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Warrick is a Practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warrick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love.

Hi, my name's Doctor Warrick Bishop, and I'd like to welcome you to my podcast channel. Today I'd like to discuss energy drinks. We all know they're incredibly common. We see them advertised. We see them in shops and we see not only sportspeople but young adults and teenagers consuming these beverages regularly. Well, what are they? What sort of things do they contain? What benefits might they offer? What risks might they carry? And what's a little bit of the history to these drinks and their arrival on the global market?

Dealing with the history first, one of the most recognized brands in the energy drinks space is Red Bull, and Red Bull was released in Austria as far back as 1987. It wasn't until approximately ten years later when it was released in the US. And then subsequently grew and grew with other energy drinks coming into the market so that by the time we reached 2013, there was over 5.8 Billion litres of energy drink being consumed in over 160 countries around the world. In the U.S. alone, in 2012, the estimated market value of the industry was 12.5 billion dollars. And it had been growing at a staggering pace, year on year energy drinks are just too big for them to ever go away, so with us understanding that they're going to always remain in our marketplace, then there are some questions that we have to consider for ourselves as potential users. Or as responsible adults in charge of people; our children who may be potential users.

Why do people take energy drinks and what can you expect from taking energy drinks? The main reason is a boost in, as you would guess, energy. These drinks promote wakefulness, they maintain alertness and is said to help with cognitive function and mood enhancement.

There's also some research that would suggest they can improve motor function and coordination. That's things like catching a ball for example or driving something. Things that may require quick reflexes and coordination.

Although these are quite tantalizing thoughts, I do need to point out that although there are some clear studies which demonstrate a suggestion of benefit taking these energy drinks, there are also many studies that don't necessarily show benefit at all. So what are the active ingredients within most energy drinks? Well, the most common active ingredient is caffeine. And that caffeine ranges between 30 milligrams to over 140 milligrams in different preparations. And you have to simply read the label of the product to know what it is for that particular preparation.

It's useful to put that into context though when we think about caffeine in a coffee shot. By checking on the Starbucks website, one can quickly find out that a standard espresso shot through Starbucks is going to have about 90 milligrams of caffeine within it, and a double shot, therefore, can range depending on where you get it from, between 60 and 180 milligrams.

So for energy drinks, caffeine is considered the main ingredient. But there's also other ingredients that go in with it. The most significant and now the most common ingredient is sugar. And these drinks contain large hits of sugar so that the person consuming these drinks is getting both a hit of coffee and a sugar rush. Other constituents of these drinks to varying degrees include things like taurine, methylxanthines, vitamin B, ginseng, Gharana, Yerba Mate, maltodextrin, inositol, carnitine, creatine, glurono, lactone, and ginkgo biloba, but of course these are all in varying amounts and there is no clear data at all to reflect their impact on the individual. Only speculation, really, which can be transferred across from their use as standard vitamins for individuals.

These agents are taken for energy, and therefore we might expect a physical benefit. There is some research to support that individuals taking these agents do demonstrate an enhanced or improved aerobic endurance. They also describe an improvement in mood and an increase in alertness. There's also some work that's shown that these agents improve response times. And reduce fatigue. So if you think about it, it makes perfect sense if you're playing a game that requires focus, a good attitude, plenty of energy; something like a team sport, for example, volleyball.

You could imagine if you were able to enhance your performance in those different categories, then your team performance, if everyone was consuming these energy drinks of course, would improve. I don't wish to go into details of those studies as they're mainly fairly small and they're also offset by an equal number of studies that didn't show a significant benefit.

What I would like to do, however, is move on to some of the limitations of these agents and in particular the physiological or the effects on the body and the psychological or effects on the mind aspects related to these drinks.

One of the most notable effects of these agents is on the cardiovascular system where, not surprisingly, the shot of caffeine has a significant effect on heart rate increase and arterial blood pressure to a degree. This might be an acceptable side effect in small doses, but there is also observational data to suggest that high doses of caffeine can lead young patients young people into abnormal rhythm disturbance with changes on their EEG that may well lead to problems with rhythm and even risk of death.

This is from a direct effect of the caffeine on the electrical cells of the heart. The caffeine also affects other cells within the heart and one of the important cell groups within the heart are the special lining of the arteries within the heart.

The lining of arteries is a very special organ. It is the organ that allows transfer of nutrients from the bloodstream into the tissues. But it is also a special Teflon, if you like, that keeps the blood flowing through the arteries without any of the components or particles of the blood sticking to the wall. This lining of the arteries, also known as the endothelium, needs to work, and it needs to work properly for it to do its job effectively. There is certainly some suggestion from research that high doses of caffeine, as seen in excessive use of energy drinks, can have an impact on the endothelial function, affecting not only the possibility of components of the blood aggregating or clotting within the artery, but also changing blood pressures and running the risk of a blockage within the artery and subsequently a heart attack. For anyone who has had a couple too many coffees during the day, you will relate easily to the sort of neurological effects that might come from excess use of energy drinks.

At caffeine doses above about 200 milligrams for a standard adult, then features of anxiety or insomnia may occur. Patients may describe gastrointestinal upset or restlessness, and of course some degree of agitation. It turns out that the Diagnostic and Statistical Manual of Mental Disorders actually has four caffeine-induced psyche or psychiatric disorders recognised. These disorders are: #1 Caffeine Intoxication, #2 Caffeine-Induced anxiety, #3 Caffeine-Induced sleep disorder, and #4 Caffeine-Related Disorder, which is slightly less specific, but you get the drift.

There have been some reports of hallucination and even epilepsy with patients who consume greater than 300 milligrams of caffeine through energy drink consumption. Because of the significant sugar load that most of these energy drinks contain, they can also have an effect on the gastrointestinal and metabolic systems. Some researchers have observed tooth decay as you might expect from the sugary drinks. Some have reported a possible changing gut microbiome from the increased sugar load.

Others have suggested that the change in insulin sensitivity brought about by the combination of caffeine and high sugar can be detrimental and even lead to weight loss in the future and deranged metabolic processes for that person in later life should they pursue long term use of these beverages. Most of us who have had a cup of coffee in the morning will realise that there is also a diuretic effect from caffeine and that means it allows water to be lost through the kidneys.

Of course, energy drinks do the same. But the concern in this situation is if you are of a good mood, full of energy and exercising, then it's quite possible that you may dehydrate without being aware of it. So there is a concern that appropriate use of energy drinks be offset and balanced with appropriate hydration for fear of damage to the kidneys. From a personal perspective, because I have teenage children, I think one of the most significant and important aspects of energy drinks is the impact on psychological processes of the consumer taking them, and this is particularly the case with teenagers and young adults. Having said that there is some clear information that caffeine and sugar do help people concentrate and perform better in mental activities, and this is in combination with improved mood, we have to offset that against what deleterious effects these agents may have on young people or anyone using them to any extent.

Certainly, sleep, is affected. And anyone who's been tired and wanted to try caffeine to keep awake would realise that it actually works, nut the research would suggest it works but leaves you depleted the following day. So there's really no net gain. And it is important to be aware that you are going to lose, as it is, swings and roundabouts. There have been studies looking at university age students who have engaged in frequent energy drink consumption at parties. And there is no question that the association of energy drinks with risky behavior is either sexual or fighting or the use of drugs or even the use of seatbelts in cars has been suggested and documented by some researchers.

This, in particular, poses one of the challenges for energy drinks, which is they're now being marketed, often as mixes to alcoholic beverages. Why this is so concerning is that the individuals consuming these mixed energy and alcoholic beverage drinks can be under the false impression that the energy drink offsets the detrimental effects of the alcohol, although this is really quite an enticing thought and would be nice if it was the case, it turns out that it's not. It turns out that the consumption of energy drinks in association with alcohol simply gives people the impression they are better than they are, but on formal testing, that's not proven to be the case. If you stop and think about that, that's actually quite a dangerous situation where the users of energy drink and alcohol beverages together can have a false bravado and a false assessment of risks of danger and their capabilities.

From my own perspective, I am a regular user of caffeine. I Would regularly have a cup of coffee in the morning. Often I'll have one mid-morning, and quite commonly one mid-afternoon with each of those being around about 60 grams and spread over the course of the day.

I believe that's an altogether different scenario to consuming multiple energy drinks all in one hit and in certain circumstances combining that with alcohol which I believe presents a significant concern in terms of the safety of the individual in terms of their judgment. And of course in terms of their physical well-being I think the final take-home message is that energy drinks are here to stay, but we really need to understand what we're hoping for in terms of their benefits and that there are still limitations that we don't fully understand to their use and particularly their use in younger people.

Thank you for joining me. I hope you've enjoyed this podcast on energy drinks. I'm going to go and have a coffee now. Take care.

You have been listening to another podcast from Dr. Warrick. Visit his website at www.drwarrickbishop.com for the latest news on heart disease. If you love this podcast, feel free to leave us a review.

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