Guest Commentary

Speak with your patients about the harms of energy drinks

Photo of Sadrine N. Defeu, BS, MPH 
Sandrine N. Defeu
Photo of Bhargavi B. Kola, MD, MPA, FAAP 
Bhargavi B. Kola

In this guest editorial, medical student Sandrine N. Defeu, BS, MPH, and her mentor, Bhargavi B. Kola, MD, MPA, FAAP, an associate professor and regional vice-chair in the department of pediatrics at Texas Tech University, Permian Basin campus, discuss current evidence regarding the health effects of energy drink consumption among adolescents, how these drinks are marketed to youth, and why providers should raise the subject with their younger patients.

Energy drinks are being marketed as immune system stimulants, energy boosters and highly vitalizing beverages. The contents range from nutritive ingredients like sugar to non-nutritive elements such as caffeine, taurine, ginseng, guarana and bitter orange. The amount of caffeine in most energy drinks in the United States is unknown. The FDA does not require the disclosure of caffeine content in beverages, including energy drinks, leaving the energy drink companies to determine the need to disclose that information. Internationally, the U.S. has the highest sales of energy drinks (including brands such as Rockstar, Monster and Full Throttle). These beverages are sold in many forms, ranging from powder to ready-to-drink packages and shots. Estimates show that approximately one-third of adolescents consume energy drinks in the U.S., and about 5,000 poison control calls were related to energy drinks between 2010 and 2011, according to a report from the U.S. National Poison Data System.

Are these energy drinks safe for adolescents to consume? Do we need to talk to our patients during their office visit and alert their parents about the consequences of consumption in high doses? To address these questions, we conducted a review to summarize the facts about energy drinks and investigate the amount of caffeine found in them. In addition, we sought to evaluate research that is consistent with the claim that the consumption of excess energy drinks among adolescents leads to health problems. Some of the associated health complications include obesity, sleep disorder and cardiovascular diseases. The American Association of Poison Control Centers reported that it received more than 4,600 calls for questions regarding caffeine exposure in 2005. Among them, 2,600 patients were aged younger than 19 years, and 2,345 patients required treatment. Here in the U.S., the FDA has placed no restrictions on caffeine limit in energy drinks.

What are energy drinks?

Energy drinks are beverages that are promoted to help improve resistance to stress, to enhance physical balance, and to energize the body. They first appeared in Europe and Asia in the 1960s, when consumers demanded a dietary supplement that would boost their energy. Red Bull was the first energy drink introduced in the U.S. market way back in 1997. Caffeine is known as a direct stimulant and a drug because it directly affects the nervous system when ingested. Ginseng, on the other hand, is known to improve concentration and memory.

How much caffeine is found in energy drinks?

Among energy drinks, Red Bull and SoBe No Fear contain approximately 10 mg/oz of caffeine. Some researchers found that among 10 energy drinks studied, only four were labeled with some form of warning. Three such labels — for SoBe Adrenaline Rush, SoBe No Fear and Amp Energy — advise that the product is not recommended for children and pregnant women, and the fourth label (Red Devil) advises that kids, pregnant women and caffeine-sensitive persons should not use their product in large amounts. According to the AAP, adolescents should not exceed more than 100 mg of caffeine a day. Surprisingly, some energy drinks contained more than 500 mg of caffeine in a can or bottle — the equivalent of 14 cans of some types of soda. Such a large amount can result in caffeine toxicity.

Adolescents: A vulnerable population

Energy drink manufacturers make most of their revenues from teenagers’ consumption. These companies advertise directly to adolescents through the media (TV, radio and social media). In 2010, reports indicated that U.S. adolescents view on average 124 television ads for beverages such as energy drinks and shots. Energy drink companies also use young music icons and other tactics to attract youth to watch their ads and buy their products. According to the Yale Rudd Center for Food Policy and Obesity, teens viewed 9% to 16% more ads than adults for three energy drink brands. Most of these advertisements involved 5-Hour Energy, Red Bull drinks and events, and Amp Energy. In addition, most of the energy drink ads viewed by adolescents appeared on cable networks with disproportionately more adolescent than adult viewers such as Adult Swim (80% to 90% more adolescent viewers), MTV and MTV2 (88% to 199% more adolescent viewers), and Comedy Central (20% to 30% more adolescent viewers).

Cans of an energy drink 
Although many energy drinks are targeted towards adolescents, the AAP has raised concerns about the effect of caffeine on brain and cardiovascular development.
Source: Adobe

Energy drinks’ harmful effects

Caffeine toxicity is a concern for youth. The AAP has raised additional concerns about the effect of caffeine on children because it can interfere with the development of the neurological and cardiovascular systems. Also, kids can be addicted to such a drug. The AAP also stated: “energy drinks have no place in the diet of children and adolescents” because of their stimulant content. Caffeine can also cause restlessness, insomnia and nervousness, headaches, stomach upset, muscle tremor, frequent urination and anxiety.

Most energy drinks contain sugars in the form of sucrose, glucose or high fructose corn syrup similar to those found in sodas and fruit drinks. Two cans of energy drinks could contain approximately 120 to 180 mg of sugar, which exceeds the daily sugar intake about up to five times, according to the U.S. Department of Agriculture dietary guidelines. Due to high sugar intake, adolescents who consume excess energy drinks may develop both medical (obesity, diabetes) and dental health problems. Energy drinks also contain high sodium levels, and several energy drinks may have up to 340 mg per 8 oz serving,” according to researchers. A high-sodium diet can result in high blood pressure, kidney failure, increased risk for heart disease and stroke. Large doses of caffeine can cause massive catecholamine release and subsequent sinus tachycardia, metabolic acidosis, hyperglycemia and ketosis. A fatal caffeine overdose, which usually results from ventricular tachycardia, can occur at doses of 10 to 14 g (150-200 mg/kg).

Conclusion

With existing evidence supporting a positive correlation between caffeine in energy drinks and adverse health effects, the AAP’s Committee on Nutrition and the Council on Sports Medicine and Fitness strictly mentions that energy drinks have no place in the diet of children and adolescents. Caffeine, the most abundant ingredient in energy drinks, is a drug. Consumers of energy drinks should be aware of its fatalities, especially among adolescents. Although energy drink manufacturers claim that their product improves physical performance, boosts the immune system and helps in memory retention, research done on these beverages has not shown any significant benefit related to these claims. In fact, these drinks have been more harmful to teenagers than many over-the-counter drugs. Because the amount of caffeine in these drinks is not generally reported on the labels, teens are not aware of the potential risks associated with excess caffeine intake.

Added to the above-mentioned reasons, there exists limited knowledge about the interactions of energy drinks with other medications that teenagers take — including antidepressants, antipsychotics and stimulant drugs — making it extremely important to discuss with the patient and parent in detail about energy drinks in every provider encounter. The AAP recommends excellent screening tools (ie, HEADSS/CRAFFT), which is a perfect avenue to incorporate in adolescent exams. Risks, morbidity and fatalities should be discussed with the patient and parents. Although the FDA has not set caffeine recommendations for children and adolescents, the AAP recommends that children should not consume caffeine.

Photo of Sadrine N. Defeu, BS, MPH 
Sandrine N. Defeu
Photo of Bhargavi B. Kola, MD, MPA, FAAP 
Bhargavi B. Kola

In this guest editorial, medical student Sandrine N. Defeu, BS, MPH, and her mentor, Bhargavi B. Kola, MD, MPA, FAAP, an associate professor and regional vice-chair in the department of pediatrics at Texas Tech University, Permian Basin campus, discuss current evidence regarding the health effects of energy drink consumption among adolescents, how these drinks are marketed to youth, and why providers should raise the subject with their younger patients.

Energy drinks are being marketed as immune system stimulants, energy boosters and highly vitalizing beverages. The contents range from nutritive ingredients like sugar to non-nutritive elements such as caffeine, taurine, ginseng, guarana and bitter orange. The amount of caffeine in most energy drinks in the United States is unknown. The FDA does not require the disclosure of caffeine content in beverages, including energy drinks, leaving the energy drink companies to determine the need to disclose that information. Internationally, the U.S. has the highest sales of energy drinks (including brands such as Rockstar, Monster and Full Throttle). These beverages are sold in many forms, ranging from powder to ready-to-drink packages and shots. Estimates show that approximately one-third of adolescents consume energy drinks in the U.S., and about 5,000 poison control calls were related to energy drinks between 2010 and 2011, according to a report from the U.S. National Poison Data System.

Are these energy drinks safe for adolescents to consume? Do we need to talk to our patients during their office visit and alert their parents about the consequences of consumption in high doses? To address these questions, we conducted a review to summarize the facts about energy drinks and investigate the amount of caffeine found in them. In addition, we sought to evaluate research that is consistent with the claim that the consumption of excess energy drinks among adolescents leads to health problems. Some of the associated health complications include obesity, sleep disorder and cardiovascular diseases. The American Association of Poison Control Centers reported that it received more than 4,600 calls for questions regarding caffeine exposure in 2005. Among them, 2,600 patients were aged younger than 19 years, and 2,345 patients required treatment. Here in the U.S., the FDA has placed no restrictions on caffeine limit in energy drinks.

What are energy drinks?

Energy drinks are beverages that are promoted to help improve resistance to stress, to enhance physical balance, and to energize the body. They first appeared in Europe and Asia in the 1960s, when consumers demanded a dietary supplement that would boost their energy. Red Bull was the first energy drink introduced in the U.S. market way back in 1997. Caffeine is known as a direct stimulant and a drug because it directly affects the nervous system when ingested. Ginseng, on the other hand, is known to improve concentration and memory.

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How much caffeine is found in energy drinks?

Among energy drinks, Red Bull and SoBe No Fear contain approximately 10 mg/oz of caffeine. Some researchers found that among 10 energy drinks studied, only four were labeled with some form of warning. Three such labels — for SoBe Adrenaline Rush, SoBe No Fear and Amp Energy — advise that the product is not recommended for children and pregnant women, and the fourth label (Red Devil) advises that kids, pregnant women and caffeine-sensitive persons should not use their product in large amounts. According to the AAP, adolescents should not exceed more than 100 mg of caffeine a day. Surprisingly, some energy drinks contained more than 500 mg of caffeine in a can or bottle — the equivalent of 14 cans of some types of soda. Such a large amount can result in caffeine toxicity.

Adolescents: A vulnerable population

Energy drink manufacturers make most of their revenues from teenagers’ consumption. These companies advertise directly to adolescents through the media (TV, radio and social media). In 2010, reports indicated that U.S. adolescents view on average 124 television ads for beverages such as energy drinks and shots. Energy drink companies also use young music icons and other tactics to attract youth to watch their ads and buy their products. According to the Yale Rudd Center for Food Policy and Obesity, teens viewed 9% to 16% more ads than adults for three energy drink brands. Most of these advertisements involved 5-Hour Energy, Red Bull drinks and events, and Amp Energy. In addition, most of the energy drink ads viewed by adolescents appeared on cable networks with disproportionately more adolescent than adult viewers such as Adult Swim (80% to 90% more adolescent viewers), MTV and MTV2 (88% to 199% more adolescent viewers), and Comedy Central (20% to 30% more adolescent viewers).

Cans of an energy drink 
Although many energy drinks are targeted towards adolescents, the AAP has raised concerns about the effect of caffeine on brain and cardiovascular development.
Source: Adobe

Energy drinks’ harmful effects

Caffeine toxicity is a concern for youth. The AAP has raised additional concerns about the effect of caffeine on children because it can interfere with the development of the neurological and cardiovascular systems. Also, kids can be addicted to such a drug. The AAP also stated: “energy drinks have no place in the diet of children and adolescents” because of their stimulant content. Caffeine can also cause restlessness, insomnia and nervousness, headaches, stomach upset, muscle tremor, frequent urination and anxiety.

PAGE BREAK

Most energy drinks contain sugars in the form of sucrose, glucose or high fructose corn syrup similar to those found in sodas and fruit drinks. Two cans of energy drinks could contain approximately 120 to 180 mg of sugar, which exceeds the daily sugar intake about up to five times, according to the U.S. Department of Agriculture dietary guidelines. Due to high sugar intake, adolescents who consume excess energy drinks may develop both medical (obesity, diabetes) and dental health problems. Energy drinks also contain high sodium levels, and several energy drinks may have up to 340 mg per 8 oz serving,” according to researchers. A high-sodium diet can result in high blood pressure, kidney failure, increased risk for heart disease and stroke. Large doses of caffeine can cause massive catecholamine release and subsequent sinus tachycardia, metabolic acidosis, hyperglycemia and ketosis. A fatal caffeine overdose, which usually results from ventricular tachycardia, can occur at doses of 10 to 14 g (150-200 mg/kg).

Conclusion

With existing evidence supporting a positive correlation between caffeine in energy drinks and adverse health effects, the AAP’s Committee on Nutrition and the Council on Sports Medicine and Fitness strictly mentions that energy drinks have no place in the diet of children and adolescents. Caffeine, the most abundant ingredient in energy drinks, is a drug. Consumers of energy drinks should be aware of its fatalities, especially among adolescents. Although energy drink manufacturers claim that their product improves physical performance, boosts the immune system and helps in memory retention, research done on these beverages has not shown any significant benefit related to these claims. In fact, these drinks have been more harmful to teenagers than many over-the-counter drugs. Because the amount of caffeine in these drinks is not generally reported on the labels, teens are not aware of the potential risks associated with excess caffeine intake.

Added to the above-mentioned reasons, there exists limited knowledge about the interactions of energy drinks with other medications that teenagers take — including antidepressants, antipsychotics and stimulant drugs — making it extremely important to discuss with the patient and parent in detail about energy drinks in every provider encounter. The AAP recommends excellent screening tools (ie, HEADSS/CRAFFT), which is a perfect avenue to incorporate in adolescent exams. Risks, morbidity and fatalities should be discussed with the patient and parents. Although the FDA has not set caffeine recommendations for children and adolescents, the AAP recommends that children should not consume caffeine.

PAGE BREAK

References:

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Blankson KL, et al. Pediatr Rev. 2013;doi:10.1542/pir.34-2-55.

Clauson KA, et al. J Am Pharm Assoc (2003). 2008;doi:10.1331/JAPhA.2008.07055.

Committee on Nutrition and the Council on Sports Medicine and Fitness. Pediatrics. 2011;doi:10.1542/peds.2011-0965.

Harris JL, et al. Evaluating sugary drink Nutrition and marketing to youth. https://www.albany.edu/anthro/files/SugaryDrinkFACTS_ReportSummary.pdf. Accessed October 11, 2018.

Heckman M, et al. Compr Rev Food Sci Food Saf. 2010;doi:10.1111/j.1541-4337.2010.00111.x.

Holmgren P, et al. Forensic Sci Int. 2004;139:71-73.

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Pomeranz JL, et al. J Public Health Policy. 2013;doi:10.1057/jphp.2013.6.

Rath M. J Am Acad Nurse Pract. 2012;doi:10.1111/j.1745-7599.2011.00689.x.

Reissig CJ, et al. Drug Alcohol Depend. 2009;doi:10.1016/j.drugalcdep.2008.08.001.

Seifert SM, et al. Pediatrics. 2011;doi:10.1542/peds.2009-3592.

Shearer J, Graham TE. Nutr Rev. 2014;doi:10.1111/nure.12124.

Watson WA, et al. Am J Emerg Med. 2005;23:589-666.

Zenith. US overtakes Thailand as world leader in energy drinks. Zenithglobal.com, Website. https://www.zenithglobal.com/articles/704?US+overtakes+%20Thailand%20+as+world+leader+in+Energy+drinks. Accessed October 11, 2018.

Disclosures : Kola and Defeu report no relevant financial disclosures.

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