October 1, 2015 Energy Drinks: A Classic Example of a Harmful, Unregulated Product

Health Letter, October 2015

By Azza AbuDagga, M.H.A., Ph.D.

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Image: Photographee.eu/Shutterstock.com

“Unleash the Beast!” Energy drink companies typically market their products with slogans like this, claiming these drinks boost energy, decrease fatigue and increase mental alertness.[1] Instead, products such as Red Bull, Monster, Sting and others unleash a rash of health harms for consumers.

The multibillion-dollar energy drink industry has become the fastest-growing segment of the beverage market in the U.S.[2] Yet it continues to be unregulated, despite the serious safety risks associated with these products.

Risky ingredients in massive amounts

“Energy drink” is a term invented by manufacturers and adopted by others outside the industry; it has not been defined by the Food and Drug Administration (FDA), the agency responsible for regulating such products in the U.S.

The term refers to bottled or canned liquid beverages that are loaded with stimulants, such as caffeine, guarana (a plant-based product that contains concentrated caffeine) and taurine (an amino acid that increases the effects of caffeine).[3] Additionally, energy products usually contain B vitamins, and some contain sugar along with other substances that have not been well studied.[4]

Doses of energy drink ingredients vary across brands, but in general, they greatly exceed recommended dietary levels. For example, the total caffeine content found in a single can of some brands can reach 500 milligrams (equivalent to 14 cans of a caffeinated soft drink).[5] However, unlike a typical hot coffee drink, which is sipped slowly, energy drinks are cold and can therefore be swallowed quickly — thus compounding their risks.

Adverse reactions, overdoses and toxicities associated with energy drinks are mainly due to their stimulant content.[6] Consuming excessive quantities of caffeine- and taurine-containing energy drinks and vigorously exercising is believed to trigger serious constriction of the blood vessels in the heart, with potentially fatal results.[7]

Caffeine overdose can lead to nausea, vomiting, rapid heartbeat, hypertension (high blood pressure), hallucinations, seizures, coma and even death in rare cases. High caffeine also diminishes insulin sensitivity, which increases the risk of developing Type 2 diabetes.[8] Both caffeine and sugar have dehydrating effects, which can be life-threatening if not promptly reversed with fluid intake.[9] Some studies also link high-sugar energy drink brands to obesity.[10]

Emergency department visits related to energy drinks have steadily increased over the years. For example, a 2013 federal report from the Substance Abuse and Mental Health Services Administration found that nearly 20,800 emergency department visits were related to these products in 2011, compared with approximately 10,100 such visits in 2007.[11]

While the exact number of deaths attributed to energy drinks is unknown, FDA officials reported that the agency was investigating five and 13 separate cases of death tied to two energy drink brands in 2012 and 2013, respectively.[12],[13] The exact number of lives lost to energy drink consumption is likely much higher, because the FDA’s adverse event surveillance systems are believed to capture, at best, 10 percent of the true adverse events experienced by consumers.

A greater danger to young people

Energy drinks are increasingly popular among young consumers — largely due to the industry’s advertising, imaging and packaging tactics.[14] Survey data show that 30 to 50 percent of adolescents and young adults consume these products.[15]

Adolescents are more likely to experience adverse events because of their ignorance of caffeine’s risks and their tendency to consume larger quantities of these beverages.[16] Several studies link energy drink consumption among younger consumers to increased risk for unhealthy habits, including smoking, illicit drug abuse and heavy alcohol consumption.[17] Notably, alcohol consumption has been shown to increase the adverse effects of caffeine,[18] making it imperative not to mix energy drinks with alcohol.

There were over 4,800 energy-drink-related calls to the National Poison Data System in 2011 alone,[19] with nearly half of the calls involving unintentional exposures in children less than 6 years old.

Inadequate regulation in the U.S.

Due to the side effects accompanying these products, many countries (such as Australia, Denmark, Germany and Turkey) have banned certain types of — or all — energy drinks.[20] Other countries regulate consumption by young people. For example, Sweden bans the sale of energy drinks to children younger than 15 and also requires label warnings to discourage consumption after exercise and mixing with alcohol. Norway regulates these products by allowing them to be sold only in pharmacies.

Most energy drinks are marketed in the U.S. as dietary supplements. This classification precludes the FDA from requiring manufacturers to disclose the caffeine content on drink labels, making it difficult for consumers to know how much caffeine they would be ingesting.[21] This classification also exempts the majority of energy drinks from the caffeine level limitations that soft drink manufacturers are subjected to, just because all of the latter products are classified as foods.[22]

While the American Beverage Association recently has reported that its members that manufacture energy drinks have agreed to add warnings and disclose caffeine contents on product labels, the actual implementation of these practices has been slated for “as soon as commercially practicable”[23] — which could be months or years away.

The American Academy of Pediatrics (AAP) took a firm stand against energy drinks in 2011, when it recommended against their intake by children and youth, stating, “Energy drinks have no place in the diet of children and adolescents.”[24] The AAP also encouraged efforts to educate parents and children about these products and their health risks.

Similarly, the American Medical Association supports imposing a ban on the marketing of energy drinks to adolescents under the age of 18 because, as one of its board members puts it, this policy would be a “common sense action that we can take to protect the health of American kids.”[25]

Yet the FDA has chosen not to take any action. It is neither protecting the health of all Americans (by requiring energy drink manufacturers to comply with the same regulations that limit caffeine content in soft drinks) nor protecting minors (by banning sales to these groups). The agency has even failed to publicly disclose the results of its investigations of deaths related to these products.

In the absence of appropriate action by the FDA, consumers need to protect themselves by refraining from consuming energy drinks, and parents must educate their children about the dangers of these products.

References

[1] Schneider MB. Testimony on behalf of the American Academy of Pediatrics before the Senate Committee on Commerce, Science and Transportation: “Energy drinks: Exploring concerns about marketing to youth.” 2012. https://www.aap.org/en-us/advocacy-and-policy/federal-advocacy/documents/schneidersenatecommercecommitteeenergydrinkstestimony_7_31_13.pdf. Accessed September 1, 2015.

[2] Seifert SM, Schaechter JL, Hershorin ER, Lipshultz SE. Health effects of energy drinks on children, adolescents and young adults. Pediatrics. 2011;127(3):511-528. doi:10.1542/peds.2009-3592.

[3] Schneider MB. Testimony on behalf of the American Academy of Pediatrics before the Senate Committee on Commerce, Science and Transportation: “Energy drinks: Exploring concerns about marketing to youth.” 2012. https://www.aap.org/en-us/advocacy-and-policy/federal-advocacy/documents/schneidersenatecommercecommitteeenergydrinkstestimony_7_31_13.pdf. Accessed September 1, 2015.

[4] CaffeineInformer.com. Energy drink ingredients and what they do. http://www.caffeineinformer.com/energy-drink-ingredients. Accessed August 30, 2015.

[5] Schneider MB. Testimony on behalf of the American Academy of Pediatrics before the Senate Committee on Commerce, Science and Transportation: “Energy drinks: Exploring concerns about marketing to youth.” 2012. https://www.aap.org/en-us/advocacy-and-policy/federal-advocacy/documents/schneidersenatecommercecommitteeenergydrinkstestimony_7_31_13.pdf. Accessed September 1, 2015.

[6] Breda JJ, Whiting SH, Encarnação R, et al. Energy drink consumption in Europe: A review of the risks, adverse health effects, and policy options to respond. Frontiers in Public Health. Published online Oct. 14, 2014. doi:10.3389/fpubh.2014.00134.

[7] Trabulo D, Marques S, Pedroso E. Caffeinated energy drink intoxication. Emergency Medicine Journal. 2011;28(8):712-714. doi:10.1136/emj.09.2010.3322rep.

[8] Breda JJ, Whiting SH, Encarnação R, et al. Energy drink consumption in Europe: A review of the risks, adverse health effects, and policy options to respond. Frontiers in Public Health. Published online Oct. 14, 2014. doi:10.3389/fpubh.2014.00134.

[9] Attila S, Çakir B. Energy-drink consumption in college students and associated factors. Nutrition. 2011;27(3):316-322. doi:10.1016/j.nut.2010.02.008.

[10] Breda JJ, Whiting SH, Encarnação R, et al. Energy drink consumption in Europe: A review of the risks, adverse health effects, and policy options to respond. Frontiers in Public Health. Published online Oct. 14, 2014. doi:10.3389/fpubh.2014.00134.

[11] Schneider MB. Testimony on behalf of the American Academy of Pediatrics before the Senate Committee on Commerce, Science and Transportation “Energy drinks: Exploring concerns about marketing to youth.” 2012. https://www.aap.org/en-us/advocacy-and-policy/federal-advocacy/documents/schneidersenatecommercecommitteeenergydrinkstestimony_7_31_13.pdf. Accessed September 1, 2015.

[12] FDA investigates five deaths, one heart attack linked to Monster Energy Drinks. October 2012. CBS News. http://www.cbsnews.com/news/fda-investigates-five-deaths-one-heart-attack-linked-to-monster-energy-drinks/.

[13] Castillo M. FDA investigating 13 deaths tied to 5-hour Energy. July 2013. CBS News. http://www.cbsnews.com/news/fda-investigating-13-deaths-tied-to-5-hour-energy/. Accessed September 1, 2015.

[14] Schneider MB. Testimony on behalf of the American Academy of Pediatrics before the Senate Committee on Commerce, Science and Transportation: “Energy drinks: Exploring concerns about marketing to youth.” 2012. https://www.aap.org/en-us/advocacy-and-policy/federal-advocacy/documents/schneidersenatecommercecommitteeenergydrinkstestimony_7_31_13.pdf. Accessed September 1, 2015.

[15] Seifert SM, Schaechter JL, Hershorin ER, Lipshultz SE. Health effects of energy drinks on children, adolescents and young adults. Pediatrics. 2011;127(3):511-528. doi:10.1542/peds.2009-3592.

[16] Higgins J, Yarlagadda S, Yang B. Cardiovascular complications of energy drinks. Beverages. 2015;1(2):104-126. doi:10.3390/beverages1020104.

[17] Ibid.

[18] Ibid.

[19] Ibid.

[20] Seifert SM, Schaechter JL, Hershorin ER, Lipshultz SE. Health effects of energy drinks on children, adolescents and young adults. Pediatrics. 2011;127(3):511-528. doi:10.1542/peds.2009-3592.

[21] Schneider MB. Testimony on behalf of the American Academy of Pediatrics before the Senate Committee on Commerce, Science and Transportation “Energy drinks: Exploring concerns about marketing to youth.” 2012. https://www.aap.org/en-us/advocacy-and-policy/federal-advocacy/documents/schneidersenatecommercecommitteeenergydrinkstestimony_7_31_13.pdf. Accessed September 1, 2015.

[22] Kumar G, Park S, Onufrak S. Perceptions about energy drinks are associated with energy drink intake among U.S. youth. American Journal of Health Promotion. 2015;29(4):238-244. doi:10.4278/ajhp.130820-QUAN-435.

[23] American Beverage Association (ABA). ABA guidance for the responsible labeling and marketing of energy drinks. http://www.ameribev.org/files/resources/2014-energy-drinks-guidance–approved-by-bod-43020.pdf. Accessed September 1, 2015.

[24] Committee on Nutrition and the Council on Sports Medicine and Fitness. Clinical report — Sports drinks and energy drinks for children and adolescents: Are they appropriate? Pediatrics. 2011;127(6):1182-1189. doi:10.1542/peds.2011-0965.

[25] American Medical Association (AMA). AMA adopts new policies on second day of voting at annual meeting. http://www.ama-assn.org/ama/pub/news/news/2013/2013-06-18-new-ama-policies-annual-meeting.page. Accessed September 1, 2015.