Energy drinks can threaten consumer health, especially younger people. Their habitual and/or massive consumption is indeed associated with damage to the cardiovascular system.
The market survey on 16 energy drinks available in Italy also reveals the presence of undesirable dyes and chemical additives, as well as caffeine and sugar in quantity.
Red Bull, Monster and other energy drinks
The basic recipe of energy drinks consists of a high caffeine content, in combination with taurine, sucrose (or synthetic sweeteners, in the sugar free versions), B vitamins, ginseng and other herbal extracts.
Caffeine, in all examined products, always has a concentration above 150 mg/L. And it is therefore mandatory to report on the label of such beverages, pursuant to Food Information Regulation (EU) 1169/11, the warning:
‘High caffeine content. Not suitable for children or pregnant or breastfeeding women'.
Caffeine, concentrations and crazy doses
The concentration of caffeine, in the 16 products examined, ranges from 240 to 320 mg/L. That is, from 160% up to 213% of the dose that the European legislator classifies as 'high'.
The amount of caffeine Moreover, it increases in proportion to the can size, exceeding 160 mg of caffeine in a can of Monster. An objectively excessive dose.
Caffeine, ‘health claims’ not allowed and food safety
The ingredient Characteristic of energy drinks – caffeine, declared as natural origin only in the Coop beverage – can stimulate the central nervous system and increase mental alertness, reducing sleepiness. The related ‘health claims’ have not been approved pursuant to the Nutrition and Health Claims Regulation (EC) 1924/06, and their even implicit suggestion is therefore prohibited.
Food safety Of beverages containing caffeine has been assessed by EFSA (European Food Safety Authority) in 2015. According to the Authority, they do not raise concern in a healthy adult weighing 70 kg
– single doses up to 200 mg of caffeine and
– up to 400 mg total substance throughout the day. (1)
Children and adolescents, one drink is enough to exceed
For children and adolescents, instead, ‘the available information is insufficient to derive a safe caffeine intake’, declares the Authority. The criterion established for healthy adults is therefore extended to this population group (vulnerable by definition).
The daily dose not to be exceeded is therefore set at 3 mg per kg of body weight. That is, for example
- 150 mg per day for a body weight of 50 kg, typical of an adolescent
- 120 mg for a pre-adolescent (13 years old) weighing 40 kg
- 75 mg for a ten-year-old child weighing 25 kg.
The calculations are quickly done. Ai più giovani basta una lattina di energy drink per superare la soglia di sicurezza. Senza contare l’ulteriore consumo di caffeina contenuta in altre fonti alimentari come tè, cioccolato e altre bevande (come la Coca-Cola, che ne contiene oltre 106 mg/L).
Excess caffeine, what effects?
Adults have almost certainly experienced at least once the unpleasant effects of excess caffeine, even just from one too many coffees. Effects that ‘energy drinks’ can amplify due to dosage and combination with sugar and other ingredients (see the next paragraph).
Agitation, palpitations, insomnia and other sleep disorders are the most well-known side effects. But not the only ones. In fact, the cardiovascular system is also affected.
A study (Kaur et al., 2022) highlights that energy drink consumption has repeatedly been associated with cardiovascular system damage, such as atrial and ventricular arrhythmias, myocardial infarctions, cardiomyopathies, and sudden cardiac death. The authors define its consumption as ‘a growing public health problem in recent decades’. (2)
Caffeine mixed with other stimulants
Each ingredient of energy drinks can contribute to these harmful effects.
Caffeine acts on the cardiovascular system through various mechanisms – such as blocking vasodilation of vascular beds, increasing sympathetic tone, and a positive inotropic effect on the myocardium – which cause an acute increase in heart rate and blood pressure.
The other ingredients characteristic of energy drinks – such as taurine, sugars, and B vitamins – in turn ‘can contribute to these outcomes by increasing heart rate, blood pressure (BP), and heart contractility, as well as prolonging the QTc (the interval measured by ECG).'.
Simple sugars, cardiovascular diseases, and diabetes
Simple sugars, namely sucrose, glucose, or high fructose corn syrup, are also responsible for the cardiovascular risks described in the study under review. In the products we examined, sugar content ranges from 7.4 to 15%. Up to a dose of 55 g – equivalent to 11 teaspoons of sugar in a single serving – in one can of Monster.
‘It has been noted that sugar and caffeine have synergistic effects that cause a significantly higher increase in blood glucose and insulin after their consumption.’ This means that in the long term, consuming these drinks leads to obesity and insulin resistance. ‘Diabetes is an important risk factor and one of the most common causes of cardiovascular diseases’.
Other 'active' ingredients
B group vitamins are almost always present in energy drinks. Known as a beneficial supplement, these may also probably enhance the stimulating effects of other ingredients present in these beverages, hypothesize the authors of the study.
Guarana and yerba mate, two plants often present in energy drinks, are themselves rich in caffeine. ‘These ingredients could also increase the adverse effects of caffeine on the cardiovascular system’, note the researchers.
Ginkgo biloba and ginseng, themselves often present in energy drinks, are identified by researchers (Kaur et al., 2022) as potentially harmful:
– some clinical cases describe severe hemorrhagic events caused by ginkgo biloba extracts, probably due to its antagonistic effect on platelet activating factor;
– prolonged use of ginseng is instead associated with cardiovascular side effects, such as increased blood pressure, long QT syndrome, or atrial fibrillation.
Salt/sodium
Despite the sweetened flavors, energy drinks also contain non-negligible doses of salt.
The highest content, 0.24%, is present in the Eurospin drink which thus provides 60 mg of salt per serving. The maximum salt dose per can is contained in Monster, 0.96 g.
Additives and colorants
Additives, flavors and colorants complete the recipe of ‘energizing’ drinks.
Physik, Burn, Monster, Lemonsoda, Crazy Tiger and Eurospin contain the preservative sodium benzoate (E 211) or benzoic acid (E 210), whose presence in beverages suggests the ease of exceeding the tolerable daily intake for children. Both additives are associated with hypersensitivity and allergy reactions (asthma, itching, redness) and are suspected of promoting hyperactivity in children, alone or in combination with some azo dyes.
Lemonsoda contains instead sodium phosphates, linked to an increased cardiovascular risk and worsening of intestinal inflammation. (3)
Many energy drinks 'Classic' ones also contain strongly discouraged colorants:
– Burn and Lidl add ammoniacal caramel (E 150d), which may contain a compound suspected of being carcinogenic (group 2b) by IARC and should be avoided in case of sulfite intolerance.
– Eurospin and Lidl zero instead use caramel E150c, ammonia-based, which may contain an immunotoxic substance (THI) and one suspected by IARC of being carcinogenic (class 2b). Psychik instead contains caramel 150b, to be avoided in case of sulfite intolerance.
San Benedetto, finally, adds a Southampton colorant, red E129, which, as the mandatory label warning states ‘May negatively affect children's activity and attention'.
Sugar free, from the frying pan into the fire
The search for sugar free products is a consolidated and growing trend, as noted for several years by the Immagino Observatory. (4) Even among energy drinks the supply flourishes. But what is sugar replaced with?
In the sample, the sugar free version is always based on synthetic sweeteners: aspartame, acesulfame K, and sucralose. In Eurospin and San Benedetto products we also find cyclamates. All these substances are discouraged by WHO because they are ineffective for weight loss and expose to diseases such as type 2 diabetes, cardiovascular diseases, and mortality. (5)
Aspartame and acesulfame K, moreover, in a recent cohort study conducted on 102,865 French adults (Debras et al., 2022) are also associated with an increased risk of cancer, particularly breast cancer, and obesity-related tumors. (6)
The 'no added sugar' versions sometimes also contain gum arabic and xanthan, whose abuse causes intestinal disorders.
Flavors and colorants in the fruit-flavored version
With or without sugar, fruit-flavored energy drinks multiply. A subgroup that however is not better from a nutritional quality point of view.
The basic recipe is essentially identical to that of 'classic' energy drinks. Same amount of sugars or same synthetic sweeteners, caffeine, taurine, etc.
The various flavors are obtained with synthetic flavors (generically defined as 'flavors'), like in Red Bull, or natural flavors (in Monster) that recall the taste of the fruit mentioned on the label.
As for the colorings, besides the presence of caramel coloring already mentioned, Monster Energy Ultra Strawberry Dreams is noted for including E129 and E110 in its drink with 160 mg of caffeine per serving, substances reported as causes of ADHD and therefore accompanied by a warning on the label: 'May negatively affect children's activity and attention'.
Use, abuse and warnings
In any form and flavor, it is a fact that energy drinks are considered by certain population groups as a stimulant useful for 'getting high'.
Gulping down several cans of drink or mixing them with alcohol (with the effect of reducing alcohol-induced drowsiness but not the stupefying effects) is dangerous, and producers – aware of this – try to limit their liabilities with warnings on the label such as:
'Do not mix with alcohol. Consume responsibly', Monster.
'Consume responsibly', Burn.
'Consume moderately', Red Bull and Lemonsoda.
'Not suitable for diabetics and people sensitive to caffeine. Do not consume with alcohol or during intense physical activity', Lidl.
Unbridled marketing
It is difficult to reconcile the warnings to caution with the encouragement to consume conveyed by marketing and sponsorships with events and sports personalities considered role models. Some examples.
Drinking a can of Burn ‘will fuel the fire within you. Artists, Musicians, Stylists and Enthusiasts all know what we’re talking about. Open a can of Burn Energy and you will discover it too!'.
The creatives - or aspiring ones - are in the marketing’s crosshairs. 'Musicians, revolutionaries, students, street warriors, metalheads, geeks, hipsters and bikers love it... you will love it too!', guarantees Monster.
Temporary and permanent damage
The consumption of energy drinks, despite marketing, is associated with temporary sufferings and very serious reactions. The authors of the study under review (Kaur et al., 2022) summarize them as follows:
‘The acute side effects associated with ED (energy drinks, editor’s note) are headache, discomfort, irritability, excitability, malaise, dehydration, nervousness, insomnia, nausea/vomiting, abdominal pain and xerostomia (dry mouth, editor’s note).
Some other more serious and even fatal consequences that have been reported from ED consumption include epileptic seizures, intracerebral hemorrhage, acute hepatitis, rhabdomyolysis, acute renal failure and psychosis.
All this in addition to the already mentioned cardiovascular damage, which ‘include supraventricular and ventricular arrhythmias, coronary vasospasms, ischemia/myocardial infarctions and sudden cardiac death in otherwise healthy patients. The presenting symptoms in these patients were often chest pain, palpitations, nausea and vomiting’.
A recent Italian study (Costantino et al., 2023) offers a comprehensive review of the confirmed effects of acute or chronic abuse of energy drinks on human health. An impressive collection of data accompanied by a disturbing consideration:
‘This review highlights the need for greater rigor in evaluating the sudden cardiac death, particularly among young people, as legal substances such as energy drinks may be involved’, write the authors of the study. (7)
Restrictions on the sale of energy drinks
The researchers call for regulation of these drinks and further studies on the interaction of the various ingredients contained in them. Instead, energy drinks continue to be available without restrictions, even in vending machines.
Only in some countries are restrictions on sales to minors provided. In Poland, Lithuania, Latvia, and Turkey, sales are allowed only to those over 18 years old. The Czech government has voted a similar measure and the United Kingdom is discussing it. (8)
Marta Strinati
Notes
(1) EFSA Panel on Dietetic Products, Nutrition and Allergies. Scientific Opinion on the safety of caffeine. EFSA Journal. 27.5.15 https://doi.org/10.2903/j.efsa.2015.4102
(2) Amandeep Kaur, Hamza Yousuf, Devyani Ramgobin-Marshall, Rahul Jain, Rohit Jain. Energy drink consumption: a rising public health issue. Rev. Cardiovasc. Med. 2022, 23(3), 83. https://doi.org/10.31083/j.rcm2303083
(3) Marta Strinati. Ginseng coffee, beware of additives. 20 products compared. GIFT (Great Italian Food Trade). 5.7.24
(4) Marta Strinati. Food consumption in Italy in the XVI edition of the Immagino Observatory. FT (Food Times). 21.12.24
(5) Marta Strinati. 'Sugar-free'? Synthetic sweeteners are useless and harmful, warns WHO. GIFT (Great Italian Food Trade). 15.5.23
(6) Marta Strinati. Aspartame and health risks, brief scientific review. FT (Food Times). 20.8.23
(7) The Italian study. Costantino A, Maiese A, Lazzari J, Casula C, Turillazzi E, Frati P, Fineschi V. The Dark Side of Energy Drinks: A Comprehensive Review of Their Impact on the Human Body. Nutrients. 2023 Sep 9;15(18):3922. doi: 10.3390/nu15183922. PMID: 37764707; PMCID: PMC10535526.
(8) Energy Drink: Europe calls for bans for minors, but EFSA does not set limits for young people. Beverfood. 29.11.24
Professional journalist since January 1995, she has worked for newspapers (Il Messaggero, Paese Sera, La Stampa) and magazines (NumeroUno, Il Salvagente). Author of investigative journalism on food, she published the book 'Reading labels to know what we eat'.
