An exploratory study on perceived relationship of alcohol, caffeine, and physical activity on hot flashes in menopausal women

doi:10.4236/health.2010.29146

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Vol.2, No.9, 989-996 (2010) Health

doi:10.4236/health.2010.29146

An exploratory study on perceived relationship of

alcohol, caffeine, and physical activity on hot

flashes in menopausal women

Jay Kandiah, Valerie Amend*

Department of Family and Consumer Sciences, Ball State University, Muncie, USA;

*Corresponding Author: vaamend@bsu.edu

Received 30 May 2010; revised 25 June 2010; accepted 1 July 2010.

ABSTRACT

This study examined the effects of caffeine, al-

cohol, and physical activity (PA) on the per-

ceived frequency and severity of hot flashes in

menopausal women. Female employees at a

Mid-Western university were invited to partici-

pate in an on-line survey. The 26-itemized Wo-

men’s Health Survey (WHS) included questions

regarding demographics, menopausal stage, ex-

perience of hot flashes, consumption of caf-

feinated beverages and alcohol, and participa-

tion in PA. One-hundred and ninety-six women

completed the study. Ordinary Least Squares

regressions revealed PA, caffeine, and alcohol

intake were significant in predicting the severity

of hot flashes (R2 = 0.068, F(6,180) = 2.195, p =

0.046), though they did not predict frequency of

hot flashes (R2 = 0.043, F(6,184) = 1.39, p = 0.221).

Participation in aerobic PA increased frequency

of hot flashes (p = 0.031); while higher intensity

of aerobic PA had an inverse relationship on

both frequency and severity of hot flashes (p =

0.011, p = 0.003, respectively). Spearman corre-

lations demonstrated a positive relationship

between caffeinated soda intake and frequency

(r = 0.17, p = 0.06) and severity (r = 0.19, p = 0.04)

of hot flashes. Beverage consumption and PA

may predict severity of hot flashes in women.

Less frequent, higher intensity aerobic PA may

lead to fewer, less severe hot flashes.

Keywords: Hot Flashes; Caffeine; Alcohol; Physical

Activity

1. INTRODUCTION

Menopausal hot flashes, with varying degrees of severity,

are a significant concern for women across the world.

There are more than 40 million women in the United

States over the age of 40, and it is estimated that ap-

proximately 46 million women in the U.S. will have

reached menopause by the year 2020 [1]. Seventy-five

percent of women over the age of 50 will experience hot

flashes to some degree. For some, eight to ten flashes a

day is not uncommon, interfering with their daily lives

(North American Menopause Society) [2]. Episodes may

last from 30 seconds to five minutes, generally averag-

ing four minutes [1]. Women with hot flashes are more

likely to experience disturbed sleep, depressive symp-

toms and significant reductions in quality of life as

compared to asymptomatic women [3]. These symptoms

may continue to occur for 5 years or more [4]. Geo-

graphic variation in the frequency of this phenomenon

may be related to the diet and lifestyle of the area [1].

However, little research is available on the relationship

of these factors to hot flashes.

A hot flash is described as a transient episode of flush-

ing, sweating and a sensation of heat, often accompanied

by palpitations and a feeling of anxiety, and sometimes

followed by chills [5]. While the exact cause and mecha-

nism is not well understood, there is a prevailing theory.

As estrogen levels are decreased in women, due to sur-

gery, chemicals, or age, the temperature regulation me-

chanism in the hypothalamus is affected. As a result, the

core body temperature is lowered, and the threshold be-

tween acceptable and unacceptable body heat levels is

more easily crossed. This causes signals to be sent to the

rest of the body to release heat, causing perspiration

from the sweat glands, leading to the dramatic rise in

skin temperature associated with menopausal hot flashes

[5].

Several factors have been studied for their contribu-

tions to the severity and frequency of hot flashes in

menopausal women. Among those are dietary intake,

biological factors, and modifiable behaviors. Studies

J. Kandiah et al. / HEALTH 2 (2010) 989-996

990

have also demonstrated a link between inten sity and

frequency of physical activity and characteristics of hot

flashes. Some have found that increased activity leads to

increase in menopausal symptoms; while others show

that a more active lifestyle may lead to a decrease in

occurrence [6-10]. According to current studies, women

have reported alcohol consumption as precursors to hot

flashes, with research both supporting and refuting this

claim [1-3,5,9-11]. Others report a link between caffeine

ingestion and menopausal symptoms; however, minimal

research has been completed on this factor [7].

With new data regarding the association between

these variables and characteristics of menopausal hot

flashes, the need to more clearly define lifestyle recom-

mendations for menopausal women has arisen. The pur-

pose of this research study was to examine the effects of

consumption of caffeine, alcoholic beverages, and phy-

sical activity on the perceived frequency and severity of

hot flashes in menopausal women.

2. METHODS

2.1. Participants

Female employees at a Mid-Western University were

invited to participate in an on-line survey. The inclusion

criteria for participants were: 1) ≥ 40 years of age; 2)

devoid of taking medications for treatment of meno-

pausal symptoms; 3) absence of smoking; and 4) educa-

tional status of sixth grade or higher. The recruitment

email informed participants of the following parameters

related to the study: their random selection, criteria for

participating, purpose of research procedures, and ap-

proximate time needed to participate in the study. Sub-

jects were informed that by completing and submitting

the survey, they were giving their consent. Duration for

completion of the survey was one month. Ball State

University’s Institutional Review Board approved all

aspects of this study.

2.2. Instrumentation

The 26-itemized Women’s Health Survey (WHS), de-

veloped by the researchers, was accepted for face valid-

ity by three experts (two dietitians, one physician). Re-

liability was established by utilizing a small (n = 20)

sample of subjects other than the study population who

were of similar characteristics. Subjects took the survey

twice, with two weeks between each administration.

Test-retest results were observed from the same partici-

pants to assess similarity of answers for each test. The

Kappa coefficients from the test-retest ranged from a

low of 0.44 to 1.00, with a median coefficient of 0.77.

Except for two questions where the Kappa coefficient

could not be calculated due to zero variance in responses,

all coefficients were statistically significant (see Appen-

dix).

The WHS included questions regarding demographics,

stage of menopause, hot flashes, average daily consump-

tion of caffeinated beverages, alcohol, and participation

in physical activity. Caffeinated beverages were divided

into subcategories based on usual number of servings.

Weekly consumption of coffee, tea, and cocoa were

listed as eight fluid ounces (236.56 mL), while energy

drinks and soda were 12 fluid ounces (354.84 mL). In-

take of caffeinated pills, diet pills containing caffeine,

and dark chocolate were also recorded. Usual weekly

intake of alcoholic beverages was divided into subcate-

gories, namely, beer (12 fluid ounces, 354.84 mL), white

wine or champagne (5 fluid ounces, 147.85 mL), red

wine (5 fluid ounces, 147.85 mL), and mixed drinks

(1.5-2 fluid ounces, 44.36-59.14 mL). Usual physical

activity per week assessed separately 30 minute intervals

of aerobic (e.g. running) and strength activity (e.g.

weight lifting). Usual intensity of physical activity was

measured using descriptors mild (don’t break a sweat

during activity), moderate (break a light sweat), or heavy

intensity (break a sweat, heart rate very increased).

Usual daily frequency and severity of hot flashes were

evaluated with rating scales. The subjective 10-point

rating scale ranged from 1 being very mild (a warm sen-

sation without sweating or disruption of normal activity)

to 10 being very severe (heat sensation with sweating

that may have interrupted daily activities) [5].

2.3. Statistical Analysis

Separate ordinary least squares (OLS) regressions were

used to evaluate frequency and severity of hot flashes.

Level of self-reported physical activity, average daily

caffeine, and alcohol intake were the predictors. Spear-

man rank correlations were used to examine the rela-

tionships of categories of beverage intake levels with hot

flash frequency and severity. This analysis was per-

formed in order to look at beverages individually after

excluding those who never consumed the beverage in the

last week. Significance was established at p < 0.05.

3. RESULTS

3.1. Demographics and Menopausal

Characteristics

One-hundred and ninety-six women successfully com-

pleted the study. As observed in Table 1, more than half

were 50-59 years, Caucasian, and in the naturally post-

menopausal reproductive stage. Most participants had

experienced hot flashes (81.1%), and were not taking

medications (92.9%) or using alternative therapies

J. Kandiah et al. / HEALTH 2 (2010) 989-996

991

(91.3%). Mean number of hot flashes ± standard devia-

tion (SD) were 2.2 ± 1.5 per week, while the mean usual

severity ± SD was 3.26 ± 2.58 on a scale of one to ten.

3.2. Physical Activity

More than half the subjects reported participating in

aerobic physical activity 0-2 times per week (n = 110,

56.2%) and at moderate intensity (n = 89, 45.4%). In

reference to strength activity, 60.2% participated 0-2

times per week with 38.3% performing at light to mod-

erate intensity. Mean ± SD weekly participation in 30

minutes of aerobic physical activity and strength exer-

cises were 2.48 ± 1.25 times and 1.51 ± 0.724, respec-

tively (Table 2).

3.3. Caffeine and Alcohol

Based on reported intake of caffeinated beverages (ma-

jority consumed 0-3 servings of each beverage), total

mean ± SD caffeine intake was 1144 mg ± 1008 mg,

while total mean ± SD servings of alcohol was 2.52 ±

Table 1. Demographics and menopausal characteristics of parti-

cipants (n = 196).

Characteristic Description n* (%)

Age 40-44 21 (10.7)

45-49 37 (18.9)

50-54 54 (27.6)

55-59 50 (25.5)

60 + 34 (17.3)

Ethnicity White 187 (95.4)

African-American 6 (3.1)

Hispanic 1 (0.5)

Asian/Pacific Islander 1 (0.5)

Reproductive Stage Pre-menopausal 32 (16.3)

Peri-menopausal 28 (14.3)

Menopausal 11 (5.6)

Naturally postmenopausal 81 (41.3)

Post-menopausal due to

surgery, chemotherapy, or

radiation

44 (22.4)

Currently using

alternative

therapies

Yes 15 (7.7)

No 179 (91.3)

Currently taking

medications for

menopausal

symptoms

Yes 13 (6.6)

No 182 (92.9)

Have experienced

menopausal

hot flash

Yes 159 (81.1)

No 36 (18.4)

Table 2. Subjects participation in 30 minutes of physical activ-

ity (PA) per week (n = 196).

Characteristic Description N (%)*

Aerobic PA

Frequency 0 times 46 (23.5)

1-2 times 64 (32.7)

3-4 times 48 (24.5)

5-6 times 23 (11.7)

7-8 times 11 (5.6)

> 8 times 4 (2.0)

Intensity Don’t participate 38 (19.4)

Light 47 (24.0)

Moderate 89 (45.4)

Heavy 21 (10.7)

Strength PA

Frequency 0 times 118 (60.2)

1-2 times 60 (30.6)

3-4 times 14 (7.1)

5-6 times 4 (2.0)

Intensity Don’t participate 116 (59.2)

Light 39 (19.9)

Moderate 36 (18.4)

Heavy 2 (1.0)

3.46 servings per week. The median reported weekly

intake of caffeine and alcohol among participants were

1080 mg and 1.20 servings, respectively.

Although 196 women participated in this research,

due to insufficient information, only data for 188 were

analyzed using Ordinary Least Squares (OLS) regression.

Overall, the regression results revealed that the effects of

self-reported physical activity, average daily caffeine,

and alcohol intake were not significant in predicting the

frequency of hot flashes (R2 =0.043, F(6,184) = 1.39, p =

0.221). However, after controlling for the other inde-

pendent variables, the regression indicated that, rela-

tively, more participation in aerobic physical activity

increased frequency of hot flashes (B= 0.241, β = 0.20, p

= 0.031); while higher intensity of aerobic physical ac-

tivity had an inverse relationship (B = –0.423, β =

–0.261, p = 0.011). All other variables remained statisti-

cally insignificant (Table 3).

Overall, regression analysis also revealed a small, but

statistically significant effect of physical activity, caf-

feine, and alcohol on severity of hot flashes (R2 = 0.068,

F(6,180) = 2.195, p = 0.046). Interestingly, after controlling

for all other independent variables, the regression indi-

cated that relatively, higher intensity of aerobic exer-

cise decreased severity of hot flashes (B = –0.875, β=

–0.315, p = 0.003) (Table 3).

Spearman rank correlations showed a small relation-

ship between higher consumption of caffeinated soda for

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both frequency (r = 0.17, p = 0.06) and severity (r = 0.19,

p = 0.04) of hot flashes. No significant relationship be-

tween the other caffeinated or alcoholic beverages and

hot flashes was revealed (Table 4).

4. DISCUSSION AND CONCLUSIONS

Several studies have examined the effect of lifestyle

factors on hot flashes, however, to date; no research has

focused simultaneously on the effect caffeine and alco-

hol consumption and physical activity had on the fre-

quency and severity of hot flashes in women over the

age of 40.

Findings from the present study related to frequency

of workouts and incidence and severity of hot flashes

are congruent with previous research. Whitcomb and

colleagues looked at the relationship between physical

activity prior to the time of the last menstrual period

and hot flashes [6]. This population based study using

512 peri-menopausal and post-menopausal women

found highly active women (reported exercising > 16

times per month) were significantly more likely to

have moderate to severe hot flashes (OR = 1.70, p =

0.01) and daily hot flashes (OR = 1.79, p < 0.01) than

less active women (report exercising 0-15 times per

month). Similarly, Thurston, et al., found a higher in-

cidence of subjective hot flashes after physical exer-

tion (OR, 1.49; 95% CI, 0.99-2.25; p = 0 .05), although

regular aerobic exercisers had fewer hot flashes than

sporadic exercisers [7].

Table 3. Ordinary least squares regression analysis of the influence of alcohol, caffeine, and physical activity on frequency and se-

verity of hot flashes (n = 188).

Note: 1R2 = 0.043, F(6, 184) = 1.39, p = 0.221; Dependant variable: Q8 In the last week, how many hot flashes have you had? 2R2 = 0.068, F(6,180) = 2.195, p =

0.046; Dependant variable: Q9 In the last week, how would you rate the usual severity of hot flashes?

Unstandardized

Coefficients

Standardized

Coefficients

B Std.Error Beta t Sig

Frequency of Hot Flashes1 Constant 2.406 0.360 6.688 0.000

How many times in the last week did you participate in

30 minutes of aerobic physical activity? 0.241 0.111 0.200 2.17 0.031

How intense would you rate your participation in aero-

bic activity? –0.423 0.165 –0.261 –2.554 0.011

How many times in the last week did you participate in

30 minutes of strength exercises? –0.259 0.285 –0.125 –0.909 0.364

How intense would you rate your participation in

strength exercise? 0.339 0.257 0.186 1.316 0.19

Total estimated caffeine for the week (mg) 0.000 0.000 0.026 0.327 0.744

Total servings of alcohol for the week 0.019 0.035 0.044 0.550 0.583

Severity of Hot Flashes2 Constant 4.789 0.611 7.842 0.000

How many times in the last week did you participate in

30 minutes of aerobic physical activity? 0.188 0.190 0.092 0.994 0.322

How intense would you rate your participation in aero-

bic activity? –0.875 0.286 –0.315 –3.056 0.003

How many times in the last week did you participate in

30 minutes of strength exercises? 0.004 0.486 0.001 0.008 0.993

How intense would you rate your participation in

strength exercise? 0.260 0.443 0.083 0.585 0.559

Total estimated caffeine for the week (mg) 0.000 0.000 –0.047 –0.595 0.552

Total servings of alcohol for the week –0.055 0.060 –0.074 –0.931 0.353

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Table 4. Spearman correlations between caffeinated beverages

and frequency of hot flashes.

Frequency of Hot Flashes n r Sig.

Energy drinks

(12 fl. oz. serving) 2 NA** NA**

Caffeinated hot tea

(8 fl. oz. serving) 60 –0.005 0.969

Caffeinated iced tea

(8 fl. oz. serving) 78 –0.016 0.887

Caffeinated soda

(12 fl. oz. serving) 123 0.173 0.055

Hot chocolate or cocoa

(8 fl. oz. serving) 19 0.214 0.378

Dark chocolate

(8 fl. oz. serving) 99 0.102 0.314

Red wine (5 fl. oz. serving) 51 0.091 0.527

Alcoholic beer products

(12 fl. oz. serving) 37 –0.025 0.881

White wine/champagne

(8 fl. oz. serving) 55 0.097 0.481

Mixed drinks

(1.5-2.0 fl. oz. serving) 30 –0.227 0.227

Severity of Hot Flashes

Energy drinks

(12 fl. oz. serving) 2 NA* NA*

Caffeinated hot tea

(8 fl. oz. serving) 60 0.033 0.804

Caffeinated iced tea

(8 fl. oz. serving) 77 –0.087 0.449

Caffeinated soda

(12 fl. oz. serving) 121 0.189 0.038

Chocolate or cocoa

(8 fl. oz. serving) 20 –0.010 0.967

Dark chocolate

(8 fl. oz. serving) 97 0.059 0.563

Red wine (5 fl. oz. serving) 49 0.229 0.114

Alcoholic beer products

(12 fl. oz. serving) 34 –0.032 0.858

White wine/champagne

(8 fl. oz. serving) 53 –0.015 0.918

Mixed drinks

(1.5-2.0 fl. oz. serving) 28 –0.149 0.449

The inverse relationship found between intensity of

physical activity and severity of hot flashes supports the

findings of Sievert et al. [10]. Women who participated

in heavy exercise (enough to speed up breathing and

heart rate, at least two times per week) were significantly

less likely to report both hot flashes and night sweats (p

= 0.05) compared to those participating in minimal exer-

cise (no exercise, or light exercise less than once per

week).

In contrast, Sternfield and colleagues investigated the

effects of regular exercise prior to the final menstrual

period [8]. There was no association between habitual

physical activity and menopausal hot flashes. Research

also revealed regular physical activity did not signifi-

cantly affect the frequency of menopausal symptoms

such as hot flashes (p = 0.291). Similar observations

were reported by Riley et al., indicating no significant

relationship exists between habitual exercise and fre-

quency or intensity of hot flashes (OR = 1.3; 95% CI =

0.78-2.16) [9].

Limited studies have looked at the effect of caffeine

on hot flashes. Even though the present study demon-

strated a there was a perceived relationship between caf-

feinated soda and frequency and severity of hot flashes

(r = 0.17, p = 0.04; r = 0.19, p = 0.04), Thurston et al.,

found an increased likelihood of objective hot flashes

(OR = 1.51; CI = 1.18-3.81; p = 0.003) after caffeine

consumption [7].

Regression analysis revealed alcohol and caffeine

consumption had no influence on frequency or severity

of hot flashes. On the contrary, earlier studies have

shown significant relationships existed between alcohol

intake and hot flashes. Freeman and colleagues [11],

found alcohol to be a significant predictor of hot flashes

(OR 1.10, p = 0.002). Observations were also noted by

Sievert et al. revealing daily alcohol consumption sig-

nificantly increased the risk of hot flashes (p < 0.01) [10].

Riley and colleagues noted in peri-menopausal women a

significant correlation prevailed with consumption of 1-5

drinks per day and bothersome hot flashes (OR = 0.52,

CI = 0.31-0.86) [9].

This research was limited to a homogeneous ethnic

group of faculty and staff at a Mid-Western University.

Recommendations for future research related to hot

flashes include: 1) assessment of participants BMI; 2)

incorporation of a larger and diverse ethnic group, with

varying age and geographical location; 3) comparison of

recreational activity to various levels and types of aero-

bic activity; 4) treatment of hot flashes using comple-

mentary and alternative medicine; 5) measurement of

actual hot flashes using objective and subjective infor-

mation; 6) comparison of co-morbidities such as obesity,

diabetes, and hypertension and their contributory roles

to menopausal symptoms and hot flashes.

Health professionals and scientists need to find a con-

nection to other modifiable behaviors to decrease the

occurrence and symptoms of hot flashes. In doing so, a

better understanding of the physiological challenges

women face can be gained, so appropriate intervention

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strategies could be implemented to improve quality of

life.

REFERENCES

[1] Philp, H.A. (2003) Hot flashes - A review of the literature

on alternative and complementary treatment approaches.

Alternative Medicine Review, 8(3), 284-302.

[2] North American Menopause Society (NAMS) (2004)

Treatment of menopause-associated vasomotor symptoms:

Position of the North American menopause society.

Menopause, 11(1), 11-33.

[3] Taylor, M. (2002) Alternative medicine and the per-

imenopause: An evidenced based review. Obstetrics and

Gynecology Clinics of North America, 29(3), 555-573.

[4] Sturdee, D.W. (2008) The menopausal hot flash:

Anything new. Maturitas, 60(1), 42-49.

[5] Kronenberg, F. (2004) Hot flashes: Phenomenology,

quality of life, and search for treatment options. Experi-

mental Gerontology, 29(3-4), 319-336.

[6] Whitcomb, B.W., Whiteman, M.K., Langenberg, P.,

Flaws, J.A. and Romani, W.A. (2007) Physical activity

and risk of hot flashes among women in midlife. Journal

of Women’s Health, 16(1), 124-133.

[7] Thurston, R.C., Blumenthal, J.A., Babyak, M.A. and

Sherwood, A. (2005) Emotional antecedents of hot fla-

shes during daily life. Psychosomatic Medicine, 67(1),

137-146.

[8] Sternfield, B., Quesenberry, C.P. and Husson, G. (1999)

Habitual physical activity and menopausal symptoms: A

case control study. Journal of Women’s Health, 8(1), 115-

123.

[9] Riley, E.H., Inui, T.S., Kleinman, K. and Connelly, M.T.

(2004) Differential association of modifiable health be-

haviors with hot flashes in perimenopausal and post-

menopausal women. Journal of General Internal Medi-

cine, 9(1), 740-746.

[10] Seivert, L.L., Oberdweyer, C.M. and Price, K. (2006)

Determinents of hot flashes anf night sweats. Annals of

Human Biology, 33(1), 4-16.

[11] Freeman, E.W., Sammel, M.D., Grisso, J.A., Battistini,

M., Garcia-Espagna, B. and Hollander, L. (2001) Hot

flashes in the late reproductive years: Risk factors for

African-American and Caucasian women. Journal of

Women’s Health & Gender-Based Medicine, 10(1), 67-76.

Appendix: Women’s Health Survey

1. Age (years)

a. 40-44

b. 45-49

c. 50-54

d. 55-59

e. 60 or over

2. Ethnicity

a. White

b. African-American

c. Hispanic

d. Asian/Pacific Islander

e. Other

3. Are you a smoker?

a. Yes

b. No

4. Do you currently take any medications to treat

menopausal symptoms?

a. Yes

b. No

5. Are you currently using any alternative thera-

pies to treat menopausal symptoms (e.g. black

cohosh, dong quai root, ginseng, kava, red clo-

ver, soy)?

a. Yes

b. no

6. What is your current reproductive stage?

a. Pre-menopausal (regular menstrual cy-

cle)

b. Peri-menopausal (last menstrual period

within the last 3 months)

c. Menopausal (last menstrual period

within the last year)

d. Naturally Post-menopausal (last men-

strual period more than 12 months

ago)

e. Post-menopausal due to surgery or ch-

emotherapy/radiation

7. Have you ever had a menopausal hot flash? (An

episode of flushing, sweating, and a sensation

of heat, often accompanied by palpitations and

a feeling of anxiety, and sometimes followed by

chills)

a. Yes

b. No

8. In the last week, how many hot flashes have you

had?

a. 0

b. 1-3

c. 4-6

d. 7-9

e. 10-12

f. More than 12

9. In the last week, how would you rate the usual

severity of the hot flashes? 1 being very mild

(a warm sensation without sweating or disrup-

tion of normal activity) and 10 being very se-

vere (heat sensation with sweating that may

have interrupted daily activities)?

J. Kandiah et al. / HEALTH 2 (2010) 989-996

995

a. Did not experience hot flashes

b. 1

c. 2

d. 3

e. 4

f. 5

g. 6

h. 7

i. 8

j. 9

k. 10

10. In the last week, how many times did you par-

ticipate in 30 minutes of aerobic physical ac-

tivity (running, swimming, hiking, walking,

etc.)?

a. 0

b. 1-2

c. 3-4

d. 5-6

e. 7-8

f. More than 8

11. How intense would you rate your participation

in aerobic activity?

a. Don’t participate

b. Light (don’t break a sweat)

c. Moderate (break a light sweat, heart rate

increased)

d. Heavy (break a sweat, heart rate very in-

creased

12. How many times per week do you participate in

30 minutes of strength exercises (weight lifting,

Pilates)?

a. 0

b. 1-2

c. 3-4

d. 5-6

e. 7-8

f. More than 8

13. How intense would you rate your participation

in strength exercises?

a. Don’t participate

b. Light (don’t break a sweat)

c. Moderate (break a light sweat, heart rate

increased)

d. Heavy (break a sweat, heart rate very in-

creased)

14. In the last week, how many times did you con-

sume caffeinated coffee (8 ounce serving)?

a. Never

b. 1-3

c. 4-6

d. 7-9

e. 10-12

f. 13-15

g. 16-18

h. More than 18 per week

15. In the last week, how many times did you

consume energy drinks (e.g. Red Bull, Sobe;

12 ounce serving)?

a. Never

b. 1-3

c. 4-6

d. 7-9

e. 10-12

f. 13-15

g. 16-18

h. More than 18 per week

16. In the last week, how many times did you

consume caffeinated hot tea (8 ounce serv-

ing)?

a. Never

b. 1-3

c. 4-6

d. 7-9

e. 10-12

f. 13-15

g. 16-18

h. More than 18 per week

17. In the last week, how many times did you

consume iced tea (8 ounce serving)?

a. Never

b. 1-3

c. 4-6

d. 7-9

e. 10-12

f. 13-15

g. 16-18

18. In the last week, how many times did you

consume caffeinated soda (e.g. Coke, Pepsi,

etc, 12 ounce)?

a. Never

b. 1-3

c. 4-6

d. 7-9

e. 10-12

f. 13-15

g. 16-18

h. More than 18 per week

19. In the last week, how many times did you

consume hot chocolate or cocoa (8 ounce

serving)?

a. Never

b. 1-3

c. 4-6

d. 7-9

e. 10-12

f. 13-15

g. 16-18

h. More than 18 per week

20. In the last week, how many times did you

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consume dark chocolate (at least 1 ounce

serving)?

a. Never

b. 1-3

c. 4-6

d. 7-9

e. 10-12

f. 13-15

g. 16-18

h. More than 18 per week

21. In the last week, how many times did you

take caffeine pills (e.g. no-doz, vivarin, 1-

200 mg pill)?

a. Never

b. 1-3

c. 4-6

d. 7-9

e. 10-12

f. More than 12

22. In the last week, how many times did you take

caffeinated diet pills?

a. Never

b. 1-3

c. 4-6

d. 7-9

e. 10-12

f. More than 12

23. In the last week, how many times did you

consume red wine (1 serving, 5 ounce gla-

ss)?

a. Never

b. 1-3

c. 4-6

d. 7-9

e. 10-12

f. More than 12

24. How many times per week do you consume

alcoholic beer products (12 ounce serving)?

a. Never

b. 1-3

c. 4-6

d. 7-9

e. 10-12

f. More than 12

25. How many times per week do you consume

wine (not red; 5 ounce serving)?

a. Never

b. 1-3

c. 4-6

d. 7-9

e. 10-12

f. More than 12

26. How many times per week do you consume

mixed drinks (1.5-2 ounce serving)?

a. Never

b. 1-3

c. 4-6

d. 7-9

e. 10-12

f. More than 12