Energy drinks: cause for concern or scaremongering?BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f6343 (Published 24 October 2013) Cite this as: BMJ 2013;347:f6343
Caffeine is a stimulant that has been ubiquitously consumed across cultures from time immemorial. But new forms of caffeinated products—including energy drinks, chewing gum, and maple syrup—have the US Food and Drug Administration (FDA) wondering whether the compound should continue to be categorised as “generally regarded as safe” and regulated with minimal restrictions.
Proponents of regulation point to basic science suggesting the potential for cardiovascular risk and that children might be a particularly vulnerable population that needs protection, even if the risk is slight.
Opponents say that theory flies in the face of extensive experience with caffeine products and the consumption of tens of billions of cans of energy drinks; there is no evidence of a problem on a population basis or in the emergency room—it is scaremongering by a few people out to make a name and a buck for themselves.
Sales of energy drinks such as Red Bull and Monster have rocketed to $12.5bn (£7.7bn; €9bn) in 2012 in the US and are projected to reach $21.5bn by 2017. Most of these drinks go down the gullets of teens and 20-somethings, who are a generational divide from regulators, and this perhaps as much as anything explains their elders’ unease with these new formulations of traditional ingredients.
Four Loko was the poster child for the first round of restrictions on these products. It was first marketed in 2005 as an energy drink containing alcohol, caffeine, taurine, and guarana in a variety of sweet flavors. But concern that the stimulants might mask the depressant effects of the alcohol led some universities and state regulators to issue a blanket ban on Four Loko and similar products.
The final blow came in late 2010 when the FDA sent a letter to four energy drink manufacturers warning them, “There is evidence that the combinations of caffeine and alcohol in these products pose a public health concern.”1
The companies either dropped the stimulant additives and promotion as energy drinks to market the brands as alcoholic beverages, or they dropped the line entirely.
Jacob Sullum in an article in Reason magazine, compared the episode to demonization of other alcoholic drinks such as gin at various times throughout history and to the “reefer madness” approach to marijuana.2 He also noted elements of class and age discrimination in the efforts, such as when a New York Times columnist trashed inexpensive malt beverages containing caffeine but soon praised “hoity-toity coffee cocktail” made with coffee. It all suggested to Sullum an attitude that some people needed more regulation than others in the pursuit of their happiness.
Stripping alcohol from energy drinks did little to depress soaring sales. Those who wanted alcohol with caffeine could easily combine the two on their own.
The American Academy of Pediatrics has deplored the marketing of energy drinks to children, saying, “Energy drinks are never appropriate for children or adolescents.”3 The academy has long opposed consumption of sugary sodas by children and says that energy drinks add further stimulants to that base mix, posing potential risks to the neurologic and cardiovascular systems. It proposed drinking more water.
The American Medical Association added its voice to a marketing ban to children last summer.4
An enterprising law firm is attempting to make the case that energy drinks led to the injury and death of their clients. It is soliciting for other victims through a website and freephone number.
Leading the political charge for tighter regulation of energy drinks is a trio of democrat US senators, Edward Markey (Massachusetts), Richard Blumenthal (Connecticut), and Dick Durbin (Illinois). They issued a report at the end of July, What’s all the BUZZ about.5
“The spike in the number of energy drinks in the marketplace and the frequency in which these are marketed to children and teens raises serious questions, both about the safety of this class of products and whether they fulfill their claims to consumers,” said the report.
“Emergency room visits related to energy drinks doubled from 10,000 to 20,000 visits between 2007 and 2011,” it said, citing a report from the Department of Health and Human Services. But the senators ignored the fact that 42% of these visits also involved other drugs.6 There were no data on the seriousness of the incidents, and the report did not provide the context that emergency room visits top 130 million annually in the US.
Lacking convincing medical evidence of a need to restrict energy drinks, the senators fell back to urging regulation to “ensure that children and teens are adequately protected from deceptive advertising practices.”
But there was little evidence that young people are any more bamboozled by advertising claims for energy drinks than for other consumer products, or that are they more vulnerable than adults. As for enhanced product labeling leading to changes in behavior, the lesson from restaurant and fast food menu labeling is at best mixed.7
Evidence of harm?
The FDA contracted with the Institute of Medicine (IOM) to hold a public hearing on energy drinks in early August. “With caffeine now appearing in so many different product types, it may be that a young child may be at risk of ingesting caffeine from many sources in a given day without even having any sense of the exposure they are having. The consequences of this cumulative exposure are deserving of greater analysis, attention, and understanding,” FDA commissioner Margaret Hamburg said in her opening statement.
Some have made the comparison with acetaminophen (paracetamol), where broad inclusion in products like cough medicine, cold capsules, and prescription opioid drugs can easily lead to consumption of unsafe levels. But whereas the threshold for acetaminophen toxicity and overdose is low, well known, and results in hundreds of deaths a year, there is little evidence of too much caffeine having lethal effects.
“Energy drinks [when a person is] at rest appear to decrease endothelial cell function,” they can decrease blood flow, argued John Higgins, a cardiologist at the University of Texas Health Sciences Center. Before the IOM, he cited studies showing a 14% decrease in myocardial blood flow in people aged 45-71 (average age 58) and a 22% decline in younger people (average age 27, range 21-33) as measured by positron emission tomography. But the studies were small, 15 and 18 subjects, respectively, and did not include children.8
“We have seen quite a lot of youngsters in our emergency room running into problems when they have consumed energy beverages,” Higgins said, but offered no data to back up the assertion.
Alvin Bronstein did provide data at the IOM meeting, mined from the linked database of the 2.5 million calls a year made by the public and medical providers to the nation’s 57 poison control centers. He is medical director of the Rocky Mountain Center in Denver.
“From 1 January 2000 to 22 July 2013, US poison centers received 48 177 calls where the agent was identified to be caffeine,” he said. “From 18 June 2010 through 22 July 2013, there were 6724 energy drink product calls to US poison centers. These were single substance calls.”
He said that calls relating to energy drinks “seem to be leveling off,” though it is a bit early to tell for sure. About 40% of the 6724 calls were for products in which caffeine was the only potential poison. Not all calls were followed, mainly because only minimal effects were possible, but Bronstein said that in about 18% of the energy drink calls consumption had no medical effect; in about 10% it had a moderate effect with “symptoms like tachycardia that went away, and some had very minor effect (hyperactivity), and these would generally resolve.” There was one death associated with consuming energy drinks, in 2011.9
“We believe that the energy product clinical effect pattern is very similar to [that of] caffeine ingestion, but more work on this needs to be done,” Bronstein concluded.
California emergency room physician Michael Forman added, “I and my colleagues in emergency medicine are really not seeing serious side effects from caffeine from any source other than intentional overdose, which is over the counter pills.” With about six billion cans of energy drinks consumed each year, he would expect to see more of a signal in the emergency room if energy drinks really were a problem.
“There is no difference in the systemic handling of naturally occurring caffeine to that which is added to food and beverages such as energy drinks,” invited speaker Ashley Roberts told the IOM. “The premise that adolescents react differently to adults following caffeine consumption is currently not supported by the science.”
Roberts told the hearing that the level of acute toxicity of caffeine is reported to be around 3 g in young children, rising to 10 g in adults. “These dose are equivalent to drinking approximately 28 and 93 8oz cans [Red Bull size] of energy drink per day, which is not physically possible.”
Additionally, greater levels of caffeine than found in energy drinks are available for sale in pill form over the counter for use in children aged 12 years and older. Caffeine has been used to treat several disorders in younger children, including attention-deficit/hyperactivity disorder.
Perhaps there are negative synergistic interactions between caffeine and other compounds in energy drinks such as taurine, but we really have no studies, argued Michael Jacobson of the pro-regulation group Center for Science in the Public Interest.
Roberts said each of the ingredients individually has gone through the FDA consensus review process and is regulated as generally regarded as safe (GRAS). He noted that the caffeine in guarana is included in total caffeine on the product label. Taurine is a component of meat, poultry, seafood, and dairy products; it is even added to infant formula.
But cardiologist Higgins was not convinced. “I’m literally putting on my doctor’s lab coat here,” he said with a melodramatic flourish during the public comment session, “because I’m now speaking to you as a physician . . . First do no harm. I believe that these energy beverages are different to coffee. Pure caffeine by itself seems to be a different beast to coffee.”
The overwhelming evidence does not support that belief. It remains to be seen what, if anything, the FDA will do when it receives the IOM meeting report later this fall.
Cite this as: BMJ 2013;347:f6343
Competing interests: I have read and understood the BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.