Clinical Nutrition ESPEN xxx (xxxx) xxx

Contents lists available at ScienceDirect

Clinical Nutrition ESPEN

journal homepage: http://www.clinicalnutritionespen.com

Short Communication

Is consumption of fast-food and carbonated soft drink associated with

anxiety-induced sleep disturbance among adolescents? A population-
based study
Asaduzzaman Khan a, b, *, Riaz Uddin a, b
a
School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, 4072, Australia
b
Active Healthy Kids Bangladesh (AHKBD), Dhaka, Bangladesh

a r t i c l e i n f o s u m m a r y

Article history: Background & aims: Unhealthy dietary behaviours have been associated with poor sleep among ado-
Received 12 September 2019 lescents in many developed countries; however, evidence is lacking from resource-limited settings. This
Accepted 20 January 2020 study aimed to examine the associations of fast-food or carbonated soft drink consumption with anxiety-
induced sleep disturbance among adolescents in Bangladesh.
Keywords: Methods: We analysed data from the 2014 Bangladesh Global School-based Student Health Survey. Data
Adolescence
on past 12-month anxiety-induced sleep disturbance, and past 30-day carbonated soft drink and past 7-
Dietary behaviour
day fast-food consumption were collected. We used Poisson regression to examine the associations.
Fast-food
Sleep difficulties
Results: Data were available for 2742 adolescents aged 12e15 years (37% females). The prevalence of
Carbonated sugar-sweetened soft drinks anxiety-induced sleep disturbance was 4.5%, while that of soft drink (
3 times/day) and fast-food (
3
Wellbeing days/past week) consumption were 17% and 26%, respectively. Multivariable analysis showed that ado-
lescents who consumed carbonated soft drink
3 times/day had double the odds of reporting sleep
disturbance than those who consumed < once/day (OR 2.05, 95% CI 1.01e4.18). Compared to those who
did not have any fast-food in the past week, the odds of reporting sleep disturbance was 2.6 times higher
among those who had fast-food
3 days during the past week (OR 2.64, 95% CI 1.33e5.24). Adolescents
who had high intake of both fast-food and soft drink had 3.4 times higher odds of reporting sleep
disturbance compared to those who had neither (OR 3.40, 95% CI 1.37e8.44).
Conclusions: Our findings suggest positive associations between frequent consumption of soft drinks
and/or fast-food with anxiety-induced sleep disturbance among adolescents. Prospective studies are
needed to understand these associations better.
© 2020 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights
reserved.

1. Introduction
Poor mental health has become common among contemporary
youth with, globally, 10e20% of adolescents experiencing mental
health conditions such as depression and anxiety [1]. According to
the World Health Organization (WHO), 16% of the global burden of
disease and injury in the 10-19-year-old age group are attributable
to mental ill-health [1]. In addition to physical health conse-
quences, adolescents with mental health problems are often stig-
matised, have difficulties with education, and are vulnerable to
* Corresponding author. School of Health and Rehabilitation Sciences, The Uni-
versity of Queensland, Therapies Annex, St Lucia, Brisbane, QLD, 4072, Australia.
Fax: þ61 7 3365 1877.
E-mail address: a.khan2@uq.edu.au (A. Khan).
social exclusion, inequality, and human rights violations [1]. Health
promotion programmes, therefore, should have a strong focus on
adolescent's mental health needs.
Adequate sleep and sleep quality are important determinants of
adolescents' physical and mental health and cognitive develop-
ment [2]. Insufficient sleep and other sleep problems, including
sleep disturbance, can harm adolescents' emotional wellbeing,
mood, attention, daytime functioning, and educational attainment
[2]. Insufficient sleep and impaired sleep quality have also been
associated with obesity, which is a common risk factor for future
cardiometabolic disorders such as diabetes and cardiovascular
disease during adulthood [3]. Identifying modifiable risk factors for
sleep disturbance can therefore be critical to improving adoles-
cents' health.

https://doi.org/10.1016/j.clnesp.2020.01.011
2405-4577/© 2020 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.

Please cite this article as: Khan A, Uddin R, Is consumption of fast-food and carbonated soft drink associated with anxiety-induced sleep
disturbance among adolescents? A population-based study, Clinical Nutrition ESPEN, https://doi.org/10.1016/j.clnesp.2020.01.011
2 A. Khan, R. Uddin / Clinical Nutrition ESPEN xxx (xxxx) xxx

In the recent years, several studies have identified that un-
healthy dietary behaviours, particularly carbohydrate-rich and
calorie-dense foods, are associated with poor mental health
including insufficient sleep, disturbed sleep, and sleep difficulties
and dissatisfaction among adolescents [4e7]. For example, ado-
lescents who consumed excessive fast-food or soft drinks had
lower odds of being satisfied with sleep in a recent study in South
Korea [5]. Most of these studies, however, are from developed
countries [4,5,7] with little evidence from developing countries
such as Bangladesh, where resources are limited to address the
mental health needs of adolescents, and consumption of fast-food
and soft drinks has become increasingly popular among contem-
porary youth [8]. The aim of this study, therefore, is to examine
whether fast-food or carbonated soft drink consumption is asso-
ciated with anxiety-induced sleep disturbance among adolescents
in Bangladesh.
survey collected information on age, sex, weight status, food inse-
curity, smoking, physical activity (PA), loneliness, and number of
close friends.
Three Poisson regression models were used to examine the re-
lationships of: (a) fast-food consumption with sleep disturbance;
(b) soft drink consumption with sleep disturbance; and (c) con-
sumption of both fast-food and soft drink with sleep disturbance,
adjusted for age, sex, body mass index (BMI, computed from height
and weight by age and sex, using the WHO Growth Reference Data),
food insecurity, smoking, PA, and number of close friends. Loneli-
ness was not considered in any subsequent analysis due to its high
collinearity with the number of close friends. A sensitivity analysis
was conducted with different cut-off values to demonstrate
robustness of the findings. Data were weighted for non-response
and probability selection. All statistical analyses were performed
using Stata 14.0 SE.

2. Methods 3. Results

We used publicly available data from the 2014 Bangladesh
Global School-based Student Health Survey (GSHS), which is a
population-based nationally representative survey of school stu-
dents. The Bangladesh GSHS used an anonymous and self-
administered survey to collect data from school students about
their health and behavioural risk and protective factors. As the
current study used retrospective, de-identified, and publicly avail-
able data, we did not seek ethics approval from any Institutional
Ethics Review Committee.
In the GSHS, students' sleep disturbance due to anxiety was
measured with the question ‘During the past 12 months, how often
have you been so worried about something that you could not sleep
at night?’ with answer options: ‘never’; ‘rarely’; ‘sometimes’; ‘most
of the time’; and ‘always’. As used elsewhere [9], those who
answered ‘most of the time’ or ‘always’ were considered to have
anxiety-induced sleep disturbance. Fast-food consumption was
assessed with the question ‘During the past 7 days, on how many
days did you eat food from a fast-food restaurant, such as KFC, BFC,
or Pizza Hut?’ This variable was categorised as ‘none’, ‘1e2’, and
‘
3’ days during the past week. Consumption of carbonated soft
drinks was assessed with the question ‘During the past 30 days,
how many times per day did you usually drink carbonated soft
drinks, such as Coke, Fanta, or 7-Up?’ The students were instructed
not to include diet soft drinks. This variable was categorised as
‘none to < once’, ‘1e2 times’, and ‘
3 times’ per day. In addition, the
Of the 2753 survey participants aged 12e15 years, 2742
responded to the anxiety-induced sleep disturbance question and
formed the analytical sample. Among those, 38% were female ad-
olescents, and the mean age of the participants was 13.96 (SD: 0.81)
years.
Overall, 4.5% (122 out of 2742) of adolescents had anxiety-
induced sleep disturbance. About half (48%; 1291 out of 2700) of
adolescents had carbonated soft drink
1 time(s)/day with about
17% (445 out of 2700) having had
3 times/day. A quarter (26%, 700
out of 2713) of adolescents had fast-food
3 days during the past
week, while another quarter (28%, 747 out of 2713) had one to two
days. Percentages of adolescents with anxiety-induced sleep
disturbance by consumption of fast-food and carbonated soft drink
are presented in Fig. 1.
Multivariable Poisson regression analysis showed that adoles-
cents who had carbonated soft drink
3 times/day had double the
odds of reporting sleep disturbance due to anxiety than their
counterparts who had <1 time or no soft drink per day (OR 2.05,
95% CI 1.01e4.18; p ¼ 0.045). The odds of reporting sleep distur-
bance was 2.6 times higher among adolescents who had fast-food

3 days during the past week compared to those who did not
have any fast-food (OR 2.64, 95% CI 1.33e5.24; p ¼ 0.005). Further
analysis showed that adolescents who consumed both fast-food
(
3 days during the past week) and had carbonated soft drink
(
3 times/day) had 3.4 times higher odds of reporting anxiety-

Fig. 1. Percent distribution of adolescents with anxiety-induced sleep disturbance by consumption of fast-food and carbonated soft drink. Note: error bars represent 95% confidence
intervals. The numbers present the percentages of anxiety-induced sleep disturbance within each of the three groups, and their weighted sum is equal to the overall prevalence of
4.5%.

Please cite this article as: Khan A, Uddin R, Is consumption of fast-food and carbonated soft drink associated with anxiety-induced sleep
disturbance among adolescents? A population-based study, Clinical Nutrition ESPEN, https://doi.org/10.1016/j.clnesp.2020.01.011
 A. Khan, R. Uddin / Clinical Nutrition ESPEN xxx (xxxx) xxx
induced sleep disturbance compared to those who neither had fast-
food nor had soft drink (OR 3.40, 95% CI 1.37e8.44; p ¼ 0.009), after
adjusting for a set of covariates.
A sensitivity analysis with different cut-offs for consumption of
fast-food [none, 1e3 days,
4 days during the past week] and
carbonated soft drink [none, 1e3 times/day,
4 times/day] provided
similar results with frequent consumption being associated with
higher odds of reporting anxiety-induced sleep disturbance among
the participating adolescents.
4. Discussion
The present study adds to the limited evidence on the associa-
tions between unhealthy diet and mental ill-health among ado-
lescents from a developing country. In this population-based study,
we found that adolescents who frequently had carbonated soft
drinks and/or fast-food had higher odds of reporting anxiety-
induced sleep disturbance than their non- or moderate-consumer
counterparts.
Finding that frequent consumption of soft drinks is associated
with sleep difficulties is consistent with other studies that reported
a positive association of frequent soft drink consumption with sleep
disturbance [6], insufficient sleep [4], and dissatisfaction with sleep
[5] among adolescents. Frequent consumption of carbonated soft
drinks, which have a high level of sugar, can adversely affect mood
and elevate depressive symptomology [10] that have been associ-
ated with sleep problems among adolescents [2]. Added sugar can
displace the consumption of micro-nutrient rich foods, which are
essential for adolescents’ mental wellbeing [10]. In addition, soft
drinks often contain caffeine, which is a known stimulant and has
been associated with insufficient sleep, disrupted sleep, and day-
time sleepiness among adolescents [2]. We have not been able to
asses if other sugar-sweetened beverages such as fruit juices or
energy drinks affect sleep among adolescents. More research,
therefore, is needed to better understand the associations of
carbonated sugar-sweetened soft drinks and sleep among adoles-
cents in developing countries.
Consistent with other studies [5e7], frequent fast-food con-
sumption was associated with sleep disturbance among adolescents
in our study. Adolescents who are “short sleepers” have been found
to consume calorie-dense high fat and high carbohydrate food such
as snacks, takeaways, and fast-foods [2]. Fast-foods, including pro-
cessed food such as hamburgers and hot dogs, pizzas, chips, and fries,
have been associated with increased mental health problems among
adolescents [10]. Poor nutrient content of these foods can adversely
affect mood, appetite, and sleep by interfering with the synthesis of
neuromodulators such as serotonin [10].
While our study suggests that unhealthy dietary behaviours
affect sleep, the opposite (i.e., sleep affects diet) is also possible.
There is evidence from experimental studies that sleep duration
and quality influence appetite-regulating hormones such as ghrelin
and leptin [2]. Sleep deprivation may cause a hormonal imbalance
of ghrelin and leptin (e.g., increasing circulation of ghrelin and
decreasing circulation of leptin), which can induce the need for
energy-dense food such as those high in fat and sugar [2]. It is,
therefore, possible that an unhealthy diet and sleep disturbance
among adolescents are mutually reinforcing, and more research is
needed to understand the directionality of these associations.
The strength of this study is the inclusion of a nationally
representative sample of school-attending adolescents and
adjustment of the associations for a number of potential con-
founders. We, however, did not have data on family environment,
which can be associated with dietary behaviour and sleep of ado-
lescents. The study is limited by its cross-sectional design, and as
such directionality of the relationships cannot be established. Data
Please cite this article as: Khan A, Uddin R, Is consumption of fast-food and carbonated soft drink associated with anxiety-induced sleep
disturbance among adolescents? A population-based study, Clinical Nutrition ESPEN, https://doi.org/10.1016/j.clnesp.2020.01.011
3
for this study are self-reported and therefore are vulnerable to
social desirability and recall bias. Recall periods for fast-food (past 7
days), soft drinks (past 30 days), and sleep disturbance (past 12
months) did not overlap completely. Sleep disturbance was
measured with a single item without information on different as-
pects of sleep, such as sleep duration, sleep efficiency, and sleep
onset latency. Fast-food consumption was assessed with partici-
pants having food from fast-food restaurants, which are more likely
to offer nutritionally unbalanced meals with a remote chance of
having nutrient balanced food as well. This may have introduced
measurement bias in assessing consumption of fast-food.
In conclusion, our study demonstrates that frequent consump-
tion of soft drinks and/or fast-food were associated with anxiety-
induced sleep disturbance among adolescents in Bangladesh. Our
findings add additional weight to the growing body of evidence for a
link between unhealthy dietary behaviours and mental ill-being in
adolescents. Restricting the consumption of these unhealthy foods
and beverages can be a pragmatic strategy to improve sleep and
overall wellbeing of adolescents. Prospective studies with device-
based measures of sleep or self-report valid assessment that can
measure different components of sleep are needed to better un-
derstand these associations, including their causal pathways.
Statement of authorship
Both authors contributed to the conceptualisation of the study,
data analyses and interpretation, and manuscript writing. Both
authors have approved the final manuscript.
Ethics approval and consent to participate
The GSHSs received ethics approval from both a national gov-
ernment administration and an institutional review board or ethics
committee. Only adolescents and their parents who provided
written/verbal consent participated. As the current study used
retrospective publicly available data, we did not require ethics
approval from any Institutional Ethics Review Committee for this
secondary analysis.
Consent for publication
All participants involved in the GSHSs gave consent for
publication.
Availability of data and material
The 2014 Bangladesh GSHS dataset is publicly available at the
WHO data repository https://www.who.int/ncds/surveillance/
gshs/bangladeshdataset/en/
Funding sources
None to declare.
Declaration of Competing Interest
The authors have no conflict of interest to disclose.
Acknowledgements
The authors would like to thank the US Centers for Disease
Control and the World Health Organization for making Global
School-based Student Health Survey (GSHS) data publicly available
for analysis. The authors also thank Bangladesh GSHS country
coordinator and other staff members.
4 A. Khan, R. Uddin / Clinical Nutrition ESPEN xxx (xxxx) xxx

References [6] Zahedi H, Kelishadi R, Heshmat R, Motlagh ME, Ranjbar SH, Ardalan G, et al.
Association between junk food consumption and mental health in a national
sample of Iranian children and adolescents: the CASPIAN-IV study. Nutrition
[1] World Health Organization. Adolescent mental health. Geneva, Switzerland:
2014;30:1391e7.
World Health Organization; 2018.
[7] Kruger AK, Reither EN, Peppard PE, Krueger PM, Hale L. Do sleep-deprived
[2] Owens J. Insufficient sleep in adolescents and young adults: an update on
adolescents make less-healthy food choices? Br J Nutr 2014;111:1898e904.
causes and consequences. Pediatrics 2014;134:e921e32.
[8] Mistry SK, Puthussery S. Risk factors of overweight and obesity in childhood
[3] St-Onge M-P, Mikic A, Pietrolungo CE. Effects of diet on sleep quality. Adv Nutr
and adolescence in South Asian countries: a systematic review of the evi-
2016;7:938e49.
dence. Publ Health 2015;129:200e9.
[4] Franckle RL, Falbe J, Gortmaker S, Ganter C, Taveras EM, Land T, et al. Insuf-
[9] Sharma B, Lee HT, Nam WE. Loneliness, insomnia and suicidal behavior among
ficient sleep among elementary and middle school students is linked with
school-going adolescents in Western Pacific Island countries: role of violence
elevated soda consumption and other unhealthy dietary behaviors. Prev Med
and injury. Int J Environ Res Publ Health 2017;14:791.
2015;74:36e41.
[10] Khalid S, Williams CM, Reynolds SA. Is there an association between diet and
[5] Park S, Rim SJ, Lee JH. Associations between dietary behaviours and perceived
depression in children and adolescents? A systematic review. Br J Nutr
physical and mental health status among Korean adolescents. Nutr Diet
2017;116:2097e108.
2018;75:488e93.

Please cite this article as: Khan A, Uddin R, Is consumption of fast-food and carbonated soft drink associated with anxiety-induced sleep
disturbance among adolescents? A population-based study, Clinical Nutrition ESPEN, https://doi.org/10.1016/j.clnesp.2020.01.011