So-called energy drinks: ANSES warns against dangerous consumption patterns

“Energy drink” is a commercial designation and is not defined by any specific regulations. So-called energy drinks (scEDs) are sodas fortified with various substances already present in food (caffeine, guarana, taurine, vitamins, ginseng, etc.). ANSES has catalogued over 100 of these drinks marketed in France. Their composition is relatively heterogeneous except as regards caffeine, which is found almost systematically in all of these beverages. A standard 250 ml can of so-called energy drink contains on average the same amount of caffeine as two espresso coffees (50 ml) or slightly more than two cans of cola (330 ml).

ANSES has been investigating the safety of so-called energy drinks for several years. In this context, the Agency is notified of cases collected as part of the nutrivigilance scheme of suspected adverse effects related to the consumption of these products. In a press release dated June 2012, ANSES requested health professionals to send in as many declarations of such cases as possible. More than 200 cases were reported, bringing the final total to 257, of which 212 were sufficiently well documented to allow analysis as a part of the risk assessment related to the consumption of so-called energy drinks that is being published today. 

The implication of the consumption of so-called energy drinks in the onset of these adverse effects was judged, according to the nutrivigilance criteria for assessing causality, to be very likely or likely for 25 cases, i.e. 12% of those reported. The principal symptoms observed in these cases are essentially: cardiovascular (chest tightness or pain, tachycardia, high blood pressure, arrhythmia leading even to cardiac arrest, etc.), and psycho-behavioural or neurological (irritability, nervousness, anxiety and even panic attacks, hallucinations, epileptic seizures, etc.). 

ANSES considers that the cases of cardiac arrest reported under the nutrivigilance scheme and those reported in the literature arose very probably in genetically predisposed subjects. These frequent predispositions (canalopathies) are mostly asymptomatic and generally undiagnosed. They may affect about one individual in 1000. Cardiac arrest in these subjects could occur as the result of drinking so-called energy drinks in association with certain supplementary risk factors such as physical exercise (sport, dancing, etc.), high alcohol consumption, hypokalaemia, certain medications or individual sensitivity to caffeine.

The other effects studied (cardiovascular, psycho-behavioural or neurological) correspond to adverse effects commonly observed after intake of large quantities of caffeine. After analysis of the nutrivigilance cases and the bibliographical data, the caffeine found in these drinks was considered to be the key explanatory factor.

Caffeine is found naturally in more than 60 plants (coffee, tea, kola, guarana, yerba maté, etc.) and is well known for its effects as a stimulant and its many adverse effects: anxiety, tachycardia, sleep disorders, and the risk in children of later developing addictive behaviour. In the population at large there is great variability in individual sensitivity to the effects of caffeine. On the basis of the different thresholds used as references internationally, it can be seen that a non-negligible fraction of the French population exceeds the recommended levels of caffeine: 

• about 30% of the adult population exceeds the threshold established as causing anxiety (which for an adult corresponds to about six espresso coffees);
• and almost 7% of the adult population exceeds the threshold beyond which more general chronic toxicity is suspected (bone and cardiovascular health, cancer, male fertility, etc.).
• 11% of 3 to 10-year-olds and 7% of 11 to 14-year-olds exceed the threshold for developing tolerance to caffeine and triggering withdrawal symptoms (which for a child weighing 35 kg corresponds to less than a half of a standard can of so-called energy drink or one can of cola).

Although caffeine has long been consumed throughout the world, its novel and increasingly popular presentation in the form of so-called energy drinks is changing consumption patterns:

• use by consumers who until now had had little exposure to caffeine, including children and adolescents of whom, in Europe, 3% and 8% respectively consume so-called energy drinks more often than 4 to 5 times a week;
• consumption of very high quantities: 25% of French consumers of so-called energy drinks sometimes consume more than 500 ml in a single day; 
• consumption in new contexts of exposure: in France, about 32% of consumers of so-called energy drinks drink them during festive occasions (bars, nightclubs, concerts, etc.), 41% in association with sporting activities, and 16% while also consuming alcohol.

ANSES considers that the multiplication of sources of caffeine, notably via so-called energy drinks, combined with current consumption patterns of these drinks, is capable of generating risk situations.

The Agency therefore recommends:

1. that consumers refrain from consuming so-called energy drinks in association with alcohol and during physical exercise;
2. that the following groups be particularly vigilant concerning their caffeine intake, especially via so-called energy drinks: pregnant women and nursing mothers, children and adolescents, and individuals sensitive to the effects of caffeine or presenting certain pathologies, especially: certain cardiovascular or psychiatric and neurological disorders, kidney failure or serious liver diseases. 
3. that all consumers in general moderate their consumption of caffeinated beverages.

Furthermore, the Agency calls on health professionals, and especially doctors, to:

1. include questions about consumption of so-called energy drinks when interviewing patients with relevant symptoms (paroxysmal tachycardia, high blood pressure, convulsions, etc.) and to try and determine as early as possible the level of caffeine consumed; 
2. continue to report to ANSES any new cases of adverse effects suspected of being related to the consumption of so-called energy drinks.

Lastly, ANSES also draws attention to the emergence in other countries (Canada, United States, Lithuania, etc.) of government policies to regulate the market for so-called energy drinks. Considering the divergence between the Agency's recommendations and current practice as reported in France, and also the lack of information available to the public, ANSES calls for measures to be taken to inform vulnerable population groups and to regulate the advertising of so-called energy drinks to these groups and in contexts (festive, sporting, etc.) where consumption involves special risk.