What You Really Need To Know About The Safety Of 5-Hour Energy Drink
Are those tiny 5-Hour Energy shots dangerous?
Should you worry about drinking too much Monster Energy -- or any other energy drink for that matter?
These are the questions on our minds this week following another U.S. Food and Drug Administration missive on deaths and hospitalizations as reported by energy drink manufacturers. Those specifically cited in this week's report (PDF) include Monster and Rockstar energy drinks as well as 5-hour Energy "shots" that are ubiquitous throughout US convenience stores and pharmacies.
These 5-hour Energy products are no stranger to Forbes: Staff Writer Clare O'Connor had this article and sidebar in the February 27, 2012 issue of the magazine. O'Connor reported that 5-hour Energy accounts for a whopping 90% of the national energy shot market.
So, exactly how dangerous are these drinks and energy shots?
The main number being batted around -- beginning with The New York Times article by Barry Meier -- is that 5-hour Energy has been cited in reports of 13 deaths; that is, 13 people who died had ingested 5-hour Energy drink at some time prior to their passing. The first death was reported on December 17, 2009.
But a close analysis of the report itself leads me to conclude that two of those deaths were reported twice, lowering the number to a still-disturbing 11.
The non-fatal reports extend back to 2005 and include typical symptoms such as dizziness, anxiety, and nausea all the way to seizures, brain hemorrhages, and heart attacks.
Monster drinks were listed in five deaths and about 35 other non-fatal adverse reactions. Rockstar was listed in 13 cases, none of which were deaths.
What's in these drinks?
Monster and Rockstar are brightly-labeled beverages that contain 160 to 175 milligrams of caffeine in drink sizes ranging from 5 to 16 fluid ounces. That's about three-to-five times the amount of caffeine in 12-ounce serving of a typical mass-marketed soda. The more concentrated 5-hour Energy doesn't list its caffeine content but Consumer Reports recently determined that it contains 215 milligrams of caffeine per 2 fl. oz. bottle (the "extra strength" only contains a bit more at 242 milligrams.).
I'm a coffee drinker. Is that a lot of caffeine?
Well, it depends on where you get your coffee. One of the most comprehensive sources for caffeine content of beverages is this database at energyfiend.com. There you'll see that a large McDonald's coffee (16-ounce) has 145 milligrams of caffeine, just a bit less than the same as in a typical regular Rockstar or Monster product. But if you are a Starbucks fan, a 16-ounce serving (Grande) of their regular brewed coffee (not espresso-based) there can average 330 milligrams of caffeine but range from 259 to a whopping 564! These are Starbucks' own reported values, levels that led energyfiend.com to list this product's caffeine content as "Extreme."
But think about this: that high end for the "Extreme" content of Starbucks is roughly the same as only two small bottles of 5-hour Energy, perhaps telling us how deceivingly potent these "shots" can be.
Is the problem only with the caffeine? What else might be dangerous in these drinks?
They also contain various combinations of vitamins and amino acids, with some vitamins far exceeding recommended daily values. Among all of these components, I'm most concerned about phenylalanine, an amino acid that cannot be adequately broken down by people with a genetic disorder called phenylketonuria. This is why you'll see diet sodas containing the artificial sweetener aspartame listed with a warning for phenylketonurics: aspartame contains phenylalanine. In such individuals, the amino acid gets converted instead to a chemical that can cause seizures, and even mental retardation in developing infants and children. Phenylketonuria is rather common in the US, occurring in 1 out of 15,000 people but is three-to-five times more common in Turkey and Scotland.
Does this mean that 5-hour Energy caused the reported deaths and hospitalizations?
This is the question that FDA scientists are trying to assess. The major problem is that these reports don't list other very important information such as age, weight, pre-existing conditions such as heart disease, or any indication of drugs or dietary supplements that might have contributed to these adverse reactions. For example, younger (and smaller) people are more sensitive to the effects of caffeine and might also be taking other substances that could make the energy drink deadly.
We need to remember that caffeine is a drug, capable of providing us with mental alertness but at higher doses can make us anxious, shaky, and have gastrointestinal problems such as diarrhea. In energy drinks caffeine is regulated as a food additive but its drug status is complicated by the fact that it occurs naturally in foods such as coffee and chocolate. Caffeine was previously classified by the FDA as an additive "Generally Recognized As Safe" (or GRAS) at levels commonly used since 1958.
I've always been wary of the so-called GRAS list. No chemical, natural or synthetic, is 100% safe. The dose determines the relative safety of anything, as does what that chemical is taken with.
In 1969, President Nixon ordered the FDA to re-review the substances on the GRAS list. The special review committee didn't get to caffeine until 1978 but they expressed serious concerns about its health risks that include high blood pressure with doses as little as 4 milligrams per kilogram body weight. That's roughly a 16-ounce Starbucks coffee for a 180-lb adult.
The committee specifically concluded, "It is inappropriate to include caffeine among the substances generally recognized as safe (GRAS)." Yet caffeine remains a food additive almost 35 years later.
But if these adverse reactions and deaths are shown to be directly due to the energy products, remember that caffeine might not be the culprit in all cases. Phenylalanine could causes some of the same problems in phenylketonurics, particularly seizures and convulsions.
Why does the press seem to be more fixated on 5-hour Energy than on Monster or Rockstar?
Well, the majority of cases in the current FDA report are with 5-hour Energy. But we don't know if this relates simply to the tremendous sales numbers of the shots relative to the energy drinks. The concentrated versions of the shots also make it easier for one to take large doses of caffeine without the bulk of all that other liquid in the drinks. And not discussed in many stories is that the old-time caffeine pills we took in college in the 1980s such as No-Doz are now sold in an extra-strength version that contains 200 milligrams per pill, almost as much as a 5-hour Energy shot. (Imagine popping a No-Doz and washing it down with a Monster.)
It's entirely possible that 5-hour Energy might be more dangerous than Monster or Rockstar. A local internist told me that the larger volume of energy drinks might offset the dehydration and electrolyte losses (especially potassium) normally caused by caffeine.
Why are we hearing about deaths and hospitalizations with 5-hour Energy and Monster but not Starbucks or other high-caffeine beverages?
First, Starbucks coffee doesn't contain phenylalanine. I suspect that some of the problems reported with the energy drinks are not due to the caffeine but are rather cases where phenylketonurics have ingested high concentrations of phenylalanine (again, information that would have been useful in the FDA report).
Second, Starbucks drinkers are likely to be more tolerant to the effects of caffeine than a 115-lb, 15-year-old kid drinking a couple of energy drinks for the first time. The Starbucks drinker is also more likely to be comfortable with the effects of caffeine. I expect to get anxious and jittery if I drink too much coffee but that freaked me out a bit when I started drinking coffee late in high school.
Another consideration relates to what else is being taken by people drinking any high-caffeine product. An increasing concern among neuroscientists is that caffeine seems to increase the lethality of drugs like ecstasy (X, MDMA), amphetamine, and methamphetamine in rats given caffeine doses in the range of human consumption (reviewed here). Since energy drinks are primarily targeted toward teens and young adults, the likelihood of caffeine and illicit drug use might be higher than in the Starbucks-drinking adult (perhaps, but not always). If you choose to use MDMA, amphetamine, or meth, STAY AWAY FROM ENERGY BEVERAGES.
So what's the bottom line?
The true risks of energy shots and energy drinks can't be fully evaluated if we don't have all the information about people who've died or experienced other adverse effects. We don't know if they already had heart rhythm problems, were recreational drug users, or if they were taking anything else that might predispose one to these adverse reactions. For example, the antidepressant Wellbutrin (bupropion) can cause seizures in some individuals. Consuming energy drinks while on Wellbutrin might not be a very good idea.
In addition, energy drinks are often mixed with alcoholic drinks. We have no information on the blood alcohol levels in the cases listed in this FDA report. Caffeine makes people feel less drunk but does absolutely nothing to change the actual blood alcohol level. It's possible to get up to near-lethal blood alcohol concentrations with high-caffeine drinks. That's why Four Loko had to take the caffeine out of their 12%(!) alcohol beverage two years ago. (And I certainly worry about the mega-high caffeine in some products such as 5150 that are designed to make any drink high in caffeine).
In fact, ask yourself why you'd want to drink some of these products. Are you trying to stay awake while working or studying late or driving long hours? Can you take some time to get some sleep instead of exposing yourself to high caffeine levels?
But if you absolutely must have caffeine, be sure you talk with your doctor or pharmacist to learn if your health status and/or medications might interact negatively with caffeine.