Received: 28 January 2020 | Revised: 10 July 2020 | Accepted: 29 July 2020

DOI: 10.1002/da.23090

RESEARCH ARTICLE

Consumption of energy drinks is associated with depression,

anxiety, and stress in young adult males: Evidence from a
longitudinal cohort study

Simrat Kaur1 | Hayley Christian1,2 | Matthew N. Cooper2 | Jacinta Francis2 |

Karina Allen3,4,5 | Gina Trapp1,2

1
School of Population and Global Health, The
University of Western Australia, Perth, Abstract
Western Australia, Australia
2 Background: Energy drinks (EDs) claim to boost mental performance, however, few
Telethon Kids Institute, The University of
Western Australia, Perth, Western Australia, studies have examined the prospective effects of EDs on mental health. This study
Australia
examined longitudinal associations between ED use and mental health symptoms in
3
School of Psychological Science, The
University of Western Australia, Perth, young adults aged 20 years over a 2‐year period.
Western Australia, Australia Methods: Data were drawn from Gen2 (Generation 2) of the Raine Study, a pro-
4
Institute of Psychiatry, Psychology, and
spective population‐based study in Western Australia. Self‐report questionnaires
Neuroscience, King's College London,
London, UK assessed ED consumption and mental health symptoms (Depression Anxiety Stress
5
Eating Disorders Service, South London and Scale [DASS]‐21) when Gen2 participants were 20 and 22 years old. Changes in ED
Maudsley NHS Foundation Trust, London, UK
use and DASS‐21 scores over time were analyzed and results presented for the
Correspondence whole sample and by sex.
Simrat Kaur, School of Population and Global
Health, The University of Western Australia,
Results: For the whole sample (n = 429), participants who changed from being a non‐
35, Stirling Highway, Crawley, WA 6009, ED user to an ED user had an average increase in stress scores of 2.30 (95%
Australia.
Email: simrat28@gmail.com
confidence interval [CI] = 0.04, 4.55) across the 2‐year follow‐up. Males, but not
females who changed from being a non‐ED user to an ED user had an average
Funding information
increase in depression, anxiety, and stress scores of 6.09 (95% CI = 3.36, 8.81), 3.76
Curtin University of Technology; Edith Cowan
University; University of Notre Dame (95% CI = 1.82, 5.70), and 3.22 (95% CI = 0.47, 5.97), respectively.
Australia; Murdoch University; Raine Medical
Conclusion: ED consumption may be a possible marker for mental health symptoms
Research Foundation; National Health and
Medical Research Council (NHMRC), in young male adults. Practicing clinicians could consider screening for ED use in
Grant/Award Numbers: 1021858, 1027449,
routine assessments of mental health, particularly for young males presenting with
104480, 1021105, 1022134; University of
Western Australia; Telethon Kids Institute; depression, anxiety, and stress symptoms.
Womens and Infants Research Foundation
KEYWORDS

anxiety, caffeine, depression, energy drinks, mental health, prospective study, young adult

1 | INTRODUCTION a wide range of negative psychological problems. For example, ED

Over the past decade, the popularity of energy drinks (EDs) has in-
creased exponentially (Gunja & Brown, 2012), with the consumption
of these drinks highly prevalent among young people, particularly
males (Richards & Smith, 2016; Trapp et al., 2014). While EDs are
often marketed to improve mood (Burrows, Pursey, Neve, &
Stanwell, 2013), emerging evidence suggests they are associated with
use has been associated with increased feelings of stress (Pettit &
DeBarr, 2011), anxiety (Stasio, Curry, Wagener, & Glassman, 2011),
elevated depressive symptoms (Azagba, Langille, & Asbridge, 2014)
and anger (Evren & Evren, 2015). However, most studies to date have
been cross‐sectional, thus there is a significant evidence gap
surrounding the prospective relationship between ED use and young
people's mental health.

Depress Anxiety. 2020;37:1089–1098. wileyonlinelibrary.com/journal/da © 2020 Wiley Periodicals LLC | 1089


1090 | KAUR
It is plausible that ingredients within EDs play a role in initiating
or exacerbating mental health problems (Babu, Church, & Lewander,
2008). EDs contain caffeine which at higher doses (e.g., 210–500 mg),
can cause restlessness, nervousness, anxiety, insomnia, tremors,
seizures, psychosis, depression, hallucinations, and anxiety (Babu
et al., 2008; Clauson, Shields, McQueen, & Persad, 2008; Itany
et al., 2014; Jin et al., 2016; Kim, Sim, & Choi, 2017; Rath, 2012;
Toblin, Adrian, Hoge, & Adler, 2018). Guarana is another ingredient
in EDs which has stimulating properties similar to caffeine (Gunja &
Brown, 2012), and has been implicated in insomnia and anxiety.
Other ED ingredients, such as sugar, ginseng, and aspartame have
been associated with lowering serotonin concentration (Rath, 2012),
mania (Clauson et al., 2008), and anxiety and depression (Walton,
Hudak, & Green‐Waite, 1993).
Single‐patient case studies in adults suggest that ED con-
sumption can precede mental health problems (Hernandez‐Huerta,
Martin‐Larregola, Gomez‐Arnau, Correas‐Lauffer, & Dolengevich‐
Segal, 2017; Szpak, Allen, Szpak, & Allen, 2012). In contrast, an
Italian cross‐sectional study, conducted with children 10–16 years
old, found ED intake was associated with regular smoking but not
psychological distress (Cofini, Cecilia, Di Giacomo, Binkin, & Di Orio,
2019). To date, it appears that only one longitudinal study has in-
vestigated the prospective relationship between ED consumption
and mental health outcomes in youth. The study found the
frequency of ED consumption predicted increases in inattention
attention deficit hyperactivity disorder and conduct disorder
among U.S. 10 to 14‐year‐olds, over a 16‐month period
(Marmorstein, 2016). However, these findings were limited by the
study's small sample size (n = 134) and a relatively short length of
follow‐up. This highlights the need for further prospective studies
that incorporate a representative community sample, longer follow‐
up periods, and older age groups of youth.
The aim of this study was to use a population‐based sample of
young adults (20–22 years) to examine the longitudinal relationship
between ED use and mental health symptoms (depression, anxiety, and
stress symptoms) and to determine any differences by sex. This study
extends our previously published cross‐sectional study in the same
sample where we found a positive correlation between ED consump-
tion and increased anxiety in 20‐year‐old males (Trapp et al., 2014).
2 | METHODS
2.1 | Study design and participants
Data from the Raine Study were analyzed. The methodology for the
Raine Study has been published previously (Newnham, Evans,
Michael, Stanley, & Landau, 1993). Briefly, the Raine Study is a pro-
spective birth cohort study that has followed participants from
gestation to early adulthood (Newnham et al., 1993). Between
May 1989 and November 1991, a total of 2,900 pregnant women
(i.e., Generation 1 or Gen1) were recruited at 16–20 weeks of ge-
station through the public antenatal clinic at King Edward Memorial
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ET AL.
Hospital and local private clinics in Perth, Western Australia. These
Gen1 pregnant women gave birth to 2,868 infants, who were re-
tained to form Generation 2 or Gen2 (our participants). The cohort of
2,868 infants and their families have been followed at regular in-
tervals. Full details on study attrition have been described previously
(Newnham et al., 1993). In brief, more Gen2 participants character-
ized by greater socioeconomic disadvantage at the time of enroll-
ment (i.e., 16‐20 weeks' gestation) were lost to follow‐up, which is
consistent with other longitudinal studies (McLeod, Horwood, &
Fergusson, 2016). Nonetheless, the cohort remains representative of
the Western Australian population (Straker et al., 2017). At the Gen2
20‐year and Gen2 22‐year follow‐up, 1,462 and 1,234 participants
participated, respectively (Figure 1).
ED consumption was measured for the first time at the 20‐year
follow‐up and then at the 22‐year follow‐up. Data collection occurred
from March 2010 to March 2012 and March 2012 to July 2014,
respectively. At the 20‐ and 22‐year follow‐up, 1,236 and 1,115
participants (Gen2) provided ED data, respectively (Figure 1). A total
of 897 participants provided ED data at both follow‐ups (Figure 1).
The differences in characteristics of participants included in the
current study compared with non‐participants from the original co-
hort are presented in Table 1.
Ethics approval for the 20‐ and 22‐year follow‐ups and for the
current study was obtained from The University of Western Australia
Human Research Ethics Committee RA/4/1/7729.
3 | MEASURES
3.1 | ED consumption
ED consumption (independent variable) was self‐reported by parti-
cipants via a questionnaire. Participants reported never consuming
EDs or consuming EDs <1/month, 1 day/month, 2 days/month,
3 days/month, 1 day/week, 2 days/week, 3 days/week, 4 days/week,
5 days/week, 6 days/week, or every day.
3.1.1 | Binary ED variable
A binary variable was created to compare participants who reported
any ED consumption (“ED users”) to those who reported never
consuming EDs (“non‐ED users”).
3.1.2 | Frequency ED variable
Frequency of ED use variable was created for both follow‐ups separately,
where participants who consumed EDs either <1/month, 1 day/month,
2 days/month, or 3 days/month were coded as using EDs on a “monthly
or less” basis. Participants who consumed EDs between 1 day/week and
every day were coded as using EDs on a “weekly or less” basis. Those
reporting no ED consumption were coded as “non‐ED user”.
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KAUR ET AL. | 1091

F I G U R E 1 Participants from the original Raine Study cohort and those included in the longitudinal analyses. *“Eligible to participate” means
participants who were not dead and had not withdrawn from the study. **Completed at least ≥1 component of Raine study follow‐up. ***A total
of 1,236 and 1,115 participants make up the samples for the 20‐ and 22‐year follow‐up, respectively. ****A total of 897 participants make up our
study's longitudinal sample between the 20‐ and 22‐year follow‐up

3.1.3 | Change in ED variable
Using the binary variable, a change in ED variable was created for
longitudinal analyses. Participants who did not consume EDs at either
the 20‐year or the 22‐year follow‐up were categorized as “non‐energy
drink users”; participants who did not consume EDs at the 20‐year
follow‐up but consumed EDs at the 22‐year follow‐up were categor-
ized as “becomes an ED user from a non‐user”; and participants who
consumed EDs at both time points were categorized as an “energy
drinker user”. Only two participants changed from being an ED user at
the 20‐year follow‐up to a non‐ED user at the 22‐year follow‐up and
were, therefore, included in the “non‐energy drink users” category.
These changes in ED use variables were our independent variables.
has been validated in both clinical and nonclinical samples (Henry &
Crawford, 2005; Szabó, 2010) and young adults (Patrick, Dyck, &
Bramston, 2010). A change variable was created where the subscale
scores obtained at the 20‐year follow‐up were subtracted from the
22‐year follow‐up. These changes in DASS depression, DASS anxiety,
and DASS stress scores were our outcome variables.
3.3 | Potential confounding variables
Factors that could potentially confound the association between ED
consumption and mental health symptoms in young adults were ad-
justed for. These variables have previously been linked to ED con-
sumption and/or negative mental health symptoms and included.

3.2 | Depression, anxiety, and stress symptoms

Depression, anxiety, and stress symptoms (dependent variable) were
self‐reported by participants at the 20‐ and 22‐year follow‐ups
using the 21‐item self‐reported Depression Anxiety Stress Scales
(DASS‐21). The DASS‐21 was developed using Australian data and
3.3.1 | Sociodemographic variables
Indices of sociodemographic variables included highest level of sec-
ondary education attained by the mother (Gen1) at the time of parti-
cipants birth (Gen2), maternal age at the time of participants birth,
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1092 | KAUR ET AL.

T A B L E 1 Characteristics of participants included in the current 3.3.3 | Physical activity

study of energy drink and mental health compared with
non‐participants from the original cohort
Physical activity was assessed at the 20‐ and 22‐year follow‐up using
Participants Non‐participants the short‐form of the International Physical Activity Questionnaire
(n = 897) % (n = 1,971) % (IPAQ). A change variable was created where the scores (i.e., meta-
Maternal age at birtha,b 29.80 (5.51) 27.31 (5.94)*** bolic equivalents [METs]‐min/week) obtained at the 20‐year follow‐
(M [SD]) up were subtracted from the 22‐year follow‐up.
Maternal BMIa (M [SD]) 22.12 (3.84) 22.48 (4.82)*

Mother drinking alcohola

Never 51.00 56.12** 3.3.4 | Body mass index (BMI)
Less than once a week 34.60 27.43
Approximately once a week 8.26 10.72 A trained research assistant recorded height and weight measure-
Several times a week 5.36 5.02 ments at the 20‐ and 22‐year follow‐up using standard calibrated
Daily 0.78 0.71 equipment. A continuous BMI score (i.e., body weight (kg)/height
Mother smoking cigarettes a (m)2) was used. To create the change variable, 20‐year follow‐up
None 80.49 69.46 *** scores were subtracted from the 22‐year follow‐up scores.
1–5 daily 5.57 9.74
6–10 daily 5.13 8.02
11–15 daily 4.24 6.09 3.3.5 | Dietary pattern and alcohol consumption
16–20 daily 2.90 4.31
21 or more per day 1.67 2.38 Dietary pattern and alcohol consumption were assessed at 20‐ and
Mother completed secondary 50.56 42.40* 22‐year follow‐ups using the self‐administered and validated Antic-
schoola ancer Council of Victoria Food Frequency Questionnaire (ACCVFFQ).
Family income a The ACCVFFQ has been shown to be a valid and reliable measure of
<$7,000 5.63 10.01*** dietary intake in large epidemiological studies (Hodge, Patterson,
$7,000‐$11,999 5.40 11.00 Brown, Ireland, & Giles, 2000). Data were used to create western and
$11,999–$23,999 20.20 28.77 healthy dietary patterns at the 20‐year follow‐up and has been de-
$24,000–$35,000 28.47 22.92 scribed previously (Ambrosini et al., 2009). Total energy expenditure
$35,001 or more 40.30 27.30 (kJ/day) was calculated from a product of basal metabolic rate and
Biological father living at 92.05 84.26*** physical activity level. This variable was adjusted for because most
homea nutrient intakes are directly related to total energy intake (Oddy
Offspring gestational age at 38.75 (2.23) 38.60 (2.44) et al., 2009); thus, controlling for this variable ensures any observed
birth (weeks; M [SD]) association is independent of total energy consumption.
Offspring birth weight (kg; 3.31 (0.59) 3.28 (0.64) Change in alcohol intake was created by subtracting 20‐year
M [SD]) follow‐up scores (i.e., grams of ethanol per day) from the 22‐year
Preterm birth (<37 weeks) 8.58 9.14 follow‐up scores. Dietary patterns and total energy intake variables
*** were only available at the 20‐year follow‐up.
Offspring sex (% male) 45.26 53.22

Abbreviations: BMI, body mass index; M, mean; SD, standard deviation.

a
Antenatal data measured at 18 weeks’ gestation.
b
Included in regression analyses as a continuous variable.
*p < .05.
**p < .01.
***p < .001.
parental family income at 18 weeks' gestation, and the highest level of
secondary education attained by participants at the 22‐year follow‐up.
3.3.2 | Parental mental health
Primary caregivers (Gen1) self‐reported at the 16‐/17‐year follow‐up
if they had ever been treated for an emotional or mental problem
besides postnatal depression (“yes” or “no”).
3.3.6 | Illicit drugs
A detailed methodology for this variable has been described pre-
viously (Trapp et al., 2014). Briefly, a change variable was created
where participants who responded affirmatively that they used any
of 10 listed illicit drugs (i.e., marijuana/cannabis, inhalants [speed and
ice], hallucinogens [acid/lysergic acid diethylamide (LSD)], nitrous
oxide/nags, cocaine, methadone, gamma‐hydroxybutyrate [GHB],
ketamine “K,” benzodiazepines, rohypnol) on a daily or weekly basis
at both follow‐ups were coded as “drug‐users”; participants who
started using illicit drugs at the 22‐year follow‐up but were not using
illicit drugs at the 20‐year follow‐up were coded as “became an illicit
drug user from a non‐user”; participants who stopped consuming
illicit drugs at the 22‐year follow‐up but were consuming at the

KAUR ET AL.
20‐year follow‐up were coded as “became a non‐user from an illicit
drug user”; and all other participants were coded as “non‐users.”
3.4 | Statistical analysis
All analyses were performed using SPSS (version 23.0) for Windows
(i.e., Windows 7) with the level of significance set at p < .05 for all
the comparative analyses (IBM Corp., 2015). Descriptive statistics
were calculated for males and females separately at the 20‐ and
22‐year follow‐up. χ and independent sample t tests were used for
2
categorical and continuous variables, respectively, to identify the
differences between participants and non‐participants. Linear re-
gression was used to examine the association between the outcome
variables (in turn), that is, change in DASS depression, change in
DASS anxiety, and change in DASS stress scores, and the primary
predictor, that is, change in ED use (using change scores as de-
scribed in Section 3.1.3). Data were analyzed for the complete
sample and also stratified by sex. These linear regression models
were adjusted for maternal age, mother completed secondary
education, and family income at 18 weeks' in gestation, parental
mental health at the 16‐year follow‐up, dietary patterns at the
20‐year follow‐up, participants who had completed high school at
the 22‐year follow‐up, change in participants' physical activity,
engagement in illicit drug use, alcohol intake, and BMI between
20‐ and 22‐year follow‐up.
The use of complete case analysis restricted the sample size to
those participants who provided data at both time points for all 12
variables included in models (n = 429). The presence of data at just
two time points prevented the use of statistical analyses that can
account for missing data in repeated measures longitudinal sam-
ples (e.g., linear mixed models or generalized estimating equa-
tions). Nonetheless, even our smallest dichotomous variable (e.g.,
“became an ED user from a non‐ED user” [n = 36] compared with
“remained a non‐ED user” [n = 150] over 2 years) would have at
least 80% power to demonstrate a minimum difference of 6%
DASS depression, anxiety, and stress scores between groups.
This is deemed a clinically significant difference in DASS scores
over time.
4 | RESULTS
4.1 | Characteristics of participants
The characteristics of participants are shown in Table 2. The average
age of participants, in our study sample, at the Gen2 20‐year follow‐
up was 20 ± 0.5 years and the Gen2 22‐year follow‐up was 22 ± 0.5
years. At both follow‐ups, 45% of participants were male (Table 2).
Around 80% of participants had completed high school (females: 86%
vs. males: 81%). The average age of the Gen1 mother at 18 weeks in
gestation was 29.80 years (range: 15.3–43.7 years) and nearly half of
the mothers had completed high school (Table 2).
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| 1093
4.2 | Frequency of ED consumption
The proportion of participants who consumed EDs on a monthly or
less basis increased across the 2‐year follow‐up period (i.e., from
36.8% to 49.8%) while the proportion who consumed EDs on a weekly
or daily basis decreased (i.e., from 21.7% to 16.8%; results not shown).
A higher proportion of males consumed EDs compared with females
(p < .001 for both 20‐year and 22‐year follow‐up) which informed the
decision to carry out analysis stratified by sex. Across the 2‐year
period, the frequency of male ED use on a monthly or less basis in-
creased by 12%, whereas on a weekly or daily basis it decreased by
almost 3% (Table 2). A similar, but larger trend was observed in
females, whereby the frequency of ED use on a monthly or less basis
increased by 14%, while the frequency of ED use on a weekly or daily
basis decreased by 7% across the 2‐year period (Table 2).
4.3 | Mental health outcomes
For all participants, as well as males and females separately, the DASS
Depression, Anxiety and Stress scores remained similar across the
2‐year period, however, females had a higher DASS Depression,
Anxiety and Stress score compared with males (all p < .05), and this
was evident at both the 20‐year and 22‐year follow‐ups (Table 2).
4.4 | Association between change in ED use and
change in mental health symptoms
For the whole sample, after adjustment for confounding variables,
there was a significant positive association between change in ED use
and change in the DASS Stress score (Table 3). Participants who
changed from being a non‐ED user to an ED user had an average
increase in DASS Stress scores of 2.30 (95% confidence interval
[CI] = 0.04, 4.55; p = .046) across the 2‐year follow‐up. There was no
significant association between change in ED use and change in DASS
Depression and Anxiety scores (Table 3).
For males, change in ED use was positively associated with a
change in DASS Depression, Anxiety, and Stress symptoms after con-
trolling for potential confounders (Table 3). Males who changed from
being a non‐ED user to an ED user had an average increase in the
DASS Depression score of 6.09 (95% CI = 3.36, 8.81; p < .001), an in-
crease in the DASS Anxiety score of 3.76 (95% CI = 1.82, 5.70;
p < .001) and an increase in the DASS Stress score of 3.22 (95% CI =
0.47, 5.97; p = .022). Males who remained an ED user across the
2‐year follow‐up period had an increase in their DASS Anxiety score of
1.15 (95% CI = 0.05, 2.25) compared with the non‐ED users at both
time points (p = .041; Table 3). No significant association was found
for males who remained an ED user across the 2‐year period and
DASS Depression or Anxiety scores (Table 3).
For females, no significant associations were found between
change in ED use and change in either DASS Depression, Anxiety, or
Stress scores between 20‐ and 22‐year follow‐up (all p > .05; Table 3).
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1094 | KAUR ET AL.

T A B L E 2 Descriptive statistics of all study variables in males and females for the longitudinal sample

n (% or M [SD])

Males Females

20‐year follow‐ 22‐year follow‐ 20‐year follow‐ 22‐year follow‐up

Independent variables up (n = 406) up (n = 406) up (n = 491) (n = 491)

Energy drink consumption

Categorical: frequency of energy drink consumption

Zero consumption at all times (%) 149 (36.70) 111 (27.34) 223 (45.42) 188 (38.29)
Consumes monthly or less (%) 145 (35.71) 194 (47.78) 185 (37.68) 253 (51.53)
Consumes weekly or daily (%) 112 (27.59) 101 (24.88) 83 (16.90) 50 (10.18)

Mental health
DASS Depressiona (M [SD]) 362 (5.77 [6.95]) 394 (5.78 [7.34]) 429 (7.89 [8.30]) 484 (8.07 [9.04])
Range DASS Depression scores 0–40 0–42 0–40 0–42
DASS Anxiety scalea (M [SD]) 362 (4.14 [4.57]) 393 (3.91 [4.62]) 429 (5.70 [6.26]) 482 (5.31 [6.39])
Range DASS Anxiety scores 0–32 0–32 0–36 0–38
DASS Stress scalea (M [SD]) 362 (7.41 [7.29]) 393 (7.52 [7.10]) 429 (10.09 [8.24]) 481 (10.72 [8.76])
Range DASS Stress scores 0–36 0–42 0–42 0–42

Participants sociodemographics
Completed high school (%) 366 (79.78) 402 (80.60) 435 (87.82) 488 (87.91)

Lifestyle factors
Physical activity (MET‐min/week; M [SD]) 388 (4,680.90 406 (4,679.64 478 (2,538.77 491 (2,719.07
[4,326.46]) [4,056.43]) [2,464.14]) [2,629.38])
Engages in weekly illicit drug use (%) 369 (9.49) 335 (13.73) 434 (8.99) 400 (6.50)
Alcohol consumption (ml of ethanol/day; M [SD]) 369 (18.73 [20.52]) 397 (19.21 [19.98]) 436 (12.03 [14.31]) 483 (11.08 [13.32])
2
BMI (kg/m ; M [SD]) 363 (24.08 [4.25]) 367 (24.99 [4.45]) 423 (24.37 [5.72]) 419 (25.32 [6.28])

Dietary intake
Healthy pattern z score (M [SD]) 353 (0.06 [0.995]) 420 (−0.01 [0.83])
Western pattern z score (M [SD]) 353 (0.36 [0.92]) 420 (−0.37 [0.68])
Total energy intake excluding energy drinks 369 (100,666.34 436 (7,300.94
(kJ/day; M [SD]) [4,660.02]) [4,007.42])
Dietary misreporting (%)
Under‐reporting 348 (34.77) 408 (49.75)
Plausible reporting 348 (57.47) 408 (46.08)
Over reporting 348 (7.76) 408 (4.17)

Parental sociodemographics
Maternal age at birthb (M [SD]) 406 (30.00 [5.38]) 406 (30.00 [5.38]) 491 (29.64 [5.62]) 491 (29.64 [5.62])
Mother completed secondary education at birthb (%) 369 (52.57) 369 (52.57) 436 (48.9) 436 (48.9)
Family income at birthb (%)
<$7,000 400 (6.25) 400 (6.25) 471 (5.10) 471 (5.10)
$7,000–$11,999 400 (5.25) 400 (5.25) 471 (5.52) 471 (5.52)
$12,000–$23,999 400 (19.00) 400 (19.00) 471 (21.23) 471 (21.23)
$24,000–$35,999 400 (29.25) 400 (29.25) 471 (27.81) 471 (27.81)
$36,000 or more 400 (40.25) 400 (40.25) 471 (40.34) 471 (40.34)

Parental mental health

Ever treated for emotional/mental health problemc (%) 335 (37.31) 335 (37.31) 387 (37.73) 387 (37.73)

Note: Data presented for parental sociodemographics and mental health are from birth cohort and 16‐yearfollow‐up, respectively. Thus, the results
presented for these variables in both the 20‐ and 22‐yearfollow‐up are similar. Data from dietary intake (i.e., healthy pattern, western pattern, total
energy intake excluding EDs, and dietary misreporting) were only available for the 20‐yearfollow‐up.
Abbreviations: BMI, body mass index; DASS: Depression Anxiety Stress Scores questionnaire; M, mean; MET, metabolic equivalent; SD, standard
deviation.
a
Scores represent severity rating; scores have a possible range of 0–42, with higher scores indicating greater depression, anxiety, or stress. Empirical
validation is lacking for the DASS cut‐off points used in the table, thus are not recommended to be used in research.
b
In pregnancy, antenatal data measured at 18 weeks' gestation.
c
Measured at 17 years of follow‐up.
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KAUR ET AL. | 1095

T A B L E 3 Linear regression models of change in energy drink use and change in mental health between the 20‐ and 22‐yearfollow‐up
Δ Depression Δ Anxiety Δ Stress
B (95% CI) B (95% CI) B (95% CI)

All

Adjusted modela,b (n = 429)

Δ Energy drink use

Energy drink user −0.09 (−1.41, 1.24) −0.01 (−0.93, 0.91) 0.94 (−0.34, 2.21)
Becomes an energy drink user 1.87 (−0.50, 4.23) 1.52 (−0.11, 3.15) 2.30 (0.04, 4.55)*
from a non‐user
Non‐energy drink user 0 0 0
(reference)

Males

Adjusted modela,b (n = 210)

Δ Energy drink use

Energy drink user 0.66 (−0.86, 2.17) 1.15 (0.05, 2.25)* 0.79 (−0.78, 2.35)
**
Becomes an energy drink user 6.09 (3.36, 8.81) 3.76 (1.82, 5.70)** 3.22 (0.47, 5.97)*
from a non‐user
Non‐energy drink user 0 0 0
(reference)

Females

Adjusted modela,b (n = 219)

Δ Energy drink use

Energy drink user −0.78 (−2.88, 1.32) −1.15 (−2.58, 0.28) 0.867 (−1.09, 2.82)
Becomes an energy drink user −1.90 (−5.71, 1.91) −0.05 (−2.64, 2.55) 2.43 (−1.11, 5.96)
from a non‐user
Non‐energy drink user 0 0 0
(reference)

Note: Bold values denote p ≤ .05.

Change in energy drink use categories: “Energy drink user”: used energy drinks at both the 20‐ and 22‐yearfollow‐up; “Becomes an energy drink user from
a non‐user”: was not using energy drinks at the 20‐yearfollow‐up, but was using energy drinks at the 22‐yearfollow‐up; “Nonenergy drink user”: includes
participants who did not use energy drinks at both follow‐ups; and those who were energy drink users at the 20‐yearfollow‐up but not at the
22‐yearfollow‐up (n = 2).
Abbreviations: 95% CI, 95% confidence interval; All, whole sample (males and females combined); B, beta‐estimate; BMI, body mass index;
MET, metabolic equivalent.
a
These models presenting results for DASS depression and stress had 1 male participant and 2 female participants less, respectively due to missing data.
b
Adjusted for—maternal age at 18 weeks in gestation, “Western” dietary pattern at the 20‐yearfollow‐up, “Healthy” dietary pattern at the 20‐yearfollow‐
up, dietary misreport at the 20‐yearfollow‐up, mother completed secondary education in pregnancy, at 18 weeks in gestation, family income at 18 weeks
in gestation, participants completed high school at the 22‐yearfollow‐up, change in physical activity of participants (MET min/week) between the 20‐ and
22‐yearfollow‐up, change in participants engagement in illicit drug use between the 20‐ and 22‐yearfollow‐up, change in alcohol consumption between
the 20‐ and 22‐yearfollow‐up, change in BMI between the 20‐ and 22‐yearfollow‐up, parental mental health at the 16‐yearfollow‐up, and total energy
intake excluding energy drinks at the 20‐yearfollow‐up.
*p < .05.
**p < .001.

5 | D I S C U S SI O N from cross‐sectional studies that have found positive associations

This study found significant positive associations between ED con-
sumption and depression, anxiety, and stress symptoms in young
adult males (but not females) over a 2‐year period. Males who
changed from being a non‐ED user to an ED user had increased
symptoms of depression, anxiety, and stress over time. Males who
were an ED user across both time points had increased anxiety
symptoms at the 22‐year follow‐up relative to those who did not use
EDs at either time point. Our findings are consistent with results
between ED use and depression (Marmorstein, 2016), anxiety (Trapp
et al., 2014), and stress symptoms (Pettit & DeBarr, 2011). Cross‐
sectional studies have also shown that these associations are more
apparent in males than females (Pettit & DeBarr, 2011; Trapp
et al., 2014). A recent pilot study of 10 participants found a short‐
term decrease in symptoms of anxiety and depression 15–20 min
after intake of 250 ml of ED, which later returned to normal levels
(Petrelli et al., 2018). They also reported gaining a burst of energy in
this short time, improvement in subjective alertness, including mental

1096 | KAUR
alertness, concentration, and memory. However, like other addictive
substances (e.g., alcohol, cannabis, and other illicit drugs) EDs may
provide an initial short‐term feeling of wellness, which may turn
negative upon regular use (Petrelli et al., 2018). In the only long-
itudinal designed study to date, Marmorstein (2016) found no asso-
ciation between the use of EDs and depression or anxiety symptoms
in 10 to 14‐year‐olds, across a 16‐month period. This is possibly due
to the onset of mental illness most commonly being mid‐to‐late
adolescence with the highest prevalence among 18–24 years old
(Slade, McEvoy, Chapman, Grove, & Teesson, 2015). Our sample was
also larger, and we had a slightly longer follow‐up period. Thus, ex-
amining the longitudinal relationship between ED consumption and
mental health may be more relevant in young adults than in children.
Further studies with longer follow‐up periods and different age
groups are required.
It is likely that the ingredients in EDs may initiate or exacerbate
the symptoms of anxiety, depression, and stress. EDs contain various
ingredients including caffeine, sugar, guarana, ginseng, and aspar-
tame. Various studies have shown the differential effects of these
ingredients on mental health. However, only a few studies have in-
vestigated the interactive psychological effects of caffeine, taurine,
and sugar (Park, Lee, & Lee, 2016). To date, there are insufficient
studies examining how these ingredients work separately or interact
with each other to cause mental health problems. It is plausible that
consumption of caffeinated and sugary EDs might cause alterations
in sleep behavior (i.e., sleep–wake cycle) by stimulating the adre-
nergic system (Lien, Lien, Heyerdahl, Thoresen, & Bjertness, 2006;
Park et al., 2016; Scuri et al., 2018), which may lead to poor man-
agement of psychological distress and causing mental health pro-
blems. Future studies could incorporate a measure of caffeine and
sugar sensitivity and examine the role sleep behavior plays in the
causal pathway between ED consumption and mental health
symptoms.
In our study, males consumed EDs more frequently compared
with females, which could be one of the reasons for the sex differ-
ences in the longitudinal relationships between ED consumption and
mental health we observed. Moreover, it is also possible that dif-
fering hormones in males and females may account for the differ-
ences observed since mediating factors (e.g., inflammation and
oxidative stress) between ED consumption and mental health pro-
blems are affected by gonadal hormones (Mills, Scott, Wray, Cohen‐
Woods, & Baune, 2013; Walker et al., 2014).
Internationally, community concern about the negative health
effects associated with ED consumption has led to an outright ban in
Denmark, Uruguay, and Turkey and the sale of EDs are restricted in
Norway, Iceland, Lithuania, Latvia, and Sweden (Breda et al., 2014).
The United Kingdom have recently conducted a parliamentary in-
quiry into the safety of EDs and have now moved to ban the sale of
EDs to children under 16 years (Arthur, 2019). The American
Academy of Pediatrics recommends that adolescents between
12 and 18 years should not exceed 100 mg of caffeine per day. Yet
current Australian regulations (Standard 2.6.4), permit the amount of
caffeine present in EDs to be up to 320 mg/L (Federal Register of
15206394, 2020, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/da.23090 by University Of Szeged, Wiley Online Library on [01/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ET AL.
Legislation, 2016) and these drinks are widely available and acces-
sible to children in Australia and many other countries. It is important
that policy makers keep up‐to‐date with the latest evidence regard-
ing the potential negative health effects of these drinks, in both
children and adults. Moreover, Scuri et al. (2018) found the majority
of the students who consumed EDs were aware of the active in-
gredient, but not aware of the side effects upon excessive con-
sumption. Some participants who were aware of ED negative effects
reported that they still consumed them to experience improved
concentration and alertness (Scuri et al., 2018), a benefit often fea-
tured in ED advertisements (Galimov et al., 2019). Clearly, education
programs are required to raise awareness among young people about
the possible adverse effects linked with ED consumption and alter-
nate, healthy ways to improve energy, concentration, and alertness
levels, such as consuming a nutritious diet, participating in regular
physical activity, and getting adequate amounts of sleep.
5.1 | Study strengths and limitations
The longitudinal study design, large population‐based cohort, vali-
dated measure of mental health, and inclusion of confounders are
strengths of this study. However, ED use and mental health symp-
toms were self‐reported so may be subject to under‐ and/or over‐
reporting bias. Participants lost to follow‐up were characterized by
greater socioeconomic disadvantage which may limit the findings
generalizability to low socioeconomic groups. While we adjusted for
a wide range of confounders, it is possible that other factors (i.e.,
sleep problems, caffeine from other sources, volume of ED con-
sumed) may have influenced the results. Lastly, participants who had
been previously diagnosed or treated for mental health problems or
conditions, or antidepressant use were not able to be identified and
could not be excluded from analyses.
6 | C O N CL U S I O N
This study found an increase in ED consumption over a 2‐year period
was associated with increased stress scores in a population‐based
sample of young adults. For young adult males specifically, an in-
crease in ED consumption over a 2‐year period was associated with
increased depression, anxiety, and stress symptoms. ED use may be a
possible predictor of mental health symptoms in young adults, and
thus, practicing clinicians may wish to consider screening for ED use
in routine assessments of mental health, particularly for young males
presenting with depression, anxiety, and stress symptoms.
AC KNO WL EDG M EN TS
We would like to acknowledge the following institutions for provid-
ing funding for the core management of the Raine Study: the
University of Western Australia, Curtin University, Women and In-
fants Research Foundation, Edith Cowan University, Murdoch Uni-
versity, The University of Notre Dame Australia, The Raine Medical

KAUR ET AL.
Research Foundation, and the Telethon Kids Institute. We are ex-
tremely grateful to the Raine Study participants and their families for
their long‐term support of the study and the Raine Study team for
cohort coordination and data collection; the National Health and
Medical Research Council (NHMRC) for their long term contribution
to funding the study over the last 30 years. The eye data collection of
the Gen2 20‐year follow‐up of the Raine Study was funded by
NHMRC Grant 1021105, Ophthalmic Research Institute of Australia
(ORIA), Alcon Research Institute, Lions Eye Institute, and the
Australian Foundation for the Prevention of Blindness. The NHMRC
project Grant 1022134 funded the serum 25(OH)D assays that were
conducted by RDDT in Melbourne Victoria, Australia. The Raine
Study Gen2 22‐year follow‐up was funded by NHMRC project Grants
1027449, 104480, and 1021858. Funding was also generously pro-
vided by Safe Work Australia. Dr. Trapp is supported by a NHMRC
Early Career Research Fellowship (ID1073233). Dr. Christian is
supported by an Australian National Heart Foundation Future Leader
Fellowship (#100794). Dr. Francis is supported by a Healthway Early
Career Research Fellowship (#33020).
CO NFLICT OF I NTERE STS
The authors declare that there are no conflict of interests.
D A T A A V A I L A B I LI TY S TA T E ME N T
The data that supports this study are not publicly available due to
privacy or ethical restrictions.
OR CID
Simrat Kaur http://orcid.org/0000-0002-0329-7634
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How to cite this article: Kaur S, Christian H, Cooper MN,
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