a research paper on energy drink

• Open access
• Published: 04 June 2022

Is the consumption of energy drink beneficial or detrimental to health: a comprehensive review?

• Hani’ Ariffin 1 ,
• Xiu Qing Chong 1 ,
• Pei Nee Chong 2 &
• Patrick Nwabueze Okechukwu   ORCID: orcid.org/0000-0002-3855-2666 1  

Bulletin of the National Research Centre volume  46 , Article number:  163 ( 2022 ) Cite this article

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Energy drinks (EDs) are a type of beverage that mostly contains caffeine and other dietary supplements (if present) and does not contain any alcohol in the ingredients. The products in this category include Red Bull, Redline, Monster, Full Throttle, and others. They are claimed to help in boosting energy, stamina, sports performance, and concentration among individuals. This article focused on the review of the benefits and disadvantages of consumption of energy drinks to health and well-being. ED provides health benefits effects such as improved physical performance, mood and attitude, cognition, and weight loss. Some adverse negative health challenges have been linked to consumption of ED. Therefore, this review is a wholistic appraisal of benefits or detriments of consumption of energy drink to our health and suggestions to curtail the excesses of ED consumption.

Energy drink has been around since 1950, and it is marketed as energy booster and comes in different types, energy shots, fruit-based, non-fruit-based (regular), sugar-free, and plant-based. These products are marketed as a low-calorie “instant” energy drink that can be consumed in a single sip, or bottle to boost energy or to boost the nutritional value of conventional products. Many of them contain different ingredients such as caffeine, guarana, ginseng, yerba mate, acai berry, ginkgo biloba, methylxanthines, sugar, glucuronolactone, taurine, maltodextrin, B vitamins. Vitamin B2 (riboflavin), B3 (niacin), B6 (pyridoxine, pyridoxal, and pyridoxamine), Inositol B8 and B12, vitamin C and vitamin D; calcium, Iron, chromium, zinc, manganese, molybdenum; artificial sweeteners, aspartame, and sucralose. Health benefits such as improved physical performance, improved mood and attitude, improved concentration, and memory, good source of vitamin B and weight loss have been reported. Negative impact on health such as adverse cardiovascular effect, headaches, epileptic seizures, ischemic stroke, hallucinations, muscular twitching, restlessness, sleeplessness, anxiety, depression, gastrointestinal effect, renal effects, dental effects, obesity and type II diabetes, cancer, and caffeine toxicity has been reported.

Conclusions

Most of the health detriments caused because of consumption of energy drink is mostly due to the presence of excess quantity of caffeine and sugar. If the quantities of caffeine and sugar content in energy drink are kept at FDA- and WHO-recommended daily consumption amount, then it will not be present any problem to health. Consumption of energy drink that contains natural ingredients such as yerba mate, acai berry, ginkgo biloba, methylxanthines, amino acid, guarana, and ginseng with moderate FDA- and WHO-approved daily consumption of caffeine and sugar is not detrimental to health.

Energy drinks (EDs) are a type of liquid beverage that contains caffeine and may or may not contain other dietary supplements (Alsunni 2015 ). They are non-alcoholic drinks that claim to boost energy, stamina, sports performance, and concentration (Al-Shaar et al. 2017 ). Energy drinks use a combination of stimulants and energy boosters to give the consumer an “energy boost.” Caffeine is the main ingredient in most energy drinks. They typically have 80–150 mg of caffeine per 8 oz, which is about the same as 5 oz of coffee or two 12-oz cans of caffeinated soda (Alsunni 2011 ). Most brands on the market are high in glucose, while some do provide artificially sweetened variants. The common ingredients used in ED are being classified into 4 different categories: natural extracts (ginseng, guarana, yerba mate, acai, caffeine, and ginkgo biloba), macronutrients (carbohydrates and protein), micronutrients (vitamins and minerals), and artificial sweeteners (aspartame and sucralose).

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. The capability of EDs to control mood, increase alertness, reduce fatigue, improve athletic performance (Giles et al. 2012 ), and lower high levels of perceived stress has been promoted aggressively among college students (Pettit and DeBarr 2011 ).

Currently, there are major concerns about the safety of these products. There have been several reports linking energy drinks to negative health effects. Despite this, energy drink manufacturers believe that their products are safe and appropriate for customers. Scientists are conflicted on whether energy drinks have negative health impacts. There are only a few extensive reviews of the literature evaluations that show the acceptability and safety of energy drink intake, especially among young individuals.

Article was obtained through online database search from Mendeley, Science direct, Scopus, PubMed, Google Scholar. Search was limited between 2001 and 2021.

Brief introduction of ED

Japan was the first country to invent the energy drink. Amphetamines were immensely popular in the postwar period until legislation was implemented in the 1950s to restrict their usage. Then, in 1962, Taisho released Lipovitan D shown in Fig.  1 A, a legal, stimulating tonic packaged in minibar-size bottles. By the 1980s, Japanese businessmen tried to push the frequent consumption of fortified vitamins and extra-caffeinated drinks (Engber 2013 ). The first energy drink appeared in the USA in 1949 and was marketed as “Dr. Enuf.” They were originally introduced in Europe in 1987, and the market quickly spread across the globe with the introduction of Red Bull in 1997 (Zucconi et al. 2013 ). Since then, the energy drink market has grown rapidly, with several new brands hitting the markets across the world. In 2013, energy drinks were consumed in more than 160 countries for a total of 5.8 billion liters (Bailey et al. 2014 ). In 2017, energy drinks accounted for 30% of all packaged beverages sold in convenience stores in the USA in terms of dollar sales. According to energy drink sales data, the global market for energy drinks was worth $53 billion in 2019 (Edgson 2021 ).

A Energy shots, B variety of fruit-flavored energy drinks, C non-fruit-based (regular) energy drink, D sugar-free energy drink, E plant-based energy drink

Types of ED

Energy shots.

There are two types of energy drinks on the market. One is marketed in bottles the same size as regular soft drinks, such as a 16-oz bottle. The other type, known as “energy shots,” comes in little bottles that hold 2 to 212 oz of concentrated drink (NCCIH 2021 ). Energy shots can contain the same total amount of caffeine, vitamins, or other functional ingredients as their larger versions and may be considered concentrated forms of energy drinks. Energy shots are typically marketed as a low-calorie “instant” energy drink that can be consumed in a single sip (or “shot”), as opposed to energy drinks that encourage users to drink a full can, which can have 250 cal or more (We-energy 2015 ). An example of energy shots of ED (Lipovitan D brand) is shown in Fig.  1 A.

Fruit-based

The development of blended drinks is a successful way to boost the nutritional value of conventional products or to overcome the problems associated with current products (Márquez Cardozo et al. 2017 ). Several researchers have created alternatives to energy drinks based on fruits. For example, Márquez Cardozo et al. ( 2017 ) formulated mango energy drinks containing caffeine at a concentration of 30 mg/100 mL, though Nowak and Goslinski ( 2020 ) evaluated various fruit energy drinks containing pineapple, apple, strawberry, raspberry, carrot, and pomegranate juice. An example of a variety of fruit-based energy drinks is shown in Fig.  1 B.

Non-fruit-based (regular)

Regular or non-fruit-based EDs are beverages that contain large doses of caffeine, sugar, and a variety of other stimulants and substances such as guarana, taurine, or vitamins (Higgins et al. 2010 ). Examples include ED brands such as Red Bull, Rockstar, Monster, Full Throttle ED, and NOS. Figure  1 C shows the non-fruit-based (regular) ED of Red Bull brand (Table 1 ).

In recent years, consumption of sugar-free energy drinks has increased possibly because of the low-calorie, refined sugar content. The main active ingredient in sugar-free energy drinks such as Red Bull is caffeine. Caffeine is one of the most widely used ergogenic aids, with acute caffeine ingestion increasing aerobic exercise endurance and reducing fatigue. Although they are claimed as sugar-free, artificial sweeteners are heavily used as the ingredients such as Aspartame (Null Chiropractic LLC n.d.). It is also known as non-nutritive sweeteners which are high-intensity sweeteners that are used in small amounts to reduce the caloric and sugar content of food and beverages (Choudhary and Pretorius 2014 ). An example of a sugar-free energy drink is shown in Fig.  1 D.

Plant-based

Most energy drinks incorporate additional artificial mood enhancers, synthetic caffeine, and a huge amount of sugar. Plant-based energy drinks, on the other hand, contain only natural caffeine, electrolytes, vitamins, and antioxidants, as well as a blend of natural caffeine, electrolytes, vitamins, and antioxidants. An example of plant-based energy drinks is shown in Fig.  1 E.

Major ingredients and constituents of ED

Natural extracts.

Natural ED may get a boost from the antioxidants, vitamin, minerals, and naturally occurring caffeine derived from the fruits, herbs, and plants. The natural extracts found in various types of ED are summarized in Table 2 .

Caffeine concentration in ED varies significantly, ranging from 47 to 80 mg per 8 oz to 207 mg per 2 oz, and comes from a variety of sources (Generali 2013 ), while moderate caffeine consumption (up to 400 mg per day) is usually regarded as safe and even beneficial to adults' well-being (McLellan et al. 2016 ). Caffeine is a stimulant that antagonizes adenosine receptors and stimulates dopamine neurotransmission in the central and peripheral nervous systems. Interactions with various receptors result in a variety of outcomes. O’Mathúna ( 2021 ) stated that moderate acute dosages (200–350 mg) reduce heart rate and raise blood pressure in adults, while also enhancing emotions of well-being, focus, and arousal.

Reports on other constituents of ED are relatively limited. Guarana is a plant extract native to South America which contains a significant amount of caffeine, with 1 g of guarana equivalent to 40 mg of caffeine (Al-Shaar et al. 2017 ). Guarana is frequently added as an ingredient in ED for its stimulatory impact due to its high caffeine content (Heckman et al. 2010 ). The effects of guarana are currently unknown. It is uncertain whether it has an additional or synergistic impact when coupled with caffeine. However, it has been found that guarana can act as an antioxidant, traditional medicinal, and an effective stimulant. It can also treat fatigue and depression related to cancer treatment (Moustakas et al. 2015 ). The amount of guarana in a 16-oz energy drink can range from 1.4 to 300 mg. Although there are no standard quantities, the FDA considers guarana to be safe. It is also unclear how much guarana is in each drink because many manufacturers do not specify the milligram value. As a result, it is safe to believe that the amount of caffeine in the products is higher than the amount listed, especially if guarana is present (Schimpl et al. 2013 ).

Ginseng has been used as a medicinal herb for ages and is claimed to boost energy, reduce fatigue, relieve stress, and improve memory. It is also claimed to activate the hypothalamus and pituitary glands, which subsequently release an anti-inflammatory hormone called adrenal corticotropic hormone. Normal ginseng-incorporated energy drink appears to have a regular amount of 200 mg per day, although most people can safely take up to 2700 mg through supplementation (Caffeineinformer n.d). However, there are several adverse effects caused by ginseng abuse which include maniac episodes, uterine bleeding, gynecomastia, long QT syndrome, atrial fibrillation with bradycardia, hypertensive crisis, and acute lobular hepatitis (Ratan et al. 2021 ).

Yerba mate is derived from the Ilex paraguariensis plant, which is native to South America and is mostly used to make yerba mate tea. Yerba mate tea has historically been a popular beverage in South American countries; however, its global appeal is growing due to its high concentration of bioactive components such as polyphenols, xanthines, flavonoids, saponins, amino acids, minerals, and vitamins (Valenca et al. 2013 ). Yerba mate has anti-inflammatory and anti-diabetic effects, as well as functioning as an oxidative stress regulator. Furthermore, yerba mate has demonstrated in vitro cytotoxicity to cancer cells as well as inhibition of Topoisomerase II, which is involved in cell division and hence inhibits cancer cell proliferation; however, further in research is needed (Heckman et al. 2010 ). Both in vivo and in vitro yerba mate has a beneficial effect on the management of obesity. In both normolipidemic and dyslipidemic people, yerba mate consumption improved blood lipid markers considerably. Additionally, yerba mate assisted in the decrease in LDL cholesterol levels in people who were taking statins (Yunusa and Ahmed 2011 ).

Acai berry is an ingredient that is increasingly appearing in energy drinks. The acai berry is produced by the Acai Palm tree, which is native to South America. Antioxidants are abundant in the berries, but not as much as in a concord grape or blueberry (Yunusa and Ahmed 2011 ). Most acai berry advantages are unproven and linked to marketing hype. It contains a high number of oxidants, nutrient dense, has anticancer properties, and helps to lower cholesterol levels (Arakelyan 2020 ).

Ginkgo Biloba

The ingredient ginkgo biloba is named after the unique tree from which it derives. It is associated with improvement of memory retention, focus, and circulation, as well as acting as an antidepressant and showing indications of aiding persons with Alzheimer's disease. It is recognized by the German government as a treatment for memory loss, attention problems, and depression. A normal supplemental dose is 60 mg. Most energy drinks, on the other hand, do not contain enough ginkgo to be beneficial. Blood thinning, nausea, vomiting, diarrhea, headaches, dizziness, heart palpitations, and restlessness are some of the other side effects of ginkgo (Yunusa and Ahmed 2011 ).

Methylxanthines

Methylated xanthines (methylxanthines) are produced by many different plant species.

They are commonly found in regular diet, as well as in a variety of incredibly common beverages and meals. Caffeine, theophylline, and theobromine are the most common methylxanthines found in nature. Methylxanthines have a long history of usage as therapeutic agents in a diverse variety of medical applications. Methylxanthines have been/were utilized in medicine as CNS stimulants, bronchodilators, coronary dilators, diuretics, and anticancer adjuvant therapies. Aside from these uses, methylxanthines have been linked to several other health benefits, including neurodegenerative disorders, cardio protection, diabetes, and fertility (Monteiro et al. 2019 ). However, methylxanthines have a limited therapeutic spectrum and, as a result, a high rate of side effects. When concentrations of methylxanthines are below 20 mcg/ml, milder side effects such as nausea, vomiting, increased stomach acid secretion (and subsequent gastroesophageal reflux), polyuria, sleeplessness, palpitations, headaches, and tremors are more common (Gottwalt and Tadi 2021 ).

Macronutrients

Breakdown of macronutrients such as carbohydrates and proteins will contribute to the major sources of energy. Different classes of macronutrients are summarized in Table 3 .

Carbohydrates

Simple sugars (such as sucrose, fructose, or beet sugar) are a fast-acting source of energy and are used in energy drinks to boost cognitive performance. Sugar content in drinks is normally around 27 g per 8 oz. Energy drinks with a higher volume surpass the daily sugar limit of 32 g (Rath 2012 ). The amount of sugar in one can of ED (500 mL or 16.9 oz) is usually around 54 g (Higgins et al. 2010 ). Due to the strong significant evidence linking added sugar consumption to poor health, many institutions, including the World Health Organization, have advised limiting sugar intake (WHO 2015 ).

Glucuronolactone

The human body produces glucuronolactone (DGL) when glucose is broken down by the liver.

This component is found in all connective tissue. DGL is believed to help with detoxification, the release of hormones and other compounds, and vitamin C production. It is included in energy drinks because it claimed to help with glycogen depletion by preventing other compounds from depleting muscle glycogen stores. (Yunusa and Ahmed 2011 ).

A semi-essential amino acid that is not involved in protein synthesis and is abundant in mammalian tissues is known as taurine (2-aminoethanesulfonic acid). It is naturally found in human bodies, mostly in the brain, eyes, heart, and muscles (Beyranvand et al. 2014 ). Taurine is also naturally found in protein sources such as milk, meat, and fish. It is a common ingredient in sports supplements, energy drinks, dietary supplements, and non-caffeinated energy drinks. It has also been proved to help athletes perform better. Taurine is normally included in levels of 1–2 g per serving in products that specify the amount of taurine contained (Childs 2014 ). Taurine has been recommended as a treatment for epilepsy, heart failure, cystic fibrosis, and diabetes due to its anti-inflammatory properties (Caine and Geracioti 2016 ). Taurine may help to manage blood sugar levels and fight diabetes. Without any modifications in food or exercise, long-term supplementation reduced fasting blood sugar levels in diabetic rats used in research labs (Chauhan and Piracha 2021 ). According to some animal studies, increasing taurine intake can help prevent type 2 diabetes by lowering blood sugar levels and insulin resistance (Ito et al. 2012 ). However, additional research is required before any conclusions can be drawn.

Maltodextrin

Maltodextrins (C 6 H 10 O 5 ) n·H 2 O are saccharide polymers composed mostly of glucose units linked by -1,4 glucosidic boundaries. Maltodextrins are produced by enzymatic hydrolysis with or without acid, although only to a lesser amount than starch syrups (Klinjapo and Krasaekoopt 2018 ). Commercially accessible, typically white powders with excellent purity and microbiological safety are utilized in a wide range of food and beverage products, including baked goods and sports drinks (Hofman et al. 2016 ). Maltodextrins are known for their relatively high molecular weights and limited reducing power. Maltodextrin solutions have low osmotic pressures, high viscosities, and little or no sweetness due to their high molecular weights (Featherstone 2018 ). Maltodextrins, like any other carbohydrate, were found to reduce net glycogen breakdown during long-duration exercise while maintaining a high whole-body glucose oxidation rate (Hofman et al. 2016 ).

Micronutrients

Many EDs are fortified with various types of vitamins and minerals. The purpose of the micronutrients (vitamins and minerals) improves person’s emotion and increases the alertness and focus. The health benefits and side effects of the micronutrients in different types of ED are summarized in Tables 4 and 5 .

A group of eight water-soluble vitamins that play a significant role in cell function is referred to as B vitamins. Vitamin B 2 (riboflavin), B 3 (niacin), B 6 (pyridoxine, pyridoxal, and pyridoxamine), inositol B 8 and B 12 are the most common B vitamins added to ED (Heckman et al. 2010 ). Considering the significance of B vitamins as coenzymes in many metabolic processes, most people in the USA already consume the necessary daily quantity, and thus, any additional B vitamins added to ED are often lost in the urine, with no further health benefits (Heckman et al. 2010 ). Other additives including l-carnitine, d-glucuronolactone, and inositol have less research on their composition and function, with just a few studies showing minimal advantages (Yunusa and Ahmed 2011 ).

Riboflavin (B 2 )

Riboflavin, often known as crucial vitamin B2, is a heat-stable water-soluble vitamin. The flavoenzymes of the respiratory chain require riboflavin (B2), which facilitates energy metabolism involving lipids, carbs, and proteins (Yunusa and Ahmed 2011 ). It is also an important vitamin for a variety of physiological functions in the body, such as lowering migraines and boosting the immune system (Suwannasom et al. 2020 ). Riboflavin levels taken orally in a diet or from most multivitamin supplements rarely give side effects or toxicity (Pinto and Zempleni 2016 ).

Niacin (B 3 )

Niacin is used to make the reduced form of nicotinamide adenine dinucleotide (NADH) (vitamin B3). This coenzyme is necessary for supplying protons for oxidative phosphorylation and is important for cell energy production. It also raises the production of l-dopa, dopamine, serotonin, and norepinephrine, among other neurotransmitters (Yunusa and Ahmed 2011 ). Niacin dosage, either alone or in addition with statins and/or bile acid sequestrants, was reported to significantly improve markers of atherosclerosis, such as carotid intima-media thickening and stenosis incidence and balance out the ratio of HDL/LDL cholesterol in patients with dyslipidemia (Meyer-Ficca et al. 2016 ). The characteristics including skin flushing and itching were reported in clinical trials, as well as more significant disorders such as gastrointestinal and musculoskeletal issues, heart failure, diabetic complications, and new-onset diabetes (Meyer-Ficca and Kirkland 2016).

Pyridoxine (B 6 )

Vitamin B6 (pyridoxine hydrochloride) is a coenzyme that plays a role in amino acid and homocysteine metabolism, glucose and lipid metabolism, neurotransmitter generation, and DNA and RNA synthesis. Pyridoxine hydrochloride is involved in protein and red blood cell metabolism, as well as immune system function and the conversion of tryptophan to niacin (Yunusa and Ahmed 2011 ). It also works to utilize a protection reaction against chronic diseases including cardiovascular diseases (CVD) and diabetes by inhibiting inflammation, inflammasomes, oxidative stress, and carbonyl stress (Thanutchaporn et al. 2020 ). However, vitamin B6 can be toxic if its concentration inside the body is too high, resulting in sensory neuropathy with no apparent cause. Degeneration of peripheral nerve sensory fibers and myelin, as well as the dorsal columns of the spinal cord, results in bilateral loss of peripheral sensation or hyperesthesia, as well as limb pain, ataxia, and loss of balance (Abosamak and Gupta 2021 ).

Inositol (B 8 )

Inositol (previously vitamin B8, but no longer considered a vitamin because it is produced by the human body) comes in nine different stereoisomers, the most common of which being myoinositol. It is a component of cell membranes, aids in the digestion of fats by the liver, and aids muscle and nerve function (Higgins et al. 2010 ). The consumption of inositol may also help in preventing the development of chronic diseases—including obesity, diabetes, polycystic ovary syndrome (PCOS), metabolic syndrome, cardiovascular diseases, and cancer (Dinicola et al. 2017 ).

Cyanocobalamin B 12

Cyanocobalamin is a vitamin B12 synthetic compound used to treat vitamin B12 deficiency. It is involved in several methylation reactions in the human body. In the body, it functions as a cofactor in the conversion of homocysteine to methionine as methylcobalamin, and as adenosylcobalamin in the conversion of methylmalonyl-CoA to succinyl-CoA as adenosylcobalamin. Cell division and expansion rely on both responses (Vasavada and Sanghavi 2020). This vitamin also aids nerve cell function, is required for DNA creation, and is necessary for red blood cell formation.

Vitamin C is required for the body's basic physiological activities. It aids in tyrosine, folic acid, and tryptophan synthesis and metabolism, as well as the hydroxylation of glycine, proline, lysine, carnitine, and catecholamine. It promotes cholesterol conversion to bile acids easier, decreasing blood cholesterol levels. Vitamin C also improves iron absorption in the intestines by converting ferric to ferrous. It protects the body from the harmful effects of free radicals, pollution, and poisons as an antioxidant (Chambial et al. 2013 ). Although large doses of vitamin C are safe, there have been reports that they can induce hemolytic anemia in individuals who have glucose-6-phosphate dehydrogenase deficiency (Unlu et al. 2016 ).

Vitamin D is exceptional that it can be produced in the skin because of sun exposure (Nair and Maseeh 2012 ). Vitamin D is both a vitamin and a hormone produced by our bodies. It is a fat-soluble vitamin that has long been recognized to aid in the absorption and retention of calcium and phosphorus, both of which are essential for bone formation. Vitamin D may help prevent cancer, heart disease, fractures and falls, autoimmune illnesses, influenza, type 2 diabetes, and depression, according to recent studies (Nair and Maseeh 2012 ). However, a higher possibility of exogenous hypervitaminosis D with symptoms of hypercalcemia also known as vitamin D toxicity (VDT) is caused by excess intake or overdose of vitamin D (Marcinowska-Suchowierska et al. 2018 ).

Calcium (Ca)

Calcium is most typically associated with the development and metabolism of bone as a nutrient. Calcium hydroxyapatite (Ca 10 [PO 4 ] 6 [OH] 2 ) makes up almost 99% of total body calcium and is found in bones and teeth, where it gives hard tissue its strength. Calcium is required for vascular contraction and vasodilation, muscular function, neuronal transmission, intracellular interaction, and hormone production in the circulatory system, extracellular fluid, muscle, and other tissues. Through the process of bone remodeling, bone tissue serves as a calcium storage and supplier for these key metabolic demands (Ross et al. 2011 ). The prevention of hypertensive disorders of pregnancy and blood pressure reduction not only been linked to a sufficient of dietary calcium consumption but also with low-density lipoprotein (LDL) cholesterol levels and prevention of osteoporosis and colorectal adenomas (Cormick and Belizan 2019 ). However, excess consumption of calcium might lead to increase in the incidence of constipation, severe diarrhea, and abdominal pain (Li et al. 2018a , b ).

Iron is a vital element for practically all living creatures since it is involved in a range of metabolic activities such as oxygen transport, DNA synthesis, and electron transport (Abbaspour et al. 2014 ). The most important health benefits that this nutrient provides are to prevent iron deficiency anemia especially to pregnant mothers and women during menstruation. As for its adverse effects associated with oral iron intake, it is frequently reported to be gastrointestinal side effects which include nausea, flatulence, abdominal pain, diarrhea, constipation, and black or tarry stools (Tolkien et al. 2015 ).

Chromium (Cr)

Chromium is a trace mineral that can help with insulin sensitivity as well as protein, carbohydrate, and lipid metabolism. The exact mechanism by which chromium improves the body is unknown, and human insufficiency reports are uncommon. A deficit could be linked to a variety of health issues. Impaired glucose tolerance leads to poor blood sugar management in persons with type 2 diabetes, and ineffective cholesterol control, which increases the risk of atherosclerosis and heart disease. However, there is insufficient evidence to back up either the advantages of chromium or the risks associated with a deficiency (Wilson and Ware 2021 ).

Zinc is an essential nutrient, which means that your body cannot make or store it. It is an essential trace mineral for maintaining good health and is only second to iron in terms of body content among the trace minerals. It is present in every cell of the body, and it is required for the normal functioning of the body's defensive (immune) system. Zinc can be present in a wide range of foods, both plant and animal. Breakfast cereals, snack bars, and baking flour are typically fortified with synthetic forms of zinc because they do not naturally contain the mineral. Cell division, cell development, wound healing, and glucose digestion are all facilitated by this protein. The senses of smell and taste require zinc as well. The body requires zinc to grow and develop normally during pregnancy, infancy, and childhood. Zinc also helps insulin perform better (MedlinePlus n.d.). There are several adverse effects for excessive intake of zinc which includes immediate symptoms such as abdominal pain, nausea, and vomiting (Plum et al. 2010 ).

Manganese (Mn)

Manganese (Mn) is a mineral that is mostly derived from food and water in the human body. Mn is absorbed by the gastrointestinal system and subsequently delivered to mitochondria-rich tissues (the liver, pancreas, and pituitary, in particular), where it is rapidly concentrated. Mn is also involved in the synthesis and activation of many enzymes (e.g., oxidoreductases, transferases, hydrolases, lyases, isomerases, and ligases); glucose and lipid metabolism; protein, vitamin C, and vitamin B synthesis; hematopoiesis catalysis; endocrine regulation; and immune function improvement (Li and Yang 2018 ). The health benefits for the consumption of manganese in our diet include regulation of cellular energy, bone and growth of connective tissue, blood clotting and improve brain development. However, there are also adverse effects in Mn which includes the increase in oxidative stress, a well-established molecular mechanism of Mn-induced toxicity (Avila et al. 2013 ).

Molybdenum (Mo)

Molybdenum is a crucial trace element for microorganisms, plants, and mammals. It can be found in large amounts in legumes, grains, and organ meats. It helps break down toxic sulfites and prevents toxins from building up in the body by activating enzymes. Mo is required in extremely small amounts by the human body (usually 100 mg per day1), as opposed to macronutrients such as nitrogen, phosphorus, salt, calcium, magnesium, potassium, chlorine, and others, which are required in larger amounts (Sabatino et al. 2018 ).

Artificial sweeteners

The role of artificial sweeteners is to provide sweetness to ED without adding extra calories and glucose. They may also aid in controlling blood glucose level and thus reduce the risk of obesity and diabetes. The health benefits and side effects of the artificial sweeteners in different types of ED are summarized in Table 6 .

Aspartame (E951) is a dipeptide-based synthetic sweetener that is nearly 180–200 times sweeter than sucrose while having a low calorific value. The consumption of regular sugar is restricted in diabetics who have trouble controlling their blood sugar levels. This is caused by diabetics' insufficient amounts of insulin, a hormone that regulates sugar absorption in the bloodstream. Aspartame helps to restrict sucrose intake by acting as a sugar substitute and release a very small amount of energy. Since it is digested more slowly than sucrose, blood sugar levels stay steadier over time. After swiftly absorbing glucose into the bloodstream, people with reactive hypoglycemia produce an excess of insulin (Zafar et al. 2017 ). Aspartame metabolites may also be a primary cause for adverse effects, such as headache, compromised memory, mood changes, and depression and others which are not being identified yet (Lindseth et al. 2014 ). Aspartame's metabolic metabolites (aspartic acid, phenylalanine, and methanol) have been determined to be more toxic to the body than the original chemical. After ingesting aspartame, both normal persons and phenylketonurics saw a significant increase in plasma phenylalanine levels (Stegink et al 1977 ; Koch et al 1976 ). Many studies have linked aspartame consumption to health implications. There could be a link between aspartame consumption and the development of diabetes mellitus (DM) and type 2 diabetes (T2D), as well as effects on obesity levels, glucose and insulin intolerance, and alterations in the microbiota of rats' offspring. In humans, there have been reports of premature birth, allergic reactions, and weight gain in newborns, increased risk of early first menstruation (11 years), mood disorders, mental stress, and depression, autism development in children, neurodegeneration, modification of neuronal cell functions, disruption of homeostasis, learning, and memory. Aspartame, whose metabolite is phenylalanine, is a common food additive that is particularly toxic to those with phenylketonuria. Aspartame releases 50% of its mass as phenylalanine after digestion, resulting in an increase in phenylalanine levels in the blood. Although the genotoxicity of aspartame is unknown, it has been shown to promote proliferation and slow apoptosis in test cells, suggesting that it may have carcinogenic qualities. Increases in the markers Ki 67, PCNA, and bcl-2 were also seen. The markers c-myc, Ha-ras, and the p53 suppressor gene have all increased significantly. Females who are exposed to aspartame from a young age are more likely to develop lymphomas and leukemias. P27 and H-ras expression has also been found to be higher in studies. There is no evidence of a link between aspartame and pancreatic, gastric, or endometrial cancer. Aspartame's consumption has been linked to free radical generation and decrease in antioxidant enzyme activity (Mohammad et al. 2017 ; Ab Qayoom et al. 2018 ; Zafar et al. 2017 ; Czarnecka et al. 1957 ; Iman 2011 ). Table 7 shows effects of aspartame in various diseases.

Sucralose is a modified version of ordinary sugar (sucrose) with the E number E955 attached to it. It is typically available in granular, liquid, or mini-tablet form under the brand name “Splenda,” or as individual Canderel yellow packets (no other versions of Canderel as they contain different sweeteners). Sucralose has no calories, but because it is so sweet (about 600 times sweeter than sugar), it is frequently blended with other sweetening substances like maltodextrin in granulated form. This adds volume and texture while diluting the strong sweetness. These, on the other hand, are not calorie-free, and a teaspoon has roughly 2–4 cal in it. This is roughly 20% of the sugar calories that the granulated product is supposed to (British Dietetic Association 2018 ). The health benefits for sucralose as a beverage sweetener include improvement in weight loss, as well as prevention of tooth decay, diabetes, and reactive hypoglycemia. Safety concerns regarding sucralose were mostly related to the fact that it comes from a class of chemicals called organic chlorides, some types of which are known as toxic or carcinogenic; however, the chlorine presence in an organic compound does not guarantee its toxicity (Lindseth et al. 2014 ). Thus, there is lack of evidence or study regarding the toxicity and carcinogenic effect of sucralose consumption.

Health benefits of ED

Improved physical performance.

Walsh et al. ( 2010 ) investigated the effects of energy drinks on treadmill exercise time to exhaustion. During a moderate-intensity endurance run, they noticed a significant increase in time to exhaustion, as well as improvements in perceived feelings of focus, energy, and tiredness (Walsh et al. 2010 ). Another research examined how caffeinated energy drinks affected acceleration tolerance and strength when subjected to a “G” load. Energy drinks improved relaxed G tolerance and increased strength but did not influence acceleration tolerance duration, according to the findings (Walker et al. 2010 ). According to the findings of a recent study, caffeinated energy drinks containing around 3 mg/kg of caffeine greatly increased the physical performance of female volleyball players (Perez-Lopez et al. 2015 ).

Improves mood and attitude

Taurine is found in ED ingredients and plays a role in metabolic processes. Amino acids are often added to energy drinks and supplements because they are the building blocks of proteins and precursors of neurotransmitters. The assumption is that enhanced amino acid availability will improve protein synthesis and neurotransmitter reserve, influencing consumer mood (Childs 2014 ). Another research found that 50 mg of guarana in EDs given twice daily for 21 days improved fatigue and tiredness ratings without affecting anxiety or depression in people receiving systemic chemotherapy. Prolonged treatment sessions did not create any noticeable mood effects in healthy participants (e.g., 360 mg 3 times daily for 3 days) or in people undergoing radiation therapy (75 mg daily for 28 days) (Silvestrini et al. 2013 ).

A range of automated memory and attention tests were used to examine cognitive performance, while the mood was assessed using a variety of questionnaires such as the Profile of Mood States (POMS), Bond–Lader, and Chalder Fatigue Scales. Both cognitive function and mood were dramatically enhanced in partially sleep-deprived persons who drank energy drinks, according to the findings. They were able to maintain their initial levels of attention for six hours, but the placebo group was unable to do so (Wesnes et al. 2013 ).

Improved concentration and memory

Only a few randomized controlled trials (RCTs) on energy drinks have been reported. 5-way crossover research with 20 college students (mean age 21 years) was conducted in one of the studies. They drank 250 mL of either flavorants (not expected to have physiological effects), the energetic drink (glucose, caffeine, ginseng, and gingko), or a placebo consisting of the medium used for the other drinks. The energy drink considerably increased “secondary memory” ( P  = 0.007) and “speed of attention” ( P  = 0.044) when compared to the placebo (O’Mathúna 2021 ).

Other studies involving Red Bull energy drink and sports performance have also been documented, in which participants were given either Red Bull or a placebo drink to drink. The Red Bull groups improved their aerobic endurance by 9% ( P  < 0.05), as well as their anaerobic performance by up to 24% ( P  < 0.05). Significant improvements also occurred in mental performance, including choice reaction time, concentration, and memory (O’Mathúna 2021 ).

Good source of vitamin B

Energy drinks frequently include significant amounts of B-group vitamins, often at higher doses than the daily recommended requirement for healthy people. High dietary folate and vitamin B6 intakes have been related to a lower risk of death from stroke, coronary heart disease, and heart failure, according to studies (Cui et al. 2010 ). B vitamins have also been proven to lower homocysteine levels, which have been associated with a variety of comorbidities, including pregnancy problems, cognitive impairment and mental illnesses, and cardiovascular risks. Although B vitamin supplementation lowered homocysteine levels and has a significant protective impact against stroke, there was no advantage in reducing cardiovascular disease, myocardial infarction, coronary artery disease, cardiovascular death, or all-cause mortality, according to a meta-analysis (Huang et al. 2012 ).

Weight loss

Energy drinks have been shown to be relatively useful in stimulating metabolic alterations in various studies (Jeffers et al. 2014 ). Caffeine in energy drinks may accelerate metabolism by fewer than 100 cal per day, which might burn around 1 pound of fat in a month. Caffeine's weight loss effect is dose-dependent, according to Tabrizi et al. 2019 . Repeated energy drinks in a day, on the other hand, can have major health and well-being effects. Nevertheless, there is a lack of evidence and study investigating the effects of energy drinks on weight loss endeavors (Jeffers et al. 2014 ).

Health disadvantages of ED

Adverse cardiovascular effect.

Several researchers have examined the short-term effects of ED on the cardiovascular system, focusing on caffeine and sugar (38–40). Consuming 355 mL of ED raised systolic and diastolic blood pressure, heart rate, and cardiac output according to a recent randomized crossover study on healthy adults (Grasser et al. 2014 ). A meta-analysis of 15 studies published in 2016 found that acute ED consumption led to higher systolic and diastolic blood pressure across the pooled results (Shah et al. 2016 ). Aspartame administration (54.87.3 mg kgG1 b.wt. day) resulted in elevated blood pressure, increased body weight, and a short-term increase in blood pressure, plasma glucose and triglyceride values, as well as a transitory reduction in plasma urea, all of which could affect cardiovascular risk factors (Martinez-Morales et al 2015 ). When compared to a control group, aspartame (40 mg kgG1 b.wt.) causes a rise in blood glucose, cholesterol, and triglycerides (Prokic et al 2014 ).

Caffeine toxicity is assumed to cause at doses higher than 400 mg per day for adults, 100 mg per day for adolescents (12–18 years), and 2.5 mg per kilogram of body weight for children (< 12 years), with serious symptoms often linked to cardiovascular consequences (Seifert et al. 2013 ). The US National Poison Data System received 4,854 ED-related calls between October 2010 and September 2011, including significant adverse events like seizure, dysrhythmia, and tachypnea (Seifert et al. 2013 ). In addition to palpitations, agitation, and tremor, data from Australian poison control centers indicate these primary symptoms of recreational or accidental ED consumption among children and adolescents (Gunja and Brown 2012 ). Considering that these data are based on self-reported signs and symptoms, and most consumers may not recognize ED as a toxin, ED-related toxicity concerns are likely to be underestimated.

Neurological effect

Caffeine causes a pro-nociceptive condition of cortical hyperexcitability, which is connected to acute and recurrent daily headaches (Espinosa and Sobrino 2017 ). Using a statistical model, Mostofsky et al. 2019 determined that drinking one or two caffeinated beverages did not alter the likelihood of getting a migraine headache on the same day. The probabilities were much higher when the volunteers took three or more caffeinated drinks. There was a nonlinear relationship between caffeinated beverage consumption and the likelihood of a migraine headache on that day in this study. This shows that excessive consumption of caffeinated beverages on that day may be a migraine trigger (Mostofsky et al. 2019 ).

Epileptic seizures

Caffeine has been shown to cause seizures in people who are sensitive to it, especially when they are sleep-deprived. There has been no conclusive evidence of a relationship between seizures and energy drinks. Nonetheless, after drinking a lot of energy drinks, some people started having new adult-onset seizures without any signs of intracranial abnormalities or electroencephalography (Dikici et al. 2013 ). In kainic acid-induced seizure models in rats, long-term administration of taurine in drinking water increases seizure susceptibility and reduces clonic seizure latency. Caffeine is also a natural stimulant that can be found in coffee and tea. Caffeine overdose has been linked to seizures in humans (Dikici et al. 2013 ).

Ischemic stroke

In young- and middle-aged adults, alcohol misuse is also an independent risk factor for ischemic stroke. Rapid absorption and the resulting increase in the CNS may cause more negative effects when high-volume energy drinks are consumed with vodka on an empty stomach (Dikici et al. 2013 ). According to Steinke et al., after consuming 500 mL of energy drink on a weekly basis, heart rate increased 5 to 7 beats per minute, and maximum mean systolic blood pressure increased 10 mm Hg. On an empty stomach, drinking a high-energy drink with vodka may contribute to ischemic stroke by raising blood pressure and heart rate. In addition, the patient has hemorrhoid-related iron deficiency anemia. Anemia due to iron deficiency may play a role in ischemic stroke (Dikici et al. 2013 ). In Syrian weanling hamsters, aspartame increased appetite and weight gain and caused histological alterations in brain and liver cells, while aspartame metabolites, aspartic acid, phenylalanine, and diketopiperazine are responsible for neuron and astrocyte degeneration (Hassan 2016 ; Rycerz and Jaworska-Adamu 2013 ).

Hallucinations

Hallucinations may occur in people who consume more than 300 mg of caffeine per day. High levels of cortisol can be caused by caffeine consumption, which could explain the above. Cortisol amplifies the physiological effects of stress, increasing the risk of hallucinations (Crowe et al. 2011 ).

Physiological effect

Muscular twitching.

Caffeine overdose can result in muscle twitching, which can be caused by minor muscle contractions or uncontrollable twitching in muscle groups controlled by motor nerve fibers. Dietary deficiencies, medication side effects, and strenuous exercise are all possible causes.

Muscle twitching can be caused by stress or anxiety, or it can indicate a nervous system disorder (MedlinePlus 2021 ).

Restlessness

Energy drinks significantly increased the odds of insomnia and jitteriness/activity when compared to the control group (P 0.05), according to a meta-analysis. Caffeine intoxication, a clinical syndrome described in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, is linked to many of the negative effects of energy drinks. Caffeine intoxications are typically indicated by restlessness. (Nadeem et al. 2021 ).

Sleeplessness

There is currently inadequate research evaluating how these substances function alone or in combination to produce mental health issues. It is possible that caffeinated and sugary EDs influence sleep behavior (i.e., the sleep–wake cycle) by stimulating the adrenergic system, which could contribute to poor psychological distress management and mental health issues (Kaur et al. 2020 ).

Psychological effect

According to report from Hofmeister et al. ( 2010 ), in two samples of students, anxiety levels were found to be higher in energy drink consumers compared to non-consumers. Nevertheless, in one of the two groups, anxiety was only higher among regular users compared to nonregular users, making it difficult to say whether the association was dosage-dependent or not. In addition, another study found that energy drink use was associated with anxiety in a large sample ( N  = 4957) of Turkish 10th grade students; anxiety scores were higher in those who had used the products once in their lifetime, once to three times a month, once to five times a week, and every day, compared to nonusers in the previous year. However, at the multivariate level, the impacts were no longer significant (Evren and Evren 2015 ).

Over a two-year period, this study discovered strong positive relationships between ED use and depression, anxiety, and stress symptoms in young adult males (but not females). Males who switched from non-ED to ED use experienced greater depression and stress symptoms over time. The findings backed up previous research that found a link between ED use and sadness and stress symptoms. Males are more likely than females to have these relationships, according to cross-sectional studies (Kaur et al. 2020 ). Consumption of aspartame has been linked to mood problems, mental stress, and sadness. Long-term aspartame usage affects the cerebral and cerebellar cortex, causing neurodegeneration, altering neuronal cell activities, and disrupting homeostasis, learning, and memory (Czarnecka et al. 1957 ).

Gastrointestinal effect

A case with a woman that presented with jaundice, abdominal pain, and highly increased liver enzymes was reported following energy drink overconsumption (Vivekanandarajah et al. 2011 ). The same result was reported by Huang et al. in a 36-year-old man (Huang et al. 2014 ). More research is needed to determine which people are particularly vulnerable and the mechanism by which energy drinks cause hepatic injury.

Renal effects

EDs are not the same as “sports drinks,” which provide hydration and electrolyte replenishment. EDs are rich in carbohydrates, which influence fluid absorption and cause gastrointestinal distress, as well as caffeine, which tends to cause diuresis, which results in greater urinary output and natriuresis rather than hydration (Higgins et al. 2010 ). Excessive Red Bull consumption has been linked to a variety of effects, including acute renal failure, greater systolic and diastolic blood pressure, heart rate, and even decreased blood supply to the brain (Greene et al. 2014 ). According to Schöffl et al. ( 2011 ), after consuming 750 mL of energy drink, this patient developed acute kidney failure with tubular necrosis and rhabdomyolysis. Due to its potential to change renal blood flow and regulate osmolarity in the renal medulla, the authors speculated that excessive intake of taurine may be implicated in the development of kidney injury; however, this role has yet to be proven (Chesney et al. 2010 ). Nephrotoxicity is caused by the ingestion of aspartame (Martins et al 2007 ; Bahr and Zaki 2014 ).

Dental effects

There is growing evidence that the intake of possibly erosive beverages is on the rise. Also, there has been a significant correlation discovered between the consumption of energy drinks and the deterioration of teeth (Hasselkvist et al. 2010 ). The consumption of ED was linked to a 2.4-fold rise in tooth deterioration. This has been related to energy drinks' low pH and high sugar content (Li et al. 2012 ). The sugars in drinks are metabolized by plaque microorganisms to generate organic acids that bring about demineralization (Li et al. 2012 ). Pinto et al. have discovered that drinking energy drinks can cause cervical dentin hypersensitivity by eliminating the smear layer of the teeth (Pinto et al. 2013 ).

Obesity and type II diabetes

Energy drinks often have high sugar content, ranging from 21 to 34 g per ounce. Sucrose, glucose, and high-fructose corn syrup are the main sources of sugar. As a result, excessive consumption of high-energy drinks may raise the risk of obesity and type 2 diabetes (Bedi et al. 2014 ). Furthermore, the amount of sugar in energy drinks may decrease intestinal bacteria activity, variety, and gene expression, increasing the risk of obesity and metabolic syndrome (Greenblum et al. 2012 ). Acute caffeine consumption reduces insulin sensitivity, which may justify the spike in blood glucose levels observed in some studies after energy drink consumption (Ragsdale et al. 2010 ). Caffeine intake lowers insulin sensitivity in a dose-dependent approach, with a 5.8% increase in insulin for each mg/kg increase in caffeine (Beaudoin et al. 2012 ). There may be a link between aspartame consumption and the development of diabetes mellitus (DM) and type 2 diabetes (T2D), and it was found to be dangerous to mice in terms of behavior and biochemical analysis parameters when used as a food additive (Czarnecka et al. 1957 ; Abu-Taweel 2016 ; Zafar et al. 2017 ; Collison et al. 2012 ). When C57BL/6J mice are exposed to chronic aspartame treatment beginning in utero, it causes changes in blood glucose levels, spatial learning, and memory, as well as weight growth (Collison et al 2013 ).

The link between sugary drinks and cancer risk has received far less attention. Nevertheless, because of its mechanical plausibility, this potential relationship raises growing concern. Sugary drinks are, in fact, strongly linked to the development of obesity, which is now identified as a major risk factor for several cancers. Besides obesity and adiposity, insulin resistance induced by high glycemic index or glycemic load, which has been linked to breast cancer, hepatocellular cancer, and diabetes-related carcinomas, could be a mechanism behind a link between sugary drinks and cancer. Chemical compounds in sugary drinks, such as 4-methylimidazole in drinks containing caramel colorings (described as possibly carcinogenic to humans by the International Agency for Research on Cancer, IARC), pesticides in fruit juices, and artificial sweeteners like aspartame, could all play a role in cancer development (Chazelas et al. 2019 ). Another study revealed that a combination of caffeine, taurine, and guarana may stimulate and increase apoptosis by lowering superoxide dismutase and catalase activity in human neuronal SH-SY5Y cells in vitro (Zeidán-Chuliá et al. 2013 ). In both male and female rodents, aspartame ingestion has been shown to be a carcinogenic and angiogenic agent. The markers Ki 67, PCNA, and bcl-2 all showed an increase. According to rat studies, 200 mg/kg body weight caused a considerable surge in the markers c-myc, Ha-ras, and the p53 suppressor gene in rats. Females who are exposed to aspartame from a young age are more likely to develop lymphomas and leukemias. P27 and H-ras expression has also been found to be higher in studies (Czarnecka et al. 1957 ; Soffritti et al 2010 ; Alleva et al 2011 ; Gombos et al 2007 ; Martins et al 2007 ).

Caffeine toxicity

Caffeine is a stimulant that has been used for ages around the world because of its ability to increase mental alertness. Caffeine lethal dosages have been reported at blood concentrations of 80 to 100 µg/ml, which can be achieved with a dose of 10 g or more. Caffeine overdoses in adults are uncommon, but when they do occur, they are frequently triggered by an intentional overdose of medications (Murray and Traylor 2020 ). Four caffeine-induced psychiatric disorders have been classified by the Diagnostic and Statistical Manual of Mental Disorders. Caffeine intoxication, anxiety, sleep disturbance and other related disorders are all examples of caffeine related disorders (Juliano et al. 2012 ). Caffeine intoxication symptoms are most common in individuals who consume 200 mg or more of the stimulant. Anxiety, insomnia, gastrointestinal problems, muscle twitching, restlessness, and spells of exhaustion are just a few of the symptoms (Bedi et al. 2014 ).

Combined effects of alcohol

Underage and younger consumers enjoy alcohol combined with energy drinks, and the beverage industry has benefited on this dynamic trend by aggressively marketing to teenagers and young adults. Nonetheless, there have recently been concerns about the combination's potential public health implications. Consequently, the FDA issued warning letter to manufacturers, effectively banning the manufacture and sale of pre-mixed caffeinated alcoholic beverages (CABs); however, consumers continue to combine energy drinks with alcohol by hand (e.g., Red Bull and vodka, Jaeger Bomb) (Heinz et al. 2013 ). CAB use is linked to problematic alcohol use and harmful alcohol-related effects. In a large multi-site survey, college students who consumed alcohol mixed with energy drinks reported more alcohol-related risk behaviors (e.g., riding in a car with a drunk driver, being hurt or injured, sexually exploiting another student, being taken advantage of sexually) than students who consumed alcohol alone. Furthermore, students who drink caffeine–alcohol combination drink more alcohol and engage in riskier drinking behaviors (e.g., binge drinking) than students who solely consume alcohol (Heinz et al. 2013 ).

Reduction of antioxidant enzyme activity

Aspartame use lowers hepatic tissue superoxide dismutase (SOD), superoxide dismutase SOD and catalase CAT activity in renal tissue, and glutathione (GSH) levels while increasing glutathione S-transferase (GST) activity in liver tissue. This could be due to the creation of methanol or other metabolites, as aspartame is metabolized into aspartic acid, phenylalanine, and methanol in the ratio of 50:40:10, as well as a little quantity of aspartyl phenylalanine diketopiperazine, especially when heated (Abhilash et al 2011 ; Iman 2011 ; Prokic et al 2014 ; Choudhary and Devi 2014 ; Alwaleedi 2016 ; Adaramoye and Akanni 2016 ; Iyyaswamy and Rathinasamy 2012 ).

Inflammation

Aspartame caused neurotoxicity, oxidative stress, and inflammation in rat brain tissue, as well as a large increase in protein carbonyl content and a significant drop in reduced glutathione concentration. Also, a significant increase in brain interleukin-1 (IL-1) and tumor necrosis factor- “(TNF-)” production was accompanied by a significant reduction in brain-derived neurotropic factor (BDNF), serotonin, and acetylcholine esterase (AchE) activity, as well as a substantial increase in acetylcholine (Ach) accumulation in brain homogenates (Lindseth et al 2014 ; Kamel 2015 ).

Preterm birth and maternity problem in women

Intake of artificially sweetened drinks containing aspartame as one of the ingredients has been associated with an increased risk of premature birth in both normal-weight and overweight women, indicating that aspartame intake and use, particularly during pregnancy, may have detrimental consequences (Halldorsson et al 2010 ; Czarnecka et al. 1957 ; Martins et al 2007 ; Czarnecka et al. 1957 ). There have been instances of allergic reactions, and weight growth in babies in humans. Aspartame has been proven to enhance the probability of an early first menstruation (11 years) in females aged 9–10. Aspartame absorption by mothers during pregnancy is linked to autism in children. Maternal absorption of aspartame during pregnancy correlates with autism in children (Halldorsson et al 2010 ; Czarnecka et al. 1957 ; Martins et al 2007 ).

This review has given a lot of insight into the benefits and detriments of the consumption of energy drink to human health. The author’s view is that the ingredient type and the amount contained in the energy drink determine to a major extent the effect on health. The presence of caffeine in ED is not a threat to health; rather a moderate acute dose ranging from 200–350 mg reduces heart rate and raise blood pressure in adults, while also enhancing emotions of well-being, focus, and arousal. Moderate caffeine consumption of up to 400 mg per day is usually regarded as safe and even beneficial to adults' well-being. Guarana has been reported to possess antioxidant, effective stimulant and may be effective in treatment of fatigue and depression related to cancer treatment. A 16-oz energy drink can range from 1.4 mg to 300 mg and is considered safe by Food and Drug Administration (FDA). Ginseng is useful in boosting energy, reducing fatigue, relieving stress, and improving memory and anti-inflammatory activity through activation of corticotropic hormone release from hypothalamus and pituitary glands, and consumption of regular amount of 200 mg per day is considered safe. However, the consumption of more than 2700 mg per day may pose a threat to health such as maniac episodes, uterine bleeding, gynecomastia, long QT syndrome, atrial fibrillation with bradycardia, hypertensive crisis, and acute lobular hepatitis.

Yerba mate and acai berry possess useful pharmacological such as anti-inflammatory, anti-diabetic, antioxidant, in vitro anticancer, inhibition of topoisomerase II, anti-obesity and reduces LDL cholesterol levels. Ginkgo biloba has good health benefits, a normal supplemental dose of 60 mg per day present biological effect such as improvement of memory retention, focus, enhanced blood circulation, and antidepressant. However, consumption of ginkgo biloba maybe poses health discomfort of blood thinning, nausea, vomiting, diarrhea, headaches, dizziness, heart palpitations, and restlessness. Methylxanthines act as CNS stimulants, bronchodilators, coronary dilators, diuretics, and anticancer adjuvant therapies, aside from treatment of neurodegenerative disorders, cardio protection, diabetes, and fertility. Consumption of methylxanthines at lower dose may pose milder side effects such as nausea, vomiting, increased stomach acid secretion, polyuria, sleeplessness, palpitations, headaches, and tremors which are more common.

Energy drink that contains sugar concentration of 500 mL or 16.9 oz usually around 54 g maybe detrimental to health, strong evidence has associated sugar consumption to poor health, and many institutions, including the World Health Organization, have advised limiting sugar intake. This is because the consumption of regular sugar for diabetics who have trouble controlling their blood sugar levels causes insufficient amounts of insulin that regulates sugar absorption in the bloodstream. Consumption of ED that the sugar content is above the daily sugar limit of 32 g for sure will be detrimental to health and Rath 2012 reported that energy drinks with a higher volume usually surpass the daily sugar limit of 32 g. Glucuronolactone is useful in detoxification, the release of hormones and vitamin C production, and protection of muscle glycogen stores. Taurine is associated with treatment of epilepsy, heart failure, cystic fibrosis, and diabetes; however, additional research is required before any conclusions can be drawn. Carnitine acts as antioxidant and anti-inflammatory compound and may reduce the exercise-induced muscle damage. Maltodextrins reduce net glycogen breakdown during long-duration exercise while maintaining a high whole-body glucose oxidation rate. Artificial sweeteners such as aspartame and sucralose are added in energy drink to replace sugar and restrict absorption of sugar. Aspartame helps to restrict sucrose intake by acting as a sugar substitute and releases a very small amount of energy. Aspartame metabolites may also be a primary cause for adverse effects, such as headache, compromised memory, mood changes, and depression and others which are not being identified yet.

The presence of vitamins such as vitamin B, riboflavin (B2), niacin (B3), pyridoxine (B6), inositol (B8), cyanocobalamin B12, vitamin C and vitamin D in energy drink has various health benefits. B vitamins as coenzymes in many metabolic processes facilitate energy metabolism involving lipids, carbs, and proteins, boast immune system, oxidative phosphorylation, and cell energy production; amino acid and homocysteine metabolism, glucose and lipid metabolism, neurotransmitter generation, and DNA and RNA synthesis. The consumption of inositol (former B8) is reported to assist in preventing the development of chronic diseases, including obesity, diabetes, polycystic ovary syndrome (PCOS), metabolic syndrome, cardiovascular diseases, and cancer. Incorporation of mineral such as calcium, iron, chromium, zinc, manganese, and molybdenum is very useful to health. Most of the minerals are useful for vascular contraction and vasodilation, muscular function, neuronal transmission, intracellular interaction, and hormone production in the circulatory system, extracellular fluid, muscle, and other tissues. Oxygen transport, DNA synthesis, and electron transport prevent iron deficiency anemia, protein, carbohydrate, and lipid metabolism. They help in glucose and lipid metabolism; protein, vitamin C, and vitamin B synthesis, hematopoiesis catalysis, endocrine regulation, regulation of cellular energy, bone and growth of connective tissue, blood clotting, improvement of brain development, and immune function improvement (Li and Yang 2018 ); consumption of aspartame and the development of diabetes mellitus (DM) and type 2 diabetes (T2D), obesity, changes in the microbiota of the offspring of rats. In humans, there has been evidence of premature birth, allergic reactions, weight gain in the newborns, increase in the risk of an early first menstruation, mood disorders, mental stress, and depression, development of autism in children, neurodegeneration, modification of the functions of neuronal cells, interruption of homeostasis, learning and memory, harmful people with phenylketonuria, free radical generation, impairment of antioxidant enzymes and carcinogenic.

Consumers should be aware of the potential side effects of aspartame, notwithstanding the lack of solid clinical data on those side effects. The author concludes that the oral treatment with a high dose of aspartame used in those animal trials was rare in humans. Future epidemiological studies and clinical trials are needed to look at the long-term effects of aspartame use at the recommended daily amount. The position of aspartame has remained controversial due to the lack of scientific data supporting and opposing its use. The negative side effects of aspartame ingestion, on the other hand, are extensively documented in human and animal studies. Investigations in similar fresh avenues are strongly urged to cover existing research gaps and put an end to the debate regarding aspartame use. The critical assessment of the literature supporting aspartame use appears to be affected in part by interest groups. The authors propose that bias-free comprehensive trials be used to investigate the safety of aspartame in a variety of groups with varying clinical circumstances. As a result, authorities such as the US Food and Drug Administration (FDA), the European Food Safety Authority (EFSA), the Agence Française de Sécurité Sanitaire des Aliments (AFSSA), the FSSAI (Food Safety and Standard Authority of India), and the Joint FAO/WHO Expert Committee on Food Additives (JECFA) should reconsider the acceptable daily intake (ADI) of aspartame among the public.

In the food and pharmaceutical industries, aspartame is a common sweetener; therefore, it is critical to understand the benefits and drawbacks of aspartame to determine the danger of negative health effects. Based on current knowledge, the benefits of using aspartame outweigh the risks of adverse effects, and thus, this artificial sweetener will continue to be a common ingredient in products. Given the widespread use of aspartame as an artificial sweetener, it appears reasonable to continue study into its safety. Nonetheless, whether aspartame is the direct cause of sickness is unknown.

Most of the health detriments caused because of consumption of energy drink is mostly due to the presence of excess quantity of caffeine and sugar, and presence of aspartame. Scientific reports from in vitro and in vivo have linked aspartame to many detrimental health issues. The presence of aspartame in the energy drink may pose a health risk to consumers. However, if the quantities of caffeine and sugar content in energy drink are kept at FDA- and WHO-recommended daily consumption amount, and no aspartame content, then it may not present any problem to health. Consumption of energy drink that contains natural ingredients such as yerba mate, acai berry, ginkgo biloba, methylxanthines, amino acid, guarana, and ginseng with moderate FDA- and WHO-approved daily consumption of caffeine and sugar is not detrimental to health.

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

Abbreviations

• Energy drinks

Cyanocobalamin

Ascorbic acid

Cholecalciferol

Ergocalciferol

World Health Organization

Maltodextrins

Cardiovascular diseases

Low-density lipoprotein

Randomized controlled trials

International Agency for Research on Cancer

Caffeinated alcoholic beverages

Food and Drug Administration

Polycystic ovary syndrome

Ribonucleic acid

Central nervous system

Deoxyribonucleic acid

Superoxide dismutase

Glutathione

Glutathione S -transferase

Diabetes mellitus

Type 2 diabetes

Marker of proliferation Ki-67

B-cell lymphoma 2

C-myelocytomatosis

Tumor suppressor protein

Cyclin-dependent kinase inhibitors

European Food Safety Authority

Agence Française de Sécurité Sanitaire des Aliments

Food Safety and Standard Authority of India

Joint FAO/WHO Expert Committee on Food Additives

Acceptable daily intake

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We thank UCSI University for supporting and providing facility for this project.

Research fund was fully supported by UCSI University CERVIE REIG grant number REIG-FAS-2020-031.

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Ariffin, H., Chong, X.Q., Chong, P.N. et al. Is the consumption of energy drink beneficial or detrimental to health: a comprehensive review?. Bull Natl Res Cent 46 , 163 (2022). https://doi.org/10.1186/s42269-022-00829-6

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The Relationship Between Energy Drink Consumption, Caffeine Content, and Nutritional Knowledge Among College Students

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We sought to determine which demographic characteristics influence energy drink consumption habits and to examine whether caffeine content and knowledge of human nutrition affect college students’ decisions to consume these beverages. We used an online survey to ask 265 college students, who did not participate in a varsity sport, to complete a survey consisting of demographic questions, the General Knowledge Questionnaire for adults, and questions about energy drink consumption habits. We found, overall, that 23.1% of our sample used energy drinks. When compared to non-consumers (76.9%), users had a significantly lower GPA, were older, and preferred drinks with a higher caffeine content. Users reported that they consumed these drinks because they wanted to feel more alert and they enjoyed the taste, even though they reported adverse effects such as trouble sleeping, shaking and tremors, and stomachaches. Knowledge of human nutrition did not affect users’ choice to consume these drinks. Although the majority of college students do not consume energy drinks, room for improvement remains to curb the use of these caffeinated beverages amongst college students.

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Hardy, R., Kliemann, N., Dahlberg, P. et al. The Relationship Between Energy Drink Consumption, Caffeine Content, and Nutritional Knowledge Among College Students. J Primary Prevent 42 , 297–308 (2021). https://doi.org/10.1007/s10935-021-00635-2

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A survey of energy drink consumption patterns among college students

• Brenda M Malinauskas 1 ,
• Victor G Aeby 2 ,
• Reginald F Overton 3 ,
• Tracy Carpenter-Aeby 4 &
• Kimberly Barber-Heidal 1  

Nutrition Journal volume  6 , Article number:  35 ( 2007 ) Cite this article

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Energy drink consumption has continued to gain in popularity since the 1997 debut of Red Bull, the current leader in the energy drink market. Although energy drinks are targeted to young adult consumers, there has been little research regarding energy drink consumption patterns among college students in the United States. The purpose of this study was to determine energy drink consumption patterns among college students, prevalence and frequency of energy drink use for six situations, namely for insufficient sleep, to increase energy (in general), while studying, driving long periods of time, drinking with alcohol while partying, and to treat a hangover, and prevalence of adverse side effects and energy drink use dose effects among college energy drink users.

Based on the responses from a 32 member college student focus group and a field test, a 19 item survey was used to assess energy drink consumption patterns of 496 randomly surveyed college students attending a state university in the Central Atlantic region of the United States.

Fifty one percent of participants ( n = 253) reported consuming greater than one energy drink each month in an average month for the current semester (defined as energy drink user). The majority of users consumed energy drinks for insufficient sleep (67%), to increase energy (65%), and to drink with alcohol while partying (54%). The majority of users consumed one energy drink to treat most situations although using three or more was a common practice to drink with alcohol while partying (49%). Weekly jolt and crash episodes were experienced by 29% of users, 22% reported ever having headaches, and 19% heart palpitations from consuming energy drinks. There was a significant dose effect only for jolt and crash episodes.

Using energy drinks is a popular practice among college students for a variety of situations. Although for the majority of situations assessed, users consumed one energy drink with a reported frequency of 1 – 4 days per month, many users consumed three or more when combining with alcohol while partying. Further, side effects from consuming energy drinks are fairly common, and a significant dose effect was found with jolt and crash episodes. Future research should identify if college students recognize the amounts of caffeine that are present in the wide variety of caffeine-containing products that they are consuming, the amounts of caffeine that they are consuming in various situations, and the physical side effects associated with caffeine consumption.

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Energy drink consumption has continued to gain popularity since the 1997 debut of Red Bull, the current leader in the energy drink market [ 1 ]. More than 500 new energy drinks were launched worldwide in 2006 and beverage companies are reaping the financial rewards of the 5.7 billion dollar energy drink industry [ 1 ]. Energy drinks, including Red Bull, Amp, Monster, Rock Star, Rip It, Full Throttle, and Cocaine, are designed to give the consumer a "jolt" of energy provided by the combination of stimulants and "energy boosters" that they provide, including caffeine, herbal extracts such as guarana, ginseng, and ginkgo biloba, B vitamins, amino acids such as taurine, amino acid derivatives such as carnitine, and sugar derivatives, including glucuronalactone and ribose [ 1 ]. Energy drinks typically contain 80 to 141 mg of caffeine per 8 ounces, the equivalent of five ounces of coffee or two 12-ounce cans of caffeinated soft drink such as Mountain Dew, Coca Cola, Pepsi Cola or Dr. Pepper [ 2 ]. Energy drinks have sugar-containing and sugar-free versions. For example, Monster Energy provides 24 grams of sugar per 8 ounces (12% sugar concentration) and Rip It A'Tomic Pom provides 33 grams (14% concentration) [ 3 , 4 ]. Similar to the booming energy drink market, the size of the energy drink container has increased over 300-fold; Monster energy offers consumers a 23 ounces option [ 3 ].

Do energy drinks provide the consumer an extra burst of energy as the advertisements would have you believe? Yes, they do. Smit and colleagues found that energy drinks, as compared to placebo, had energizing effects among 18 to 55 year old participants, with effects being strongest 30 to 60 minutes after consumption and sustained at least 90 minutes [ 5 ]. Caffeine was found to be the primary constituent responsible for these effects. Although there is no human requirement for caffeine, even low doses of caffeine (12.5 to 100 mg) improve cognitive performance and mood [ 6 ]. However, caffeine has been found to have detrimental health consequences. Riesenhuber and colleagues found that the caffeine (but not taurine) in energy drinks promotes diuresis and natriuresis [ 7 ]. Further, acute caffeine consumption reduces insulin sensitivity [ 8 ] and increases mean arterial blood pressure [ 9 ]. High caffeine consumption is associated with chronic daily headaches, particularly among young women (age < 40 years) and among those with chronic episodic headaches and of recent onset (< 2 years) [ 10 ]. Central nervous system, cardiovascular, gastrointestinal, and renal dysfunction have been associated with chronic caffeine ingestion [ 11 ]. In sum, the caffeine in energy drinks will provide the consumer the desirable effects of increased alertness, improved memory, and enhanced mood. However, caffeine can have harmful physical consequences.

Although energy drinks are targeted to the 18 to 35 year old consumer [ 12 ], there has been little research regarding energy drink consumption patterns among young adults in the United States. The purpose of this study was to determine (1) energy drink consumption patterns among college students, (2) prevalence and frequency of energy drink use for six situations, namely for insufficient sleep, to increase energy (in general), while studying, driving long periods of time, drinking with alcohol while partying, and to treat a hangover, (3) and prevalence of adverse side effects and energy drink use dose effects among college energy drink users.

A Registered Dietitian and a Health Educator designed a questionnaire that assessed consumption patterns of energy drinks among college students. We initially interviewed a focus group of 32 college students who were enrolled in a senior-level course. We asked these students open-ended questions regarding situations in which college students use energy drinks, the most common energy drinks college students were using, frequency patterns (average number of energy drinks consumed for each situation the focus group identified and the average number of times per month throughout a semester students use energy drinks for each situation), and side effects from using energy drinks.

Based on the focus group responses we developed a 19-item questionnaire. Questions 1 and 2 assessed demographic information (age and sex). Question 3 was a screening question, used to identify energy drink users, and asked "in an average month for the current semester do you drink more than one energy drink per month?" If a participant indicated "no", then they were instructed to skip the remaining questions in the survey and return the questionnaire to the research assistant. Participants who indicated "yes" to Question 3 were instructed to continue the survey, which assessed the type of energy drink usually consumed (regular or sugar-free), side effects associated with energy drink use (jolt and crash episodes, headaches, heart palpitations), and six situations for energy drink use (insufficient sleep, needing more energy (in general), studying for an exam or to complete a major course project, driving a car for a long time, drinking with alcohol while partying, and to treat a hangover).

For the purpose of this study, a jolt and crash episode was in reference to a feeling of increased alertness and energy (the jolt) followed by a sudden drop in energy (the crash) that occurs in response to using energy drinks.

Each of the six situation questions had two follow up questions that assessed the average number of energy drinks consumed for that situation (for example, how many energy drinks do you drink at one time following a night of not getting enough sleep?) and the average number of times per month for the current semester the student consumes energy drinks for that situation.

To provide a frame of reference regarding what constituted an energy drink, the introduction of the questionnaire included examples of energy drinks that were popular on the campus and in social establishments in the immediate geographic region when the survey was administered, these included Red Bull, Rock Star, Amp, and Full Throttle. The questionnaire was field tested among 10 randomly chosen students who were in a public location on campus. The questionnaire took approximately two minutes to complete and modifications to the questionnaire were not necessary based on the field test responses.

From mid-November to the first week of December 2006, 11 trained research assistants (undergraduate and graduate college students) recruited students at a single college from public locations across campus to participate in the study. The research assistants first ensured that those they approached were students at the university and that the student had not previously completed the questionnaire.

The institution is a state university, located in the Central Atlantic region of the United States. The fall 2006 enrollment statistics indicate an undergraduate enrollment of approximately 18,000 undergraduate and 6,000 graduate students, 85% of undergraduates were 18 to 24 years of age, 12% were 25 to 40 years of age and 3% 41 years of age and older [ 13 ]. Further, 92% of undergraduates attended school full-time whereas the majority (60%) of graduate students attended part time. In regard to ethnicity of the student body, 76% were non-Hispanic White, 16% non-Hispanic Black, 2% Asian, 2% Hispanic, 2% unknown, < 1% American Indian, and < 1% non-resident alien.. Sixty two percent of the total student body is female [ 13 ].

To diversify our sample, research assistants varied the time of day and days of the week during weekdays to recruit participants. In compliance with the university's Institutional Review Board for Research with Human Subjects (University and Medical Center Institutional Review Board number 06-0718), students were informed of the study protocol and those willing to participate anonymously completed the self-administered questionnaire. The project was carried out in compliance with the Helsinki Declaration.

Analyses were performed using JMP IN ® software [ 14 ]. Descriptive statistics included means, standard deviations, 95% confidence intervals, and frequency distributions. Pearson χ 2 was used to evaluate differences in frequency distribution of responses. An alpha level of .05 was used for all statistical tests.

A total of 496 participants, aged 21.5 ± 3.7 years (95% CI 21.3, 21.8) completed the questionnaire. In regard to the first research question, energy drink consumption patterns among college students, 51% of participants ( n = 253) reported drinking greater than one energy drink each month in an average month for the current semester, with significantly more female (53%) than male (42%) energy drink users reported, χ 2 (1, N = 496) = 6.46, p = .01. Seventy four percent ( n = 187) of the 253 users drank sugar-containing versions with significantly more females (35%) than males (12%) drinking sugar-free versions, χ 2 (1, N = 247) = 16.56, p < .01.

Energy drink consumption patterns of college energy drink users for the six situations assessed are reported in Table 1 . Insufficient sleep was the most common reason to drink energy drinks, as indicated by 67% of energy drink users. The majority of users consumed energy drinks to increase their energy (65%) and to drink with alcohol while partying (54%). Fifty percent drank while studying or completing a major course project, 45% while driving a car for a long period of time, and 17% to treat a hangover. There were no significant differences in use of energy drinks for the six situations assessed by sex, as reported in Table 1 .

In regard to the second research question, the percent of users drinking one, two, and three or more energy drinks by situation are reported in Table 2 . The majority of energy drink users consumed one to treat a hangover, for insufficient sleep, to increase energy, and while driving a car for a long period of time. Using three or more was a common practice (49% of users) to drink with alcohol while partying. The percent of users drinking energy drinks 1 – 4, 5 – 10, and 11 or more days in an average month for the current semester are also reported in Table 2 . For the six situations assessed, the majority of users (73% to 86%) consumed energy drinks 1 – 4 days in a month.

To further identify relationships between the six situations of energy drink use and energy drink consumption patterns, we summed the number of situations for reported energy drink use and compared this to the maximum number of energy drinks consumed for any of the six situations. These results are reported in Table 3 . By sum of situation categories, 16% to 20% of energy drink users consumed energy drinks for a total of one to five of the six situations, 7% consumed energy drinks for a total of all six. As total situations increased so did the maximum energy drink consumption for at least one situation. For example, 40% to 81% of energy drink users who reported a total of three or more situations consumed three or more energy drinks for at least one situation, whereas 29% of those with a total of one situation and 18% of those with a total of two consumed three or more for at least one situation.

Regarding the third research question, weekly jolt and crash episodes were experienced by 29% of users, 22% reported ever having headaches and 19% heart palpitations from consuming energy drinks, which did not differ significantly by sex, χ 2 (1, N = 253) < 0.01, p = .97 for jolt and crash episodes, χ 2 (1, N = 234) = 0.37, p = .54 for heart palpitations, χ 2 (1, N = 252) = 0.45, p = .50 for headaches. The data for side effects by energy drinks consumed are reported in Table 4 . There was a significant dose effect for jolt and crash episodes but not for heart palpitations or headaches. For example, 57% of energy drink users who reported experiencing weekly jolt and crash episodes also consumed three or more energy drinks for at least one situation, whereas 35% of those who denied jolt and crash episodes consumed three or more.

Energy drinks are marketed to young adults and marketing efforts may be particularly appealing among college students. For example, Cocaine energy drink, with a Cut Cocaine variety, has been marketed as a "legal alternative" to the class A drug [ 15 ]. On April 4, 2007, the Food and Drug Administration issued a warning to Drink Reboot, the firm that markets Cocaine, citing numerous marketing violations, including promoting this product as a street drug alternative [ 15 ]. Red Bull energy drink is reportedly a "functional beverage" that was designed to increase physical and mental performance and "is appropriate to drink during sports, while driving, and during leisure activities" [ 16 ] whereas Monster energy provides a "double shot of our killer energy brew. It's a wicked mega hit that delivers twice the buzz of a regular energy drink..." [ 3 ]. The purpose of this study was to identify energy drink consumption patterns and side effects associated with consumption of energy drinks among college students. We found that energy drink consumption is a popular practice among college students, particularly if the student has had insufficient sleep, if they need more energy in general, while studying for exams or working on major course projects and while driving an automobile for a long period of time.

Improvements in mental functioning are of interest among college students, many who suffer from sleep deprivation. The American College Health Association reported that 71% of college students whom they surveyed reported insufficient sleep and not feeling rested for at least five of the past seven days [ 17 ]. Sleep deprivation is associated with selecting less difficult cognitive tasks and college students who have sleep difficulties report a greater frequency of stress [ 18 , 19 ]. Findings from our study support the premise that college students use energy drinks to treat sleep deprivation and while studying for exams or completing major course projects. On the other hand, caffeine consumption has not been found to affect academic performance among college students [ 20 ].

The primary ingredient in energy drinks that has a cognitive stimulating effect is the caffeine [ 5 ], whereas high sugar content (18% concentration) does not improve reaction times slowed by sleep deprivation [ 21 ]. Further, the combination of caffeine and taurine has no effect on short-term memory [ 9 ]. Although low doses of caffeine (12.5 to 50 mg) have been found to improve cognitive performance and mood [ 6 ] and 200 mg doses have been found to improve cognitive task speed and accuracy and increase alertness among young adults [ 22 ], the amount of caffeine provided in energy drinks can easily far exceed the amount necessary to promote cognitive functioning [ 23 ]. This is especially true if a student is consuming 16- or 23-ounce cans or multiple cans of energy drinks for a given situation. Although we did not assess the size of the energy drink cans that participants normally consumed, results from our study indicate that in some situations while students are consuming energy drinks, the amount of caffeine that they consume can exceed the amount needed simply to promote cognitive stimulation. For example, 50% of energy drink users in our study drank two or more energy drinks while studying for an exam or working on a major course project, and 36% to 37% drank two or more following insufficient sleep, when they needed energy throughout the day, or while driving an automobile for a long period of time. Further, drinking multiple energy drinks with alcohol was a popular practice among 73% of energy drink users. The practice of consuming greater amounts of caffeine while socializing has also been documented among American youth [ 24 ] and an alcoholic setting is considered by many college students a primary locus to socialize and to meet people [ 25 ].

Results from the present study indicate that female and male college students are using energy drinks in a similar fashion. Whereas we found a greater prevalence of energy drink consumption and greater use of sugar-free varieties of energy drink use among females, we identified no situation differences nor prevalence of side effects from consuming energy drinks between sexes.

There are a number of limitations to this study that deserve discussion. First, in an effort to ensure the survey instrument could be completed quickly, we collected limited demographic information. Based on the descriptive statistics regarding age, we primarily had undergraduate participants and a slightly greater percentage of male participants as compared to the sex distribution at the university. On the other hand, random sampling throughout the weekdays and times of the day at central locations throughout campus was an advantage to the study design. Additionally, this is a rural state university with a fairly homogenous student body. Second, the data collected was self-reported. In particular, frequency patterns of energy drink intake were asked by situation and were treated as independent and distinct events, which may not have been the case. For example, and energy drink user may consume energy drinks because they had not gotten enough sleep and because they were studying for an exam. As a result, assessment of energy drink consumption may have been overestimated for each of the situation events. On the other hand, the results from this study provide important and novel information regarding energy drink consumption habits among college students. Of particular importance is the finding that using energy drinks for a number of situations is common among college students and that those who use energy drinks for three or more of the situations that we assessed tended to drink three or more energy drinks for at least one situation. Further, side effects of jolt and crash episodes, heart palpitations, and headaches are fairly common, as reported by approximately 25% of users, and there is a significant dose effect of energy drink consumption and jolt and crash episodes.

Using energy drinks is a popular practice among college students, as we found that 51% of 496 college students surveyed reported drinking greater than one energy drink each month. Among college energy drink users, consuming energy drinks is particularly popular for insufficient sleep, when one needs more energy in general, to drink with alcohol while partying, and when studying for an exam or completing a major course project. Drinking three or more for a given situation occurs more frequently among those who consume energy drinks for three or more of the six situations that were assessed. Side effects of consuming energy drinks, including experiencing jolt and crash episodes, hear palpitations, and headaches occur in many energy drink users. However, a dose effect was found only for jolt and crash episodes. Further research should identify if students recognize the amounts of caffeine that are present in the wide variety of caffeine-containing products they consume, the amounts of caffeine that are consumed in various situations, and the physical side effects associated with caffeine consumption.

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Victor G Aeby

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BMM participated in the study design, performed the statistical analysis, and drafted the manuscript. VGA conceived of the study and drafted the manuscript. AJC assisted with statistical analysis and helped to draft the manuscript. RFO, TCA, and KBH participated in coordination and data collection and helped to draft the manuscript. All authors read and approved the final manuscript.

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Energy Drinks: A Contemporary Issues Paper

Higgins, John P. MD, MBA, M.PHIL, FACC, FACP, FAHA, FACSM, FASNC, FSGC 1 ; Babu, Kavita MD, FACEP, FACMT 2 ; Deuster, Patricia A. PhD, MPH, FACSM 3 ; Shearer, Jane PhD 4

1 McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX; 2 Division of Medical Toxicology, Department of Emergency Medicine, UMass Memorial Medical Center, Worcester, MA; 3 Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, D Consortium for Health and Military Performance, Bethesda, MD; and 4 Faculty of Kinesiology, Department of Biochemistry and Molecular Biology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, CANADA

Address for correspondence: John P. Higgins MD, MBA, MPHIL, FACC, FACP, FAHA, FACSM, FASNC, FSGC, Division of Cardiology, Lyndon B. Johnson General Hospital, 5656 Kelley St., UT Annex Rm 104, Houston, TX 77026; E-mail: [email protected] .

Since their introduction in 1987, energy drinks have become increasingly popular and the energy drink market has grown at record pace into a multibillion-dollar global industry. Young people, students, office workers, athletes, weekend warriors, and service members frequently consume energy drinks. Both health care providers and consumers must recognize the difference between energy drinks, traditional beverages ( e.g. , coffee, tea, soft drinks/sodas, juices, or flavored water), and sports drinks. The research about energy drinks safety and efficacy is often contradictory, given the disparate protocols and types of products consumed: this makes it difficult to draw firm conclusions. Also, much of the available literature is industry-sponsored. After reports of adverse events associated with energy drink consumption, concerns including trouble sleeping, anxiety, cardiovascular events, seizures, and even death, have been raised about their safety. This article will focus on energy drinks, their ingredients, side effects associated with their consumption, and suggested recommendations, which call for education, regulatory actions, changes in marketing, and additional research.

The focus of this American College of Sports Medicine (ACSM) Contemporary Issues Paper is on energy drinks and their consumption in relation to physical activity and exercise. The term energy drink refers to high caffeine-containing beverages that often contain a myriad of vitamins, minerals, amino acids, and herbal mixtures. Where applicable, interpretation of the available scientific evidence was made by consensus of the writing group members using the evidence rating system of the National Heart Lung and Blood Institute ( Table 1 ) ( 1 ). Data examining the impact of energy drinks on exercise performance were derived from experimental trials and meta-analyses. To assess the risks of energy drinks and their physiological interactions, observational studies and case reports were the primary sources of information. The stated recommendations represent the consensus of the writing panel and incorporate guidance from professional, legislative and educational organizations with positions on energy drinks ( e.g., American Academy of Pediatrics, Health Canada, National Federation of State High School Associations).

Introduction

Energy drinks are beverages that typically contain caffeine, taurine, glucuronolactone, vitamins, herbal extracts, proprietary blends, and/or amino acids, and marketed as boosting mental alertness and physical stamina. They are available with or without sugar and may or may not be carbonated, thus the range of products is broad. Importantly, energy drinks are popular, with frequent consumption being reported by athletes, service members, and secondary school students: up to 80% of college athletes reporting use them to potentially enhance their performance ( 2,3 ). In addition, energy drinks have been, and continue to be, marketed to children and adolescents ( 4 ). The global energy drink market was worth USD 39 billion in 2013, and is forecast to reach 61 billion by 2021 ( 5 ).

Despite high market demand, the current evidence for safety, efficacy, and performance benefits is unsystematic and often contradictory, given different protocols and types of products consumed: this makes it difficult to draw firm conclusions ( 6 ). Also, much of the available literature is industry-sponsored. One major concern with energy drinks is that they often contain high concentrations of caffeine ( 7 ).

According to the U.S. Food and Drug Administration (FDA), 400 mg·d −1 , or about four or five cups of coffee, is the amount of caffeine “not generally associated with dangerous, negative effects” for healthy adults ( 8 ). Anything over that amount could potentially cause serious problems in adults and certainly children and adolescents. Importantly, the amount of caffeine in over-the-counter products is limited to a maximum of 200 mg per dose, whereas there is no limit for energy drinks.

Within the FDA, energy drinks are classified as either dietary supplements (require adverse events reporting, but contents not as strictly controlled) or foods/beverages (do not require adverse events reporting, contents strictly controlled), either of which provide manufacturers with loopholes regarding their specific contents, especially the amount of caffeine ( 9 ). It is important to recognize the difference between energy drinks and traditional beverages ( e.g. , coffee, tea, sports drinks, sodas): energy drinks usually have herbal blends, taurine, glucuronolactone, and vitamins in high concentrations ( 10 ), whereas traditional beverages do not.

The scientific community, media, governments, athletic departments, and the general public have expressed safety concerns over energy drinks, due to adverse events to include trouble sleeping, anxiety, cardiovascular events, seizures, and even death ( 2 ). These safety concerns seem to be especially important in certain vulnerable populations, including those younger than 18 yr, pregnant or breastfeeding women, caffeine naïve or sensitive individuals, individuals taking stimulant or other caffeine-based medications, those with certain cardiovascular or medical conditions, and/or heavy consumption patterns — defined as two or more energy drinks in one session ( 11 ).

The majority of energy drink-related health concerns appear to be linked to caffeine, caffeine-like additives, and/or other energy drink substances such as taurine that may interact with caffeine ( 7 ). The multiple ingredients, often in combination with heavy consumption patterns, appear to be more problematic than coffee or caffeine alone ( 12 ), and particularly in individuals with long QT syndrome ( 13 ), an inherited or acquired heart condition.

Unfortunately, marketing for energy drinks primarily targets children, adolescents, and other vulnerable groups with content and experiential based ( e.g. , high risk sports) advertisements on television channels, internet, and social media sites, and/or as posters, wall murals, digital videos, and other such displays in public transportation venues ( 14–16 ). In addition, energy drink companies may provide free samples at youth and adult sporting events. In response to these concerns some groups and legislators have developed policies and educational approaches to limit consumption of energy drinks, particularly in vulnerable populations ( 2 ). Much of this information forms the basis of the ACSM-endorsed recommendations found at the end of this manuscript.

Energy Drink Ingredients

Caffeine and caffeine pharmacology.

Caffeine, a methylxanthine, is the most common psychoactive ingredient found in energy drinks. It is rapidly and completely absorbed after ingestion, generally reaching peak concentrations within 30 to 120 min ( 7 ). Caffeine is primarily metabolized in the liver by CYP1A2 to a number of physiologically active metabolites, including paraxanthine, theobromine and theophylline ( 17 ). Pharmacologically, consuming more than 6 mg of caffeine per kg body mass appears to saturate hepatic caffeine metabolism ( 17 ). However, there are significant interindividual variations in caffeine metabolism, sensitivity, as well as its impact on alertness and/or performance ( 17 ).

Caffeine is usually added as a synthetic alkaloid rather than a naturally-occurring constituent of plant based beverages (as in tea or coffee); however, guarana and yerba mate, which are often present as part of the “energy blend” of energy drinks, are natural sources of caffeine, whose levels are often not part of the package labeling ( 7 ). Levels of caffeine in energy drinks vary widely, most contain 32 mg·100 mL −1 , but others can contain 30 to 134 mg of caffeine per 100 mL, a concentration greatly exceeds the FDA-imposed limit of 20 mg of caffeine per 100 mL of traditional soda ( e.g. , Coke, Pepsi). Of note, the caffeine content of small format energy shots (~60 mL) is approximately 6-fold to 12-fold the concentration limit ( 18 ). The caffeine content of coffee also can vary widely between 48 mg and 317 mg per serving ( 19 ). Although caffeine in coffee also can be harmful, coffee is generally hot, and sipped over a longer period. In addition, the coffee bean contains many beneficial antioxidants, which have been associated with improved metabolic and cardiovascular health ( 20 ). Coffee is less frequently consumed by youth, and less likely to be used in a setting of sports and exercise ( 21 ). In contrast, energy drinks are usually chilled, highly sweetened, consumed rapidly, and often used in the setting of exercise and sports ( 18 ). The caffeine content of selected coffees, teas, sodas, and some popular energy drinks can be found on the caffeine chart at the Center for Science in the Public Interest website: https://cspinet.org/eating-healthy/ingredients-of-concern/caffeine-chart .

There are striking differences in the caffeine doses considered safe by different authorities. One group of authors reported that agitation and tachycardia can occur at doses as low as 50 mg; ( 2 ) however, the European Food Safety Authority scientific opinion on the safety of caffeine notes that caffeine doses of less than 200 mg in a 70-kg adult are unlikely to produce toxicity ( 22 ). Additionally, the role of rate of consumption and preexisting conditions which may be occult at the time of energy drink exposure ( e.g. , mitral valve prolapse) in serious energy drink-related adverse events has not been elucidated.

Other Ingredients

Most energy drinks are sweetened with sugar and frequently include taurine (an amino acid), B vitamins (B3, B6, B12) and glucuronolactone (a glucose metabolite) as ingredients. Other minor ingredients can include ginseng extract, guarana (contains caffeine, theobromine, and theophylline), ephedra, yohimbine, gingko, kola nut, theophylline, other vitamins, herbs, and/or L-carnitine ( 18 ). The health consequences of these additives — alone or in combination, are poorly described ( 7 ). Evidence to substantiate claims that ingredients other than caffeine contribute to performance enhancement is minimal ( 23 ); however, a recent meta-analysis found a significant association between taurine dosage and physical performance ( 24 ). The literature describing adverse events from these additives alone is limited; however, some herbals in energy drinks have been associated with minor to severe adverse effects including seizures, myocardial infarctions, ventricular tachycardia, and gastrointestinal upset ( 7,23 ). Likewise, the literature describing adverse events from the additives and their interactions with caffeine has raised concerns about a possible taurine and caffeine interaction producing endothelial dysfunction ( 18 ).

Energy Drink Ingredients and Athlete Testing

Energy drinks have the potential to expose athletes governed by anti-doping rules to inadvertent positive doping tests ( 25 ). The primary concern is not caffeine, but rather products that contain proprietary blends, herbals and unrecognizable ingredients that may be banned. The labeling of such dietary supplement ingredients is often unclear and inaccurate ( 26 ).

Energy Drinks and Performance

Caffeine contained in energy drinks has ergogenic potential for affecting both physical and mental performance. Exercise data evaluating pure caffeine ( e.g. , administered in pill or powered format) generally show an increase in athletic performance by approximately 2% to 4% ( 27–29 ). These benefits extend to muscular, sprint type, and endurance exercise. The dose required for ergogenic benefit generally ranges from 3 to 6 mg·kg −1 body weight, although some studies have reported benefits with lower doses ( 13,30,31 ).

The data for energy drinks in relation to performance are less clear, although there appears to be an ergogenic benefit in the range observed for caffeine alone (3.4%) ( 24,28 ). Inconsistent and larger variance in energy drink data is likely related to the populations studied, amount consumed, type of exercise, specific energy drink tested, concentration of caffeine administered (not normally administered by body mass), taurine content, test circumstances, and the sensitivity of the outcome metrics ( 24,28 ). A recent meta-analysis shows energy drinks have the potential to increase performance in muscle strength and endurance, but not sprinting and power type activities ( 24 ). However, the caffeine dosage was not associated with the increases in performance. The authors found a relation between taurine and performance, but given that no analyses of intervention ingredients were conducted, no firm conclusions can be made ( 24 ). Although the quality of the studies in the systematic review, as determined by the Physiotherapy Evidence Database (PEDro) scale, ranged from 7 to 10, other important issues for dietary and nutrition intervention studies to ensure transparency and reproducibility are critical ( 32 ). These include preparation of dietary ingredient used in the intervention, baseline/background diet, control of diet during intervention, actual analysis of intervention being studied, and analysis of absorption of study ingredients. Because none of these issues were addressed, the quality may be much lower. Lastly, some studies included in the analysis were industry sponsored (not incorporated in the PEDro scale of quality). The impacts of industry sponsorship on study outcomes are well documented ( 33,34 ).

Evidence Statement: The acute impacts of caffeine alone on exercise performance are ergogenic, performance may increase by an estimated 2% to 4% depending on the type, intensity, and duration of the exercise performed (ACSM Evidence Category A). Energy drinks also may show benefit, but the evidence is often highly variable, due to poor study design, inconsistent dosing, and industry sponsorship (ACSM Evidence Category B).

Adverse Effects Associated with Energy Drink Consumption

Acute and chronic adverse health effects of energy drinks are still being elucidated, and it is unclear to what extent adverse events occur while individuals are engaged in sport or physical activity ( 18 ). Based on Australian poison control center data over a 7-yr period, the most commonly reported symptoms after energy drink use were palpitations, agitation, tremor, and gastrointestinal upset ( 35 ). Between 2000 and 2012, the U.S. Poison Control Center reported 5103 exposures to energy products and among those 552 adverse events: 1 death, 24 serious, and 527 moderate adverse events. Importantly, 44.7% were children younger than 6 yr ( 36 ). According to the FDA’s Center for Food Safety and Applied Nutrition Adverse Event Reporting System, between 2004 and 2012, 166 reports were received describing adverse events associated with energy drink consumption, to include 18 deaths ( 37 ). Together the FDA and Poison Control results of more than 700 adverse events being reported may constitute a signal that requires regulatory action.

The FDA reports describe a single event and exposure related to acute consumption of an energy drink, but unfortunately do not specify the amount of energy drinks consumed. The FDA’s reporting system is estimated to capture only approximately 1% of the true adverse events associated with energy drinks; thus, the number of adverse events and deaths is likely to be much higher ( 18 ).

The most common adverse events associated with energy drink consumption are related to their effects on the cardiovascular and neurological systems, followed by gastrointestinal, renal, endocrine, and psychiatric systems ( 38 ). It is important to consider that the limited evidence for adverse effects comes from clinical reports, cases studies, and reports on small groups; these levels of evidence are not as strong as randomized studies, however they are all that is available at this time.

The long-term effects of consuming energy drinks are unclear and remain to be documented. Although the epidemiological evidence supporting an association between obesity and type 2 diabetes mellitus and consuming sugar laden beverages is consistent, many other factors in the diet provide excess calories ( 39 ). Reducing all sugar sweetened beverage intake (including energy drinks) is likely beneficial in this regard.

Acute Cardiovascular Adverse Effects of Energy Drinks

Endothelial function.

In the majority of well conducted placebo controlled trials, acute exposure to caffeine and other components in energy drinks (typically consumed in less than 5 min) impairs arterial endothelial function (within the next few hours) in healthy young adults at rest ( 18 ). Endothelial function is a barometer of vascular health, and abnormal endothelial cell function termed “endothelial dysfunction” acutely is associated with vasoconstriction, poor vascular reactivity, pro-thrombosis, pro-adhesion, pro-inflammation, and growth promotion ( 18,40 ). While acute effects of energy drinks on endothelial function suggest a reduction in such function, long-term effects of chronic exposure have not been adequately studied ( 18 ).

Hemodynamics

Increased norepinephrine levels of 74% were recently noted in a study involving young healthy volunteers consuming energy drinks ( 41 ). Norepinephrine increases heart rate and blood pressure, triggers the release of glucose from energy stores, and increases blood flow to skeletal muscle ( 41 ). One to 2 h after consumption of energy drinks, healthy individuals usually have a 6- to 10-mm Hg increase in systolic and 3 to 6 mm Hg increase in diastolic blood pressure, as well as an increase in heart rate of approximately 3 to 7 bpm ( 18 ). Such changes may be of concern if an underlying heart condition is present. It is important to remember that excessive caffeine from any source, whether energy drink, tea, coffee, or soda, also can result in increases in blood pressure and heart rate.

Electrocardiographic Abnormalities and Dysrhythmias

A significant increase in corrected QT (QTc) interval in apparently healthy persons 1 to 2 h after consumption of energy drinks of up to 22 to 25 ms has been described ( 42 ). Supraventricular arrhythmias, especially atrial fibrillation, can be seen in apparently healthy persons after the consumption of energy drinks ( 18 ). Ventricular arrhythmias (ventricular tachycardia and ventricular fibrillation) can be seen in apparently healthy persons, associated with consumption of multiple energy drinks over a short period ( 18,43 ). Sudden Cardiac Death has been described in case reports to be triggered by energy drinks, especially in conjunction with exercise ( 18,43 ). It is important to note that in many of these cases, confounding variables such as co-ingestions ( e.g. , drugs, alcohol), genetic predispositions, underlying cardiovascular abnormalities, and strenuous exercise were discovered, so specific causality cannot be attributed to energy drink consumption alone ( 18 ). However, some cases of sudden cardiac death have occurred in young healthy individuals, with no predisposing conditions, in association with energy drink consumption ( 18 ).

Vascular Pathology

Coronary artery spasm may occur in apparently healthy persons after consumption of multiple (2-8 cans) of energy drinks ( 18 ). Coronary artery thrombosis has been associated with consumption of energy drinks in apparently healthy persons, and is likely related to hypercoagulability (increased risk of blood clots), endothelial dysfunction, and elevated norepinephrine levels ( 18 ). A single case report described spontaneous coronary artery dissection after energy drink consumption in a healthy child ( 18 ). Aortic dissection has been reported to be precipitated after consuming more than the recommended servings of energy drinks ( 18 ). ST-segment elevation myocardial infarction in young healthy persons has been associated with excessive consumption of energy drinks (3 to 8 cans), and is likely related to endothelial dysfunction, platelet adhesion, and/or coronary artery vasospasm ( 18 ). A single 240- to 250-mL can of an energy drink has been shown to attenuate or result in endothelial dysfunction in healthy young volunteers aged 22 to 34 yr, so consuming just one energy drink may result in adverse effects on endothelial function ( 44,45 ). Stress cardiomyopathy or Takasubu cardiomyopathy, an acute heart muscle dysfunction, has been reported in a healthy young 24-yr-old man after consumption of a single energy drink, and the mechanism is likely related to a surge in norepinephrine levels ( 4,18 ).

Extra-Cardiac Effects

Several case reports and one National Poison Data System study have noted adverse neurologic effects in association with excessive energy drink consumption. These include epileptic seizures, ( 46–48 ) reversible cerebral vasoconstriction,( 47 ) and intracerebral hemorrhage ( 49 ).

Gastrointestinal

Self-reported symptoms associated with energy drink consumption from emergency room visits indicate about 6% of patients experience gastrointestinal upset with consumption, likely related to the emetic effects of caffeine ( 50 ). Two cases have been reported in which patients developed elevated transaminases and jaundice after heavy energy drink consumption with suspected hepatitis; one of these patients had previously undergone orthotropic liver transplantation ( 49 ).

Acute renal failure, rhabdomyolysis, and metabolic acidosis have been described in association with energy drink consumption ( 49,51 ).

Obesity is associated with energy drink consumption, secondary to the caloric content, with a usual can of energy beverage containing 54 to 62 g of carbohydrates, usually sucrose, high-fructose corn syrup, and/or glucose ( 7 ). Additionally, the endocrine impacts of acute caffeine consumption include hyperinsulinemia and approximately a 30% decline in whole body insulin sensitivity ( 28,30 ).

Psychiatric

Acute psychosis also has been reported in the setting of energy drink use ( 52 ). When compared with caffeine users, adolescents and young adults who consumed energy drinks were more likely to report mind racing, restlessness or jitteriness, and trouble sleeping ( 7 ). Additionally, energy drink users were more likely to report indulging in risk-taking behaviors, including risky driving behaviors ( e.g. , fast driving and seat belt omission), sexual risk taking, tobacco use, marijuana use, psychedelic drug use, cocaine use, alcohol/binge drinking, other illegal drug use, mixing alcohol and energy drinks, and nonmedical use of prescription stimulants ( 53,54 ). Energy drinks may serve as a gateway to other forms of drug dependence ( 55 ). Energy drinks are often combined with alcohol, and young adults who mix alcohol with energy drinks consume more alcohol and experience more related harm than other drinkers ( 56 ).

Effects in Special Populations

The health concerns associated with energy drink use are amplified in children and adolescents ( 3,4 ). Children and adolescents experience adverse effects from energy drinks in greater numbers than adults because of the higher total body concentrations of caffeine relative to body mass, and their relative caffeine naivety ( 9 ). In response to concerns that energy drinks negatively affect performance, behavior, and health of schoolchildren and adolescents, the American Academy of Pediatrics and the National Federation of State High School Associations each issued position statements about energy drink use ( 4,57 ). In particular they recommended that energy drinks should never be consumed by children or adolescents, or used for hydration before, during, or after physical activity. Additionally, the American Beverage Association has recommended that energy drinks should 1) be marketed as separate from sports drinks, 2) not be sold or marketed in schools, and 3) not be marketed to children ( 58 ).

Health Canada also has released a series of measures regarding energy drinks, including caffeine limits, acceptable ingredients, prohibition with premixed alcohol, warning labels for vulnerable populations, and clear labeling of contents ( 59 ). Subsequently, the 2015 Dietary Guidelines Advisory Committee, addressed energy drinks and key points included the vulnerability of children and adolescents to the detrimental health consequences of caffeine, as well as the paucity of information on caffeine consumption in this demographic ( 60 ).

In case of a severe adverse effect ( e.g. , palpitations, seizures), emergency care should be sought immediately. Although information can be obtained from regional Poison Control Centers (1-800-222-1222), to facilitate signal detection, consumers and health care providers should report cases of energy drink-associated events via the FDA’s Safety Reporting Portal ( https://www.safetyreporting.hhs.gov/SRP2 ).

Evidence Statement: The serious and detrimental impacts of energy drink consumption are well documented in the case report literature (ACSM Evidence Category C). The ACSM writing group concurs that energy drink consumption, especially in vulnerable populations can be potentially hazardous (ACSM Evidence Category D).

ACSM Endorsed Recommendations

The following ACSM recommendations are derived from current legislative and organization guidelines, adverse events reported in the literature and clinical experience and consensus of the collective writing group. All ACSM recommendations are shown in Table 2 . Additional substantive recommendations regarding energy drinks can be offered, however implementation of such recommendations requires the efforts of many. The key concepts are detailed here.

• First, the message that these beverages are not intended for children needs to be re-enforced and widely disseminated. Warnings should be prominently displayed on the front of products stating vulnerable populations, including those younger than 18 yr, pregnant or breastfeeding women, caffeine naive or sensitive individuals, taking stimulant or caffeine-based medications, or those with certain cardiovascular or medical conditions, should avoid energy drink use ( 63 ).
• Second, regulatory actions are needed. Many groups have advocated for regulatory limits on the caffeine content of energy drinks, as well as requiring labels to identify the actual amount of caffeine contained per serving ( 32 ). Health Canada has already mandated changes to improve transparency and provide labels instructing vulnerable individuals to avoid energy drink use ( 59 ). The American Beverage Association also is in favor of clearly labeling contents ( 58 ). The Food and Beverage Association in conjunction with the FDA can help ensure the health and safety of susceptible individuals and vulnerable populations, by requiring labeling transparency, clearly labeled warnings, and restriction on sales to those younger than 18 yr until safety and efficacy data are provided by energy drink manufacturers ( 11 ).
• Third, marketing should not appeal to vulnerable populations. Currently, manufacturers of energy drinks advertise on websites, social media, and television channels that are highly appealing to both children and adolescents ( 15 ). Marketing should not be permitted to themes, sporting, and other events involving children and adolescents. Investment in awareness and educational resources highlighting the potential adverse effects and safe use of energy drinks is required in these populations. Significant efforts should be made to educate consumers regarding the clear and present differences between soda, coffee, sports drinks, and energy drinks. Energy drink education also should be a priority in school-based curricula related to nutrition, health, and wellness.
• Fourth, more data are needed. A research agenda must be developed to prioritize key questions about the acute and chronic effects of energy drink use. At a minimum, standard safety and efficacy studies should be performed and submitted to the FDA by manufacturers. Well-designed and controlled research is required to examine the increasing frequency of adverse events being reported by emergency departments ( 32,64 ). It appears that most healthy adults can consume a single energy drink without adverse effects ( 7 ). However, some healthy adults may have a genetic predisposition or sensitivity to their contents that may lead to adverse effects after consuming only one ( 18 ).
• Fifth, education is needed. Health care providers must talk to their patients, both young and old, about energy drink use, and report adverse events to watchdog agencies, like the Poison Control Centers, Consumer Product Safety Commission, and the FDA. We also recommend a national registry be set up in the United States to specifically track energy drink side effects, with mandated reporting requirements by health care providers who believe their patient has suffered an adverse event. Continued monitoring of adverse events related to energy drink consumption is needed to fully understand the rate, severity and nature of reactions to these products across the lifespan.

Conclusions

Energy drinks are frequently consumed and there are reports of morbidity and mortality associated with their consumption. In particular, individuals known to be more susceptible to adverse events include those of young age, small stature, caffeine-naïve or caffeine-sensitive, pregnant or breastfeeding women, those with certain medical conditions and/or taking certain medications, consuming multiple energy drinks in one session, and those with underlying cardiovascular or other diseases. Of critical importance, children and adolescents appear to be at particularly high risk of complications from energy drinks due to their small body size, being relatively caffeine naive, and potentially heavy and frequent consumption patterns, as well as the amounts of caffeine. Although most healthy adults can consume an energy drink without any significant, negative, acute health effects, the long-term effects of chronic consumption have not been well studied. We have summarized the available information regarding energy drinks and their adverse events, and provided recommendations that we hope will help improve the health and wellness of the general public, and inform them of possible dangers associated with energy drink consumption.

The authors declare no conflict of interest and do not have any financial disclosures.

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Review of the energy drink literature from 2013: findings continue to support most risk from mixing with alcohol

Affiliation.

• 1 Department of Epidemiology, College of Public Health and Health Professions, College of Medicine, University of Florida, Gainesville, Florida, USA.
• PMID: 24852059
• DOI: 10.1097/YCO.0000000000000070

Purpose of review: In the field of caffeine research, interest in and concern for energy drink consumption have grown. Most caffeine-related research studies published in 2013 focused on energy drink consumption. This article reviews this literature.

Recent findings: Prevalence of energy drink consumption varies by measure and age group. Lack of a standardized definition of use inhibits comparison across studies. Studies reviewed show that energy drink consumption is generally low, but the minority who drink the most may be consuming at unsafe levels. Energy drinks are popular among adolescents and young adults. They boost energy and alertness in some conditions, but may have adverse hemodynamic effects. Harmful consequences, including involvement in risky driving, riding with an intoxicated driver and being taken advantage of sexually, were reported significantly more often by adolescents and young adults who combined energy drinks with alcohol compared with those who did not.

Summary: This review of recent literature focused on prevalence, motivation, and consequences of energy drink use. Clear findings emerged only on the dangers of mixing alcohol and energy drinks. The lack of a standardized measure made the comparison across studies difficult. Future research should extend and clarify these findings using standardized measures of use.

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Coffee and energy drink use patterns in college freshmen: associations with adverse health behaviors and risk factors

• Dace S. Svikis 1 , 2 ,
• Pamela M. Dillon 3 ,
• Steven E. Meredith 4 ,
• Leroy R. Thacker 5 ,
• Kathryn Polak 2 ,
• Alexis C. Edwards 6 ,
• David Pomm 2 ,
• Danielle Dick 2 , 7 ,
• Kenneth Kendler 8 &

Spit for Science Working Group

BMC Public Health volume  22 , Article number:  594 ( 2022 ) Cite this article

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Metrics details

Public health concern over college students mixing caffeine-containing energy drinks (EDs) and alcohol has contributed to an array of ED-focused research studies. One review found consistent associations between ED use and heavy/problem drinking as well as other drug use and risky behaviors (Nutr Rev 72:87–97, 2014). The extent to which similar patterns exist for other sources of caffeine is not known. The present study examined associations between coffee and ED consumption and alcohol, tobacco and other drug use; alcohol use problems; and parental substance abuse and mental health problems in a sample of college freshmen.

Subjects were N  = 1986 freshmen at an urban university who completed an on-line survey about demographics; caffeine; alcohol, tobacco and other drug use; and family history. The sample was 61% female and 53% White. Chi-square analyses and multivariable binary or ordinal logistic regression were used to compare substance use, problem alcohol behavior, and familial risk measures across 3 caffeine use groups: ED (with or without Coffee) (ED  +  Co; N  = 350); Coffee but no ED (Co; N  = 761); and neither coffee nor ED (NoCE; N  = 875) use.

After adjusting for gender and race, the 3 caffeine use groups differed on 8 of 9 symptoms for alcohol dependence. In all cases, the ED  +  Co group was most likely to endorse the symptom, followed by the Co group and finally the NoCE group (all p  < .002). A similar pattern was found for: use 6+ times of 5 other classes of drugs (all p  < .05); extent of personal and peer smoking (all p  < .001); and paternal problems with alcohol, drugs and anxiety/depression as well as maternal alcohol problems and depression/anxiety ( p  < .04).

Conclusions

The response pattern was ubiquitous, with ED  +  Co most likely, Co intermediate, and NoCE least likely to endorse a broad range of substance use, problem alcohol behaviors, and familial risk factors. The finding that the Co group differed from both the ED  +  Co and NoCE groups on 8 measures and from the NoCE group on one additional measure underscores the importance of looking at coffee in addition to EDs when considering associations between caffeine and other risky behaviors.

Peer Review reports

While caffeinated energy drink (ED) use has been linked to numerous physical and mental health problems, the popularity of ED use worldwide continues to rise [ 1 ]. In the US, since 2011, ED sales have shown steady growth, with sales in 2016 exceeding $2.8 billion [ 2 ]. ED use is most prevalent in adolescents and young adults, with one-third to one-half of adolescents and college students reporting recent (past month) ED use [ 3 , 4 , 5 , 6 ]. These are the age groups often targeted by aggressive ED marketing efforts [ 7 ].

In the US, early ED research was kindled by the landmark study of O’Brien and colleagues (2008) who examined the consumption of EDs mixed with alcohol, which was gaining popularity on college campuses across the country [ 8 ]. The investigators found that college drinkers who mixed alcohol with EDs (AMED) were at greater risk for alcohol-related consequences than non-AMED drinkers, even after adjusting for amount of alcohol consumed. It should be noted, however, that the investigators did not assess or adjust for group differences in other sources of caffeine intake [ 8 ].

Subsequent cross-sectional studies focused almost exclusively on EDs as a source of caffeine and showed that ED use alone was associated with alcohol, tobacco, and drug use and other risky behaviors [ 1 ]. In a review of the literature, Arria et al. (2014) [ 9 ] summarized studies showing correlations between ED consumption and: alcohol use [ 4 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 ], symptoms of Alcohol Use Disorder [ 11 , 15 ], tobacco use [ 4 , 10 , 12 , 14 , 16 ], illicit drug use [ 4 , 10 , 12 , 14 , 16 , 18 , 19 ], nonmedical use of prescription drugs [ 10 , 12 , 14 , 20 ], other risky behavior (sexual risk taking, fighting, not wearing a seatbelt, etc.) [ 14 , 21 ], and poor nutrition habits [ 18 ].

Given the cross-sectional nature of this research, the mechanisms governing the associations between ED use and other risky behaviors are unknown. Some researchers have suggested that ED consumption is one of many activities associated with a broader pattern of risk-taking behavior [ 14 ]. Advertising campaigns that tout the stimulant effects of EDs and, in some cases, glorify drug use may help promote the use of EDs among risk takers or sensation seekers who are more likely to use drugs [ 22 ].

The key to the relationship between ED use and other risky behavior, however, might not be ED consumption, per se. Rather, it might lie in the main psychoactive ingredient in EDs—caffeine. Some research has shown that heavy caffeine use (i.e., coffee, tea, and/or soft drinks) and caffeine dependence are associated with dependence on alcohol and illicit drugs [ 23 ]. This is significant because in a recent survey of college students, it was coffee, in fact, that was reported as the most widely consumed caffeinated product with almost three-fourths of students (72%) reporting past-year use [ 24 ]. Kelpin et al. (2018), using survey data collected prior to ED popularity in the USA, found college females who were daily coffee drinkers were more likely than non-daily coffee users to report heavy alcohol use and a variety of alcohol-related problems [ 25 ].

The present study, then, examined associations between coffee and ED consumption and other substance use and related problems in a sample of college freshmen to better understand the significance of caffeine source on observed associations between caffeine intake and adverse health behaviors. Study variables included alcohol and other drug use and related problems, self and peer cigarette smoking, and parental drug and alcohol abuse and mental health concerns. We hypothesized that students reporting ED consumption with or without Coffee (ED  +  Co) would be most likely to use and report problem behaviors, followed by those consuming only coffee (Co) and finally those reporting no use of either substance (NoCE).

Participants

Participants were college students attending an urban university and participating in the Spit for Science study (see Dick et al., 2014) [ 26 ]. They were drawn from an initial pool of N  = 2056 college freshmen who completed an on-line survey and provided a saliva DNA sample in the fall of 2011. Seventy subjects were subsequently dropped from analyses because of missing data for gender ( N  = 12); caffeine use ( N  = 55) or both ( N  = 3), yielding a final sample of N  = 1986.

Students were initially informed via campus email about the Spit for Science study. They were told the 15–30-min survey focused on personality and behavior, as well as family, friends, and experiences growing up. For students interested in the study, the email message also contained a link to an on-line survey, where they were given additional information about the study. Informed consent was obtained from students who chose to participate, using Institutional Review Board approved procedures. Compensation ($10 and a “Spit for Science” T-shirt) was dispensed at a central location on-campus, at which time students were invited to provide a saliva DNA sample for an additional $10 (for a more detailed description of Spit for Science study procedures, see Dick et al., 2014) [ 26 ].

The on-line survey was designed to collect broad-based data on substance use (including caffeine) and problems as well as mental health symptoms, personality traits and various risk and protective factors. Study data were collected and managed using REDCap electronic data capture tools hosted at Virginia Commonwealth University [ 27 ]. When possible, standardized measures were used for data collection. The present study analyzed survey responses from the following domains:

Demographics

Variables included age, gender and race/ethnicity (dichotomized into White vs Non-White).

Caffeine use

Participants were asked about recent consumption of caffeine (“In the last month, in a typical week, on how many days did you drink …” ). The present study focused specifically on coffee, EDs (e.g., Red Bull, Monster, AMP), and energy shots (e.g., 5-Hour Energy). Coffee drinkers were defined as those reporting coffee consumption 1 or more days per week, and caffeinated ED users were defined as those reporting ED use (EDs and/or shots) 1 or more days per week.

Alcohol use

Participants were asked to classify their current alcohol use into one of seven categories, which, for purposes of analyses, were collapsed into four groups: Non-users (abstainers); Minimal Users (infrequent and light drinkers); Moderate Users (moderate drinkers) or Heavy/Problem Users (heavy drinkers + problem drinkers + former problem drinkers).

Alcohol problems

Symptoms of alcohol dependence were assessed with nine questions adapted from the Semi-Structured Assessment of the Genetics of Alcoholism [ 28 ]. Two items had yes/no response options: a) Strong desire to drink or drank too much in situations where alcohol was not permitted; and b) Tolerance (need to drink more alcohol to get the same effect). The other 7 items had three response options (never; 1–2 times; > 3 times) and focused on: wanting to stop drinking; drinking despite self-promise not to drink or drinking more than intended ; getting drunk when did not want to; stopping or cutting back on important activities to drink; spending several days drinking or recovering from the effects; continuing to drink despite knowing it was causing physical or mental problems; and having withdrawal symptoms (feeling sick for several days after stopping regular drinking). Responses for these 7 items were subsequently dichotomized into No (the symptom never happened) or Yes (it happened 1 or more times).

Other drug use

Participants were asked whether they had used each of the following drugs or classes of drugs (illicit or non-medical) 6 or more times in their lives: cannabis, sedatives, stimulants, cocaine, and opioids. Non-medical use was defined as “use without a doctor’s prescription, in greater amounts than prescribed, or for other reasons than those recommended by a doctor.”

Tobacco use

Respondents were asked how many cigarettes they had smoked in their lifetime. Responses were classified into 3 groups: 0 cigarettes (never smoked); 1–99 cigarettes; or  >  100 cigarettes. Peer smoking was assessed using items from the Monitoring the Future survey [ 29 ]. Specifically, participants were asked to think about friends they saw regularly and spent time with (in or outside of school) during the past year and describe the extent to which such friends smoked. Initial response items were combined to create 3 categories: None of them; A Few or Some of them; and Most or All of them.

Parental history

Participants were asked whether they thought their biological mother and father had ever experienced problems (yes/no) separately for alcohol, other drugs, and depression/anxiety [ 26 ].

Coffee/ED use groups

For the present study, self-reported coffee and ED consumption were used to classify N  = 1986 participants into one of three groups: a) No coffee or ED use (NoCE; N  = 827); b) Coffee but no ED use (Co; N  = 761); and c) Use of ED with or without coffee (ED ± Co; N  = 350). The latter group (ED ± Co) was similar to published literature looking specifically at ED use and included N  = 266 individuals with ED and coffee use and N  = 84 individuals with ED use only.

Data analysis

Categorical data are presented as percentages while continuous data are presented as mean  +  SD. Group comparisons for categorical data were performed using the χ 2 test with the corresponding degrees of freedom, while group comparisons for continuous variables were performed with either a one-way analysis of variance or a non-parametric Kruskal-Wallis test. For all analyses, a p -value < 0.05 was considered to be statistically significant. Percentages adjusted for gender and race as well as adjusted odds ratios (OR’s) and 95% confidence intervals for the adjusted OR’s were calculated using either a multivariable binary logistic regression model or an ordinal logistic regression model for variables with more than two levels.

The sample of N  = 1986 freshmen had a mean age of 18.5 (SD = 0.6) years; approximately one-third was male (38.8%) and half were white (52.7%). Demographic characteristics for the total sample and across the 3 coffee/ED use groups are summarized in Table  1 . While the 3 groups were similar in age, they differed on gender (χ 2  = 87.91, d.f. = 2, p  < 0.0001) and race (χ 2  = 19.25, d.f. = 2, p  < 0.0001). Specifically, there were more females in the Co group (74.5%) as compared to both the NoCE (52.2%) and ED ± Co (54.6%) groups. The 3 groups also differed in racial representation, with a higher percentage of White participants in the ED ± Co (63.0%) as compared to the Co (54.9%) and NoCE (46.6%) groups. Subsequent group comparisons were adjusted to take into account differences in gender and race composition.

Alcohol use and problems by coffee/ED use group

The data for gender and race-adjusted group effect test comparisons of the 3 coffee/ED use groups on measures of alcohol, tobacco and other drug use as well as parental history variables are summarized in Table  2 . In addition, adjusted odds ratios are shown for all possible 2-group comparisons (Co to NoCE, ED ± Co to NoCE and ED ± Co to Co).

For alcohol, group effects were found for pattern of alcohol use (None, Minimal users, Moderate users and Heavy/Problem users), with greater moderate and heavy use among the ED ± Co group and higher rates of abstinence in the NoCE group. Group effects were also found for 8 of the 9 symptoms of alcohol use disorder (AUD) and in all but one case, the ED ± Co group was most likely to endorse the item, followed by the Co and finally the NoCE group. For 3 of the symptoms, (tolerance; wanting to stop; consuming more than intended), the Co group was 1.46–1.78 times more likely to endorse the symptom than the NoCE group. The ED ± Co group differed from the NoCE group on all 8 symptoms, with Adjusted Odds Ratios (AORs) ranging from 2.04 (95% CI: 1.42–2.93) for desire to cut down/stop drinking to 3.13 (95% CI: 2.02–4.84) for drinking more than they intended. Finally, the ED ± Co group differed from the Co group on 7 of the 8 symptoms, with AORs ranging from 1.70 (95% CI: 1.23–2.33) for drinking more than they intended to 2.19 (95% CI: 1.36–3.52) for reduced other activities due to drinking.

Other drug use and problems by coffee/ED use group

For other drug use (6+ times lifetime), significant group effects were found for all 5 classes of drugs. The Co and NoCE groups differed significantly for 2 drug classes, with the Co group 1.29 times more likely than NoCE group to report cannabis use (95% CI: 1.02–1.63) and 1.89 times more likely to report stimulant use (95% CI: 1.10–3.22). The ED ± Co group was more likely than the NoCE group to use 3 of the 5 categories of drugs, with AORs ranging from 2.43 for cannabis (95% CI: 1.85–3.19) to 3.10 for stimulants (95% CI: 1.78–5.40) to 3.51 for sedative/hypnotics (95% CI: 1.76–7.0). Finally, the ED ± Co group was more likely than the Co group to report use of all drugs except stimulants, with AORs ranging from 1.89 for cannabis (95% CI: 1.43–2.49) to 4.10 for cocaine (95% OR = 1.21–13.90).

Tobacco use by coffee/ED use group

For tobacco, significant group effects were found for all three cigarette smoking variables: smoking at least one cigarette (lifetime), number of cigarettes smoked (lifetime) and proportion of friends who smoke. Specifically, ED ± Co group members were 1.53 times more likely to have ever smoked a cigarette than Co group members (CI: 1.18, 2.0) and Co group members were 1.91 times more likely to have ever smoked than NoCE group members (CI: 1.53, 2.39). The largest difference was found between the ED ± Co and NoCE groups, with ED ± Cos nearly 3 times more likely to report ever smoking than NoCEs (AOR: 2.94; CI: 2.25, 3.84). Similar patterns were seen for smoking quantity (lifetime), with AOR’s ranging from 1.73 (ED ± Co vs CO) to 3.21 (ED ± Co vs NoCE), as well as peer smoking (ED ± Cos most likely and NoCEs least likely to report most/all of their friends smoked).

Parental problems by coffee/ED use group

The 3 coffee/ED use groups differed in prevalence of maternal alcohol problems and depression/anxiety (.005 <  p  < .01) and paternal alcohol and drug problems and mental health (.004 <  p  < .04). For maternal alcohol problems and depression/anxiety, only the ED  +  Co group differed from the NoCE group with OR’s ranging from 1.57 for mental health to 1.97 for alcohol problems. For fathers, group effects were found for alcohol problems, with ED  +  Co group members differing from both the Co (AOR: 1.55; CI: 1.15, 2.11) and NoCE (AOR: 1.17; CI: 1.17, 2.12) groups. Similarly for paternal drug problems, the ED ± Co group differed from both the Co (AOR: 1.61; CI: 1.14, 2.29) and NoCE (AOR: 1.50; CI: 1.07, 2.10) groups. For paternal depression/anxiety, only the ED ± Co group differed from the NoCE group (AOR: 1.47; CI: 1.0 2.12). symptoms.

Principal findings

Spurred by the steady rise in ED use and the targeted marketing of these drinks to young adults, much of the existing research regarding caffeine use by college students has focused exclusively on EDs and their associations with a variety of risky health behaviors [ 9 ]. Studies have shown, however, that other sources of caffeine such as coffee and soft drinks are more frequently used by college students than EDs, and these sources of caffeine should be considered when evaluating associations between caffeine and other substance use and problem behaviors [ 25 ]. The present study is among the first to look concurrently at coffee and ED use in college students and to evaluate associations between their use and alcohol, tobacco and other drug use; alcohol use problems; and parental substance abuse and mental health problems. Analyses found students who consumed EDs (with or without concurrent coffee use) were most likely to report other substance use, alcohol-related problem behaviors, and peer/family risk factors for substance use followed by students who consumed coffee only, and finally, students who reported using neither EDs nor coffee. The data are particularly noteworthy for the consistent response pattern observed across almost all domains assessed.

In most previous research, the relationship between other sources of caffeine and adverse health behaviors was either not considered ,14,17,30 or used as a covariate in the data analysis [ 11 ]. The focus on EDs as the singular source of caffeine in these studies started with the compelling data from O’Brien and colleagues (2008) who reported an association between the use of EDs mixed with alcohol and both risky drinking and alcohol-associated adverse health behaviors [ 8 ]. Subsequent researchers continued to focus on EDs and risky health behaviors, in part because of the intense marketing efforts ED makers directed at college-age students and the relatively higher amounts of caffeine in EDs compared to traditional sources of caffeine (e.g., 40 mg caffeine in a 12-oz can of Coca-Cola vs 80 mg in a 12-oz can of Red Bull). More recently, however, many specialty coffee drinks (150 mg in a 12-oz cappuccino) and even soft drinks (110 mg caffeine in a 12-oz can of Coke Energy) contain caffeine in amounts like those found in EDs. Another reason researchers focused singularly on EDs was because these beverages often are consumed more rapidly than hot caffeinated beverages like coffee. Many thought the relatively rapid rate of consumption of EDs may lead to higher caffeine levels and thus, greater association with risky health behaviors, compared to caffeinated drinks that are typically consumed more slowly, like hot coffee drinks. White et al. (2016) however, recently showed there was no clinically significant difference in caffeine exposure (i.e., T max , MRT, MAT or AUC 0–∞ ) regardless of the rapidity with which caffeine was consumed [ 30 ].

Much of the early research in college students who mixed EDs with alcohol showed that these students consumed alcohol more frequently, in higher amounts, and with more episodes of binge and problem drinking than students consuming alcohol without ED mixers [ 8 , 30 , 31 ]. Not surprisingly, AmED users also were more likely than non-AmED users to engage in other risky health behaviors including risky sexual behavior, dangerous driving behavior, and physical altercations [ 8 , 32 , 33 ]. Both clinical and laboratory research suggest students who consume AmED have altered perceptions of their levels of intoxication, with these students not recognizing their levels of impairment [ 8 , 34 ]. Early research also consistently found college students who used ED, independent of concomitant alcohol use, were more likely to report alcohol use; meet criteria for alcohol dependence; use tobacco, marijuana, and nonmedical prescription drugs; and engage in risky sexual and physical behaviors [ 10 , 14 , 21 ].

A few significant exceptions to the early ED-only and AmED-only focused research in college students showed that other sources of caffeine also were associated with risky health behaviors. Thombs and colleagues (2011) compared the effects of AmEDs to alcohol mixed with cola and alcohol alone on alcohol use in college students [ 35 ]. The researchers found a dose-dependent relationship between the estimated amount of caffeine consumed from both EDs and soft drinks and risky alcohol use. Using data from a group of Icelandic college students, Kristjansson et al. (2015) showed that daily consumption of coffee, soft drinks, and EDs, but not tea, was positively associated with drinking AmEDs [ 36 ]. In addition, Anderson and Juliano (2012) showed that estimated mean weekly caffeine consumption, regardless of the source, was positively correlated with the amount of alcohol consumed by college students [ 37 ]. These cross-sectional studies suggest the amount of caffeine consumed is more important than the source of caffeine with regard to the likelihood that college students will engage in adverse health behaviors. More recently, Dillon and colleagues (2019) investigated the relationship between all sources of caffeine and adverse health behaviors in college freshmen [ 38 ]. They found that students who consumed caffeine daily from any source were more likely to report alcohol, cigarette, and nonmedical drug use and problem drinking than those who did not consume caffeine.

In the present study, we elected to focus on coffee and ED consumption in college students for three reasons. First, these beverages typically have the highest caffeine content and, over time, they have come to represent a greater proportion of caffeine intake in US children and adolescents [ 39 ]. Second, coffee is used frequently by college students [ 24 , 40 ], with one recent convenience sample survey of college students finding coffee to be their primary source of caffeine intake (72%), followed by soft drinks (69%), tea (61%), and EDs (36%) [ 24 ]. Third, research done by our group prior to the surge in popularity of EDs underscored the importance of considering coffee when evaluating the effects of caffeine on substance use. Our research showed that college women who drank coffee daily were more likely to report heavier drinking and alcohol-related problems than non-daily coffee drinkers [ 25 ].

Like previous work, this research found an association between caffeine and risky health behaviors. This relationship was more robust for students in the ED  +  Co group compared with those who drank coffee only and those consuming neither beverage. While the cross-sectional nature of the work limits our ability to establish a causal relationship between caffeine, other substance use, and alcohol use problems, the associations are likely a result of a combination of genetic, psychobiological, and environmental factors.

Our study is among the first to look at familial factors associated with caffeine use. We found participants reporting ED ± Co use were more likely to report maternal alcohol problems and depression/anxiety symptoms as well as paternal alcohol and drug problems and depression/anxiety. Such familial clustering may occur because of both a shared environment and genetic factors. In fact, Kendler, Myers, and Gardner (2006) [ 23 ], in a study in adult twins, found that a link between caffeine use and the development of substance use and psychiatric disorders was due primarily to familial factors, including genetic factors. With the compelling and consistent association between EDs and risk-taking behaviors, most frequently other substance use, researchers have linked sensation-seeking personality traits and ED use. College students who scored higher on measures of sensation-seeking were more likely to consume ED and AmED [ 10 , 14 , 41 ]. This may be due to caffeine’s potentiation of the psychostimulant effect of other drugs of abuse through its effects on the adenosine and dopamine pathways. In addition, when combined with alcohol, caffeine blunts the depressant effects and enhances the stimulant effects of alcohol, which alone is associated with risk-taking, by affecting the same pathways [ 42 ]. The increased stimulant effect, decreased depressant effects, and propensity for risk-taking may lead to increased sensation-seeking behavior, including ED use.

Environmental factors likely impact the association between caffeine use and risky health behaviors as well. Almost all college students use caffeine regularly [ 43 ]. At the same time, most college students are in the age range, late teens and early 20s, at highest risk for the onset of many substance use disorders [ 26 ]. The temporal intersection between high frequency caffeine use and increased prevalence of substance use may explain the association between caffeine and risky health behaviors. Patterns between ED use and other drug use have also been found in younger age groups (8th, 10th, and 12th graders) [ 3 ]. In addition, alcohol and other substances like marijuana and tobacco are often part of the college milieu, and students may use caffeine to affect the pharmacodynamic effects of these other substances. For instance, students may concurrently consume caffeine to offset the depressant effects of alcohol or marijuana while socializing or use caffeine to increase their energy when they have school obligations after a night of heavy drinking. Finally, there is evidence that peer influence increases adolescents’ substance use, and this may contribute to the risky behaviors reported by our sample [ 44 ]. Indeed, we found that students who used EDs and/or coffee (ED ± Co and Co groups) were more likely to report smoking and having friends who smoked than the NoCE group.

Limitations

There are several limitations to the present study. First, we relied on retrospective self-report data to address our research question. Second, participants were surveyed about recent (past 30 days) caffeine consumption, which did not allow us to examine use patterns over longer periods. Nonetheless, a 30-day timeframe focused on recent caffeine use appeared to be an appropriate starting point for examining substance use/problems associated with cross-beverage caffeine consumption. Third, the low number of ED only (no coffee) users ( N  = 84) prevented statistical power for a 4-group comparison. Instead, present study analyses included an ED  +  Co group in which three-fourths of the sample reported use of both ED and coffee (76%) and one-fourth reported ED use but no coffee. One advantage of the ED  +  Co group is that it is similar to much of the published research in which ED use was defined without attention to concurrent coffee use, and this allows our data to be compared to the extant literature. Fourth, only frequency of caffeine use was assessed, with no quantity of use data. The survey used for this research was originally designed to assess alcohol use in college students, with limited caffeine use questions, and future research should collect more detailed quantitative data about quantity and frequency of caffeine use. Fifth, caffeine use was restricted to only coffee and ED use; other sources of caffeine intake (e.g., tea, sodas) were not included.

The current study presents benchmark data on the elevated risks associated with ED  +  Co and Co use compared to use of neither substance (NoCE). Specifically, we found a consistent response pattern in which NoCE users were least likely to report substance use and related problem behaviors and ED ± Co users were most likely to endorse such behaviors, with Co users falling in the middle. Whereas the relationship between caffeine use and risky behavior has been previously established [ 14 ], the mechanisms underlying these associations are unknown and are likely a confluence of factors. Additional research is needed to disentangle the effects of amount and type of caffeine use from genetic factors, personality traits, and environmental influences that may mediate these adverse health behaviors.

Present study findings have significant public health implications. Caffeine use is ubiquitous on college campuses, and it is associated with a host of substance-related and other risky adverse health behaviors. The present study found relationships between coffee and ED use and other substance use, alcohol-related problems, and several risk factors for alcohol and drug use. These relationships were strongest for the ED group, but coffee consumption was also associated with risky health behaviors. While evaluating regular caffeine use from a variety of sources including coffee and EDs is important for research purposes, the findings from this research unequivocally show that ED use is most significant for identifying students at risk for other substance use and associated adverse health behaviors. With the social acceptability of EDs, screening for regular ED use in college students may provide a non-stigmatizing way to identify students at higher risk for alcohol/drug misuse, and to prioritize them to receive substance use education and intervention.

Availability of data and materials

Data from this study are available to qualified researchers via dbGaP (phs001754.v2.p1).

Abbreviations

Energy Drink

Coffee and Energy Drink Use

Coffee but no Energy Drink Use

Neither Coffee nor Energy Drink Use

Alcohol Mixed with Energy Drinks

Alcohol Use Disorder

Adjusted Odds Ratio

Confidence Interval

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Acknowledgements

We would like to thank the Spit for Science participants for making this study a success, as well as the many University faculty, students, and staff who contributed to the design and implementation of the project.

The Spit for Science Working Group j :

Spit for Science Director: Danielle M. Dick h,j .

Registry management: Kimberly Pedersen, Zoe Neale, Nathaniel Thomas.

Data cleaning and management: Amy E. Adkins, Nathaniel Thomas, Zoe Neale, Kimberly Pedersen, Thomas Bannard & Seung B. Cho.

Data collection: Amy E. Adkins, Peter Barr, Holly Byers, Erin C. Berenz, Erin Caraway, Seung B. Cho, James S. Clifford, Megan Cooke, Elizabeth Do, Alexis C. Edwards, Neeru Goyal, Laura M. Hack, Lisa J. Halberstadt, Sage Hawn, Sally Kuo, Emily Lasko, Jennifer Lend, Mackenzie Lind, Elizabeth Long, Alexandra Martelli, Jacquelyn L. Meyers, Kerry Mitchell, Ashlee Moore, Arden Moscati, Aashir Nasim, Zoe Neale, Jill Opalesky, Cassie Overstreet, A. Christian Pais, Kimberly Pedersen, Tarah Raldiris, Jessica Salvatore, Jeanne Savage, Rebecca Smith, David Sosnowski, Jinni Su, Nathaniel Thomas, Chloe Walker, Marcie Walsh, Teresa Willoughby, Madison Woodroof & Jia Yan.

Genotypic data processing and cleaning: Cuie Sun, Brandon Wormley, Brien Riley, Fazil Aliev, Roseann Peterson & Bradley T. Webb.

Spit for Science has been supported by Virginia Commonwealth University, P20 AA017828, R37AA011408, K02AA018755, P50 AA022537, and K01AA024152 from the National Institute on Alcohol Abuse and Alcoholism, and UL1RR031990 from the National Center for Research Resources and National Institutes of Health Roadmap for Medical Research. This research was also supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Number U54DA036105 and the Center for Tobacco Products of the U.S. Food and Drug Administration. The content is solely the responsibility of the authors and does not necessarily represent the views of the NIH or the FDA.

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Dace S. Svikis

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Dace S. Svikis, Kathryn Polak, David Pomm & Danielle Dick

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Pamela M. Dillon

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Steven E. Meredith

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Alexis C. Edwards

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Contributions

DS designed the study; played key role in data analyses and was primary author of the manuscript. PD co-designed the study and contributed to interpretation of findings and manuscript writing. SM provided expert guidance on subject matter and guided interpretation of findings and manuscript writing. LT contributed to data analytic plan and conducted the analyses. KP was involved in drafting of the manuscript; DP contributed to literature review; AE contributed to interpretation of findings; and DD and KK played integral roles in primary study data collection and made important contributions to intellectual content of the manuscript. All authors reviewed manuscript drafts and contributed important intellectual content that helped shape the final version of the manuscript. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. The author(s) read and approved the final manuscript.

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Svikis, D.S., Dillon, P.M., Meredith, S.E. et al. Coffee and energy drink use patterns in college freshmen: associations with adverse health behaviors and risk factors. BMC Public Health 22 , 594 (2022). https://doi.org/10.1186/s12889-022-13012-3

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Energy Drinks

Plain water is the best hydrating beverage for most people, but sports and energy drinks are advertised to appeal to those who exercise or need a boost of energy to get through the day.

Though sometimes confused with sports beverages , energy drinks are a different product entirely. They are marketed to increase alertness and energy levels, containing significant amounts of caffeine and as much or more sugar as in soda. Many energy drinks pack about 200 mg of caffeine, the amount in two cups of brewed coffee. Other substances purported to increase energy may be added, like B vitamins and herbs such as ginseng and guarana. Most concerning is a lack of regulation about the safety of these drinks, as well as aggressive marketing tactics geared toward adolescents. [1] The Centers for Disease Control and Prevention reported that in 2007, 1,145 adolescents ages 12 to 17 went to the emergency room for an energy drink-related emergency. In 2011 that number climbed to 1,499. [2]

After water, sugar is the main ingredient in energy drinks. A nutritional comparison shows that a 12-ounce cola drink contains about 39 grams of sugar, 41 grams of sugar in an energy drink. Research has found that consuming high-sugar drinks of any kind can lead to weight gain and an increased risk of type 2 diabetes, cardiovascular disease, and gout.

Because of the amount of sugar and stimulant ingredients, there is concern that these beverages may not be helpful, and even worse, harmful to adolescents and people with certain health conditions.  

Energy Drinks and Health

Sipping a beverage that offers quick energy may appeal to people who feel fatigued or who believe the caffeine can provide an edge when exercising or playing competitive sports. Although statements on the websites of energy drinks warn that these beverages may not be suitable for children, youth are among their largest consumers. An energy drink may be used by adolescents or college students cramming for exams through the night, or by a young athlete before an important game. While it is true that some controlled trials have shown temporary improved alertness and reversal of fatigue after taking energy drinks, as well as enhanced physical performance in young athletes, the majority of studies show an association with negative health effects. These include increased stress, aggressive behaviors like fighting, alcohol/cigarette abuse, increased blood pressure, increased risk of obesity and type 2 diabetes, poor sleep quality, and stomach irritation. [1]

A typical energy drink may contain the following: carbonated water, around 40 grams of sugar (from sucrose and/or glucose), 160 mg or more of caffeine, artificial sweetener , and herbs/substances associated with mental alertness and performance but that lack scientific evidence with controlled trials (taurine, panax ginseng root extract, L-carnitine, L-tartarate, guarana seed extract, B vitamins).

Special concerns with energy drinks:

• Amplified negative health effects in adolescents. Children and teens may experience heightened effects from the high amounts of caffeine, added sugars including high fructose corn syrup, low-calorie sweeteners , and herbal stimulants, partly due to their smaller body size. [3]
• Marketing tactics towards youth. Estimates show more than a 240% increase in U.S. and worldwide sales of energy drinks. It is a $21 billion industry, with marketing campaigns targeting youth and being sold in places that are easily accessed by this age group. [1,4] Youth are exposed to energy drink advertising on children’s websites, computer games, television, supermarkets, and sporting events. [5] Research has shown that adolescents lack maturity in key areas of the brain and are more likely to engage in risk-taking behavior, making them vulnerable to risky behaviors sometimes portrayed in energy drink marketing. Youth are attracted to energy drinks due to effective marketing, influence from peers, and lack of knowledge about their potential harmful effects. [4]
• Negative health outcomes. Emerging evidence has linked energy drink consumption with negative health consequences in youth like risk-seeking behaviors, poor mental health, adverse cardiovascular effects, and metabolic, renal, or dental problems. [1]
• Excessive caffeine. Too much caffeine from any beverage, particularly when several are taken in one day in sensitive individuals, can lead to anxiety, insomnia, heart problems like irregular heartbeat and elevated blood pressure, and in rare cases seizures or cardiac arrest. Some energy drinks may contain as much as 500 mg per can (the amount in 14 cans of cola). [4.6]
• High sugar content. Because of the excessive sugar content in some energy drinks, they carry the same health risks associated with other sugar-sweetened beverages. See Sugary Drinks .
• Dangers with alcohol. A greater danger is introduced if energy drinks are combined with alcohol, a trend largely seen in underage drinkers and associated with binge drinking. Studies suggest that drinking this type of cocktail leads to a greater alcohol intake than if just drinking alcohol alone. This may be because energy drinks increase alertness that masks the signs of inebriation, leading one to believe they can consume even more alcohol. [1] In case reports, high consumption of energy drinks—especially when mixed with alcohol—has been linked to adverse cardiovascular, psychological, and neurologic events, including fatal events. [2]
• Lack of regulation. The Food and Drug Administration (FDA) does not regulate energy drinks but enforces a caffeine limit of 71 mg per 12 ounces of soda; energy drinks typically contain about 120 mg per 12 ounces. However, energy drink manufacturers may choose to classify their product as a supplement to sidestep the caffeine limit. For companies that classify their energy drinks as beverages, the American Beverage Association published voluntary guidelines that advise accurate listings of caffeine content, restriction of marketing to children, and reporting of adverse events to the FDA. However, compliance to these guidelines has been found to be low. [1]
• The International Society of Sports Nutrition (ISSN) issued a position statement on energy drinks after analyzing their safety and efficacy. (8) They concluded that consuming energy drinks 10-60 minutes before exercise can improve mental focus, alertness, anaerobic performance, and endurance in adults, largely through the effects of caffeine. However, other ingredients in these drinks require more study to demonstrate their safety and effects on performance. ISSN cautioned that higher-calorie energy drinks can lead to weight gain, and that their high glycemic load could negatively affect blood glucose and insulin levels. They discouraged use of energy drinks for children and adolescents unless under careful parental monitoring, and for people with diabetes or cardiovascular disease who could be negatively affected by the stimulant ingredients.
• The American Academy of Pediatrics’ Committee on Nutrition and the Council on Sports Medicine and Fitness encourage pediatric health care providers to discourage the use of and discuss potential health risks of stimulant ingredients in energy drinks with youth and parents, and to limit or avoid sugar-sweetened beverages of any kind in youth due to risk of excessive calorie intake and weight gain, as well as dental erosion. [7]  

Bottom Line

Water that is calorie-free and accessible without cost to most people is the beverage of choice taken with and between meals. Energy drinks are a source of caffeine that people may choose as an alternative to coffee or tea. However, they also contain high amounts of sugar, vitamins, and herbs that may not be necessary for the average person. Energy drinks can pose a health risk in vulnerable groups including children, teenagers, pregnant women, and those with medical conditions like diabetes and cardiovascular disease. Adults who choose to consume energy drinks should check the label for caffeine content and avoid high consumption (over 200 mg of caffeine per drink); consumption in combination with alcohol should be avoided. [9] Pediatricians should discuss the use of energy drinks with their young patients and parents to ensure that all are aware of the health risks, and if used, are monitored carefully. [7]  

Sugary Drinks Sports Drinks

• Al-Shaar L, Vercammen K, Lu C, Richardson S, Tamez M, Mattei J. Health Effects and Public Health Concerns of Energy Drink Consumption in the United States: A Mini-Review. Front Public Health . 2017;5:225.
• Ehlers A, Marakis G, Lampen A, Hirsch-Ernst KI. Risk assessment of energy drinks with focus on cardiovascular parameters and energy drink consumption in Europe. Food and Chemical Toxicology . 2019 Aug 1;130:109-21.
• Centers for Disease Control and Prevention. The Buzz on Energy Drinks.  https://www.cdc.gov/healthyschools/nutrition/energy.htm Accessed 8/21/19.
• Pound CM, Blair B; Canadian Paediatric Society, Nutrition and Gastroenterology Committee, Ottawa, Ontario. Energy and sports drinks in children and adolescents. Paediatr Child Health . 2017 Oct;22(7):406-410.
• De Sanctis V, Soliman N, Soliman AT, Elsedfy H, Di Maio S, El Kholy M, Fiscina B. Caffeinated energy drink consumption among adolescents and potential health consequences associated with their use: a significant public health hazard. Acta Biomed . 2017 Aug 23;88(2):222-231.
• Wiggers D, Asbridge M, Baskerville NB, Reid JL, Hammond D. Exposure to Caffeinated Energy Drink Marketing and Educational Messages among Youth and Young Adults in Canada. Int J Environ Res Public Health . 2019 Feb 21;16(4).
• Schneider MB, Benjamin HJ. Sports drinks and energy drinks for children and adolescents: Are they appropriate? Pediatrics . 2011;127(6):1182–9.
• Campbell B, Wilborn C, La Bounty P, Taylor L, Nelson MT, Greenwood M, Ziegenfuss TN, Lopez HL, Hoffman JR, Stout JR, Schmitz S, Collins R, Kalman DS, Antonio J, Kreider RB. International Society of Sports Nutrition position stand: energy drinks. J Int Soc Sports Nutr . 2013 Jan 3;10(1):1.
• van Dam RM, Hu FB, Willett WC. Coffee, Caffeine, and Health.  NEJM .  2020 Jul 23; 383:369-378

Last reviewed July 2020

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Impact of energy drink versus coffee consumption on periodic repolarization dynamics: an interventional study

Dominik schüttler.

1 Department of Medicine I, University Hospital, LMU Munich, Marchioninistrasse 15, 81377 Munich, Germany

2 German Center for Cardiovascular Research (DZHK), Partner Site Munich, Munich Heart Alliance (MHA), 80802 Munich, Germany

3 Institute of Surgical Research at the Walter-Brendel-Centre of Experimental Medicine, University Hospital, LMU Munich, Marchioninistrasse 27, 81377 Munich, Germany

Wolf-Stephan Rudi

4 University Hospital for Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria

Wolfgang Hamm

Stefan brunner, associated data.

All data sets can be obtained from the corresponding author by request.

Caffeinated beverages are consumed daily throughout the world. Caffeine consumption has been linked to dysfunction of the autonomic nervous system. However, the exact effects are still insufficiently understood.

Sixteen healthy individuals were included in the present non-randomized cross-over interventional study. All study subjects consumed a commercial energy drink (containing 240 mg caffeine), and in a second independent session coffee (containing 240 mg caffeine). High-resolution digital ECGs in Frank-lead configuration were recorded at baseline before consumption, and 45 min after consumption of the respective beverage. Using customized software, we assessed ECG-based biomarker periodic repolarization dynamics (PRD), which mirrors the effect of efferent cardiac sympathetic activity on the ventricular myocardium.

The consumption of energy drinks resulted in an increase in PRD levels (3.64 vs. 5.85 deg 2 ; p  < 0.001). In contrast, coffee consumption did not alter PRD levels (3.47 vs 3.16 deg 2 , p  = 0.63). The heart rates remained unchanged both after coffee and after energy drink consumption. Spearman analysis showed no significant correlation between PRD changes and heart rate changes ( R  = 0.34, p  = 0.31 for coffee, R  = 0.31, p  = 0.24 for energy drink).

Our data suggests that sympathetic activation after consumption of caffeinated beverages is independent from caffeine and might be mediated by other substances.

Trial Number: {"type":"clinical-trial","attrs":{"text":"NCT04886869","term_id":"NCT04886869"}} NCT04886869 , 13 May 2021, retrospectively registered

Introduction

Consumption of caffeinated drinks has a long cultural and social tradition throughout the world making caffeine the most widely used psychoactive and stimulating agent [ 1 ]. Both, deleterious and beneficial health effects have been attributed to caffeine consumption: in the past, major concerns have been raised about potential systemic adverse effects of a long-term consumption of caffeinated beverages including the development of cancer, arrhythmias and other cardiovascular diseases [ 2 , 3 ]. In contrast, a large prospective study showed that coffee consumption—one of the most widely consumed caffeine containing beverages—was inversely associated with total and cause-specific mortality [ 4 ]. However, these contrary research findings should be interpreted with caution, since caffeinated beverages contain many other biologically active substances, and therefore, health effects may not only be related to caffeine [ 3 , 5 ].

From the cardiovascular point of view, caffeinated beverages may contribute to the development of arrhythmias [ 5 , 6 ]. The underlying mechanisms of arrhythmogenesis are not completely understood. One potential mechanism is the caffeine-induced imbalance of the autonomic nervous system (ANS). Various studies intended to support this hypothesis by demonstrating changes of heart rate variability, a measure of the balance of the ANS [ 7 ]. However, results remain still inconclusive.

Periodic repolarization dynamics (PRD) is a novel ECG-based biomarker, which most likely reflects the activity of the sympathetic branch of the ANS on the level of the ventricular myocardium [ 8 ]. It has proven its strong prognostic power in large trials of patients with ischemic and non-ischemic cardiomyopathy [ 8 , 9 ]. Several studies demonstrated its regulation among physiological states which are known to activate the sympathetic nervous system [ 10 – 12 ]. However, the effect of caffeine consumption on PRD levels and on cardiac repolarization instability, is still insufficiently explored. Thus, the aim of the present pilot study was to investigate the effect of consumption of caffeinated beverages on PRD.

Participants

For the present study, 16 healthy individuals (6 females and 10 males) with a mean age of 30.2 ± 7.9 years (standard deviation) were recruited between March and May 2021. Subjects with any previous history of cardiovascular disease or on daily medication were excluded from the study. Table ​ Table1 1 provides further information about baseline characteristics.

Overview of baseline characteristics. Values show mean ± standard deviation

The study protocol was approved by the local ethics committee ( “Ethikkommission der Medizinischen Fakultät der LMU München”, project no. 370–16). Informed consent was obtained from each patient, and the study protocol conforms to the ethical guidelines of the Declaration of Helsinki.

Sample size

As there is no data available regarding the effect of caffeine on PRD levels, we estimated sample size by looking at comparable studies which investigated the effect of caffeine on HRV [ 13 , 14 ]. PRD has been proven to be a highly sensitive parameter to monitor sympathetic nervous system on the level of ventricular myocardium [ 8 , 15 ]. Previous studies of our group with similar sample sizes showed robust statistical differences on PRD changes in response to triggers stimulating the sympathetic nervous system [ 10 – 12 ]. We thus assumed that our number of participants would be sufficient to see possible effects.

In this cross-over intervention study, each participant took part in two sessions in a randomized order. There was an interval of at least 48 h between the sessions. In session 1, study participants consumed 750 mL of a commercial energy drink (containing 32 mg caffeine/100 mL (0.03%), 0.4% taurine, 11 g/100 ml sugar according to the manufacturer’s information). In session 2, study participants consumed three cups of coffee (containing 80 mg caffeine/cup according to the manufacturer’s information). Volunteers were urged to consume drinks within 15 min time. In each session, a baseline high-resolution (1000 Hz) digital 20-min ECG (Schiller medilog AR4plus; Schiller AG, Switzerland) was performed in Frank-lead configuration in a resting sitting position, not talking, and quiet surroundings. After baseline recordings, the respective beverage was consumed within 5 min. Caffeine absorption is known to be completed approximately 45 min after intake and blood levels peak around that time [ 16 ]. Therefore, after another resting period of 45 min, a second 20-min high-resolution ECG was recorded. Study participants were required to abstain from caffeine and alcohol consumption 48 h before each session. To exclude volume effects of drinks on PRD changes, we performed an additional experimental session, where study participants drank 750 ml of tap water, and calculated PRD before and after water intake.

All data were collected and analyzed by the study investigators at the Department of Cardiology at the University Hospital Munich (LMU). PRD was calculated out of ECG recordings by a blinded investigator.

Outcome measures

PRD was calculated as described [ 8 ]. In brief, the spatiotemporal properties of each T wave were integrated into a single vector (T°). The angle between two successive vectors (dT°) is plotted over time representing the instantaneous degree of repolarization fluctuations. Typically, an oscillating pattern of the dT° signals can be observed. PRD is calculated by use of wavelet analyses in the low-frequency spectrum (≤ 0.1 Hz).

ECG signals were analyzed using the MATLAB software with established algorithms for calculation of PRD.

Results are expressed as median and corresponding interquartile range (IQR). Statistical analyses were performed with R version 4.0.3. Wilcoxon signed rank test was used to detect differences in PRD levels and heart rates in response to coffee as well as ED consumption ( p  < 0.05 estimated as statistical significance). Spearman correlation analysis were performed to test the correlation between changes in heart rate and changes in PRD levels.

After coffee consumption PRD values did not change significantly compared to baseline values ( p  = 0.64): PRD at baseline was 3.47 deg 2 (IQR 1.88 deg 2 ) and remained unchanged at 3.16 deg 2 (IQR 1.89 deg 2 ) after coffee consumption (Fig.  1 A). Additionally, mean heart rate did not change when comparing values before and after coffee intake (80.8 bpm (IQR 5.4 bpm) vs. 75.0 bpm (IQR 5.7 bpm); p  = 0.15). There was no significant correlation in Spearman analysis between changes in heart rates and changes in PRD levels (Spearman’s rank correlation coefficient R  = 0.34, p  = 0.31).

Boxplots show changes in PRD levels after coffee consumption (A) and energy drink consumption (B) . Boxes visualize medians with interquartile ranges. Wilcoxon signed rank tests were performed to detect statistical differences ( p  < 0.05)

In contrast to coffee consumption, PRD values increased significantly after consumption of energy drinks from 3.64 deg 2 (IQR 1.80 deg 2 ) at baseline to 5.85 deg 2 (IQR 4.40 deg 2 ) ( p  < 0.001; Fig.  1 B). Mean heart rate did not change significantly after ED consumption (78.9 bpm (IQR 7.8 bpm) before vs. 80.4 bpm (IQR 9.8 bpm) after intake; p  = 0.56) and we did not detect a significant correlation between PRD changes and changes in heart rate (Spearman’s rank correlation coefficient R  = 0.31, p  = 0.24). Consumption of tap water (750 ml) did not alter PRD levels (2.94 deg 2 (IQR 0.85 deg 2 ) vs. 2.77 deg 2 (IQR 1.1 deg 2 ), p  = 0.79).

In our study, we investigated the acute effect of consumption of caffeinated beverages on the sympathetic activity by means of analysis of PRD levels. For this purpose, we have chosen two popular caffeine containing beverages, coffee and energy drinks. We detected a significant increase of PRD levels after consumption of energy drinks indicating enhanced efferent cardiac sympathetic activity. In contrast, we did not observe an effect on PRD levels after coffee consumption. Water consumption did not change PRD levels, excluding an effect on PRD in response to volume intake.

A previous study investigated the effect of energy drink consumption on standard electrocardiographic and blood pressure parameters. The authors described a significant increase of systolic blood pressure after energy drink consumption indicating an activation of the sympathetic branch of the autonomic nervous system [ 7 ]. In another study by this group, the authors compared the effect of energy drinks with another caffeinated beverage. The systolic blood pressure was significantly higher with energy drinks [ 17 ]. A study by Corti et al. detected an increased muscle sympathetic nerve activity after coffee consumption. However, in this study, the sympathetic activity was likewise activated in caffeinated and decaffeinated coffee. Thus, the observed effect was independent from caffeine [ 18 ].

In line with these studies, our findings on changes in PRD levels suggest, that the effect of caffeinated beverages on sympathetic activity-mediated cardiac repolarization instability is independent from caffeine and is mediated by other substances. The ingredients of caffeinated beverages are various. It is well known that energy drinks contain additional energy-boosting substances, such as taurine, guarana, and sugar. These substances may affect the cardiovascular system and may lead to a proarrhythmic substrate via sympathetic activation [ 3 , 5 ]. There are several reports linking an overuse of energy drinks to the occurrence of sudden cardiac deaths [ 5 , 6 ]. This risk may be reflected by the elevated PRD levels after consumption of energy drinks, since PRD is an excellent predictor of mortality and in particular of sudden cardiac deaths in patients with underlying heart diseases [ 8 , 9 ].

A number of considerations are necessary when interpreting our results. With a single ECG recording, we cannot elucidate the temporal relation between caffeine consumption and PRD changes. Further, we did not investigate dose dependent effects of caffeine on PRD levels. In addition, we cannot exclude individual differences of caffeine absorption, since we did not measure blood caffeine levels. Results are limited by the small sample size, further studies investigating the effect of caffeine on PRD, e.g. in combination with HRV-derived parameters might be useful to further support our findings.

In conclusion, our results suggest that sympathetic activity-mediated repolarization instability after consumption of caffeinated beverages is independent from caffeine and might be triggered by other substances.

Authors` contributions

DS collected, analyzed and interpreted data and wrote the original draft. WSR collected data and revised the manuscript for intellectual content. AB revised the manuscript for intellectual content. WH collected, analyzed and interpreted data and revised the manuscript for intellectual content SB was responsible for conceptualization and project administration and revised the manuscript for intellectual content. All author’s read the manuscript and agreed to its submission.

Open Access funding enabled and organized by Projekt DEAL. Dominik Schüttler is supported by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation)—413635475—and the Munich Clinician Scientist Program (MCSP) of the LMU Munich. Funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Declarations

All authors declare no competing interest.

Not applicable.

Research was approved by the local ethics committee (Ethikkommission der Medizinischen Fakultät der LMU München (project no. 370–16)).

All subjects gave written informed consent in accordance with the Declaration of Helsinki.

Consent for publication was obtained from all study volunteers.

Wolfgang Hamm and Stefan Brunner have contributed equally to this study and share authorship.

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Another Sugar Substitute Is Called Out for Potential Heart Risks

New research suggests the sweetener xylitol is linked to health issues. Here’s what to know.

By Knvul Sheikh

A new study linking the low-calorie sugar substitute xylitol to an increased risk of heart attack or stroke has once again raised questions about the risks and benefits of sugar substitutes.

Xylitol is a sugar alcohol found naturally in fruits and vegetables, and even produced in the human body at very low levels. But it is often synthetically produced and is increasingly being added to processed foods, like candies and “low-sugar” baked goods, because it has 40 percent fewer calories than regular sugar does and doesn’t cause blood glucose to spike after a meal. The study authors said this rise in consumption was concerning, as the people most likely to turn to the sugar substitute may already be trying to manage conditions like obesity and diabetes that also increase the risk of cardiovascular issues.

“They may think they’re making a healthy choice by picking xylitol over sugar, yet the data argues that it is not the case.” said Dr. Stanley Hazen, the chair of cardiovascular and metabolic sciences at the Cleveland Clinic’s Lerner Research Institute and an author of the study. Last year, Dr. Hazen and his colleagues found a similar association with another sugar alcohol, called erythritol .

For the new study, the researchers measured the levels of xylitol in blood plasma samples of over 3,000 participants who had fasted overnight. They found that people with the highest xylitol levels had roughly double the risk of heart attack, stroke or death within the next three years compared to people with the lowest levels. The results were published in the European Heart Journal this month .

The research does not prove that sugar alcohols like xylitol and erythritol directly cause heart attacks, only that they’re associated with an increased risk. Because the researchers did not track the participants’ diets, other foods may also have contributed to that risk, said Marta Yanina Pepino, an associate professor of food science and human nutrition at the University of Illinois at Urbana-Champaign. And it’s possible some of the participants naturally produce more xylitol, and their high levels did not come entirely from food and drink, she said.

To address some of these concerns, Dr. Hazen’s team also fed xylitol to mice, added it to human blood samples in a lab and also gave drinks containing xylitol to 10 healthy volunteers. In each of the tests, xylitol increased how quickly platelets formed clots, which could eventually lead to a heart attack or stroke.

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