Energy drinks and sudden death: US regulators investigate

The US Food and Drug Administration (FDA) is investigating a series of deaths reportedly linked to the consumption of energy drinks and shots. The investigation comes amid a growing number of reports of various adverse events related to energy drink consumption. Energy drink consumption has grown exponentially…

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A growing number of adverse events are reportedly linked to the consumption of energy drinks, such as Monster. Steven Depolo

The US Food and Drug Administration (FDA) is investigating a series of deaths reportedly linked to the consumption of energy drinks and shots. The investigation comes amid a growing number of reports of various adverse events related to energy drink consumption.

Energy drink consumption has grown exponentially over the past five to ten years. The main active ingredients of such drinks, which include Red Bull and Mother, are a combination of varying amounts of caffeine, guarana extract, taurine and ginseng. Other additives include carbohydrates, amino acids and vitamins.

The intended purpose of these drinks, according to the manufacturers, is to sustain alertness, so their target markets are athletes, students, and people in professions that require prolonged alertness. Energy drinks are also commonly consumed at nightclubs and dance parties, where they are often combined with alcohol, and recreational drugs, such as ecstasy.

The adverse effects of these energy drinks, either alone or in combination, are being increasingly reported worldwide, and recently in Australia.

Caffeine and other additives

The main component of energy drinks is caffeine and it has been associated with many adverse health outcomes in susceptible individuals. In terms of heart health, there are three main effects – increased heart rate, increased blood pressure, and evidence of increasing blood viscosity that can lead to clots forming in the heart and beyond.

Three independent cases where consumption of energy drinks led to catastrophic consequences, including cardiac rhythm disturbances and cardiac arrest, have recently been described in medical literature.

To be clear, these are life-threatening cardiac rhythm disturbances that can lead to sudden death, particularly in young people. And these effects have been observed with the consumption of as little as one can of energy drink.

Energy drink consumption has also been linked to anxiety, insomnia, vomiting, nervousness, addictive behaviours, and panic attacks. In pregnant women, caffeine consumption is associated with risk of late miscarriage, stillbirth, and small-for-gestational-age infants.

The other additives in energy drinks exacerbate many of these effects. And the manner in which these drinks are marketed – to be drunk fast and in high concentrations for a quick energy boost – magnifies their adverse effects. Indeed, the introduction of “energy shots”, the small volume, high-concentration shots of caffeine, guarana and taurine, available at petrol stations and the like, support this marketing strategy.

What to do?

The major challenges for both health professionals and the general community is the vast array of energy drinks on the market, the differences in their content, and that overall, the industry is largely unregulated. And the fact that the target of these types of energy drinks clearly includes children, adolescents and young adults is cause for great concern.

It’s likely that people will be unaware of the variations in the chemical composition and caffeine dosage in energy drinks. And with minimal and poorly stated warnings on energy drink cans, the potential for adverse effects, overdose, poisoning, and potentially death all remain distinct possibilities.

In Australia, energy drinks are regulated under Standard 2.6.4 of the Code by the Food Standards Australia New Zealand (FSANZ), and the maximum amount of caffeine allowed is 320 milligrams per litre. But because many energy drinks are sold in small volumes, their numerous additional additives exceed this limit.

A typical can of energy drink contains up to 300 milligrams of caffeine, from added caffeine and natural sources such as guarana, but importantly, in volumes far less than a litre – usually 200 millilitres or less. This includes “energy shots”, which clearly also don’t meet the requirements of Standard 2.6.4. Many energy drinks are also marketed as “dietary supplements” or “conventional foods” in an attempt to circumvent standard requirements of both the FDA and FSANZ.

Given the potentially catastrophic consequences of energy drink consumption in susceptible young people, we clearly need greater community education and awareness. This may require somewhat drastic measures, such as clear, graphic warnings on energy drink cans to warn people of their potential dangers (much like the highly successful packaging of cigarette cartons which include images of the consequences of smoking, such as cancer).

Another initiative may be to restrict the sales of energy drinks to children and adolescents, who are often the target of energy drink advertising and who face significant peer influence. The collective goal of such measures is to protect the young by raising community awareness of the potential detrimental effects of energy drinks.

Needless to say, the outcome of the current FDA investigation into the 13 reported deaths will be followed in Australia with great interest.

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13 Comments sorted by

  1. Jason Mazanov

    Senior Lecturer, School of Business, UNSW-Canberra at University of New South Wales

    Prof Semsarian has hit the proverbial nail on the head when it comes to the role of caffeine in contemporary society. One of the big epochs in the history of caffeine was when it came of the World Anti-Doping Agency's prohibited list. The anecdotal evidence is that caffeine misuse and abuse is at epidemic proportions in non-elite sport. There are reports of young men and women washing down handfulls of caffeine pills with various "energy drinks" before games. What is more worrying is the consumption…

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  2. neral

    logged in via Twitter

    Good article, thank you.

    What's the issue with FSANZ not being able to quickly close the loophole you point out, as it seems so obviously flawed?

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  3. Geoff Parker

    Chief Executive Officer - Australian Beverages Council

    I have read the article with interest. As you know, as CEO of the Australian Beverages Council my job in part is to ensure any discussion is balanced and factual, so I wanted to suggest a few of the facts to provide your article with context.

    Firstly, standard 2.6.4 limits the amount of caffeine in a standard 250mL can to 80mg (not 300mg) from all sources. This amount is equivalent to a cup of coffee or two cans of cola. Secondly, there are important differences between Australia and the US…

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    1. Sue Ieraci

      Public hospital clinician

      In reply to Geoff Parker

      One of the real issues here is the cultural use of caffeine and related compounds.

      Caffeine has traditionally been served in a form that is not attractive to children, and not promoted to them (too strong, bitter, hot).

      We now have caffeinated drinks that are cold and sweet, and easy to "throw down". What view does the Aus Beverages Council have of how various drinks should be promoted to children?

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  4. Caleb Ferguson

    Lecturer (Faculty of Health) & PhD Candidate (Centre for Cardiovascular & Chronic Care ) at University of Technology, Sydney

    Thank you Chris for a fantastic read. I think you make an excellent key point. Community awareness and education is vital. This is a clear public health issue. There is an urgent need to restrict the sales of such beverages to protect children and adolescents where mass consumption combined with alcohol seems to be an emergent issue with undesired negative health consequences.

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  5. rory robertson

    rory robertson is a Friend of The Conversation.

    former fattie

    Good afternoon Professor Semsarian,

    I think Jason may be stretching it a bit by suggesting that "caffeine sits alongside tobacco and alcohol as legal substances that do more harm than the all the illicit substances combined". The added sugar in our energy drinks and coffees - and in most processed foods and drinks - seems likely to be much more harmful over time than caffeine for a greater proportion of the population.

    Or is there a particularly convincing piece that has been written showing…

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    1. Sue Ieraci

      Public hospital clinician

      In reply to rory robertson

      Mr Robertson - you are confusing the acute cardio-toxicity of caffeine and related compounds with the long-term effects of excess sugar consumption.

      Sugars are not cardiac "toxins" - nor toxins of any nature. Yes, excess sugar consumption, out of balance with other nutrients and energy expenditure can lead to obesity.

      There is no need to badger every clinical academic over your view of one particular published paper. There is no reason why a research cardiologist's article on the toxic effects of caffeine and guarana on the myocardium needs to be re-railed onto your fructose obsession.

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  7. rory robertson

    rory robertson is a Friend of The Conversation.

    former fattie

    Geoff Parker, it's great that you are keen to ensure that any discussion on beverages is "balanced and factual". So I'm a bit surprised that you have never felt the need to correct Professor Jennie Brand-Miller and Dr Alan Barclay's deeply flawed Australian Paradox paper, in which they falsely claim that "Food industry data indicate that per capita sales of low calorie (non-nutritively sweetened) [non-sugary] beverages doubled from 1994 to 2006 [correct] while nutritively sweetened [sugary] beverages…

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    1. Alan Barclay

      Dietitian

      In reply to rory robertson

      Mr Robertson, is by definition a Troll "someone who posts inflammatory,[1] extraneous, or off-topic messages in an online community, such as a forum, chat room, or blog, with the primary intent of provoking readers into an emotional response[2] or of otherwise disrupting normal on-topic discussion" (http://en.wikipedia.org/wiki/Troll_(Internet)). I am surprised he is tolerated on this and other websites. I believe trolling is illegal in Australia...

      For those who are interested, his fallacious arguments have been addressed elsewhere: http://www.theaustralianparadox.com.au/index.php

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  8. rory robertson

    rory robertson is a Friend of The Conversation.

    former fattie

    Good afternoon, David. That $40,000 is still safe and sound in my keeping, as no-one has put the slightest dent in my critique. Indeed, for those interested, I've documented the sugar industry's recent spectacularly unsuccessful attempt to rescue the University of Sydney's faulty Australian Paradox paper, as part of industry attempts to kill the NHMRC's plan to toughen national nutrition advice to "limit" the consumption of added sugar: http://www.australianparadox.com/pdf/Sugarindustry-uni-sugarstudy25.pdf

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