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Associations between soft drinks
intake and primary dysmenorrhea
among Chinese undergraduate
female students
Lijiao Wang
1,6, Shuo Wen
1,6, Xinyuan Li
1,6, Ahiafor Maxwell
5, Hanwei Chi
2, Shijie Fan
1,
Guanghe Wang
3, Qiang Guo
4* & Peng Lu
1*
Primary dysmenorrhea (PD) is a common global health concern. However, limited studies explored
the association between soft drinks intake and PD among female undergraduates in China. To
determine the association between soft drinks (carbonated soft drinks, etc.) as well coee intake and
the incidence/severity of PD among female undergraduates in China. We performed a cross-sectional
study among 1809 female undergraduates in China from September 29, 2020 to October 22, 2020.
The demographic information and menstrual information of the participants were collected by a
self-administrated questionnaire. Chi-square test, ANOVA test, and logistic regression test were used
to investigate the association between soft drinks intake and the incidence/severity of PD. We also
conducted stratication analysis among dierent locations (rural or urban). The prevalence of PD was
47.1% (n = 852). There were 221 (25.9%) participants suered from severe pain. In the participants with
PD, the OR of carbonated soft drinks intake was 1.244 (95% CI 1.010–1.533). Among the participants
with PD from rural areas, the OR of carbonated soft drinks intake was 1.402 (95% CI 1.045–1.881),
compared with the non-carbonated soft drink group. In the participants with moderate and severe
PD, the OR of coee intake was 0.451 (95% CI 0.228–0.892), compared with the non-coee-drinking
group. There was a signicant association between carbonated soft drinks intake frequency and the
severity of PD (P < 0.05). Our study showed that carbonated soft drinks intake is a risk factor for PD,
especially in participants from rural areas. Coee intake is a protective factor for the severity of PD.
Periodical awareness programs about adverse eects of excessive soft drink consumption should be
introduced to reduce the prevalence and exacerbation of PD. Coee intake might be helpful to relieve
the severity of PD.
Keywords Primary dysmenorrhea, Female undergraduates, So drinks intake
Primary dysmenorrhea (PD) is dened as painful menstruation in absence of pelvic pathological changes, char-
acterized by recurrent, cramp-like lower abdominal pain during menstruation1,2. It doubles as the most common
gynecologic condition and one of the most common causes of pelvic pain in pre-menopausal women1,3,4. e
prevalence of PD among female university students varies widely, ranging from 45 to 95%5. ough not a life-
threatening condition, PD can cause substantial burden on the quality of life2,6. In the United States, about 600
million work hours and 2 billion dollars annual economic loss has been attributed to PD7. In Japan, it has been
reported that the total healthcare cost for patients with PD is 2.2 times higher than the healthcare cost for females
without dysmenorrhea8. PD is highly prevalent among Chinese college girls, with a high burden of symptoms
aecting productivity and assimilation into society9. With a prevalence rate of over 40% among Chinese College
girls, there’s the need to understand why10.
OPEN
1School of Public Health, Binzhou Medical University, No. 346 Guanhai Road, Laishan District, Yantai, Shandong,
China. 2School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing 100029,
China. 3Department of Environmental Health, School of Public Health, Shanghai Jiao Tong University School of
Medicine, Shanghai 200025, China. 4College of Child Development and Education, Zhejiang Normal University,
Hangzhou, China. 5Tsinghua Medicine - School of Clinical Medicine, Tsinghua University, Beijing, China. 6
These
authors contributed equally: Lijiao Wang, Shuo Wen and Xinyuan Li. *email: guoq1989@zjnu.edu.cn; peng.lu@
monash.edu
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So drinks include soda water, syrup, or other carbonated or non-carbonated beverages11. Also known some-
times as carbonated beverages or sodas, so drinks are non-alcoholic beverages that are typically carbonated
and avored. Coee is considered a beverage that is brewed from roasted coee beans12. One of the primary
ingredients in so drinks is sugar, with an average content 100 g/L13. e global consumption of so drinks has
increased dramatically over the past several decades with the greatest increase among young people14. While the
exact amount diers from study to study, they all indicate that so drink consumption has been on the rise in
China in recent years15, resulting in a remarkably increase in various health conditions and diseases.
Similarly, coee consumption which was considered a western lifestyle, has signicantly gained popularity
in China, a country with long history of drinking green tea. e demand for coee has also grown rapidly in
recent years16. Statistical reports show that Chinese population consumed around 4.8 million 60-kg bags of cof-
fee, as coee production volume in China amounted to around 1.8 million bags in the same period. Although
considered a beverage, coee has a stimulant eect on the human nervous system due to it’s caeine content17.
Notable of these eects are caeine in coee possess an antagonistic eect on adenosine A1 and A2A receptors,
causing hyperexcitability of the central nervous system18, also aects physical stamina, cognitive function and
in some cases amplify symptoms of anxiety19.
A cross-sectional study conducted in Ethiopia in 2016 found that among students who consumed one or
more servings of cola daily, the risk of PD was approximately seven times higher than those non-consumers,
suggesting a potential link between sugary carbonated beverages and menstrual pain20. Additionally, a cross-
sectional study conducted among 857 university students in Turkey in 2009 also found a positive association
between excessive intake of sugary beverages, such as cola and the high prevalence of dysmenorrhea21. Our
study buttresses the many previous studies examining the prevalence and characteristics of PD among female
undergraduates in China. e relationship between so drinks intake and the incidence and pain severity of PD
is not well documented10,20,22,23. e association between coee intaking and the incidence of dysmenorrhea are
controversial. In a 2019 cross-sectional study conducted in Kuwait involving 763 12th-grade female students from
public high schools aged between 16 and 21 years, found a signicant association between coee consumption
frequency and increased risks of dysmenorrhea6; however, a cross-sectional study conducted in 2020 revealed
no signicant association between coee intake and the prevalence of dysmenorrhea among university students
in Zimbabwe24.
To bridge research gap, we conducted a cross-sectional study to analyze the association between so drink
and the incidence/severity of PD among Chinese female undergraduates. is is the rst study to analyze the
association between so drinks consumption and PD incidence and severity among Chinese female undergradu-
ates. We also did a stratication analysis according to the place of residence (urban or rural).
Methods
Study design and sample size considerations
We performed a cross-sectional study to analyze the association between so drinks intake and the incidence
and severity of PD among female undergraduates in China from September 29, 2020 to October 22, 2020. e
inclusion criteria of the study are: (1) Students from all across China enrolled in Binzhou Medical University in
2019; (2) Female; (3) No history of gyanecologic pathological changes. e distribution of participants is shown
in Fig.1. All participants had to provide informed consent before participation. is study was approved by
Binzhou Medical University ethics committee. We estimated the sample size by
n
=
Z
2
1−α/2×
pq
d
2
Fig. 1. e distribution of the participants.
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According to Iacovides’ study9, we conservatively determined that the prevalence (P) is 0.45, and we set per-
missible error (d) at 0.1p, α = 0.05, then the minimum sample size was calculated to be 489. Finally, we included
1809 samples from the Chinese Undergraduates Cohort (CUC).
Data collection
e participants’ information was collected by a self-administrated questionnaire. is self-administrated ques-
tionnaire included demographic information and menstrual information of the participants.
Covariates
Demographic information include age, residence, smoking, passive smoking, physical activity, carbonated so
drinks intake, carbonated so drinks intake frequency, coee intake, and coee intake frequency. Participants
were classied into urban and rural areas. In addition, anthropometric data including height and weight were
self-reported. Each participant’s Body Mass Index (BMI) was calculated as weight in kilograms divided by
the height in meters squared. According to the Asian-Population Criteria of the World Health Organization:
Underweight is dened as < 18.5 kg/m2, Normal weight ranges from 18.5 to 23.0 kg/m2, Overweight is from
23.0 to 27.5 kg/m2, and Obese is ≥ 27.5 kg/m225. e following demographic information variables were dened
as categorical variables and the denitions used were: smoking—at least one cigarette per day in the past three
months; passive smoking—at least 15min of passive smoking per day for the past three months; physical activ-
ity—at least once a week for the past three months26. Data about so drinks or coee intake were collected by
the question, “Do you oen drink carbonated so drinks/coee?”. People who drank so drinks or coee had to
report the intake frequency, and the frequency was classied as “ < 1 times/week”, “1–3 times/week”, “4–6 times/
week”, “ ≥ 7 times/week”.
Menstrual information included menstrual cycle, menstrual duration and menstrual ow. Collecting men-
strual information was based on those questions: “How oen have you menstruated in the past three months?”,
“What’s the duration of your menstruation in the past three months?”, “How is the menstrual ow in the past
three months?”. PD was identied on the basis of the questions, “Have you experienced one or more of menstrual
cramps or abdominal pain during your menstrual period in the past three months?”. Participants with PD had
to report the level of their pain severity. e pain severity was categorized as mild, moderate, and severe, which
are respectively dened as 1–3 points.
Statistical analysis
We divided participants into PD group and normal group according to their PD condition. e χ2 test was used
to compare the distribution of PD characteristics across groups with dierent levels of pain severity. Logistic
regression models were employed to assess the association between the intake of so drinks and the incidence of
PD, as well as the association between the intake of coee and the severity of PD. In logistic regression analysis,
PD was designated as the dependent variable, and the independent variables included: coee, smoking, passive
smoking, intake of so drink, intake of milk tea, tea, physical exercise, BMI and urban versus rural status. A
forward stepwise method was utilized for univariate regression to select independent variables, resulting in the
most tting model. Multivariate binary logistic regression was conducted to explore the relationship between the
study variables and the incidence and severity of PD. e Kruskal–Wallis test was applied to determine the asso-
ciation between carbonated so drinks intake frequency and the severity of PD, as well as the association between
coee intake frequency and the severity of PD. For categorical variables, χ2 test with a pre-set P(signicance
value) ≤ 0.05 was used to test for signicant association between so drinks intake and PD.
We also conducted a stratication analysis according to participants’ places of residence (urban or rural) to
investigate the association between so drinks intake and the incidence of PD among dierent populations in
multiple logistic regression (TableS1). e data extracted from the questionnaires were statistically analyzed
using the Statistical Package for Social Sciences (SPSS) 23.0 soware aer coding all answers. e level of statisti-
cally signicance was set at P < 0.05.
Results
Characteristics of the study subjects
Table1 shows the baseline demographic characteristics of participants. A total of 1809 participants were recruited
in this study. e majority of the participants in this study were Han Chinese. Additionally, this study also
included a small but diverse group of participants from dierent ethnic backgrounds. ree participants were
from the Tujia ethnic group, three from the Yi ethnic group, two from the Buyi ethnic group, two from the
Zhuang ethnic group, one from the Manchu ethnic group, one from the Miao ethnic group, one from the
Mongolian ethnic group, one from the Bai ethnic group and one from other ethnic groups. e average age of
participants was 19.7 ± 1.2 years. ere were 852 (47.1%) participants experienced PD in the past three months.
For PD group, 51.2% had consumed carbonated so drinks compared with 48.8% in non-PD group. Moreover,
44.8% participants of the PD group drank coee, whereas 55.2% in the non-PD group. ere were 906 (50.1%)
participants from rural areas. e distribution of the severity of PD cases was as follows: mild 24.4% (n = 208),
moderate 49.6% (n = 423), and severe 26.0% (n = 221).
Table2 reects the baseline menstrual characteristics of participants in both non-PD and PD groups. Both
non-PD and PD groups had a similarity in menstrual cycle. It can be noticed in the menstrual ow data of the
participants that those in the PD group reported 62.3% having heavy ow as opposed to the 37.7% reported by
the non-PD group.
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Carbonated soft drinks intake and PD
Table3 shows the association between carbonated so drinks intake and the incidence of PD. e results showed
that the risk of PD incidence in carbonated so drink group was about 1.24 times higher (OR = 1.244, 95%CI
1.010–1.533) than non-carbonated so drink group. Table4 shows the association between carbonated so
drinks intake frequency and the severity of PD (x ± s). e results found that there is a dose–response relationship
between frequencies of carbonated so drinks intake and the pain severity of PD. For example, when carbonated
so drinks intake frequency is less than once a week, the pain severity is mild. As the frequency of so drink
consumption increases, the pain severity gradually worsens.
Coee intake and PD
Table5 shows the association between the amount of coee intake and the severity of PD. Aer analyzing the
variables related to PD severity, we found that there is a signicant association between coee intake and PD
severity. Specically, participants with moderate to severe PD who consume coee have lower odds of experienc-
ing severe symptoms, with an odds ratio of 0.451 (95% CI 0.228–0.892) (P < 0.05).
Table 1. e distribution of demographic characteristics of participants. Signicant values are in bold.
Primary dysmenorrhea
P valueNo (n = 957) Yes (n = 852)
Sociodemographic information
Location (%) 0.287
Rural 468 (51.7) 438(48.3)
Urban 489 (54.2) 414 (45.8)
BMI (%) 0.236
Underweight 363 (52.0) 335 (48.0)
Normal 462 (52.0) 426 (48.0)
Overweight 64 (57.7) 47 (42.3)
Obese 68 (60.7) 44(39.3)
Lifestyle habits information
Smoking (%) 0.604
NO 956 (52.9) 850(47.1)
YES 1(33.3) 2(66.7)
Passive smoking (%) 0.600
NO 918 (53.0) 813 (47.0)
YES 439(50.0) 39(50.0)
Physical activity (%) 0.028
NO 224(48.5) 238 (51.5)
YES 733 (54.4) 614(45.6)
Carbonated so drinks intake (%) 0.033
NO 720 (54.4) 603 (45.6)
YES 237 (48.8) 249(51.2)
Tea intake (%) 0.124
NO 808 (52.2) 741 (47.8)
YES 149(57.3) 111(42.7)
Coee intake (%) 0.568
NO 877 (52.7) 787 (47.3)
YES 80(55.2) 65 (44.8)
Carbonated so drinks intake frequency (%) 0.154
< 1 times/week 720 (54.4) 603 (45.6)
1–3 times/week 210(48.2) 226(51.8)
4–6 times/week 22 (55.0) 18 (45.0)
≥ 7 times/week 5 (50.0) 5 (50.0)
Coee intake frequency (%) 0.591
< 1 times/week 877 (52.7) 787 (47.3)
1–3 times/week 574 (52.4) 49 (47.6)
4–6 times/week 16(66.7) 8 (33.3)
≥ 7 times/week 10 (55.6) 8 (44.4)
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Table 2. e distribution of menstrual characteristics of participants. Signicant values are in [bold].
Menstrual characteristics
Primary dysmenorrhea
P valueNo (n = 957) Yes (n = 852)
Menstrual cycle (%) 0.101
21–28days 421 (55.3) 340 (44.7)
28–30days 284 (53.0) 252 (47.0)
30-35days 252 (49.2) 260 (50.8)
Menstrual duration (%) 0.333
2–5days 583 (53.8) 500 (46.2)
5–7days 374 (51.5) 352 (48.5)
Menstrual ow (%) < 0.001
Mild 63 (52.1) 58 (47.9)
Moderate 836 (54.5) 698(45.5)
Heavy 58(37.7) 96 (62.3)
Table 3. Associations between carbonated so drink intake and incidence of PD. Signicant values are in
[bold].
Var iabl e OR (95%CI) P value
Carbonated so drinks
No Ref
Yes 1.244 (1.010–1.533) 0.040
Table 4. Associations between carbonated so drinks intake frequency and the severity of PD (
x
± s).
Var iabl e Nχ2P
Carbonated so drinks intake frequency 9.217 0.027
< 1 times/week 603
1–3 times/week 226
4–6 times/week 18
>= 7 times/week 5
Table 5. Associations between coee intake and the severity of PD (n = 644). Signicant values are in [bold].
Var iabl e OR (95%CI) P value
Coee intake
No Ref
Yes 0.451 (0.228–0.892) 0.019
Table 6. Associations between coee intake frequency and the severity of PD (
x
± s).
Var iabl e Nχ2P
Coee intake frequency 1.333 0.721
< 1 times/week 787
1–3 times/week 49
4–6 times/week 8
>= 7 times/week 8
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Table6 shows the association between coffee intake frequency and the severity of PD (x ± s) using
Kruskal–Wallis test. e results did not nd signicant associations between coee drinking frequencies and
severity of PD.
e associations between menstrual ow and the incidence and severity of PD are shown in TablesS2–S4.
Menstrual ow and menstrual cycle were associated with the incidence of PD (P < 0.05).
Discussion
is is the rst study to analyze the association between so drinks consumption and PD incidence and severity
among Chinese female undergraduates. Our ndings revealed a high prevalence of PD, with 47.1% of participants
experiencing it, and 26% of those experiencing severe pain. We found that women who consumed carbonated
so drinks had a higher risk of developing PD. However, those who drink more coee had less chance of devel-
oping into sever PD pain.
Prevalence of PD among female undergraduates in China
According to our study, there were 46.1% of PD cases among female undergraduates in China, which is com-
parable to previous studies that reported rates ranging from 40 to 90%27. A previous study conducted in China
indicated that the rate of PD among female university students was 41.7% 10. Our study used a self-administered
questionnaire to assess the level of pain severity in the subjects, which showed that 24.4% of participants expe-
rienced mild pain, 49.6% had moderate pain, and 26.0% had severe pain. A study conducted in Saudi Arabia
conrmed our ndings, reporting that 23% of participants experienced mild dysmenorrhea, 50% suered from
moderate pain, and 27% reported severe pain28.
Although there were slight dierences in the percentage distribution of pain severity in dierent studies,
most of the results agree that approximately one-fourth of female undergraduates described their PD as severe21.
Similarly, studies conducted in Turkey and other countries have reported the prevalence of severe dysmenor-
rhea to be between 10 and 27%29, indicating that PD is still a signicant gynecological and public health issue
among female undergraduates. ese ndings underscore the urgent need for better prevention protocols and
intervention measures to address this condition.
Relationship between carbonated soft drinks consumption and PD
Our study further revealed that the intake of carbonated so drinks had a statistically signicant association with
the incidence of PD. We also identied a signicant relationship between carbonated so drinks intake frequency
and the severity of PD (P < 0.05). Our ndings were backed up by several studies conducted in Turkish29, in
Ethiopia20 and Indonesia30. ese study found a positive correlation between carbonated so drinks intake and
PD incidence31. is could be due to the fact that the high sugar content in carbonated so drinks can disrupt
the absorption and processing of certain vitamins and minerals, leading to nutritional imbalances that can cause
abnormal muscle contractions and ultimately muscle spasms29.
Besides, the cause of PD is likely related to the cyclooxygenase pathway producing higher levels of prostanoids,
specically prostaglandins (PGs), in the endometrium during ovulation cycles3,4. Some studies indicate that the
concentration of prostaglandin F2α in menstrual uid is twice as high in women who experience dysmenorrhea
compared to those who don’t32. e elevated levels of PGs bring about contractions in the uterus, resulting in the
production of anaerobic metabolites that activate pain receptors3. ese metabolites may be derive from meals
that contain sugar33. e heightened levels of PGs prompt the uterus to contract, which restricts blood ow and
generates anaerobic metabolites that activate pain receptors. Prior study has suggested that consuming excessive
sugar can impact the amount of steroids circulating in the body34. High-sugar beverages lead to increased cortisol
(steroid) levels in young women. Cortisol is a hormone that is released in response to stress and is involved in
regulating various physiological processes in the body. A study found that women with PD had higher levels of
cortisol compared to women without menstrual pain, suggesting that the dysregulation of the stress response
system, which includes cortisol secretion, may be involved in the development of primary dysmenorrhea35.
However, these ndings are inconsistent with the results of several other researchers who reported there was
no correlation between carbonated so drinks consumption and PD36,37. e possible explanation may be there
should be a threshold amount of carbonated drinks consumed to be able to cause PD. Normal consumption
(not excessive) shows no evidence of a direct relationship with PD. Our study found a signicant association
between carbonated so drinks intake frequency and the severity of PD (P < 0.05), which could better account
for causal associations than ordinary cross-sectional study. However, additional studies are required to explore
the connection between drinking carbonated so drinks and PD.
The relationship between coee consumption and PD
According to our study, drinking coee has been shown to potentially decrease the risk of developing PD
(P > 0.05). However, this nding contradicts some previous studies that have suggested otherwise23,38. Specically,
our research indicates that among individuals experiencing moderate to severe pain severity from PD, those who
consumed coee had a 0.451 lower risk compared to those who did not consume coee. However, no signicant
correlation was found for participants experiencing only mild pain severity from PD.
Our study aligns with a Spanish study that reported a statistically signicant association between dysmenor-
rhea or its severity and factors such as caeine intake, supporting our results 31. Additionally, a study conducted
in Saudi Arabia found a signicant association between PD and caeine consumption28.
e relationship between coee intake and PD has been the subject of controversy in previous studies. While
some studies have reported a positive association between coee intake and the risk of PD21,39, others have found
no correlation between PD and daily coee consumption37,40. For instance, a study on medical sciences students at
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Babol University of Medical Sciences demonstrated that the risk of dysmenorrhea was twice as high in individu-
als who were high consumers of caeine (≥ 300 mg/day) compared to those who were low/moderate consumers
of caeine (< 300 mg/day) (OR = 1.97, 95% CI 1.09–3.59)39. e conicting results of these studies contribute
to the controversy surrounding the association between coee intake and PD. e variations in study designs,
sample sizes, and populations may be factors inuencing the divergent ndings. A study conducted in medical
students at Babol University of Medical Sciences found that moderate/moderate caeine consumers (< 300 mg/
day) showed a two-fold higher risk of dysmenorrhea (OR = 1.97 (95% CI 1.09–3.59))38. Another cross-sectional
study of 1183 women, based on the Shanghai Birth Cohort Study, found that coee consumption was positively
associated with the severity of dysmenorrhea aer considering potential confounding factors38.
In contrast, the prospective study of 428 women conducted in Saint Vincent and the Grenadines reported
no statistically signicant association between PD and caeinated beverages41. Also, a cross-sectional study
conducted in Surakarta on 274 female adolescents aged between 15 and 17 years old found that caeine intake
was not signicantly associated with the severity of dysmenorrhea42. Additionally, other studies have shown
a correlation between caeine intake and dysmenorrhea21,41. Caeine, the main component of coee, is an
adenosine analogue that blocks adenosine receptors (potent vasodilators)43. Blocking these receptors causes
vasoconstriction, reducing blood ow to the uterus and making menstrual pain even worse44. Caeine also has
a strong vasoconstrictor eect and has been associated with pelvic pain. e mechanisms by which caeine may
induce crampy pain have not yet been identied and require further research28.
Potential pharmacodynamic eects have been shown for how inn helps in PD. Prostaglandin E1 (PGE1)
increases cAMP, which essentially causes smooth muscle relaxation and vasodilation. PGE1 increases during
menstruation along with PGE2 and other prostaglandins45. e eectiveness of individual PGs depends on con-
centration, potency, genetics, etc. Caeine in coee synergistically increases PGE1, causing uterine relaxation.
Another study showed that a 1mM concentration of caeine stimulated cyclic AMP levels to 151% of control
levels aer 60min. Higher concentrations of caeine produced even greater stimulation of cyclic AMP levels46.
We believe our ndings further clarify the fact that coee consumption is not always positively correlated with
the severity of PD. More study on this topic is needed. ough there are various hypotheses on mechanism of
action between PGE1 and cAMP. For example, PGE1 does at least not exclusively act by changing cAMP levels,
but rather directly inuences cell membrane functions47. We believe that our study result throws more light
on the fact that coee intake doesn’t always bear a positive correlation with severity of PD pains and that more
research is required on the subject matter.
Implications for policy and practice
Our study has several public health implications. Our study examined the evidence of adverse eects of so
drinks consumption on Chinese female undergraduates, and found that frequent carbonated so drinks intake
is a risk factor for PD whereas coee intake is a protective factor for PD. ere are known non-modiable risk
factors such as menstrual ow and menstrual cycle, are also identied in our study, which increase the prob-
ability of suering from PD. As modiable risk factors, carbonated so drinks intake and coee intake had a
signicant association with PD. However, concerning lifestyle and eating habits, and based on our results and
previous reports, further studies about so drinks intake are necessary to provide recommendations on the most
advisable diets or lifestyle habits for minimizing the consequences or reducing the risk of PD. Firstly, we should
formulate corresponding policies to restrict the sale of so drinks. In addition to strategies at country level, female
undergraduates with PD could try to avoid the frequent intake of so drinks, especially carbonated so drinks
and nd other substitutes such as some type of tea (black tea, matcha green tea, etc.) or coee.
Limitations and future directions
e advantages of our study are also worth noting. e large sample size made the results more precise. In
addition, this study was based on a large cohort, which enables us to involve more potential confounders in the
analyses. is study explored the association between so drinks intake and the incidence as well as the severity
of PD among female undergraduates. We have, in our discussion, highlighted a few issues that require further
comprehensive research such as carbonated so drinks intake (a risk factor) and coee intake (a protective fac-
tor). We also divided the degree of PD pain severity into 3 levels of and further explored the impact of so drinks
intake on PD under the dierent levels of pain severity of PD. What’s more, we have also done the stratication
analysis which enabled us explore the association between so drink consumption and PD in dierent groups
according to their places of residence (urban or rural). Our results indicated a signicantly positive association
between so drinks intake and PD, which bear notable public health ramications.
We are aware of some limitations. First, the study design is a cross-sectional study with no causal interpreta-
tion. Second, although the students in the sample are not only from Shandong, there are relatively many stu-
dents from Shandong, so the sample may not be representative of all Chinese women. Further generalization of
results in the future requires an expansion of the proportions of sample in dierent areas in China. Finally, pain
and menstrual ow are measured by subjective assessment methods, which could lead to recall bias and over-
reporting or under-reporting of certain variables. Despite these limitations, our study can be used to increase
general perceptions of PD among Chinese female students.
Conclusion
Overall, a high portion of female undergraduates suer from PD in China. We identied that carbonated so
drinks were a risk factor for the occurrence and severity of PD, while coee consumption was a protective fac-
tor against PD. Furthermore, there maybe a dose–response relationship between carbonated so drinks intake
frequency and the severity of pain in PD. Being aware of this makes it possible for health professionals to organize
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better focused programs to reduce the adverse eects of PD. Our ndings highlight the need for interventions
to reduce undergraduates’ so drinks consumption by educating them about the harmful eects of so drinks.
Data availability
Data described in the manuscript, code book, and analytic code will be made available upon request pending
application to and approval from the corresponding author Peng Lu.
Received: 8 May 2024; Accepted: 30 August 2024
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Acknowledgements
e authors wish to thank all undergraduates who participated in the study for their collaboration in the study.
Author contributions
L.W.: Methodology, Formal analysis, Soware, Writing—original dra, Writing—review & editing. S.W.: Meth-
odology, Formal analysis, Soware, Resources, Writing—review & editing. X.L.: Methodology, Soware, Formal
analysis, Resources, Writing—review & editing. A.M.: Resources, Writing—review & editing. H.C.: Resources,
Writing—review & editing. S.F.: Resources, Writing—review & editing. G.W.: Resources, Writing—review &
editing. Q.G.: Supervision, Methodology, Resources, Writing—review & editing, Funding acquisition. P.L.:
Conceptualization, Supervision, Methodology, Project administration, Resources, Writing—review & editing,
Funding acquisition.
Funding
e study was supported by Taishan Scholar Program. PL was sponsored by Taishan Scholar Foundation
(tsqn202211228), National Natural Science Foundation of China (42307549) Natural Science Foundation
of Shandong Province (ZR202103050697) and Shandong Province Environmental Health Innovative Team.
Guanghe Wang was supported by the Foundation of Shanghai Municipal Health Commission (202140204).
Qiang Guo is supported by National Natural Science Foundation of China (62407040).
Ethics approval and consent to participate
is study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures
involving research study participants were approved by Binzhou Medical University ethics committee (NO.
2019075). Written informed consent was obtained from all subjects.
Competing interests
e authors declare no competing interests.
Additional information
Supplementary Information e online version contains supplementary material available at https:// doi. org/
10. 1038/ s41598- 024- 71802-8.
Correspondence and requests for materials should be addressed to Q.G.orP.L.
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