Original article
Coffee consumption and health-related quality of life
Esther Lopez-Garcia
, Pilar Guallar-Castillon, Luz Leon-Muñoz, Auxiliadora Graciani,
Fernando Rodriguez-Artalejo
Dept. Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid/IdiPAZ, CIBER of Epidemiology and Public Health
(CIBERESP), Spain
a r t i c l e i n f o
Article history:
Received 11 December 2012
Accepted 6 April 2013
Keywords:
Coffee
Health-related quality of life
Population study
s u m m a r y
Background and aims: Understanding the effect of coffee on health-related quality of life (HRQL) would
contribute to explain the mechanisms of the long-term effect of coffee on health. The aim of this study
was to examine the association between coffee consumption and HRQL.
Methods: Cross-sectional study conducted in 2008
e2010 among 11,423 individuals representative of the
Spanish population aged
18 years. Habitual coffee and food consumption was assessed with a validated
diet history. HRQL was measured using the Spanish version of the SF-12 questionnaire. The analyses were
performed using linear regression and adjusted for the main confounders.
Results: Among men, no association was found between coffee consumption and the physical and mental
composite summaries (PCS and MCS) of the SF-12. Among women, compared to those who did not
consume coffee, habitual coffee drinkers showed similar scores on the PCS [beta coef
ficients (p value) for
1, 2, 3, and
4 cups/day: 0.49 (0.20), 0.62 (0.21), 0.50 (0.45), and 0.36 (0.59)]; but slightly better scores on
the MCS [beta (p value): 1.58 (
<0.001), 1.58 (0.004), 0.80 (0.31), and 1.22 (0.10)]. These results reflect
mostly the consumption of non-
filtered caffeinated coffee. Tea consumption and total caffeine intake did
not show an association with HRQL.
Conclusion: We found no evidence of an adverse effect of coffee on HRQL. These results are consistent
with the null association between this beverage and several chronic diseases and all-cause mortality
reported in many studies. The weak positive association of coffee with the MCS found among women
needs further con
firmation.
Ó 2013 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
1. Introduction
There is substantial interest on the health effects of coffee
because this beverage is widely consumed throughout the world.
Although caffeine intake produces an acute increase in blood
pressure
and coffee can trigger acute myocardial infarction
and
stroke,
habitual coffee consumption has a null or inverse associ-
ation with long-term risk of several chronic diseases (e.g. diabetes,
ischemic heart disease, stroke, several types of cancer, depression,
etc.) and all-cause mortality.
The mechanisms of the long-term effects of coffee are unclear.
First, because it is uncertain if habitual coffee drinkers develop
tolerance to the acute effects of caffeine.
Second, because in
addition to caffeine, coffee contains hundreds of substances whose
biological effects are mostly unknown.
Moreover, among the few
substances whose effects are established, some seem to be bene-
ficial (e.g., phenolic compounds, magnesium, trigonelline and qui-
nides, which have antioxidant or antiin
flammatory properties)
while others may be detrimental (e.g., diterpenes, which might
increase total and serum LDL-cholesterol).
Thus, the net long-
term impact of coffee on health should result from a balance of
the effects of all those substances.
Health-related quality of life (HRQL) represents the individual
perception of the impact of health status on different spheres of life,
including physical, mental and social aspects.
A decline in HRQL
has been shown to predict increased mortality in subsequent years,
while its improvement is predictive of lower mortality.
However,
no previous study has examined the association between coffee
consumption and HRQL. A positive or null association would
contribute to a better understanding of the mechanisms of the
long-term effect of coffee on health and would add biological
plausibility to the association between coffee and lower all-cause
mortality reported in many studies.
Thus, the objective of this
study was to assess the association between habitual coffee con-
sumption and HRQL in a representative sample of the Spanish
population.
* Corresponding author. Dept. Preventive Medicine and Public Health, School of
Medicine, Universidad Autónoma de Madrid, Avda Arzobispo Morcillo n
4, 28029
Madrid, Spain. Tel.:
þ34 91 4972738.
E-mail address:
(E. Lopez-Garcia).
Contents lists available at
Clinical Nutrition
j o u r n a l h o m e p a g e : h t t p : / / w w w . e l s e v i e r . c o m / l o c a t e / c l n u
0261-5614/$
e see front matter Ó 2013 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
http://dx.doi.org/10.1016/j.clnu.2013.04.004
2. Methods
2.1. Study design and participants
Data were taken from the ENRICA study, whose methods have
been reported elsewhere.
This is a cross-sectional study con-
ducted in 2008
e2010 among 12,948 individuals representative of
the non-institutionalized Spanish population aged
18 years. In-
formation was obtained in the households of study participants.
Data collection included a health interview, samples of blood and
urine, a physical examination, and a computerized dietary history
to obtain habitual diet. Study participants gave written informed
consent. The ENRICA study was approved by the Clinical Research
Ethics Committees of the University Hospital
‘La Paz’ in Madrid and
the Hospital
‘Clinic’ in Barcelona.
2.2. Coffee consumption
Habitual food consumption in the previous year was assessed
with a computerized dietary history, developed from the one used
in the EPIC-Spain cohort study.
Coffee consumption was
recorded in detail by asking the participants whether they
consumed caffeinated or decaffeinated coffee and also about the
method of preparation: drip coffee (
filtered), percolated, espresso
or instant (un
filtered). We considered the size of the cup and the
addition of milk to the beverage to calculate the total amount of
coffee in ml per day. Caffeine and other nutrient intakes were
estimated using standard food composition tables.
Thus, a cup
of percolated caffeinated coffee (70 ml) was considered to provide
80 mg of caffeine, a cup of drip caffeinated coffee (70 ml) 115 mg of
caffeine, and a cup of espresso caffeinated coffee (50 ml) 75 mg of
caffeine.
To calculate the total caffeine intake per day we included
caffeine from coffee and also from tea (a bag contained 30 mg of
caffeine), caffeinated soft drinks (a 200 ml glass contained 20 mg of
caffeine, and a 333 ml bottle contained 33 mg) and from chocolate
(150 ml of hot chocolate contained 4 mg of caffeine, and 28.34 g of
solid chocolate contained 6 mg).
2.3. HRQL
HRQL was measured using the Spanish version of the SF-12
questionnaire.
This is a reduced version of the SF-36 question-
naire, one of the most widely used instruments to evaluate HRQL.
This shorter version was obtained with a selection of 12 items,
whose responses are coded and analyzed to reproduce the physical
composite summary (PCS) and the mental composite summary
(MCS) from the longer version. The PCS and MCS scores are stan-
dardized to a national norm with a mean of 50.0 and a standard
deviation of 10.0. A zero score in PCS or MCS indicates the lowest
level of health, and 100 indicates the highest level.
2.4. Other variables
Study participants reported their age, educational level, smok-
ing habit, the total amount of hours of sleep per day, and whether
they were living alone or not. Information on physical activity
during leisure time was obtained with the questionnaire developed
for the EPIC-Spain cohort, and was expressed in METs h/wk.
Also,
a Mediterranean diet adherence scale was calculated according to
Trichopoulou et at.
In this scale, the intake of vegetables, legumes,
fruits and nuts, cereal, and
fish was considered beneficial and, thus,
we assigned a value of 1 to consumption above the median in the
study sample; in contrast, the intake of red meat, poultry and dairy
products was considered detrimental, and a value of 0 was assigned
to consumption above the median. The range of the scale was 0
e8.
We did not include alcohol consumption in the scale because its
effect on the association between coffee and HRQL was accounted
for separately.
Weight and height were measured in each subject under stan-
dardized conditions. Body mass index (BMI) was calculated as
weight in kg divided by squared height in m. Blood pressure was
measured using a standard protocol.
Hypertension was de
fined as
systolic BP
140 mm Hg, diastolic BP 90 mm Hg, or being under
antihypertensive drug treatment. Type 2 diabetes was de
fined as
fasting serum glucose
126 mg/dl or being treated with oral drugs
or insulin, and hypercholesterolemia as serum total cholesterol
200 mg/dl or receiving lipid lowering drugs. Finally, participants
also reported if they had suffered in the previous year any of the
following physician-diagnosed diseases: pneumonia, asthma or
chronic bronchitis, cardiovascular disease, sleep apnea, arthritis,
hip fracture, gallstones, intestinal polyps, cirrhosis of the liver,
peptic ulcer, urinary infection, cataracts, periodontal disease, can-
cer at any site, Parkinson disease, and Alzheimer disease.
2.5. Statistical analysis
Of the 12,948 study participants, we excluded 966 with missing
or invalid information on diet, and 559 who lacked data on the rest
of the study variables. Thus, the analyses were conducted with
11,423 persons. We calculated the age-adjusted means and their
95% CI for the PCS and MCS in the following
five categories of coffee
consumption: no consumption, 1, 2, 3, and
4 cups per day. In
addition, we performed linear regression models for the associa-
tion between coffee consumption and the SF-12 summaries.
Regression models were adjusted for age, educational level,
smoking status, alcohol intake, sleep hours, living alone, physical
activity during leisure time, Mediterranean diet score, BMI, hy-
pertension,
diabetes,
hypercholesterolemia,
and
reported
morbidity. All variables were modeled as categorical with dummy
terms.
Additionally, we calculated odds ratios (OR) for the association
between coffee consumption and suboptimal HRQL, considering
‘suboptimal’ to be PCS and MCS scores below the sex-specific me-
dian. To assess the robustness of results, we also conducted strat-
i
fied analyses by categories of age, smoking status, and alcohol
intake. We tested the interaction between coffee and the categories
of the strati
fication variables with the PCS and MCS by using
likelihood-ratio tests, which compared the nested models with and
without cross-product interaction terms. Finally, we studied the
association of tea and total caffeine intake with the SF-12 sum-
maries. All analyses were conducted using SAS (version 9.2, SAS
Institute Inc, Cary, NC) statistical software and used techniques
appropriate to the complex survey design of this study.
3. Results
In this study, 4297 (76.2%) men and 4504 (77.8%) women
consumed at least 1 cup of coffee per day. The mean consumption
of coffee was 78.7 ml/d (standard deviation: 86.1) in men and 81.4
(90.4) ml/d in women. Most of total coffee consumed was caffein-
ated (79%) and non-
filtered coffee (85%) in this cohort. In com-
parison with those who did not drink this beverage, participants
who drank coffee were older, had lower educational level, higher
BMI and slightly higher prevalence of hypertension, diabetes, hy-
percholesterolemia and other diseases (
). In addition, the
higher the amount of coffee consumption, the higher the preva-
lence of smoking and alcohol consumption, and the lower the
amount of physical activity performed during leisure time. Also,
those with higher consumption of coffee were more likely to live
E. Lopez-Garcia et al. / Clinical Nutrition 33 (2014) 143
e149
144
alone. Coffee consumption was slightly associated with better
adherence to the Mediterranean diet score (
).
In
, we show the age-adjusted mean PCS and MCS of the
SF-12 by categories of consumption of different types of coffee and
tea. No association was seen between coffee consumption and the
scores of either summary of the SF-12, although there was a sta-
tistically signi
ficant positive association between tea and caffeine
intake and the PCS (p
¼ 0.01 and p < 0.001, respectively). In addi-
tion, when we strati
fied the results by sex, no association was seen
between coffee consumption and caffeine intake and the scores of
either summary of the SF-12 for men. Among women, the age-
adjusted means of PCS and MCS showed no association with
most types of coffee consumption, although there was a statistically
signi
ficant association between filtered coffee and the MCS
(p
¼ 0.05), and between tea and caffeine intake and the PCS
(p
¼ 0.01 and p < 0.001, respectively). Of note, the magnitude of all
the signi
ficant differences in the SF-12 summaries between the
extreme categories of coffee consumption was less than 2 points.
In
, we present the adjusted regression coef
ficients for
the association of coffee and tea with the SF-12 summaries among
men. Compared to those who did not consume coffee, habitual
coffee drinkers had similar scores on the PCS and MCS. Among
women (
), total coffee consumption did not show an asso-
ciation with PCS; however, consumption of small amounts of coffee
was associated with slightly better scores on the MCS. No associ-
ation was seen for tea consumption and the SF-12 summaries.
In additional analyses, we calculated the frequency of subopti-
mal HRQL by categories of coffee consumption. Again, no sugges-
tion of a detrimental effect on the PCS and MCS summaries was
observed among coffee drinkers. The adjusted OR (95% CI) of sub-
optimal PCS for total coffee consumption of
4 cups/day versus no
consumption was 0.87 (0.64
e1.19) in men and 1.11 (0.82e1.52) in
women, while the adjusted OR (95% CI) of suboptimal MCS was 1.11
(0.81
e1.52) in men and 0.77 (0.58e1.02) in women. When we
examined the association between coffee and HRQL only among
participants without physician-diagnosed morbidity (1371 men
and 1633 women free of hypertension, hypercholesterolemia,
diabetes and other self-reported diseases), we did not
find any
suggestion of a lower score on the PCS or MCS among coffee con-
sumers. Finally, analyses strati
fied by age, smoking status and
alcohol intake did not show differences in the study associations
across the strata of these variables.
4. Discussion
In this study, we found no association between coffee and HRQL.
Our results mainly apply to non-
filtered coffee, which was the type
of coffee most frequently consumed in Spain. The weak positive
association of coffee with the MCS found in women needs further
con
firmation. In any case, no detrimental effect of coffee on HRQL
was observed. This study allowed us to combine several physical
and mental aspects of health that until now had been investigated
separately. Our result of a null association between coffee con-
sumption and the PCS of the SF-12 is consistent with previous
publications showing no increased risk of diabetes,
coronary
heart disease,
and cancer
associated with coffee
consumption.
Because the impact of mental health on mortality is minor
compared to that due to physical health, the effect of coffee on
mental health may have been underestimated when studied using
premature mortality as the global measure of health. However,
there is emerging evidence that coffee has mental health effects
which are in line with our
findings. For example, Ruusunen et al.
found that in 2232 individuals from Finland, those who reported
the highest coffee consumption (
>813 ml/d) had lower risk of
depression than non-consumers.
In addition, in a large longitu-
dinal study, Lucas et al. found that consumption of 4 or more cups
of coffee per day was associated with 20% lower risk of depression
in middle aged American women.
As regards cognitive function, in
a recent meta-analysis of case-control and cohort studies exam-
ining the association between caffeine and cognitive impairment or
decline, the pooled relative risk for consumers versus non-
consumers
was
0.84
(95%
CI:
0.72
The
authors
concluded that although a bene
ficial effect of caffeine might exist,
Table 1
Characteristics of men and women according to categories of total coffee consumption in the ENRICA study. N
¼ 11,423.
Men
Women
Total coffee consumption (cups/d)
Total coffee consumption (cups/d)
0
1
2
3
4
0
1
2
3
4
Participants, n
1339
2701
921
355
320
1283
2976
840
352
336
Age, y
39.3 (19.1) 47.8 (16.7) 48.5 (14.8)
48.3 (12.6)
47.3 (13.6)
42.2 (19.2) 49.3 (16.9) 50.9 (13.9)
49.1 (12.8)
47.3 (12.2)
Education, primary or less, %
20.0
27.4
25.2
20.1
24.5
28.9
38.1
36.8
32.0
32.7
Current smoker, %
23.3
27.8
37.8
39.5
46.2
19.6
22.2
29.7
37.3
42.4
Alcohol intake, g/d
10.6 (19.7) 13.5 (18.5) 15.4 (19.5)
15.4 (20.9)
15.6 (20.3)
3.0 (8.9)
4.5 (8.9)
4.9 (8.8)
7.4 (13.2)
4.9 (10.4)
Sleep, hours/d
7.4 (1.3)
7.3 (1.2)
7.1 (1.2)
7.2 (1.2)
7.1 (1.2)
7.4 (1.5)
7.2 (1.3)
7.1 (1.2)
7.1 (1.2)
7.1 (1.2)
Living alone, %
4.7
4.9
7.1
5.9
8.7
8.3
10.0
10.2
11.6
9.0
Leisure-time physical activity,
metabolic equivalent tasks
h/wk
39.8 (29.4) 33.7 (25.3) 31.3 (24.0)
29.9 (21.8)
30.8 (21.5)
24. (17.5)
22.2 (15.9) 22.6 (14.9)
21.7 (15.8)
20.7 (13.1)
Mediterranean diet score
3.6 (1.8)
4.0 (1.7)
4.0 (1.7)
3.9 (1.5)
3.9 (1.6)
3.7 (1.7)
4.0 (1.6)
3.9 (1.5)
4.0 (1.5)
3.9 (1.5)
BMI, kg/m
2
26.3 (4.3)
27.6 (4.1)
28.0 (4.2)
28.1 (3.8)
28.0 (4.2)
25.1 (5.1)
26.6 (5.0)
26.8 (5.0)
26.6 (4.6)
26.8 (4.6)
Hypertension, %
30.3
39.7
34.5
43.4
39.9
20.9
30.2
30.5
24.6
23.4
Diabetes, %
4.5
9.4
7.5
9.8
6.4
5.2
6.1
5.0
4.4
5.2
Hypercholesterolemia, %
33.8
50.2
55.8
60.5
59.1
41.7
53.6
60.2
54.8
51.3
At least one self-reported
disease
27.4
32.0
33.9
29.7
29.0
46.3
51.6
52.2
49.7
48.4
Total coffee consumption,
ml/d
0
55.5 (36.8) 137.3 (41.3)
189.9 (47.2)
262.9 (123.0) 0
56.2 (38.3) 144.1 (40.7) 191.4 (56.6)
279.9 (118.8)
Total caffeine intake, mg/d
18.5 (38.5) 71.4 (67.6) 160.7 (111.1) 253.0 (142.0) 326.4 (251.0) 21.5 (35.1) 61.8 (61.0) 137.7 (99.7) 224.5 (143.0) 350.4 (239.2)
For continuous variables, the mean (standard deviation) is provided.
a
According to Trichopoulou et al.
b
Including: pneumonia, asthma or chronic bronchitis, cardiovascular disease, sleep apnea, arthritis, hip fracture, gallstones, intestinal polyps, cirrhosis of the liver, peptic
ulcer, urinary infection, cataracts, periodontal disease, cancer at any site, Parkinson disease, and Alzheimer disease.
E. Lopez-Garcia et al. / Clinical Nutrition 33 (2014) 143
e149
145
Table 2
Age-adjusted means (95% con
fidence interval) of SF-12 health questionnaire summaries, by categories of coffee and tea consumption in the ENRICA study. N ¼ 11,423.
Categories of consumption, cups/d
0
1
2
3
4
P for trend
Overall
All coffee
n
2622
5677
1761
707
656
PCS
50.0 (49.5
e50.4)
49.9 (49.6
e50.2)
50.5 (49.9
e51.0)
50.1 (49.4
e51.0)
49.9 (49.1
e50.7)
0.51
MCS
49.4 (48.9
e49.9)
50.3 (50.0
e50.6)
50.4 (49.8
e50.9)
50.2 (49.4
e51.1)
49.8 (48.9
e50.7)
0.24
Caffeinated coffee
n
4427
4663
1330
531
472
PCS
49.6 (49.3
e50.0)
50.2 (49.9
e50.5)
50.6 (50.0
e51.2)
50.3 (49.4
e51.2)
49.9 (48.9
e50.9)
0.07
MCS
49.6 (49.2
e49.9)
50.5 (50.1
e50.8)
50.5 (49.9
e51.1)
50.4 (49.4
e51.3)
49.2 (48.2
e50.3)
0.21
Decaffeinated coffee
n
8569
2226
399
229
e
PCS
50.2 (50.0
e50.5)
49.3 (48.8
e49.8)
50.3 (49.2
e51.3)
49.5 (48.1
e50.9)
e
0.10
MCS
50.0 (49.7
e50.2)
50.4 (49.9
e50.9)
49.4 (48.1
e50.6)
50.8 (49.2
e52.4)
e
0.58
Filtered coffee
n
10,325
837
261
e
e
PCS
50.1 (49.8
e50.3)
49.5 (48.7
e50.2)
50.4 (49.0
e51.8)
e
e
0.67
MCS
50.0 (49.8
e50.2)
50.9 (50.2
e51.6)
49.9 (48.6
e51.2)
e
e
0.23
Non-
filtered coffee
n
3238
5422
1560
625
578
PCS
49.9 (49.5
e50.3)
50.0 (49.7
e50.3)
50.5 (50.0
e51.0)
49.9 (49.1
e50.8)
49.9 (49.0
e50.8)
0.58
MCS
49.6 (49.2
e50.0)
50.3 (50.0
e50.6)
50.4 (49.9
e51.0)
50.3 (49.3
e51.2)
49.6 (48.7
e50.6)
0.32
Tea
n
10,651
327
445
e
e
PCS
49.9 (49.7
e50.2)
51.7 (50.6
e52.9)
50.9 (49.8
e51.9)
e
e
0.01
MCS
50.1 (49.9
e50.3)
48.7 (47.5
e49.9)
50.1 (49.0
e51.2)
e
e
0.50
Caffeine intake (quintiles)
n
2387
2306
2273
2271
2186
PCS
49.4 (48.9
e49.9)
50.0 (49.6
e50.5)
50.1 (49.6
e50.5)
50.1 (49.6
e50.5)
50.6 (50.2
e51.0)
<0.001
MCS
49.7 (49.2
e50.2)
49.9 (49.4
e50.4)
50.1 (49.6
e50.6)
50.1 (49.6
e50.6)
50.5 (50.1
e51.0)
0.01
Men
All coffee
N
1339
2701
921
355
320
PCS
51.7 (51.2
e52.3)
51.1 (50.8
e51.5)
51.6 (51.0
e52.3)
51.3 (50.4
e52.2)
51.4 (50.4
e52.5)
0.80
MCS
51.8 (51.1
e52.4)
52.1 (51.7
e52.4)
51.8 (51.2
e52.5)
52.7 (51.8
e53.7)
51.7 (50.7
e52.8)
0.63
Caffeinated coffee
N
2104
2328
706
268
230
PCS
51.4 (51.0
e51.8)
51.4 (51.0
e51.7)
51.4 (50.6
e52.2)
51.6 (50.5
e52.7)
51.5 (50.2
e52.8)
0.75
MCS
51.8 (51.3
e52.3)
52.1 (51.6
e52.5)
52.1 (51.4
e52.9)
52.8 (51.7
e53.9)
51.2 (49.9
e52.5)
0.73
Decaffeinated coffee
N
4367
964
193
112
e
PCS
51.6 (51.3
e51.9)
50.4 (49.8
e51.1)
52.8 (51.5
e54.1)
50.5 (48.8
e52.2)
e
0.37
MCS
51.9 (51.6
e52.2)
52.4 (51.7
e53.1)
50.1 (58.5
e51.8)
53.7 (52.1
e55.3)
e
0.65
Filtered coffee
N
5116
401
119
e
e
PCS
51.4 (51.2
e51.7)
50.6 (49.6
e51.6)
52.0 (50.5
e53.5)
e
e
0.60
MCS
52.0 (51.7
e52.3)
52.1 (51.3
e53.0)
51.4 (49.6
e53.3)
e
e
0.79
Non-
filtered coffee
N
1608
2609
818
315
286
PCS
51.6 (51.1
e52.0)
51.3 (50.9
e51.6)
51.6 (50.8
e52.3)
51.3 (50.4
e52.3)
51.4 (50.3
e52.5)
0.89
MCS
51.7 (51.1
e52.3)
52.1 (51.7
e52.5)
52.0 (51.3
e52.6)
52.9 (51.8
e53.9)
51.4 (50.3
e52.6)
0.61
Tea
N
5365
120
151
e
e
PCS
51.3 (51.0
e51.6)
53.6 (52.1
e55.2)
52.8 (51.0
e54.6)
e
e
0.02
MCS
52.0 (51.7
e52.3)
50.5 (48.7
e52.3)
51.7 (50.0
e53.5)
e
e
0.41
Caffeine intake (quintiles)
n
1161
1121
1047
1088
1219
PCS
51.0 (50.5
e51.6)
52.1 (51.6
e52.6)
51.5 (50.9
e52.2)
50.7 (50.1
e51.4)
51.6 (51.1
e52.1)
0.94
MCS
52.1 (51.5
e52.7)
51.6 (50.9
e52.3)
51.8 (51.2
e52.4)
52.0 (51.3
e52.6)
52.4 (51.9
e52.9)
0.12
Women
All coffee
n
1283
2976
840
352
336
PCS
48.3 (47.6
e49.0)
48.8 (48.4
e49.3)
49.3 (48.5
e50.1)
49.0 (47.8
e50.3)
48.4 (47.1
e49.6)
0.44
MCS
47.0 (46.3
e47.8)
48.9 (48.2
e49.1)
48.8 (48.0
e49.6)
47.7 (46.4
e49.1)
47.9 (46.5
e49.3)
0.31
Caffeinated coffee
n
2323
2335
624
263
242
PCS
48.1 (47.6
e48.7)
49.1 (48.7
e49.6)
49.7 (48.8
e50.7)
49.0 (47.6
e50.5)
48.3 (46.8
e49.9)
0.07
MCS
47.5 (47.0
e48.1)
48.9 (48.4
e49.4)
47.7 (47.8
e49.7)
48.1 (46.6
e49.5)
47.4 (45.9
e49.0)
0.33
Decaffeinated coffee
n
4202
1262
206
117
e
PCS
48.9 (48.5
e49.3)
48.5 (47.8
e49.2)
47.9 (46.5
e49.4)
48.0 (45.8
e50.1)
e
0.12
MCS
48.1 (47.7
e48.4)
48.8 (48.1
e49.5)
48.6 (46.7
e50.5)
47.8 (45.2
e50.5)
e
0.50
E. Lopez-Garcia et al. / Clinical Nutrition 33 (2014) 143
e149
146
more research was needed because of the methodological hetero-
geneity among studies. Finally, although coffee may increase
nervousness, the long-term effect of this beverage on anxiety is
largely unknown. The single study on this topic is a cross-sectional
analysis of the US Health and Nutrition Examination Survey, where
no correlation was found between coffee consumption and a scale
of self-reported symptoms of anxiety.
Several biological mechanisms might underlie the mental ef-
fects of coffee. Caffeine is an antagonist of adenosine receptors A1
and A2.
These receptors are distributed in brain structures related
to cognitive skills, such the hippocampus, cerebral cortex, and hy-
pothalamus. The blockage of these receptors by caffeine leads to an
increase in adenosine within the noradrenergic, cholinergic,
dopaminergic and serotoninergic systems, which are regulated by
adenosine. Stimulation of noradrenergic and cholinergic systems
increases alertness and attention. Activation of the dopaminergic
system acts as a psychostimulant and also increases alertness. In
addition, stimulation of the serotoninergic system increases the
feeling of wellness and energy. The above acute effects of caffeine
can be observed starting 30
e45 min after intake and last for 3e
6 h.
However, it is possible that habitual coffee consumers
develop partial tolerance to these effects, so that coffee compo-
nents other than caffeine may become more relevant in the long
term. For example, phenolic compounds (chlorogenic, ferulic, and
p-coumaric acids) are antioxidants,
and could improve neuronal
function by reducing total free radicals and oxidative stress.
Table 2 (continued )
Categories of consumption, cups/d
0
1
2
3
4
P for trend
Filtered coffee
n (%)
5209
436
142
e
e
PCS
48.8 (48.5
e49.1)
48.4 (47.3
e49.4)
49.0 (46.8
e51.2)
e
e
0.81
MCS
48.1 (47.7
e48.4)
49.8 (48.7
e50.9)
48.6 (46.6
e50.5)
e
e
0.05
Non-
filtered coffee
n
1630
2813
742
310
292
PCS
48.4 (47.8
e49.0)
48.9 (48.4
e49.3)
49.5 (48.7
e50.3)
48.6 (47.3
e50.0)
48.3 (47.0
e49.7)
0.59
MCS
47.6 (46.9
e48.2)
48.6 (48.1
e49.0)
48.7 (47.9
e49.6)
47.7 (46.2
e49.1)
47.9 (46.4
e49.4)
0.52
Tea
n
5286
207
294
e
e
PCS
48.6 (48.3
e49.0)
50.6 (49.1
e52.2)
49.9 (48.6
e51.1)
e
e
0.01
MCS
48.2 (47.8
e48.5)
47.8 (46.2
e49.3)
49.3 (47.9
e50.6)
e
e
0.19
Caffeine intake (quintiles)
n
1226
1185
1226
1183
967
PCS
47.8 (47.1
e48.5)
48.2 (47.5
e48.9)
48.8 (48.2
e49.5)
49.6 (48.9
e50.2)
49.6 (48.8
e50.3)
<0.001
MCS
47.4 (46.6
e48.1)
48.3 (47.6
e49.1)
48.7 (48.0
e49.4)
48.4 (47.7
e49.1)
48.3 (47.6
e49.0)
0.40
PCS: physical composite summary; MCS: mental composite summary.
Table 3
Linear regression models
for the association of coffee and tea with the SF-12 health
questionnaire summaries among 5636 men in the ENRICA study.
Categories of consumption, cups/d
0
1
2
3
4
P for
trend
All coffee
PCS
Ref.
0.23 (0.44)
0.51 (0.22)
0.08 (0.88)
0.09 (0.87) 0.27
MCS Ref.
0.40 (0.29)
0.48 (0.30)
1.19 (0.06)
0.28 (0.67) 0.30
Caffeinated coffee
PCS
Ref.
0.06 (0.81)
0.36 (0.41)
0.26 (0.66)
0.15 (0.82) 0.54
MCS Ref.
0.24 (0.46)
0.65 (0.15)
0.98 (0.14)
0.48 (0.50) 0.61
Decaffeinated coffee
PCS
Ref.
0.60 (0.09)
1.60 (0.006)
0.32 (0.69) e
0.40
MCS Ref.
0.58 (0.12)
1.52 (0.09)
2.08 (0.02)
e
0.34
Filtered coffee
PCS
Ref.
0.54 (0.28)
1.16 (0.13)
e
e
0.21
MCS Ref.
0.28 (0.55)
0.28 (0.75)
e
e
0.65
Non-
filtered coffee
PCS
Ref.
0.09 (0.75)
0.45 (0.28)
0.21 (0.71)
0.02 (0.98) 0.49
MCS Ref.
0.44 (0.19)
0.62 (0.16)
1.32 (0.04)
0.02 (0.97) 0.36
Tea
PCS
Ref.
1.82 (0.02)
0.22 (0.81)
e
e
0.46
MCS Ref.
1.62 (0.08)
0.76 (0.36)
e
e
0.17
Caffeine intake (quintiles)
PCS
Ref.
1.09 (0.004)
0.31 (0.48)
0.28 (0.49)
0.56 (0.14) 0.18
MCS Ref.
0.52 (0.25)
0.39 (0.40)
0.07 (0.87)
0.33 (0.46) 0.28
Values are beta coef
ficients (p value). PCS: physical composite summary; MCS:
mental composite summary.
a
Adjusted for age (18
e44, 45e64, 65 years), educational level (primary or less,
secondary, university), smoking status (never, ex-smoker, current smoker), alcohol
intake (quintiles of g/d), sleep duration (quintile of h/d), living alone (yes, no),
physical activity during leisure time (quintiles of METs h/week), Mediterranean diet
score (below or above the media), BMI (
<25, 25e<30, 30 kg/m
2
), and hyperten-
sion, hypercholesterolemia, diabetes and other diseases.
Table 4
Linear regression models
for the association of coffee and tea with the SF-12 health
questionnaire summaries among 5787 women in the ENRICA study.
Categories of consumption, cups/d
0
1
2
3
4
P for
trend
All coffee
PCS
Ref.
0.49 (0.20)
0.62 (0.21)
0.50 (0.45) 0.36 (0.59) 0.20
MCS Ref.
1.58 (
<0.001)
1.58 (0.004)
0.80 (0.31) 1.22 (0.10) 0.23
Caffeinated coffee
PCS
Ref.
0.39 (0.24)
0.65 (0.18)
0.26 (0.71) 0.21 (0.77) 0.13
MCS Ref.
1.10 (0.002)
0.84 (0.11)
0.57 (0.47) 0.31 (0.70) 0.55
Decaffeinated coffee
PCS
Ref.
0.18 (0.61)
0.46 (0.54)
0.05 (0.96)
e
0.85
MCS Ref.
0.95 (0.01)
0.60 (0.53)
0.004 (0.99)
e
0.34
Filtered coffee
PCS
Ref.
0.91 (0.09)
0.19 (0.85)
e
e
0.75
MCS Ref.
1.38 (0.008)
0.91 (0.36)
e
e
0.12
Non-
filtered coffee
PCS
Ref.
0.49 (0.17)
0.73 (0.12)
0.24 (0.73) 0.31 (0.66) 0.16
MCS Ref.
1.04 (0.005)
1.06 (0.05)
0.29 (0.72) 0.74 (0.34) 0.52
Tea
PCS
Ref.
0.77 (0.28)
0.28 (0.66)
e
e
0.84
MCS Ref.
0.96 (0.25)
0.23 (0.75)
e
e
0.84
Caffeine intake (quintiles)
PCS
Ref.
0.13 (0.78)
0.30 (0.50)
0.70 (0.12) 0.73 (0.12) 0.21
MCS Ref.
0.70 (0.16)
1.06 (0.03)
0.62 (0.23) 0.57 (0.28) 0.84
Values are beta coef
ficients (p values). PCS: physical composite summary; MCS:
mental composite summary.
a
Adjusted for age (18
e44, 45e64, 65 years), educational level (primary or less,
secondary, university), smoking status (never, ex-smoker, current smoker), alcohol
intake (quintiles of g/d), sleep duration (quintiles of h/d), living alone (yes, no),
physical activity during leisure time (quintiles of METs h/week), Mediterranean diet
score (below or above the median), BMI (
<25, 25e<30, 30 kg/m
2
), and hyper-
tension, hypercholesterolemia, diabetes and other diseases.
E. Lopez-Garcia et al. / Clinical Nutrition 33 (2014) 143
e149
147
The magnitude of the association between the consumption of
up to 2 cups/day of coffee and the MCS score among women was
small (about 1.5 points). However, in the IQOLA project,
which
examined the impact of chronic conditions on HRQL in different
countries, the authors found that people with chronic conditions
that produced a major impact on HRQL (arthritis, chronic lung
disease and congestive heart failure) had a less than 2-point lower
MCS than people without these conditions. Therefore, the direct
association of coffee with MCS among women observed in our
study might be of some clinical relevance.
Our data showed a slightly lower prevalence of diabetes among
men who did not drink coffee than among coffee drinkers. A
possible explanation is the younger age of those in the non-coffee
consumption category. In addition, we did not
find a lower preva-
lence of diabetes among women, probably because age difference
between the non-drinkers and the coffee drinkers was smaller than
in men. Prevalence of other diseases was also slightly lower among
coffee drinkers and non-drinkers. However, when we examined the
association between coffee and HRQL only among participants
without self-reported diagnosed diseases, the results still showed a
higher MCS score among coffee consumer women versus non-
consumers. This suggests that the modest association between
coffee and better HRQL was not likely due to a reduction in coffee
consumption among the ill individuals. Our hypothesis is that in
Spain and other Mediterranean countries, coffee consumption may
be a marker of social interaction. Coffee shops are meeting places,
so people reporting consuming coffee on a regular basis may be
more likely to have a good social network. Moreover, in a previous
work in Spain we observed that a good social network, in particular,
seeing family and friends frequently, was associated with better
score in the mental health subscale of the SF-36.
Thus, coffee
might also improve the MSC through psychosocial mechanisms.
Non-
filtered coffee is the main type of coffee consumed in Spain.
This variety includes beverages prepared using pressure (espresso
coffee), a percolator (type of pot that brews coffee passing boiling
water over the grounds) and also instant coffee. On the other hand,
filtered coffee is the most common coffee consumed in the US. It is
also called drip coffee, because the preparation involves pouring
water over roasted, ground coffee beans contained in a
filter. When
preparing
filtered coffee, diterpenes (kahweol and cafestol)
are
retained in the
filter. Thus, only non-filtered coffee would have a
hypercholesterolemic effect.
In our study, we found a different
effect of non-
filtered and filtered coffee on HRQL among women;
however, this difference might only be due to the lower con-
sumption of
filtered coffee among the Spanish population.
Strengths of this study was measurement of coffee using a di-
etary history that distinguished between consumption of different
types of coffee, including caffeinated, decaffeinated,
filtered and
non-
filtered, as well as cup size, in a large sample representative of
the adult population of an entire country. Another advantage was
that results were adjusted for well measured potential con-
founders, such as BMI and the Mediterranean diet score. On the
other hand, among the limitations of the study was the cross-
sectional design, which does not allow establishing causality.
Given that we aimed to understand the concurrent effect of coffee
on HRQL, a cross-sectional study may seem appropriate, but we
cannot rule out that those individuals who felt better, either
physically or mentally, tended to consume more coffee. The study
design may have precluded the observation of a deleterious effect
of coffee on HRQL had it existed. Another limitation was that we
could not differentiate between habitual coffee drinkers and new
drinkers. Since coffee consumption is basically a lifestyle, it is likely
that most of the current coffee drinkers in our study were habitual
consumers. Lastly, the weak positive association between coffee
and MCS in women should be further examined. We found in
previous studies that changes in lifestyles produced a higher
impact on HRQL in women, compared to men.
In this study, our
data showed a worst HRQL among women, so in this subgroup, a
greater
opportunity
of
improvement
through
lifestyle
in-
terventions exists.
In conclusion, we found no evidence of an adverse effect of
coffee consumption on the SF-12 physical and mental summaries,
which is consistent with previous
findings showing non-
detrimental effect of this beverage on several chronic diseases
and all-cause mortality.
Funding sources
The ENRICA study was funded by Sano
fi-Aventis. Specific
funding for this analysis was obtained from FIS grant 09/00104. The
ENRICA study is being run by an independent academic steering
committee.
Authors
’ contributions
ELG and FRA conceived the study and drafted the manuscript.
ELG analyzed data. All authors contributed to data interpretation
and reviewed the manuscript for important intellectual content.
ELG had primary responsibility for
final content. All authors read
and approved the
final manuscript.
Con
flict of interest
None declared.
Acknowledgments
None of the authors has a con
flict of interest.
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