Abstract
Background
Sugar-sweetened beverage (SSB) consumption among adolescents worldwide continues to rise, physical fitness metrics such as grip strength are declining, the prevalence of psychological symptoms has risen, and this has become a major public health issue. However, the independent and combined associations of SSB and grip strength with psychological symptoms remain unexplored in large adolescent samples. This study aims to examine these associations in Chinese adolescents.
Methods
This cross-sectional study was conducted from March to June 2025. A total of 52,035 adolescents aged 12–17 were recruited from 27 provincial-level administrative regions in China. SSB consumption was self-reported. Grip strength was categorized into low, medium, and high by sex and age tertiles. The Multidimensional Subhealth Questionnaire for Adolescents (MSQA) was used to assess psychological symptoms. The associations among these three variables were assessed using t-tests, chi-square tests, binary logistic regression, and ordered logistic regression.
Results
The prevalence of psychological symptoms among Chinese adolescents was 20.8%. The prevalence for emotional problems, conduct problems, and social adjustment difficulties were 27.4%, 26.6%, and 17.6%. Mean grip strength was 30.0 ± 9.9 kg, with boys 35.0 kg and girls 25.0 kg; 83.4% consumed SSB < 1 time/week. After adjusting for covariates, compared with adolescents with high grip strength and who consumed SSB < 1 time/week, adolescents with low grip strength and who consumed SSB > 4 times/week have a 2.20-fold higher risk of psychological symptoms (OR = 2.20, 95% CI: 1.57–3.08, P < 0.001).
Conclusion
Higher SSB consumption was associated with greater psychological symptoms in adolescents. While grip strength showed no independent link, its combination with high SSB consumption significantly increased the risk, especially in males. These findings support integrated school-based interventions targeting both diet and muscle strength to promote adolescent mental health.
Keywords: Sugar-sweetened beverage consumption, Grip strength, Psychological symptoms, Adolescents, Cross-sectional study
Introduction
The high prevalence of psychological symptoms among adolescents has drawn growing attention worldwide. According to data from the Global Burden of Disease studies 293 million children and adolescents aged 5–24 years suffered from psychological symptoms globally in 2019, representing a prevalence of 11.63% [1], while approximately 15.2% of those aged 10–19 years were affected by at least one mental disorder in 2021 [2], indicating that adolescent psychological symptoms have become a substantial public health burden. This trend is not restricted to specific regions; as a developing country, China faces an equally prominent public health challenge in this regard. A systematic review and meta-analysis indicated that the overall prevalence of depressive symptoms among adolescents in China is 24.3%, with significant sex differences observed. The prevalence among girls was significantly higher than that among boys [3]. A survey of nearly 100,000 adolescents in southwest China further revealed that approximately 5.6% of students were in an extremely high-risk state for psychological early warning, with this high-risk state more pronounced in girls than in boys [4]. Accordingly, in-depth exploration of the potential factors influencing the psychological symptoms of Chinese adolescents has become a critical prerequisite for developing precise intervention strategies and safeguarding the holistic physical and mental development of adolescents.
Among numerous influencing factors, eating behaviors and muscle strength have received extensive attention due to their high modifiability for intervention. A systematic review demonstrated that combined interventions targeting diet and physical activity can significantly ameliorate anxiety symptoms and eating disorders in adolescents [5], suggesting a potential synergistic effect between dietary behaviors and physical fitness. A randomized controlled trial further confirmed that lifestyle education interventions aiming to reduce SSB consumption and increase physical activity can significantly alleviate depressive symptoms in adolescents [6]. A cross-sectional study of Chinese adolescents also found that adolescents who consumed ultra-processed foods (including SSB) more than 6 times/week and had less than 30 min of daily physical activity had a 1.54-fold higher risk of psychological symptoms than those with healthy behaviors [7]. Additionally, higher sugar-sweetened beverage (SSB) consumption is significantly associated with an increased risk of psychological symptoms among Chinese adolescents [8]. Taken together, these findings suggest that a lifestyle centered on diet and physical activity plays a critical protective role on the psychological symptoms of adolescents.
From the perspective of a single risk factor, the connection between SSB consumption and psychological symptoms in adolescents has been supported by extensive research. A meta-analysis revealed a positive correlation between SSB consumption and anxiety disorders in adolescents [9]. From the perspective of sleep, SSB may exacerbate psychological symptoms by disrupting sleep rhythms, thereby impairing the emotion regulation ability of adolescents [10]. Other studies have identified an interaction among SSB consumption, waist-to-height ratio, and psychological symptoms [11], and a dose-response association between the SSB consumption and psychological symptoms in certain populations [12]. Meanwhile, co-consumption of fast food and SSB exerts a synergistic amplifying effect on the adverse consequences of these factors on psychological symptoms [13, 14]. An umbrella review further confirmed the consistency of epidemiological evidence linking SSB consumption to adverse outcomes including depression [15]. Nonetheless, these findings are not entirely uniform. Some studies have reported that SSB consumption is associated with poor psychological symptoms, while no such association is observed for 100% pure fruit juice, suggesting that sugar sources perceived as “natural” may have differential effects on psychological status [16]. Further prospective studies have indicated that free sugars from beverages significantly increase the risk of depression, whereas free sugars from solid foods show no significant association [17].
On the other hand, grip strength, a widely used indicator of overall muscle strength, has also been extensively investigated for its association with psychological symptoms [18, 19]. A study based on data from over 40,000 participants in the UK Biobank shows that grip strength is significantly associated with brain structure and psychological symptoms, and that individuals with lower grip strength had a higher risk of psychological symptoms [20]. However, a nationwide cross-sectional study of Chinese adolescents aged 12–18 reported no significant association between grip strength and depressive symptoms after covariate adjustment [21]. A recent meta-analysis of prospective cohort studies found that lower handgrip strength was associated with a 42% higher risk of incident depression [22], but also identified for the first time that reduced grip strength is linked to an elevated risk of suicidal ideation [23]. Collectively, existing evidence indicates that muscle parameters (including grip strength) have important predictive value for anxiety and depressive symptoms [24].
Previous studies have linked SSB consumption to increased odds of anxiety disorders in adolescents [9], but evidence on grip strength is inconsistent [23]. However, empirical research examining the combined effects of SSB consumption and grip strength on psychological symptoms in large adolescent samples remains scarce to date. In this study, psychological symptoms were defined using the MSQA, with a cutoff of ≤ 3 on at least 8 of the 39 items. This study aims to examine the associations among SSB consumption, grip strength, and psychological symptoms in Chinese adolescents, thereby providing empirical evidence for the development of comprehensive mental health promotion strategies from the integrated perspective of nutritional behaviors and muscle strength. To address this research gap, this study utilized a nationally representative sample of 52,035 Chinese adolescents. For the first time, it employed the MSQA and conducted a sex-stratified analysis to investigate the associations between sugar-sweetened beverage consumption and grip strength both individually and in combination and psychological symptoms among Chinese adolescents.
Methods
Research subjects and operation procedures
A multistage stratified cluster random sampling method was used to recruit participants from 27 provincial-level administrative regions in China from March to June 2025. To ensure the geographic representativeness of the sample, this study randomly selected 2–4 prefecture-level cities as survey sites in each provincial-level administrative region according to local economic development level and geographic location. Within each selected prefecture-level city, this study recruited 4 to 6 schools for the next sampling stage. In each included school, grades 8 to 12 were covered as far as possible with classes in each grade set as the sampling unit, and 2–4 classes were randomly selected from each grade.
The inclusion criteria of this study were as follows: junior or senior high school students currently enrolled in school, aged 12–17 years, whose parents/guardians and the students themselves provided voluntary informed consent to participate in this survey. Initially, this study surveyed 52,869 adolescents aged 12–17 years from 27 provincial-level administrative regions in China. After the survey, a total of 834 invalid questionnaires were collected. Exclusion criteria included: 20 participants aged < 12 years or > 17 years; these participants did not meet the inclusion age range. 321 questionnaires with a completion rate lower than 80%, such incomplete responses were excluded because they would not provide sufficient information for multivariable analyses. 152 questionnaires missing key demographic information, these variables were essential for covariate adjustment; their absence would lead to listwise deletion in regression models. 341 questionnaires with ambiguous responses, selecting the same answer for all MSQA items or reporting daily SSB consumption but also “never” in the same section. Finally, 52,035 valid questionnaires were included in the final analysis, with a valid response rate of 98.42%. The flow chart of participant screening is presented in Fig. 1.
Fig. 1.
Participant extraction process for Chinese adolescents
SSB consumption
To assess SSB consumption, a self-reported questionnaire was used. The questionnaire listed common types of sugar-sweetened beverages, including carbonated soft beverages, fruit-flavored beverages, sweetened tea and coffee, sports/energy beverages and sweetened milk-based beverages. The questionnaire showed good test‑retest reliability with Spearman’s r = 0.82, P < 0.001, n = 50, and excellent content validity, with item‑level content validity indices I‑CVI ranging from 0.83 to 1.00 based on evaluation by a panel of three experts. This tool was designed to collect data on participants’ weekly SSB consumption over the previous month. During the survey, questionnaires were distributed and collected in a standardized manner by the participating schools. Before participants filled out the questionnaires, trained investigators explained the filling instructions to ensure the consistency and comparability of the collected data. Based on their actual consumption, participants were divided into three groups [25]: almost never (< 1 time/week), occasionally (2–3 times/week), and regularly (> 4 times/week).
Grip strength
Grip strength was assessed using the standardized methods and equipment specified in the China National Survey on Students’ Constitution and Health (CNSSCH) [26]. The Zhongti Tongfang electronic grip strength tester (Model: CSTF-WL) was used for all measurements; this device has been widely applied in large-scale domestic adolescent physical fitness surveys, with confirmed good reliability and validity. Prior to formal testing, trained investigators provided a full demonstration of the standardized procedure and explained all relevant precautions to participants. Participants were also asked whether they had sustained any hand injuries in the past three months, such as fractures, sprains, or pain. Participants with such injuries were excluded from this test to ensure the accuracy of the results. For the test, participants were required to stand upright, with their arms hanging naturally at their sides and feet separated at shoulder width. All measurements were performed on the dominant hand. Each participant performed two maximal voluntary contractions, and the maximum value was recorded in kilograms (kg). Given the well-documented physiological sex differences in grip strength among adolescents, stratified analyses by sex and age were performed. Grip strength values for males and females were separately divided into three groups: low, medium, and high using tertile splits, to facilitate subsequent categorical comparison and analysis.
Psychological symptoms
This study used the Multidimensional Sub-health Questionnaire of Adolescents (MSQA) to assess the psychological sub-health status of middle school students [27]. This scale has been adopted by numerous research projects, and its validity and reliability have been well-established in previous large-scale studies. The Cronbach’s alpha coefficient for this sample was 0.96. The MSQA consists of 39 items that assess three dimensions: emotional problems, behavioral problems, and social adjustment difficulties. Each item is scored on a six-point scale, where 1 indicates that symptoms have persisted for more than 3 months and 6 indicates no symptoms or symptoms lasting no longer than 1 week; the lower the score, the longer the duration of symptoms. According to relevant studies, if an individual scores 3 or less on 8 or more of the 39 items, they are considered to have psychological symptoms. Furthermore, the criteria for determining suboptimal mental health across each dimension are as follows: in the emotional dimension, a score of 3 or lower on at least 3 items; in the behavioral dimension, a score of 3 or lower on at least 1 item; and in the social adjustment difficulties dimension, a score of 3 or lower on at least 4 items.
Covariates
Covariates covered three domains: participants’ anthropometric measurements, lifestyle indicators, and demographic characteristics. The body measurement indicator is the BMI; Lifestyle indicators include sleep duration and mode of transportation to and from school; Demographic characteristics include age and family economic level. All measurements followed the standards of the China Student Physical Fitness and Health Survey (CN-SSCH).
Height and weight were measured by trained research assistants using standard protocols. Height was measured to the nearest 0.1 cm using a portable stadiometer, with participants standing upright and barefoot. Weight was measured to the nearest 0.1 kg using a calibrated electronic scale, with participants wearing light clothing and no shoes. Body mass index (BMI) was calculated as weight (kg) divided by height squared (m²) using the following formula: BMI = weight(kg) / height² (m²). BMI categories were defined according to the 2000 CDC growth charts for the United States [28]: underweight (BMI < 5th percentile), normal weight (5th ≤ BMI < 85th percentile), overweight (85th ≤ BMI < 95th percentile), and obese (BMI ≥ 95th percentile). Family economic level is divided into four categories: <2000 RMB/month, 2001–5000 RMB/month, 5001–8000 RMB/month, >8000 RMB/month [29]. Sleep duration is categorized into three groups: <6 h/day, 6–8 h/day, and > 8 h/day [30]. Commuting to and from school can be categorized into two types: active modes (such as walking and cycling) and passive modes (such as buses and subways) [31].
Statistical analysis
This study used binary logistic regression to examine how grip strength and SSB consumption relate to the risk of psychological symptoms, as well as emotional problems, behavioral problems, and difficulties with social adjustment. Descriptive comparisons between boys and girls and across other subgroups were performed using independent-samples t-tests for continuous variables and chi-square tests for categorical variables. During the modeling process, based on existing literature and the findings of this study, adjustments were made for various factors that might influence psychological symptoms. Model 1 did not include any covariates; Model 2 adjusted for age and family economic level; Model 3, building on Model 2, further controlled for BMI, sleep duration, and mode of transportation to and from school. To examine the associations between the SSB consumption, the cumulative risk of reduced grip strength, and psychological symptoms in adolescents, the study further employed ordered logistic regression for analysis. Statistical analyses were performed using SPSS 25.0 software. The strength of associations between variables was assessed using logistic regression analysis, with odds ratios (OR) and corresponding 95% confidence intervals (CI) presented as measures of effect. The significance level was set at P < 0.05.
Results
We analyzed data from 52,035 Chinese adolescents aged 12–17 (26,104 boys, 50.17%); mean age was 14.68 ± 1.64 years. The overall prevalence of psychological symptoms was 20.8%. The overall prevalence rates for emotional problems, conduct problems, and social adjustment difficulties were 27.4%, 26.6%, and 17.6%, respectively. In terms of sex, the prevalence of social adjustment difficulties and psychological symptoms was higher among boys than among girls, and the differences were statistically significant (χ² values of 73.11 and 11.87, respectively; P < 0.001). There were no statistically significant sex differences in emotional and behavioral problems (P > 0.05). Table 1 presents the demographic characteristics of participants in China by sex.
Table 1.
Basic characteristics of Chinese adolescent subjects(N = 52,035)
| Characteristic | Boys | Girls | χ²/t-value | P-value | Total |
|---|---|---|---|---|---|
| Numbers | 26,104 | 25,931 | 52,035 | ||
| Age (M ± SD) | 14.65 ± 1.63 | 14.71 ± 1.65 | -3.81 | < 0.001 | 14.68 ± 1.64 |
| BMI (M ± SD) | 20.39 ± 3.69 | 19.74 ± 3.17 | 21.8 | < 0.001 | 20.06 ± 3.44 |
| Grip strength (M ± SD) | 35.04 ± 10.21 | 24.97 ± 6.30 | 135.25 | < 0.001 | 30.00 ± 9.85 |
| Family economic level [N (%)] | 216.91 | < 0.001 | |||
| < 2000 RMB/month | 2788 (10.7%) | 3013 (11.6%) | 5801 (11.1%) | ||
| 2001–5000 RMB/month | 8766 (33.6%) | 9836 (37.9%) | 18,602 (35.8%) | ||
| 5001–8000 RMB/month | 7915 (30.3%) | 7767 (29.9%) | 15,682 (30.1%) | ||
| > 8000 RMB/month | 6635 (25.4%) | 5315 (20.5%) | 11,950 (23.0%) | ||
| Sleep duration [N (%)] | 104.87 | < 0.001 | |||
| < 6 h/day | 3476 (13.3%) | 3850 (14.8%) | 7326 (14.1%) | ||
| 6–8 h/day | 18,253 (69.9%) | 18,524 (71.4%) | 36,777 (70.7%) | ||
| > 8 h/day | 4375 (16.8%) | 3557 (13.7%) | 7932 (15.2%) | ||
| Commuting to and from school [N (%)] | 190.83 | < 0.001 | |||
| Positive approach | 12,029 (46.1%) | 10,394 (40.1%) | 22,423 (43.1%) | ||
| Negative approach | 14,075 (53.9%) | 15,537 (59.9%) | 29,612 (56.9%) | ||
| BMI Classification [N (%)] | 627.13 | < 0.001 | |||
| Underweight | 8615(33.2%) | 9508(36.9%) | 18,123(35.1%) | ||
| Normal | 13,299(51.3%) | 14,067(54.6%) | 27,366(53.0%) | ||
| Overweight | 2876(11.1%) | 1680(6.5%) | 4556(8.8%) | ||
| Obese | 1136(4.4%) | 499(1.9%) | 1635(3.2%) | ||
| SSB consumption [N (%)] | 5.63 | 0.06 | |||
| < 1 times/week | 21,686 (83.1%) | 21,722 (83.8%) | 43,408 (83.4%) | ||
| 2–3 times/week | 3321 (12.7%) | 3205 (12.4%) | 6526 (12.5%) | ||
| > 4 times/week | 1097 (4.2%) | 1004 (3.9%) | 2101 (4.0%) | ||
| Grip strength [N (%)] | 0.46 | 0.795 | |||
| Low | 8709 (33.4) | 8667(33.4) | 17,376 (33.4) | ||
| Medium | 8728 (33.4) | 8601(33.2) | 17,329(33.3) | ||
| High | 8867(33.2) | 8663 (33.4) | 17,330(33.3) | ||
| Emotional problems [N (%)] | 2.94 | 0.086 | |||
| No | 18,851 (72.2%) | 18,900 (72.9%) | 37,751 (72.6%) | ||
| Yes | 7253 (27.8%) | 7031 (27.1%) | 14,284 (27.4%) | ||
| Conduct issues [N (%)] | 2.94 | 0.086 | |||
| No | 18,726 (71.7%) | 19,461 (75.0%) | 38,187 (73.4%) | ||
| Yes | 7378 (28.3%) | 6470 (25.0%) | 13,848 (26.6%) | ||
| Social adjustment difficulties [N (%)] | 73.11 | < 0.001 | |||
| No | 21,233 (81.3%) | 21,646 (83.5%) | 42,879 (82.4%) | ||
| Yes | 4871 (18.7%) | 4285 (16.5%) | 9156 (17.6%) | ||
| Psychological symptoms [N (%)] | 11.87 | < 0.001 | |||
| No | 20,514 (78.6%) | 20,696 (79.8%) | 41,210 (79.2%) | ||
| Yes | 5590 (21.4%) | 5235 (20.2%) | 10,825 (20.8%) | ||
Data are presented as mean ± SD for continuous variables and N (%) for categorical variables. Comparisons between boys and girls were performed using independent‑samples t‑tests for continuous variables and chi‑square tests for categorical variables
Table 2 shows the distribution of psychological symptoms and their three dimensions among adolescents with different characteristics. Overall, sex, family economic level, sleep duration, commuting to and from school, BMI, SSB consumption, and grip strength were all significantly associated with psychological symptoms (P < 0.05). For sex, the overall prevalence of psychological symptoms among male students was 21.4%, which was significantly higher than the 20.2% observed among female students (χ² = 11.87, P < 0.001). In terms of family economic level, the prevalence in the 5,001–8,000 RMB/month group was relatively low (19.5%), < 2,000 RMB/month (26.4%). Dimensions of sleep, the prevalence among those who slept ≥ 8 h/day was 20.1%, which was lower than the 22.2% observed in the group that slept less than 6 h. Transportation mode dimension, the prevalence of illness among students who use active modes of transportation to and from school (19.4%) is lower than that among students who use passive modes (21.9%). As for BMI, the prevalence of psychological symptoms was lowest in the underweight group (19.5%) and highest in the obese group (24.0%). Importantly, SSB consumption shows a clear dose-response relationship with psychological symptoms: The prevalence of those who consumed SSB less than once a week is 19.2%, the proportion of those consuming 2–3 times a week was 25.6%, the proportion of those consuming more than four times a week was 38.3%, the differences between groups were highly pronounced (χ² = 545.77, P < 0.001). In contrast, the prevalence rates in the low, medium, and high grip strength groups were relatively similar, at 20.1%, 21.3%, and 21.1%, respectively.
Table 2.
Characterization of adolescents’ psychological symptoms in China [N (%)]
| Characteristic | Emotional problems [N(%)] | Conduct issues [N(%)] | Social adjustment difficulties [N(%)] | Psychological symptoms [N(%)] | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| χ² | p-value | χ² | p-value | χ² | p-value | χ² | p-value | |||||
| Sex | 2.939 | 0.086 | 73.109 | <0.001 | 40.908 | <0.001 | 11.871 | <0.001 | ||||
| Boys | 7253(27.8) | 7378(28.3) | 4871(18.7) | 5590(21.4) | ||||||||
| Girls | 7031(27.1) | 6470(25.0) | 4285(16.5) | 5235(20.2) | ||||||||
| Family economic level | 81.065 | <0.001 | 67.495 | <0.001 | 131.909 | <0.001 | 130.702 | <0.001 | ||||
| <2000 | 1876(32.3) | 1794(30.9) | 1319(22.7) | 1534(26.4) | ||||||||
| 2001–5000 | 5052(27.2) | 4949(26.6) | 3295(17.7) | 3784(20.3) | ||||||||
| 5001–8000 | 4136(26.4) | 4000(25.5) | 2558(16.3) | 3063(19.5) | ||||||||
| >8000 | 3220(26.9) | 3105(26.0) | 1984(16.6) | 2444(20.5) | ||||||||
| Sleep duration | 65.748 | <0.001 | 16.982 | <0.001 | 43.072 | <0.001 | 12.337 | 0.002 | ||||
| <6 h/day | 2257(30.8) | 2093(28.6) | <0.001 | 1481(20.2) | <0.001 | 1630(22.2) | ||||||
| 6–8 h/day | 10,044(27.3) | 9688(26.3) | 6364(17.3) | 7604(20.7) | ||||||||
| ≥ 8 h/day | 1983(25.0) | 2067(26.1) | 1311(16.5) | 1591(20.1) | ||||||||
| Commuting to and from school | 44.235 | <0.001 | 40.17 | <0.001 | 90.64 | <0.001 | 47.115 | <0.001 | ||||
| Positive approach | 5820(26.0) | 5651(25.2) | 3536(15.8) | 4350(19.4) | ||||||||
| Negative approach | 8464(28.6) | 8197(27.7) | 5620(19.0) | 6475(21.9) | ||||||||
| BMI Classification | 14.345 | 0.002 | 34.061 | <0.001 | 13.488 | 0.004 | 38.937 | <0.001 | ||||
| Underweight | 4801(26.5) | 4732(26.1) | 3063(16.9) | 3528(19.5) | ||||||||
| Normal | 7614(27.8) | 7194(26.3) | 4893(17.9) | 5800(21.2) | ||||||||
| Overweight | 1291(28.3) | 1308(28.7) | 808(17.7) | 1019(22.4) | ||||||||
| Obese | 476(29.1) | 515(31.5) | 325(19.9) | 392(24.0) | ||||||||
| SSB consumption | 416.897 | <0.001 | 468.631 | <0.001 | 611.817 | <0.001 | 545.765 | <0.001 | ||||
| < 1 times/week | 11,231(25.9) | 10,851(25.0) | 6963(16.0) | 8349(19.2) | ||||||||
| 2–3 times/week | 2141(32.8) | 2075(31.8) | 1458(22.3) | 1672(25.6) | ||||||||
| > 4 times/week | 912(43.4) | 922(43.9) | 735(35.0) | 804(38.3) | ||||||||
| Grip strength | 2.27 | 0.322 | 11.55 | 0.003 | 8.06 | 0.018 | 8.22 | 0.016 | ||||
| Low | 4713(27.1) | 4463(25.7) | 2955(17.0) | 3491(20.1) | ||||||||
| Medium | 4824(27.8) | 4701(27.1) | 3148(18.2) | 3683(21.3) | ||||||||
| High | 4747(27.4) | 4684(27.0) | 3053(17.6) | 3651(21.1) | ||||||||
Data are presented as N (%). Group comparisons for each characteristic were performed using chi‑square tests
As shown in Table 3, the incidence of psychological symptoms increases significantly with higher frequency of sugar-sweetened beverage consumption, and the incidence of psychological symptoms is slightly higher in the low grip strength group than in the high grip strength group. Emotional problems, behavioral problems, and difficulties with social adjustment also follow the same trend. A sex-based analysis shows that the association between SSB consumption and psychological symptoms across various dimensions was significant in both male and female adolescents (P < 0.001); nonetheless, the association between grip strength and psychological symptoms was notable only in male adolescents (P = 0.005), while among female students, the difference did not reach statistical significance (P = 0.389).
Table 3.
Univariate analysis of SSB consumption, grip strength with psychological symptoms in Chinese adolescents
| Variable | N | Emotional problems N(%) | Conduct issues N(%) | Social adjustment difficulties N(%) | Psychological symptoms N(%) | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| χ² | p-value | χ² | p-value | χ² | p-value | χ² | p-value | ||||||
| Boys | |||||||||||||
| SSB consumption | 199.39 | < 0.001 | 205.74 | < 0.001 | 317.31 | < 0.001 | 264.9 | < 0.001 | |||||
| < 1 times/week | 21,686 | 5701 (26.3) | 5798 (26.7) | 3701 (17.1) | 4317 (19.9) | ||||||||
| 2–3 times/week | 3321 | 1070 (32.2) | 1089 (32.8) | 766 (23.1) | 844 (25.4) | ||||||||
| > 4 times/week | 1097 | 482 (43.9) | 491 (44.8) | 404 (36.8) | 429 (39.1) | ||||||||
| Grip strength | 8.09 | 0.018 | 9.2 | 0.01 | 4.36 | 0.113 | 10.48 | 0.005 | |||||
| Low | 8709 | 2394 (27.5) | 2393 (27.5) | 1565 (18.0) | 1774 (20.4) | ||||||||
| Medium | 8728 | 2519 (28.9) | 2569 (29.4) | 1672 (19.2) | 1953 (22.4) | ||||||||
| High | 8667 | 2340 (27.0) | 2416 (27.9) | 1634 (18.9) | 1863 (21.5) | ||||||||
| Girls | |||||||||||||
| SSB consumption | 220.02 | < 0.001 | 264.21 | < 0.001 | 292.24 | < 0.001 | 282.62 | < 0.001 | |||||
| < 1 times/week | 21,722 | 5530 (25.5) | 5053 (23.3) | 3262 (15.0) | 4032 (18.6) | ||||||||
| 2–3 times/week | 3205 | 1071 (33.4) | 986 (30.8) | 692 (21.6) | 828 (25.8) | ||||||||
| > 4 times/week | 1004 | 430 (42.8) | 431 (42.9) | 331 (33.0) | 375 (37.4) | ||||||||
| Grip strength | 2.96 | 0.227 | 12.39 | 0.002 | 4.14 | 0.126 | 1.89 | 0.389 | |||||
| Low | 8667 | 2319 (26.8) | 2070 (23.9) | 1390 (16.0) | 1717 (19.8) | ||||||||
| Medium | 8601 | 2305 (26.8) | 2132 (24.8) | 1476 (17.2) | 1730 (20.1) | ||||||||
| High | 8663 | 2407 (27.8) | 2268 (26.2) | 1419 (16.4) | 1788 (20.6) | ||||||||
| Total | |||||||||||||
| SSB consumption | 416.9 | < 0.001 | 468.63 | < 0.001 | 611.81 | < 0.001 | 545.77 | < 0.001 | |||||
| < 1 times/week | 43,408 | 11,231 (25.9) | 10,851 (25.0) | 6963 (16.0) | 8349 (19.2) | ||||||||
| 2–3 times/week | 6526 | 2141 (32.8) | 2075 (31.8) | 1458 (22.3) | 1672 (25.6) | ||||||||
| > 4 times/week | 2101 | 912 (43.4) | 922 (43.9) | 735 (35.0) | 804 (38.3) | ||||||||
| Grip strength | 2.27 | 0.322 | 11.55 | 0.003 | 8.06 | 0.018 | 8.22 | 0.016 | |||||
| Low | 17,376 | 4713 (27.1) | 4463 (25.7) | 2955 (17.0) | 3491 (20.1) | ||||||||
| Medium | 17,329 | 4824 (27.8) | 4701 (27.1) | 3148 (18.2) | 3683 (21.3) | ||||||||
| High | 17,330 | 4747 (27.4) | 4684 (27.0) | 3053 (17.6) | 3651 (21.1) | ||||||||
Data are presented as N (%). χ² tests were used to compare the prevalence of psychological symptoms across different SSB consumption frequency and grip strength groups
Table 4 presents the results of a binary logistic regression analysis examining the associations between the SSB consumption, grip strength, and psychological symptoms among Chinese adolescents. With adolescent psychological symptoms as the dependent variable, and SSB consumption and grip strength as the independent variables, three models were set up: Model 1 does not adjust for covariates, Model 2 controls for age and family economic, Model 3 additionally included BMI, sleep duration, and commuting to and from school. Results show that using SSB consumption less than once a week as a reference, the risk of developing psychological symptoms was significantly higher in the 2–3 times/week group (OR = 1.44, 95% CI: 1.35–1.53, P < 0.001) and the more than 4 times/week group (OR = 2.57, 95% CI: 2.35–2.82, P < 0.001). Using high grip strength as a reference, neither low grip strength (OR = 0.97, P = 0.351) nor medium grip strength (OR = 1.04, P = 0.198) showed a significant association. After stratifying by sex, the association between SSB Consumption and psychological symptoms was consistent across both male and female adolescents (P < 0.05). In terms of grip strength, among males, only medium grip strength was statistically markedly associated with psychological symptoms (OR = 1.04, P = 0.014), there was no significant association with any of the grip strength levels in females. See Fig. 2 for details on the change in the OR value.
Table 4.
Binary logistic regression analysis of sugar-sweetened beverages consumption, grip strength, and psychological symptoms among Chinese adolescents
| Sex/variable | Model 1 | Model 2 | Model 3 | ||||
|---|---|---|---|---|---|---|---|
| OR (95% CI) | P-value | OR (95% CI) | P-value | OR (95% CI) | P-value | ||
| Boys | |||||||
| SSB consumption | < 1 times/week | 1.00 | - | 1.00 | - | 1.00 | - |
| 2–3 times/week | 1.38(1.27 ~ 1.50) | < 0.001 | 1.36(1.25 ~ 1.48) | < 0.001 | 1.36(1.25 ~ 1.48) | < 0.001 | |
| > 4 times/week | 2.58(2.28 ~ 2.93) | < 0.001 | 2.54(2.23 ~ 2.88) | < 0.001 | 2.55(2.24 ~ 2.89) | < 0.001 | |
| Grip strength | High | 1.00 | - | 1.00 | - | 1.00 | - |
| Medium | 1.06(0.98 ~ 1.13) | 0.149 | 1.05(0.98 ~ 1.13) | 0.178 | 1.04(1.01 ~ 1.16) | 0.014 | |
| Low | 0.93(0.86 ~ 1.00) | 0.054 | 0.93(0.86 ~ 1.00) | 0.053 | 0.98(0.90 ~ 1.05) | 0.503 | |
| Girls | |||||||
| SSB consumption | < 1 times/week | 1.00 | - | 1.00 | - | 1.00 | - |
| 2–3 times/week | 1.53(1.40 ~ 1.67) | < 0.001 | 1.52(1.40 ~ 1.66) | < 0.001 | 1.52(1.40 ~ 1.66) | < 0.001 | |
| > 4 times/week | 2.61(2.29 ~ 2.98) | < 0.001 | 2.59(2.27 ~ 2.96) | < 0.001 | 2.60(2.28 ~ 2.97) | < 0.001 | |
| Grip strength | High | 1.00 | - | 1.00 | - | 1.00 | - |
| Medium | 0.97(0.90 ~ 1.05) | 0.417 | 0.97(0.90 ~ 1.05) | 0.475 | 0.98(0.91 ~ 1.06) | 0.641 | |
| Low | 0.96(0.89 ~ 1.03) | 0.268 | 0.96(0.89 ~ 1.04) | 0.325 | 0.97(0.90 ~ 1.05) | 0.419 | |
| Total | |||||||
| SSB consumption | < 1 times/week | 1.00 | - | 1.00 | - | 1.00 | - |
| 2–3 times/week | 1.45(1.36 ~ 1.54) | < 0.001 | 1.44(1.35 ~ 1.53) | < 0.001 | 1.44(1.35 ~ 1.53) | < 0.001 | |
| > 4 times/week | 2.60(2.37 ~ 2.85) | < 0.001 | 2.57(2.34 ~ 2.81) | < 0.001 | 2.57(2.35 ~ 2.82) | < 0.001 | |
| Grip strength | High | 1.00 | - | 1.00 | - | 1.00 | - |
| Medium | 1.01(0.96 ~ 1.07) | 0.634 | 1.01(0.96 ~ 1.07) | 0.609 | 1.04(0.98 ~ 1.09) | 0.198 | |
| Low | 0.94(0.90 ~ 0.99) | 0.029 | 0.95(0.90 ~ 1.00) | 0.038 | 0.97(0.92 ~ 1.03) | 0.351 | |
Model 1 did not include any covariates; Model 2 adjusted for age and family economic level; Model 3 further controlled for BMI, sleep duration, and mode of transportation to and from school based on Model 2. Reference categories: SSB consumption is < 1 time/week; grip strength is high
Fig. 2.
Binary logistic regression analysis of the trend in OR values for psychological symptoms related to SSB and grip strength in Chinese adolescents
Table 5 presents the ordered logistic regression analysis of SSB consumption, grip strength, and psychological symptoms among Chinese adolescents. The model accounts for factors such as age, family economic level, sleep duration, mode of transportation to and from school, and BMI. Overall, using the reference group with high grip strength and SSB consumption of < 1 time/week, the analysis showed that in the group consuming SSB > 4 times/week, the risk of psychological symptoms was significantly elevated in all subgroups except for females with medium grip strength. The group consuming 2–3 times/week showed a significant risk of psychological symptoms across all subgroups, whereas no significant association with the risk of psychological symptoms was observed in the group consuming < 1 time/week.
Table 5.
Ordered logistic regression analysis of SSB consumption, grip strength, and psychological symptoms among Chinese adolescents
| sex | Grip strength | SSB consumption | OR(95%CI) | p-value |
|---|---|---|---|---|
| Boys | High | < 1 times/week | 1.00 | - |
| 2–3 times/week | 2.83(2.29 ~ 3.50) | < 0.001 | ||
| > 4 times/week | 2.16(1.68 ~ 2.77) | < 0.001 | ||
| Medium | < 1 times/week | 1.06(0.79 ~ 1.42) | 0.715 | |
| 2–3 times/week | 2.94(1.96 ~ 4.41) | < 0.001 | ||
| > 4 times/week | 2.23(1.43 ~ 3.48) | < 0.001 | ||
| Low | < 1 times/week | 1.25(0.92 ~ 1.68) | 0.151 | |
| 2–3 times/week | 3.42(2.36 ~ 4.95) | < 0.001 | ||
| > 4 times/week | 2.58(1.72 ~ 3.86) | < 0.001 | ||
| Girls | High | < 1 times/week | 1.00 | - |
| 2–3 times/week | 2.48(1.99 ~ 3.10) | < 0.001 | ||
| > 4 times/week | 1.74(1.35 ~ 2.24) | < 0.001 | ||
| Medium | < 1 times/week | 0.88(0.65 ~ 1.20) | 0.425 | |
| 2–3 times/week | 2.14(1.38 ~ 3.31) | < 0.001 | ||
| > 4 times/week | 1.49(0.92 ~ 2.43) | 0.103 | ||
| Low | < 1 times/week | 1.08(0.79 ~ 1.49) | 0.623 | |
| 2–3 times/week | 2.59(1.70 ~ 3.95) | < 0.001 | ||
| > 4 times/week | 1.82(1.15 ~ 2.88) | 0.011 | ||
| Total | High | < 1 times/week | 1.00 | - |
| 2–3 times/week | 2.65(2.26 ~ 3.11) | < 0.001 | ||
| > 4 times/week | 1.94(1.60 ~ 2.35) | < 0.001 | ||
| Medium | < 1 times/week | 0.97(0.77 ~ 1.22) | 0.786 | |
| 2–3 times/week | 2.54(1.86 ~ 3.47) | < 0.001 | ||
| > 4 times/week | 1.85(1.30 ~ 2.63) | < 0.001 | ||
| Low | < 1 times/week | 1.16(0.93 ~ 1.44) | 0.181 | |
| 2–3 times/week | 3.02(2.23 ~ 4.08) | < 0.001 | ||
| > 4 times/week | 2.20(1.57 ~ 3.08) | < 0.001 |
The model adjusted for age, commuting to and from school, sleep duration, BMI, family economic level. Reference category: The reference group is high grip strength combined with SSB consumption < 1 time/week
Discussion
This study is based on survey data from 52,035 adolescents across 27 provincial-level administrative regions in China. The sampling design, which stratified by economic development level and geographic location, was implemented to ensure broad geographic representativeness. Nevertheless, formal testing of regional differences was not performed, and this remains a valuable direction for future research. The study systematically examined the combined effects of SSB consumption and grip strength on psychological symptoms. Results show that there is a substantial positive association between SSB consumption and psychological symptoms in adolescents. This trend is largely corroborated by findings of numerous previous studies [32–34]. In contrast, grip strength was not significantly associated with psychological symptoms in the overall sample, a finding that may reflect developmental stage differences. Furthermore, when broken down by sex, the link between SSB consumption and psychological symptoms was consistently observed in both male and female adolescents (P < 0.001); grip strength was significant only among boys (medium grip strength: OR = 1.04, P = 0.014). This sex-specific pattern may partly reflect the greater inter-individual variability in muscle development and strength among adolescent boys during puberty [35]. However, in the overall sample, low grip strength did not show a significant independent association with psychological symptoms after full adjustment, indicating that any potential link between grip strength and mental health may be subgroup-dependent rather than uniformly applicable across all adolescents. Instead, the elevated risk is conditional on the combination of high SSB consumption, as demonstrated in the joint effect analysis, and may also exist in combination with other unmeasured risk factors.
Research has shown that excessive consumption of SSB among adolescents is associated with an increased risk of various mental disorders [36]. These findings are highly consistent with the results of the present study, confirming that SSB consumption is positively associated with adverse mental health outcomes among adolescents and that a dose-response relationship exists. Nevertheless, existing evidence is not entirely uniform: Cross-sectional studies have shown no significant association between the consumption of 100% fruit juice and mental health [16]. A recent large-scale prospective cohort study found that consumption of 100% fruit juice is associated with a reduced risk of depression, while increased consumption of SSB is associated with an increased risk of depression [37]. This conclusion may stem from differences in study design, the characteristics of the target population, or the criteria used to classify SSB. Similarly, the health benefits of fermented beverages are also closely linked to how sugar is added: Fermentation without added sugar promotes the growth of beneficial bacteria and the production of short-chain fatty acids, whereas the version with added sucrose enriches the culture with potentially pathogenic bacteria [38]. These findings suggest that the current academic community’s definition and classification of SSB remain somewhat vague, combining beverages with significantly different production processes and ingredients into a single category may lead to biased research conclusions. Future research should further refine the classification of SSB, distinguish between added sugars and natural sugars, as well as between industrial processing and traditional methods, in order to provide more precise guidance for mental health promotion practices among adolescents.
Compared with the consistent association observed with SSB consumption, the association between grip strength and psychological symptoms exhibits a more complex pattern. In the total sample, after adjusting for multiple factors, the association between grip strength and psychological symptoms in adolescents did not reach statistical significance, suggesting that the association between the two is dependent on developmental stage [39]. This conclusion is consistent with the findings of a Chinese cross-sectional study of adolescents [21]. After stratifying by sex, a pronounced association between grip strength and psychological symptoms was observed only among male adolescents, while no significant trend was observed among female adolescents. This sex-specific pattern may partly reflect the greater inter-individual variability in muscle development and strength among adolescent boys during puberty [35], or the higher levels of systemic inflammation often associated with low muscle strength, which has been linked to various mental disorders [40]. Notably, the joint effect analysis further revealed that adolescents with low grip strength and SSB consumption ≥ 4 times/week had a substantially elevated risk of psychological symptoms, indicating a potential synergistic association between dietary behavior and muscle strength, a pattern that is cross-sectionally observed rather than mechanistically established.
This study has certain strengths and limitations. As for the strengths, it is the first to draw on a large, representative sample from 27 provincial-level administrative regions across the country, and it analyzed the combined effects of SSB consumption, grip strength, and psychological symptoms among Chinese adolescents, as well as potential sex differences, providing an evidence-based foundation for joint interventions in adolescent mental health. Second, including multidimensional covariates in the research analysis facilitates an objective examination of the associations between the SSB consumption, grip strength, and psychological symptoms. Nonetheless, this study also has several limitations. First, this study employs a cross-sectional design, which allows only for the analysis of associations between SSB consumption, grip strength, and psychological symptoms; it cannot establish causal relationships. Second, survey results may be influenced by individual memory and may differ from the actual situation. Third, SSB was not broken down by beverage type or specific sugar content, nor did we take into account confounding factors such as academic pressure, parents’ educational attainment, physical activity level. In addition, we did not collect information on participants’ prior mental health diagnoses; therefore, we could not exclude individuals with known mental illnesses from the analysis, which may limit the generalizability of the study results. Fourth, body weight status may influence grip strength. Although we adjusted for BMI in Model 3 and the ordered logistic regression model, the null association for grip strength persisted after adjustment, suggesting that body weight status did not substantially bias our findings. Nevertheless, residual confounding cannot be completely ruled out. These omissions may have some impact on the accuracy of the results. Further research could help refine this approach.
Conclusion
Higher SSB consumption was associated with a higher prevalence of psychological symptoms among Chinese adolescents. There were no statistically notable differences in grip strength across the entire sample. The analysis of synergistic effects showed that with the exception of the subgroup of girls with both low grip strength and SSB consumption > 4 times/week, all other subgroups, those consuming SSB 2–3 times/week and > 4 times/week, exhibited a notably increased risk of psychological symptoms. These findings suggest that reducing SSB consumption is associated with lower psychological symptoms, whereas grip strength alone showed no independent association. Schools and education authorities should strengthen oversight to ensure that students’ daily physical activity requirements are strictly met, and should place greater emphasis on muscle strength training and improving students’ grip strength and overall physical fitness. In addition, schools can create a healthy eating environment by limiting SSB availability and promoting nutritious food options, further supporting adolescent mental health.
Acknowledgements
Thanks to all participants for their support and assistance with our research.
Authors’ contributions
Jian Dong: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing—original draft, Writing—review & editing. Cunjian Bi: Resources, Software, Supervision, Funding acquisition, Validation, Visualization, Writing—original draft, Writing—review & editing. Mengmeng Zhang: Conceptualization, Data curation, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing—original draft, Writing—review & editing. Tianyu Zhou: Project administration, Resources, Software, Writing—original draft, Writing—review & editing. Min Zhang: Conceptualization, Data curation, Writing—original draft, Writing—review & editing.
Funding
Supported by the National Social Science Fund of China (25BTY107); General Project of Cultivating Excellent Young Teachers in Anhui Universities (YQYB2023058); The Scientific Research Startup Fund Project for High-level Talents of Chizhou University (CZ2024YJRC47); Research results of Anhui Province Philosophy and Social Sciences Planning Youth Project (AHSKQ2024D087).
Data availability
The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This study was conducted in accordance with the Declaration of Helsinki. The study protocol was approved by the Institutional Review Board of Chizhou University (approval number: CZU-2025-LL091) prior to the start of the survey. Written informed consent was obtained from all participants’ parents or legal guardians, and voluntary assent was provided by the participants themselves.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.