Tag: energy drinks

08/9/22

Energy Drinks Are No More Effective Than Caffeine

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Energy drinks have become a common sight almost where ever you go. Your local convenience store will feature a display of two Monsters, Rockstars or Red Bulls at a discounted price next to the cash register and counter. Sitting nest to the cash register will be a display rack with 5 Hour Energy shots. Statistica reported that energy drinks accounted for 31% of packaged beverage drink sales sold at U.S. convenience stores. Overall, energy drink sales in the U.S. neared $14 billion in 2021. Global energy drink sales reached $57.4 billion in 2020.

History of Energy Drinks

Coca-Cola was developed as a nausea and heartburn tonic, but came with an added extract from coca leaves and caffeine-filled kola nuts to boost energy. Succumbing to government pressure, the company modified its recipe to be cocaine-free in 1929. The first modern energy drink was Lipovitan, created by the Japanese company, Taisho in 1962. It looked, smelled and tasted like cough syrup. Not surprisingly, it didn’t catch on.

The modern enthusiasm for energy drinks began in Thailand in 1976, when a pharmacist invented Krating Daeng, which translates as “Red Bull.” In 1984 an Austrian marketing exec drank a bottle of Red Bull to help with his jet lag. Afterwards he contacted the pharmacist in hope of them teaming up to market it. They added more sugar and caffeine, switched from bottles to cans in an effort to appeal to Europeans, and Red Bull energy drink was created in 1987. A decade later, it came to America.

By the beginning of the 2000s, energy drinks are everywhere. Brands start popping up left and right, and everyone has a preference. In 2001, Rockstar is introduced, followed by Monster Energy in 2002, Pimp Juice by Nelly in 2003, Pit It in 2004. The latter two drinks weren’t very popular, so there’s a good chance you haven’t heard of them. The same year Rip It was introduced, a former monk in India decided to throw his hat in the energy drink ring after seeing the potential for a new kind of boost. He took all the things that give you energy in an energy drink but put them into a tiny, more concentrated shot form, calling it 5 Hour Energy. The shot is a huge success with truckers, who don’t want to drink a lot and stop to pee often but need to stay awake.

Red Bull was the bestselling brand of energy drink in 2021, at $3.26 billion.  No surprise, Monster was the second leading energy drink that year with $3.24 billion in sales. Bang Energy was third, at $1.20 billion. 5 Hour Energy sales were $824.5 million. Sales of energy drinks have been growing at a rate of around 5% every year since 2013.

Adverse Effects with Energy Drinks

While they are the fastest growing product in the beverage industry, there has been growing concern about the adverse effects of energy drinks. By 2015, there had been several reports showing adverse effects. “Energy Drink Consumption: Beneficial and Adverse Health Effects” concluded while there may be beneficial effects from energy drinks, there was also evidence of detrimental health consequences. The reported adverse effects were with the cardiovascular system, ischemic stroke and contributing to epileptic seizures. High sugar content could increase the risk of obesity and type 2 diabetes with high energy drink intake.

A Swedish study showed a strong relationship between dental erosion and energy drinks.  An American study showed similar results in American children. “Energy drink consumption was associated with about a 2.4-fold increase in dental erosion.” Low pH and high sugar levels of energy drinks are the likely causes.

In “Energy Drinks and Their Adverse Health Effects,” Nadeem et al did a systematic review of 32 studies to evaluate the reported adverse effects. “Only clinical studies reporting adverse events after energy drink consumption were included.” Frequent adverse events with children included insomnia (35.4%), stress (35.4%) and depressed mood (23.1%).

With adults, frequently reported adverse events were insomnia (24.7%), jitteriness/shaking hands (29.8%), and gastrointestinal upset (21.6%). The odds of insomnia and jitteriness were significantly increased with energy drink consumption. When alcohol was mixed with energy drinks, it significantly reduced the sedation effects of the alcohol, “but increased the likelihood of stimulatory effects.” See the following chart from the study:

The authors recommended that individuals avoid frequent energy drink consumption (5-7 energy drinks per week) and avoid co-consumption with alcohol. They suggested increased regulatory standards with the sale of energy drinks, particularly with regard to children.

The National Institutes of Health and the CDC reported a number of safety concerns when consuming energy drinks, beginning with the amount of caffeine. This is accomplished with a hidden-in-plain sight ingredient commonly included in energy drinks called guarana, which has one of the highest concentrations of caffeine in any plant. It may contain up to 3.6% to 5.8% caffeine by weight. Coffee only has up to 2%. So, the addition of guarana increases an energy drink’s total caffeine content.

There are a number of concerns when combining energy drinks with alcohol. It worsens your ability to tell how intoxicated you are. Yet your motor coordination and reaction time may be just as impaired. Drinkers who mix alcohol and energy drinks are also more likely to report unwanted or unprotected sex, driving drunk or riding with someone who is intoxicated.

Drinkers aged 15 to 23 who mix alcohol with energy drinks are four times more likely to binge drink at high intensity (i.e., consume six or more drinks per binge episode) than drinkers who do not mix alcohol with energy drinks.

Between 2007 and 2011 the number of energy drink-related emergency department (ED) visits doubled. “In 2011, 1 in 10 of these visits resulted in hospitalization.” Around 25% of college students consume alcohol with energy drinks; and they binge-drink more often than students who don’t mix alcohol with energy drinks. 42% of all ED visits related to energy drinks involved combining them with alcohol or other drugs (i.e., marijuana, prescription or over-the-counter medicines). The bottom line for the NIH was that “a growing body of scientific evidence shows that energy drinks can have serious health effects, particularly in children, teenagers, and young adults.”

Concern that increased energy drink consumption poses a public health danger, led a team of researchers from the World Health Organization Regional Office for Europe to review the literature of published health risks, consequences and policies with energy drinks. They were concerned particularly with the potential adverse effects on young people. “As energy drink sales are rarely regulated by age, unlike alcohol and tobacco, and there is a proven potential negative effect on children, there is the potential for a significant public health problem in the future.” They gave several suggestions to minimize the potential for harm from energy drinks:

  • Establishing an upper limit for the amount of caffeine allowed in a single serving of this type of drinks in line with available scientific evidence;
  • Regulations to enforce restriction of labelling and sales of energy drinks to children and adolescents;
  • Enforcing standards for responsible marketing to young people by the energy drink industry;
  • Training health care practitioners to be aware of the risks and symptoms of energy drinks consumption;
  • Patients with a history of diet problems and substance abuse, both alone and combined with alcohol, should be screened for the heavy consumption of energy drinks;
  • Educating the public about the risks of mixing alcohol with energy drinks consumption;
  • Further research on the potential adverse effects of energy drinks, particularly on young people.

Calls for FDA Energy Drink Regulation

Despite the growing consensus and concern with the adverse effects of energy drinks, the industry has been successful in blocking FDA regulation. Lawyers and Settlements.com reported that members of Congress, consumer watch dog groups and federal health officials have been calling on the FDA to modify the rules and regulations governing energy drinks without any change. One of the difficulties is with how the manufacturer categorizes their product.

Manufacturers can decide on their own whether to call their energy drinks beverages or dietary supplements.  5-Hour Energy, Monster and Rockstar are marketed as dietary supplements. Red Bull is marketed as a conventional food. They also don’t need to disclose how much caffeine their drinks contain. “There are different sets of rules for what can be added and what must be disclosed on the label.”

Producers of energy drinks are not required under current federal regulations to disclose caffeine amounts. The FDA reports there are no limits on the amount of caffeine that dietary supplements can contain, whereas over-the-counter stimulant medications are regulated by the FDA as to how much caffeine they can contain, and so are soft drink manufacturers.The FDA stipulates that soft drinks contain no more than 71.5 mg of caffeine per 12 oz drink, but it cannot regulate the caffeine content in energy drinks – with the exception of energy drink companies that self- classify their products as a dietary supplement, such as Monster and Rockstar.

Law practices willing to see if they can get energy drink manufacturers to pay out on wrongful death claims, or as Red Bull GmbH, the beverage’s Austrian parent company did, pay $640,000 for making false claims about their products usefulness. Despite the claims of “numerous scientific studies” showing the ability of energy drinks to improve energy and performance, the truth is they are no more effective than caffeine or other caffeine-containing products.

05/12/20

Concerns with Energy Drinks

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On February 5, 2011, Cassondra Reynolds awoke to hear her husband John gasping for breath from sudden cardiac arrest. She performed CPR as emergency services rushed to their home. At the hospital, the doctor told Cassondra that John’s sugar levels were sky high and asked her a series of questions about his lifestyle, including whether he used drugs or had any health issues. She said he did use energy drinks, but only had one per day. “John was healthy, he worked out every day, he had had a full physical examination the month prior and all his results came back fine.” The doctor explained one energy drink could throw off the rhythm of his heart causing his heart attack.

John remained in a coma and was on life support for the next two weeks, but he suffered from repeated seizures due to the lack of oxygen during his sudden cardiac arrest. On February 17th, John was declared brain dead. The doctors told Cassondra John had irreversible brain damage from the seizures and that he would never recover. She made the difficult decision to remove him from life support, and John died on February 19, 2011.

Energy drink sales in the U.S. reached $9.27 billion in 2019. They contain a variety of substances, but caffeine is the main ingredient. Others include: sugar, taurine, vitamin B complex, guarana and ginseng. Guarana contains caffeine and two chemicals similar to caffeine, theophylline and theobromine. One gram of guarana is equal to 40 milligrams of caffeine. Instead of being labeled as beverages, energy drinks (EDs) are labeled as dietary supplements. Under the Dietary Supplement Health and Education Act of 1994, dietary supplement ingredients do not require FDA approval and the agency has a limited role in their regulation.

In “Energy Drinks and the Risk of Cardiovascular Disease,” the authors said energy drinks are commonly used by young adults and adolescents as a source of energy in order to enhance physical and mental performance.  Safety is the biggest concern with the consumption of EDs and case reports, observational studies and meta-analyses have been done to determine the effects of EDs on cardiovascular events. There are a variety of cardiovascular changes in people using EDs, with the most common one being arrhythmias. “The detrimental effects of EDs are cardiac arrhythmias, myocardial infarctions, prolonged QT interval, aortic dissection, and death.”

Their review said case reports have shown that EDs can cause arrhythmias as with John Reynolds, but the mechanism is not clear. Some of the case reports discussed patients who had underlying structural heart disease, abuse of other substances along with EDs. Nevertheless, “it is suggested EDs can be dangerous when used alone or in combination with other substances of abuse.”

In November of 2018, Cassondra Reynolds was asked to share her husband’s story on a social media website. It was quickly shared nearly 400,000 times on Facebook alone. Cassondra started receiving messages from all over the world from people with similar stories. “She wanted a place where she could document cases of energy drink related adverse events and deaths as well as a place to share some of the factual information about energy drinks she herself had learned since her husband’s death.” This eventually led to her starting a nonprofit organization in order to raise awareness about the dangers of energy drinks and pre-workout supplements called The Awareness Project.

A Canadian study on adverse effects sought to assess adverse events from energy drinks in a web-based survey. The researchers found that more than 41.5% the youth and young adults surveyed reported experiencing at least one adverse event. A total of 1.2% reported seeking medical help or having talked to a health care professional about an adverse event(s). Another 1.8% considered seeking medical attention. The most common adverse events reported were: fast heartbeat, chest pain, headache, jitteriness or gastrointestinal issues. A substantial proportion reported they were simultaneously drinking alcohol (22.5%) and participating in sports or physical activity (18.5%), but 44.6% reported none of those activities.

The current findings are consistent with those of Health Canada’s Expert Panel on Caffeinated Energy Drinks, which concluded that, although the probability of serious adverse events is low, given the high volume of use, the risk of adverse events “is considered to be a public health issue.” Public health authorities may be warranted in considering additional regulations on energy drinks, including minimum age restrictions and enhanced health warnings. To assess the prevalence and nature of adverse events from energy drinks, broader consumer surveys should be conducted, in addition to monitoring through current consumer reporting mechanisms.

Advertisements for EDs target young adults, especially men, so it’s not surprising the military services are especially prone to energy drink use. There was a study published in Military Medicine that examined the association between energy drink use and mental health problems, aggressive behaviors and fatigue in soldiers recently returned from a combat deployment. Seven months after their deployment, 75.7% of soldiers reported consuming energy drinks, and 16.1% said they had more than two energy drinks per day. High energy drink use (2 or more per day) was associated with mental health problems, aggressive behaviors and fatigue. Moderate energy drink use (at least once a week or 1 per day) was associated with aggressive behaviors, fatigue and depressive symptoms.

Daily energy drink use was five times higher in this Army sample (29.2%) than in previous studies of Air Force personnel and youth in the general population, and not much lower than the quantity of use reported in a previous study of Army personnel surveyed during a combat deployment (44.8%). It was remarkable that 16% of soldiers in this study reported continuing to consume two or more energy drinks per day in the post-deployment period. In the deployed context, the appeal of energy drinks is understandable given that there is substantial restriction in sleep as well as regular circadian disruption due to night-time operations; indeed, caffeine is a recommended option to sustain alertness in this environment. During the wars in Iraq and Afghanistan, energy drinks were often made readily available to deployed service members at no cost. It is unclear, however, whether the high use reported in this post-deployment sample is representative of Army life in general or the result of continuing deployment-related habits.

The present study provided evidence for an association of high energy drink use and greater mental health problems. Mental health problems like depression, anxiety, PTSD and alcohol misuse were strongly associated with high levels of energy drink use. Previously, it was unclear whether there was a link between high energy drink use and mental health problems. The data from the present study provides further evidence of such a connection.

Aggressive behaviors were also strongly associated with energy drink use. They are problematic because of their link to several issues such as risky behaviors and unhealthy habits, relationship problems, intent to harm others, and suicidal behaviors. In this study they were assessed using a four-item measure. Participants were asked how often they had engaged in the following behaviors in the past month: (1) yelling or shouting, (2) kicking, smashing, or punching something, (3) threatening physical violence, and (4) fighting and hitting someone.

It was interesting that there was an association of energy drink use and fatigue. The finding stands in contrast to the marketing of energy drinks as a way to increase energy and reduce fatigue. This warrants further investigation into whether energy drink use results in greater fatigue over time. The findings are also important from a policy perspective, “given the association between protracted fatigue and problems such as poor job performance or making mission critical errors.”

This study has implications for clinical treatment, namely that providers should assess energy drink use, particularly in those serving in the military, as its use appears to be associated with mental health problems and aggressive behavior. “Research has found that aggressive behaviors are associated with being less responsive to evidence-based treatments for PTSD.” So, in order to maximize treatment outcomes, clinicians should recommend limiting energy drink use during mental health treatment. Tracking energy drink use in civilian clinical settings and assessing their association with aggressive behavior or mental health issues also seems advisable.

Public health messaging should be communicated in a way that centers on the reason energy drinks are so popular. “That is, although energy drinks are marketed as a way to increase energy and decrease fatigue, overuse of the products may be associated with fatigue.” As with many other health-risk behaviors, the message that moderation is critical needs to be communicated on the short-term gains with caffeine use. Military leaders are asked to re-evaluate how energy drinks are made available in the operational environment to best sustain performance without leading to their overuse.

Integrating treatment, prevention, and organizational strategies that support moderation can lead to a cultural change regarding energy drink use. Such strategies may have a role in reducing high-risk behaviors that are current priorities in the military and may enhance the health of service members.

These findings and recommendations should be considered beyond the military. In mental health and addiction treatment settings the use of energy drinks needs to be assessed and monitored for their potential effects on mental health problems like depression, anxiety, PTSD and drug and alcohol misuse. Particularly with high use of energy drinks, two or more daily, monitoring for an association with aggressive behavior should be done. Risky behaviors and unhealthy habits, relationship problems, intent to harm others, and suicidal behaviors are not only found in soldiers returning home from a combat deployment. The paradoxical connection between fatigue and energy drinks has relevance to treatment programs attempting to motivate their clients to develop lifestyle changes in order to support a new way of living.

Here is a link to a website that give the caffeine content of various beverages: coffee, soda, energy drinks and energy shots. For example, here are two of the top selling energy drinks and their caffeine content for 16 oz: Red Bull Original, 160 mg, Monster Energy Original, 160 mg.

06/29/15

Overdosing on Energy Drinks

© energy drink by reticent | stockfresh,com
© energy drink by reticent | stockfresh,com

A healthy 26-year-old Hispanic man with no family history and no apparent risk factors for hear attack went to an ER in Texas complaining of left-sided chest pains. He arrived at the hospital about nine hours after he began having chest pain.  “His left arm felt numb, he was sweating profusely and he reported vomiting prior to his arrival at the hospital.” He reported to the medical personnel that he drank between 8 and 10 energy drinks that day, his typical daily consumption of energy drinks.

In addition, the man also had a pack a day smoking habit for the past two years. He underwent a cardiac catheterization where a 100% occlusion of his left circumflex artery was found. There was no evidence on underlying artery plaque in that region of his heart. And no other evidence of coronary artery disease in his other coronary vessels was noted. A stent was placed in the occluded artery. After two days, he was discharged. “He agreed to stop smoking and consuming energy drinks.” Read a published case report of his medical treatment here.

The authors hypothesized that the large amount of energy drink consumption contributed to the acute thrombus blocking the man’s blood vessel. Excessive levels of caffeine and the possible effects of other substances contained in the energy drinks contributed to the man’s heart problem. They also acknowledged a reasonable alternative hypothesis was that his smoking caused or contributed to his “coronary artery vasospasm.”

Energy drinks have actually been around for a long time, with cocaine-laced Coca Cola being one of the first. Pemberton’s original formula included five ounces of coca leaf per gallon of syrup. Coca-Cola was estimated to contain about nine milligrams of cocaine per glass. It was removed from the syrup formula in 1903 and replaced with caffeine.

The modern introduction of energy drinks can be traced to the initial sale of “Red Bull” in 1997. Today there are a wide variety of additional energy drinks (such as Rock Star and Monster) with multiple energy-producing ingredients. The most common are: caffeine, taurine, glucuronolactone, and ginseng. Guarana is another caffeine-based stimulant commonly used in energy drinks. A typical energy drink contains between 75 milligrams to over 200 milligrams of caffeine per serving. This compares to 34 mg in Coke and 55 mg in Mountain Dew. Eight ounces of brewed coffee contains between 65 and 120 mg of caffeine. Two ounces of espresso contains 60 to 100 mg.

Brown University has a handy page of information on energy drinks where it noted that if a drink advertises no caffeine, the energy probably comes from guarana.  Short-term dangers from energy drinks include: increased heart rate and blood pressure (sometimes to the point of heart palpitations), dehydration, and sleep disturbance. Occasional use of energy drinks was not seen as harmful, but the claims of some for improved performance and concentration was said to be misleading. Thinking of them as highly-caffeinated drinks gives you a more accurate picture of how they affect you.

Mixing energy drinks (a stimulant) with alcohol (a depressant) brings with it a number of potential dangers. The energy drink can give the person the impression they aren’t impaired from the alcohol; or prevent them from realizing how much alcohol they have consumed. “No matter how alert you feel, your blood alcohol concentration (BAC) is the same as it would be without the energy drink.” Once the energy drink wears off, fatigue, respiratory depression and vomiting can occur. Both substances are very dehydrating and can hinder the body’s ability to metabolize alcohol, increasing its toxicity—and therefore the hangover you get the next day.

The FDA has been collecting reports on adverse effects from energy drinks within its Center for Food Safety and Adverse Event Reporting System (CAERS). A report tracking adverse events from Red Bull between January of 2004 and October of 2012 had 22 adverse events. The noted symptoms ranged from dehydration, vomiting, convulsions, anxiety and aggression, to vertigo, blindness, pancreatitis, chest pain, increased heart rate and blood pressure.

Another FDA CAERS report noted adverse events for 5-Hour Energy (92), Monster (40), and Rockstar (13). The symptoms ranged from vomiting, dizziness, increased heart rate, anxiety and diarrhea to convulsions, chest pain, loss of consciousness and even death. There were eleven deaths related to the 5-Hour Energy reports, five for the Monster reports and none for Rockstar.

Health concerns with energy drinks are not just confined to FDA adverse events. A Live Science article last year by Tia Ghose reported that more than 5,000 cases of people getting sick from energy drinks were reported to US poison control centers between 2010 and 2013. Many of the cases involved serious side effects like seizures, irregular heart rhythms, and dangerously high blood pressure. Children under the age of six were frequently consuming the beverages without knowing what they were drinking. Stephen Lipshultz, a pediatrician from Michigan, noticed the association in 2007 and began tracking data from poison control centers from around the world.

In 2011, Lipshultz and his colleagues published their findings in the journal Pediatrics. They discovered that self-report surveys found that energy drinks are used by 30% to 50% of adolescents and young adults. In 2007, 46% of the 5,448 reported caffeine overdoses occurred in those younger than 19 years of age. Energy drinks were found to have no therapeutic benefit. Both the known and unknown pharmacology of the various ingredients in them, combined with reports of toxicity, suggested that energy drinks put some children at risk for serious adverse health effects.

Long-term research objectives should aim to better define maximum safe doses, the effects of chronic use, and effects in at-risk populations (eg, those with preexisting medical conditions, those who consume energy drinks during and after exercise, or those who consume them in combination with alcohol), and better documentation and tracking of adverse health effects. Unless research establishes energy-drink safety in children and adolescents, regulation, as with tobacco, alcohol, and prescription medications, is prudent.

A new study by researchers at the Yale School of Public Health found that middle school children who consume energy drinks are 66% more likely to be at risk for hyperactivity/inattention (ADHD) symptoms. They said that interventions to reduce sweetened beverage consumption should focus on energy drinks and other emerging sweetened beverages such as sports and sweetened coffee drinks. “Boys were more likely to consume energy drinks than girls.”

Over the last few years I’ve seen a regular parade of energy drinks consumed by individuals in early recovery. However I don’t think I ever knew someone drinking 8 to 10 of them daily. Doing the research for this article impressed upon me their potential to contribute to the instability of early recovery. So I think I’ll begin paying more attention to who is drinking them and how many energy drinks they consume.