The findings revealed a higher level of attitude, moderate level of knowledge, and poor level of lifestyle choices amongst SSB intake for the participants. The positive attitudes show that the participants were more attentive toward reducing the SSB consumption. In general, they were aware of the needs to read the food labels and ingredients, and to choose beverages without simple sugars. This shows that, although they had a good attitude towards SSB intake, it did not change the way they limited this intake. This is in agreement prior work (20), which suggests that these positive attitudes are neither preventive, nor health-promoting. As the level of knowledge was considered relatively low, this may reflect the low level of awareness amongst the participants in practicing good habits associated with avoiding SSBs and limiting their intake in general.
There was an association between knowledge levels on SSBs, and monthly family income of the participants. It was reported that low level family monthly income groups were a contributing factor toward having excellent knowledge on SSB, as compared to those who earned ≥ RM 5,000 as a monthly family income. Income-related factors have previously been described as factors that attribute to inequalities of knowledge in nutrition (21). This study brought forward interesting findings that demonstrate that those with low income also reflected good knowledge in SSBs. This finding is in agreement with the suggestion by Xu et al. (2020), who mention that the inequality of knowledge is also strongly related to geographical areas with good accessibility to education facilities (22). Hence, the area considered in this study has good accessibility to facilities such as well-equipped public educational institutions and also multiple areas with free internet hot spots. All these knowledge related sources can be gained by anyone, without any additional cost. However, another important issue that needs to be addressed is that this knowledge cannot be translated into practice by those families with limited income, as they do not have the option to buy healthier foods such as fresh fruits and vegetables. The concern was more on satisfying hunger, and to fulfil the desire of food with good taste. Therefore, there was a higher tendency to buy high sugar foods and SSBs (23). It was also shown that parental influence on the intake of a child’s drinks may be linked to the knowledge associated with diet and health (24). Based on previous studies for children and adolescents, it was shown that the availability of SSBs was correlated with the child’s intake, which was much better correlated amongst well-educated and high income parents (25). The participants who had a high income could explain that they afforded to buy SSBs, which led to their children consuming more SSBs, as compared to low income level groups. As in agreement with a recent systematic review (26), we also found that neither level of education nor income have any association with good practices in SSBs intake.
This study discovered that gender, age and location of school impact the overall attitude towards SSB intake. Female with an older age, living in urban areas were found to have a high awareness (attitude) towards SSB intake. Similar observations have also been reported in previous studies amongst Australians (27). Our findings also support previous studies showing that boys had a higher intake of SSBs than girls (28). Females may respond more favourably to these efforts, as they appear to be more concerned about body weight issues, and are more likely to rate behaviours of food choice as an essential means for their life, as compared to males (29). The same goes to the participants who were from urban schools, as they had a good attitude, compared to those who were from the rural schools. This is because rural residents have many characteristics, including widespread socioeconomic disadvantages, and can easily access unhealthy foods that increase their risk for chronic diseases, food insecurity, poor dietary behaviours, and higher intake of SSBs (30).
The results by this study also demonstrate that 19% of the participants were overweight, and 17% were obese. This shows that one-third of the participants fall between the overweight and obese categories, which reflects the high rate of overweight and obesity issues amongst the adolescents. These findings were almost similar to those from a related study that was also conducted amongst adolescents in Malaysia (31). The findings of this study also found that the average waist circumference measurements of the respondents was 74 cm for boys, and 75 cm for girls. In a study conducted by Higgins et al. (32), it was stated that children with a waist circumference level of 71 cm or more, were 14 times more likely to develop a negative risk profile than a normal one. Therefore, 26% of the boys and girls in this study had a high waist circumference measurement, and were more likely to develop a negative risk profile. The findings also show that nearly half of the participants had a high body fat percentage, which is associated with a high risk of diseases such as hypertension, type 2 diabetes, cardiovascular diseases and metabolic syndromes (33).
The findings of this study pointed out that the most frequently consumed beverage on a daily basis was plain water. This finding is similar to that in the study by Zahran (34), in which most of their participants consumed plain water on a daily basis. Tea and caffeinated drinks (25.5%) were the most consumed SSBs on a daily basis amongst the participants in the present study. This trend is similar to studies by Norimah et al. (35) and Teng et al. (36), which reported a high consumption of coffee and tea amongst their participants. These findings are in agreement with a study that demonstrated that the reasons behind the high consumption of coffee and tea amongst students included helping them to concentrate, keep them awake at night during exam preparation phases, and stay active during classes (37). The majority of the participants either never drank SSB, or consumed it less than once a week. This reflects that this particular population sample consumed SBBs occasionally rather than regularly. Alcoholic drinks were the least consumed beverages. This is because of religious issues, since most of the participants were Muslims, and all Muslims are prohibited from consuming alcoholic drinks. Further statistical analyses could not find any significant association between the SSB consumption patterns, and KAP levels. However, we found that those participants with a high body fat percentage did have a high attitude percentage score.
There were a few limitations in this study. Firstly, the data for beverages intake in the survey was self-reported. Self-reported data has the potential of being underreported in terms of beverage consumption, especially for overweight or obese children, due to social desirability bias and other factors. While exploring the associations between SSB and body composition, other dietary, physical, genetic and environmental factors that could also impact the value of the body composition, were not studied.
Nevertheless, our findings have implications on future research. As we found a reasonable gap between knowledge, attitude and practices (KAPs), it is necessary to develop or strengthen strategies by which positive attitudes can be converted into promising practices. The education towards improvement of knowledge of SSBs should be enhanced in the education syllabus. It is recommended to implement this strategy by taking into consideration the socioeconomic status, as such emphasizing on the nutrition information about SSBs as well as healthy eating among participants belonging to high income families. Attempts should also be made to reinforce the consequences of high SSB intake in order to transform them to positive practices. The availability of SSBs should be minimised, both in school and at home, to support healthier lifestyle changes.