Socioecological factors influencing sugar-sweetened beverage consumption among adolescents in South Korea: a cross-sectional study

Article information

Child Health Nurs Res. 2025;31(1):28-39
Publication date (electronic) : 2025 January 31
doi : https://doi.org/10.4094/chnr.2024.041
1Professor, College of Nursing, Chungnam National University, Daejeon, Korea
2Graduate Student, College of Nursing, Chungnam National University, Daejeon, Korea
Corresponding author Sun Hwa Kim College of Nursing, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Korea Tel: +82-42-538-8333 Fax: +82-42-530-8309 E-mail: ksh5140@cnuh.co.kr
Received 2024 October 23; Revised 2024 December 3; Accepted 2024 December 15.

Abstract

Purpose

This study explored the intrapersonal, interpersonal, and school factors, following the socioecological model, associated with sugar-sweetened beverage (SSB) consumption in Korean high-school students.

Methods

A total of 231 students from first to third grade, aged 15–18 years, participated in this cross-sectional study. Multiple linear regression analysis was conducted to identify the factors.

Results

Among the intrapersonal factors, fast-food consumption (β=0.13, t=1.97, p=.050) and habit strength of SSB consumption were positively associated (β=0.35, t=4.30, p<.001), and sleep duration was negatively associated with SSB consumption (β=–0.14, t=–2.02, p=.045). Among interpersonal factors, perceived SSB consumption by peers was positively associated (β=0.30, t=4.93, p<.001), and among school factors, vending machines at school (β=0.13, t=2.07, p=.039) and supermarkets and convenience stores near schools were positively associated with SSB consumption (β=0.17, t=2.87, p=.005).

Conclusion

School nurses should propose policies and interventions that consider the multilevel factors to reduce SSB consumption in adolescents.

INTRODUCTION

Sugar-sweetened beverages (SSBs) are drinks with added sugar, including soft drinks, sports drinks, and energy drinks. Adolescents, particularly high-school students, are major consumers of SSB in the United States and South Korea [1,2]. Similarly, 29% of US adolescents (including high-school students) and 37.6% of South Korean high school students consume SSBs at least once daily [3,4], indicating that SSB consumption is a common dietary habit of adolescents in these countries.

SSBs have no nutritional benefits and are leading sources of excessive sugar and calorie intake in adolescents, with a daily average consumption of 143 calories in the United States [5]. Excessive SSB consumption is associated with increased body mass index (BMI) and metabolic health problems in children and adolescents [6]. In addition, previous studies have reported that it may be associated with psychological problems such as depressive symptoms in adolescents [7]. Thus, preventing excessive SSB consumption is important for promoting physical and psychological health in adolescents, including high-school students. Previous studies have emphasized the need for effective strategies to reduce SSB consumption in adolescents, particularly high-school students [1,5]. However, as a first step in developing interventions, individual and environmental factors associated with SSB consumption in adolescents should be identified [8].

According to the socioecological model of beverage consumption proposed by von Philipsborn et al. [9], which represents the factors associated with beverage consumption as divided into micro, meso, and macro levels, beverage consumption is influenced by intrapersonal factors (e.g., sex, age, and ethnicity), interpersonal factors (e.g., parenting practice, peer pressure, and support), and settings (e.g., beverage environment in educational contexts). With growing autonomy as a developmental characteristic, adolescents tend to choose their own dietary habits, including SSB consumption [10]. In addition, as parents and family represent the closest environments for children and adolescents, parental role-modeling practices and SSB availability at home significantly influence their SSB consumption [11]. School is an educational setting that enhances knowledge of and behavior toward healthy dietary habits [5]. Vézina-Im et al. [5] reported that the school environment is responsible for healthy habit formation, including dietary habits (e.g., SSB consumption) in adolescents. Thus, the school environment may significantly influence adolescents’ dietary habits. In these contexts, the multilayered intrapersonal, interpersonal, and school factors influencing SSB consumption must be identified based on the socioecological model.

However, few previous studies that have explored the multilevel factors associated with SSB consumption in adolescents have focused on Western countries [8]. Individual dietary habits are developed within social contexts and influenced by sociocultural characteristics [12]. Thus, factors associated with SSB consumption in adolescents may vary according to race and ethnicity [13]. In particular, South Korean high school students tend to spend most of their waking hours preparing for college entrance exams. In addition, they often meet peers at private academies after school and on weekends and have snacks and dinners together. Thus, factors related to peers and schools may be more significantly associated with SSB consumption in South Korean high-school students than family factors. In contrast, family factors are more significantly associated with SSB consumption in adolescents in Western countries [8]. However, a previous study based on a national data source (the Korea Youth Risk Behavior Web-based Survey) mainly focused on identifying the individual factors (e.g., sociodemographic factors, health-related behaviors) associated with SSB consumption in South Korean high-school students [14]. In this context, this study aimed to identify the factors associated with SSB consumption among South Korean high-school students based on the socioecological model and literature review.

METHODS

Ethics statement: This study was approved by the Institutional Review Board of Chungnam National University Hospital in South Korea (CNUSH 2023-11-010-001). Informed consent was obtained from all participants and their legal guardians.

1. Study Design

This cross-sectional study was based on the socioecological model of beverage consumption proposed by von Philips­born et al. [9]. The reporting of this study was based on the Strengthening the Reporting of Ob­servational Studies in Epidemiology (STROBE) reporting guidelines [15].

2. Conceptual Framework

According to this model, beverage consump­tion is affected by factors within multi-layered systems, in­cluding intrapersonal factors (e.g., age, gender, health status, knowledge, and self-efficacy), interpersonal factors (e.g., family structure, parenting practices, and peer pressure and support), and community settings (e.g., environments of ed­ucational settings). Referencing the model, this study focused on identifying intrapersonal factors, interpersonal factors, and school factors for understanding SSB consumption in adolescents. The model explores intrapersonal, interpersonal, and school-level factors associated with beverage consump­tion. Thus, it may be an appropriate conceptual framework for an integrated understanding of the factors associated with SSB consumption in adolescents.

According to the literature review based on the socioecological model of von Philipsborn et al. [9], intrapersonal factors include demographic characteristics (sex [16], grade [2], adiposity [16]), pocket money [16], raw vegetable and fruit consumption [16], sugar-sweetened snack consumption [16], fast-food consumption [8], physical activity [16], screen time [17], sleep duration [8], knowledge of SSB consumption [18], perception of SSB consumption [18], habit strength of SSB consumption [19], and self-efficacy in controlling SSB consumption [18]. Interpersonal factors include perceived SSB consumption by peers [20], social influences of peers on SSB consumption [20], social influences of parents on SSB consumption [11], easy access to SSBs at home [21], allowed consumption of SSBs without restriction at home [21], adiposity of parents [11], educational level of parents [21], perceived socioeconomic status of family [21], number of supermarkets and convenient stores near home [16], and number of visits to the supermarkets and convenient stores near home [22]. Finally, school factors included the availability of beverage vending machines and cafeterias in school [16] and supermarkets and convenience stores near school [16] (Figure 1).

Figure 1.

Hypothesized model. BMI, body mass index.

3. Participants

The participants were 231 students from first to third grade of high school and aged 15–18 (mean age, 16.32±0.88 years). Using a convenience sampling method, the students were recruited from three high schools located in Daejeon Province (a metropolitan area). The selection criteria were as follows: (1) able to read, understand, and respond to a questionnaire without others’ help; (2) no health problem or disability diagnosed by specialists, which may influence lifestyle behaviors such as dietary habits, sitting behaviors, and physical activity (e.g., diabetes, chewing and swallowing problems, digestive and absorption disorders, difficulty in sitting and voluntary range of motion, and sleep disorders); and (3) students and their parents/legal guardians voluntarily agreed to participate in the study and submitted informed consent. The required sample size with an effect size of 0.15 (medium), a significance level of 0.05, a statistical power of 0.80, and 39 predictors in the multiple linear regression model was 211. Thus, 231 participants were sufficient for power analysis.

4. Study Variables

1) Measurements outcome variables

(1) SSB consumption

SSB consumption was assessed using two items: weekly SSB consumption (in number of days) and the average amount of SSB consumed on those days [23]. Responses were obtained as 0 days (none) to 7 days (every day) and self-reported cups (rounded up to one decimal place; 1 cup=250 mL), respectively. Based on these two items, the average SSB consumption per day was calculated as [(days of SSB consumption in a week×cups of SSB consumption on the day)/7].

2) Independent variables

(1) Intrapersonal factors

Demographic characteristics: Sex was classified as boy or girl. Grades were categorized into first (15–16 years), second (16–17 years), and third (17–18 years), following the high-school grading system in South Korea. For adiposity, the BMI was calculated using self-reported height and weight (kg/m2). The BMI values were transformed into BMI percentiles using the South Korean national growth chart for children and adolescents [3].

Pocket money: Pocket money was assessed by asking about the average weekly pocket money (in won), which was converted to US dollars (1 USD=1,350 Korean won).

Raw vegetable and fruit consumption: Raw vegetable and fruit consumption was assessed by asking how often raw vegetables and fruits were consumed from three meals, with options of once to thrice.

Sugar-sweetened snack consumption: Sugar-sweetened snack consumption (e.g., ice cream, candy, jelly, snack, and candied fruit skewers) was assessed using daily consumption. Responses were self-recorded in terms of daily frequency.

Fast-food consumption: Fast food consumption was assessed using weekly consumption. Responses were self-recorded in terms of daily or weekly frequency.

Physical activity: Physical activity was assessed by asking the number of days in the past week they engaged in at least 60 minutes of activity that increased their heart rate or made them feel out of breath (moderate and vigorous physical activity). Responses were self-recorded in terms of daily frequency.

Screen time: Screen time (e.g., watching TV, using a mobile phone, computer, laptop, and video games) was assessed using two items that asked about the average screen time per day on weekdays and weekends. Based on the responses to the two items, the average screen time per day was calculated as [(average screen time per day on weekdays×5)+(average screen time per day on weekends×2)]/7.

Sleep duration: Sleep duration was assessed using usual wake-up and bedtime on weekdays and weekends. The average sleep durations per day on weekdays and weekends were recorded. Finally, the average sleep duration per day was calculated as [(average sleep duration per day on weekdays×5)+(average sleep duration per day on weekends×2)]/7.

Knowledge of SSB consumption: Knowledge of SSB consumption was assessed using a tool developed targeting high-school students in Taiwan [24]. The instrument consists of nine items, with the following response options: “true,” “false,” and “don’t know.” One point was awarded for correct responses, while 0, for incorrect or “don’t know.” The total score ranged from 0 to 9 points, and higher total scores indicated greater knowledge of SSB consumption.

Perception of SSB consumption: For the perception of SSB consumption, perceived benefits and barriers of SSB consumption were assessed using four items developed by Wang and Chen [24]. For example, SSB consumption can refresh me (perceived benefit), but SSB consumption would not be helpful for my health (perceived barrier). Responses were obtained on a 5-point Likert scale ranging from 0 (not probable) to 4 (very probable). The total score ranged from 0 to 16 points. Higher total scores indicated more perceived benefits and barriers to SSB consumption. Cronbach’s α of the instrument was 0.84 in a previous study [24] and 0.89 in this study. In addition, Cronbach’s α for perceived barriers was 0.78 in a previous study [24] and 0.77 in this study.

Habit strength of SSB consumption: To assess habit strength, we used the Self-Report Habit Index (SRHI) developed by Verplanken and Orbell [25]. It consists of 12 items evaluating three features of habitual behaviors: automaticity, repeated characteristics, and the sense of identity reflected by the behavior. Responses to the items were obtained on a 5-point Likert scale ranging from 0 (completely disagree) to 4 (completely agree). The total score ranges from 0 to 48 points, and a higher total score indicates increased habit strength of SSB consumption. The SRHI has sufficient reliability and validity [25]. Cronbach’s α of 0.88 was obtained in a previous study [23] and 0.91 in this study.

Self-efficacy in controlling SSB consumption: Self-efficacy was assessed using the Self-Efficacy Scale [24]. The instrument consists of nine items in three subscales: mental exhaustion (three items), need for company (three items), and high accessibility (three items). The scores ranged from 0 (not sure at all) to 3 (extremely sure), based on the perceived control of the respondents on their SSB consumption. The total score ranges from 0 to 9 points, and a higher total score indicates increased self-efficacy in controlling SSB consumption. Cronbach’s α of the subscales reported in a previous study was 0.83 for mental exhaustion, 0.77 for need company, and 0.72 for high accessibility [24] and 0.75, 0.79, and 0.76, respectively, in the present study.

(2) Interpersonal factors

Perceived SSB consumption by peers: Perceived SSB consumption by peers was assessed by asking about the subjective perception of the average amount of SSB consumption by peers. The responses were self-recorded in the number of cups, which was converted into mL (one cup=250 mL).

Social influences of peers on SSB consumption: The social influence of peers regarding SSB consumption was assessed with three items on three subscales: subjective norms (one item), modeling (one item), and social pressure (one item) [26]. Responses to each item were scored from –2 (definitely not) to 2 (definitely yes).

Social influences of parents on SSB consumption: The social influence of parents on SSB consumption was assessed using three items on three subscales: subjective norms (one item), modeling (one item), and social pressure (one item) [26]. Responses to each item were scored from –2 points (definitely not) to 2 points (definitely yes).

Easy access to SSB at home: Easy access to SSB at home was assessed by asking whether sugary drinks were readily and easily accessible at home, with response options of yes or no.

Allowed consumption of SSB without restriction at home: Allowed consumption of SSBs without restrictions at home was assessed by asking whether they could consume SSBs without restrictions from their parents. The response options were yes or no.

BMI of parents: The BMI (kg/m2) of parents was calculated based on self-reported weight and height provided by the participants.

Education level of parents: The educational levels of parents were assessed with a single question about the highest level of education obtained. Responses options were “less than middle school,” “high school,” “junior college and 4-year university,” and “graduate school.”

Perceived socioeconomic status of family: The perceived socioeconomic status of the family was assessed by asking about the subjective perception of the socioeconomic status, with options of high, middle, and low levels.

Number of supermarkets near home: The participants were asked about the number of supermarkets within 15 minutes walking distance from home. The responses were self-recorded in terms of number.

Number of visits to supermarkets near home: The participants’ number of visits to supermarkets near home was self-recorded in terms of frequency of visits over the past week.

Number of convenience stores near home: The participants were asked about the number of convenience stores within 15 minutes of walking distance from their homes.

Number of visits to convenience stores near home: The frequency of the participants’ visits to convenience stores near home in the past week was self-recorded.

(3) School factors

Vending machines at school: Vending machines at schools were assessed by asking about the presence of SSB vending machines at schools. The responses to each item were yes or no.

Supermarkets and convenient stores near school: Supermarkets and convenience stores near schools were assessed by asking about the presence of supermarkets and convenience stores within 15 minutes walking distance of the school. The responses to each item were yes or no.

5. Data Collection Procedure

The data were collected between March and April 2024 by two trained research assistants with master’s degrees in nursing. After obtaining approval from the principal, the research assistants posted a recruitment notice on the school bulletin board, with the cooperation of the school nurse. Those who wished to participate in this study were asked to contact the research assistants via their mobile phones or email. Self-reported electronic questionnaires were provided to the participants’ cell phones with their permission. Trained research assistants explained the purpose and data collection procedure of this study and provided verbal and text message instructions on how to respond to the questionnaire. A total of 240 questionnaires were distributed, and 231 (response rate=96.3%) were collected.

Regarding ethical considerations, trained research assistants explained the purpose and data collection procedures. They also explained the voluntary nature of participation, the possibility of withdrawal at any time, and the rights of individuals. In addition, they explained that the collected data would be anonymized using unique codes to protect personal information and would be used only for this study. Participants were provided with a 20,000 Korean won gift voucher (approximately 15 USD) that could be used at convenience stores.

6. Data Analyses

The data were analyzed using IBM SPSS for Windows ver. 29.0 (IBM Corp.). Descriptive statistics were used to describe the frequency, percentage, and mean of the individual, parental, familial, peer, and school factors. In addition, a multiple linear regression analysis was performed to assess the factors associated with SSB consumption in adolescents using three models (models 1, 2, and 3) based on the hypothesized model. Intrapersonal, intrapersonal, and school factors were included in models 1, 2, and 3, respectively. Akaike information criterion (AIC) value was used for the model selection, and a lower AIC value indicates a better model fit.

RESULTS

1. Participant Characteristics

The mean daily SSB consumption of the participants was 241.61±157.90 mL (range, 0–612.50 mL). Table 1 shows the intrapersonal, interpersonal, and school factors. Of the 231 participants, 48.9% (n=113) and 51.1% (n=118) were boys and girls, respectively. In addition, 33.8%, 34.2%, and 32.0% were in first, second, and third grades, respectively, with a mean age of 16.32±0.88 years (range, 15–18 years).

Characteristics of intrapersonal, interpersonal, and school factors (N=231)

2. Factors Associated with Adolescents’ SSB Consumption

In model 1 with intrapersonal factors, screen time (β=0.12, t=2.03, p=.044) and habit strength of SSB consumption (β=0.39, t=4.97, p<.001) were positively associated with SSB consumption in adolescents. In addition, sleep duration (β=–0.26, t=–4.31, p<.001) was negatively associated with SSB consumption. In model 2 with intrapersonal and interpersonal factors, habit strength of SSB consumption (β=0.33, t=4.06, p<.001) was positively associated, and sleep duration (β=–0.15, t=–2.20, p=.029) was negatively associated with SSB consumption in adolescents. Among interpersonal factors, perceived SSB consumption by peers (β=0.32, t=5.35, p<.001) was positively associated with SSB consumption in adolescents (Table 2).

Factors associated with adolescents’ sugar-sweetened beverage consumption (N=231)

Finally, in model 3 with intrapersonal, interpersonal, and school factors, fast-food consumption (β=0.13, t=1.97, p=.050) and habit strength of SSB consumption (β=0.35, t=4.30, p<.001) were positively associated, and sleep duration (β=–0.14, t=–2.02, p=.045) was negatively associated with SSB consumption in adolescents. Among interpersonal factors, perceived SSB consumption by peers (β=0.30, t=4.93, p<.001) was positively associated with SSB consumption in adolescents. Among school factors, vending machines at school (β=0.13, t=2.07, p=.039) and supermarkets and convenience stores near schools (β=0.17, t=2.87, p=.005) were positively associated with SSB consumption in adolescents (Table 2). Without autocorrelation (d=1.84) or multicollinearity (variation inflation factors: 1.22–2.86) between the variables, the explanatory powers (adjusted R2) of models 1, 2, and 3 were 36.0% (F=8.09, p<.001), 48.7% (F=6.39, p<.001), and 50.3% (F=6.34, p<.001), respectively. AIC values in models 1, 2, and 3 were 2,956.15, 2,887.36, and 2,839. 97, respectively.

DISCUSSION

This study identified the factors associated with SSB consumption in South Korean adolescents and high-school students. Among the intrapersonal factors in the socioecological model, frequent fast-food consumption, increased habit strength of SSB consumption, and short sleep duration were associated with increased SSB consumption.

A previous study found that frequent consumption of fast foods (more than thrice a week) is associated with increased SSB consumption among adolescents [8]. Furthermore, previous studies have reported a positive linear association between fast food and SSB consumption [27]. Miller et al. [28] reported that fast food consumption was the strongest behavioral risk factor associated with SSB consumption. As fast food and SSBs are usually offered as a set menu with promotions in fast food restaurants, they can be easily obtained without a long wait time, and their prices tend to be cheaper than those of meals with fresh ingredients [28]. Thus, adolescents are more likely to consume meals or snacks containing fast food and SSBs. In addition, frequent exposure to positive images of fast food and soda through media advertising (e.g., TV) can increase the preference for these products [14]. Thus, reducing fast food consumption may be an effective strategy for decreasing SSB consumption. Healthcare providers at schools (school nurses) must educate adolescents and their parents about reducing fast food consumption and suggest healthy replacement foods. In addition, policies should be proposed to restrict the sale and marketing of fast food in schools, including banning the sale in school cafeterias.

Additionally, the strength of habit in SSB consumption was positively associated with SSB consumption in adolescents. Habits are unconscious and automatized patterns of behavior that respond to external cues [29]. Thus, habitual behavior can persist for a long time, even if the related information is insufficient and the intention or motivation is absent, and can be further strengthened through repetitive performance [29]. Furthermore, habitual behaviors may be performed without considering efficiency or intentional control [29]. Lifestyle behaviors, such as dietary behavior, are habitual behaviors repeated in similar contexts (time and place) in daily life [29]. Thus, the strength of habit in dietary behavior may be a significant predictor of dietary behavior [30].

Similarly, as habit strength surpasses the intention to eat healthy snacks, it becomes the strongest predictor of unhealthy snacking [30]. De Vet et al. [30] reported that strong habits of unhealthy snacking in adolescents were positively associated with increased consumption of unhealthy snacks, even after considering the effects of the intention to eat healthy snacks. In this context, healthy drinking habits are required to reduce SSB consumption in adolescents. According to a systematic review [31], habit was the strongest modifiable determinant of SSB consumption in adolescents. Although habits represent behaviors that have already been formed, some recent evidence shows that habitual behavior can be successfully changed. In these contexts, interventions need to focus on habit chance and formation in order to effectively reduce SSB consumption [31]. Thus, healthcare providers at schools should develop interventions for habit formation for healthy drinking (e.g., drinking water instead of SSB) based on the suggested strategies for behavioral change with habit formation.

The American Academy of Sleep Medicine recommends 8–10 hours as the appropriate sleep duration at night for adolescents [32]. However, on weekdays and weekends, the average nightly sleep hours for South Korean high-school students were 7.4 and 6.2 hours, respectively [33]. According to Liu et al. [34], short sleep might lead to increased high-calorie food intake with decreased leptin (appetite-suppressing hormone) levels and increased ghrelin (appetite-stimulating hormone) levels in the serum. Increased feelings of hunger and appetite with sleep deprivation result in the intake of high-calorie foods and carbohydrates, such as SSBs [34]. In addition, adolescents who sleep more at night have less time to eat as well as less screen time, which reduces their chances of exposure to SSB advertisements [11]. Thus, maintaining sufficient sleep duration is important to reduce SSB consumption in adolescents. In addition, the consumption of caffeinated drinks as SSBs may reduce sleep duration in adolescents [35]. As caffeine consumption and sleep duration have a cyclical relationship, caffeine may reduce short sleep duration associated with daytime sleepiness or tiredness, and short sleep duration may increase the consumption of caffeinated drinks [35]. Thus, healthcare providers at schools should emphasize the need for adolescents, parents, and teachers to have sufficient sleep duration and consider the adverse effects of caffeinated drinks on sleep in adolescents. In addition, interventions should be developed to reduce the consumption of SSBs containing caffeine (e.g., energy drinks, coffee drinks, soda, and caffeine).

As a more statistically significant associated factor, perceived SSB consumption by peers was positively associated with adolescents’ SSB consumption among the interpersonal factors. Social influences may determine adolescents’ beverage consumption [12]. Additionally, adolescents want to follow social norms (expectations of behaviors in social groups) to avoid judgment by their social groups. High school students tend to be independent of their parents while spending a lot of time with their peers and building close relationships with them. Thus, the perceived social norms of peer groups may determine adolescents’ dietary behaviors [12]. Similarly, misperception of peers’ SSB consumption (descriptive norms) was more strongly associated with SSB consumption among adolescents than with peers’ actual SSB consumption [12]. That is, the overestimation of SSB consumption by peers may be associated with an increased SSB consumption in adolescents. Lally et al. [12] emphasized the need to modify the misperception of peers’ SSB consumption as a strategy to reduce adolescents’ SSB consumption. Thus, school healthcare providers should develop strategies for correctly perceiving peers’ SSB consumption and peer group-based interventions.

Finally, among the school factors, beverage vending machines in schools and supermarkets and convenience stores near schools were positively associated with adolescents’ SSB consumption. The increased availability of SSBs in schools is significantly associated with increased SSB consumption [16]. Godin et al. [22] also reported that purchasing snacks from vending machines in schools, corner stores, and canteens near schools was associated with increased SSB consumption (soda, sweetened coffee/tea, and energy drinks) among adolescents. School is an important setting in which adolescents spend their daytime. In particular, South Korean high school students may spend more awake time at school than at home. Thus, the increased availability of SSB in/near schools may increase their SSB consumption. In this context, mandatory restrictions on SSB availability in schools are a major strategy for reducing adolescent consumption [20]. Along with American Academy of Pediatrics and American Heart Association, Muth et al. [36] also emphasized the importance of the school environment and proposed implementing school-based public policies to reduce SSB consumption in children and adolescents (e.g. prohibiting the sale of SSB in school or allowing limited quantity of SSBs in school meals). Thus, school healthcare providers should propose policies focused on prohibiting the sale and advertising of SSBs in school.

Based on the results of this, social relationships and school environments, rather than parents and familial environments, might have more significant influences on SSB consumption in South Korean adolescents. Thus, school is primarily the most important community where strategies and interventions to reduce SSBs consumption in South Korean adolescents should be applied. School nurses should develop or propose strategies for maintaining healthy eating habits, including reducing SSB consumption at multiple levels, in adolescent students. According to a systematic review, school-based interventions (e.g., education, social support, restructuring of the physical environment, and behavioral change) are effective in reducing SSB consumption in adolescents [5]. Thus, school nurses should consider associated factors when developing their interventions.

This study had some limitations. Participants were recruited using convenience sampling from three high schools in a city. Thus, the generalizability of the results is limited. Future studies should use randomized sampling methods. Furthermore, a nationwide study would be helpful for obtaining more reliable evidence. In addition, the data collected for several variables (e.g., SSB consumption, screen time, sleep duration, height, and weight) were self-reported. Thus, subjective estimations were analyzed, and data may have been over- or underestimated. Many variables were also assessed using a single item, which may reduce validity and reliability. Therefore, future studies should use objective and systematic measurements with sufficient validity and reliability. Although this study was conducted among South Korean high-school students, dietary behaviors differed according to their sociocultural background. Thus, the factors associated with SSB consumption must be compared with those of adolescents from other countries. Additionally, as a further source of factors potentially associated with SSB consumption of adolescents in South Korea, the characteristics of significant family members such as parents and siblings (e.g. attitudes, SSBs consumption) should be evaluated in the context of South Korea’s specific sociocultural attributes in future studies. Finally, this study focused on the intrapersonal, interpersonal, and school factors associated with SSB consumption among adolescents. Thus, the association between community environments, policies, and SSB consumption must be verified.

CONCLUSION

Based on the results of this study, school nurses should propose policies to develop healthy food environments to decrease SSB consumption, such as restricting sales and marketing of SSBs in schools. In addition, considering the factors associated with SSB consumption at the intrapersonal, interpersonal, and school levels, school nurses need to develop educational programs (to introduce healthy food and beverages that replace fast food and SSB) and interventions for healthy drinking habit formation, reduced consumption of SSB associated with short sleep duration, and correct perception of peers’ SSB consumption.

Notes

Authors' contribution

Conceptualization: JSR, SHK; Data collection: JSR; Formal analysis: JSR; Interpretation of data: JSR, SHK; Writing–original draft: JSR; Writing–review and editing: JSR, SHK; Final approval of published version: JSR, SHK.

Conflict of interest

No existing or potential conflict of interest relevant to this article was reported.

Funding

This study was supported by a National Research Foundation of Korea (NRF) grant funded by the government of the Republic of Korea (No. 2021R1A2C100682811).

Data availability

Please contact the corresponding author for data availability.

Acknowledgements

None.

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Article information Continued

Figure 1.

Hypothesized model. BMI, body mass index.

Table 1.

Characteristics of intrapersonal, interpersonal, and school factors (N=231)

Characteristic Value
Intrapersonal factors
 Sex
  Boys 113 (48.9)
  Girls 118 (51.1)
 Grade
  1st 78 (33.8)
  2nd 79 (34.2)
  3rd 74 (32.0)
 BMI percentile 55.77±26.31 (1–100)
  Underweight 8 (3.5)
  Normal weight 182 (78.8)
  Overweight 30 (13.0)
  Obesity 11 (4.7)
 Pocket money (US$/wk) 34.21±22.05 (7.41–222.22)
 Raw vegetable and fruit consumption (times out of 3 meals/day) 1.10±0.68 (0–3)
 Sugar-sweetened snack consumption (times/day) 1.99±1.49 (0–7)
 Fast-food consumption (times/wk) 1.88±1.95 (0–14)
 Physical activity (day/wk) 1.54±1.70 (0–7)
 Screen time (hr/day) 2.45±1.03 (0.25–4.00)
 Sleep duration (hr/day) 6.91±0.85 (4.75–9.13)
 Knowledge of SSB consumption 4.68±1.62 (0–8)
 Perception of SSB consumption
  Perceived benefits 12.84±2.05 (7–19)
  Perceived barriers 10.01±2.79 (2–16)
 Habit strength of SSB consumption 23.84±8.79 (0–48)
 Self-efficacy in controlling SSB consumption
  Mental exhaustion 5.19±1.77 (0–9)
  Need for company 5.46±1.70 (0–9)
  High accessibility 5.29±1.62 (0–9)
Interpersonal factors
 Perceived SSB consumption by peers (mL/day) 879.87±515.96 (0–1,750)
 Social influences of peers on SSB consumption
  Subjective norms 0.11±0.91 (–2 to 2)
  Modelling 0.82±0.83 (–2 to 2)
  Social pressure –0.18±0.95 (–2 to 2)
 Social influences of parents on SSB consumption
  Subjective norms –0.66±0.96 (–2 to 2)
  Modelling –0.12±1.03 (–2 to 2)
  Social pressure –0.81±0.89 (–2 to 2)
 Easy access to SSBs at home
  Yes 154 (66.7)
  No 77 (33.3)
 Allowed consumption of SSBs without restriction at home
  Yes 220 (95.2)
  No 11 (4.8)
 BMI of fathers (kg/m2) 25.35±1.88 (20.68–30.84)
 BMI of mothers (kg/m2) 22.74±2.68 (16.41–29.48)
 Education level of fathers
  ≤Middle school 1 (0.4)
  High school 70 (30.3)
  Junior college and 4 years university 147 (63.7)
  Graduated school 13 (5.6)
 Education level of mothers
  ≤Middle school 5 (2.2)
  High school 85 (36.8)
  Junior college and 4 years university 133 (57.6)
  Graduated school 8 (3.4)
 Perceived socioeconomic statues of family
  Low 39 (16.9)
  Middle 179 (77.5)
  High 13 (5.6)
 No. of supermarkets near home (within 15 minutes by foot) 1.79±1.32 (0–10)
 No. of visits to supermarkets near home (/wk) 1.27±1.70 (0–16)
 No. of convenient stores near home 2.43±1.59 (0–10)
 No. of visits to convenient stores near home (/wk) 2.33±1.55 (0–10)
School factors
 Vending machines at school
  Yes 218 (94.4)
  No 13 (5.6)
 Supermarkets and convenient stores near school
  Yes 213 (92.2)
  No 18 (7.8)

Values are presented as mean±standard deviation (range) or number (%).

BMI, body mass index; SSB, sugar-sweetened beverage.

Table 2.

Factors associated with adolescents’ sugar-sweetened beverage consumption (N=231)

Variable Model 1a)
Model 2a)
Model 3a)
β t p β t p β t p
(Constant) 3.05 0.70 0.46
Intrapersonal factors
 Sex (ref: girls) 0.02 0.41 .683 0.05 0.90 .370 0.07 1.17 .242
 Grade (ref: 1st)
  2nd 0.10 1.54 .125 0.06 0.87 .385 0.03 0.52 .606
  3rd 0.06 0.92 .361 0.06 0.94 .347 0.03 0.50 .618
 BMI percentile 0.08 1.26 .211 0.05 0.90 .368 0.07 1.18 .240
 Pocket money –0.06 –0.93 .356 –0.05 –0.77 .444 –0.11 –1.19 .061
 Raw vegetable and fruit consumption –0.10 –1.65 .101 –0.07 –1.22 .225 –0.09 –1.54 .125
 Sugar-sweetened snack consumption 0.08 1.19 .236 0.05 0.83 .409 0.04 0.62 .539
 Fast-food consumption 0.11 1.73 .085 0.13 1.93 .056 0.13 1.97 .050
 Physical activity 0.01 0.17 .867 0.002 0.03 .973 0.01 0.17 .867
 Screen time 0.12 2.03 .044 0.01 0.07 .942 –0.03 –0.43 .669
 Sleep duration –0.26 –4.31 <.001 –0.15 –2.20 .029 –0.14 –2.02 .045
 Knowledge of SSB consumption 0.08 1.27 .206 0.08 1.32 .187 0.06 1.08 .283
 Perception of SSB consumption
  Perceived benefits –0.01 –0.24 .809 –0.05 –0.78 .438 –0.03 –0.57 .568
  Perceived barriers 0.08 1.33 .185 0.12 1.93 .055 0.11 1.76 .081
 Habit strength of SSB consumption 0.39 4.97 <.001 0.33 4.06 <.001 0.35 4.30 <.001
 Self-efficacy in controlling SSB consumption
  Mental exhaustion –0.09 –1.06 .289 –0.05 –0.59 .559 –0.05 –0.63 .527
  Need for company –0.04 –0.47 .638 –0.08 –0.94 .348 –0.09 –1.07 .288
  High accessibility 0.04 0.45 .656 0.07 0.91 .363 0.10 1.26 .208
Interpersonal factors
 Perceived SSB consumption by peers 0.32 5.35 <.001 0.30 4.93 <.001
 Social influences of peers on SSB consumption
  Subjective norms 0.07 0.91 .366 0.09 1.09 .276
  Modelling 0.04 0.59 .554 0.04 0.55 .584
  Social pressure –0.06 –0.78 .438 –0.10 –1.35 .178
 Social influences of parents on SSB consumption
  Subjective norms 0.01 0.06 .952 0.01 0.16 .873
  Modelling –0.08 –1.16 .249 –0.11 –1.61 .108
  Social pressure 0.09 1.09 .275 0.07 0.91 .363
 Easy access to SSBs at home 0.06 0.84 .400 0.07 0.97 .335
 Allowed consumption of SSBs without restriction at home 0.05 0.89 .375 0.04 0.80 .427
 BMI of fathers –0.09 –1.53 .127 –0.09 –1.65 .101
 BMI of mothers 0.05 0.78 .435 0.06 0.89 .377
 Education level of fathers (ref: less than high school) 0.09 1.45 .148 –0.04 –0.71 .481
 Education level of mothers (ref: less than high school) 0.04 0.61 .543 0.01 0.15 .884
 Perceived socioeconomic statues of family (ref: low)
  Middle 0.04 0.06 .952
  High –0.03 –0.55 .586
 No. of supermarkets near home –0.04 –0.57 .567
 No. of visits to supermarkets near home 0.03 0.43 .668
 No. of convenient stores near home –0.07 –0.87 .387
 No. of visits to convenient stores near home 0.10 1.49 .137
School factors
 Vending machines at school (ref: no) 0.13 2.07 .039
 Supermarkets and convenient stores near school (ref: no) 0.17 2.87 .005

BMI, body mass index; SSB, sugar-sweetened beverage.

a)

Adjusted R2=0.36 in model 1, adjusted R2=0.49 in model 2, and adjusted R2=0.51 in model 3.