Energy drinks for children and adolescentsBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b5268 (Published 15 December 2009) Cite this as: BMJ 2009;339:b5268
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Globally, the demand for nutraceuticals is driven by rising consumer
awareness of diet-disease links, ageing populations, rising healthcare
costs, and advances in food technology and nutrition. Changing consumer
lifestyle and desire to look good have had a significant impact upon
demand for foods which are perceived as healthy and nutritious1.
It is common knowledge that foods provide macronutrients and micronutrient
content that help to nourish our bodies and keep our systems in proper
working condition. However, from early in human history, it was also known
that certain foods confer additional health benefits to humans such as
prevention and treatment of various types of diseases. ‘‘Let food be the
medicine and medicine be the food’’ was embraced 2,500 years ago by
Hippocrates the father of medicine, therefore the conception that foods
might provide therapeutic benefits in disease prevention with addition to
their being simply nutrient providers is not new2.
According to Business insights, the turn down of the carbonated soft drink
market has motivated a huge number of manufacturers to enter the
nutraceutical field, making it the most energetic sector in soft drinks.
Consequently, market leaders of soft drink manufacturers have diversified
their portfolios, by gaining nutraceutical brands, expanding current lines
with nutraceutical variants or by developing their own nutraceutical
brands in order to capitalize on this market opportunity. The market is
flooded with too many nutraceutical products.
The global market is dominated by the US having a market share of 36%
followed by European market having 24% share and Asia with 30% whereas rest
of world has 10% of market share in 2007 as per the Cygnus estimates. In
Europe Germany, France, UK, Italy and Switzerland dominate the market with
20%, 25%, and 8% 11% and11% shares respectively. In the Asian continent
Japan sweeps the market share by 22% of the global market where as
remaining 8% share is shared among the other Asian countries. The
nutraceutical soft drink market is expected to reach a value of $10.3bn in
Europe by 2010. It is expected to be worth $9.9bn in the US3.
Asia-Pacific is the most innovative region for nutraceutical soft drinks.
36% of product launches were in the region in 2006. Fruit drinks were the
largest category in terms of share of nutraceutical launches with 28% in
However, the term nutraceutical as commonly used in marketing has no
regulatory definition in most of the developed and developing countries.
There is not, as such, a regulatory framework for ‘functional foods’ or
‘nutraceuticals’ in EU Food Law. In Japan, ongoing efforts to loosen tight
restrictions on health claims have been an issue between US manufacturers
and Japanese authorities5. In India, the sector is at present governed by
three laws: Prevention of Food Adulteration Act, Food Products Order and
Drugs and Cosmetics Act.
It is high time that regulatory authorities prescribe regulatory
guidelines for nutraceuticals to check which products works and which do
1. Gray J, Armstrong G and Farley H. Opportunities and constraints in
the functional food market. Nutrition and food science 2003; 33(5): 213-8.
2. Sarkar S. Functional foods as self-care and complementary medicine.
Nutrition & Food Science 2007; 37(3): 160-7.
3. http://www.globalbusinessinsights.com/content/rbcg0162p.htm accessed on
13th January 2010.
Innovation-in-sports-ener accessed on 13th January 2010.
5. Coppens P, Fernandes da Silva M, and Pettman S. European regulations on
nutraceuticals, dietary supplements and functional foods: A framework
based on safety. Toxicology 2006; 221: 59–74
Competing interests: No competing interests
Energy drinks can be consumed alone, producing in some cases
side effects related to excessive caffeine intake (1), but
frequently, energy drinks are ingested in combination with
alcohol (2). Some recent epidemiological surveys showed
that students' intake of energy drinks in combination with
alcohol has risen dramatically since their introduction in
the market (3). In one of these surveys, 24% of respondents
that consumed alcohol (n=697), had used energy drinks with
alcohol at least once in the last 30 days (4). In other
survey (n=450), most users associate energy drinks and
alcohol (48.4%), and a 35.8% of energy drinks and alcohol
users have consumed the combination more than 3 times in the
last month (5).
One reason for the alcohol-energy drink combination is the
consumer expectation that caffeine (a stimulant) could
counteract some of the cognitive and motor symptoms of
alcoholic intoxication (a depressant). Due to this
expectation risk behaviors can be taken more easily, as
driving a car despite alcohol consumption (6). Increased
heavy episodic drinking has also been observed associated
with the use of these drinks in combination with alcohol
Several studies have evaluated the effects of intake of
energy drinks on the alcohol intoxication. In one study (7)
the effects of the combination were evaluated in the context
of strenuous exercise. It was reported that there were no
differences in physical exercise measured by an ergometer
among individuals who had consumed alcohol and those who had
used the combination, suggesting that the energy drink
consumption does not reduce the deficits associated with
alcohol intake. Ferreira et al. (8) studied the effects of
the combination in 26 healthy volunteers (Red Bull at a dose
of 3.57 mL/kg, equivalent to 1 can for a 70-kg person and
two doses of alcohol at doses of 0.6 or 1.0 g/kg). A
reduction of some subjective effects on the central nervous
system due to alcohol (headache, weakness, dry mouth, and
motor coordination) was observed when it was taken with the
energy drink. Objective measures of intoxication such as
motor coordination, reaction time and breath alcohol
concentrations did not change significantly with the
combination. In the study of Curry and Stasio (9), the
addition of the energy drink to alcohol reduced
significantly overall performance score of
neuropsychological status, mainly visuospatial,
constructional and language performance scores were altered.
These results are consistent with other studies
investigating caffeine–alcohol interactions (10), and the
combination of ethanol with other psychostimulants (11, 12).
Thus, when mixing energy drinks and alcohol, users may not
feel the symptoms of alcohol intoxication and to conclude
mistakenly that they are capable of potentially dangerous
activities such as driving, and may increase the potential
for alcohol-related injury (2, 3).
Given the boom in consumption of both beverages at the same
time, manufacturers of some countries have created a new
class of energy drinks with an alcoholic content ranging
between 6 and 10% by volume. The sell of some of these
brands stopped because they directed marketing to underage
consumers (2) and they are actually under scrutiny by Food
and Drug Administration (14).
It is necessary to educate adolescents and youth to reduce
the consumption of tenergy drinks with high caffeine content
(1), but also to provide information and explain the risks
of taking these drinks in combination with alcohol.
1. Oddy WH, O'Sullivan TA. Energy drinks for children and
adolescents. BMJ 2009;339:b5268.
2. Simon M, Mosher J. Alcohol, energy drinks and youth a
dangerous mix. San Rafael, CA: Marin Institute, 2007.
3. Reissig CJ, Strain EC, Griffiths RR. Caffeinated energy
drinks- a growing problem. Drug Alcohol Depend 2009;99:1-10.
4. O'Brien MC, McCoy TP, Rhodes SD, Wagoner A, Wolfson M.
Caffeinated cocktails: energy drink consumption, high-risk
drinking, and alcohol-related consequences among college
students. Acad Emerg Med 2008;15:453-60.
5. Oteri A, Salvo F, Caputi AP, Calapai G. Intake of energy
drinks in association with alcoholic beverages in a cohort
of students of the School of Medicine of the University of
Messina. Alcohol Clin Exp Res 2007;31:1677-80.
6. Thombs DL, O'Mara RJ, Tsukamoto M, Rossheim ME, Weiler
RM, Merves ML, et al. Event-level analyses of energy drink
consumption and alcohol intoxication in bar patrons. Addict
Behav 2009 Nov 24. [Epud ahead of print].
7. Ferreira SE, de Mello MT, Rossi MV, Souza-Formigoni
ML.Does an energy drink modify the effects of alcohol in a
maximal effort test?. Alcohol Clin Exp 2004;28:1408-12.
8. Ferreira SE, de Mello MT, Pompéia S, de Souza-Formigoni
ML. Effects of energy drink ingestion on alcohol
intoxication. Alcohol Clin Exp Res 2006;30:598-605.
9. Curry K, Stasio MJ. The effects of energy drinks alone
and with alcohol on neuropsychological functioning. Hum
Psychopharmacol Clin Exp 2009;24:473-81.
10. Marczinski CA, Fillmore MT. Clubgoers and their trendy
cocktails: implications of mixing caffeine into alcohol on
information processing and subjective reports of
intoxication. Exp Clin Psychopharmacol 2006;14:450-8.
11. Farré M, de la Torre R, Llorente M, Lamas X, Ugena B,
Segura J, Camí J. Alcohol and cocaine interactions in
humans. J Pharmacol Exp Ther. 1993;266:1364-73.
12. Hernández-López C, Farré M, Roset PN, Menoyo E, Pizarro
N, Ortuño J, Torrens M, Camí J, de la Torre R. 3,4-
Methylenedioxymethamphetamine (MDMA, ecstasy) and alcohol
interactions in humans: Psychomotor performance, subjective
effects, and pharmacokinetics. J Pharmacology Exp Ther.
13. Food and Drug Administration [Homepage on the Internet].
FDA To Look Into Safety of Caffeinated Alcoholic Beverages.
November 13, 2009 [cited 2009, Dec 21]. Avalaible from:
Competing interests: No competing interests
Caffeine consumption is not restricted to energy drinks but rather is
widespread in many products that children and adolescents may consume in
isolation or in combination.
Caffeine occurs naturally in the plant beverages tea, coffee and
mate. The amount of caffeine per cup of beverage varies considerably: tea
from 1 to 90 mg (mean 40 mg), instant coffee from 21 to 120 mg (mean 54
mg), ground coffee from 15 to 254 mg (mean 105 mg) (Food Standards Agency
2004), espresso coffee 25 to 214 mg (Desbrow et al. 2007) and mate 25 to
80 mg (Olmos et al. 2009). Some speciality coffees may even contain 500 mg
per serving (McCusker et al. 2003).
25% of worldwide caffeine use occurs within the pharmaceutical and
soft drink industries (Heilmann 2001). Pharmaceutical preparations
containing 15 to 250 mg are used to reduce fatigue, increase wakefulness,
delay the onset of sleep as well as being combined with oral analgesics
such as aspirin, paracetamol and codeine (Sweetman 2002). Caffeine is also
present in antacids, cold medications, allergy preparations and weight
reduction preparations (Durrant 2002). Substantial amounts of caffeine are
added to dietary supplements based on herbs containing natural caffeine.
In an analysis of 53 products the amount of caffeine obtained at the
suggested daily doses exceeded 200 mg in 26 cases 400 mg in 15 cases and
600 mg in 4 cases (Andrews et al. 2007).
Caffeine is used in the soft drink industry both for its flavour and
stimulant qualities. Caffeine’s bitter taste enhances sweetness and
saltiness and masks “off-flavors” (Allison and Chambers 2000). Caffeine in
the range of 30 to 65 mg per 330 ml (Durrant 2002) is added to colas which
are sold in bottles and cans ranging from 100 to 2500 ml. Caffeine is also
added to bottled water, 30 to 80 mg per 330 ml, and bottled herbal teas,
including lemon, mint, peach and raspberry, 30 mg per 330ml and (Durrant
2002). Energy or sport drinks are non-cola soft drinks with added
caffeine as well as an assortment of commonly used nutritional substances
in low dosages. The caffeine content of energy drinks ranges from 50 to
500 mg per bottle or can with the top selling drinks containing 240 to 480
ml and containing between 75 and 175 mg caffeine (Reissig et al. 2009).
Single doses of caffeine above 250 mg may produce caffeine
intoxication (caffeinism) in adults with symptoms including nervousness,
restlessness and facial flushing (Durrant 2002) and obviously should be
avoided. In the Editorial “Energy drinks for children and adolescents”
(Oddy and O'Sullivan 2009) the impact of energy drinks is discussed with
limited reference to these other common sources of caffeine intake.
Clearly doses exceeding 250 mg can be easily reached by consuming
singularly or in combination strong coffee, pharmaceutical products,
caffeinated botanical products, colas, caffeinated waters and of course
When discussing bans on energy drinks it noteworthy that a 250 ml can
of an energy drink may contain less caffeine than 500 ml bottle of cola.
The content of energy drinks varies considerably from one to another and
rather than restricting products termed or marketed as energy drinks it is
more scientific to restrict the caffeine content per container. From a
public health perspective it is surely unacceptable to sell products
exceeding 250 mg per serving whether it is a cup of coffee or an energy
drink as doses of this magnitude are associated with health problems. For
a child even 250 mg is probably much too much.
Caffeine is a psychostimulant and the world’s most popular drug used
regularly by more than 90% of adults (Durrant 2002). Adults banning energy
drinks used by a younger generation risk being accused of “ageism” if
their arguments are based on a products name/identity/charisma/advertising
rather than on a scientific assessment of ingredients. There is a good
argument for banning caffeine products containing excessive levels of
caffeine but it does not apply to all energy drinks and the argument
should be extended to include some colas and coffees.
Allison A-MA, Chambers EI (2000) The importance of caffeine as a
flavor component in beverages. Journal of Sensory Studies 15: 449-457
Andrews KW, Schweitzer A, Zhao C, Holden JM, Roseland JM, Brandt M,
Dwyer JT, Picciano MF, Saldanha LG, Fisher KD, Yetley E, Betz JM, Douglass
L (2007) The caffeine contents of dietary supplements commonly purchased
in the US: analysis of 53 products with caffeine-containing ingredients.
Analytical and Bioanalytical Chemistry 389: 231-239
Desbrow B, Hughes R, Leveritt M, Scheelings P (2007) An examination
of consumer exposure to caffeine from retail coffee outlets. Food and
Chemical Toxicology 45: 1588-1592
Durrant KL (2002) Known and hidden sources of caffeine in drug, food,
and natural products. J Am Pharm Assoc (Wash) 42: 625-37
Food Standards Agency (2004) Survey of Caffeine Levels in Hot
Beverages: Food Surveys. . Food Standards Agency, United Kingdom.
Heilmann W (2001) Decaffeination of coffee. In: Clark RJ, Vitzthum OG
(eds) Coffee. Recent developments. Blackwell Science, Ltd, Oxford, pp 108-
McCusker RR, Goldberger BA, Cone EJ (2003) Caffeine content of
specialty coffees. Journal of Analytical Toxicology 27: 520-522
Oddy WH, O'Sullivan TA (2009) Energy drinks for children and
adolescents. BMJ 339: b5268-
Olmos V, Bardoni N, Ridolfi AS, Lepori ECV (2009) Caffeine levels in
beverages from Argentina's market: application to caffeine dietary intake
assessment. Food Additives and Contaminants Part a-Chemistry Analysis
Control Exposure & Risk Assessment 26: 275-281
Reissig CJ, Strain EC, Griffiths RR (2009) Caffeinated energy drinks-
-A growing problem. Drug and Alcohol Dependence 99: 1-10
Sweetman SC (2002) Martindale. The complete drug reference.
Pharaceutical Press, London, UK
I am currently undertaking research studies on the effect of taste on the cardiovascular system as part of a PhD at Westminster University
Competing interests: No competing interests