“Deaths linked to energy drinks” has become a sad and all too frequent headline in recent years. The rise in energy drink use in the sporting world has been exponential as few products have inserted themselves into athlete's lives the way that caffeine-laden energy drinks have over the last 30 years. What began as a novel way to party through the night has become a mainstay of athletic preparation for a large portion of active adolescents and young adults who are seeking some magical performance edge. On the surface, this sounds reasonable until we consider that energy drinks have a number of crucial flaws. The simple fact is that energy drinks fail to provide their implied value for most consumers, and they contain one or multiple ingredients that may place athletes in peril for adverse outcomes, including death. It is time for the sports medicine community to take a stronger stand on the use of energy drinks if we are to be true to our mission to safeguard the health and well-being of our athletic population.
Energy drinks and energy “shots” are nonalcoholic beverages typically comprised of solutions of sugar and carbohydrate, moderate to high amounts of caffeine, and a variety of other proprietary chemicals touted to have energy-giving properties. Though their marketing often focuses on these other chemicals, most notably taurine, glucuronolactone, guarana, yerba mate, and even ephedra, at their core, energy drinks are just cleverly crafted vehicles for sizable quantities of caffeine. Because the FDA considers them supplement products and not foods, energy drinks and shots are not held to the same caffeine limits used for standard beverages. This allows manufacturers to produce them with far higher caffeine concentrations than would be acceptable for soda or coffee, and this lack of regulation clearly contributes to the risk for misuse. Standard 8-oz. energy drinks contain 80 mg to 100 mg of caffeine (a large cup of coffee may contain 200+ mg) while “shots” may contain nearly 200 mg of caffeine in only 2 oz. Though product labels do accurately reflect the synthetic alkaloid caffeine content of these drinks, many of the natural additives, most notably guarana and yerba mate, are powerful natural sources of caffeine that are not included in the labeled total. The end result is a product with a far higher caffeine concentration than even the savvy consumer could reasonably determine.
So is there justification for the sports world's obsession with caffeine and related stimulant products? Caffeine has long been heralded as a performance-enhancing chemical, but exercise physiology studies to date have shown caffeine to have limited to no value for sport. Moderate caffeine consumption in the range of 3 to 6 mg·kg−1 has been shown to have a positive impact on performance but only in trained athletes during sustained maximal endurance exercise. No value has been consistently proven for short-burst or power activities, resistance exercise, or with consumption of 9 mg·kg−1 or higher. This lack of proven efficacy is ironic in light of the fact that energy drink use is highly associated with the desire to “amp up” a gym workout or power lifting session where caffeine has no proven ergogenic value. They also are widely consumed in the precompetition time frame as a means of increasing energy or intensity for sport but, again, the data do not support value in those settings either. For most, caffeine intake enhances the perception of athletic prowess but fails to deliver the physiologic value to justify its use. All risk, and no gain. And the risks are substantial.
Considering the widespread use of stimulant products, it is no surprise that there have been an alarming number of case reports of significant adverse reactions in association with energy drink consumption. Visits to emergency rooms and calls to poison control centers relating to excessive caffeine or stimulant intake are increasing each year. Tragically, energy drink consumption has been associated with cardiac arrest, myocardial infarction, spontaneous coronary dissection, coronary vasospasm, and ventricular tachyarrhythmias. Other serious adverse effects have included seizures, stroke, subarachnoid hemorrhage, acute renal failure, rhabdomyolysis, hallucinations, anxiety, agitation, acute psychosis, and high risk/aggressive behavior. These adverse events often result from a “perfect storm” of physiologic factors coming together, the foundation of which is generally an undiagnosed underlying medical condition which becomes manifest when sufficient exacerbating factors are present. In these energy drink cases, the effects of caffeine and other stimulants, coupled with the stresses of sport-elevated heart rate and blood pressure, dehydration, heat stress, and other ingested substances, especially psychostimulants — may precipitate a serious or even lethal event. It is important to note that these risks are even greater in adolescents who often have limited tolerance to caffeine due to infrequent consumption. As a result, younger athletes are more subject to complications, particularly when consuming large and rapid doses of caffeine present in energy drinks, especially in combination with exercise.
Concerning trends in the use and misuse of energy drinks can be traced to the obvious appeal generated through aggressive advertising and implied claims of sport benefit. Young, impressionable athletes are inherent risk takers and are increasingly seeking whatever advantage they can gain to augment their sport performance. Energy drink consumption then becomes an accepted part of their athletic preparation because of the inaccurate sense that these products provide a physiologic boost that cannot be obtained without them. These beliefs are further fueled by clever and often deceptive marketing to this vulnerable population. Bright, colorful packaging with a variety of powerful images and enticing names lure athletes with their implied benefits of enhanced athletic performance and boundless energy. Sponsorships of prominent sports teams and major sporting events only deepen the association between energy drinks and visions of athletic success. Unfortunately, there are no safeguards in place to desensationalize these products and their purported athletic value. Products with legitimate athletic value should be safe and should stand on their physiologic properties alone; energy drinks simply do not.
So, what are we as a group to do? The sports medicine community owes it to our athletes and active patients to stand up against the rampant and uncontrolled use of energy products. We must be on the front lines of efforts to change the trajectory of this societal trend. All sports medicine providers need to be vocal in our educational efforts for prudent use and to ensure that every athlete knows what the risks and benefits, if any, are from stimulant products that they may be consuming. We need to reiterate again and again that caffeine and its related stimulant chemicals have little to no value to the vast majority of athletes, but the risks extend to everyone who consumes them. Pressure must be applied to compel manufacturers to market their products in a fair and unbiased way with a focus on scientific fact rather than unfounded hype and profit motive, and they should be prevented from targeting vulnerable populations who stand to be harmed the most by energy drink use. Manufacturers also should be required to fairly represent what they know about the potentially harmful effects of their products and clearly provide point of sale information to help consumers make choices appropriate to their athletic or activity goals. The FDA should classify all energy drinks as foods, rather than supplements, so that they will be held to the same caffeine concentration standards as soda and related drinks. Finally, much research is needed to fully understand the safety and efficacy of this group of products; we have really only scratched the surface. If athletes are going to use energy drinks and related products, they need guidance in product choice, caffeine amount, prudence of use for a given athletic endeavor, and avoidance of accidental or intentional overuse. We as sports medicine providers are in a unique position to meet these needs. Our consistent message must be that athletic feats are achieved through hard work and optimal lifestyle management. Energy drinks are a hazardous shortcut that only puts athletes in harm's way. All risk, no gain.
The author declares no conflict of interest and does not have any financial disclosures.