1. Introduction
Coffee is one of the most widely consumed beverages in the world. It is a complex chemical mixture containing hundreds of biologically active compounds including carbohydrates, lipids, nitrogenous compounds, vitamins, minerals, alkaloids, and phenolic compounds [
1]. Caffeine, a substance that belongs to a group of compounds called methylxanthines, is one of the compounds with known biological activity. According to preparation techniques, the content of caffeine varies widely in different foods and beverages [
2]. Generally, caffeine is responsible for the beneficial effects of coffee, but studies also suggest the role of other compounds in the health effects of coffee consumption [
3].
Coffee has received a great deal of attention due to the high global prevalence of its consumption, and it is estimated to be increasing gradually in Asia, Africa, Europe, and North America [
4]. The daily average caffeine consumption in United States (US) adults is estimated to be 180–190 mg of caffeine, equivalent to 2–3 cups of coffee [
5]. Caffeine has both harmful and favorable health effects on the human body, such as anxiety, insomnia, tachycardia, irritability, and other cardiovascular disease (CVD) [
6]. The health effects of caffeine depend largely on the dosage used, and it has been established that moderate consumption of coffee is associated with favorable health effects and behaviors [
7]. On the basis of current research, the recommended portion for favorable and safe health effects of caffeine ranges between 300 and 400 mg/day of caffeine which is equivalent to 3–4 cups/day [
8,
9]. This dose is even less in the case of pregnant and lactating mothers [
10]. The consumption of coffee is often associated with unhealthy eating behaviors leading to adverse health effects [
11]. It has been reported that university students might be at a particularly high risk of negative effects due to the excessive intake of caffeine [
5].
There were several studies presented from various regions in Saudi Arabia regarding caffeine and caffeinated energy drink consumption in university students. However, only limited studies are available from this country regarding the consumption of coffee in female university students. A study performed in Saudi Arabian dental students (
N = 200, 98 females (20–25-year-olds), 102 males) showed higher consumption of caffeine in males than females. [
12]. Another study performed by Ahmed and colleagues in young Saudi females (112 Saudi nonpregnant young women, age of 26 ± 1.85 years) observed a negative association between knowledge about caffeine and attitude toward use of caffeine during pregnancy [
13]. Lack of awareness about caffeinated drink ingredients and unreliable resources as major sources of knowledge about their health effects were reported among Saudi adolescents and adults (
N = 1062 subjects (867 males and 195 females) aged 18–60 years) [
14].
Although the above-mentioned studies observed the relationship of caffeine consumption with many factors, including sociodemographic and behavioral [
12,
13,
14], the results reported were biased due to either a low response rate or a small number of participants, specifically regarding females. Moreover, there is no study in Saudi Arabia observing the prevalence, determinants, use pattern, and awareness of coffee consumption in young female students. To fill this gap, the present study aimed to report the prevalence and observe the pattern of coffee consumption and its association with factors including obesity (body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR)), sociocultural aspects, health behaviors, symptoms, and awareness. Moreover, to our knowledge, the present study is one of the first of its kind including such a large number of young female participants.
4. Discussion
Over the past few decades, the tradition of coffee consumption has grown in popularity in Middle Eastern countries, including Saudi Arabia. The present study highlighted a high prevalence (88.2%) and trends of coffee consumption among female university students. Moreover, the study indicated strong predictors of coffee consumption to be high BMI and high family income level.
The consumption of caffeine depends on age and, therefore, main dietary caffeine sources may differ as age advances [
15]. The reports from The National Health and Nutrition Examination Survey NHANES showed positive linear trends between age and total caffeine consumption until 45–55 years of age [
5]. Around 70% of United States (US) children and adolescents (aged <22 years) consume some form of caffeine on any given day, and approximately 89% of adults consume caffeinated beverages on a daily basis [
16,
17]. Moreover, the prevalence of caffeine consumption among Hungarian males and females is quite high (91.5% and 93.2%, respectively) [
18]. A study among students (aged 18–24 years) at the University of Sarajevo, Bosnia and Herzegovina, demonstrated a prevalence of 71.2 % (
N = 673) coffee consumption [
19]. The prevalence of caffeine intake per day among students from six different universities in Bahrain was high (98%), with coffee as the main source of caffeine intake (76%) [
20]. A similar study reported 72.3% coffee intake among Brazilian students with a higher prevalence among females (68.3%) [
21]. Moreover, a study performed in United Arab Emirates (UAE) university students (male 30.1% and female 69.9%) showed a high prevalence (85.1%) of caffeinated energy drink consumption [
22]. A high prevalence (86%) of caffeinated drink consumption was observed among students at Zayed University, UAE, with coffee as the major contributor of caffeine intake [
23].
The prevalence of coffee consumption in our present study is considerably high (88.2%) as compared to Bahrain (76%), Brazil (68.3%), US (70%), and Bosnia and Herzegovina adolescents (71.2%), and it is nearly equal to UAE university students (86%).
The possible reasons for this high consumption can be mainly attributed to the culture and traditions of this country. Like other Middle Eastern countries, the consumption of Arabic coffee is a social norm and an essential part of hospitality, which is highly practiced for every occasion and event [
24]. Saudi families drink Arabic coffee 1–2 times daily and most of them drink coffee after evening prayer (Maghreb) around 6:00–7:00 p.m. [
25]. Moreover, in Arab and other Muslim countries, caffeinated beverages are the only popular drink products which are quite common and easily available to university students.
The consumption of coffee and its effect on body weight and body fat distribution is still controversial. Coffee contains several biologically active compounds that result in beneficial effects on obesity and other interrelated abnormalities. However, there are studies reporting direct [
26], inverse [
27], and neutral relationships between coffee consumption and obesity [
28]. Variations in coffee composition and consumption pattern (such as coffee type and amount of intake) are major factors for the inconsistent effect of coffee on human health. Moreover, as abnormal lipid metabolism is common in conditions such as obesity, diabetes, and metabolic syndrome, the effects of coffee bioactivity on lipid metabolism are suggested as underlying mechanisms of its positive health effects [
9]. The health effects of Arabic coffee consumption are still controversial with a lack of scientific evidence about the benefits and/or risk factors. The consumption of Arabic coffee in healthy individuals was shown to result in high total serum cholesterol level as compared to non-consumers, especially in females [
29]. A study performed in healthy women consuming Arabic coffee with added spices like cardamom demonstrated a neutral effect on blood pressure and biomarkers of inflammation (e.g., C-reactive protein), but resulted in an increased level of low-density lipoprotein cholesterol and total cholesterol [
30]. In addition, Arabic coffee consumption in healthy individuals modestly increased the plasma glucose response of dates compared to that of dates consumed with water, probably due to the presence of caffeine, which could impair glucose tolerance and decrease insulin sensitivity [
31]. A recent study of Taibah university students and employees (18–45 years of age) demonstrated a high level of Arabic coffee consumption and its positive association with obesity (28% overweight and 33% obese), indicating a health warning against its excessive intake [
32]. Our present study supports the above findings [
26,
32], showing a direct association between coffee consumption and BMI among female students.
The association of coffee consumption with marital status is still inconsistent with mixed data. It was reported that married women consume caffeinated beverages nearly twice as frequently as unmarried women [
33]. However, a study performed at Zayed University, UAE, demonstrated a higher consumption of coffee in single than in married females [
23], which is similar to the findings of our present study. In addition, it was postulated that marital status and having children could bring a difference in dietary consumption and other lifestyle behaviors. Studies suggests that married men and women have healthier dietary behaviors compared to unmarried men and women, and this could be another reason for the lower coffee consumption among married students [
34,
35].
A study from the Hail region in Saudi Arabia demonstrated the increased used of caffeinated energy drinks in self-dependent low-income participants compared to those with high income [
14]. Similarly, a Korean study suggested a direct association between high household income level and the prevalence of coffee consumption [
33]. Moreover, low-income adults were shown to consume less caffeine than higher-income adults [
34]. The present study supports the above findings [
36,
37], demonstrating a significant increase in the prevalence of coffee consumption with an increase in family income level. The direct effect of income and coffee consumption was somewhat diminished in the high-income level since the majority of the participants belonged to the moderate range of family income (10,000–27,000 SAR). Our present study demonstrated a high proportion of coffee consumption (57.5%) within families having 6–8 members. As far as family size is concerned, reports suggested that the poverty–income ratio (PIR), an index calculated by dividing family income by a federal poverty threshold specific to family size, generally used as a proxy for socioeconomic status, was not associated with caffeine consumption [
15].
There are reports on the consumption of caffeinated energy drinks from different regions of Saudi Arabia [
38]; however, until recently, limited information was available about coffee consumption from different region of the capital city. Similar to a Korean study [
36], our present study observed the highest consumption of coffee in students originally from the central Saudi Arabia region than any other part of the Kingdom of Saudi Arabia.
Caffeine, being a central nervous system and metabolic stimulant, is capable of reducing fatigue and inducing alertness along with improving performance during sleep deprivation [
39]. Considering its effect on performance, students generally take it to keep awake during study. The high prevalence of caffeine intake in German students exclusively for the purpose of cognitive enhancement is much higher than the prevalence rate of stimulants [
40].
Coffee’s long-term effect on cognitive function remains unclear with studies suggesting both benefits and adverse effects [
41].A protective effect of coffee use was reported against cognitive impairment or decline, showing stronger effects among females than males [
42], but this study lacked a dose–response relationship. It was demonstrated that caffeine consumption resulted in higher levels of alertness, energy, concentration, and arousal level during lecture time as compared to placebo [
43]. With respect to cognitive function and alertness, the results of our present study support the above findings [
39,
42,
43], demonstrating higher academic performance among students consuming increased amounts of coffee. Moreover, in the present study, the majority of students generally got 6–8 hours of sleep, and this could have had a favorable effect on maintaining concentration during classroom lectures, leading to better academic performance. The freshman students in the present study showed a higher consumption of coffee as compared to final-year students. A possible explanation is that a freshman is more susceptible to stress due to their new course burden and study environment, leading to several coping methods, such as more coffee consumption.
In Saudi Arabian culture, the use of “qahwa” or Arabic coffee, as a hot beverage which is generally served in a small cup, is regular practice during many special occasions [
24]. Among different types of coffee consumption, our present study demonstrated a higher use of Arabic coffee. The mean intake of different types of coffee consumption ranged from 2.0 ± 1.6 cups/day (mocha) to 3.1 ± 2.6 (Americano), which falls within the acceptable range of many dietary recommendations [
8,
9]. However, the mean intake of Arabic coffee was slightly high with 4.8 ± 2.8 cups/day due to social and cultural trends, as explained earlier.
The results of our study showed that awareness about the health benefits of coffee consumption among consumers was considerably higher than in non-consumers, but some misconceptions and doubts were also observed. Studies demonstrated that only 16% of US consumers know about coffee’s health benefits, while 49% of European consumers believe that coffee may cause health problems [
44,
45]. Hence, positive health impacts provided by coffee may incline consumers toward consumption, while negative heath impacts are key factors for not drinking coffee. An increased consumption of caffeine or caffeinated energy drinks was reported during stress conditions such as exams [
46]. In the present study, the majority of coffee consumers were well aware that coffee is a stimulant (92.7%), reduces tiredness, and causes insomnia [
47]. It is well known that high doses of coffee can lead to negative health effects in users, such as tachycardia, palpitations, and anxiety [
48]. Among consumers, only 39.1% responded correctly that excess coffee intake is associated with increased anxiety, while the majority (68.3%) of them were well aware about the association of excess coffee dose with increased heart rate and conductivity. More than half of the coffee consumers (55.7%) were aware that there is a need to moderate coffee intake during pregnancy, but only 41.7% responded positively that acute, moderate intake of caffeine (1–3 mg/kg) in adults and children increases blood pressure [
49]. About 49.3% of coffee consumers were aware that low doses of caffeine are present as an adjuvant in many over-the-counter analgesics such as cold and allergy tablets and headache medications, which may prove useful without any serious adverse health effects [
50]. Although students consuming coffee have information that it improves intellectual abilities, as discussed earlier, this topic is still inconsistent and needs further studies in the future.
An increase in academic load is often related to stress [
46], leading to increased coffee consumption with negative consequences such as unhealthy behavior, bad lifestyle, and poor dietary habits [
5,
11]. The consumption of caffeinated beverages, especially coffee and soft drinks, increases among students during high-stress conditions such as exams. A study from Puerto Rico demonstrated a high consumption of coffee among students used to stay awake during exams [
51]. Stressed female students in Kuwait were reported to consume unhealthy snacks with high sugar and fat content along with high amounts of beverages [
52]. A similar study among university students in Kuwait demonstrated unhealthy dietary habits such as adding sugar while consuming tea or coffee [
53]. Similarly, our present findings demonstrate a high consumption of coffee among majority of our participants during exam and stress conditions, associated with unhealthy dietary habits such as adding sugar and spices.
Drinking qahwa with dates or other sweets is an Arabian staple. Unlike typical European black coffee, qahwa is prepared with two main ingredients: blond coffee beans and cardamom. Optional spices include saffron, ginger, cloves, etc. [
32]. According to the cultural method of preparing Arabic coffee, the participants of our present study obviously used more spices like cardamom and saffron during its preparation and consumption.
The temporal distribution pattern of caffeine consumption among the US population (except for adolescents) occurs predominantly in the morning, driven primarily by coffee. However, adolescents distribute their caffeine consumption throughout the day [
54]. Similarly, about 42.2% of our coffee consumers reported habitual consumption before breakfast, while the rest distributed it throughout other times of the day.
Nutritional information on food labels affects consumers purchasing attitude and behavior, prompting healthy food choices and serving as a good rationale to buy them [
55]. The significant determinants for frequent label use include health reasons, specific nutrition information, weight control, and knowledge, while determinants of infrequent label use include purchasing food regardless of nutrient content, time constraints, and a “do not care” attitude [
56]. In the present study, the majority of coffee consumers were not very concerned with reading food labels, showing their ignorance toward the positive effects of food label use during coffee purchase and product selection. In addition, the consumers did not have much of an understanding about the contents of the food label.
The majority of participants responded negatively with respect to any frequent side effects and symptoms associated with coffee consumption. However, these symptoms (insomnia, stomach pain, disturbed heart rate, and tension) were present in some students but not long-lasting. A possible reason for this effect may be the excessive consumption of caffeine along with artificial flavors or spices that could have a stimulant impact on the body. Moreover, increased coffee consumption can lead toward such side effects, mostly in females [
57].
Few limitations should be considered while interpreting the results of this study. First, the sample size is high but does not represent the overall adult female population of Saudi Arabia. Second, due to its cross-sectional nature, no plausible causation can be obtained from our present study. Although we adjusted the odds ratios in our logistic regression, the potential for unmeasured and residual confounding factors may still exist. The questionnaires did not include reference to the size of a cup of coffee, which could have led to misclassification of mean cup intake. Moreover, the information about variables such as coffee consumption and academic performance could have led to recall bias.
Despite these limitations, our study has numerous strengths. To our knowledge, the present study is a novel contribution to the literature in observing the simultaneous cross-sectional association between coffee consumption and various sociodemographic variables, health awareness, associated food habits, health symptoms, and consumption determinants. The trends of coffee consumption were examined specifically for various types of coffee consumed among Saudi students. Moreover, the present study used a pretested questionnaire for a representative sample.