Healthy Living : energy

Long days, a lot of runs, sleepless nights, several shifts in a row. 
It’s not surprising that coffee is a staple at firehouses across the 
country. Increasingly, firefighters also are consuming energy drinks to 
get the extra boost they need to make it through their shifts. 
 While sales of soda are sliding due to health concerns and a 
struggling economy, the rate of sales for energy drinks are steadily 
growing. Redbull and Monster have long dominated the energy drink market
 and sell a combined $8 billion worth of product annually.1

Impact of caffeine
 The topic of energy drinks has been receiving some increased scrutiny
 in the fire service after the June 10, 2017, collapse of a Kansas City 
firefighter during a routine training on a warm day. He ended up in a 
week-long coma due to heat stroke. According to his cardiologist, the 
firefighter’s use of energy drinks may have contributed to the severity 
of the event due to the diuretic effect of caffeine contained in the 
drinks.
 Unfortunately, the incident was not an isolated event. A report from 
the Substance Abuse and Mental Health Services Administration (SAMHSA) 
found rates of emergency room visits due to energy drinks doubling 
between 2007 and 2011.2
 But it remains unclear how dangerous energy drinks are, what 
constitutes an appropriate or safe level of use, and whether they are 
something that firefighters can or should use on a regular basis.
 An 8-ounce cup of brewed coffee hosts about 95 mg of caffeine. While a
 12-oz. Redbull or 16-oz. Monster have similar amounts of caffeine to 
brewed coffee, others can have twice that amount, and energy “shots” can
 host up to three times the caffeine of coffee.
 There is no exact universal amount of caffeine that is appropriate 
for all people. The amount of caffeine and the effect it has on any 
given person varies by personal factors, such as BMI, medication use, 
genetics, age, medical disorders, and how much caffeine the person 
typically consumes. Bodies can build a tolerance to caffeine, requiring 
more of it for the same effect over time.
 As with any drug, caffeine also has addictive properties, and 
stopping can lead to withdrawal. According to a report by Dr. Catherine 
Striley3 in the Journal of Caffeine Research, 35 percent of people meet 
the diagnostic criteria for caffeine dependence. Withdrawal can lead to 
headaches, aches and pains, depression and irritability. 
 The level of caffeine in energy drinks may not be the only concern. 
Several other ingredients common to energy drinks or shots have other 
energy-enhancing ingredients— taurine, guarana, yerba, and green tree 
extract—that mimic the effects of caffeine.   
 According to a report by Dr. Fahad Ali published in the journal 
Postgraduate Medicine,4 the most common negative effects of energy 
drinks are cardiovascular and neurological. Of particular concern in his
 review of the literature was the interaction of ingredients. While the 
ingredients have all been found to be safe on their own, research on the
 combinations is limited.
 A few literature reviews have been conducted on the health effects of
 energy drinks, examining results across individual studies to form 
conclusions on the science thus far. Many of the beneficial and negative
 physiologic, cognitive, behavioral and performance effects of energy 
drinks likely come from the caffeine and taurine content.

The upside
 There are benefits associated with energy drinks as well. Energy 
drinks have been associated with increased cognitive and physical 
performance.5 Research examining the effect of energy drinks on 
cognition has found increased memory performance, improved performance 
on information processing tasks, improved performance on six composite 
cognitive function measures, and increased alertness. There was also 
evidence of improvement on subjective measures, such as anxiety and 
levels of stress. 
 The effects of energy drinks on physical performance have also been 
positive, likely due to taurine.6 Energy drinks have been found to 
improve physical performance in muscle strength and endurance, endurance
 exercise tests, jumping, and sport-specific movements, but not 
sprinting. 
The downside
 While there are some researched benefits of energy drinks, there also
 have been a number of negative effects noted.5 Multiple self-report 
surveys and a randomized placebo-controlled clinical trial found 
insomnia, nervousness, increased pulse rate/palpitations, and activeness
 to be the most common side effects.
 Energy drinks have been shown to have negative effects on the 
cardiovascular system.5 Among normal healthy individuals, energy drinks 
have been shown to significantly increase mean 24-hour systolic, 
diastolic and mean arterial blood pressure when compared to a simple 
caffeine solution with similar levels of caffeine as a cup of coffee. 
Thus, energy drink consumption is not recommended for those with high 
blood pressure. Myocardial contractility, or the innate ability of the 
heart to contract, can be also increased by consumption of energy drinks
 containing both caffeine and taurine, which may be dangerous for those 
with cardiac arrhythmia. 
 Looking at 17 case studies of acute cardiovascular events associated 
with energy drink consumption, only one case had any sign of previous 
cardiac disease, and there were no predisposing cardiac abnormalities in
 most cases.5 The high caffeine content of energy drinks, and 
consumption of multiple drinks, are likely associated with the 
cardiovascular complications in these cases.

Energy drinks and alcohol
 The FDA announced in November 2010 that caffeine was an unsafe food 
additive to alcoholic beverages, which eliminated the pre-mixed 
alcoholic energy drink market.5 However, drinks such as “Red Bull 
Vodkas” are still sold and widely consumed at bars. Mixing energy drinks
 with alcohol has been associated with binge drinking, risky sexual 
behavior, and driving while intoxicated. Another concern with mixing 
energy drinks and alcohol is the possibility the caffeine content from 
the energy drinks will keep the individual awake longer, extending the 
drinking session and therefore encouraging intoxication. 
More research is needed
 Self-report and clinical studies have shown negative health effects 
of energy drinks, but there is still much more that needs to be 
answered. One of the main concerns about energy beverages revolves 
around the lack of research on the interaction of the ingredients. While
 many of the ingredients in energy beverages are generally recognized as
 safe on their own within a certain range of doses, the safety of the 
effect of these ingredients together has not been examined in depth, 
especially in the long term.7 Further, many consume more than the 
recommended one can serving per day, or may drink other caffeinated 
beverages during the day.  
 Another concern is the lack of regulation around energy beverages. 
The United States has one of the least stringent regulatory systems for 
energy beverages.7 Energy beverages are classified as dietary 
supplements, which doesn’t require the strict regulation food products 
endure. For example, energy beverage companies are only required to list
 the ingredients, not the amount of the ingredient on the label. In 
2012, Consumer Reports examined the level of caffeine in 20 popular 
energy beverages. It found that of the 16 that listed a specific amount 
of caffeine, five had caffeine levels more than 20 percent of what was 
listed on the label.8 So an individual may know they are consuming 
caffeine in their energy drink, but either not know how much is in that 
drink, or the amount contained differs from the amount reported.

Firefighters and hydration
 The firefighting environment poses many challenges to maintaining 
hydration. Firefighting tasks have been found to be particularly 
stressful and lead to dehydration.9 The heat stress associated with 
being in encapsulating gear in a high-heat environment is the perfect 
environment for dehydration.
 A study by Gavin Horn and colleagues in the journal Prehospital 
Emergency Care suggests that firefighters often are dehydrated even when
 they arrive on the fire ground or at training.9 Energy drinks in 
particular, and caffeine in general, work as diuretics, which also can 
lead to dehydration. Consuming energy drinks and high levels of caffeine
 without proper water consumption may exacerbate dehydration during 
firefighting tasks.
What is a firefighter to do?
 Given energy drinks are used to combat tiredness, working to avoid 
extreme tiredness as much as possible is an important step for avoiding 
needing energy drinks on a regular basis. Sleep hygiene and trying to 
get as much sleep as you need when you are off duty is as important as 
getting sleep on duty. For busy stations where you will likely be awake 
during the night, try to get a nap during the day. Drinking caffeine 
immediately before taking a short nap might be the best way to combat 
fatigue.
 Pay attention to the quality of the sleep you are getting. More than 
80 percent of firefighters report symptoms of sleep disorders, but most 
have not received a diagnosis or treatment.10 If you snore or have other
 symptoms of sleep disorders, discuss them with your doctor.

Do not count energy drinks toward your hydration goal for the day. 
Trying to hydrate yourself with water once you are on shift is too late 
to combat dehydration. Make water your staple beverage and be sure to 
drink up (the water that is) the day before you go on shift. If you are 
drinking a lot of caffeine or energy drinks, you may need to up your 
water intake even more. 
 As with most things, moderation is key. What is most important for 
the fire service is being responsible consumers of what they are taking 
in to their bodies. While there is no specific rule for safe caffeine 
consumption, 400 mg a day is typically recommended as safe. That amount 
is approximately 4 cups of brewed coffee, 10 sodas or just 2 energy 
shots—or one depending on the type of shot. For those who use energy 
drinks to stay awake and alert, it is important to know how much 
caffeine and sugar is being consumed and titrate both the consumption of
 energy drinks and other caffeine containing products as appropriate. 
References
 1. Top Selling Energy Drink Brands. March 14, 2016 caffeineinformer.com/the-15-top-energy-drink-brands.
 2. Substance Abuse and Mental Health Services Administration, Center 
for Behavioral Health Statistics and Quality. The DAWN Report: Update on
 Emergency Department Visists Involving Energy Drinks: A Continuing 
Public Health Concern. Rockville, MD; 2013.
 3. Striley, CLW; Griffiths, RR; Cottler, LB. Evaluating Dependence 
Criteria for Caffeine. J Caffeine Res. 2011;1(4):219-225. 
doi:10.1089/jcr.2011.0029.
 4. Ali, F; Rehman, H; Babayan, Z; Stapleton, D; Joshi, D-D. Energy 
drinks and their adverse health effects: A systematic review of the 
current evidence. Postgrad Med. 2015;127(3):308-322. 
doi:10.1080/00325481.2015.1001712.
 5. ManchesterJulianne, EshelInbal, W M. The Benefits and Risks of 
Energy Drinks in Young Adults and Military Service Members. Mil Med. 
July 2017. doi:10.7205/MILMED-D-16-00339.
 6. Souza, DB; Del Coso, J; Casonatto, J; Polito, MD. Acute effects of
 caffeine-containing energy drinks on physical performance: a systematic
 review and meta-analysis. Eur J Nutr. 2017;56(1):13-27. 
doi:10.1007/s00394-016-1331-9.
 7. Higgins, JP; Tuttle, TD; Higgins, CL. Energy Beverages: Content 
and Safety. Mayo Clin Proc. 2010;85(11):1033-1041. 
doi:10.4065/mcp.2010.0381.

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 8. Caffeine levels in energy drinks - Consumer Reports. 
consumerreports.org/cro/magazine/2012/12/the-buzz-on-energy-drink-caffeine/index.htm.
 9. Horn, GP; DeBlois, J; Shalmyeva, I; Smith, DL. Quantifying 
dehydration in the fire service using field methods and novel devices. 
Prehospital Emerg Care Off J Natl Assoc EMS Physicians Natl Assoc State 
EMS Dir. 2012;16(3):347-355. doi:10.3109/10903127.2012.664243.
 10. Barger, LK; Rajaratnam, SMW; Wang, W, et al. Common sleep 
disorders increase risk of motor vehicle crashes and adverse health 
outcomes in firefighters. J Clin Sleep Med JCSM Off Publ Am Acad Sleep 
Med. 2015;11(3):233-240. doi:10.5664/jcsm.4534.

Health & Wellness: The Energy Drink Issue

Long days, a lot of runs, sleepless nights, several shifts in a row. It’s not surprising that coffee is a staple at firehouses across the ...

Health & Wellness: The Energy Drink Issue

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