Behavioural correlates of energy drink consumption among adolescents: A review of the literature

Abstract

Despite regulatory measures on the labelling of energy drinks (EDs), their consumption among adolescents continues to grow in popularity, but teachers increasingly report significant behavioural concerns among students who disclose habitual ED consumption. A review of papers published between January 2010 and October 2016 was undertaken to determine whether an association between adverse behaviour and consumption of ED exists. Findings indicate that ED consumption among adolescents is associated with alcohol and substance use, risky behaviours and psychological states including sensation seeking, depression and anxiety symptoms. ED consumption impacts negatively on executive functions and increases hyperactivity/inattention symptoms among adolescents. An inverse association between ED consumption and sleep duration exists. The findings highlight the need for greater awareness of the potential risk of ED consumption among adolescents.

Keywords

Adolescents energy drinks risky behaviours young people

Introduction

It is widely recognized that adolescents engage in risk-taking behaviours, the causes of which are multiple including developmental, social, health and environmental influences (Leather, 2009). This article explores concerns around a more recently identified risk-taking behaviour, adolescent consumption of high levels of caffeine, through energy drinks (EDs). ED consumption is growing in popularity among adolescents (Miyake and Marmorstein, 2015), with over two-thirds of adolescents in the United Kingdom reported to consume them (Alcohol and Drug Education and Prevention Information Service (ADEPIS), 2013). Growth in consumption is attributed to aggressive marketing strategies (Miller, 2008), their taste, the need for energy and combating sleepiness (ADEPIS, 2013). Increased consumption, ready availability, easy accessibility and the limited regulation of EDs in the United Kingdom are increasingly a significant public health concern (ADEPIS, 2013; Visram and Hashem, 2016).

Background

EDs are caffeinated beverages that contain a mix of other energy promoting ingredients including taurine, ginseng, guarana and B-vitamins, and frequently sugar or sweeteners (Wolk et al., 2012). Caffeine is the main ingredient, ranging from 50 to 505 mg per serving, three or more times the amount of caffeine present in soft drinks (Reissig et al., 2009; Seifert et al., 2011). Caffeine is known to provide the drink’s energizing effect through its ability to block adenosine from signalling the brain that the body needs to rest (Rockett and Putnam, 2002).

In adults, moderate consumption of EDs has been found to reduce perception of fatigue, improve alertness and concentration, enhance mental and physical performance, endurance and reaction time (Ruxton, 2008). However, excessive caffeine intake has been associated with adverse health outcomes including cardiovascular symptoms, sleep impairment, nervousness, gastrointestinal disturbances (Trapp et al., 2014) and death (Reissig et al., 2009). Adolescents are likely to be more susceptible to the adverse health risks of high-caffeine content, as they are not habitual caffeine users and have lower levels of tolerance for caffeine (Reissig et al., 2009).

Evidence, largely generated from the United States, indicates that many secondary school students consume EDs to increase energy levels and improve their sense of awareness and have become habitual ED consumers, which can impact on their ability to focus and concentrate in school (Crane, 2009; Pennington et al., 2010). Teachers in the United States have reported more significant behavioural issues among students who have disclosed habitual consumption including tachycardia and dehydration requiring emergency intervention (Crane, 2009). The adverse effects of ED consumption have led to the doubling of emergency department attendances (Bonar et al., 2015), with 20,783 visits in 2011; 42% accounted for by 12–25-year-olds (Mattson, 2013).

Given the increasing popularity of ED consumption among adolescents, there is a surprising dearth of UK studies (Visram et al., 2015; Visram and Hashem, 2016). Given the relative gap in research literature, this review aims to explore behavioural correlates of ED consumption among adolescents to determine lessons that might be applied for practise in the United Kingdom.

Literature search

A three-step strategy was undertaken to identify peer-reviewed papers published in English language between 2010 and 2016. In stage one, EBSCOhost Databases which include CINAHL, Medline, PsycINFO, Psychology and Behavioural Sciences Collection, Academic Search Premier and SportDISCUS were searched. Search terms used were ‘energy drink* AND (adolescen* OR teen* OR youth*) AND (risk* OR effect* OR behavio*)’. The search was conducted by AA, the suitability of the papers for inclusion independently reviewed by both authors.

After the removal of duplicates, stage two entailed the screening of located papers for relevance. As the aim of this review was to explore the adverse behavioural correlates of ED consumption among adolescents, the titles and abstracts of the papers were assessed for eligibility using the following inclusion criteria:

reported primary research;

reported behavioural outcomes on a human population not older than 18 years of age;

reported outcomes on whole ED, not individual ingredients; and

reported on outcomes where EDs were the sole beverage, that is, not co-consumed with other beverages.

During stage three, a Google Scholar search was conducted after hand-searching the reference list of the eligible papers identified. A final search was conducted in October 2016.

The initial search yielded 601 papers. Applying the filters, peer-reviewed papers published in English from 2010 to July 2015, and removing exact duplicates, limited the number to 228 papers. The abstracts of these papers were reviewed against the inclusion criteria resulting in the inclusion of 12 papers. Papers meeting the inclusion criteria were critically appraised and scored for methodological rigor using Critical Appraisal Skills Programme tools (CASP, 2013). This enabled the assessment of the methodology and reliability of the results of each of the eligible papers (Hannes et al., 2010). Each paper was graded as ‘good’, ‘fair’, ‘poor’ and ‘very poor’ based on their overall quality rating (see Figure 1).

Figure 1.

Summary of Search Strategy. Modified Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA; Moher et al., 2009).

Twelve papers, all quantitative studies, mostly employing a cross-sectional survey design were included. All papers employed self-report questionnaires largely administered online. It is recognized that social desirability, the tendency for individuals to present a favourable image of themselves, can confound survey/questionnaire results (Van de Mortel, 2008) undermining the validity of and reliability of research. Brener et al.’s (2003) extensive review of the literature on adolescents’ self-reports on a range of behaviours, including tobacco, alcohol and other drug use, found that while self-reports are affected by cognitive and situational factors, this varied according to behaviour, as did the extent to which behaviours can be validated by objective measures (Brener et al., 2003). Nevertheless, Brener et al. (2003) note that it is important to assess adolescent risk-taking behaviours and self-reports are the most effective way of capturing this data, researchers therefore need to be familiar with the inherent threats to validity these approaches entail.

Data were extracted from the eligible papers using a modified version of Hawker et al.’s (2002) standardized table (see Table 1).

Table 1.

Summary of studies included in the review.

Authors/date/location	Study aims and objectives	Sample characteristics	Research design and method(s)	Analysis	Findings/conclusions
Azagba et al. (2014), Canada	To examine the prevalence, patterns and correlates of ED use among adolescents, and determine whether more frequent use of EDs is associated with poorer health and behavioural outcomes.	n = 8210; 7th, 9th, 10th and 12th grade students; male = 48.2%, female = 51.8%; mean age = 15.2 years	Quantitative cross-sectional survey	Multinomial logistic regression analysis was used to examine correlates of ED use patterns, including substance use, sensation seeking, risk of depression and socio-economic status.	Nearly two-thirds of survey respondents (62%) reported consuming ED at least once in the previous year, with about 20% reporting use once or more per month. Sensation seeking, depression and substance use were all higher among ED users relative to non-users and in higher frequency users’ relative to lower frequency users.
Emond et al. (2014), United States	To assess the association between ED use and hazardous alcohol use among a national sample of adolescents and young adults.	n = 3342; 15–17 years old = 45.1%, 18–20 years old = 32.7%, ≥21 years old = 22.1%; male = 51%, female = 49%	Quantitative cross-sectional survey; computer-assisted telephone interview	Hazardous alcohol use outcomes were measured with the AUDIT demographic characteristics, and sensation-seeking propensity was assessed. Multivariate logistic regression was used to fit each of the four alcohol use outcomes on ED use measures.	Among 15–17-year-olds, 13.3% recently consumed an ED, 9.7% ever consumed an ED mixed with alcohol and 47.1% ever drank alcohol. Recent ED use predicted ever alcohol use among 15–17-year-olds only. Of these 15–17-year-olds, 17% met the 6+ binge drinking criteria, 7.2% met the 8+AUDIT criteria and 16.0% met the 4+AUDIT criteria. Rates of ED use and all alcohol use outcomes increased with age.
Evren and Evren (2015), Turkey	(1) To determine the prevalence of ED consumption among 10th grade students. (2) To compare users and non-users of EDs with respect to gender, sensation seeking and substance-use characteristics, while controlling the effect of psychological factors. (3) To examine the interaction between the effects of three clusters of substances on ED consumption.	n = 4957; 10th grades students from 45 schools in 15 districts; male = 52.7%, female = 47.3%; mean age (years) = 15.56 ±2.74 (SD)	Quantitative online self-report questionnaire	Logistic analysis (Forward Wald) was conducted. A multivariate analysis (two-way ANCOVA).	Psychological states (heightened sensation seeking, elevated depression, anxiety, anger and impulsivity) self-destructive behaviour (self-harming and suicidal thoughts) and risky behaviours (tobacco, alcohol, and other drug use) were all associated with an increased likelihood of ED consumption. Associations between ED consumption and the use of tobacco, alcohol and drug through sensation seeking were independent from each other.
Gallimbert et al. (2013), Italy	To investigate the frequency of ED consumption in children and early adolescents, and to study factors, such as addictive behaviours, associated with regular, at least once in a week, ED consumption.	n = 913 (11–13-year-olds); male = 52.5%, female = 47.5%; age = 12.2 (±1.1) years	Quantitative cross-sectional survey	Bivariate analysis – to seek the relationship between demographic, environmental and behavioural variables and the consumption of EDs. Multivariate logistic regression – to seek any association between the frequent consumption of EDs and demographic, environmental and behavioural variables emerging from the bivariate analysis.	The independent variables conferring a higher likelihood of being a regular consumer (at least once a week) of EDs were smoking and alcohol consumption. Awareness among the students of the potential damage caused by EDs was found to have a protective role, reducing the likelihood of the students’ drinking them.
Hamilton et al. (2014), Canada	To examine ED consumption and its association with demographic characteristics, drug use, and injury among adolescents.	n = 4342; grade 7 to 12 students; male = 53.2%, female = 46.8; age = 15.1 ± 0.1 years	Quantitative data were derived from the 2011 (OSDUHS).	Logistic regression was used to examine the associations between various independent variables and ED consumption. Separate two-way interactions were used to test interactions involving the independent variables and sex.	ED consumption in the previous year was highly associated with having used tobacco and cannabis in the previous year, the non-medicinal use of prescription drugs in the previous year and binge drinking in the previous month. Consumption was also highly associated with sensation seeking and self-reports of medical treatment for an injury. The odds of consuming ED did not vary significantly for males and females, and sex was not a significant moderator of the associations examined.
Jackson et al. (2013), United States	To assess the prevalence of physiologic and behavioural adverse effects among adolescent (13–17 years) and adult (18–25 years) emergency department patients who reported past 30-day ED and/or caffeinated-only beverage use.	n = 167 emergency department patients; males: 96, females: 73	Quantitative cross-sectional pilot study. Computer-based, self-administered, anonymous questionnaire	Multivariable logistic regression and negative binomial regression models, adjusted for age, gender and substance use, were created to compare the occurrence of each adverse effect between ED and caffeinated-only beverage users.	53.3% reported consuming EDs, 39.1% caffeinated-only beverages and 7.6% no ED or caffeinated-only beverages within the past 30 days. ED users were more likely than caffeinated-only beverage users to report having ‘gotten into trouble at home, school, or work’ in the past 30 days. More behavioural effects were reported among drug users and more physiologic effects were reported among tobacco users but not among ED users.
Larson et al. (2014), United States	To examine patterns of adolescent sports and energy drink (SED) consumption and identify behavioural correlates.	n = 2793; grades 6–12 students; male = 46.8%, female = 53.2%; mean age = 14.4 years (SD, 2.0 years)	Quantitative cross-sectional study	Linear and logistic regression models were used to estimate associations between health behaviour and SED consumption, adjusting for demographics.	ED and sports drink were consumed at least once a week by 14.7% and 37.9% of sample. SED consumption were related to higher video game use, sugar-sweetened beverage and fruit juice intake and smoking but did not significantly influence the mean hours of sleep per day.
Miyake and Marmostei (2014), United States	To examine concurrent and longitudinal associations between ED and alcohol use.	Initial assessment, n = 144; 6th and 7th grade students; male = 50%, female = 50%; Final assessment, n = 127	Quantitative self-report questionnaire	Linear regression (to assess any concurrent association); Multiple imputation procedure (PROCMI) (to handle missing data); MIANALYZE procedure (to combine the results of the analyses of imputation).	Frequency of ED use at the initial assessment predicted increases in frequency of alcohol use 16 months later (adjusting for initial frequency of alcohol use). While levels of parental monitoring partially accounted for this association, there was no evidence that sensation seeking was related to this association.
Nowak and Jasionowski (2015), Poland	To assess the association between ED use and hazardous alcohol use among a national sample of adolescents and young adults.	n = 3342 youth aged 15–23 years	Quantitative cross-sectional analysis	Bivariate analyses compared the frequency of ED use in the past 7 days and each of the 4 alcohol use outcomes by baseline characteristics. Multivariate logistic regression was used to fit each of the four alcohol use outcomes on ED use measures; models for the three hazardous alcohol use outcomes were limited to participants who reported ever drinking alcohol.	17-year-olds (n = 1508), 13.3% recently consumed an ED, 9.7% ever consumed an ED mixed with alcohol and 47.1% ever drank alcohol. Recent ED use predicted ever alcohol use among 15–17-year-olds only. Of these 15–17-year-olds, 17% met the 6+ binge drinking criteria, 7.2% met the 8+AUDIT criteria and 16.0% met the 4+AUDIT criteria. Rates of ED use and all alcohol use outcomes increased with age. Positive associations between ED use and hazardous alcohol use behaviours are not limited to youth in college settings.
Schwartz et al. (2015), United States	To examine the association of sweetened beverage (including EDs) consumption with hyperactivity/inattention symptoms among middle school students.	Students n = 1649; male = 46%, female = 54%	Quantitative online self-administered survey	Descriptive statistics (n/% and mean/SD). Multivariable logistic regression analysis to estimate the association of EDs consumption with risk of hyperactivity/inattention.	Mean score (SD) on the Hyperactivity/Inattention subscale (HIS) of the Strengths and Difficulties Questionnaire(SDQ) = 3.2 (2.1) (n = 242, 15%) scored in the at-risk category. Students categorized as ‘Normal’ were less likely to consume ED (13.4% vs. 21.1%) compared to at-risk category. Students reporting consumption of EDs were 66% more likely to score in the at-risk category on the HIS.
Terry-McElrath et al. (2014), United States	To examine ED/shot and regular and diet soft drink use among US secondary school students in 2010–2011, and associations between such use and substance use.	n = 21995; 8th, 10th and 12th grade students; male = 49%, female = 51%	Quantitative cross-sectional survey using self-completed questionnaires.	Multivariate survey logistic regression models in Stata 12 were used to compare the relative strength of observed associations between beverage and substance use.	Beverage consumption was strongly and positively associated with past 30-day alcohol, cigarette and illicit drug use. The observed associations between EDs and substance use were significantly stronger than those between regular or diet soft drinks and substance use.
Van Batenburg-Eddes et al. (2014), Netherlands	To study the associations of both caffeine intake and ED consumption with EFs, and the role of pubertal status and sleeping problems.	n = 509; male = 52%, female = 48%; mean age: 13.1 years, SD: 0.85	Quantitative Cross-sectional survey.	Linear regression analysis to assess association between ED intake and EF.	Consuming on average one or more ED(s) a day was associated with more problems in self-reported behaviour regulation and metacognition, and with more problems in parent-reported metacognition. The sum of caffeine and ED use was associated with a higher amount of problems with self-reported metacognition and parent reported behaviour regulation. The effect estimates for the association between caffeine and ED use combined and EFs did not exceed those of EDs or caffeine separately. Adjusting for pubertal status, gender, educational level, number of sleeping problems and hours of sleep did not change the effect estimates substantially.

Note: SD: standard deviation; ED: energy drink; SED: sports and energy drink; AUDIT: Alcohol Use Disorders Identification Test; ANCOVA: analysis of covariance; OSDUHS: Ontario Student Drug Use and Health Survey; PROC MI: multiple imputation procedure; EF: executive function.

The primary outcome measures of the included papers were collated, organized and grouped, enabling the identification of recurrent findings and the subsequent emergence of potential associations. An association with ‘substance use’ was drawn from a pattern, which emerged from 10 papers. Several measures associated with ‘psychological well-being’ were assessed; sensation seeking/risk-taking was assessed as a primary outcome in six of the papers; other psychological outcomes including anxiety, depression, anger, impulsivity and self-harming behaviour and suicidal thoughts were also examined. The influence of the adolescent brain development on ED consumption was highlighted in the discussion section of two studies.

ED and alcohol/substance use

An association between ED consumption and alcohol and substance use was found in eight studies. Evren and Evren’s. (2015) cross-sectional study compared users and non-users of EDs among 10th grade Turkish students; ED consumption was associated with heightened risk for lifetime tobacco, alcohol and illicit drug use, with more frequent consumption having a stronger connection with substance use. Likewise, Terry-McElrath et al.’s. (2014) study, which examined the association between ED and soft drink consumption and substance use among American secondary school students, found a strong and positive association between ED consumption and past 30-day alcohol, cigarette and illicit drug use. This association was further reported to be significantly stronger than the association between regular or diet soft drinks and substance use.

Azagba et al. (2014) assessed whether more frequent use of EDs among 7th, 9th, 10th and 12th grade Canadian students was associated with poorer health and behavioural outcomes. They found that involvement in risky behaviours including tobacco, alcohol, marijuana and other drug and substance use was higher among consumers of EDs relative to non-users. Similarly, Hamilton et al. (2013) found that ED consumption was reported to be greatly associated with binge drinking in the previous month, tobacco and cannabis smoking in the previous year and non-medicinal prescription drug use in the previous year.

Larson et al.’s (2014) study which examined patterns and behavioural correlates of sport and ED consumption among adolescents found that a minimum weekly consumption of EDs was significantly associated with cigarette smoking, a finding also apparent in Gallimberti et al.’s (2013) study of consumption among 11–13-year-olds.

Several studies reported an association between ED use and early onset alcohol use (Emond et al., 2014; Miyake and Marmorstein, 2014; Novak and Jasionowski, 2015). Miyake and Marmorstein (2014) reported that parental monitoring (albeit as reported by adolescents participating in the study) is a contributory factor to the association between initial frequency of ED consumption and later frequency of alcohol use; Miyake and Marmorstein (2014) concluded that parents were more likely to monitor their children’s food and beverage intake if they closely monitor their children’s behaviour and whereabouts.

ED and psychological outcomes

An association between ED consumption and psychological outcomes was evident. In Hamilton et al.’s (2013) study, 38.8% of adolescents who reported high sensation seeking had consumed EDs in the previous week, compared to 15.5% of those who did not. Likewise, heightened sensation seeking and elevated depressive symptoms were among the outcome measures identified to be significantly associated with an increased likelihood of ED consumption in Azagba et al.’s (2014) cross-sectional study; sensation seeking was found to be associated with adolescents who consumed EDs, the association linked with level of consumption.

Similarly, Evren and Evren (2015) found that psychological states (including sensation seeking, depression, anxiety symptoms, anger and impulsivity scores) and involvement in other self-destructive (self-harming and suicidal thoughts) and risky behaviours (tobacco, alcohol and other drug use) were associated with an increased likelihood of ED consumption among high-school students. Terry-McElrath et al. (2014) found an association between high sensation-seeking adolescent groups to both ED consumption and substance use but suggest that any observed association might weaken after controlling for sensation seeking.

EDs, sleep and functioning patterns

Sleep is a critical element in adolescent brain maturation (Dahl and Lewin, 2002); three papers assessed sleep as an outcome measure. Jackson et al. (2013) hypothesized that consumers of EDs would be more likely than those consuming caffeinated beverages only, such as tea, coffee and soft drinks, to report disordered sleep. ‘Trouble sleeping’, ‘mind racing’, ‘headaches’ and ‘nausea’ were among the physiological effects found to be more commonly reported by adolescents who consumed EDs, although ‘trouble sleeping’ and ‘headaches’ were also among physiological effects commonly reported by the caffeinated-only beverage users. The physiological adverse effects studied (including ‘trouble sleeping’) were less compelling after adjusting for age, gender and other substance use. Nevertheless, the findings substantiate earlier reports which suggest that adolescents with higher caffeine consumption were more likely to have trouble sleeping and to be tired in the morning, compared with those who had low caffeine consumption (Orbeta et al., 2006).

Larson et al. (2014) studied and compared the health behaviours associated with different frequencies of ED consumption. Data from their study suggested that after controlling for race/ethnicity, grade and socio-economic status, boys and girls who are regular consumers of EDs had approximately 18 and 12 minutes less sleep, respectively, when compared with peers who consumed EDs infrequently, findings reflected in studies examining consumption of caffeine-only drinks (Calamaro et al., 2009; Lodato et al., 2013).

Van Batenburg-Eddes et al.’s (2014) study assessed the associations of ED consumption with executive functions and found that young adolescents who regularly consume EDs display poorer performance in executive functions than those who do not. Consuming (on average) at least one ED/day was also associated with more problems in self-reported behaviour regulation and metacognition. Similarly, Scwhartz et al. (2014) studied patterns of sweetened beverage consumption, including EDs, to determine whether an association between consumption and hyperactivity/inattention existed. As in other studies reviewed (Azagba, 2014; Emond et al., 2014; Evren and Evren, 2015; Gallimbert et al., 2013; Nowak and Jasionowski, 2015; Schwarz et al., 2015), ED consumption was higher in boys than girls. An association between hyperactivity/inattention was observed; adjusting for age, race/ethnicity, sex, school lunch eligibility, family structure and sugary food consumption, risk of these behaviours increased by 14% for each additional sweetened beverage consumed, risk increased by 66% when EDs were consumed.

Discussion

Evidence from the literature reviewed indicates that an association between consumption of EDs and alcohol and substance use, risky behaviours and alterations in sleep and executive performance exists.

A recurring theme across the studies was the association between consumption of EDs and alcohol use. However, it is not clear whether drinking alcohol increases likelihood for ED consumption or vice versa. The link between ED use and alcohol assumption is important as research that has examined the concomitant use of EDs and alcohol has found this to be associated with a range of risky behaviours including increased risk of marijuana, cocaine and ecstasy use (Mann et al., 2016; Snipes and Benotsch, 2013); alcohol-related aggressive behaviours; risky sexual behaviours; and increased likelihood of alcohol-related accidents and injuries (Azagba et al., 2013; Howland and Rohsenow, 2013; Howland et al., 2011; Marczinski et al., 2011). Moreover, as EDs counter the depressant effects of alcohol, thereby increasing alertness, a risk arises that individuals’ perception of alcohol intoxication is reduced, leading to a longer time frame of drinking, culminating in a higher risk of binge drinking (Arria et al., 2014; Patrick et al., 2014), further exacerbating the likelihood to exposure of the risks listed above. Evidence indicates that adult risk behaviours, particularly smoking and alcohol use when initiated in adolescence, is related to dependency in adulthood (Hale and Viner, 2012), thus raising awareness of these risk factors could prove to be an important preventative/early intervention measure.

Findings from the review also suggest an association between ED consumption and psychological states (including sensation seeking, depression, anxiety symptoms, anger and impulsivity scores) and involvement in other self-destructive (self-harming and suicidal thoughts) and risky behaviours (tobacco and substance misuse). A clear dose–response pattern was also reported. ED consumption was found to impact negatively on executive functions and increase hyperactivity/inattention symptoms among adolescents.

Despite findings of insignificant associations between ED consumption and sleep duration, an inverse association was argued to be more likely based on evidence reported on caffeine (the primary ingredient in EDs), which suggest that caffeine is strongly associated with lower sleep duration among adolescents. Sleep is a critical element in adolescent brain maturation (Dahl and Lewin, 2002), but caffeine consumption alters normal brain development during critical development periods (Temple, 2009). The need to educate and raise awareness of the detrimental effects of ED consumption on sleep in adolescents who consume EDs to counteract insufficient sleep cannot be overemphasized (Carrier et al., 2009). More awareness of the wide range of behavioural deficits linked to sleep deprivation, such as attention problems, irritability, behaviour regulation problems and reduced metacognitive skills (Beebe et al., 2008; O’Brien, 2009), is also necessary.

Although ED consumption is a significant public health concern in the United Kingdom, no UK-based papers were located, a finding also noted in Visram et al.’s (2015) review. A review by Visram and Hashem’s (2016) draws on European and North American and Middle Eastern evidence and makes several recommendations for UK practise, many focused on school-based interventions. School nurses could therefore make a substantial contribution to raising awareness of the risks associated with EDs, providing leadership in developing and implementing health promotion/awareness raising strategies.

Studies that investigate the mechanism by which EDs counteract sleepiness in adolescents may provide further understanding of mechanisms of sleep regulation; investigation on both the short- and long-term effects of using EDs as a counteractive measure for sleep on adolescents’ health outcomes and academic performance is also recommended.

Conclusion

Despite current EU and UK regulatory measures on the labelling of EDs, consumption among UK adolescents continues to grow (ADEPIS, 2013, Visram and Hashem, 2016). This review has reported on international literature examining behavioural correlates of ED consumption among adolescents to determine lessons that might be applied for practise in the United Kingdom. The cross-sectional nature of most of the studies limits findings to associations only; causality in the relationships discussed cannot be inferred. The studies mainly relied on young peoples’ self-reports which, combined with recall bias, may influence accuracy of data, with over and underreporting of ED use, as well as misuse of alcohol and other substances possible. However, the studies included in the review drew on a range of young people drawn from different countries and communities, with most studies reporting findings based on sample sizes of more than 1000 participants.

The health risks associated with EDs are evident from this review, notably the risks around polysubstance use, alcohol dependence, binge drinking, alcohol-related aggressive behaviours, risky sexual behaviours and alcohol-related accidents and injuries (Azagba et al., 2013; Howland and Rohsenow, 2013; Howland et al., 2011; Marczinski et al., 2011; O’Brien et al., 2008). Moreover, as the findings of the review suggest that ED consumption might be used as a risk-marker for alcohol and substance use among adolescents (Miyake and Marmorstein, 2014), frequent ED consumption may serve as a useful screening indicator to identify students at risk of substance use and/or other risky health behaviour (Miller, 2008). Enquiring about an adolescent’s recent ED consumption could therefore be a non-confrontational means of commencing a discussion about alcohol use, which could facilitate opportunities for early intervention and prevention.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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