 2011); and the results of current study may reflect the trend. Although soft drink consumption has decreased, nondiet soft drinks still remain the leading source of added sugars in the U.S. diet

(Marriott et al., 2010; Nielsen & Popkin, 2004).

College students’ consumption of soft drinks can be explained by increased accessibility and exposure to soft drinks, which can be found in vending machines, fast food locations, and campus food sites. Researchers have questioned whether actions or interventions are needed to decrease soft drink consumption and whether they can benefit public health (Vartanian et al., 2007). Research evidence has shown a positive association between soft drink consumption and the consumption of fast food like hamburgers and pizza (Bes-Rastrollo et al., 2006). Another study found soft drink consumption negatively related to an overall healthy eating index (Rodriguez-Artalejo et al., 2003).

Sweetened Coffee

This study is one of the few in which sweetened coffee was considered a SSB; other studies excluded sweetened coffee (Park et al., 2015; Marriott et al., 2019). The findings of this study could not be compared to previous studies because of the lack of research conducted on sweetened coffee. Sweetened coffee has been neglected in research as a result of dietary questionnaires that provided no quantitative estimate for

added sugar. For instance, the NHANES survey measured sugar added to coffee by asking “How often is sugar added to your coffee?” Responses ranges from “Never” to “6 or more per day” (Thomas & Hodges, 2019).

In the current research, students consumed an average of 5.73 fluid ounces during the three-day period. In the meantime, sweetened coffee was the most popular SSB among college students, with 24.4% of the participants consuming sweetened coffee.

These findings were expected because coffee is one of the most consumed beverages among U.S. adults, accounting for 14.9% of total nonalcoholic beverage consumption among them (C. B. Martin et al., 2020). The results of the current investigation were lower compared to those of the NHANES study, which reported that 51% of U.S. adults were coffee drinkers and two thirds of the coffee drinkers added sugar to their coffee (An

& Shi, 2017). This translates into approximately 34% of U.S. adults drinking sweetened coffee. The discrepancy in the results can derive from the difference in data collection methods and the age of study populations. The other study used NHANES data from

2001‒2012 that examined 24-hour dietary recalls from adult population; whereas the current investigation collected SSB consumption data using three-day dietary records from college students.

The consumption of coffee with added sugar can be a concern because sweetened coffee might reduce the health benefits of coffee (O’Connor et al., 2018). Research has shown that the addition of sugar to coffee was associated to glycaemia and inflammatory markers. In addition, high caffeine content in coffee has a negative impact on hydration

status because of its diuretic effect. The current study population was vulnerable to dehydration because sweetened coffee was the most commonly consumed SSB and the average water intake was 54.6 fluid ounces, less than the Institute of Medicine recommendations for water intake for men (at least 101 ounces) and women (74 ounces).

The National Coffee Data Trends (NCDT) report showed a significant change in the quality of coffee rather than quantity as gourmet coffee achieved a new high of 61% in sales in 2019. Adroit Market Research (2019) also reported estimates that 30 million U.S. adults daily drink specialty coffee drinks (mocha, espresso, latte, cappuccino, mocha café, and coffee beverages). Other research has shown that adults aged 18‒39 were more likely than older coffee consumers to purchase coffee away from home (National Coffee

Association, 2015). One study showed that college women who consumed gourmet coffee drinks consumed 206 more calories and 32 more grams of sugar per day than those who consume nongourmet coffee (Shields et al., 2004). This finding suggests that consumption of sweetened coffee during college years might contribute to weight gain in this population.

Sweetened Tea

The third common type of SSB among college students was sweetened tea: 15.8% of students consumed sweetened tea during the three-day period, and the daily average intake was 4.01 fluid ounces. These results are lower than those from another study in which 33.4% of tea drinkers consume tea with caloric add-ins, mainly sugar (An & Shi,

2017). The discrepancy in results can derive from the larger sample size of 6,215 young

adults reporting tea consumption with add-ins compared to the present study. In addition, the study used logistic regression to estimate the odd ratios of tea consumption with add- ins; however, this study included descriptive data to quantify sweetened tea consumers from the overall study population.

Tea is widely popular, and consumption continues to increase in Western countries because of its overall health benefits; however, researchers investigating the association between tea with add-ins and body weight status found that the use of add-ins reduced a beneficial effect of tea—weight loss (Bouchard et al., 2010; Mukhtar &

Ahmad, 2000). Consumption of sweetened tea has been positively associated with an increase in daily energy intake of 43 calories, mainly from sugar (An & Shi, 2017).

Research on sweetened tea is limited because most researchers have focused on tea without added sugars (Cabrera et al., 2006; Chin et al., 2008; Mukhtar & Ahmad, 2000).

Recent reports showed an increase in sales of sweetened tea in the US (IBIS World,

2020), so further research is needed.

Sugar Intake and Calorie Intake From Sugar-Sweetened Beverages

Many research studies have shown a positive association between calories derived from unhealthy sources (e.g., sugary drinks and potato chips) and weight gain

(Ello-Martin et al., 2007; Ledikwe et al., 2007; Mozaffarian et al., 2011; Rolls et al.,

2005). Previous findings from various studies have shown that excessive caloric intake from SSBs affected diet quality because of underconsumption of foods and drinks of high nutritional quality (Bray, 2003; Gao & Bermudez, 2010). The Dietary Guidelines for

Americans, therefore, include a recommendation that added sugars should not exceed 200 calories per a day for a 2,000-calorie diet (U.S. Department of Health and Human

Services and U.S. Department of Agriculture, 2015).

The current study showed that 5% of kcal (99.83/1998.81 kcal) consumed by participants daily was derived from 20.56 grams of added sugar to SSBs. The Dietary

Guidelines for Americans recommend that no more than 10% of daily calories consumed should derive from added sugars, that is, approximately 50 grams of added sugar for

2,000 calories per day (U.S. Department of Health and Human Services and U.S.

Department of Agriculture, 2015). The American Heart Association has suggested a stricter limit for added sugars with no more than 100 calories for women and 200 calories for men, which is equivalent to 24 and 36 grams of sugar, respectively. Although current study findings did not exceed those recommendations, college students who consumed more than one SSB per day might have exceeded these recommendations. This investigation did not explore per capita SSB consumption, which would have resulted in higher average of sugars and calories intake derived from SSBs. In addition, college students consume other sources of added sugar, such as cereals or candies, which would lead to exceeding the recommendations.

In this study population, calorie intake from SSBs was lower than results from a study by West et al. (2006), who reported an average of 543 kcal per day. The difference in the results may be explained by the use of various measurements to calculate calories from SSBs. In the current investigation nutrition labels from the actual reported SSBs

were used to calculate calories from them, whereas West et al. (2006) calculated estimates of caloric intake from SSBs by multiplying daily frequency by typical serving size (in ounces) and kilocalories per ounce for the beverage type. In addition, college students were recruited from a Science of Human Nutrition class to receive credit in the current study, but West et al. (2006) administered a voluntary survey to college students from the College of Sciences and Math and the College of Arts and Humanities; therefore, differences in survey administration may have influenced the reporting of actual SSB consumption of college students.

Limitations

This study has multiple limitations. Findings from this retrospective study failed to support the hypothesis, which may be the result of the small overall sample size, limiting the power of the study to detect significant differences between groups. Students were recruited from three sections of Science of Human Nutrition, which could indicate that students were already interested in nutrition and practiced a healthier lifestyle than the other college students; therefore, recruitment through convenience sampling may have resulted in sampling bias.

Second, the present study depended on self-reported dietary intake, which may have led students to inaccurately log their intake by under or overestimation of actual intake. Previous research showed that adults underreported their dietary intake by approximately 25% (Bingham et al., 1994; Briefel et al., 1997). The accuracy of measuring SSB consumption is possibly compromised by measurement error in reliance

on food frequency questionnaires and bias toward underreporting SSB intake (Dhingra et al., 2007; Freedman et al., 2004; Kimm et al., 2006; Lanctot et al., 2008; Natarajan et al.,

2006). Other researchers also indicated that study participants selectively underreported foods high in added sugar (Bolton-Smith & Woodward, 1994; Poppitt et al., 1998).

Similar to these studies, students may not have reported their actual SSB intake in the current study. In addition, the self-reported dietary intake was considered an assignment, and students received credit if they completed it. Thus, students may not have reported their actual dietary intake.

Third, the study did not account for students practicing unhealthy weight loss practices or whether they were on a weight-loss diet. The literature has suggested that college students are more likely than the general population to practice unhealthy weight loss practices, such as fasting, diet pills, laxatives, or self-induced vomiting (Gordon et al., 2000; Lowry et al., 2000; Serdula et al., 1994; Tylka & Sublich, 2002). In the present study more than half of the students were college women (~70%), who studies have shown are more likely than college men to experience eating disorders, body image dissatisfaction, and use unhealthy weight loss practices (Hayes & Napolitano, 2012;

MacNeill et al., 2017; Striegel-Moore et al., 2009). Students may, therefore, avoid consumption of SSBs if they are trying to lose weight despite their weight status. A

NHANES study demonstrated a significant difference in SSB consumption between U.S. adults with weight-loss intention and those not trying to lose weight; it also showed that

overweight and obese adults trying to lose weight consumed lower amounts of SSBs than those who are not trying to lose weight (Bleich et al., 2009).

Finally, the current study excluded other important factors that influence weight status. The study controlled for average caloric intake without controlling for other confounding variables concerning the diet or activity level of students. The other confounding variables include macronutrients intake, micronutrients intake, fruits and vegetables, whole grains, and physical activity. Researchers controlling for baseline and changes in physical activity and other lifestyle covariates and for intake of total fat, protein, carbohydrates, dietary fiber, added sugar found significant association between

SSB consumption and weight status (Bermudez & Gao, 2010; Schulze et al., 2004). For instance, college students might increase their physical activity to help maintain their body weight; therefore, controlling for other confounding variables is important to understand the consumption pattern of college students.

Scientifically, obesity is simply defined as an imbalance of energy homeostasis, but it is known to be a more complex process influenced by many interactions and factors. Obesity is influenced by intertwined genetic, metabolic, cultural, environmental, socioeconomic, and behaviors factors (Morrill & Chinn, 2004). Standardized effective strategies for the prevention and treatment of obesity remain unknown, but the study of consumption patterns can help understand the increasing rate of overweight and obesity.

In the United States, the increase in overweight and obesity rates has paralleled the increased consumption of carbohydrates, mainly in the form of added sugars (Anand &

Basiotis, 1998; Kantor, 1998). Further research, particularly larger studies with follow-up and repeated measures of diet, weight, activity level, socioeconomic status, environmental factors, and behaviors, is needed to understand consumption patterns of college students.

Implications

The current study has several implications. Although soft drink consumption was lower than other studies, more than half the sample population in this study consumed

SSBs. This indicates SSB consumption is still prevalent in college students, so the need exists for intervention to reduce SSB intake and to increase the quality of their diets. This study also showed that the SSB consumption trend might have changed. The most popular SSB among college students appeared to be sweetened coffee, shifting away from soft drinks as the most consumed SSB in young adults in previous decades. In addition to added sugar, both soft drinks and sweetened coffee contain caffeine, suggesting that college students might drink these beverages as a caffeine source. College students in the current investigation drank inadequate amounts of water, suggesting their vulnerability to dehydration. College students should, therefore, be taught to consume caffeine with less sugar and to consume sufficient fluid to replace fluid lost from caffeine consumption.

Health policies to decrease SSB consumption in college students may improve their overall diet quality and long-term health. Research has shown that a higher intake of

SSBs is associated with higher energy intake and lower intake of fiber, orange juice,

low-fat milk, added sugars, and carbohydrates (Bermudez & Gao, 2010). Frequent SSB consumption is also linked to infrequent breakfast meals, low fruit and vegetable intake, and food insecurity (Sharkey et al., 2011). Furthermore, long-term high consumers of

SSBs aged 25 to 33 years were associated with higher caloric intake; fewer of them were physically active, and a higher proportion regularly smoked when compared to long-term low consumers.

The findings of this study along with those of previous research have provided a foundation for evidence-based interventions aimed at college students to help educate them and change their patterns of SSB consumption. Implementing interventions that target reductions of SSB intake may play a role in obesity prevention efforts for this population. In order to set effective interventions, environmental modifications are needed in college campuses to reduce accessibility to SSBs. College administrators should consider replacing unhealthy options offered in vending machines and at campus food sites with healthier options. Vending machines may offer nutrient-dense drinks like low-fat milk and snacks like almonds, which will promote healthy eating among college students.

This study is one of the few in which the association between SSB consumption and BMI was examined. Although the current study showed no significant association between SSB consumption and BMI, the results indicate that more than half the students consumed SSBs. These results draw attention to need to increase knowledge and efforts

to promote healthier beverages and implement modifications on college campuses to reduce exposure to SSBs.

Conclusion

The results showed no significant differences in SSB consumption by students in various BMI categories; however, the results showed that approximately 65% of students consumed SSBs during the three-day period, suggesting the importance of the study. The most popular SSB among college students was sweetened coffee, but soft drinks have been the most consumed SSB among college students. These results raise a concern because SSBs have no nutritional value, highlighting them as a health concern in this population.

APPENDIX

APPENDIX A

SSB INTAKE DATA SHEET

Appendix A

SSB Intake Data Sheet

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