Energy Drinks: Safe As Coffee But Somehow Lethal

An alarmist Washington Post story conflates Red Bull with pure caffeine powder.

The Food and Drug Administration (FDA) recently warned manufacturers of caffeine powder that it considers their products, which are sold as dietary supplements, to be "adulterated" because they pose "a significant or unreasonable risk of illness or injury under the conditions of use recommended or suggested in the labeling." That conclusion, while arguable, was not completely far-fetched, since measurement errors involving pure caffeine, which is meant to be mixed into beverages, can easily lead to uncomfortable and even life-threatening overdoses. "The difference between a safe amount and a toxic dose of caffeine in these pure powdered products is very small," the FDA notes. "Safe quantities of these products can be nearly impossible to measure accurately with common kitchen measuring tools."

But Washington Post reporter Ariana Eunjung Cha latched onto the FDA's warning letters as an excuse to attack products that are not only much less potent than caffeine powder but in most cases contain less of the stimulant than coffee does. Under the headline "How America's Love Affair With Caffeine Sparked a Crisis of Overdoses—and What the FDA Is Trying to Do About It," Cha writes:

There was a time when getting your daily dose of caffeine meant a simple cup of coffee or tea.

Poured into a ceramic mug, the steaming liquid tended to be enough to give most people that extra burst of energy to get out the door. Back then, you'd have to drink a heck of a lot—81 cups of brewed coffee, or 317 cups of black tea, for the average 195-pound U.S. male—to reach a lethal dose. So while you might still get the occasional shakiness, nausea and fast heartbeat associated with ingesting too much caffeine, you were highly unlikely to die from it.

But somewhere along the way, caffeine became an obsession, a need for many Americans; and an entire industry sprang up to try to make caffeine ingesting more efficient.

The clear implication is that the products Cha is about to discuss are in some important way more dangerous than coffee, which is true of caffeine powder but not of the energy drinks and caffeinated gum that she lumps together with it. Cha specifically mentions Red Bull and Monster Energy, which contain, respectively, 9.5 milligrams and 10 milligrams of caffeine per fluid ounce. Starbucks coffee contains twice as much caffeine per fluid ounce. Cha also mentions Jolt gum, which contains 45 milligrams of caffeine per piece, compared to about 165 milligrams in a "short" (eight-ounce) Starbucks coffee.

For some reason Cha's list of new, worse-than-coffee products also includes Stay Awake, which is Walmart's version of  NoDoz, a product that has been around for more than half a century. Both contain 200 milligrams of caffeine per tablet, making them as potent as a 16-ounce Starbucks iced coffee. Fun fact: NoDoz's slogan used to be "Safe As Coffee." 5 Hour Energy, which Cha also mentions, likewise contains 200 milligrams of caffeine per serving.

Cha claims "the new products have led to an alarming public health development in recent years that was unheard of in the many previous decades that people enjoyed caffeine: a rash of thousands of overdoses and reports of addiction and withdrawal." Cha apparently has in mind calls to poison control centers, because later she mentions that "poison centers across the country logged 1,675 reports involving energy drinks" in the first half of this year. To put that in perspective, poison control centers receive more than 46,000 exposure calls a year involving plants and more than 66,000 involving vitamins.

Another indicator of problems with caffeinated products is "adverse event" reports to the FDA. In November 2012 the FDA said it had received a total of 60 "adverse event" reports related to Monster and Rockstar energy drinks (two of the leading brands) since 2004—an average of six or seven a year. By comparison, the FDA receives thousands of such reports about aspirin each year and hundreds about coffee.

It's true that not every bad experience with caffeinated products is reported to the FDA, but it's also true that such a report does not prove causation. It simply means someone experienced symptoms after consuming the product; it does not necessarily mean the product caused the symptoms—a point that is especially important to keep in mind when people die after consuming a particular product.

Cha mentions "a 14-year-old with a heart condition" who "died after going into cardiac arrest shortly after she drank two caffeinated energy drinks in 24 hours" in the same paragraph as "a 19-year-old Connecticut resident who took a dozen caffeine pills" and "a healthy Ohio teen" who "died after consuming powdered caffeine." Lumping these cases together is misleading because they involve different products and dramatically different caffeine doses.

The 14-year-old, Anais Fournier, drank one 24-ounce can of Monster Energy, then another one a full day later. The total amount of caffeine was 480 milligrams over two days, nowhere near a lethal dose, which is something like 10,000 milligrams for an adult. Fournier would have gotten more caffeine from two 16-ounce Starbucks coffees.

By contrast, the Connecticut teenager, James Stone, consumed something like 2,400 milligrams in one sitting, still less than a fatal dose but five times Fournier's two-day dose, while a postmortem test of blood from the Ohio teenager, Logan Stiner, found that it contained 70 micrograms of caffeine per milliliter—above the lethal level. Yet Cha, following in the footsteps of alarmists like New York Times business reporter Barry Meier, presents these three examples of caffeine consumption as if they were equally risky, implying that you are taking your life into your hands every time you consume an energy drink.

The biological absurdity of that fear is apparent from a 2013 meta-analyses of 23 studies that looked at the association between coffee consumption and cardiovascular health. It found that the lowest cardiovascular risk was associated with drinking three to five cups of coffee a day.  An eight-ounce cup of coffee (the usual definition in these studies) typically contains between 100 and 200 milligrams of caffeine. Assuming an average of about 150, three to five cups contain 450 to 750 milligrams of caffeine.

In other words, the upper limit of the healthiest consumption range in these studies is equivalent to more than three 24-ounce cans of Monster energy drink per day. Lower limits may be appropriate for teenagers or for people with pre-existing cardiovascular problems. But it is nothing but cheap scaremongering to suggest that energy drinks pose a potentially lethal threat to the average consumer.

Addendum: Cha's article was republished by The Independent on Tuesday, under the puzzling headline "Thousands Overdosing on Caffeine As Coffee Crisis Sparks Call for Urgent Action." In addition to implying that every call to a poison control center represents a life-threatening event (when in fact most calls involve minor incidents that do not require medical attention), the headline suggests that the article is all about the danger posed by coffee, which of course it isn't—although Cha's lack of concern about coffee makes no sense if the issue is too much caffeine.

[cross-posted at Forbes.com]