Energy Drinks and the ER - perspective

Energy drinks are in the news again, and this time the story is the reported increase in emergency room visits attributed to energy drinks. Consider this brilliant article from Food Navigator USA:
DAWN report on energy drinks and ER visits Correlation is not causation but something is going on here

A few very important points:

* 42% of the visits attributed to energy drinks also involved alcohol or other drugs
Mixing alcohol and energy drinks is indeed very dangerous, as people feel more alert but still have impaired reflexes: "The mix of behavioral impairment with reduced fatigue and enhanced stimulation may lead AmED (alcohol mixed with energy drinks) consumers to erroneously perceive themselves as better able to function than is actually the case." Published Study: Effects of energy drinks mixed with alcohol on information processing, motor coordination and subjective reports of intoxication.


* The Drug Abuse Warning Network (DAWN) report doesn't include any data on how much caffeine was consumed prior to the emergency room visit, or over what period of time it was consumed
"...for the healthy adult population, moderate daily caffeine intake at a dose level up to 400 mg day(-1) (equivalent to 6 mg kg(-1) body weight day(-1) in a 65-kg person) is not associated with adverse effects..."Published Study: Effects of caffeine on human health

* DAWN project leader Albert Woodward poses a crucial question: if it's the high caffeine from the energy drink causing the trips to the ER, why don't people who've consumed high caffeine intakes from coffee come in to the ER?
This is the million dollar question, because we don't know if the people admitted to the ER have had multiple energy drinks or energy shots in a short amount of time or if they were using the product as directed. How long does it take to drink one energy shot? How long does it take to make/brew/buy coffee? 

Are those admitted to the ER an indication that energy drinks (including energy shots) have some inherent danger that isn't apparent from the Generally Recognized As Safe ingredients on the label, or should we suspect these people are not using the product as intended - like a small child that likes the taste of vitamin gummies so much they eat half the jar? Would limiting energy drinks to single-serving containers alleviate the problem? (Perhaps, but go ask a New Yorker how much they like it when you try to limit their sodas to single-serving size)

No one knows whether energy drinks are inherently dangerous when used as directed, because the people making the news aren't always following the instructions and warnings on the label.  We should be cautious of using and abusing these products. We should keep monitoring the situation and collect as much data as possible about all the circumstances involved.

Remember these words from the "Father of Toxicology", Paracelsus:
All things are poison, and nothing is without poison; only the dose permits something not to be poisonous.

Or, as the band Circa Survive put it, "The Difference Between Medicine And Poison Is In The Dose."





Other Resources:

Published Review (FULL TEXT - FREE): Caffeine (1, 3, 7-trimethylxanthine) in Foods: A Comprehensive Review on Consumption, Functionality, Safety, and Regulatory Matters 

Letter from FDA to Senator Durbin, addressing his concerns about energy drinks: (available as a pdf file through a link within this article from Food Products Insider)
FDA Tells Durbin It's Investigating Safety of Energy Drinks

Does drinking diet soda make you sad or do sad people drink diet soda?

As reported in the IFT Weekly newsletter:
IFT Weekly Newsletter article

A study to be presented at the American Academy of Neurology’s 65th Annual Meeting in San Diego, Calif., March 16–23, shows that drinking sweetened beverages, especially diet drinks, may be associated with an increased risk of depression in adults. However, drinking coffee may be tied to a slightly lower risk. 

Any time you hear claims about "X is associated to Y", you should remember that a correlation does not mean a causation. Example: studies show that people who get less than 6 hours of sleep per night have a higher risk of health problems and tend to die younger than those that get more sleep. The question is are these night-owls dying younger because of the lack of sleep or are they dying because they're working two full-time jobs or jobs that are incredibly stressful--thus, their lives are too hectic to allow for decent sleep and it's the STRESS that's killing them?

In this case, we need to look at the details of this particular study:
* The study involved 263,925 people between the ages of 50 and 71 at enrollment
>>>This age group is not young, and not typically active; other studies have shown that exercise increases well-being because it releases endorphins and boosts both the mood and the immune system--already I have doubts about the claims of this study

*From 1995 to 1996, consumption of drinks such as soda, tea, fruit punch, and coffee was evaluated
>>>How was the consumption evaluated? Some methods are more accurate than others. For example Food Frequency Questionaires (FFQs) are usually given to patients in these types of studies. FFQs ask questions such as, "In the last year, how often do you consume food A: Less than 1/day, 1-3/day, More than 3/day?"
An alternative to the FFQ is the food diary, where patients are asked to record everything they eat and drink for a certain period, usually 24-48 hours. The problem with food diaries is that someone may record an atypical day or weekend, and those results are interpreted as the patient's normal habits.
Published studies, such as this one in the European Journal of Clinical Nutrition demonstrate that FFQs are a good, valid method. The press release does not say whether FFQs where used to evaluate beverage intakes in the study participants


* About 10 years later, researchers asked the participants whether they had been diagnosed with depression since the year 2000. A total of 11,311 depression diagnoses were made.
People who drank more than four cans or cups per day of soda were 30% more likely to develop depression than those who drank no soda. Those who drank four cans of fruit punch per day were about 38% more likely to develop depression than those who did not drink sweetened drinks. People who drank four cups of coffee per day were about 10% less likely to develop depression than those who drank no coffee. The risk appeared to be greater for people who drank diet than regular soda, diet than regular fruit punches, and for diet than regular iced tea. 
>>>Depression is a serious condition that affects more than just the individual with depression. I do not in any way mean to mock this condition, those who have been diagnosed with it or who are at risk for developing it. I only wish to point out one part of this study press release that caught my attention: more than four cans or cups per day of soda 
Four cups or cans of soda is not a small amount of soda, in fact this significant consumption of soda is often attributed to OBESITY. That's what this study from the American Journal of Clinical Nutrition found. The authors of this study did a systematic review, meaning they looked at all the articles that have been published on the topic and determined the consensus among them. They found, "The weight of epidemiologic and experimental evidence indicates that a greater consumption of SSBs is associated with weight gain and obesity."

 So here is my concern:
Among the people in this study that consumed more than four cans or cups per day of soda and were diagnosed with depression, how many became depressed because they became obese? How many patients were already obese and is that why the "risk appeared to be greater for people who drank diet than regular soda"?

Furthermore, this study should not be used by those who wish to claim that no-calorie sweeteners used in diet drinks lead to obesity and/or depression, because we don't have any data on what types of sweeteners were used in the four cans of soda these patients were drinking every day.

BOTTOM LINE: This is an interesting study, one that is sure to catch the attention of many news and media outlets. HOWEVER, further inspection of this study brings up more questions than answers.
Press Release

Niacin - Sample Chapter of Forthcoming Book

Vitamin B3 / Niacin 

In many ways Riboflavin and Niacin are similar, but if they were related niacin would be riboflavin's cooler older sibling. Niacin exists as nicotinic acid (or niacin) and nicotinamide (or niacinamide). Note, nicotine is not a vitamin and while both nicotine and nicotinamide have chemical structures with nitrogen-containing rings, the difference between them is like the difference between laughter and slaughter. 

What is it?
Nicain is readily absorbed from the stomach and intestine which means it gets absorbed faster and more efficiently than other vitamins that are only absorbed in the small intestine. Almost all niacin consumed is absorbed. Unlike riboflavin, niacin doesn't need to be consumed with food because niacin absorption doesn't rely on stomach acids to make it absorbable. Unlike riboflavin, which needs to be escorted into the system, niacin is effortlessly absorbed via passive diffusion.

Riboflavin becomes part of coenzyme FAD, but niacin is transported from the liver to all tissues where it is converted to coenzyme forms NAD+ and NADP+ (the plus sign is to indicate that these molecules are charged, not neutral). Niacin coenzymes are stored in the liver and excess is excreted as a variety of metabolic products (which are NOT brightly colored, so that's one point for riboflavin). 

Where does it come from?
Niacin is so important to our bodies that, should we fail to consume enough of it, we can synthesize it from the amino acid tryptophan. Notably, this reaction requires the help of riboflavin coenzymes. Rich sources of niacin include mushrooms, wheat bran, tuna, chicken, turkey, asparagus, peanuts and animal proteins (which are rich in tryptophan). Approximately 90 grams of protein can result in 15 milligrams of niacin. The RDA is 16 milligrams per day for male adults; 14 milligrams per day for female adults. The Daily Value is 20 milligrams.

Niacin is so prized and popular that the niacin molecules in corn are under lockdown. Corn's content of niacin is similar to that of rice, and is considerably higher than that of most other vegetables. However, a protein in corn binds the vitamin and severely limits its absorption. Soaking corn in alkaline solution such as lime water releases the bound niacin, thus making it available for absorption. 

What does it do?
Niacin is everywhere in the body. Niacin is like that person everyone wants at their party. Riboflavin coenzymes FAD/FADH2 and niacin coenzymes NAD/NADP participate in redox reactions, but niacin coenzymes are undeniably more ubiquitous. Niacin coenzymes participate in at least 200 reactions, most of those used to produce ATP (the chemical form of energy). Like riboflavin, niacin's role is to collect hydrogens to "feed the dragon", the electron transport chain, which ultimately results in a release of energy (see riboflavin chapter for dragon metaphor explanation). Despite the similar role, niacin far outshines riboflavin by the sheer number of reactions it participates in. Really, there's no contest. Another reason adults should appreciate niacin is its role in alcohol metabolism. Niacin as NAD helps the enzyme alcohol dehydrogenase convert alcohol to acetaldehyde.

A deficiency in niacin affects the whole body because NAD is used in so many metabolic reactions. Niacin deficiency leads to Pellagra, which comes from the Italian words pelle (skin) and agra (rough). When this deficiency was first discovered in 1735 by Spanish physician Casal, it was named mal de la rosa or Red Sickness. Signs of the deficiency included a red rash in the skin exposed to the sun, especially the neckline (hence the phrase "Casal's necklace"). Pellagra symptoms are more commonly known as the three D's: dementia, diarrhea and dermatitis. It can also be known for its dietary deficiency disaster.

Niacin is the only vitamin whose deficiency disease reached epidemic proportions in the United States. In 1915, more than 10,000 Americans died of Pellagra and an estimated 200,000 more suffered from the disease. Some people had dementia so severe they were put into mental institutions. How did this disease get so bad? It was the increase in corn consumption.

Niacin deficiencies became wide-spread through Europe during the 1700s as corn became more of a dietary staple. Spanish settlers in Latin American learned the ways of the native populations that soaked the corn in lime water before cooking, thereby releasing niacin from its protein lockdown. During the early 1900s, consumption of corn rose dramatically in the United States but the value of this soaking treatment was misunderstood. The cause of Pellegra was also misunderstood, and it affected so many lives for so many years because it was thought to be contagious.

Cue the hero: Dr. Joseph Goldberger. Dr. Goldberger, a public health specialist, proved that Pellagra was not contagious by exposing himself and his colleagues to biological samples from patients with Pellagra. One can only imagine the confidence and bravery it took to carry this out. Suffice to say, Dr. Goldberger helped resolve the dietary deficiency disaster by proving the cause and providing the cure. With the introduction of niacin-enriched grains in 1941 and post-wartime increases in protein consumption, Pellagra eventually disappeared in the United States.

One final reason to admire niacin is its role in combating atherosclerosis (hardening of the arteries). When under supervision of a qualified physician and when combined with appropriate diet and exercise, doses 75-100 times the RDA ("mega-doses") of nicotinic acid may help lower "bad cholesterol" LDL levels and increase "good cholesterol" HDL levels. Prescriptions are normally provided in 1.5 – 2.0 grams nicotinic acid per day. One cannot and should not self-medicate and attempt to mega-dose without the help of a physician because this amount of niacin can cause serious side effects. Mega-doses of niacin are provided with a time- release coating that should minimize flushing of the skin, itching, gastrointestinal distress with nausea and vomiting, and liver damage. 

How does this relate to energy?
The sheer number of energy-related chemical reactions niacin participates in make it an excellent candidate to add to an energy drink. However, a note of caution: the upper level of niacin intake is based on an effect called the Niacin Flush. At a daily dose as low as 35 milligrams, some people experience a red flush of the skin and itching. At amounts around 1.5 grams, other, more serious side effects like GI distress and liver damage have been reported. This flushing does not occur with niacin consumed from food, only supplemental niacin.
 

PLEASE ALWAYS READ THE LABEL FOR AMOUNT OF NIACIN, SERVING SIZE AND SERVINGS PER CONTAINER.
Even if you're playing poker, a Niacin Flush is something to be avoided.