"Red Bull and vodka is terrible for you. It's popular, however, because it makes you drunker, faster. While I don't enjoy that particular deadly cocktail, I like many college students, survive on energy drinks during finals, Sugar free Red Bull being my poison of choice. After two weeks of drinking one cup of coffee and two Red bulls a day (that's coffee around 9 a.m., first Red Bull around 3 p.m., second Red Bull around 10 p.m.), I often go through withdrawals at the beginning of my Christmas and summer breaks -- stomach aches, nausea, headaches -- and of course low energy. I know it's incredibly unhealthy for me. But for me, like many other college students with a demanding schedule, there is no way to get all of your assignments done without sleep deprivation even if you start them ahead of time and cut out all extra activities. Energy drinks improve your mood and the quality of your work." -- A College Senior
You might think these are the words of a marginal student trying to just keep up. However, I asked a high achieving college senior at a top tier school to give me some insight into the use of energy drinks at her University. My interest in energy drinks arose from the recent report of a seizure in a 15-year-old boy who drank two 5-hour Energy shots in rapid succession. Are energy drinks the new coffee? Do they have excessive health risks and do they need to be regulated, or is the problem limited to their excessive use in our youth?
Energy, Danger or Both?
Sports and energy drinks are an enormous business with projected sales in 2011 of more than 9 billion dollars. One half of these sales will be to adolescents and young adults under the age of 25 -- people like our college student who, with her Red Bull in hand, excels at all levels. A survey of 496 college students found that 51 percent consumed energy drinks on a regular basis and 54 percent of those students combined the drink with alcohol. Energy drinks contain caffeine, taurine, guarana, vitamins and herbal supplements. Currently, however, the FDA does not regulate them, because energy drinks are categorized as dietary supplements.
An energy drink may start with less caffeine than a cup of regular coffee, but guarana and other substances contain additional caffeine and can increase the amount of caffeine the drinker receives. The dose of caffeine increases as we graduate to 16 ounce cans (160 mg), Max Strength shots, Super Strengths -- and since many energy drinks have names like Monster, Rock-On, Rock Stars and Killer Buzz, their marketing is clearly focusing on a younger, risk-taking generation. Wired X505 contains 500mg of caffeine with a tag line of, "Get Wired-Stay Wired." This dose of caffeine presents a danger to the young and those who do not ingest large quantities of caffeine on a regular basis.
The major problem is in the ingestion of excessive amounts of caffeine and the ability of young people to gain access to large quantities of caffeine. Coffee has to be brewed, you may need to find a coffee shop and it is difficult to drink large quantities quickly. On the other hand, energy drinks are convenient, come in multi- packs and some, like 5-Hour Energy, come in small bottles as "shots," with websites prominently displaying banners that exhort you to "Take it in Seconds," and "Feel it in Minutes." The amount of caffeine is not listed on the 5-Hour Energy or Extra Strength 5-hour Energy Max, but is estimated to be twice that of a regular energy drink.
How Much is Too Much?
Energy drinks are promoted to increase energy and stamina, promote weight loss, improve concentration and enhance athletic performance. Since they are categorized as dietary supplements there are no regulations that require the manufacturers to prove their claims of efficacy or safety. Caffeine, the main ingredient of these drinks is the only psychoactive drug available over the counter and available to both children and adolescents. Unlike energy drinks, substances like NoDoz list a minimum age of 12 years and also list the adverse effects of caffeine.
Healthy adults can safely consume fewer than 400mg per day of caffeine, or approximately 2-4 cups of regular coffee. Like all drugs, weight matters, so what is acceptable in an adult may be toxic and deleterious to a child or adolescent. Adolescents and children should not consume more than 100 mg/day of caffeine. Remember, one 8-ounce can of Red Bull contains 77mg of caffeine and 5-hour Energy shots have two to four times as much. While an adult may notice improved exercise endurance, better cognition, increased reaction time and improved mood, the same dose of caffeine in children and adolescents may cause anxiety, jitteriness, high blood pressure, seizures and behavioral problems. Much more serious problems have been reported with higher concentrations and abuse. Energy drinks have many other ingredients -- herbs, vitamins, supplements -- but studies of these substances are inconclusive and the claims of improved mental alertness concentration and performance should be taken with a dose of skepticism.
It would be easy say, "What's the big deal?" We don't try to regulate coffee or who can drink it, but energy drinks are different for a number of reasons. Their marketing strategy is youth oriented with a prominent presence at sporting and athletic events. There are even posters on the walls of college dining halls with slogans like, "Nobody wishes they'd slept more in college." While the FDA limits the amount of caffeine in soda, there is no such limitation on energy drinks. They are packaged in such a way that it easy for someone to have instant access to large amounts of caffeine. This creates an environment that potentially promotes abuse and dependence, with withdrawal headaches and fatigue leading to increased use and dependence.
There are strong proponents for regulation, particularly when it comes to sales in children. On the other hand, energy drinks can be purchased by college students as part of their food plans and supporters of energy drinks will point to the lack of regulation of other forms of caffeine. In some ways it is not unlike the ability to sell and promote "healthy" supplements without solid scientific data. In this case, I think the main issue is the use and abuse of energy drinks by children and adolescents.
What does it all mean?
• Energy drinks have known and unknown pharmacologic effects that may put some children at risk for serious adverse effects.
• Caffeine in low to moderate doses does improve mood, attention, concentration and energy levels in healthy people.
• Energy drinks contain high levels of taurine and guarana along with other ingredients whose effects have not been scientifically studied.
• The marketing is inappropriately aimed at youth and risks taking individuals which increases the risk of overdose and abuse.
• Safe levels of many of these substances have not been established for children
Common sense would seem to tell us that we should have some regulations to protect children and adolescents. Likewise, it would make sense to force manufacturers to list the exact dose of the ingredients and known adverse effects. To be fair to all involved, it might not be a bad idea to raise the bar for scientific proof of efficacy and safety for not only energy drinks but also herbs and supplements. Tell us what you think.
Follow Richard C. Senelick, M.D. on Twitter: www.twitter.com/RichardSenelick