International Journal of Community Medicine and Public Health

Kamali R et al. Int J Community Med Public Health. 2024 Jan;11(1):182-187

http://www.ijcmph.com pISSN 2394-6032 | eISSN 2394-6040

DOI: https://dx.doi.org/10.18203/2394-6040.ijcmph20234123
Original Research Article

Knowledge, attitude and practices towards consumption of caffeine

containing drinks among medical college students in Chennai
R. Kamali1, S. Srinidhi2*, G. Srividya Purna3, G. Mithra Devi4,
R. Keerthana5, Swathy Elangovan6

1
Department of Community Medicine, Government Kilpauk Medical College, Chennai, Tamil Nadu, India
2
Department of Radiodiagnosis, Alluri Sitarama Raju Academy of Medical Sciences, Andhra Pradesh, India
3
Department of Obstetrics and Gynecology, Narayana Hrudayala Hospitals, Bengaluru, Karnataka, India
4
Department of Obstetrics and Gynecology, Madras Medical College, Chennai, Tamil Nadu, India
5
Department of Community Medicine, Madurai Medical College, Madurai, Tamil Nadu, India
6
Department of Surgery, SRM medical college, Chennai, Tamil Nadu, India

Received: 08 October 2023

Revised: 25 November 2023
Accepted: 30 November 2023

*Correspondence:
Dr. S. Srinidhi,
E-mail: srinidivasan@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Indian population has been accustomed to caffeinated beverages since time immemorial. Globally, they
have become the most preferred drink since the bloom of the twentieth century. However, unbridled consumption has
been associated with many side effects. The objectives of this study were to assess the knowledge, attitude and
practices among medical students with respect to caffeine containing drinks, and to determine the relationship
between caffeine consumption and body mass index (BMI).
Methods: It was a cross sectional study. Data was collected through a self-administered, pre-tested questionnaire
after getting informed consent. The questionnaire was in a semi-structured format.
Results: A total of 372 medical students took part in this present study, out of which 312 (83.6%) students responded
to have the habit of taking caffeinated beverages, coffee (58.06%) being the maximum preferred drink and taste
(49.1%) being the leading reason. Mean BMI was 22.16 with 50% being normal and, 16%, 17% and 17% being
underweight, overweight and obese respectively. Withdrawal effects were experienced by 47.4% of students on
stopping them for at least a day. 88.7% of medical students were aware of caffeine addiction and 62.5% were
confident that they can stop over drinking them after knowing the ill effects.
Conclusions: The study showed that students were not following healthy practises of caffeine consumption, albeit the
knowledge of caffeine addiction, in terms of BMI. However, with proper health education and awareness, the students
are ready to change their views and practises regarding caffeine consumption.

Keywords: Addiction, Adolescents, BMI, Caffeine, Energy drinks, KAP, Medical students, Obesity

INTRODUCTION influence backed by the commercial ads, introduction of

fast foods and liberal consumption of traditional Indian
Indian population has been accustomed to caffeinated beverages in our household, there has been a proliferation
beverages since time immemorial. They have become the of cafe chains, vending machines and caffeinated
most preferred drink since the bloom of the twentieth beverages during recent times. However increased
century, most notably as a vogue worthy and mind consumption when not overseen have been associated
rejuvenating supplement to our system. With large with many side effects.

International Journal of Community Medicine and Public Health | January 2024 | Vol 11 | Issue 1 Page 182
 Kamali R et al. Int J Community Med Public Health. 2024 Jan;11(1):182-187

The term energy drink refers to group of beverages used Drinking sugar-added caffeinated beverages creates the
by consumer to reduce fatigue, provide energy, promote concept of “empty calories”, i.e., consumption of a drink
wakefulness, maintain alertness and provide cognitive will cause satiety but has little nutritional value and
and mood enhancement. The main ingredient of energy globally causes obesity.10 Furthermore, increased
drinks is caffeine.1 Caffeine is a central nervous system consumption of high sugar drinks may enhance the liking
stimulant of methyl-xanthine class.2 It is the world’s most and need towards other sugar rich confectioneries such as
actively consumed psychoactive substance. It is sweets which may lead to increased incidence of obesity.
commonly found in the seeds, nuts or leaves of a number Coffee affects HCL secretions in the stomach. They
of plants native to Africa, East Asia and South America. might demineralise the tissues. Tea has an inhibitory
function on absorption of nonheme iron and may block
According to the Food and Drug Administration (FDA), it vitamin B1 inactivation.7 Though soft drinks might appear
is considered as generally recognized as safe (GRAS).2 to apparently suffice; it mainly constitutes carbon dioxide
Caffeine is present in a wide range of products, namely, and phosphoric acid which fizzes out when opened. The
coffee, tea, soft drinks, hot chocolates, and confectionery high acidity (pH ranging from 2,5 to 3.4) of a soft drink
such as chocolates and over-the-counter medications leads to gastronomic distress due to erosion and
including cold remedies and analgesics.3 Currently, over inflammation of gastric mucosa. A notable association of
10 million packs of coffee are consumed globally.4 The dental carries have been reported due to high sugar
typical content of caffeine in commonly used drinks is as content in them, affecting the enamel, outermost covering
follows: tea (45 mg/cup), instant coffee (60 mg/cup), of a tooth. Soft drinks are known to erode calcium from
brewed coffee (100 mg/cup) and cola drinks (20-25 our body, reportedly leading to nephrolithiasis (kidney
mg/can). stones). In most of the caffeinated beverages, caffeine is
deliberately added to make it more addictive. Moreover,
Researches revealed the use of energy drinks in the caffeine in carbonated drink is more easily absorbable
following six situations: for insufficient sleep, to increase than any other drink (like tea, coffee, chocolate etc).11
energy, while studying, driving long periods of time,
drinking with alcohol while partying and to treat a The cap that FSSAI is proposing for energy drinks- 300
hangover.5 Although caffeine consumption does provide ppm caffeine, and two cans (500 ml) of energy drinks per
the above said benefits, the addictive capacity potentiates day, with minimum amount of 145 ppm of caffeine per
the consumers to succumb towards caffeinism. Caffeine drink is especially of concern, since these energy drinks
activates the dopaminergic system and this attributes to are openly sold despite the warning label for ‘children,
its addictive nature.6 If you feel like you cannot get going pregnant mothers, youngsters and sportspersons’.12
in the morning, feel overtired during the day from not
having caffeine, or get headaches when you try to stop Therefore, the present study has been undertaken to find
taking caffeine regularly, these are signs of dependence.7 out what the medical students know about caffeinated
drinks, their practises regarding how often they consume,
The term “caffeinism” refers to an acute intake of for what reasons, and their attitude regarding the harmful
caffeine exceeding more than 250 mg/day and is side effects. Limited studies have been done to decipher
characterized by: restlessness, nervousness, excitement, the relationship between caffeine consumption and body
insomnia, flushed face, diuresis, GI disturbances, muscle mass index, therefore the present study aims to determine
twitching, rambling flow of thought and speech, the same.
tachycardia or arrythmias, periods of inexhaustibility,
psychomotor agitation.8 Caffeine causes decreased METHODS
classroom performance, sleep deprivation, and viewing
its addictive nature, caffeine is a giveaway drug. It is Study design
associated with several behavioral problems such as
substance abuse, increased fighting, increased addiction The investigation was studied among first year to third
to alcohol and smoking.9 year MBBS undergraduates at Government Medical
College, Omandurar Government Estate. The students
Caffeinated drinks are associated with many deleterious were selected based on inclusion and exclusion criteria.
effects on the human body and mind. These include
obesity (due to decreased satiety and fullness sensation Inclusion criteria
with high sugar beverages), diabetes (due to increase
sugar content), tooth decay (demineralization of enamel), All undergraduate students from first to third year MBBS
nutritional deficiencies, heart disorders (due to metabolic students from Government Medical College, Omandurar
and hypertensive effects) and many neurological Government Estate were included.
disorders (due to high concentration of caffeine).5
Frequent consumption of caffeine during childhood and Exclusion criteria
adolescence may affect the development of brain centers
responsible for planning and emotional control.6 Students who were not present for that session and
students who were not willing to participate in the study.

International Journal of Community Medicine and Public Health | January 2024 | Vol 11 | Issue 1 Page 183
 Kamali R et al. Int J Community Med Public Health. 2024 Jan;11(1):182-187

Sampling method The total number of medical students who took part in the
study were 372 out of which 181 (48.6%) were males and
All the undergraduate students were included by universal 191 (51.3%) were females. Age groups ranged from 17 to
sampling method and the cross-sectional study data was 24 years with mean height of 1.663 metres and weight of
taken from October to November 2018. Out of 400 61.47 kg. Around 312 (83.6%) students have caffeinated
students, 372 students participated. products on a regular basis and majority (216) of students
drink coffee, additionally 143 students drink tea, 141
Data collection students take caffeine in the form of chocolates (69) and
cola drinks (72).
Data was collected through a self-administered, pre-tested
questionnaire after getting informed consent. The
questionnaire was in a semi-structured format. All the
data collection forms were cross checked for
completeness and made unambiguous and error free.
Height was measured using stadiometer and weight was
measured using a calibrated electronic weighing machine.
BMI will be calculated using Quetelet’s index. A pilot
study was conducted with 40 students before
standardizing the questionnaire.
Underweight Normal Overweight Obese
Statistical analysis

The collected data was entered on Microsoft excel sheet Figure 3: Body mass index distribution.
and analysis was made using epi-info analysis with
appropriate descriptive and inferential statistical methods.
Sugar added Sugar not added

RESULTS
27%
The questionnaire comprised of demographic details; 13,
6, and 12 questions regarding practices, knowledge and
attitude respectively.

250 73%

200

150
Figure 4: Sugar added or not.
100
According to the Asian standard scale for BMI
50
classification, 185 individuals have normal standard range
0
(172 amongst students who take caffeinated drinks on a
Coffee Tea Chocolate Cola regular basis), 59 were underweight and 64 were
overweight and 64 (16 of them take caffeine on a regular
basis) belonged to obese category. 288 (73%) participants
Figure 1: Most preferred drink. prefer sugar in their caffeinated drinks.
109

Others
85

Peer pressure

Energy
34

Stay awake
8

Taste

0 50 100 150 200 5 OR MORE 3 TO 4 TWICE ONCE

Figure 2: Reason for preference. Figure 5: Rate of consumption.

International Journal of Community Medicine and Public Health | January 2024 | Vol 11 | Issue 1 Page 184
 Kamali R et al. Int J Community Med Public Health. 2024 Jan;11(1):182-187

Majority of students (109) answered that they consume 88.7% of students were aware of caffeine dependance and
these drinks twice a day, 85 students once, 79 students 62.9% were confident of changing their practices in view
consume them once in a while, 55 do not consume them of caffeinism.
as much, 34 students 3 to 4 times and 8 students consume
five or more times per day. Increase in consumption has DISCUSSION
been seen in 30% of students since joining college mainly
due to stress (25%) and to stay awake (19%). 41.1% Caffeinated drinks in the present day scenario have
students take them before studying and 54.5% do not become part of our regular diet, regardless of our
mind taking them on empty stomach. ethnicity, its derivatives have been inculcated into our
roots right from our childhood practices either by our own
accord or external influences of our elders,
insurmountable to resist. The present examination shows
that acculturated westernised forms of caffeine namely
30% carbonated beverages are also an equal contributor the
caffeine in our system.
Yes No
From the above data, majority of the participants (83.6%)
70%
show interest in consumption of caffeinated products with
majority choosing coffee (58.06%). From the present
study, caffeinated drinks have been introduced quite
early, with majority fitting in the age group of five to ten
years, and a fair number (52.1%) have been habituated to
Figure 6: Increment of consumption rate. drinking once or twice a day in general, with 12.04% of
people drinking more than two times a day, taste (77.4%
prefer with sugar) and refreshing energy being the
undeniable reasons, 41.1% taking them just before
19%
studying. While the consumption has increased since
Stay awake joining the course for 29.8% of medical students, it has
38% Peer pressure mainly been due to stress, especially during exam/late
8% Headache
night study sessions.
Energy
Stress
As discussed by similar study done among adolescents in
Leisure
Delhi by Gera et al, average daily consumption of
25% Other
3% caffeine in our study population thus far exceeds that
3%
4% reported in developed nations, which is alarming. Most of
this caffeine is coming from coffee (frequency 2-3 times
per day) since it contains much more amount of caffeine
Figure 7: Reason for increase in consumption. as compared to other beverages.13 Though it is to be noted
that the rate of absorption of caffeine from carbonated
Withdrawal symptoms noted by participants when drinks is more quick, that 72 (19.35%) of people have
stopped for at least a day included headache (24.7%), agreed to consume them in the present study.
anxiety (5.3%), insomnia (4.3%), nervousness (2.6%),
palpitations (2.4%), tremor (1.6%), all of the above Contingent on the amount of caffeine expended the US
(1.8%). When asked to rate their dependence out of a Food and Drug organization, and American Medical
score of 5, 15.3% gave a 5, 4.8%, 14.24%, 22.04% and Association has classifications it into three extraordinary
43.04% gave 4, 3, 2 and 1 respectively. class: low intake: utilization up to 199 mg/day i.e. 1 cup
of any caffeinated beverage/per day, (2) moderate intake:
250 utilization of around 200-399 mg/day i.e. 2 cups of any
200 caffeinated beverage/per day, and (3) high intake:
utilization more than 400 mg/day i.e., 5 or more cups of
150
any caffeinated beverage per day.11 Although caffeine
100 ingested in lower doses has been shown to have positive
effects, Brice and Smith found that low dose of caffeine
50
(less than 200 mg/65 mg taken four times over a five hour
0 period) taken over time or all at once had a positive effect
on alertness, improved performance on simple and choice
reactive tasks, improved performance on a cognitive
vigilance task and a task requiring sustained response,
and dual tracking/target detection. They also found that
Figure 8: Withdrawal symptoms. both doses increased anxiety.11 However, as cited by

International Journal of Community Medicine and Public Health | January 2024 | Vol 11 | Issue 1 Page 185
 Kamali R et al. Int J Community Med Public Health. 2024 Jan;11(1):182-187

Kaplan et al, caffeine abuse beyond 400 mg (more than intake was associated with reduced central obesity in men
five cups per day) can make a person irascible, even to a (summary RR=0.90, 95% CI=0.66, 1.23) but increased
point that it is detrimental to our concentration. Moderate central obesity in women (summary RR=1.18, 95%
consumption (200 to 399 mg/day) on a regular basis are CI=0.75, 1.86). However, the associations were not
known to hinder the very aptitudes it is known to statistically significant and there was no evidence of
improve, namely memory retention or sleep resistance.11 heterogeneity by sex (heterogeneity =0.59).16 According
to a randomised cross over study by Gavrieli et al glucose
The unswerving trend of caffeine abuse have shown its incremental area under the curve (IAUC) was
effects both in dependence and the withdrawal effects, as significantly different between interventions (p=0.009)
caffeine is considered a drug. Caffeine may not be with both coffee amounts inducing a greater area
considered as the epitome example of the term addicted compared to water. Secondary, subgroup analysis at the
or abuse potential drugs when compared with the famous nominal level showed that this might be more evident
drugs of cocaine, heroin and nicotine, though caffeine among females (PIAUC=0.05) and overweight/obese
users have reported to have got addicted to caffeine in a participants (PIAUC=0.03).17
sense that they were unable to cut down or quit their
caffeine use. A study done by Mayo clinic showed that In a scenario where the average daily consumption of
people may experience different reactions to caffeine caffeine among adolescents and youngsters in India is not
depending on regular caffeine consumption, body mass, yet documented, a cap of 300 ppm caffeine in ‘energy
age, medication use, and health conditions such as drinks’ should not be allowed. Moreover, with multitude
anxiety disorders. Their research also suggests that men of caffeine sources such as coffee, tea and soft drinks,
are more susceptible to harmful effects of caffeine than there is enormous accumulation caffeine in our system.
women. Caffeine can also have a major impact on Furthermore, a large proportion of energy drinks are
sleeping habits.11 In the present study, 20.3% have rated 4 being misused and consumed with alcohol leading to
and above on a scale of 5, and withdrawal symptoms, cognitive impairment.
24.7% agreeing to headaches, anxiety (5.3%),
nervousness (2.6%), tremors (1.6%), palpitations (2.4%), To our knowledge, a limited number of cross-sectional
with 1.8% accepting to have had all of them. However, studies have been undertaken in India to determine the
individual differences in sensitivity and tolerance affect awareness of caffeine consumption and its effects in our
the severity and likelihood of experiencing negative system. The study was conducted on a small sample size
effects. For regular caffeine users, the avoidance of low- and may not reflect the entire adolescent and adult
grade withdrawal symptoms, such as drowsiness after population. The reliability of a self-reported questionnaire
overnight abstinence, has been identified as a central might be another drawback of the study.
mechanism underlying the reinforcing effects of
caffeine.14 Despite these limitations, however, the study does point
towards an increasing trend of caffeine consumption
In the above study, significant number of people have amongst Indian youngsters. This should act as an eye
fallen in underweight, overweight and obese category. opener for setting up appropriate upper limits for caffeine
The age-old belief of consuming high sugar beverages to content in beverages and various food products.
be equivalent to a healthy wholesome meal is sadly still
prevailing amongst youngsters. Energy drinks are still CONCLUSION
widely consumed in the group of adolescents and adults,
with a partial lack of sound scientific knowledge. Though The study showed that students were not following
one should be well aware of the concept of empty calories healthy practises, measured principally through the
in soft drinks and the alike, surprisingly a good number of relation of BMI with caffeine consumption, albeit their
students have reportedly skipped their meals or had these knowledge of caffeine addiction. However, with proper
caffeinated beverages empty stomach. Coffee delayed the education and awareness, the students are ready to change
rise of insulin in response to the standardized meal and their views and practises regarding caffeine consumption.
the fall of glucose concentrations from its maximum Students have a good attitude towards changing their
levels in the entire study sample. Studies in China, as habits. With more specific knowledge and the clearance
done by BMI had a positive significant association with of common myths, good practises can be inculcated.
increased caffeinated drinks consumption (B=0.05, Though caffeinated beverages have become an
SE=0.01, p<0.01), high physical inactivity time (B=0.18, unreplaceable drinking our routine diet, with proper
SE=0.04, p<0.01), and reduced physical activity time capping of caffeine content in energy drinks and
(B=−0.44, SE=0.04, p<0.01).15 When compared gender instillation of proper habits in our present youth,
wise, study conducted by Zhang et al concluded that caffeinism can be curbed significantly. Although known
coffee intake may be modestly associated with lower for its therapeutic effects, many studies are yet to be done
adiposity as indicated by BMI and WC, particularly in in this domain for more insight and being more advertent
men. While the benefit of coffee intake against obesity about its ill effects if abused beyond that which is
was not as fundamental as balanced diets and physical required.
activity.15 In subgroup analysis by sex, higher coffee

International Journal of Community Medicine and Public Health | January 2024 | Vol 11 | Issue 1 Page 186
 Kamali R et al. Int J Community Med Public Health. 2024 Jan;11(1):182-187

Funding: No funding sources Maharashtra. Int J Med Sci Public Health.

Conflict of interest: None declared 2013;2(4):912-5.
Ethical approval: The study was approved by the 11. Edward S, Kumar MS, Gopalakrishnan S. Trend of
Institutional Ethics Committee caffeine consumption among medical students and
its side effects. Drug Invent Today. 2019;12(11).
REFERENCES 12. Food safety and standards (food products standards
and food additives) regulations, 2011. Available
1. Casuccio A, Bonanno V, Catalano R, Cracchiolo M, from: https://www.fssai.gov.in/cms/food-safety-and-
Giugno S, Sciuto V, et al. Knowledge, attitudes, and standards-regulations.php. Accessed on 2 July 2023.
practices on energy drink consumption and side 13. Gera M, Kalra S, Gupta P. Caffeine intake Among
effects in a cohort of medical students. J Addict Dis. Adolescents in Delhi. Indian J Community Med.
2015;34(4):274-83. 2016;41(2):151-3.
2. Caffeine. Wikipedia. Available from: 14. Caffeine dependence. Behavioural pharmacological
https://en.wikipedia.org/wiki/Caffeine. Accessed on research unit (BPRU) fact sheet. John Hopkins
2 July 2023. Medicine. Available from:
3. Priyadharshini T, Gayathridevi R. Caffeine https://docplayer.net/15737208-Caffeine-
consumption habits and perception of adolescents in dependence-behavioral-pharmacology-research-
Chennai population. Asian J Pharm Clin Res. unit-bpru-fact-sheet-use-and-common-sources-of-
2016;9(3):149-51. caffeine.html. Accessed on 2 July 2023.
4. Park K. Park’s textbook of social and preventive 15. Zhang Y, Xiong Y. Caffeinated drinks intake, late
medicine. 24 edn. M/s Banarsidas Bhanot chronotype, and increased body mass index among
Publishers; 2017. medical students in Chongqing, China: a multiple
5. Shafi T, Aman Z. Knowledge attitude and practices mediation model. Int J Environ Res Public Health.
(KAP) regarding carbonated drinks among female 2018.PMC6121493.
medical students of Allama Iqbal Medical College, 16. Lee A, Lim W, Kim S, Khil H, Cheon E, An S, et al.
Lahore. Proceed SZMC. 2017;31(2):92-7. Coffee intake and obesity: a meta-analysis.
6. Bhojaraja VS, Janardhan H, Hameed NA, Fahmidha Nutrients. 2019;11(6):1274.
Gulsoom AR, Ali MZ. Knowledge, attitude and 17. Gavrieli A, Fragopoulou E, Mantzoros CS,
practices towards consumption of caffeine Yannakoulia M. Gender and body mass index
containing drinks among the student population of modify the effect of increasing amounts of
Ras al-Khaimah medical and health sciences caffeinated coffee on postprandial glucose and
university, UAE. Int J Res Med Sci. insulin concentrations; a randomized, controlled,
2016;4:3537-41. clinical trial. Metabolism. 2013;62(8):1099-106.
7. Jeneta JG. Effect of coffee and tea consumption 18. Centre for Science and Environment. Available at:
among dental school students. J Pharm Sci Res. www.cseindia.org. Accessed on 2 November 2023.
2016;8(6):552. 19. Healthline. Available at: www.cseindia.org.
8. Ahuja N. A short textbook of psychiatry. 7th edn. J. Accessed on 2 November 2023.
P. Brothers Publishers; 2011.
9. Musaiger AO, Zagzoog N. Knowledge, attitudes and Cite this article as: Kamali R, Srinidhi S, Purna GS,
practices toward energy drinks among adolescents in Devi GM, Keerthana R, Elangovan S. Knowledge,
Saudi Arabia. Global J Health Sci. 2014;6(2):42. attitude and practices towards consumption of
10. Kharde A, Deshpande J, Phalke D. Knowledge, caffeine containing drinks among medical college
Attitude and Practices (KAP) regarding carbonated students in Chennai. Int J Community Med Public
drinks among students of medical college of western Health 2024;11:182-7.

International Journal of Community Medicine and Public Health | January 2024 | Vol 11 | Issue 1 Page 187