Research Energy drinks: health risks and toxicity Naren Gunja he new millennium has ush- MB BS, FACEM, Medical Abstract 1 ered in a wave of synthetic, Director and Toxicologist, Objectives: To describe the epidemiology and toxicity of caffeinated energy and Clinical Senior caffeinated high-energy 2 T drink exposures in Australia. Lecturer drinks targeted at the youth market. Design, setting and subjects: Retrospective observational study analysing data Jared A Brown Over the past 10 years, the consump- BPharm(Hons), MPH, from calls regarding energy drink exposures recorded in the database of an Senior Poisons Specialist tion of caffeinated beverages intended Australian poisons information centre over 7 years to 2010. (Research and Audit)1 to “energise” has increased signifi- Main outcome measures: Type of exposure; co-ingestants; symptoms cantly. Energy drinks were recently reported; and reported hospitalisations. 1 NSW Poisons Information shown to comprise 20% of the total Centre, The Children’s Results: Callers reported 297 exposures to energy drinks, which showed an Hospital at Westmead, convenience store beverage market, increasing annual trend from 12 in 2004 to 65 in 2010. Median age for the 217 Sydney, NSW. with “Red Bull” and “V” accounting subjects with recreational exposure was 17 years (interquartile ratio [IQR], 15–21; 2 Discipline of Emergency range, 11–60) and 57% were male. One hundred recreational users co-ingested Medicine, Sydney Medical for over 97% of sales in this multimil- 1 School, University of lion-dollar industry. Increasingly, other substances, predominantly alcohol (50) or other caffeinated products Sydney, Sydney, NSW. toxicity from caffeine overdose is (44). The number of energy drinks consumed in one session varied greatly (median, 5 units; IQR, 3–8; range, 1–80). Most subjects who reported naren.gunja@ being reported to hospitals and poi- sydney.edu.au recreational use reported experiencing symptoms (87%). The most common sons centres. symptoms were palpitations, agitation, tremor and gastrointestinal upset. The main active constituents of Twenty-one subjects had signs of serious cardiac or neurological toxicity, MJA 2012; 196: 46–49 energy drinks include varying amounts including hallucinations, seizures, arrhythmias or cardiac ischaemia. At least 128 doi: 10.5694/mja11.10838 of caffeine, guarana extract, taurine and subjects (57 with no co-ingestants) required hospitalisation. ginseng. Additional amino acids, vita- Conclusions: Reports of caffeine toxicity from energy drink consumption are mins and carbohydrates usually com- increasing, particularly among adolescents, warranting review and regulation of the labelling and sale of these drinks. Educating adolescents and increasing the plete the list of purportedly beneficial 2 community’s awareness of the hazards from energy drinks is of paramount ingredients. The intended effects of importance. energy drinks are to provide sustenance and improve performance, concentra- tion and endurance. Manufacturers on medical complications from energy in the 7-year period from January pitch their product to athletes, students drinks.8 Our study was undertaken to 2004 to December 2010. Our search and people in professions that require obtain an understanding of the scope strategy included “guarana”, “caf- sustained alertness. These drinks are of consumption-related issues and feine”, “ethanol”, “food additives”, also commonly consumed at dance toxicity from caffeinated energy “energy drink”, “alcohol: other/ parties, which require sustained energy drinks in Australia by analysing data unknown”, and “non-drug product: for prolonged activity into late hours. In from calls to the NSW Poisons Infor- other/unknown”. Due to the large this setting, they may also be combined mation Centre (NSWPIC) — the larg- number of “other/unknown” expo- with alcohol and recreational drugs est centre of its type in Australia, sures, a filter was applied to find such as ecstasy (MDMA; 3,4-methyl- taking about 110 000 calls per year, results with the name of any known enedioxymethamphetamine) or other which is 50% of all poisoning-related Australian marketed energy drink or amphetamines. Young adults and ado- calls in the country. “caffeine” or “energy” in the free-text The Medical Journallescents of Australiaare particularly ISSN: 0025- attracted to product name field. “Recreational” 729X 16 Januaryenergy 2012 196drinks 1 46-49 because of effective ingestion was defined as intentional ©The Medicalproduct Journal marketing, of Australia peer 2012influence and Methods ingestion for the purpose of gaining www.mja.com.aua lack of knowledge of the potential euphoria or other psychotropic effect. Research harmful effects.3-5 The high sugar con- We undertook a retrospective review “Accidental paediatric” ingestion was tent in caffeinated energy drinks is sim- at the NSWPIC. Data included calls defined as non-deliberate ingestion ilar to other soft drinks and is known to providing advice to the general public by a person under 18 years of age. contribute to obesity.6 and health professionals. Calls from Finally, all the cases found from this Adverse reactions and toxicity from New South Wales, Tasmania and the search were subjected to manual high-energy drinks stem primarily Australian Capital Territory are exclu- review for inclusion and subsequent from their caffeine content.7 The sym- sively handled by NSWPIC from 6 am coding and verification of the pathomimetic effects of high-dose to midnight; an after-hours call-shar- reported type of exposure, co-ingest- caffeine mostly explain the symptoms ing system is in place with interstate ants, symptoms, dose, brand of drink, and hospital presentations related to poisons centres. Ethics approval was and the subject’s age, sex and hospi- energy drinks. There is little published obtained from the human research talisation status. Symptoms and cod- literature on the extent and epidemi- ethics committee of the Children’s ing were reviewed separately by the ology of this problem. Indeed, a Hospital at Westmead. authors. Discrepancies were discussed recent literature review on the effects We searched the NSWPIC Micro- until agreement was achieved. of energy drinks in children and ado- soft Access database for calls relating We used mean and SD to describe lescents found only eight case reports to caffeinated energy drink ingestions normally distributed data, and 46 MJA 196 (1) · 16 January 2012 Research 1 Annual number of energy drink exposures reported to the NSW Poisons Information Centre, Jan 2004 – Dec 2010, by type of exposure 60 50 40 30 Recreational Accidental paediatric 20 Number of exposures 10 0 2004 2005 2006 2007 2008 2009 2010 median and interquartile range (IQR) amounts of energy drink consumption Year for non-parametric data. All statistical and were frequently reported with analyses were performed using SPSS, recreational use (87%; 188/217). The 2 Energy drinks accounting for most exposures reported to the version 19.0 for Windows (SPSS Inc, most commonly reported symptoms NSW Poisons Information Centre, Jan 2004 – Dec 2010 Chicago, Ill, USA). were related to gastrointestinal upset and sympathetic overdrive, as can be Main ingredients, dose/ Maximum Product 100 mL volume* (mL) No. of calls Results predicted for caffeine toxicity. Twenty- one callers reported signs of serious Red Bull Caffeine, 32 mg 500 126 Sugars, 11 g Over the 7-year period that we exam- toxicity such as hallucinations, sei- ined, data for 297 calls related to caf- zures, and cardiac ischaemia. At least V Caffeine, 32 mg 500 68 feinated energy drink exposures were 128 people required emergency Guarana extract, 120 mg recorded. Call numbers increased department (ED) attendance, 57 of Pulse Ethanol, 7 g 300 15 from 12 in 2004 to 65 in 2010 (Box 1). whom had not co-ingested another Caffeine, 7 mg The most common exposure type was substance. Of those attending an ED, Mother Caffeine, 32 mg 500 25 recreational (217); other exposures 79 had self-presented and 49 had Sugars, 10.5g were classified as accidental paediatric been referred by the NSWPIC for fur- RockStar Caffeine, 32 mg 473 5 (62), deliberate self-poisoning as part ther management based on the clini- Guarana extract, 10 mg of a polypharmacy overdose (16), cal significance of their symptoms. Ginseng extract, 20 mg allergic reaction (1) and paediatric lac- Sugars, 13 g Accidental paediatric ingestion tational exposure (1). The brands of Other/ ––58 energy drinks to which subjects were Sixty-two children were reported to unknown most commonly exposed and their have accidentally ingested energy Other caffeine-containing products (for comparison) active ingredients are listed in Box 2. drinks (mean age, 38 months; SD, 24 Cola drinks Caffeine, approximately – nd Sixty per cent of calls were received months; range, 7–120 months). Of 40 mg per can (11 mg per 100 mL) between 5 pm and 3 am. these, 14 had symptoms probably Coffee Caffeine, approximately –nd related to energy drink consumption 25–200 mg per cup Recreational use — most commonly hyperactivity (Box No-Doz/No- Caffeine, 100 mg/tablet – 545 Typically, recreational users were ado- 4) — and nine required assessment in Doz Plus (packs of 24 and 100) lescents or young adults. Median age hospital. nd = not determined. * Of individual serving sold. ◆ was 17 years (IQR, 15–21; range, 11– 60), and 57% were male. The number Discussion of drinks consumed in one session In 2009, the energy drink industry varied greatly (median, 5 units; IQR, Our study demonstrates the extent of spent nearly $15 million on marketing 3–8 units; range, 1–80 units). Co- the growing problem in Australia with alone in Australia. Value growth in the ingestion of other substances was energy drink consumption and toxi- convenience sector had increased by recorded for 46% of recreational users city, particularly among adolescents. 20% as compared with 10% for car- (Box 3). The most popular co-ingested Serious adverse effects and toxicity bonated beverages on the whole.9 The substances were alcohol and other are seen with energy drinks contain- target population for these types of caffeine-containing products.