Weakness of the study design The biggest flaw in any cross-sectional study design is the inability to establish a causal relationship. This made any causation deduced from the results a mere inference. Positive correlation derived from the study is not sufficient and convincing enough to be acted upon. The study is also vulnerable to recall bias or dishonesty. The accuracy of the data collected heavily depend upon the student’s ability to accurately recall events that took pace the day before and report it truthfully. Data collected also does not reflect the amount of sugar drinks participants consistently consume.
The amount of sugar drink consumed could fluctuate over the week, resulting in the statistic collected being under or overrepresented. There is also no scientific explanation provided to support the causal relationship drawn at the end of the research. The presence of caffeine in energy drink was hypothesized to contribute to the association but there is no further elaboration on the mechanism. The association between low attention span, number of drinks consumed and family support system was acknowledge to be significant but it was not investigated further.
Family structure could be a confounder found that was casually brushed off. In addiiton, the study does not include the entire student population as it allow some students to opt out with parents consent. 12. 2% students who did not not take part in the could change the charasteristic of the sample resulting in erroneous conclusion drawn. Other possible study design To improve the study, stronger study design could be used to better establish the causal relationship. The ‘gold standard, randomised controlled trial(RCT) can draw causation and remove known confounders, vastly improving the accuracy of the result.
However, RCT is an experimental study, it would not be ethical for this particular research. The next best option will be a cohort study. Prospective cohort study could be conducted, recording the number of sugar drinks consumed and the effect on hyperactivity or inattentiveness over a period of time, hence it would be excellent in establishing temporal relationship. Nevertheless, cohort study would be time consuming, expensive and requires follow up on participants. Another study design that is stronger than cross-sectional study will be case control study.
Case-control study are suitable in investigating rare disease but will not be able to show causal relationship. It is also vulnerable to confounders. This study will hence not produce additional results that will be useful for analysis. Having said that, for the research question raised, crosssectional study is the only relatively inexpensive and fast study available, despite its various limitations. Rationale for choosing cross-sectional study Cross sectional study was chosen as it is the most feasible study design available.
It is capable of adjusting for confounder and processing data from large sample size. Random error due to small sample size is hence greatly reduced. Overall, there will be enhanced credibility. Possible ethical issues concerned is few and insignificant, allowing the study to be formulated and conducted in short period of time. Compared to other studies, it is a more practical and cost effective study design that produce results in minimal time and with minimal effort.
Main findings and results analysis After adding types of sugar drinks to the model, consumption of energy drinks enhibits an independent association with the risk of inattention or hyperactivity. Significant association is found between the undesirable symptoms, number of drinks and family structure as well. Consumption of unconventional sugar beverages is found to be higher among low income students, particularly among boy, hispanic and black students. The results from the study are expressed as bivariate odd ratio; with the reference point, 1, assigned to student scoring from 0-5 in the subscale catergory.
Influence of potential confounders like age, race, gender, socioeconomic status, family structure, and other sugary food consumption were taken into account using multivariable logistic regression. 95% confidence interval(Cl) of most of the results on the association between potential counfounder and consumption of sweeted beverages includes 1. This suggest that most of the counfounders does not contribute to the risk as they are statistically insignificant. The 95% Cl for family structure is found to be significant.
The study conceded that there is statistically significant association between hyperactivity symptoms, number of drinks consumed and family support system but this point was not investigated further. Chi-square analysis and t test is also employed to ensure that there is not significant relationships between variables investigated. Associated ethical issues Due to the nature of the study and the fact that all procedures were approved beforehand, ethical issues associated are minimal. Surveys conducted is not invasive and only require minimal effort and time from the participants.
The survey also does not significantly interfere with the lives of the participatns as it only takes 30 minutes to complete. There could be instances where the unwilling participants without parental consent were forced to be part of the study, hence consent should be seek to minimise such scenarios even though they might seem unlikely to happen. There could also be a breech in confidentiality should the result be made public without consent from participants. If RCT is conducted, there will be significant ethical issues involved as investigators control the exposure.
All other study designs would be unlikely to result in obvious ethical issues. However, researchers should be aware of confidentiality issues that might arise without stringent protocols in place. Combined evaluation Consistency of media report with the medical journal article Although many ideas raised in the media report is consistent with the study, the article incorrectly implies corelation between consumption of energy drinks and academic performance in school, which is not proven in the research conducted. Some word choices were flawed and exagerrated too.
Word like”might” highlight the uncertainty involved in the causal relationship established but “dramatically)” and “guzzle” does not accurately reflect the idea postulated by the medical journal. Aside from the grossly misleading headline, the gist of the newspaper article is somewhat congruent with the medical journal. Advise for Patient When concerned patient brought up such issues, it is essential to help the patient to understand the result derived from the study accurately. Since the limitation of the study is not discussed in the media report, readers might also be deluded into thinking that the results are more valid than actual.
The intrinsic limitation of the study, in this case, the inability of crosssectional study to draw causal relationship should hence be made known to the patient. Exageration and incorrect corelation drawn should be pointed out. Discussion of the strengths of the study is also important in helping the patient to not overestimate or underestimate the importance and relevance of the study. Implication for Health Policy Making Both the media article and medical journal concluded that consumption of sugar drinks especially energy drinks should hence be limited due to its ability to contribute to lower attention span.
The media article uses excessively high sugar content as a secondary argument while the medical journal elaborated on caffeine dependency and effect of caffeine on brain developement. Causal relationship could not be established, its implcations on health policy making is hence limited. More research has to be done. Only when the causal relationship is proven, then can change be implemented on health policies to beenfit the public.
