The findings of our study are discussed below.

First, we found that the current (last one month) and lifetime prevalence of SSB consumption were 90.5% and 92.7% respectively. The reported prevalence of SSB consumption among Chinese children and adolescents aged 6-17 years was around 67%, which is lower than our study.(Gui et al., 2017) But a study conducted in Ontario showed that about 81.4% of the adolescents aged 11-20 years had consumed an SSB in the last week, and another 12% had consumed energy drinks.(Sampasa-Kanyinga, Hamilton and Chaput, 2018) This finding is similar to our study. The lower prevalence in Chinese adolescents can be ascribed to the lower age range, when parental supervision is usually high. We found that the median (IQR) consumption of SSBs was found to be 0.5 (0.2-1) L/ participant/month. Chinese adolescents had consumed around 0.61 servings per day (around 1.1 L/week).(Gui et al., 2017) Whereas, a study from USA reported much higher consumption of SSBs among adolescents i.e. 4.5L/week.(Wattelez et al., 2019) High intake of SSBs can be due to many factors such as lack of legislative measures, proper social message, peer pressure, cultural food habits etc. Also, intelligent and aggressive marketing strategies by SSB manufacturing companies play a part.(Skeie, Sandvær and Grimnes, 2019)

Second, we found that 49.9% of the participants preferred soft drinks, followed by 29.1% who preferred sweetened packaged fruit juice. Similarly, Park et al. found that students consumed more of soft drinks than energy drinks etc. Most (37%) of their participants preferred regular soda.(Park et al., 2012b) They attributed these findings to the frequent use of fast food restaurants and prolonged television viewing. About 50% of the participants in the study by Wang et al did consume carbonated SSBs.(Wang, Bleich and Gortmaker, 2008)

Third, we found that as compared to females, males had 1.8 times higher intake of SSBs. This fact has been reported in several studies.(Bjelland et al., 2011; Park et al., 2012a; Skeie, Sandvær and Grimnes, 2019) For instance, the adjusted odds ratios (OR) reported for males was 3.74 and 1.66 by Skeie G et al. and Park et al. respectively.(Park et al., 2012b; Skeie, Sandvær and Grimnes, 2019) These studies were not conducted on medical students though. One possible reason might be that male medical students in India are usually outdoors for longer times as compared to females, due to cultural and safety reasons, which increases their chances of buying packaged SSBs.

Fourth, we found that, the participants, who had consumed SSBs in last week, had 7.4 times high intake of SSBs. This may be attributed to negative symptoms experienced by participants by temporary stoppage/decrease in consumption, which might have lead to an urge to have higher and higher amounts of SSBs due to its addictive tendency. Falbe et al has reported that participants experienced headache, decreased satisfaction, low motivation to work and inability to concentrate during SSB cessation phase.(Falbe et al., 2019)

Fifth, participants who currently consumed alcohol had higher odds of high SSB intake than those not consuming alcohol. Some studies had contrasting findings, the reason ascribed being that nondrinkers might prefer SSBs to alcohol.(Park et al., 2014) Bleich et al too did find similar results.(Bleich et al., 2009) Cultural differences in type of alcohol preferences may partly explain our finding.

Sixth, participants who preferred energy drinks/sports drinks were less likely to consume high amounts of SSBs as compared to those consuming other type of SSBs. This may be because of the way they are marketed/advertised as elicited by a study of Bogart et al, with increase in advertisements resulting in increased consumption of SSBs.(Bogart et al., 2013)

Seventh, participants having permanent residence in an urban area consumed higher amount of SSBs than those from rural areas, although this was not found to be statistically significant in multivariable analysis. Some previous studies have reported similar findings.(Hearst, Pasch and Laska, 2012; Ramírez-Vélez, 2015; Mathur et al., 2020) However, one study from China did report that young children (aged 3-7 years) from rural area consumed more SSBs as compared to their urban counterparts.(Yu et al., 2016) The lower age group and higher economic status of Chinese may be a factor, it being an upper middle income country. Easy availability of different kinds of SSBs in urban areas and having a habitual urbanized lifestyle (unhealthy eating and drinking behaviors) as a part of their growing up, before getting into the medical course are possible factors.

Eighth, we did not find any statistically significant association between high intake of SSBs and age, family type, parent’s occupation and education, per capita income, tobacco use, physical activity, sleep and history of chronic disease. Skeie et al. too didn’t find any association between physical activity and SSBs consumed.(Skeie, Sandvær and Grimnes, 2019) Kenney et al. however, reported that increased SSB intake was associated with reduced physical activity.(Kenney and Gortmaker, 2017) One study reported poor sleep quality with higher intake of SSBs.(Park et al., 2012b)

So far, only few Indian studies have reported about SSB consumption. One study used secondary data from general population survey using only a limited number of variables.(Mathur et al., 2020) Also, that study did not estimate the actual quantity of SSB consumed. It has been reported earlier that medical students are prone to develop NCDs.(Adams-Campbell et al., 1988; Bertsias et al., 2003; Aslam, Mahmud and Waheed, 2004; Nyombi et al., 2016) To the best of our knowledge, this is the first study globally, reporting SSB consumption patterns and associated factors among medical students. Our sample size was also good. As data on prevalence of SSB use among medical students were not available, we did not do apriori sample size calculation. However, taking 50% prevalence (as in pilot studies), 20% relative precision and α = 0.05, the minimum sample size required was 100.

Since, the question on amount of SSB consumed in the last month was an open-ended question, there could be an element of reporting bias. It is possible, that some would have entered their consumption in litres, even after instructing them to fill in millilitres, leading to underreporting. Our findings might not be fully generalizable to private medical institutes, where the socio-economic status of students and campus culture may be different. We did not assess other unhealthy dietary practices, for example fast food intake, which might also influence SSB intake. Also, we could not objectively assess sedentary behaviour.

Targeted behavioural health interventions should be given to male medical students, alcohol users and frequent consumers of SSBs. Individual counselling by psychologists/psychiatrists should be arranged by the administration of the respective institutes for high SSB consumers. Students should be encouraged to consume home-made healthy drinks and abstain from taking alcohol. Legislation banning sale of SSBs within a certain radius of educational institutions should be brought in.

The prevalence of SSB consumption among medical students was high. Nearly half of the students preferred soft drinks, followed by sweetened packaged fruit juice (29%). Male gender, alcohol use in the last month and recent consumption of SSBs predicted high intake of SSBs. Behavioural change and legislative measures will help not only safeguard optimal health for future healthcare providers, but will also help prevent manpower shortage, excessive costs and compromised quality of care leading to inefficient health systems