Soft and energy drinks consumption and associated factors in Saudi adults: a national cross-sectional study

Introduction The consumption of soft and energy drinks poses a significant risk for non-communicable diseases, such as diabetes and heart disease. Studies in Saudi Arabia have reported elevated consumption of soft/energy drinks, but nation-wide data is not available. Therefore, this study aims to explore the prevalence of soft and energy drinks consumption and its associated factors among a representative sample of Saudi adults. Methods The present research is a secondary data analysis of the 2021 Sharik Diet and Health National Survey (SDHNS). Current analysis used data on socio-demographics, anthropometrics, physical activity, and soft and energy drink consumption. The frequency of soft and energy drinks consumption is assessed on a weekly basis. Results Of the 5,194 Saudi adults, 3,928 were analyzed. Overall, 67% consumed soft drinks weekly, while 30% consumed energy drinks weekly. In multiple logistic regression, consumption of either soft drinks or energy drinks was associated with males, a younger age, lower income, and lower physical activity. Individuals with overweight or obesity were less likely to consume energy drinks [OR (95%CI): 0.83 (0.71, 0.99) and 0.73 (0.60, 0.90), respectively] than those with healthy weight. However, education level was not associated with either soft or energy drink consumption. These findings highlight the need for targeted interventions designed to reduce soft and energy drinks consumption in Saudi adults.


Introduction
Energy drinks, also referred to as power drinks, are liquid refreshments that typically incorporate a variety of ingredients, such as caffeine, sugar, amino acids like taurine, and other energizing substances such as guarana and ginseng (1).These beverages are often promoted because of their apparent advantages, including enhanced energy levels, sharpened mental focus, and improved physical capabilities (2,3).Nevertheless, they can pose potential health hazards, particularly among youth (4)(5)(6).
The SDHNS integrates ZDataCloud ® , a data collection tool that minimizes sampling bias without human interaction (30).The dataset used in this research was collected in 2021 encompassing n = 5,194 participants.A detailed methodology of the SDHNS is available in a separate document published by the Sharik Association for Research and Studies (29).Ethical approval was obtained from the ethics committee of Sharik Association for Research and Studies (Approval no.06-2021).

Measurements
The weekly consumption was measured based on the frequency of the consumption of soft and energy drinks in separate questions.
Participants were asked "During the past week, how many times per week have you consumed soft drinks?" and "During the past week, how many times per week have you consumed energy drinks?. " Answers ranged from "none" to "seven times per week." Participant answers were classified into two groups for the regression analyses: those who drunk any soft drink per week ("none" = 0) and at least once per week ("yes" = 1).Similar classification was used for energy drinks consumption question.
Sociodemographic information, including age, sex, education level, and monthly income, was provided by the SDHNS database.Level of income was measured by asking the participant about the monthly range of their income.The possible answers were: (1) I do not have stable monthly income, (2) less than SR 5000, (3) between SR 5,000 and SR 16,000, (4) more than SR 16,000.Those who answered "I do not have stable income" were excluded, n = 1,239 as we were interested in gradient relationship across income categories.Education was measured by asking the participant about the highest attainable degree.
BMI was calculated from self-reported height and weight.Weight status was classified as underweight (BMI <18.5 kg/m 2 ), healthy (BMI: 18.5-24.9kg/m 2 ), overweight (25-29.9kg/m 2 ), and obesity (BMI ≥ 30 kg/ m 2 ) (31).Extreme BMI values were excluded (<15 kg/m 2 or ≥ 50 kg/ m 2 ).The participants' level of physical activity adhered to the World Health Organization's (WHO) recommendations, which include engaging in moderate-intensity activity for at least 30 or 20 min of high-intensity activity in the past week (32).Subsequently, the activity level was categorized as: (1) none: when the participants did not engage in any type of physical activity, (2) less than recommended level: when the participants engage in some physical activity but did reach the recommended level and (3) follow recommended level: when the participants met the WHO recommendations (32).

Statistical analyses
Categorical variables are presented as frequencies (n) and percentages (%) across four levels of weekly consumption: never, 1-2 times, 3-4 times, and 5 times or more per week.Bivariate analyses were conducted using a chi-square test of association (proportions) to identify factors associated with weekly consumers versus

Soft drinks consumption
Soft drinks consumption is shown by participants' characteristics in Table 1.About 67% reported consuming soft drinks at least once a week, with more males than females reporting weekly consumption (69% vs. 65%, p < 0.01).Consumption of soft drinks also differed by age, monthly income, physical activity level, and weight status.Education level did not differ between consumers and non-consumers.

Energy drinks consumption
Energy drinks consumption is shown by participants characteristics in Table 2. Nearly, 30% reported consuming energy drinks at least once a week, with more males than females reporting weekly consumption (34% vs. 25%, p < 0.001).Significant differences in consumption of energy drinks were observed by age, monthly income, physical activity level, and weight status.Education level did not differ between consumers and non-consumers.

Factors associated with soft and energy drinks consumption
Table 3 presents unadjusted and adjusted logistic regression models of factors associated with weekly soft drinks consumption.Females had lower odds of consuming soft drinks weekly compared to males [crude OR (95%CI) = 0.84 (0.73, 0.96)].Adults over the age of 50 y and those 30-49 y were less likely to consume soft drinks [crude ORs (95%CI): 0.26 (0.22, 0.31) and 0.70 (0.60, 0.83), respectively] compared to younger adults <29 y.Overweight, but not obesity, was associated with lower odds of soft drinks consumption compared to healthy weight adults [crude OR (95%CI): 0.83 (0.71, 0.97)].Participants with higher income >16,000 SAR and those following physical activity recommendations had lower odds of consuming soft drinks consumption than reference categories (<5,000 SAR and no physical activity, respectively).Interestingly, those who performed physical activity less than the recommended level had higher odds of consuming soft drinks than those with no physical activity.In the fully adjusted model, gender, age, monthly income, and physical activity remained significantly associated with soft drinks consumption following the same direction of association.Weight status was not associated with soft drinks consumption after adjusting for age, gender, monthly income, and physical activity.
Table 4 illustrates logistic regression analyses of unadjusted and adjusted odds ratios of factors associated with weekly energy drinks consumption.Similar to the pattern observed in soft drinks consumption, females had lower odds of consuming energy drinks weekly compared to males [AOR (95%CI): 0.53 (0.46, 0.62)].Adults over the age of 50 y and 30-49 y were less likely to consume soft drinks compared to younger adults <29 y.Both overweight and obesity were associated with lower odds of energy drinks consumption compared to adults with healthy weight.Higher income >16,000 SAR was associated with lower odds of consuming energy drinks than those who earned <5,000 SAR.Education level was not associated with weekly energy drinks consumption as observed in soft drinks.Following physical activity recommendations was associated with lower odds of consuming energy drinks; however, less than the recommended physical activity was associated with higher odds of consumption than the reference category (no physical activity).In the fully adjusted model, gender, age, monthly income, weight status, and physical activity remained significantly associated with energy drinks consumption following the same direction of association in the bivariate analyses.

Discussion
Based on nationally representative data of Saudi adults, weekly consumption of soft drinks was 67% and energy drinks consumption was 30%.Analyses showed that Saudi females were less likely to consume soft and energy drinks compared to males and that adults less than 30 years old had the highest prevalence of consuming both soft and energy drinks.Interestingly, adherence to the WHO's physical activity recommendations was inversely correlated with the consumption of soft and energy drinks.Similarly, adults with obesity exhibited a lower likelihood of weekly consumption of energy drinks.However, weight status was not associated with soft drinks consumption after adjusting for age, gender, income, and physical activity level.
In this study, the prevalence of soft drinks consumption in Saudi adult population was 67% in any given week.Our findings support the evidence that Saudi Arabia is one of the biggest consumers of soft drinks in the Middle East region (33).Globally, Saudi Arabia ranks fifth in terms of calorie consumption derived from sugar-sweetened beverages (33).The findings of the current study are consistent with findings from a national study showing that ~71% of Saudi adults consume sugar-sweetened beverages, which include soft drinks, at least once a week using data collected in 2013, with 36% of adults consume these beverages on a daily basis (34).Saudi Arabia implemented a 50% tax on sugary drinks, including soft drinks in 2017, which aligns with a broader initiative to combat the escalating rates of obesity and type 2 diabetes mellitus, conditions correlated with the overconsumption of these beverages (24,35) ).This may be due to the preference for fast food and soft drinks consumption in western and European countries.A trend toward a busy lifestyle with less emphasis on finding time to cook may also be emerging (40).We found that around 30.0% Saudi adults consume energy drinks on a weekly basis, which is in agreement with the most recent study performed among Saudi young adults (29.3%) (41).However, the results of the present study are inconsistent and lower compared with earlier studies executed in Saudi Arabia.A 2017 study that included students from the Prince Sattam bin Abdulaziz University found that 81.3% of students consumed energy drinks, while in another study conducted at the University of Dammam, 45.3% of participants consumed energy drinks (42,43).Both studies, however, did not report a clear frequency of consumption to facilitate comparison.Compared to Malaysian adults, weekly consumption appears to be higher in our study (30.0% vs. 18.8%) (27).It is suggested that these reduced consumption in recent years is due to the new rules of the Saudi Food and Drug Authority (SFDA) and the General Authority of Zakat and Tax (GAZT) related to energy drinks.In 2017, SFDA published few rules for handling energy drinks; one of these rules includes that manufacturers must write the warning phrases on the package (44).Weekly consumption has been observed in the 16 European countries (16.0%) (45) and Denmark (15.8%) (26).Energy drinks are considered new in the Danish soft drink market, which may be one reason why young adults in Denmark are less likely to consume energy drinks.Additionally, the above drinks tend to be more expensive than other drinks, which may also contribute to this phenomenon (26).
In the current study, gender, age, monthly income, and physical activity were identified as contributing factors to soft and energy drinks consumption.Gender was found to be significantly associated with soft and energy drinks consumption.Females had lower odds for consuming soft and energy drinks weekly [AOR (95%CI): 0.69 (0.60, 0.80) vs. AOR (95%CI): 0.53 (0.46, 0.62), respectively] compared to males.This finding is consistent with findings from several earlier population-based studies in Saudi Arabia (34), USA (38), and Australia (46), which revealed that males were more likely to consume soft and energy drinks than females.A study in Denmark found 25% of men consume energy drinks on a weekly basis, suggesting that the consumption of energy drink is predominantly observed among males (26).Another study in Cambodia found the men are more likely [AOR (95%CI): 1.49 (1.10, 2.00)] to consume soft drinks than women (40) This difference could be attributed to gender-driven roles, identities, and social norms.For example, men may be more likely to be influenced by advertising that targets males.It could be also that females tend to more health-conscious and the desire to be a positive role-model.Previous research in several populations (34,41,47,48) has demonstrated a strong correlation between the age of an individual and their consumption of soft and energy drinks, and the current study's findings support this.Our result was that young adults <29 y are more likely to consume soft and energy drinks compared to adults over the age of 50 y and those 30-49 y.However, a study on Cambodian adults opposes this finding (40).
Monthly income was significantly associated with soft and energy drinks consumption.Those who earned higher income >16,000 SAR per month were less likely to consume soft and energy drinks compared to those who earned <5,000 SAR per month.This observation is in line with data from Singapore, which indicates that high and middle-income individuals consume fewer soft drinks in comparison to lower-income individuals (48).In addition, a 2022 Saudi study indicated that adults with higher incomes were less likely to consume soft drinks (34).Conversely, a study conducted in Australia found that individuals with a higher annual income tended to consume more soft drinks than those with a lower annual income (39).The reason that higher income participants in this study were less likely to consume soft and energy drinks could be explained by how high income can increase people access to knowledge, material, cultural, and psychosocial resources that can influence their engagement in such behaviors (49).However, our study did not observe any association between education level and energy and soft drinks consumption.Existing evidence indicates that the consumption of energy drinks was more common among individuals with lower educational attainment levels than those with higher educational attainment levels (26).Thus, examining several socioeconomic status indicators, such as income and education, can improve our understanding of how such indicators influence soft and energy drinks consumption, as they usually represent different social processes in health and health behaviors (50).Data are presented as n (%).Proportions are row total.*Includes intense and moderate.‡ BMI was used to define weight status as follows: underweight (BMI < 18.5 kg/m 2 ), healthy (BMI: 18.5-24.9kg/m 2 ), overweight (25-29.9kg/m 2 ), and obesity (BMI ≥ 30 kg/m 2 ). 10.3389/fnut.2023.1286633 Frontiers in Nutrition 06 frontiersin.org As expected, adhering to physical activity recommendations was associated with lower odds of consuming soft and energy drinks.This conclusion is in line with the findings of a population-based crosssectional survey conducted in Spain, which showed that the prevalence of diet soda consumption was highest among inactive adolescents (51).Adolescents may consume diet soda in response to the realization that they are not consuming enough energy (51).In the context of our study in Saudi adults, it might be that participants who are following physical activity recommendations consuming less soft and energy drinks in order to follow healthy food choices and maintain overall health.Regarding weight status, we found that overweight/obesity were associated with lower odds of energy drinks consumption compared to adults with healthy weight.This result is inconsistent with previous evidence, which might reflect differences in population and methodology (52, 53).In three Eastern European cohorts have indicated positive correlation between consumption of sugar-sweetened beverage and BMI (52).A study on 515 Malaysian adults reported no bivariate association between energy drinks consumption and BMI (27).A recent systematic review of 26 observational studies showed that only one study reported no correlation between the intake of sugar-sweetened beverage and weight gain (53).It is possible that participants classified as overweight/obese in our study were avoiding the consumption of energy drinks for better weight control or under-reported consumption, causing social desirability bias and this needs to be further explored.
Advertisements and marketing campaigns frequently portray energy drinks as fashionable, pleasurable, or necessary for optimal performance, affecting consumer behaviors and attitudes (23,54).A study in Canada indicated a considerable number of energy drink postings on social media in 2020-2021, with several posts have using marketing strategies on Twitter, Facebook and Instagram, that may be appealing to adolescents.Another study in Saudi Arabia found that advertising is the primary source of information regarding   (56).Further studies are needed to understand the impact of the media on soft and energy drinks consumptions in the Saudi Arabian context.Finally, the present study measures the consumption of soft and energy drinks by asking the participants about their frequency of intake each week rather than the actual quantity of consumption.Using the frequency of consumption, as an index of actual amount consumption is easier and a relatively reliable tool to judge the amount of consumption which was adopted in many other studies (57)(58)(59).Studies have shown correlations between frequency of consumption and quantity of soft drinks consumption (57)(58)(59).Frequency of consumption has been associated with adverse health behaviors and higher rates of overweight/obesity among children, adolescents, and adults from several countries (6,60,61).
The current study has many strengths, which includes a relatively large sample size representative of Saudi adults from all regions of Saudi Arabia by using multistage quota sampling.This sampling technique was limiting the risk of selection bias and allowing for the recruitment of a balanced study sample in terms of gender and age that representing all the regions of the kingdom.On the other hand, the use of a research participant database might introduce bias, given that participation in the database was voluntary.Data integrity checks, inherent to the QPlatform data collection system, minimize invalid or erroneous data entry.The study was also able to report on soft drinks and energy drinks separately.However, the study has some limitations.The cross-sectional design might affect the causative relationship between the soft and energy drinks consumption and possible associations.The self-reported data is commonly used in nutrition research and public health surveillance, but it is vulnerable to recall bias and social desirability bias, which may result in misreporting particularly among those who are overweight.Furthermore, the soft and energy drinks consumption was measured by frequency rather than actual quantity that ingested by participants on the weekly basis.Data was not available on the sizes or types of soft and energy drinks; some might be consuming non-sugar sweetened drinks that have a different impact compared to sugar-sweetened beverages.

Conclusion
Overall, this study on a representative sample of Saudi adults shows that 67% consume soft drinks and 30% consume energy drinks weekly.Males, younger adults, and those with higher incomes are more likely to consume soft drinks weekly than females, older adults, and those with lower incomes.The soft drinks consumption remains high despite the implementation of taxes and alarm action, particularly among young adults and men.Studies are needed on the type and quantity of drinks consumed and in-depth analyses of associated factors; this could inform targeted interventions for any future programs on the prevention and/or management of non-communicable diseases.The findings of this study highlight the need for public health interventions to the consumption of soft drinks and energy drinks in Saudi Arabia.These interventions should be based on a comprehensive understanding of the factors that influence consumption and tailored to the specific needs of the Saudi population.
Logistic regression models were used to identify factors and the magnitude of association with frequency of soft or energy drinks consumption.The outcome was categorized as the consumption of at least one time per week or none.Factors that showed significant association in the bivariate analyses with weekly soft or energy consumption (p < 0.05) were included in the adjusted models.
. A 2019 study on 1,194 adults living in Saudi Arabia reported a lower rate of weekly soft drinks consumption (44%); of which, 6% reported consuming soft drinks daily (36).Consumption of soft drinks on a daily basis has been

TABLE 1
Characteristics of study sample by soft drinks consumption.
Data are presented as n (%).Proportions are row total.*Includes intense and moderate.‡ BMI was used to define weight status as follows: underweight (BMI <18.5 kg/m 2 ), healthy (BMI: 18.

TABLE 2
Characteristics of study sample by energy drinks consumption.

TABLE 3
Odd ratios of factors associated with soft drink consumption and their 95% confidence intervals (n = 3,928).

TABLE 4
Odd ratios of factors associated with energy drink consumption and their 95% confidence intervals (n = 3,928).