Consumption of sweetened beverages and symptoms of anxiety, depression and stress: an analysis of university students in the PADu-multicenter study

doi:10.21203/rs.3.rs-5269417/v1

Download PDF

Research Article

Consumption of sweetened beverages and symptoms of anxiety, depression and stress: an analysis of university students in the PADu-multicenter study

https://doi.org/10.21203/rs.3.rs-5269417/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

The aim of this study was to assess the association between the frequency of consumption of sweetened beverages and symptoms of anxiety, depression and stress in university students. This is a cross-sectional study carried out in eight Federal Higher Education Institutions in Minas Gerais, Brazil. The outcomes were symptoms of anxiety, depression and stress assessed by the Depression Anxiety Stress Scale-21. The consumption of sweetened beverages was assessed by a question from the Brazilian telephone survey (VIGITEL) and analyzed using three approaches: a) dichotomous, regular (≥ 5 days a week) and irregular (≤ 4 days a week), b) weekly frequency, considering the reference category "almost never/never" and c) weekly frequency, considering as an ordinal variable (0 to 7 days a week). Multiple logistic regression was used to estimate the association between sweetened beverages and outcomes. Of the 8.650 students, 14.1% had regular consumption. Among the participants, 59.7% were classified as having anxiety symptoms, 63.0% depression and 57.5% stress. Regular consumption was associated with symptoms of anxiety (OR: 1.30; 95%CI: 1.13–1.49), depression (OR: 1.32; 95%CI: 1.14–1.51) and stress (OR: 1.41; 95%CI: 1.13–1.61). With regard to weekly frequency, a dose-response pattern was observed for symptoms of depression and stress. It was found that for every one and a half times a week that students consumed sweetened drinks, the chance of symptoms of anxiety, depression and stress increased by 1.12 (95%CI: 1.07–1.16); 1.10 (95%CI: 1.06–1.14) and 1.12 (95%CI: 1.08–1.17), respectively. Therefore, this study is important for the development of strategies aimed at autonomy in the choice of beverages. It also contributes to proposing preventive measures in mental health.

Soft drinks

Sugars

Sweeteners

Mental health

University

Epidemiological studies discussing the increase in consumption of ultra-processed foods accompanied by a reduction in consumption of in natura or minimally processed foods and their association with the development of Chronic Non-Communicable Diseases (CNCD) have been gaining notoriety ^{(1, 2)}. Among the foods that make up the ultra-processed category are sweetened beverages, which differ from sugary drinks. Sweetened beverages are defined as liquids made up of sugars and/or sweeteners in their formulation, including, for example, regular, light and diet soft drinks, artificial juices and energy drinks. While sugar-sweetened beverages include only sugars ^(3–5).

Data from a global study revealed that among the ten countries with the highest consumption of sweetened drinks, four are in Latin America: Chile, Mexico, Argentina and Brazil ^{(6, 7)}. Consumption among young adults (20 to 24 years old) is a concern, especially among university students, due to the susceptibility of adopting obesogenic behaviors when entering university, due to the increase in responsibilities and insertion into new affective bonds ^{(8, 9)}. The annual telephone survey carried out in Brazil (VIGITEL) in 2021 found that regular consumption of soft drinks was 14.0%, and was higher among young adults aged 18 to 24 (19.7%), compared to individuals aged 65 or over (8.7%) ⁽¹⁰⁾.

Evidence suggests an association between regular consumption of sweetened beverages and an increased risk of anxiety, depression and stress symptoms ^{(11, 12)}. However, the pathophysiological mechanisms for this association have not yet been fully described. For sugar, three intermediate pathways are suggested: 1) excessive sugar consumption can cause inflammation and, subsequently, neuroinflammation; 2) it can promote a reduction in serotonin synthesis; 3) it can impact on a reduction in the consumption of essential micronutrients in the production of neurotransmitters, favoring the development of mental disorders. For sweeteners, there is an intermediate pathway where the sweeteners' degradation compounds act by inhibiting the synthesis of neurotransmitters that regulate neurophysiological activity ^(13–15). Although there are studies evaluating this association in the general population, the literature on university students from different courses and institutions is still scarce.

Given the complexity of the issue and the evidence of an association between regular consumption of sweetened beverages and symptoms of anxiety, depression and stress, understanding the prevalence of these symptoms potentially involved in this relationship is essential. In addition, considering the undergraduate period, which can predispose to psychopathological disorders, and in view of the impact of the pandemic, studies show that the mental health of students has been significantly affected ^(16–18).

To illustrate this, in Brazil, a study aimed at assessing the mental health of 91 medical students during the COVID-19 pandemic at an institution in the interior of Minas Gerais found that 81.3% had symptoms of anxiety, depression or stress at some level above normal. And of these, 40.5% had symptoms of the three disorders assessed simultaneously above the normal level ⁽¹⁹⁾.

Therefore, this study aimed to analyze the association between the consumption of sweetened beverages and symptoms of anxiety, depression and stress in university students from eight Federal Higher Education Institutions (IFES).

Study design

This cross-sectional study was part of the "Project on Anxiety and Depression in University Students" (PADu).

It is a multicenter epidemiological survey whose population was made up of students from all undergraduate courses at eight IFES in Minas Gerais: Universidade Federal de Ouro Preto (UFOP), Universidade Federal de Minas Gerais (UFMG), Universidade Federal de Juiz de Fora (UFJF), Universidade Federal de São João del-Rei (UFSJ), Universidade Federal de Lavras (UFLA), Universidade Federal de Alfenas (UNIFAL-MG), Universidade Federal de Uberlândia (UFU) and Universidade Federal do Vale do Jequitinhonha e Mucuri (UFVJM).

All students regularly enrolled in the second semester of 2021 at the IFES were invited to take part in the survey. A total of 118.828 students were considered eligible, distributed as follows: UFMG (n = 30.716), UFU (n = 19.828), UFJF (n = 18.913), UFOP (n = 12.140), UFSJ/Campus of Divinópolis (n = 10.986), UFLA (n = 10.773), UFVJM (n = 9.232) and UNIFAL-MG (n = 6.240).

This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving research study participants were approved by the Research Ethics Committees of all the IFES, under CAAE UFOP: 43027421. 3.1001.5150; UFMG:43027421.3.2004.5149; UFJF: 43027421.3.2003.5147; UFSJ: 43027421.3.2002.5545; UFLA:43027421.3.2006.5148;UNIFAL:43027421.3.2008.5142;UFU: 43027421.3.2001.5152 and UFVJM: 43027421.3.2009.5108. Written informed consent was obtained from all subjects.

The survey included students regularly enrolled in any of the undergraduate courses offered by the IFES mentioned and in any academic period, as well as those aged 18 or over. Those who did not complete the questionnaire, those who were away from academic activities or on exchange during the data collection period were excluded.

The data set consisted of valid information from 8.650 participants, with a response rate of 7.3%. To assess the adequacy of the sample size, the a posteriori sample power was calculated using the Open Epi program. The calculation was carried out for the three outcomes assessed in this study: symptoms of anxiety, depression and stress. For each outcome, the sample size of students who regularly consumed sweetened drinks (exposed) and those who did not (unexposed) was taken into account, as well as the prevalence of each symptom between the two groups. The results obtained were above 98.0% for all the outcomes, indicating that the sample was sufficient to detect the differences in prevalence between the groups studied.

Instrument and data collection

Students were invited via email to voluntarily participate in the survey, which was carried out using an online, self-administered and confidential questionnaire, made available on the Google Forms platform.

Data was collected from October 2021 to February 2022, over three months at each participating IFES.

Outcome variables

Three outcome variables were assessed: symptoms of anxiety, depression and stress. These variables are based on the answers obtained using the Depression Anxiety Stress Scale-21 (DASS-21), translated and validated into Portuguese by Vignola and Tucci ⁽²⁰⁾.

The DASS-21 is made up of three independent sub-scales, with seven items each, developed with the aim of estimating, in a self-reported way, symptoms of anxiety, depression and stress during the last week, i.e. the week before the student answered the questionnaire.

The university students' answers were obtained using a 4-point Likert scale, with answer options ranging from zero to three, varying from "0 - not applied at all" to "3 - applied a lot, or most of the time". Subsequently, the scores were summed and then multiplied by two, obtaining the following classifications: "normal", "mild", "moderate", "severe" and "extremely severe", as described by Lovibond ⁽²¹⁾.

In this study, individuals classified in the last three levels (moderate, severe and extremely severe) were considered to have symptoms.

Explanatory variable

The explanatory variable was consumption of sweetened beverages, assessed by the question "In the last 30 days, how many days a week do you usually drink soda or artificial juice (powder, carton or bottle)?". The question was based on the questionnaire from the Surveillance of Risk and Protective Factors for Chronic Diseases by Telephone Survey (VIGITEL) ⁽²²⁾. The answer options for this item were: "almost never/never", "1 to 2 days a week", "3 to 4 days a week", "5 to 6 days a week" and "every day (including Saturday and Sunday)".

The variable was classified in three ways: dichotomous, "regular" frequency (5 or more days a week) and "irregular" frequency (4 or fewer days a week), weekly frequency of consumption, categorized as "almost never/never", "1 to 2 days a week", "3 to 4 days a week", "5 to 6 days a week" and "every day", considering the reference category "almost never/never" and absolute weekly frequency considering it as an ordinal variable (0 to 7 times a week), with the average of the categories being taken.

Covariates

The questionnaire included sociodemographic variables, lifestyle habits and health conditions.

Sociodemographic characteristics included: biological sex (female and male), age (18 to 20 years; 21 to 22 years; 23 to 25 years and ≥ 26 years), race/skin color (white; brown; black and others), sexual orientation (heterosexual; homosexual; bisexual; asexual and others), religious belief (no and yes), marital status (single; married/stable union and widowed/divorced), family income (up to 2 minimum wages; 3 to 5 minimum wages; 6 to 10 minimum wages and > 10 minimum wages) and housing (alone; with family and shared residence).

The residential and academic location of the study participants was also assessed. Initially, the city of residence and city of study were investigated. In order to verify the population living in different Brazilian municipalities in 2021, demographic data accessible on DATASUS' TabNet (4) was used. The size of cities of residence and institutional locations was then classified into two distinct categories: "large city" (with more than or equal to 250.000 inhabitants) and "small city" (with less than 250.000 inhabitants) ⁽²³⁾.

Subsequently, the analysis focused on assessing the population disparity between these two locations. In order to measure this disparity, the difference in population size between the city where the student lived during data collection and the city where the educational institution was located was calculated. This procedure made it possible to classify the situations into three distinct categories: "no change", when the population size remained unchanged; "change from small town to big city", when the student moved from a smaller city to a larger one; and "change from big city to small town", when the migration occurred in the opposite direction.

The following lifestyle variables were assessed: frequency of alcohol consumption (no; 1 to 2 times a week and 3 to every day of the week - including Saturday and Sunday), tobacco consumption (no and yes), fruit consumption (regular, 5 or more days a week and irregular, 4 or fewer days a week) and physical activity (no and yes) ^(24–26).

The health condition variables assessed were: body mass index (BMI), self-reported medical diagnosis of anxiety and depression and use of psychotropic medication. Nutritional status was assessed by BMI, calculated by self-reported height (m²) and weight (kg) and classified as underweight (< 18.5 kg/m²), eutrophic (18.5 and 24.9 kg/m²), overweight (> 25 kg/m² and < 30 kg/m²) and obese (> 30 kg/m²), as recommended by the Ministry of Health. Subsequently, they were reclassified as "not overweight (BMI < 25kg/m²)" and "overweight (BMI > 25kg/m²)". Self-reported medical diagnoses of anxiety and depression (no and yes) were also assessed. The drugs were classified according to the Anatomical Therapeutic Chemical (ATC), adopted by the World Health Organization (WHO), and were considered psychotropic, defined as those that affect mood and behavior, drugs with code N03 (antiepileptics), N05 (psycholeptics), N06 (psychoanaleptics) and N07 (other drugs in the nervous system) ⁽²⁷⁾.

Statistical analysis

In order to find out the sociodemographic profile, lifestyle habits and health conditions of the sample, the categorical variables were analyzed descriptively, using relative frequency distribution and the ordinal variable (consumption of sweetened drinks), described as mean and 95% CI. Pearson's chi-square test (χ2) was used to characterize the sample according to symptoms of anxiety, depression and stress.

To verify the association between the frequency of consumption of sweetened drinks (explanatory variable) and symptoms of anxiety, depression and stress (outcome variables), unadjusted and adjusted logistic regressions were carried out, and a final model was presented for the three outcomes (symptoms of anxiety, depression and stress). The covariates included, which were the same for the three outcomes, were selected using a theoretical causality model based on a directed acyclic graph (DAG) (Fig. 1), using the online software Dagitty®, version 3.2.

In order to avoid spurious associations and unnecessary adjustments, the backdoor criterion was adopted to select the minimum set of confounding variables ⁽²⁸⁾. The final model was adjusted by the minimum and sufficient set of variables: biological sex, age, race/skin color, family income, housing, population disparity, marital status, frequency of alcohol consumption and tobacco consumption.

The significance level was set at 5% and all the analyses were carried out using STATA/SE® statistical software, version 17.0 (Stata Corp, College Station, TX, USA).

Characteristics of the study participants

Of the 8.650 university students, 65.7% were female, 29.5% aged between 18 and 20 (mean: 23.9; standard deviation: 6.3), 55.4% self-declared as white, 68.2% considered themselves heterosexual, 65.3% said they had some religious belief, 90.6% said they were single, 40.9% declared an income of between three and five minimum wages, 76.4% said they lived with relatives and 79.9% had no change in population size. With regard to alcohol consumption, 31.0% of the students consumed alcohol three times a day or every day, 15.7% reported smoking, 63.3% were classified as having irregular fruit consumption and 36.0% did not practice physical activity. With regard to BMI, 34.8% of university students were overweight, 25.6% used psychotropic medication, 56.7% had a medical diagnosis of anxiety and 31.1% of depression (Table 1).

The variable alcohol consumption was not related to the three symptoms assessed. In addition, religious belief was not related to anxiety symptoms. For depression symptoms, there was no relationship with housing and population disparity. As for stress symptoms, no relationship was identified with housing (Table 1).

Prevalence of consumption of sweetened beverages and prevalence of symptoms of anxiety, depression and stress

The prevalence of regular consumption of sweetened drinks was 14.1%. As for the analysis by category, 42.6% do not consume or almost never consume, 29.9% consume 1 to 2 days a week, 13.4% consume 3 to 4 days and 7.2% consume 5 to 6 days a week, and 6.9% consume every day, including Saturday and Sunday (Fig. 2A).

With regard to symptoms affecting mental health, 59.7% of the students were classified as having symptoms of anxiety, 63.0% symptoms of depression and 57.5% symptoms of stress. With regard to the severity of anxiety symptoms, 33.9% were classified as having normal symptoms, 6.4% mild, 16.2% moderate, 9.6% severe and 33.9% extremely severe (Fig. 2B). For depression symptoms, 26.8% were classified as having normal symptoms, 10.2% mild, 18.2% moderate, 12.3% severe and 32.5% extremely severe (Fig. 2C). For symptoms of stress, 31.9% of students were classified as having normal symptoms, 10.6% mild, 17.0% moderate, 20.8% severe and 19.7% extremely severe (Fig. 2D).

Association between consumption of sweetened beverages and symptoms of anxiety, depression and stress

When evaluating the model adjusted for confounding variables, it was found that regular consumption of sweetened beverages was associated with the presence of anxiety symptoms (OR: 1.30; 95%CI: 1.13–1.49), depression symptoms (OR: 1.32; 95%CI: 1.14–1.51) and stress symptoms (OR: 1.41; 95%CI: 1.13–1.61).

When analyzing the weekly frequency of consumption as an ordinal variable, it was found that for every one and a half times a week that a student consumes sweetened beverages, the chance of presenting symptoms of anxiety, depression and stress increases by 1.12 (95%CI: 1.07–1.16); 1.10 (95%CI: 1.06–1.14) and 1.12 (95%CI: 1.08–1.17), respectively. In addition, only the consumption of sweetened beverages on 1 to 2 days a week was not associated with symptoms of depression and stress (Table 2).

According to available data, this appears to be the first study on the association between consumption of sweetened beverages and symptoms of anxiety, depression and stress in university students from different undergraduate programs. The results indicate a prevalence of 14.1% for regular consumption of sweetened beverages and alarming prevalences for symptoms of anxiety, depression and stress. In addition, it was observed that regular consumption was associated with the presence of the three symptoms analyzed.

Monteiro et al., in a cross-sectional study with a sample of 2.163 health students from an institution in Brasília-DF, Brazil, identified a higher prevalence of consumption of sweetened beverages (32.5%) when compared to this study ⁽²⁹⁾. However, it is important to point out that the difference found can be justified, considering the similar methodology used, at least in part, by the type of sample and collection period, since in this study the data was collected during the pandemic and in eight institutions.

In addition to the consumption of sweetened drinks, another important aspect influenced by lifestyle concerns mental health. Young adulthood can be characterized by social and psychological changes, predisposing to the development of psychopathological disorders. In Brazil, prior to the covid-19 pandemic, data from the project related to this study, PADu, in a sample of 356 university students entering a public institution, showed a prevalence of 42.5% for symptoms of anxiety, 33.2% for symptoms of depression and 36.1% for symptoms of stress ⁽³⁰⁾.

However, the findings of this study identified higher prevalences for the three symptoms, and it is crucial to consider the respective evaluation periods of each study, since in the pandemic, fear, anguish and insecurity were often reported by most people ^{(31, 32)}. Results such as these are highly relevant, as symptoms that affect mental health can negatively affect academic performance, course dropout and psychosocial damage ^(33–37).

The consumption of sweetened beverages has been associated with changes in symptoms that affect mental health. However, the mechanisms that justify this relationship have not yet been fully clarified. The composition of sweetened beverages (sugar and/or sweeteners) suggests intermediate pathways for each constituent. When sweetened with sugar, the consumption of fructose, added in the form of corn syrup, can promote increased insulin release, leading to an increase in visceral fat, which in turn contributes to an increase in inflammatory markers (e.g. IL-1, IL-6, TNF-α) ⁽³⁸⁾. The increase in inflammatory markers can result in greater permeability of the blood-brain barrier, facilitating their transportation to the central nervous system, which leads to activation of the immune system, resulting in neuroinflammation ⁽³⁹⁾. Neuroinflammation has been linked to the pathogenesis of depression, because cells such as microglia and astrocytes are responsible for the synthesis of cytokines, which have been studied as inflammatory markers of depression ^{(13, 40)}. An experimental study found that rats exposed to sugar-sweetened beverages showed greater secretion of pro-inflammatory cytokines ⁽⁴¹⁾. High concentrations of pro-inflammatory cytokines are also found in people with depressive disorders ⁽¹²⁾.

Another relevant aspect between inflammation and mental disorders includes serotonin, which comes from the amino acid tryptophan and is considered a neurotransmitter in the pathophysiology of mental disorders, influencing mood ⁽⁴²⁾. In the context of neuroinflammation, pro-inflammatory cytokines can stimulate enzymes such as indolamine-2,3-dioxygenase, which participates in the kynurenine pathway, decreasing substrate reserves for conversion into serotonin and, in parallel, increasing the conversion of depressogenic and neurotoxic metabolites, with effects on the brain parenchyma, leading to susceptibility to depression ⁽⁴³⁾. It has been shown that people with depression and suicide attempts have higher levels of kynurenine ^{(44, 45)}.

The third way of justifying the association between the consumption of sweetened drinks and mental disorders corresponds to high sugar intake and a decrease in micronutrients that are important in the synthesis of neurotransmitters. With regard to this dietary relationship, a study by the Institute of Food and Health, aimed at verifying the impact of the consumption of sugar added to the diet of Irish people, concluded that due to the high consumption of sugar, there was a significant decrease in micronutrients such as Magnesium, Calcium, Zinc, Vitamin B12 and Vitamin C. Excessive sugar consumption led to a nutritional loss of important vitamins and minerals ⁽⁴⁶⁾. Similar to this study, a survey of Norwegian adolescents showed that fruit and vegetable intake was approximately 30.0–40.0% lower among those with a diet high in sugar compared to those who consumed less ⁽⁴⁷⁾.

The lack of specific dietary nutrients can contribute to the development of mental disorders, since, for example, the metabolite of vitamin B6, pyridoxal-5' phosphate (PLP), is a coenzyme in the tryptophan (essential amino acid) pathway for serotonin synthesis. Vitamins B9 and B12 have been linked to depression because they play a role in the methylation of homocysteine, providing the methyl group for the conversion of methionine into S-adenosylmethionine, which in turn influences serotonin metabolism ⁽⁴⁸⁾.

In addition, when sweetened with sweeteners, such as aspartame, which is often used in these drinks, it acts as a chemical stressor, in other words, it raises plasma cortisol levels, as well as producing excess free radicals. High concentrations of cortisol and excess free radicals can increase the vulnerability of the brain, leading to adverse effects on neurobehavioral health ⁽¹⁵⁾.

The evidence of association found in this study is consistent with studies conducted with adults in China ⁽⁴⁹⁾, the United States ⁽⁵⁰⁾, Iran ⁽⁵¹⁾ and Spain ⁽⁵²⁾. A study of 4,741 adults in Australia found that those who consumed 500 ml of soft drinks a day had a 60.0% higher risk of depression and stress ⁽¹¹⁾. Also during the pandemic and in two cities in Minas Gerais, Coletro et al. (2022), with 1.693 adults, found a higher daily consumption of soft drinks or artificial juices among those with anxiety symptoms ⁽⁵³⁾. However, despite the similarity, it is worth noting that the studies used different instruments and samples. In this study, the DASS-21 was used, while Coletro et al. used the Generalized Anxiety Disorder scale (GAD-7) and Patient Health Questionnaire (PHQ-9), and in the study with Australians, the report of medical diagnosis was used, in addition to both having assessed adults in general.

In this study, a dose-response gradient was observed for symptoms of depression and stress. The findings of Leal corroborate the results of this study. Also in Minas Gerais universities (CUME Project), between March and July 2016, with a sample of graduates (36.3 ± 9.4 years), investigating the association between consumption of soft drinks, sugars and sweets with the prevalence of depression, it was found that the higher the consumption of soft drinks, sugars and sweets, the higher the number of cases of depression ⁽⁵⁴⁾.

Therefore, the results of our study indicate the need to adopt multi-component interventions, such as taxing sweetened beverages, eliminating subsidies for industries that produce these beverages, as well as regulating advertising and publicity. Considering the persuasive and skillful advertising of sweetened beverages, food and nutrition education actions within universities are very important, such as reading food labels, which can be considered an important tool for decision-making and food choices ⁽⁵⁵⁾.

In the sphere of mental health, multifaceted approaches are crucial, such as the creation of support groups or group therapy sessions, allowing for the sharing of experiences and mutual support. Invest in increasing the number of staff to improve care coverage. Encourage regular physical exercise, recognizing the associated benefits. Make online resources available, such as apps that provide tools to help students manage their mental health. In addition, promote training for teachers and other staff, enabling them to identify the signs and advise on referral to appropriate services.

This study has some strong points. As far as we know, this is the first study to evaluate the association between consumption of sweetened beverages and symptoms of anxiety, depression and stress among university students from different courses and federal institutions. The studies found usually evaluate only one of the symptoms, in one institution and the vast majority are restricted to health courses. The strengths also include a large sample, the use of a validated scale with good accuracy, the use of DAG to decide on possible confounding factors and the adoption of different approaches to the explanatory variable, showing consistency in the association.

However, despite the relevant findings, the results should be interpreted with caution. This study has limitations that deserve mentioning, such as firstly, it is a cross-sectional study and does not allow causal inferences to be established or the bidirectionality of the data to be dealt with. The outcome was assessed by the presence of symptoms of anxiety, depression and stress, measured using a scale, and not by a medical diagnosis. Another important aspect is that although the explanatory variable was assessed using a question from an annual telephone survey in Brazil (VIGITEL), the question does not make it clear that there are other sweetened beverages besides soft drinks and artificial juices, such as tea and coffee, for example. In addition, the quantity of sweetened drinks was not measured, only the frequency of consumption. However, the VIGITEL question is validated and widely used in national studies ^{(3, 56, 57)}. Finally, self-reported variables can lead to underestimation of risk behaviors or overestimation of protective behaviors. However, self-reported measures are commonly used in epidemiological studies and the sample in this study was highly educated ^(58–60).

Therefore, the results of this study can contribute scientific evidence for the development of other studies that explore causality, as well as provide valid information for the development of strategies aimed at autonomy in the choice of beverages and collaborate in proposing measures to prevent symptoms that affect mental health.

In conclusion, this study revealed a prevalence of 14.1% for consumption of sweetened beverages and alarming prevalences for the three symptoms evaluated, as well as an association between regular consumption and increased frequency of consumption with symptoms of depression, anxiety and stress. Therefore, there is a need to implement food and nutrition education in institutions, with a view to reducing the consumption of sweetened beverages and public policies aimed at improving students' mental health and beverage consumption.

Ethics approval and consent to participate

The project “Symptoms of anxiety disorder and depression among students university students in Minas Gerais: prevalence and associated factors” was approved by the Committees of Research Ethics of all IFES, under CAAE UFOP: 43027421.3.1001.5150; UFMG: 43027421.3.2004.5149; UFJF: 43027421.3.2003.5147; UFSJ: 43027421.3.2002.5545; UFLA: 43027421.3.2006.5148; UNIFAL-MG: 43027421.3.2008.5142; UFU: 43027421.3.2001.5152 and UFVJM: 43027421.3.2009.5108. The procedures adopted in the study followed guidelines and standards Brazilian institutions for research involving human beings. Students, before reading the free and informed consent form (TCLE), were informed about their voluntary participation and the guarantee of their anonymity, being identification data collected only for bank organization purposes and never disclosed on an individual basis. Furthermore, informed about the risks and benefits, You can interrupt the research and return at any time or withdraw from participating.

Conflict of interest

None. The authors declare that the research was carried out without commercial or financial relationships that could be interpreted as a potential conflict of interest.

Funding

The Project has financing (R$ 26,435.61) approved in Notice 001/2018 - UNIVERSAL DEMAND FAPEMIG - Research Support Foundation of the State of Minas Gerais, under PROCESS number N. CDS - APQ-01089- 18 with FAPEMIG/DOF grant nº. 8288757/2019.

Authorship

MCAV: Data collection; data analysis and interpretation; drafting the manuscript; critical revision of the manuscript. LAAMJ: Analysis and interpretation of data; drafting of the manuscript; critical revision of the manuscript. WP: Conception and planning of the study, collection and consistency of data and critical revision of the manuscript. BCRB: Conception and planning of the study, collection and consistency of data and critical revision of the manuscript. LGF: Study design, coordination of data collection at the university and critical revision of the manuscript. LNN: Coordination of data collection at the university and critical revision of the manuscript. EDF: Conception of the study, coordination of data collection at the university and critical revision of the manuscript. FCV: Coordination of data collection at the university and critical review of the manuscript. CSC: Conception of the study, coordination of data collection at the university and critical revision of the manuscript. LSS: Coordination of data collection at the university and critical revision of the manuscript. ADF: Conception of the study, coordination of data collection at the university and critical revision of the manuscript. ALM: Conception and planning of the study; coordination of data collection; interpretation of data; critical revision of the manuscript. All authors approved the final version of the manuscript.

Acknowledgements

The authors are grateful for the support and encouragement of the Federal University of Ouro Preto and the partnership of all the participating Federal Higher Education Institutions. We are also grateful for the encouragement of the Research and Teaching Group in Nutrition and Collective Health (GPENSC) and the contribution of the Project on Anxiety and Depression in University Students (PADu).

Monteiro CA, Cannon G, Moubarac JC, et al. The UN Decade of Nutrition, the NOVA food classification and the trouble with ultra-processing. Public Health Nutr. 2018;21:5–17.
Bortolini GA, Moura AL, de Lima P AMC, et al. Guias alimentares: estratégia para redução do consumo de alimentos ultraprocessados e prevenção da obesidade. Rev Panam Salud Publica. 2019;43:59.
Epifânio SBO, Silveira JAC da, de Menezes RCE et al. (2020) Análise de série temporal do consumo de bebidas açucaradas entre adultos no Brasil: 2007 a 2014. Ciênc saúde coletiva 25, 2529–2540.
Martins HX, de Assis HXA, Siqueira JH, et al. Consumo de bebidas açucaradas e estado nutricional em adultos: um estudo de intervenção. Saúde e Pesquisa. 2020;13:617–29.
Miller C, Ettridge K, Wakefield M et al. (2020) Consumption of Sugar-Sweetened Beverages, Juice, Artificially-Sweetened Soda and Bottled Water: An Australian Population Study. Nutrients 12, 817.
Leal JSV, Vegi ASF, Meireles AL, et al. Burden of non-communicable chronic diseases attributable to the consumption of sugar-sweetened beverage, 1990–2019. Clin Nutr ESPEN. 2022;51:253–61.
Popkin BM, Hawkes C. Sweetening of the global diet, particularly beverages: patterns, trends, and policy responses. Lancet Diabetes Endocrinol. 2016;4:174–86.
Mendes-Netto RS, Silva CS da, Costa D et al. (2012) Nível de atividade física e qualidade de vida de estudantes universitários da área de saúde. Revista de Atenção à Saúde 10, 34.
Gomes LSA, Souza MA. de. (2017) Avaliação dos fatores de risco para condições crônicas nos estudantes de enfermagem do centro acadêmico de vitória de santo antão-pe. Revista de Ciências da Saúde Nova Esperança 15, 40–49.
BRASIL. Ministério da Saúde. Departamento de Análise em Saúde e Vigilância de Doenças Não Transmissíveis. Vigitel Brasil 2021: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2021. [Internet]. 2021 [citado 9 de agosto de 2023]. Disponível em: https://www.gov.br/saude/vigitel-brasil2021-estimativas-sobre-frequencia-e-distribuicao sociodemografica-de-fatores-de-risco-e-protecao-para-doencas-cronicas.pdf
Shi Z, Taylor AW, Wittert G, et al. Soft drink consumption and mental health problems among adults in Australia. Public Health Nutr. 2010;13:1073–9.
Kashino I, Kochi T, Imamura F, et al. Prospective association of soft drink consumption with depressive symptoms. Nutrition. 2021;81:110860.
FREITAS TH. Citocinas e quimiocinas como biomarcadores terapêuticos na depressão: revisão sistemática e meta-análise. [Universidade Federal do Ceará]; 2017.
Ma X, Nan F, Liang H, et al. Excessive intake of sugar: An accomplice of inflammation. Front Immunol. 2022;13:988481.
Choudhary AK, Lee YY. Neurophysiological symptoms and aspartame: What is the connection? Nutr Neurosci. 2018;21:306–16.
Cao W, Fang Z, Hou G, et al. The psychological impact of the COVID-19 epidemic on college students in China. Psychiatry Res. 2020;287:112934.
Patsali ME, Mousa DPV, Papadopoulou EVK, et al. University students’ changes in mental health status and determinants of behavior during the COVID-19 lockdown in Greece. Psychiatry Res. 2020;292:113298.
Teodoro MLM, Alvares-Teodoro J, Peixoto CB, et al. Saúde mental em estudantes universitários durante a pandemia de COVID-19. Revista Família Ciclos de Vida e Saúde no Contexto Social. 2021;9:372–82.
Caixeta W, de O, Almeida CMS, Almeida KC. de. (2022) Saúde mental dos estudantes de medicina durante a pandemia de Covid-19 em uma instituição do interior de Minas Gerais / Mental health of medicine students during the Covid-19 pandemic in an institution in the inside of Minas Gerais. Brazilian Journal of Health Review 5, 8602–8611.
Vignola RCB, Tucci AM. Adaptation and validation of the depression, anxiety and stress scale (DASS) to Brazilian Portuguese. J Affect Disord. 2014;155:104–9.
Lovibond PF, Lovibond SH. The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behav Res Ther. 1995;33:335–43.
BRASIL. Ministério da Saúde. Departamento de Análise em Saúde e Vigilância de Doenças Não Transmissíveis. Vigitel Brasil 2019: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2019. [Internet]. 2019 [citado 29 de julho de 2023]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/vigitel_brasil_2019_vigilanci a_fatores_risco.pdf
Vieira AB, Roma CM, Miyazaki VK. Cidades médias e pequenas: uma leitura geográfica. Caderno Prudentino de Geografia. 2017;1:135–56.
IBGE. Instituto Brasileiro de Geografia e Estatística. Pesquisa de Orçamentos Familiares 2008–2009: antropometria e estado nutricional de crianças, adolescentes e adultos no Brasil. [Internet]. 2010 [citado 31 de julho de 2023] p. 130. Disponível em: https://biblioteca.ibge.gov.br/index.php/biblioteca-catalogo?view=detalhes&id=245419
PNS. Pesquisa Nacional de Saúde. Percepção do estado de saúde, estilos de vida e doenças crônicas. Brasil, Grandes Regiões e Unidades da Federação. [Internet]. Rio de Janeiro. 2013 [citado 31 de julho de 2023]. Disponível em: https://biblioteca.ibge.gov.br/index.php/biblioteca-catalogo?id=291110&view=detalhes
BRASIL. Ministério da Saúde. Vigilância De Fatores De Risco e Proteção para Doenças Crônicas por Inquérito Telefônico. [Internet]. 2017 [citado 29 de julho de 2023]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/vigitel_brasil_2017_vigilancia_fatores_riscos.pdf
World Health Organization. Collaborating Centre for Drug Statistics Methodology. Anatomical Therapeutic Chemical (ATC) index with defined daily doses (DDDs) [Internet]. [citado 7 de agosto de 2023]. Disponível em: https://www.whocc.no/atc_ddd_index/
Menezes-Júnior LAA. Qualidade do sono durante a pandemia e suas interfaces com o consumo alimentar, comportamento sedentário e vitamina D. Tese de doutorado. Universidade Federal de Ouro Preto; 2022.
Monteiro LZ, Varela AR, de Lira BA, et al. Estilo de vida e comportamentos de risco para doenças crônicas não transmissíveis entre universitários da saúde na região Centro-Oeste, Brasil. Ciênc saúde coletiva. 2021;26:2911–20.
Vidigal MCA. Autoavaliação de saúde negativa em estudantes universitários e fatores associados. Trabalho de Conclusão de Curso, Universidade Federal de Ouro Preto.
Ornell F, Schuch JB, Sordi AO, et al. Pandemia de medo e Covid-19: impacto na saúde mental e possíveis estratégias. Debates em Psiquiatria. 2020;10:12–6.
Ozamiz-Etxebarria N, Dosil-Santamaria M, Picaza-Gorrochategui M, et al. Níveis de estresse, ansiedade e depressão na primeira fase do surto de COVID-19 em uma amostra no norte da Espanha. Cad Saúde Pública. 2020;36:e00054020.
Dutra E. Suicídio de universitários: o vazio existencial de jovens na contemporaneidade. Estudos e Pesquisas em Psicologia. 2012;12:924–37.
Bolsoni-Silva AT, Loureiro SR. Anxiety and depression in brazilian undergraduate students: the role of sociodemographic variables, undergraduate course characteristics and social skills. Br J Appl Sci Technol. 2015;5:297.
Jansen K, Mondin TC, Ores L et al. da C. (2011) Transtornos mentais comuns e qualidade de vida em jovens: uma amostra populacional de Pelotas, Rio Grande do Sul, Brasil. Cad Saúde Pública 27, 440–448.
Santos G, de BV MCGP, Goldbaum M et al. (2019) Prevalência de transtornos mentais comuns e fatores associados em moradores da área urbana de São Paulo, Brasil. Cad Saúde Pública 35, e00236318.
Quadros L, de CM L, de Gonçalves A HD, et al. Transtornos mentais comuns e fatores contemporâneos: coorte de nascimentos de 1982. Rev Bras Enferm. 2020;73:e20180162.
ALEGRIO JG de M. Relação da ingestão de açúcar (frutose, glicose e sacarose) com a variação de marcadores inflamatórios. Tese de doutorado, Universidade de Coimbra; 2017.
Machado APR, Carvalho IO, Sobrinho HM. da R. (2020) Neuroinflamação na doença de alzheimer. Revista brasileira militar de ciências 6, 14.
Almeida DB, Mota SCB, da Mesquita D S, et al. A relação entre marcadores inflamatórios e depressão: uma revisão da literatura. Scire Salutis. 2021;11:84–97.
Otero-Losada M, Gómez Llambí H, Ottaviano G et al. (2016) Cardiorenal Involvement in Metabolic Syndrome Induced by Cola Drinking in Rats: Proinflammatory Cytokines and Impaired Antioxidative Protection. Mediators Inflamm. 5613056.
Ma X, Nan F, Liang H, et al. Excessive intake of sugar: An accomplice of inflammation. Front Immunol. 2022;13:988481.
SANTOS PF da CR dos. Neuroinflamação e a depressão: novas abordagens terapêuticas no horizonte? Dissertação de mestrado. Universidade de Lisboa; 2019.
FREIRE TFV. Associação de eletroconvulsoterapia a tratamento farmacológico no transtorno depressivo maior: análise de desfecho clínico, marcadores inflamatórios e neurotrofinas. Tese de doutorado, Universidade Federal do Rio Grande do Sul; 2016.
Moroianu LA, Cecilia C, Ardeleanu V, et al. Clinical Study of Serum Serotonin as a Screening Marker for Anxiety and Depression in Patients with Type 2 Diabetes. Med (Kaunas). 2022;58:652.
Joyce T, Gibney MJ. The impact of added sugar consumption on overall dietary quality in Irish children and teenagers. J Hum Nutr Diet. 2008;21:438–50.
Lien L, Lien N, Heyerdahl S, et al. Consumption of soft drinks and hyperactivity, mental distress, and conduct problems among adolescents in Oslo, Norway. Am J Public Health. 2006;96:1815–20.
Hvas AM, Juul S, Bech P, et al. Vitamin B6 level is associated with symptoms of depression. Psychother Psychosom. 2004;73:340–3.
Yu B, He H, Zhang Q, et al. Soft drink consumption is associated with depressive symptoms among adults in China. J Affect Disord. 2015;172:422–7.
Breymeyer KL, Lampe JW, McGregor BA, et al. Subjective mood and energy levels of healthy weight and overweight/obese healthy adults on high-and low-glycemic load experimental diets. Appetite. 2016;107:253–9.
Khosravi M, Sotoudeh G, Majdzadeh R, et al. Healthy and Unhealthy Dietary Patterns Are Related to Depression: A Case-Control Study. Psychiatry Investig. 2015;12:434–42.
Aparicio A, Robles F, López-Sobaler AM, et al. Dietary glycaemic load and odds of depression in a group of institutionalized elderly people without antidepressant treatment. Eur J Nutr. 2013;52:1059–66.
Coletro HN, Mendonça R, de Meireles D AL, et al. Ultra-processed and fresh food consumption and symptoms of anxiety and depression during the COVID – 19 pandemic: COVID Inconfidentes. Clin Nutr ESPEN. 2022;47:206–14.
LEAL ACG. Consumo de refrigerantes, doces e açúcares de adição e prevalência de depressão em graduados brasileiros (projeto CUME). Dissertação de mestrado. Universidade Federal de Viçosa; 2017.
Gomes PF, da Alvarenga S, de Canella R DS. Uso e conhecimento sobre rotulagem de alimentos ultraprocessados entre estudantes universitários. Vigil Sanit Debate. 2019;7:5–81.
da Silva DCG, Segheto W, Amaral FC et al. da S. (2019) Consumo de bebidas açucaradas e fatores associados em adultos. Ciênc saúde coletiva 24, 899–906.
Silva M, dos SL B, Lima Y, de MM, Ramalho AA. (2022) Tendência temporal do consumo excessivo de refrigerantes e sucos artificiais nas capitais brasileiras e Distrito Federal (2007 a 2019). Desafios - Revista Interdisciplinar da Universidade Federal do Tocantins 9, 129–143.
Botelho VH, Barros AJD, de Oliveira RG, et al. Agreement between measured weight, height and BMI and Web-based self-reported data in participants of the 1993 Pelotas Birth Cohort, Brazil: a cross-sectional validation study. Epidemiol Serv Saúde. 2023;32:e2022590.
Lassale C, Péneau S, Touvier M, et al. Validity of Web-Based Self-Reported Weight and Height: Results of the Nutrinet-Santé Study. J Med Internet Res. 2013;15:e2575.
Touvier M, Méjean C, Kesse-Guyot E, et al. Comparison between web-based and paper versions of a self-administered anthropometric questionnaire. Eur J Epidemiol. 2010;25:287–96.

Tables 1 and 2 are available in the Supplementary Files section.

No competing interests reported.

Download PDF

Reviewers invited by journal
03 Nov, 2024
Editor invited by journal
18 Oct, 2024
Editor assigned by journal
17 Oct, 2024
Submission checks completed at journal
17 Oct, 2024
First submitted to journal
15 Oct, 2024

You are reading this latest preprint version

Consumption of sweetened beverages and symptoms of anxiety, depression and stress: an analysis of university students in the PADu-multicenter study

Status:

Version 1

Abstract

Figures

Introduction

Methods

Study design

Instrument and data collection

Outcome variables

Explanatory variable

Covariates

Statistical analysis

Results

Characteristics of the study participants

Prevalence of consumption of sweetened beverages and prevalence of symptoms of anxiety, depression and stress

Association between consumption of sweetened beverages and symptoms of anxiety, depression and stress

Discussion

Conclusion

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

Version 1