ENERGY DRINK CONSUMPTION AMONG PHYSICALLY ACTIVE PERSONS IN LEBANON: A MULTICENTER CROSS-SECTIONAL STUDY

Introduction: Energy drinks (EDs) are caffeinated drinks marketed as energy and performance boosters and commonly used by athletes worldwide. They are widely used among youth and university students, with limited research about their


Introduction
Caffeinated drinks are the most consumed and socially accepted stimulants, with approximately 90 percent of all adults worldwide consuming coffee and tea regularly (Knapik et al., 2022).Among others, energy drinks (EDs) are caffeinated drinks marketed as an energy and performance boosters and commonly used by athletes worldwide.They are soft drinks with a high sugar content, caffeine, and other stimulants such as taurine, l-carnitine, and herbal extracts (Peacock et al., 2013).EDs were initially marketed in Europe and Asia in the 1960s but remained unpopular until "Red Bull" was merchandized in Austria in 1987 and was afterward advertised worldwide (Grósz & Szatmári, 2008).EDs differ from sports drinks because the latter drinks do not contain caffeine or any other stimulant and are not intended to have any stimulant or energizing effect (Pound et al., 2017).
In contrast to the claimed advantageous effects of EDs, consuming these drinks may usually be associated with several unintended side effects, which according to the World Health Organization, are attributed to high caffeine levels (Siddique, 2014).Among others, insomnia, nervousness, headache, tachycardia, and seizures are the most reported side effects (Alamzeb Jadoon et al., 2022;Yusupova & Firdavs, 2022).An experimental study recently published reported a significant increase in hepatic and renal biochemical parameters following 3 months of consumption of EDs in rats (Mukhiddinovna, 2022).Noticeable changes were also observed among humans in the levels of low-density lipoproteins (LDL), triacylglycerols (TAG), and triiodothyronine (T3) up to 21 days after ED consumption (Akramovna, 2022).Furthermore, research found a possible contribution of ED consumption to the development of cardiovascular disorders, and changes in the gastrointestinal tract, leading to significant metabolic effects (Yusupova & Firdavs, 2022).Some consumers combine EDs with alcohol, sometimes leading to death (Nurmurodovna, 2022).A recent study showed a higher willingness to drive after consumption of such a combination than drinking alcohol solely, putting consumers and other people at a high risk of accidents (Pérez-Mañá et al., 2022).
EDs were reported to be used by teenagers to mask other tastes such as alcohol, counteract the behavioral effects of alcohol and provide more energy for prolonged activity during exams and stressful periods (Graczyk et al., 2022).Among athletes, they are primarily used to improve focus, alertness, and performance (Tambalis, 2022).In 2012 and to manage ED use and its corresponding outcomes, the Lebanese ministries of Economy and Health issued a policy targeting energy drinks' importers and producers to lower the caffeine level from 65 to 35 grams (mTV Lebanon, 2013).Nevertheless, no further steps were taken, with a lack of law application since, for example, Energy Drink Consumption among Physically Active Persons in Lebanon: A Multicenter Cross-Sectional Study a Red Bull still contains 80 mg of caffeine.Moreover, advertising campaigns promoting ED use are allowed without highlighting the possible adverse events of such consumption.In Lebanon, ED consumption is common, mainly among youth and university students (63.6%) (Itany et al., 2014), with no study assessing their use among physically active persons.Moreover, the pandemic has significantly impacted sports practices and events worldwide.While the specific guidelines and regulations can vary depending on the country and region, in Lebanon, restrictions on group sizes, social distancing measures, and hygiene practices were imposed (Hatem & Goossens, 2022), in addition to regular cleaning and disinfection of equipment and facilities and any commonly used areas such as locker rooms or restrooms (Piotrowski & Piotrowska, 2021).This study aims to assess (i) ED consumption among physically active persons in Lebanon, (ii) the association between ED use and the general characteristics of the participants, and (ii) to explore the predictors of ED use among them.

Study design
An observational cross-sectional study was carried out over three months (August-October 2022), targeting physically active persons from 8 gyms in Lebanon.

Study sample and sample size
Participants were recruited with no selection criteria based on sex, nationality, age, or ethnicity.Two gyms were located in Beirut, three in Mount Lebanon, and one in South, North, and Bekaa, respectively.Participants who refused to answer the survey and those practicing sports for less than three months were excluded.The sample size was determined using the Epi Info 7 software.The calculation assumed that the probability of consumption of EDs was 45% based on findings from a recent study published in Lebanon (Ghozayel et al., 2020).Considering a 95% confidence interval and a 5% acceptable margin of error, 381 participants were required.GPower 3.1.was used to perform a power analysis since 384 participants were included and a power of 87.5% was achieved.

Data collection
Three pharmacy students approached the participants during weekdays from 10 am to 4 pm and explained the study objectives orally.They invited them to participate by filling out a survey on a tablet.The first page of the survey mentioned above included a written version of the objectives with an estimated 12 minutes to answer.

Study tool
A questionnaire was developed and used for data collection.It was available in Arabic (the official language in Lebanon).The survey was initially piloted on 20 participants, and questions that needed more clarity were adjusted or deleted.The first part included questions about the general characteristics of the participants including sex, age (<18, 18-30, and >30), the level of education (elementary school, high school, and university or more), the governorate of residence, and the household arrangement (with family or alone).This part also collected the lifestyle habits and sport practices of the sample such as smoking (cigarettes and waterpipe), alcohol consumption, type of sports (running, weightlifting, swimming, biking, and football).The frequency of practicing sports was also Georges Hatem, Elie Eid, Ibrahim Zaraket, Sandra Mechref, Sanaa Awada, Amal Al-Hajje, Samar Rachidi reported in addition to the place of workout (gym, outdoors, and home) and if they had a workout partner.The second part of the survey comprised questions related to ED consumption.Participants were asked if they agree to 15 statements related to EDs including their use and the intended reasons, place and context of consumption, and the different side effects of ED use.They reported the frequency of ED consumption, if they encountered any side effects, whether or not they mix EDs with alcohol, and their perceived satisfaction and dependence on EDs.

Statistical analysis
Statistical analyses were performed using Statistical Package for Social Sciences (SPSS Inc, Chicago, Illinois) Version 28.Categorical variables are presented through frequencies and percentages.These variables included the general characteristics of the participants, their lifestyle habits, sport practices and questions related to ED consumption.In contrast, continuous variables such as the age, BMI, and sport frequency per week are presented in means and standard deviations.Considering the values of skewness (0.017) and kurtosis (0.271), data are normally distributed and converged toward their expected values (Hatem et al., 2022).Bivariate analyses were performed to test the association between ED use among physically active persons, and their general characteristics.Chi-square/ Fisher exact tests were used to compare percentages between the associated categorical variables.The unpaired student t-test/ Mann-Whitney test was used for the comparison of data between two different groups.A multivariate analysis using a logistic regression model was performed to assess the predictors of ED consumption.These analyses produced Odd Ratios with a 95% Confidence Interval (CI).Independent variables were only selected if they had p-values <0.20 in bivariate analyses.A p-value <0.05 was considered statistically significant.

Ethical considerations
The study protocol, survey, and consent form were reviewed and approved by the institutional review board of the faculty of pharmacy of the Lebanese University.Data were completely anonymous and non-identifiable.Written informed consent was obtained from each participant by asking them to sign before filling out the survey.They were acknowledged that they could withdraw their participation at any point during the interview and that findings would only be used for research purposes.

General characteristics of the participants
Overall, 437 potential participants were approached, and 384 agreed to participate in the study (87.9%).The general characteristics of the sample are presented in Table 1.The sample included more males (N = 291, 75.8%) than females (N = 93, 24.2%).The mean age was 26.2 (1.6), with the majority (69.3%) between 18 and 30 years.Most students (93.3%) were less than 30 years of age and had a university degree or more (74.0%).As regards the governorate of residence, participants were distributed in five governorates, with Mount Lebanon (48.2%),North (20.8%), and Beirut (16.7%) accounting for the highest proportions.Three-thirds lived with their family.Around 48% of the participants were cigarette smokers, 29.9% were waterpipe smokers, and 48.2% were passive smokers.Weightlifting (68.8%), running (46.4%), and swimming (29.0%) were the most common type of sports, while muscle gain (62.2%) and weight loss (37.0%) were the main reasons for practicing sports.More than half of the sample (56.8%) exercised for more than 4 days, 75.3% regularly went to the gym, and 51% had a workout partner.

Energy drinks consumption among physically active persons
Table 2 presents the prevalence, characteristics, and perceptions of ED use among physically active persons.The prevalence of ED consumption in the sample was 49.2%.The reasons for using them were mainly to boost energy (68.2%) and stimulate awakeness (19.3%).Around 20% used EDs during workouts, and 15.8% used them before it.Family (19.7%) and friends (21.7%) gatherings were the main occasions for using EDs, with higher consumption in public places (48.4%) than at home (26.3%).Only 9% declared that they feared being addicted to EDs, and 30.9% said that they used safer alternatives for energy stimulation.Almost 20% of the participants used Georges Hatem, Elie Eid, Ibrahim Zaraket, Sandra Mechref, Sanaa Awada, Amal Al-Hajje, Samar Rachidi EDs daily, and 17.4% used them weekly.More than half of physically active persons (56.3%) encountered side effects from EDs, with tachycardia (41.3%), headaches (18.5%), and agitation (18.0%) as the most common ones.Seventy percent of the participants reported never mixing EDs with alcohol, and only 12.3% always did it.Only 13.1% of them said they depended on EDs, and 47.5% felt satisfied after consuming them.

Association between energy drink consumption and the general characteristics of the participants
Table 3 shows the association between ED use and the participants' general characteristics.Males reported significantly higher ED use than females (55% and 31.2%,respectively, p < 0.001).Although no differences were noted when taking age as a covariate, it was noted that physically active persons younger than 18 years used fewer EDs than their older peers (34.6%, p = 0.074).Smoking, in general, was associated with ED consumption where compared to non-smokers, cigarette (62.8% vs. 49.6%,p = 0.035), waterpipe (73.7% vs. 48.3%,p < 0.001) and passive (62.7% vs. 36.7%,p < 0.001) smoking was associated with the consumption of EDs.Furthermore, 69% of alcohol drinkers used EDs compared to 43.7% of non-drinkers (p < 0.001).Regarding the association with the type of sports practice, those doing weightlifting had significantly higher ED consumption than those who did not (53.8% vs. 39.2%, p = 0.008).Moreover, 56.6% of physically active persons having a workout partner used EDs compared to 41.5% of those practicing alone (p = 0.003).Georges Hatem, Elie Eid, Ibrahim Zaraket, Sandra Mechref, Sanaa Awada, Amal Al-Hajje, Samar Rachidi

Predictors of energy drink consumption among physically active persons
The predictors of ED use among physically active persons are presented in Table 4.After adjusting for covariates, females had 59% lower odds of ED consumption than males (OR 0.41, 95% CI 0.19-0.89).The odds of ED use were 4.74 times higher among those older than 30 years compared to physically active persons younger than 18 (OR 4.74,).Waterpipe smokers had 3.68 times higher odds of ED use than non-smokers (OR 3.68, 95% CI 1.85-7.33).Moreover, passive smokers had 2.84-fold higher odds of ED consumption than other participants (OR 2.84, 95% CI 1.57-5.15).Alcohol consumers had 2.28 times higher odds of ED use than nonconsumers (OR 2.28, 95% CI 1.14-4.58).Among others, those doing weightlifting had significantly higher odds of ED consumption than others (OR 2.61, 95% CI 1.30-5.25).

Discussion
The present study aimed to assess ED consumption among physically active persons and the predictors of ED use.A high prevalence of ED consumption was reported among participants, namely for energy boosting and stimulating awakeness.More than half of physically active persons encountered side effects from ED consumption, particularly tachycardia and headaches.Around 30% of participants reported mixing EDs with alcohol, and 13.1% reported dependency.
Around half of the participants reported using EDs.A recent study showed a correlation between ED use and the perception of athletic identification and sports participation (Pfender et al., 2023).Moreover, a systematic review published in 2022 found that ED consumption increased the probability of risky behaviors, anxiety, depression, and impulsivity in addition to a progressive increase in consumption within 5 years (Silva-Maldonado et al., 2022).Previous research conducted among young athletes in the United States showed a higher prevalence (80.1%) than in this study (Hoyte et al., 2013).Since most participants in this study were adults, this might be due to the lower consumption of EDs among this group compared to younger ages (32% vs. 68%) (Erdmann et al., 2021).In Lebanon, studies reported a slightly lower prevalence of ED use (45%) among university students (Ghozayel et al., 2020), but much higher among adolescents and youth (Itany et al., 2014).Many physically active persons in this study used EDs to enhance their physical performance, making them prone to side effects such as insomnia, heart palpitation, hypertension, and anxiety (Dwaidy et al., 2018).Tachycardia was the most reported side effect in this study, which was also reported among young adults using EDs (Costa et al., 2023) and among athletes (Guerra et al., 2023).The study sample was predominantly men.Research showed gender differences in exercise habits and motives, where men tended to exercise more for fitness and shape toning while women focused on weight loss and health quality (Craft et al., 2014).As regards ED use, men reported a significantly higher consumption than women, in agreement with previous reports (Fagaras et al., 2023;Llorent-Bedmar et al., 2023).
Most participants used EDs to boost their energy, with 36% using them before or during the workout.This misuse can lead to substantial health outcomes, such as pre-workout-induced ischemia (Guerra et al., 2023), and an increase in blood sugar levels (Ragsdale et al., 2010).Smoking (cigarettes, waterpipe, or passive) was associated with higher ED consumption.This finding was also reported in previous studies (Larson et al., 2014;Pavlovic et al., 2023), where physically active persons and smokers had significantly increased use of EDs compared to others.Tobacco consumption in ED advertising (Bleakley et al., 2022), could explain this finding and call for better supervision, due to the harmful effect of substance abuse since cigarettes are cheap in Lebanon.Participants practicing weightlifting reported greater use of EDs.Weightlifting training was reported to be ameliorated with the consumption of caffeinated drinks (Menezes et al., 2022).They are mainly used to boost energy and hydration and were found to improve both aerobic and anaerobic exercise performance (Tambalis, 2022) but should be considered with caution.Working out with a partner significantly increased ED consumption, possibly related to using them as socialization tools and the self-perception of better engagement in sports (Attila & Çakir, 2011).Among the reported predictors, alcohol consumption was found to significantly induce ED use among the participants.This finding was also shown in previous research, where a high proportion of ED users tended to mix them with alcohol (Attila & Çakir, 2011;Llorent-Bedmar et al., 2023;Pavlovic et al., 2023).
This study has limitations.Selection bias may have been induced since the data collectors conveniently selected the participants in the gyms.Recall bias can affect the findings since a self-reported survey was used for data collection.However, pharmacists were uniformly trained and used the same data collection form, and a different researcher performed data coding and analysis.Despite the multi-center aspect of the study, participants were only recruited from selected gyms; therefore, results cannot be extrapolated to other physically active persons or to those practicing outside these settings.Nonetheless, the present study is among the few studies tackling the consumption of ED among physically active persons and the predictors of this consumption.Findings can allow better-informed decisions and tailored campaigns targeting this specific group.

Conclusion
A high prevalence of energy drink consumption was found among physically active persons in Lebanon.Despite the reported side effects, EDs were commonly used as energy boosters and awakeners.After adjusting for covariates, ED use was significantly higher among females, waterpipe and passive smokers, alcohol drinkers, and those practicing weightlifting.For better informed-decision and effective awareness campaigns, these predictors should be considered.

Table 1 .
Vol. 42, No. 2/2023 Energy Drink Consumption among Physically Active Persons in Lebanon: A Multicenter Cross-Sectional Study Distribution of the general characteristics of physically active persons in the study sample Results are given in terms of frequency (percentage) or Mean ± Standard Deviation.

Table 2 .
Energy drink consumption among physically active persons in Lebanon Energy Drink Consumption among Physically Active Persons in Lebanon: A Multicenter Cross-Sectional Study

Table 3 .
Association between energy drink consumption and the general characteristics of the participants

Table 4 .
Predictors of energy drink consumption among physically active persons