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The Dose Transcript for September 14, 2023

Host: Brian Goldman

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BRIAN GOLDMAN: Hi, I'm Dr. Brian Goldman. Welcome to The Dose. There's no denying that energy drinks are very popular. The market research firm Euromonitor says last year, sales in Canada reached $1.1 billion and they're on the way up. They are especially sought after by teenagers. In the U.S., the National Centre for Complementary and Integrative Health says nearly one third of teens ages 12 to 17 consume them regularly. But there are some important safety concerns about these beverages. So today, we are asking what do I need to know about teenagers and energy drinks? Hi, Olivier. Welcome to the dose.

OLIVIER DROUIN: Thank you. Thanks for having me.

BRIAN GOLDMAN: So before we have our formal conversation, I'm going to tell you that I have had an energy drink from time to time. And I want to know, have you?

OLIVIER DROUIN: Did I? I think I tried, yeah, maybe a handful of times, to be honest. And I may or may not have even combined it once with an alcoholic beverage, which obviously nobody should ever do. But I learned from that mistake and never did it again. [laughing]

BRIAN GOLDMAN: And that energy drink just might have been Red Bull.

OLIVIER DROUIN: It might have been.

BRIAN GOLDMAN: There was a certain cocktail that one of my wife's cousins introduced me to once. So I did try that. And I have to admit that, you know, I try… I've had the odd monster from time to time. No sugar, of course.

OLIVIER DROUIN: Of course not.

BRIAN GOLDMAN: And the smaller can, not the bigger can. I just want you to understand that. But I don't know about when you went to medical school, but when I went to medical school, there was a thing that said, you know, this kind of unwritten rule that said, you know, if you really want to sit in the shoes of your patients, you should sometimes, you know, do what they do as long as it's not really high risk. And this seemed to be one of those things that I could try so I could know what my patients were talking about. We're going to hear, you know, the science, you know, the effects, the side effects and the things we need to be concerned about in a moment. But before we begin, can you give us a hi, my name is? Tell us what you do and where you do it. Just adlib.

OLIVIER DROUIN: Yeah. Hi, my name is Dr. Olivier Drouin. I'm a pediatrician clinician Scientist at the CHU Sainte-Justine Children's Hospital affiliated with University of Montreal. It's in the beautiful city of Montreal, Quebec, Canada.

BRIAN GOLDMAN: Okay, let's begin our conversation. Let's start with the definition. How do we define an energy drink?

OLIVIER DROUIN: It's not easy, surprisingly, but what most people think of as energy drink is obviously a drink. So a liquid beverage that includes a certain amount of sugar typically defined as high, however you want to call high, and a stimulant, often caffeine, but it can also be another more natural, quote unquote, stimulant such as taurine. So it's really a combination of high sugar plus a stimulant, what makes… what most people think as an energy drink.

BRIAN GOLDMAN: And is the common denominator caffeine in most of these drinks?

OLIVIER DROUIN: It is. I mean, some marketing around some of the different drinks use nutter stimulant and call them more natural as if caffeine was not natural. But we can always bring them back to caffeine equivalent. So yeah, I think it's easier for conversation to think about… of them as a combination of sugar plus caffeine in a liquid format.

BRIAN GOLDMAN: Some of these energy drinks come in cans and some like in large servings and some of them come in shots. I think we should point that out. But let's stick with the caffeine for a moment. How does the caffeine content of energy drinks compare to, say, a cup of coffee or a cup of espresso?

OLIVIER DROUIN: Yeah. So that's a very good place to start. It's a bit confusing. So let me try to put that together. I mean, the first reason why it's confusing is because obviously, each company has a different quantity or concentration of caffeine. Second is obviously the size matters. So the bigger the can, the more caffeine there's going to be in the can. And the third is that just plain old coffee is not always the same Between a coffee. In a coffee, like the amount of caffeine is very different. If you take a regular shot of espresso that your local Italian barista, you know, will prepare for you, It's about 60 milligrams of caffeine. If you look up a big chain of coffee makers in Canada that starts with T and finish with Hortons, their extra-large coffee is 330 milligrams of caffeine. That's five shots of espresso in your extra-large Tim Hortons coffee. So even for coffee, there is a range. But a small Red Bull, to take the most common one, it's about 80 milligrams of caffeine. So just over what you would expect from an espresso. The larger format from this brand goes up to 150 milligrams, so that's two and a half shots of espresso. The maximum content per can for energy drinks in Canada is currently set at 180 milligrams. So three shots of espresso is the maximum amount of caffeine you can have in a single can to be sold in Canada.

BRIAN GOLDMAN: So let's put this in context. You know, based on your expertise as a pediatrician, what would be the recommended maximum amount of caffeine for teens to consume, you know, in a single dose, in a day, whichever way you know it best?

OLIVIER DROUIN: Yeah. So there are two answers. So there's what is safe and what is recommended. What is recommended is simple. The recommendation in terms of the amount of caffeine that a teenager should take is zero. The American Academy of Pediatrics say that like energy drinks or caffeine have no place in a teen's diet. Extrapolation from adult data suggests that the safe amount is probably around 100 milligrams per day. And so that would be, you know, a double shot of espresso or a medium, small to medium size energy drink. Although, you know, that's a bit of a line in the sand. There are probably people for whom they will not have symptoms above that. And there are certain people that could have symptoms with this amount the same way that adults sometimes, you know, if you take two coffee, you might feel very jittery and nauseous. Whereas, you know, some people barely get up with two cups of coffee. So the 100 milligram safety zone or safety number is a bit arbitrary.

BRIAN GOLDMAN: And, you know, I don't for a moment think that teens are sticking close to that. I mean, they're certainly not at zero. And I don't think they're sticking to 100 milligrams per day. Do we have any data? Perhaps toxicologists could tell us. Do we have any data on how much teens are consuming these days on a daily basis? Because I suspect that there are a lot of teens walking around who consume far more than 100 milligrams of caffeine a day.

OLIVIER DROUIN: So as you said in the intro, I mean, somewhere between, depending on the source, like a third and a half of teenagers consume some amount of caffeine on a regular basis. I just looked it up recently, but the Centre for Disease Control in the U.S. reported that, and that's already like 12 years ago. I don't know why they haven't updated that, but 12 years ago, like very infancy of energy drink, there were only 1500 emergency department visits associated with energy drinks in the U.S. So bear in mind, a, that is very, very, very old data, b, that like you need to be… to get that story from a teenager to be able to assign that emergency department visit to an energy drink, which many teenagers will not tell you. You know, spoiler alert, not all teenagers tell you everything about what they do every day. And third of all, the landscape of energy Drink has changed quite a lot in the interim. So it's hard to know what's the average amount of caffeine or energy drink that kids consume. But if you follow the money, given the amount of advertisement that those firms put towards marketing their products to teenagers, I would suspect that like a fair number of them, probably the majority of them consume some amount of caffeine in a given week. And, you know, anecdotal data suggest that when they do, it's probably more than one can.

BRIAN GOLDMAN: And so let's unpack what that's doing to their bodies. I'm an emergency physician. Caffeine is a stimulant. It wouldn't surprise me that in addition to causing insomnia and jitteriness, you know, nervousness, increased anxiety, that it's raising your heart rate, it would be raising a teen's heart rate, raising their blood pressure, perhaps causing palpitations, predisposing them to heart rhythm disturbances. If they have a predisposition to heart rhythm disturbances, they could develop an arrhythmia. Is that what we're talking about?

OLIVIER DROUIN: Yeah, that's I think the big ones. Other things that could present symptoms, maybe not to an emergency room, but definitely to a pediatrician or family doctors are things like heartburn, diarrhoea or, you know, general stomach upset, anxiety as well. And for certain populations, certain specific populations, obviously, those symptoms could be even worse. So those would be side effects that you would or effects that you would expect in a normal healthy person. But, you know, if you start, you know, looking at the effect on children with a pre-existing anxiety problem, then that can definitely create a crisis. If you're talking about children who have a diagnosis of ADHD and already on certain psycho stimulants, some of the effects can be exaggerated or like because they have similar mechanism of action than caffeine. But yeah, generally, the symptoms that we see are those that you mentioned. So jitteriness, palpitation, increased heart rate, difficulty sleeping and urge.

BRIAN GOLDMAN: You mentioned, you started to mention what you see in your own practice with teens. Can you say more about what you've been seeing these days as the trends go up, as more teens, and I'm assuming more teens in your practice are consuming larger amounts of energy drinks than they should?

OLIVIER DROUIN: Yeah. So I think that's right. The first thing that we do see is that we do see more… when you ask teenagers about it, because if you don't ask very specifically, they will not self-declare drinking those energy drinks because they don't think it's relevant to the medical encounter. But if you do probe them, you get a sense that a lot of those teenagers are using them, are using them regularly, are using them in increasing quantity. They are swayed by the marketing that increases energy. Many of them feel like they need it either for sport performance or for school performance. They don't see it as a threat. They don't see it as a health problem and therefore, they just go with their feeling. And unfortunately, caffeine, as most coffee consuming adults know, creates tolerance, which is that like you might be fine with a certain amount of caffeine on a regular basis, but then comes a few weeks, a few months, then like the cup of coffee that was sufficient to get you up in the morning, now you kind of need that second one at 10 a.m. and then maybe that third one after lunch. And so that's what we see in teenagers as well, is that like they start using it sporadically around sport events or exam crunch, and then within a few weeks, within a few months, they start using it or feeling the need to use them more frequently and on a daily basis.

BRIAN GOLDMAN: You said that you have to ask teens in your practice why they consume energy drinks. Do you do that and what do they tell you?

OLIVIER DROUIN: So in all transparency, I don't do that all the time. I probably should. But, you know, as most people know, health care encounters are relatively short, too short for everything that we should be doing. But definitely, it's… they never say that… like there's the answer that they give and then the real answer. So they very rarely say that they do it to fit in. Although I suspect that social norms, as we call them, meaning like what you see other people around you doing is definitely a powerful force. I think, you know, if nobody in your group of friends drink them, you're probably very unlikely to use them. But if everyone else does it, you're, you know, probably very likely to use them. Teenagers inherently try things and substances and behaviours. And if they're labelled, if those behaviours are labelled as not good for you, they're probably even more likely to try them. Many of them I think are swayed by the promise of those drinks giving you energy, giving you wings, the promise that you're going to be somewhat a better version of yourself, somewhat more productive, better at their sport or whatever they have to go through. So I think it's a combination probably and just plain curiosity that we see in teenagers, and that is not counterbalanced by worry. I mean, many, many teenagers that I speak to are actually very surprised that there are potential negative side effects. I think they know well about the dangers of alcohol, dangers of tobacco, but I think many of them don't really realize that energy drinks carry some potential negative health effects.

BRIAN GOLDMAN: And you mentioned alcohol, and I think it's worth just touching on the point that teens who consume greater quantities of energy drinks are more likely to be binge alcohol drinkers as well.

OLIVIER DROUIN: Yeah. And I mean, like we're getting into the era of multiple psychoactive substances and how mixing them blurs everything I just mentioned, alcohol being a depressant, meaning that you're more light, you're more tired. Many people feel the need when they consume alcohol to also consume energy drink to kind of compensate that effect to keep going on a dance floor. The problem is that like, you know, there are some other effects that are additive, you know, one being that both alcohol and caffeine dehydrate. They both make you pee more. So if most of what you're drinking in the night is either Red Bull or alcohol, you're more likely to get dehydrated. But it's not clear which way the arrow goes, whether, you know, consumption of alcohol leads to more consumption of energy drinks or the other way around. But as you said, they definitely go hand-in-hand together. I think it's one of the worrisome trends that we're seeing and worrisome patterns of consumption of those energy drinks, that co-consumption with alcohol.

BRIAN GOLDMAN: And these concerns over side effects, serious side effects were among the factors that led the Canadian Food Inspection Agency over the summer to recall more than 25 brands of energy drinks because of high caffeine content. What impact do you think that kind of move makes?

OLIVIER DROUIN: Probably limited in the short term. I mean, those products relatively new on the market, it was quite obvious that they were above the maximum that's allowed, the under 80 milligrams of caffeine per can. You know, they were selling around 200, 220 milligrams of caffeine. So obviously, it's a good thing that it prevents those very high caffeinated beverages to be available. But that being said, as you mentioned earlier on, there's nothing preventing a teen from drinking that amount of caffeine in separate cans. I think we might have limited somewhat the damage, but it's definitely not going away. I think the way I think about it is that we should use that landmark move to start a broader conversation about the role that those products have, how we should regulate them, how they should be marketed, how they should be sold, especially to teenagers. So I think it's a move in the right direction. I think in and of itself, it will have limited impact, and I think we should probably go at least one step further.

BRIAN GOLDMAN: So what are some of those other steps that you think regulators should take?

OLIVIER DROUIN: So there are different axes that can be thought of. And many jurisdictions both here in Canada as well as around the globe have thought of them. So I'm not coming up with new crazy ideas, but, you know, just plainly saying that those products should not be sold to minors could be a step in the right direction. We can think of taxing them just like, you know, soda taxes, for example, have been proposed in certain jurisdiction, and then use the money that we get from this to invest in public health intervention. I think the labelling could be also changed. You know, the same way that cigarette packaging has been changed to highlight the health risk, there could be a world in which caffeine content is also labelled as being dangerous, especially for teenagers. There could be regulations around marketing to certain groups. So all those are potential options. And obviously, that maximum content per can is set at the arbitrary 180 milligrams right now, but that could be revised also.

BRIAN GOLDMAN: So in the absence of tight regulations or an outright ban, teens, you know, I think we can agree that teens are going to get hold of energy drinks. What should parents and teachers do?

OLIVIER DROUIN: It's a good question. I think like most discussion about risky behaviours in teenagers, I think coming at a place of listening, of curiosity. You know, genuine listening I think goes a long way when talking to teenagers. And it might take and it's completely okay that it takes more than one conversation. I think that's the one thing I want to say. And I observe in my clinical practice, if the first interaction or the first time that you talk about energy drinks or you talk about vaping or you talk about alcohol with your teenager is to lecture them, as you mentioned, a, it's probably not going to work, and b, the teenager will only learn that like they cannot talk to you about this, about this topic because you won't listen. I will answer questions but will not make strong recommendations or shame them the first time that I talk about a topic. So practically, I think asking the questions about whether the teenager drink energy drinks. And also, just inquire about why. What are they looking for? What is it… in which situation do they feel like those energy drink are, quote unquote, useful? And also, try to elicit any concerns or any symptoms that the teenager has. And then you can later on in a second or third conversation use that as a reflective tool. So for example, I would ask the teenager, like are you aware of energy drink? Have you ever tried them? How did that make you feel? How often are you using them? Do you think there is any, you know, negative consequences associated with them? And then I would probably leave it at that as a first conversation. And then later on, you know, ask about continuous use, whether friends are using them, and then like ask about any noticeable changes or negative impact it has on their life, and then use that as a motivation to change behaviour. And the other thing that could work well depending on your teen is also mention the amount of money that's being spent on them to buy their product. So mentioning that, you know, they're being manipulated, they're being lied to by those companies that seek to profit from them. That can also be helpful in terms of at least inserting a little doubt into the claims that those companies make about the effect of their products.

BRIAN GOLDMAN: It sounds like you're using solid criteria for helping a teen figure out, maybe helping parents figure out if their teen is using energy drinks despite harm. If you find that that's the case or they’re consuming potentially dangerous quantities on a regular basis, what do you do then? How do you try to get them to cut back when the alarm bells might be going off?

OLIVIER DROUIN: Yeah. You know, a lot of times, it's helping them make the connection between how they're feeling and what they're consuming. Often, they will, they will consume… they will have symptoms related to their consumption, but they don't necessarily make the connection. They don’t make the link. So creating that link. A smart teenager can figure out that like, hey, gee, if I drink this, I feel like crap, they're going to try to cut. So I think that's kind of one way. Two is reinforcing the fact that they don't need that product and that they can do without. Substitution is obviously a very important component of cutting back, meaning like already plan with the teenager. Okay, so if you're going to cut back, so you use this, use energy drink in this context, you're going to encounter that context again. What else are you going to take or what else are you going to drink? And then the last thing I think that needs to be thought about is that the same way that if you're a regular coffee drinker and you skip coffee for a day or two, you’re going to start feeling unwell, you’re going to start having headaches and feel groggy, I think it's also important to plan that with a teenager that is consuming energy drink on a regular basis. You know, if your teenager drinks two to three Monster or Red Bull, whichever other product every single day, cutting, you know, cold turkey, if it's the teen's initiative, that could be okay. But like it's likely that they're not going to feel great the day after. So maybe weaning down might be a better approach than cutting everything altogether from one day to the next.

BRIAN GOLDMAN: Wow! That’s a sobering way to end our conversation, but an important one.

OLIVIER DROUIN: [laughing] I’m sorry.

BRIAN GOLDMAN: No, no, it's… I think it's important for teens to recognize it. And I think the important thing is that you've provided some tools that can help teens and can help parents of teens begin to recognize when their teen may be consuming too much and when it's time to stop. Dr. Olivier Drouin, I want to thank you for speaking with us on The Dose on energy drinks and the harm that they can cause.

OLIVIER DROUIN: Well, thanks for having me.

BRIAN GOLDMAN: Dr. Olivier Drouin is a pediatrician clinician scientist at CHU Sainte-Justine in Montreal. Here’s your dose of smart advice. Energy drinks are promoted as products that enhance mental alertness and physical performance. Teens and young adults are among the biggest consumers of energy drinks. Caffeine is a major ingredient, but others include vitamins, minerals, the amino acid taurine and herbal ingredients. Some energy drinks also contain guarana and yerba mate, which are natural sources of caffeine. Some energy drinks contain amounts of sugar that exceed the maximum daily amount of added sugar. It's caffeine that leads to the big safety concerns. These include increased heart rate, heart rhythm disturbances and elevated blood pressure. In children, heavy consumption can cause anxiety, sleep disturbances, digestive problems and dehydration. The higher the dose of caffeine, the greater the risk. Also, beware of prescription drug interactions. Combining caffeine energy drinks with stimulants used to treat ADHD can lead to further increases in heart rate, nervousness, insomnia, etc. In Canada, energy drinks can contain a maximum of 180 milligrams of caffeine per serving. Products containing larger amounts of caffeine have been recalled. At some point, you may want to talk to your teen about energy drinks. Be curious instead of confrontational. Ask things like what they've tried, how much, how often, and how it makes them feel. Also, ask them what they know about the potential harms. If they use them regularly, ask if they've had any of the typical unpleasant symptoms that we've talked about. Help them make the connection between side effects and too much caffeine. If they use energy drinks heavily and on a regular basis, consult with your health care provider on recommended ways to wean off. If you have topics you'd like discussed or questions answered, our email address is thedose@cbc.ca. If you like this episode, please give us a rating and review wherever you listen. This edition of The Dose was produced by Isabelle Gallant. Our senior producer is Colleen Ross. The Dose wants you to be better informed about your health. If you're looking for medical advice, see your health care provider. I'm Dr. Brian Goldman. Until your next dose.

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What do I need to know about teenagers and energy drinks? - Transcript

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