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Abstract

Consumption of energy drinks has been increasing dramatically in the last two decades, particularly amongst adolescents and young adults. Energy drinks are aggressively marketed with the claim that these products give an energy boost to improve physical and cognitive performance. However, studies supporting these claims are limited. In fact, several adverse health effects have been related to energy drink; this has raised the question of whether these beverages are safe. This review was carried out to identify and discuss the published articles that examined the beneficial and adverse health effects related to energy drink. It is concluded that although energy drink may have beneficial effects on physical performance, these products also have possible detrimental health consequences. Marketing of energy drinks should be limited or forbidden until independent research confirms their safety, particularly among adolescents.

Introduction

Energy drinks belong to a class of products, in liquid form, that typically contain caffeine, with or without other added dietary supplements. The first energy drink appeared in the U.S. in 1949 and was marketed as "Dr. Enuf". (1) In Europe, they were launched for the first time in 1987; then the market expanded throughout the world, becoming very popular after the launch of Red Bull in 1997. (2) Since then, the energy drink market has grown dramatically, with various brands released worldwide. The annual consumption of energy drinks in 2013 exceeded 5.8 billion liters in around 160 countries. (3) The estimated total U.S. retail market value for energy drinks was around 12.5 billion USD in 2012 and the market increased 56% from 2006 to 2002. (2)

Manufacturers recently have shifted their consumer focus from athletes to young people. Energy drinks are aggressively marketed in places popular with teens and young adults. Approximately, two thirds of energy drink consumers are 13-35 years old, and boys are two thirds of the market. (4) In the U.S., energy drinks are the second most common dietary supplement used by young people; about 30% consume energy drinks on a regular basis. (5) The popularity of energy drinks in the Kingdom of Saudi Arabia does not seem to differ from other parts of the world. Around half of the Saudi University students who participated in a survey admitted to regular consumption of energy. (6)

Energy drinks are designed to give an "energy boost" to the drinker by a combination of stimulants and energy boosters. The major constituent in most energy drinks is caffeine. They usually contain 80-150 mg of caffeine per 8 ounces, which is equivalent to 5 ounces of coffee or two 12-ounce cans of caffeinated soda. (7) Most of the brands on the market contain large amounts of glucose while some brands offer artificially sweetened versions. Other commonly used constituents are taurine, methylxanthines, vitamin B, ginseng, guarana, yerba mate, acai, maltodextrin, inositol, carnitine, creatine, glucuronolactone, and ginkgo biloba.

Currently, significant concerns have been raised about the safety of these products. There have been several reports that showed adverse health effects associated with energy drink. Despite this, manufactures of energy drinks claim these products are suitable for consumers and that they are safe. In fact, the adverse health effects associated with energy drink remains controversial among scientists. There are limited comprehensive literature reviews that illustrate in detail the suitability and safety related to energy drink consumption, particularly among young adults. Here we review the available literature on the beneficial and adverse health effects related to energy drinks consumption.

Potential adverse effects of energy drinks in relation to their ingredients

Cardiovascular effect

Several studies have shown an increase in heart rate and arterial blood pressure after energy drink consumption. These findings were attributed to the ergogenic effects of the caffeine content of the energy drink. In addition, significant cardiac manifestations such as ventricular arrhythmias, ST segment elevation and QT prolongation have been documented following energy drink overconsumption. (8) Additionally, atrial fibrillation has been reported after high energy drinks ingestion in two healthy boys, 14 and 16 years of age. (9) Recently, energy drink consumption has been related to myocardial infarction in healthy 17-and 19-year-old boys. (10, 11) This observation has been supported by the findings that consuming energy drinks reduces endothelial function and stimulates platelet activity through arachidonic acid-induced platelet aggregation in healthy young adults. (12) Recent reports have demonstrated a relationship between energy drink overconsumption and arterial dilatation, aneurysm formation, dissection and rupture of large arteries.(13)

Neurological and psychological effect

Individuals usually develop symptoms of caffeine intoxication in doses equal to or above 200 mg. Symptoms include anxiety, insomnia, gastrointestinal upset, muscle twitching, restlessness, and periods of inexhaustibility. (14) In addition, High caffeine intake is associated with acute and chronic daily headaches by stimulating a pro-nociceptive state of cortical hyperexcitability. (15) Four caffeine-induced psychiatric disorders have been recognized by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition: Including caffeine intoxication, caffeine-induced anxiety, caffeine-induced sleep disorder and caffeine related disorder. (16) A study of adolescents between 15- and 16-years-of age demonstrated a strong correlation between caffeine intake and violent behavior as well as conduct disorders. (17) Several reports have suggested that energy drink may contribute to ischemic stroke and lead to epileptic seizures. (18) Hallucinations might be observed in individuals that consume more than 300 mg of caffeine per day. (19) High levels of cortisol that follow caffeine intake could explain this. Cortisol enhances the physiological effects of stress resulting in a greater tendency for the subjects to hallucinate. (20)

In vitro studies found that a combination of caffeine, taurine and guarana may promote and enhance apoptosis by reducing both superoxide dismutase and catalase activities on human neuronal SH-SY5Y cells. (21)

Gastrointestinal and metabolic effects

Energy drinks usually contain large amounts of sugar ranging from 21 g to 34 g per oz. The sugar content is mainly in the form of sucrose, glucose or high fructose corn syrup. Therefore, high energy drink intake may increase the risk of obesity and type 2 diabetes. (14) In addition, the high sugar content in energy drinks may reduce the activity, diversity and gene expression of intestinal bacteria resulting in increased risk of obesity and the metabolic syndrome. (22) Acute caffeine intake decreases insulin sensitivity, (23) which could explain the rise in blood glucose levels after energy drink consumption documented in some studies. (24) Beaudoin et al. demonstrated that caffeine intake reduces insulin sensitivity in a dose dependent manner, with 5.8% increase in insulin for each mg/kg increase in caffeine. (25)

A case has been reported of a woman that presented with jaundice, abdominal pain and highly elevated liver enzymes following energy drink overconsumption. (26) Huang et al. reported the same finding in a 36-year-old man. (27) Further studies are needed to determine, which individuals are highly susceptible and the underlying mechanism by which energy drinks cause hepatic injury.

Renal effects

The caffeine in energy drinks has been shown to enhance diuresis. (28) Therefore, energy drinks should be avoided during prolonged exercise in a hot environment because of the potential for dehydration. Studies have reported that dehydration at a level of 1.5% during prolonged exercise may result in an increase in body temperature, heart rate and perceived rate of exertion. (29)

Caffeine also promotes sodium losses in urine (natriuresis), which effects the plasma volume and results in significant alteration of cardiovascular performance while exercising. (30) In addition, sodium imbalance during prolonged exercise in a hot environment may reduce isometric force in the legs. (31) Greene et al reported a case of acute renal insult in a 40-year-old-year man after daily intake of energy drinks for about 2-3 weeks. The serum creatinine was increased fivefold from baseline and returned to normal two days after energy drink consumption was discontinued. (32)

Dental effects

A study in Sweden showed a strong relationship between energy drinks and dental erosion. (33) Similarly, Marshall et al demonstrated a similar observation in American children. (34) Energy drinks consumption was associated with about a 2.4-fold increase in dental erosion. This has been attributed to a low pH and the high sugar content of energy drinks. (35) In addition, Pinto et al found that energy drink intake may lead to cervical dentin hypersensitivity by removing the smear layer of the teeth. (36)

Beneficial effects

The large amount of caffeine in energy drinks provides the consumer with the desirable effects of improved memory, increased alertness and elevated mood. The most widely cited study is the one conducted by Alford et al. (37) They examined the effects of a market leader energy drink on 36 individuals. Assessments included psychomotor performance (reaction time, concentration and memory), subjective alertness and physical endurance. They showed that the studied energy drink significantly enhanced aerobic endurance (maintaining 65-75% max. heart rate) and aerobic performance (maintaining max. speed) on cycle ergometers. Mental performance included choice reaction, concentration and memory also improved significantly, which indicated increased subjective alertness. (37) Another study showed that the same brand energy drink significantly increases the upper body muscle endurance during repeated 'Wingate cycle performance' in young physically active subjects. However, no change was documented on anaerobic peak or average power. (38) Hoffman et al also demonstrated that energy drinks caused a significant increase in reaction performance during exercise, but with no effect on anaerobic power performance. (39) Likewise, Ivy et al in a double-blinded, randomized, crossover study examined the effects of pre-exercise consumption of energy drinks on 12 professional cyclists from both genders. The results showed significant improvement in endurance performance with no change in perceived exertion in the energy drink group compared to the placebo group. (40)

Walsh et al assessed the effects of energy drinks on time to exhaustion during treadmill exercise. They observed a significant increase in time to exhaustion during a moderate intensity endurance run as well as improvement in perceived feelings of focus, energy and fatigue. (41) Another study evaluated the ability of caffeinated energy drinks to improve acceleration tolerance and strength under a "G" load. The results showed that energy drinks improved relaxed G tolerance and increased strength but had no effect on acceleration tolerance duration. (42)

The results of a recent study reported that consumption of approximately 3 mg/kg of caffeine in the form of energy drinks significantly improved the physical performance of female volleyball players. (43) Wesnes et al in a randomized, double blind, placebo controlled, cross over study examined the cognitive and mood effects of energy drinks on 94 subjects. Assessment of cognitive function was performed with a number of automated tests of memory and attention while mood was assessed with various different questionnaires such as the Profile of Mood states (POMS), Bond-Lader and Chalder Fatigue Scales. The results revealed that both cognitive function and mood were significantly improved in partially sleep-deprived individuals who consumed energy drinks. They were able to preserve their initial levels of attention for a period of six hours, whereas the placebo group failed. (44)

A number of studies have examined the behavioral effects of energy drinks containing caffeine, glucose, taurine, and vitamins amongst its components. These studies found improvements in aerobic and anaerobic cycling performance, (37) attention performance and/or reaction time tasks, (37, 45) afternoon driving performance, (46) and different indices of alertness. (37, 45, 46) Smit and Roger compared the behavioral effects of two tailor-made energy drinks with a still water and no treatment conditions. Both energy drinks contained 75 mg caffeine and the same calorie amount from glucose. In comparison to the water and no treatment groups, both drinks significantly increased reaction time and self-ratings of energetic arousal. However, no changes were observed for either memory or rapid visual information processing. (47)

The combination of caffeine and glucose in energy drinks may show restorative properties. (48) In one study, a glucose based energy drink was given to 11 tired volunteers being examined in a driving simulator. Significant improvement was observed in lane drifting and reaction times for two hours post consumption. (49) Another study examined the acute effects of a glucose based energy drink on cognitive function. The results showed that energy drink reduced both reaction times on the behavioral control tasks as well as ratings of mental fatigue, whereas it increased subjective ratings of stimulation. (50)

It is very important to note that although the above-mentioned studies have identified positive effects of energy drinks on exercise performance, other researches have documented no significant effects or detrimental health consequences. Al-fares et al (51) in a single blind placebo controlled study recently evaluated the effects of energy drinks on exercise performance in 32 untrained healthy females. They found that ingestion of energy drinks before exercise did not enhance the indices of physical performance, which included time to exhaustion, maximum oxygen consumption, blood pressure, heart rate, and capillary oxygen saturation. Similar findings were observed in a double blind, randomized, placebo controlled cross over study of 15 physically active volunteers. The study found no effect of energy drinks on ride time to exhaustion or heart rate. Subjective rating of exertion was also not changed. (52)

A recent study (53) evaluated the acute effects of energy drinks on exercise performance in 19 professional female volleyball players. The players were recruited in a double blind, randomized, crossover study to determine grip strength, vertical jump and anaerobic power during three sessions. For each performance test, there was no significant change indicating that energy drink had no effect on improving physical performance.

The variability in the results of the above studies is mainly due to methodological differences. Variations in subjects, gender, dose of caffeine, ingredients of energy drinks, and type of placebo used contribute significantly to the inconsistency of the results.

Conclusion

Energy drinks may show positive beneficial effects on exercise performance in various sport activities. However, while energy drinks might benefit performance, possible detrimental health problems have been documented, particularly amongst children and adolescents. Various parts of the body are negatively affected by energy drink consumption. Considering this fact and the increasing popularity of these drinks, caution should be exercised while consuming energy drinks. Overambitious marketing and non-scientific claims should be regulated by governments until independent studies confirm that that these products are safe.

Footnotes

Disclosure of benefit: This work was not supported by any drug or commercial company.

References

2. Zucconi S, Volpato C, Adinolfi F, Gandini E, Gentile E, Loi A, et al. Gathering consumption data on specific consumer groups of energy drinks. External Scientific Report for European Food Safety Authority. 2013 [ Google Scholar]

5. Simon M, Mosher J. Alcohol, energy drinks, and youth: a dangerous mix. San Rafael CA: Marin Institute; 2007. [ Google Scholar]

41. Walsh AL, Gonzalez AM, Ratamess NA, Kang J, Hoffman JR. Research article Improved time to exhaustion following ingestion of the energy drink. Amino Impact™ 2010 [[ PMC free article] [ PubMed] Google Scholar]

Articles from International Journal of Health Sciences are provided here courtesy of Qassim University

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Energy Drink Consumption: Beneficial and Adverse Health Effects

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Consumption of energy drinks has been increasing dramatically in the last two decades, particularly amongst adolescents and young adults. Energy drinks are aggressively marketed with the claim that these products give an energy boost to improve physical ...

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Research - Popularity of Engergy Drinks Kimberley Burns 

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Research - Popularity of Engergy Drinks Kimberley Burns 

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Information on popular UK energy drinks Kimberley Burns

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Energy drink brand awareness Kimberley Burns

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Consumption of energy drinks graph Kimberley Burns

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How Energy Drinks effect the body Kimberley Burns

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Research - when do people use energy drinks Kimberley Burns 

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When people might use energy drinks Kimberley Burns

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The most comprehensive study of its kind, published today (Monday 15 January) in the Public Health journal, has found that drinking energy drinks is associated with an increased risk of mental health issues among children and young people, including anxiety, stress, depression, and suicidal thoughts.

The researchers found that energy drink consumption was more common among boys than girls, and was also associated with increased risky behaviours such as substance use, violence, and unsafe sex.

It also links consumption of the drinks with an increased risk of poor academic performance, sleep problems, and unhealthy dietary habits.

Researchers from Fuse, the Centre for Translational Research in Public Health, at Teesside University and Newcastle University, looked at data from 57 studies of over 1.2 million children and young people from more than 21 countries.

The new study adds to the growing body of evidence that energy drinks are harmful to the health of children and young people. The researchers say it highlights the need for regulatory action to restrict the sale and marketing of energy drinks to children and young people.

Lead author Amelia Lake, Professor of Public Health Nutrition from Fuse, the Centre for Translational Research in Public Health at Teesside University, said: "Energy drinks are marketed to children and young people as a way to improve energy and performance, but our findings suggest that they are actually doing more harm than good.

"We have raised concerns about the health impacts of these drinks for the best part of a decade after finding that they were being sold to children as young as 10-years-old for as little as 25p. That is cheaper than bottled water.

"The evidence is clear that energy drinks are harmful to the mental and physical health of children and young people as well as their behaviour and education. We need to take action now to protect them from these risks."

Co-author Dr Shelina Visram, Senior Lecturer in Public Health from Fuse, the Centre for Translational Research in Public Health at Newcastle University, said: "We are deeply concerned about the findings that energy drinks can lead to psychological distress and issues with mental health. These are important public health concerns that need to be addressed.

"There has been policy inaction on this area despite government concern and public consultations. It is time that we have action on the fastest growing sector of the soft drink market."

Barbara Crowther, Children's Food Campaign Manager from Sustain: the alliance for better food and farming, said: "It's not right that companies are profiting from energy drinks when evidence shows they're harming children and young people's health.

"These concerning findings should prompt our government to act. But they've been disappointingly silent on the issue for the past five years.

"Over that time, energy drinks companies have increasingly targeted young people with even higher caffeine content drinks, putting more of them at risk.

"We need our government to step up and follow through with their planned restriction of sales of these drinks to under 16s."

William Roberts, Chief Executive of the Royal Society for Public Health, said: "This important review adds to the growing evidence that energy drinks can be harmful to children and young people's physical and mental health, both in the short and long-term.

The evidence is clear that energy drinks are harmful to the mental and physical health of children and young people as well as their behaviour and education.

Professor Amelia Lake

"That's why we need the UK Government to step up and deliver on its 2019 commitment to ban sales of energy drinks to under 16s.

"In doing so it would not only be following the evidence, but also following the example of countries that have already restricted sales to children, a move supported by the majority of the public."

This study is an update to a review in 2016. In 2017, the same researchers from Fuse, the Centre for Translational Research in Public Health, were the first to publish research exploring in-depth the views of children, as young as 10-years-old, on energy drinks. The academics called on the UK government to take action on the sale of energy drinks to under 16s after finding that they were being sold to young people cheaper than bottled water.

The research revealed that energy drinks were easily available in local shops; sold for as little as 25p ('four for £1' promotions); targeted at children through online adverts, computer games, television and sports sponsorship; and linked to extreme sports, gaming, sexuality, gender, and use of sexualised imagery.

Previous research had also found that up to a third of children in the UK consume caffeinated energy drinks on a weekly basis and that young people in the UK were the biggest consumers of energy drinks in Europe for their age group.

Professor Amelia Lake was involved in a national campaign, fronted by celebrity chef Jamie Oliver, to restrict the sale of energy drinks to teenagers, and gave evidence to the House of Commons Science and Technology Committee on the effects of energy drinks on young people's mental and physical health. Many large UK supermarkets subsequently agreed to ban the sale of energy drinks to children.

A number of countries have attempted to regulate energy drinks, including bans on sales to under 18s in Lithuania and Latvia. The UK government ran a consultation on ending the sale of energy drinks to children in England and also proposed this in their 2019 green paper 'Advancing our health: prevention in the 2020s'. While 93% of respondents to the consultation supported restricting sales to under 16s, there has been no further action. In 2022, the devolved government in Wales launched its own consultation to ban the sales of energy drinks to under 16s.

The UK Food Standards Agency says that energy drinks are generally drinks with high levels of caffeine. They are usually marketed as giving a mental and physical 'boost' by providing more 'energy' than regular soft drinks. They are different to 'sports drinks' which might be used to replace electrolytes lost during exercise. Caffeine levels in a can of energy drink can vary between 80mg (equivalent to two cans of cola or a mug of instant coffee) and 200mg (equivalent to five cans of cola).

More than 40 health related organisations have joined the researchers in calling on government to restrict the sale and marketing of energy drinks to children and young people.

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Evidence shows wide range of risks associated with energy drinks in children as experts call for urgent Government action

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Evidence shows wide range of risks associated with energy drinks in children as experts call for urgent Government action

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Calls to ban sale of energy drinks to under-16s after study links them to health risks - Latest From ITV News 

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Video report by ITV News' Social Affairs Correspondent Stacey Foster, words by Sophia Ankel, Content Producer Play Brightcove video
The consumption of energy drinks is linked with an increased risk of mental health issues among children and young people, including depression and suicidal thoughts , a new study has revealed.

The study, which is the most comprehensive of its kind so far, was published in the Public Health journal on Monday.

It found that the highly-caffeinated drinks not only have an effect on the physical health of young people, but on their mental health too, impacting everything from academic performance to diet and sleep.

Energy drink consumption, which is known to be more common among boys than girls, is also linked to increased risky behaviours such as substance abuse, violence, and unsafe sex, the study found.

Consumption is also linked with ADHD-like , including hyperactivity and inattentiveness, the added.

Data was comprised by researchers from Fuse, the Centre for Translational Research in Public Health at Teesside University and Newcastle University, who looked at 57 studies of over 1.2 million children and young people from 16 countries around the world.

Young people in the UK were the biggest consumers of energy drinks in Europe for their age group, the study showed.
UK healthcare bodies raise alarm
It did not reveal what brand of energy drinks were looked at.

The new data comes as more than 40 healthcare bodies signed a letter to the government demanding it to "finally implement the national sales restriction on these harmful drinks to under 16 year-olds."

The letter said: "The effects of these drinks are more significant and broader than previously understood - in particular negative outcomes for children's mental health in addition to physical health.

"How much more evidence is needed before the government take action?"

National supermarkets have banned selling energy drinks to under 16-year-olds. Credit: ITV News

Signatories of the letter include the Royal College of Pediatrics and Child Health, the British Diabetic Association, and the British Dental Association.

A Department of Health and Social Care (DHSC) spokesperson told ITV News: "All drinks with a high caffeine content, apart from tea and coffee, must carry warnings stating they are not suitable for children or pregnant or breastfeeding women."

The sale of energy drinks to children under 16-year-olds was also banned by most major UK supermarkets - including Tesco and Sainsburys - in 2018.
Adelle Overd confronted the owner of a corner shop who had sold her 12-year-old daughter an energy drink to be told 'if your daughter brings me money in, I will gladly sell her this energy drink.'
But experts said supermarket bands and warning labels are not sufficient enough to stop children from buying the increasingly popular drinks, which are still available to buy in local shops.

Adelle Overd took on the local corner shop that had sold her daughter Freya an energy drink when she was just 12 years old.

She said: "I was fuming, but scared. I think that was another reason why I was so angry with them, thinking what have they potentially just done to my daughter."

Ms Overd was told by the owner that they had "a business to run and if your daughter brings me money in, I will gladly sell her this energy drink."

Professor Amelia Lake, Professor of Public Health Nutrition Fuse, the Centre for Translational Research in Public Health, at Teesside University told ITV News: "If parents look at these cans, the cans will say on them that they are not suitable for children.

"But I think that there is a lot of confusion around whether they are or they are not suitable for children and it is very clear that they are not."
'Students as young as nine were bringing in a new energy drink into school', Headteacher Sarah Kent tells ITV News
The issue has prompted some schools, like Whitstable Junior School in Kent, to ban the drinks from school grounds entirely.

Headteacher Sarah Kent told ITV News: "For some time now the school hasn't allowed energy drinks in school."

She explained there was a period last year when students as young as nine were bringing in a new energy drink into school.

"In the way that that was marketed meant children didn't see it as an energy drink, they saw it as a health drink," She said.

"We've noticed that children we know that drink those drinks, there is an impact on their behavior - they find it difficult to concentrate in class and to regulate their emotions.
Energy drinks are becoming increasingly more popular with young people
"A lot of them talk about difficulties they have with sleep, so it almost becomes a vicious cycle with them," she added.

Over the years, energy drink brands have increasingly been targeting young people through online adverts, computer games, television and sports sponsorship.

On drink that has been particularly popular with children is Prime, which was launched by social media influencers and former boxing rivals Logan Paul and Olajide "KSI" Olatunji last year.

The energy drink was so in-demand that bottles flew off the shelves, leading to chaotic scenes in supermarkets and some shops selling for as much as £100.

But the company received criticism from experts and politicians alike after it was revealed the drink contains more than 200 milligrams of caffeine per can - almost twice the amount of energy drink Red Bull and equivalent to around six cans of Coke.

On the company's website, a fact page states: "Prime Energy is not recommended for children under the age of 18, women who are pregnant or nursing or individuals who are sensitive to caffeine."

British Soft Drinks Association (BSDA) Director General, Gavin Partington said: "The BSDA's voluntary Code of Practice on energy drinks, which was introduced by and for BSDA members in 2010, contains a number of stringent points on responsible marketing, meaning BSDA members do not market or promote energy drinks to under-16s, nor do they sample products with this age group.

"In addition, our members' energy drinks carry an advisory note stating 'not recommended for children'. BSDA members remain committed to supporting the responsible sale of energy drinks."

is a mental health charity which promotes the views and needs of people with mental health issues. It provides to empower anyone experiencing a mental health problem, and to improve services, raise awareness and promote understanding. Call 0300 123 3393 or email

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Energy drinks linked to depression among children, study shows | ITV News

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More than 40 medical organisations are now calling on the government to restrict the sale of energy drinks to young people. | ITV National News

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Alternatives to energy drinks - Kimberley Burns 

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Alternatives to energy drinks - Kimberley Burns 

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Alternatives to energy drinks Kimberley Burns

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Are Energy Drinks Bad For You? (What The Science Says)