Data from the 2009 national Youth Risk Behavior Survey (YRBS) were obtained. The national YRBS, a component of the Youth Risk Behavior Surveillance System of the Centers for Disease Control and Prevention (CDC) is a school-based survey conducted biennially to monitor the prevalence of priority health risk behaviors among US high school students. In 2009, a 3-stage cluster sample design was used to produce a nationally representative sample of students in grades 9 through 12 who attend public and private high schools in the 50 states and the District of Columbia. Sampling strategies and the psychometric properties of the questionnaire have been reported elsewhere.^26,27

Student participation in the survey was anonymous and voluntary, and local parental permission procedures were followed. The CDC’s institutional review board granted approval for the national YRBS.²⁷ Students completed the 98-item self-administered questionnaire during a regular class period and recorded their responses directly on a computer-scannable questionnaire booklet. The school response rate was 81%; the student response rate was 88%; and the overall response rate was 71%. Usable questionnaires were obtained from 16,410 students. For this cross-sectional analysis, we excluded 222 students who did not provide a valid response to the question about drinking nondiet soda, resulting in a final analytic sample of 16,188 students.

The main outcome measure was nondiet soda intake. Students were asked, “During the past 7 days, how many times did you drink a can, bottle, or glass of soda or pop, such as Coke, Pepsi, or Sprite? (Do not include diet soda or diet pop.)” Response options were none through 4 or more times/day. Based on our previous analysis,²⁸ we created 3 mutually exclusive nondiet soda intake categories: none, 1–6 times/week, and ≥ 1 time/day for bivariate analyses. Based on previous studies,^23,29 we dichotomized the nondiet soda intake variable into < 1 time/day and ≥ 1 time/day for logistic regression analyses.

Problem behaviors included smoking cigarettes on ≥ 1 day during the 30 days before the survey (no or yes), drinking at least one drink of alcohol on ≥ 1 day during the 30 days before the survey (no or yes), using marijuana ≥ 1 time during the 30 days before the survey (no or yes), having sex partners during the 3 months before the survey (never had sexual intercourse, had sexual intercourse but not during the past 3 months, or ≥ 1 person), and wearing a seat belt when riding in a car driven by someone else (always or less than always).

Being victimized included ever being bullied on school property during the 12 months before the survey (no or yes); being threatened or injured by someone with a weapon on school property during the 12 months before the survey (no or yes); ever being hit, slapped, physically hurt on purpose by their boyfriend or girlfriend during the 12 months before the survey (no or yes); and ever being physically forced to have sexual intercourse (no or yes). Unknown values or missing data regarding exposure variables ranged from 0.4% to 9.2% and were excluded from analyses when the variable was used.

Mutually exclusive response categories for each covariate were created. Demographic variables included were age (≤ 14, 15, 16, 17, and ≥ 18 years), sex, and race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, and non-Hispanic other). Student weight status was categorized as underweight/normal weight [< 85th percentile for body mass index (BMI) by age and sex], overweight (≥ 85th to < 95th percentile), and obese (≥ 95th percentile),³⁰ based on BMI calculated from self-reported height and weight. Previous studies showed that soft drink intake varied by age, sex, race/ethnicity, and weight status^{20, 29}; therefore, multivariable logistic regression analyses were adjusted for these variables.

Chi-square tests were used to examine the unadjusted association between nondiet soda intake and demographic characteristics, weight status, problem behaviors, and victimization. Statistical significance was set at p < .05. Multivariable logistic regression models were used to calculate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for variables associated with drinking nondiet soda at least 1 time/day after controlling for age, sex, race/ethnicity, and weight status. We created 2 multivariable logistic regression models, one to examine the association between problem behaviors and nondiet soda intake (N = 12,057) and the second model (N = 13,525) to assess the association between being victimized and nondiet soda intake. Samples varied due to missing data for variables of study. The analytic sample used in the first model had a higher proportion of older students and non-Hispanic white than the students excluded from the model. The analytic sample used in the second model had a higher proportion of older students, males, and non-Hispanic white than the students excluded from that model. The sample weight variable was applied to all analyses to adjust for nonresponse and oversampling of black and Hispanic students. All statistical analyses were performed using the Statistical Analysis Software (SAS) (version 9.2, SAS Institute Inc, Cary, NC) and incorporated appropriate procedures to account for complex sample design.

The strength of this study is that it is based on a large, nationally representative sample with a relatively high response rate. However, it has limitations. First, YRBS is based on self-report, so the potential exists for reporting bias. However, a previous study showed that YRBS survey questions demonstrated good test-retest reliability.²⁶ Kappa statistics (a measure of agreement) ranged from 58% to 82% for problem behavior variables and from 41% to 66% for being victimized variables.²⁶ Second, the associations are cross-sectional and do not permit testing for causality or ascertaining the direction of the association. Because this work represents an initial cross-sectional investigation into these associations, longitudinal research is needed to explore further the potential causal linkage. Third, evidence suggests that per-capita kilocalories from calorically sweetened beverages were higher among adolescents from lower-income households compared with adolescents from higher-income households.²⁰ However, we were not able to control for household income status because YRBS does not collect any information on socioeconomic status. Fourth, a range of portion size for soda intake might be too broad because the question asked for drinking a can, bottle, or glass of soda. Fifth, data were available on only nondiet soda intake. Therefore, other types of calorically sweetened beverages, such as fruit-flavored drinks, sport drinks, and energy drinks, were not included in this analysis. However, nondiet soda was the most commonly consumed calorically sweetened beverage and represented about 60% of all calorically sweetened beverage calories among US adolescents.²⁰ Furthermore, because the nondiet soda intake question did not specify whether or not soda was caffeinated, both caffeinated and noncaffeinated nondiet soda may be included in the responses. Lastly, for being victimized variables, the time frame was within the past 12 months, but nondiet soda intake was within the past 7 days.

High consumption of calorically sweetened beverages is a public health concern because of its association with factors indicating adverse physical^11–14 and mental health.^{16, 17} Considering the association between adverse health consequences and calorically sweetened beverage consumption, efforts to decrease calorically sweetened beverage consumption among adolescents are critical. In addition, this analysis indicates that problem behaviors and victimization are significantly associated with daily consumption of nondiet soda among high school students. These significant associations suggest research should examine why nondiet soda intake is associated with negative behaviors to understand potential mechanisms. Evidence suggests that adverse childhood exposure, such as childhood abuse and household dysfunction during childhood, has been associated with higher risk for being severely obese among adults.⁴⁰ Thus, further research is needed to examine whether calorically sweetened beverage intake might be a link between these traumatic experiences and obesity. Moreover, our findings emphasize the need for more direct and appropriate strategies to prevent and address the emotional consequences of these traumatic youth experiences.