Energy drinks, depression, insomnia, and stress in palestinian adolescents: a cross-sectional study

Implications and contributions statement

This study provides valuable insights into the association between energy drink consumption and mental health issues, including depression, insomnia, and stress, among adolescents in Palestine. Our findings highlight the widespread consumption of energy drinks in this population, particularly among smokers, and the significant mental health risks associated with this behavior. The study emphasizes the urgent need for public health interventions targeting energy drink use and smoking behaviors to improve adolescent mental health outcomes in Palestine and similar low-resource, conflict-affected settings.

This research contributes to the existing body of knowledge by.

1. Identifying the prevalence of energy drink consumption among Palestinian adolescents and its strong association with mental health conditions such as depression and insomnia.

2. Demonstrating the associations between smoking behaviors, including traditional cigarettes, electronic cigarettes, and waterpipes, and the relationship between energy drink use and mental health outcomes.

3. Highlighting the need for culturally sensitive public health campaigns and policy regulations to reduce energy drink consumption and its associated harms in this vulnerable population.

Introduction

Energy drinks (EDs) are consumed extensively across the globe, with global sales exceeding $200 billion in 2024 [1]. In the United States, they are the second most popular nutritional supplement consumed by teens and young adults. These beverages are promoted to adolescents to enhance focus, energy, athletic performance, and weight reduction [2]. The most popular components are caffeine, taurine, guarana, glucuronolactone, ginseng, vitamin B complex, and many others [2], 3].

Several studies were conducted to investigate the prevalence of ED usage among young individuals. For instance, 51.2 % of adolescents in Australia and 1.7 % in Germany have reported utilizing ED at some stage in their lives [4], 5]. The prevalence of ED use in the USA has increased significantly from 2003 to 2016, rising from 0.2 to 1.4 % among adolescents and from 0.5 to 5.5 % among young adults [6]. In the Arab World, 30 % of university students in Lebanon reported using EDs, while 84.6 % of adolescents in Saudi Arabia indicated similar usage [7].

ED consumption leads to numerous documented physical health issues and effects on the nervous and cardiovascular systems [8]. Adolescents are not usually aware of the harmful effects of ED. A study of an Australian sample showed that less than two-fifths of all ED consumers were aware of the guidelines for the maximum recommended daily intake [9]. The most common usage motivators were enjoying the taste and the need to focus while studying. The minor reasons were imitating friends and relieving headaches [3]. In Palestine, many additional factors could be added to the list: the problematic living circumstances brought on by the occupation, poverty, instability, violations of justice and equality, territorial fragmentation, cultural pressures, future insecurity, a lack of positive social outlets, a lack of recreational facilities, and the lack of access to health and mental health care services [10], [11], [12].

ED use has been connected to a number of mental health disorders and illnesses. A systematic review and meta-analysis established a connection between insomnia, stress, and depressive mood in adolescents and the consumption of ED [8]. Among Saudi Arabian adolescents, insomnia was the most prevalent symptom connected to ED usage [13]. Where in Australia, ED consumption was linked to depression, stress, and anxiety [14]. In Russia, frequent ED consumption in adolescents was associated with cigarette smoking and insomnia [15].

The consumption of ED and its effects on adolescents has not previously been examined among school children in Palestine. The purpose of this study is to increase knowledge about the prevalence of ED use among adolescents and the possible negative effects it may have on mental health. In particular, the connections between smoking, depression, insomnia, and stress in adolescents consuming EDs.

Methodology

Results

Table 1 presents the social and demographic characteristics of the participants. The study involved 1,668 adolescents, comprising 1,064 girls and 604 boys. The ages of participants varied from 12 to 18 years, with a mean age of 15.67±1.571. Smoking habits were reported as follows: traditional smoking at 9.4 %, e-cigarette use at 4.4 %, and waterpipe smoking at 6.6 %. Of the participants, 1,246 [74.7 % (95 % CI: 76.5–72.7)] reported the consumption of energy drinks (ED).

Figure 1 presents the prevalence rates of depression among participants, categorized as follows: no or minimal depression at 22.3 %, mild depression at 31.3 %, moderate depression at 24.5 %, moderately severe depression at 13.8 %, and severe depression at 8.2 %. Clinically significant insomnia, subthreshold insomnia, moderate clinical insomnia, and severe clinical insomnia were observed in 34.7, 40.4, 20.7, and 4.2 % of participants, respectively.

Figure 1:

Prevalence and severity of depression and insomnia among palestinian adolescents (n=1,668).

Table 2 shows the frequency of stress in adolescent students. Concerning personal stress, 38 % report daily struggles with aspiring to be someone and being able to focus to achieve it. 80.7 % are not in a love relationship that causes them emotional stress. One-third of participants (34.4 %) tend to overeat or undereat for several days over the last two weeks, while 31.1 % of participants can achieve more than half of what they want in a day. In relation to academic stress, 28.2 % of the sampled population reported minimal exam anxiety.A significant proportion of individuals, 73.5 % report no distress related to their parents’ separation or disagreements, suggesting minimal parental conflict. In the context of social stress, a significant majority of respondents (71.7, 67.5, and 69.7 %) do not perceive themselves as bullied by friends, feeling inferior to their peers, or have difficulties with their peers, respectively.

Male participants were 84.1 % more likely to use ED than females (69.4 %, p-value=0.001). ED consumption for participants aged 16–18 was higher (79.1 %), compared to 68.2 % for those aged 12–15 (p=0.001). Traditional cigarette smokers consumed ED at 93.6 %, substantially higher than non-smokers (p-value=0.001). Similarly, 91.9 % of e-cigarette smokers also used EDs (p-value=0.001). Examining the link between ED use and PHQ depression symptoms, participants who used EDs were more likely to have moderate to severe depression. In contrast, non-consumers were more likely to have minimal or no depression (p-value<0.001). Regarding ISI-measured insomnia and ED consumption. ED consumers were more prone to suffer moderate-to-severe clinical insomnia. Clinical insomnia of moderate severity affects 24.4 % of ED consumers and 10 % of non-consumers. Consumers had a statistically significant difference in all stressors, with a p-value of 0.001 as seen in Table 3.

On multivariable analysis, males were significantly more likely to consume EDs than females. Thus gender strongly predicted ED intake (aPR: 2.18; 95 %CI: 1.64–2.91). The results showed that smoking was a decisive factor. Smokers who used conventional cigarettes and smokers who used waterpipes (aPR: 2.99; 95 %CI: 1.49–5.59) and (aPR: 2.54; 95 %CI: 1.23–5.19), respectively, were significantly more likely to consume EDs than nonsmokers. These results suggest that there is a greater likelihood of engaging in harmful behaviors such as consuming EDs when engaging in another harmful behavior such as some type of smoking. In addition, depression showed a significant association with ED consumption (aPR: 2.25; 95 %CI: 1.51–3.37). A dose-response effect was found between insomnia and ED consumption, showing that clinical insomnia was significantly related to ED consumption (aPR: 2.42; 95 %CI: 1.56–3.47) for moderate severity and (aPR: 2.95; 95 %CI: 1.28–6.75) for severe insomnia. Finally, all levels of stress were significantly associated with ED consumption, as seen in Table 4.

Discussion

The present study investigated the significant correlates of ED consumption. Significant associations were demonstrated with gender, smoking, stress, depression, and sleep disturbance. These provide new insights into sociodemographic/personal factors influencing ED use, particularly in a Palestinian Arab adolescent context.

Males were significantly more likely to consume EDs than females. This aligns with research finding that males, especially those aged 16 to 18, exhibit a high prevalence of ED consumption influenced by peer pressure, marketing strategies, and various social environmental factors [22], [23], [24], [25]. These gender differences show that focused interventions are needed to reduce the consumption of ED and adolescent males, who are more vulnerable to its harmful effects, should be targeted.

Smokers who used conventional cigarettes and those who used waterpipes were significantly more likely to consume EDs than nonsmokers. This is consistent with other research [26], [27], [28]. In addition, studies confirm that environmental risk factors and engaging in one risky behavior increase the likelihood of adolescents engaging in other risky behaviors [26], 28], 29]. Given that smoking and ED consumption are associated with adverse health effects [30], these risky behaviors poses a severe threat to public health. Therefore, reducing smoking habits may be necessary to reduce ED use.

Studies have shown a positive association between EDs and depression. Adolescents who drank EDs were more likely to suffer from mental health symptoms [31]. Mahamid showed a significant link between ED consumption and depression in Palestinian adults [32]. The fact that EDs containing caffeine may stimulate the activity of methylxanthine, which can be linked to psychological conditions such as anxiety or depression could explain the findings. However, the effects of this stimulation may vary depending on how sensitive a person is to methylxanthine [33], 34]. Depression simultaneously influences and leads to an increase in ED consumption, [31] which logically means that the interrelation between ED and depression goes both ways.

As for insomnia, the positive relationship between ED and insomnia, the link between the consumption of EDs and insomnia, and people who drink EDs were more likely to suffer from symptoms of mental health problems such as insomnia have all been shown [32]. In addition, caffeine consumption affected the people who consume it and made them more likely to suffer from insomnia and other health problems [32]. Our study showed the ISI score of severe insomnia was significantly related to ED consumption. The explanation for this could be due to the presence of taurine in ED acting as mood disturbers and interfering with sleep cycles. Also, EDs have an extremely high amount of caffeine which lead to sleep deprivation and fatigue [35].

Living in conflict-affected areas has been consistently associated with heightened psychological stress due to exposure to violence, insecurity, and economic instability. Studies have shown that individuals in such environments often experience elevated levels of anxiety, depression, and post-traumatic stress disorder (PTSD) because of the prolonged adversity [36]. These stressors can significantly influence health behaviors, including dietary and substance use patterns. Stress-induced coping mechanisms may lead to increased consumption of ED as they are perceived to provide temporary relief from fatigue and stress. Furthermore, economic hardships caused by conflict can simultaneously constrain access to such products, creating variability in consumption patterns. In the context of Palestine, ongoing occupation and the additional stress of events such as the Gaza war likely exacerbated stress levels, contributing to shifts in ED consumption as both a coping mechanism and a reflection of economic constraints [37].

Conclusions

The significant correlation between ED consumption and sociodemographic and behavioral factors have important health implications for adolescents. Males, smokers, and those aged 16–18 years were more likely to consume EDs; thus, any form of targeted interventions should focus on these groups. A significant correlation between ED consumption and increased prevalence of depression and insomnia was found. ED consumption among adolescents was associated with a higher risk of moderate and moderately severe depressive symptoms and clinical insomnia, both moderate and severe. In addition, personal stress, academic stress, and family stress in ED consumers were significantly higher than in non-consumers and may imply that ED consumption could be a behavior that was used to cope with various forms of stress.

These findings emphasize the need for health interventions for ED consumption and other related issues, including smoking and problems with mental health and disturbed sleep, among adolescents. The results implicated a bidirectional association between ED consumption and both depression and insomnia. Consequently, addressing these issues could contribute significantly to mitigating the adverse effects of EDs on adolescent health.

Limitations

This study has several limitations. First, the ongoing political events in the West Bank resulted in significant challenges in data collection. These difficulties necessitated using a convenient sampling method instead of the initially intended cluster sampling design. This may limit the generalizability of the findings. Also, the potential impact of economic challenges, during the Gaza war, may have influenced consumption habits due to affordability constraints which could affect the results, suggesting theat other times, consumption could be higher. Administering the questionnaire at a different time, under less stressful circumstances, might yield different results. Additionally, the war and the frequent sounds of attacks and bombings at night may have affected participants’ sleep patterns, which may confound findings related to stress and insomnia. Another factor to consider is nighttime cell phone use, which is a well-documented cause of sleep problems in other contexts, and may also be relevant in Palestine [38]. Finally, the disruption of in-person schooling and the shift to online learning during this period may have contributed to increased stress and altered daily routines, further influencing the behaviors investigated in this study.

Although efforts were made to simplify the language of the questionnaire for ease of comprehension, some of the younger adolescent participants found it difficult to understand specific questions. This may have led to misinterpretation or incomplete responses, affecting the overall quality of the data collected from this subgroup.

Despite the emphasis on data confidentiality and assurances provided to the students, some participants appeared hesitant to respond truthfully to specific sensitive questions, particularly those related to smoking behaviors. A social desirability bias could have led to the underreporting of smoking prevalence or other sensitive behaviors, which may affect the accuracy of the results related to those variables. In addition, the cross-sectional study limits the ability to draw inferences on cause and effect.