Many consumers are aware of the safety concerns surrounding energy drinks combined with alcohol, but energy drinks in their own right are an increasing cause for concern. Dr. Stacy Fisher, a cardiologist who specializes in congenital heart disease and director of Complex Heart Disease on the faculty of the University Of Maryland School of Medicine, says she sees an increasing number of patients with problems such as palpitations, shortness of breath and nausea related to energy drinks. The problem is that they don’t make the connection; sometimes their doctors don’t either. “Our standard questions are about alcohol, illicit substances and tobacco use. Sometimes we ask about caffeine use, but not specifically energy drink use,” Fisher says. “The medical community is just learning to start asking about these products.” When they do ask, they find that patients are affected by products such as Monster Energy or Red Bull but never knew there was a risk in drinking them. The Risks Energy drinks have no official federal definition, but they are generally thought of as beverages with caffeine and other stimulants marketed for their energizing effect. Caffeine levels vary between these drinks. An 8-oz. can of Red Bull might have 80 mg, while a 32-oz. Monster contains 320 mg. The Monster would probably be considered four servings, but the can is non-resealable, and many people tend to drink the whole thing like they would a soda. In the U.S., 80 percent of adults consume caffeine every day, and the average adult has a daily intake of 200 mg. Every person reacts differently to the drug, but the level where someone starts to have caffeine toxicity symptoms is usually about 400 mg. A 12-oz. (tall) coffee from Starbucks will run you about 260 mg, while a 14-oz. Dunkin’ Donuts coffee contains 178 mg. But even just 50 mg of caffeine has the potential to induce tachycardia and agitation. At higher levels, “caffeine toxicity can mimic amphetamine poisoning and lead to seizures, psychosis, cardiac arrhythmias and, potentially but rarely, death,” reads one 2012 study in the Medical Journal of Australia. Another paper in Current Opinions in Pediatrics notes that the effects of chronic high caffeine intake in children and adolescents are unknown, but that it may “raise blood pressure, disrupt adolescent sleep patterns, exacerbate psychiatric disease, cause physiologic dependence, and increase the risk of subsequent addiction.” Energy drink makers are required to tell the U.S. Food and Drug Administration (FDA) about any adverse events related to their products. Data recently obtained by the Center for Science in the Public Interest (CSPI) regarding these reports show that there have been 34 deaths linked to energy drinks since 2004, with half occurring since 2012. Of these, 22 deaths were linked to 5-Hour Energy, 11 to Monster and one to Rockstar. Since the reports don’t prove causality, FDA is investigating these incidents to determine whether the deaths were caused in some way by consumption of energy drinks. Between Jan. 1, 2004, and March 10, 2014, FDA was also informed about 241 non-fatal events where consumers experienced high blood pressure, convulsions, heart attacks and other problems. Of these cases, 115 resulted in hospitalization, 15 in disability and one in miscarriage. A recent report published by the Substance Abuse and Mental health Administration (SAMHSA) found that the number of emergency department visits involving energy drinks doubled from 10,068 visits in 2007 to 20,783 visits in 2011. All of this is set against the backdrop of increased energy drink sales. In 2011, sales increased by 12.5 percent overall and by 15-30 percent for Red Bull and Rockstar. What’s in There? Federal law allows for caffeine in soda up to 71 mg per 12 ounces, but energy drinks aren’t categorized as such, even though consumer advocates think they should be because of how they’re marketed and where they’re placed in stores. In addition to no limits on the amount of caffeine in energy drinks, companies are not required to disclose the caffeine content on labels. American Beverage Association member companies and some independent ones do disclose it voluntarily, but many do not. And it’s not just the caffeine that has Fisher and other consumer advocates worried. They are also wary of other additives that are “generally recognized as safe” (GRAS). Guarana, which naturally contains caffeine, is commonly added to energy drinks on top of the synthetic caffeine but in unknown quantities. When caffeine levels are included on a drink label, Fisher says this additional stimulant is not usually included in the number. And some products have mixtures of taurine, an amino acid which makes the heart pump harder and stronger. “Can that help performance? Sure,” Fisher says. But there’s a catch. “When we take inotropes — the class of drugs [that make the heart beat harder like taurine does] — and give them to heart failure patients, they do better, but they don’t live as long.” These, along with other ingredients such as glucuronolactone and ginseng, “have no nutritional value and may, individually or collectively, pose the apparent health risks from consuming energy drinks,” according to CSPI. “As far as we can tell, the FDA has not examined some of those ingredients for safety, effectiveness, purity, or interactions with other energy-drink ingredients.” And, like any other sugar-sweetened beverage, there is also the concern that the amounts of added sugar in energy drinks can contribute to the development of obesity and diabetes. Youth Problem In addition to adults with underlying structural heart disease — like those whom Fisher treats — children are most at risk for adverse effects from energy drink consumption. While adults might be able to handle 200 mg of caffeine without a problem, children and smaller people don’t have the same kind of metabolism. There is no tolerance level established for kids and, according to the American Academy of Pediatrics, “caffeine and other stimulant substances contained in energy drinks have no place in the diet of children and adolescents.” In 2011, 14-year-old Anais Fournier from Maryland died from cardiac arrhythmia due to caffeine toxicity after consuming two 24-oz. Monster drinks in a 24-hour period. Other cases linked to the energy drinks include the death of a 19-year-old in California, brain damage in a 16-year-old in Oklahoma, and the deaths of three teenage boys in Canada. And, apart from direct injury, teens who consume energy drinks have been shown to seek out risky behavior and have higher rates of alcohol, cigarette, or drug use. Teens and young adults make up the largest percentage of those who buy energy drinks, accounting for nearly $2.3 billion in sales. It’s estimated that about 30 percent of adolescents report consuming energy drinks. According to a study from the U.S. Centers for Disease Control and Prevention (CDC), 8 percent of young people drink energy drinks weekly, 20 percent think that energy drinks are safe drinks for teens, and 13 percent think that energy drinks are a type of sports drink. Fisher says that, in her own experience, she has seen half the kids on her 14-year-old son’s football team drink a large energy drink before practices. According to CSPI, industry representatives at a Maryland legislative hearing earlier this year stated that energy drink companies define “minors” as younger than 12 years old for marketing purposes. These drinks are frequently marketed on youth-targeted cable networks such as Adult Swim, MTV and Comedy Central. Energy drink brands also have a very strong presence on social media and will sponsor events such as extreme sports competitions and music festivals. The Rudd Center for Food Policy & Obesity at Yale University has found that teens saw an average of 124 TV ads for energy drinks in 2010 — more than other beverage categories, including sodas, sport drinks and fruit drinks. “Despite the risks … these companies are really disproportionately targeting teens,” says Roberta Friedman, the Rudd Center’s director of public policy. Regulation Requests Along with release of the adverse event data, CSPI sent a letter to FDA Commissioner Margaret Hamburg on June 25 asking that the agency require energy drink containers to carry a warning label about the risks of heart attacks, convulsions and other adverse reactions. The group also wants the caffeine in energy drinks limited to the same levels as “cola-type beverages” and for the common ingredients in energy drinks to be tested for safety in combination, as well as separately. Additional regulations suggested by Fisher, the Rudd Center and others include limits on the size of energy drink containers, requiring containers to be re-sealable, and excise taxes. When it comes to marketing, it’s also been suggested that energy drink brands self-regulate like alcohol suppliers who agree not to advertise in media outlets with an audience comprising more than 30 percent minors. A 2011 Rudd Center survey found that 74 percent of parents believe that energy drinks should not be sold to teenagers. Suffolk County, NY, and Mexico have already set the precedent of restricting the sale of these beverages to minors. FDA does not regulate energy drinks as their own category, “but the products are indeed regulated, and should there be any sort of problem with a product that presents an ‘out-and-out’ demonstrated risk to consumers, we can take steps to get that particular product off the market,” an agency spokesperson tells Food Safety News. In addition, FDA says it has no current plans for warning labels. The agency has expressed concerns about caffeine added to foods and has asked the Institute of Medicine (IOM) to convene a workshop on the potential health hazards of caffeine consumption. FDA is now waiting for a report from IOM to “determine next steps” in caffeine regulation. “I honestly think that FDA needs to address this quickly,” Fisher says. “What I’m seeing in my everyday practice is a lot of illness, a lot of morbidity, and some mortality because of these products.”