3Qs: Energy drinks: What's in your can?

Over the last month, the U.S. Food and Drug Admin­is­tra­tion has con­firmed it is inves­ti­gating health reports citing energy drinks 5-​​hour Energy and Mon­ster Energy as a pos­sible factor in the deaths of 18 people since 2009 and the hos­pi­tal­iza­tion of numerous others since 2004. But the poten­tially fatal danger of these bev­er­ages hasn't stopped con­sumers from pur­chasing them. According to Bev­erage Digest, sales of energy drinks in the U.S. hit a record high last year, growing an esti­mated 16 per­cent to $8.9 bil­lion. Adam Woolley, assis­tant clin­ical pro­fessor of phar­macy prac­tice in Bouvé Col­lege of Health Sci­ences, weighs in on the FDA report and explains why stu­dents should think twice about what they consume.

Energy drinks contain high levels of caffeine. What other active ingredients should consumers be aware of?

Caf­feine can cer­tainly exac­er­bate someone's heart prob­lems by making the heart work harder than normal. It can also worsen anx­iety; ele­vate blood pres­sure; and lead to dehy­dra­tion, arrhyth­mias, seizures and mood changes. Energy drinks have var­ious levels of caf­feine depending on the brand and serving size. 5-​​hour Energy states that it "con­tains caf­feine com­pa­rable to a cup of the leading pre­mium coffee." For com­par­ison, an 8-​​ounce cup of coffee may have between 100 and 200 mil­ligrams of caf­feine depending on how it is brewed, and a 12-​​ounce can of cola has around 50 mil­ligrams of caf­feine. Keep in mind that we may alsos ingest caf­feine through other sources such as choco­lates, can­dies and teas.

Energy drinks some­times con­tain B vit­a­mins, antiox­i­dants, min­erals, tau­rine, glu­curono­lac­tone, guarana, ginkgo biloba and gin­seng. These agents could poten­tiate the effects of caf­feine and often have their own side effects. They may also have sig­nif­i­cant inter­ac­tions with pre­scrip­tion med­ica­tions or pre-​​existing med­ical con­di­tions. I think we will begin to see more atten­tion focused on all the ingre­di­ents included in energy drinks.

It's also impor­tant to note that energy drinks are not a sub­sti­tute for proper sleep and stu­dents should be aware of the poten­tial dan­gers. If a stu­dent decides to use an energy drink, it should be con­sumed in mod­er­a­tion and not more than rec­om­mended by the man­u­fac­turer. Lastly, it's impor­tant to con­sider other sources of caf­feine that could cause caf­feine tox­i­city when used in com­bi­na­tion with an energy drink.

Energy drinks are marketed as dietary supplements, and according to FDA regulations, supplement manufacturers are required to be responsible for products' safety. In light of this recent report, is it time for the FDA to reevaluate its regulation policy?

There are sev­eral fac­tors that drive the FDA's com­plex reg­u­la­tion policy and I don't believe this one report will nec­es­sarily change that. How­ever, I think the public will become more aware of how energy drinks are reg­u­lated and this knowl­edge may help to drive future changes. Cur­rent reg­u­la­tions allow for food addi­tives to be treated dif­fer­ently than dietary sup­ple­ments. The FDA eval­u­ates food addi­tives and deems them as safe for use, whereas nutri­tional sup­ple­ments aren't eval­u­ated by the FDA for safety or effi­cacy. The FDA takes action against a dietary sup­ple­ment only when that product is shown to be unsafe in the market.

It is inter­esting that the FDA limits the amount of caf­feine in a soft drink to 71 mil­ligrams per 12 ounces because it is deemed to be a food addi­tive, while there is no limit to the amount of the same ingre­dient that can be included in energy drinks mar­keted as dietary sup­ple­ments. At the very least, man­u­fac­turers should be required to clearly indi­cate the amount of all ingre­di­ents used in a product.

What factors need to be considered before coming to the conclusion that these drinks played a role in the reported deaths and hospitalizations?

Caf­feine affects each person dif­fer­ently and fac­tors such as tol­er­ance, elec­trolyte bal­ance, body size and gender can play a role. Vit­amin B3 is asso­ci­ated with flushing, which is one of the side effects described in sev­eral of the cases. It is unclear how the other ingre­di­ents may interact when used together at var­ious dosages.

In eval­u­ating these cases, the FDA will need to look at the patients' past med­ical his­tory. Did any of the patients have heart issues, seizure dis­or­ders or con­di­tions that may have put them at an increased risk? What other med­ica­tions were they taking? Did the patients take more than the rec­om­mended dose of 5-​​hour Energy? How much caf­feine and what other agents did they ingest? More infor­ma­tion is needed to reach a conclusion.