Caffeine in Food and Dietary Supplements

Caffeine in Food and Dietary Supplements is the summary of a workshop convened by the Institute of Medicine in August 2013 to review the available science on safe levels of caffeine consumption in foods, beverages, and dietary supplements and to identify data gaps.(1)

The information presented in the report reveals only what was spoken or visually presented on slides during the workshop, it is a prepublication report. Scientists with expertise in food safety, nutrition, pharmacology, psychology, toxicology, and related disciplines; medical professionals with pediatric and adult patient experience in cardiology, neurology, and psychiatry; public health professionals; food industry representatives; regulatory experts; and consumer advocates discussed the safety of caffeine in food and dietary supplements, including, but not limited to, caffeinated beverage products, and identified data gaps.

Caffeine, a central nervous stimulant, is arguably the most frequently ingested pharmacologically active substance in the world. Occurring naturally in more than 60 plants, including coffee beans, tea leaves, cola nuts and cocoa pods, caffeine has been part of countless cultures for centuries. However, the caffeine-in-food landscape is changing.

There are many new caffeine-containing energy products, such as waffles, sunflower seeds, jelly beans, syrup, and bottled water, entering the marketplace. Years of scientific research have shown that moderate consumption by healthy adults of products containing naturally occurring caffeine is not associated with adverse health effects. The changing caffeine landscape raises concerns about safety and whether any of these new products might be targeting populations not normally associated with caffeine consumption. This includes children and adolescents, and the question is whether caffeine poses a greater health risk to these groups than it does to healthy adults.

This report explains susceptible populations who may be at risk from caffeine exposure, and describes caffeine exposure and risk of cardiovascular and other health effects on these populations. It include additive effects with other ingredients and effects related to pre-existing conditions, explores safe caffeine exposure levels for general and vulnerable populations, and identifies data gaps on caffeine stimulant effects. Caffeine has been added to some alcoholic beverages, and introduced to the marketplace. In 2010, the FDA sent letters to the manufacturers of these products as they felt there was a danger of “risk behaviors” with these products which were not FDA approved. They were removed from the market. However, we now have energy drinks, which can pose some health risks. In 2012, the FDA received reports of 13 deaths over the previous four years that mentioned the possible involvement of 5-Hour Energy, a highly caffeinated energy shot.(2) This came less than a month after the FDA received reports of five people who died after consuming Monster Energy, a high-caffeine energy drink, in the past 3 years.(3) Other adverse events reported to the FDA include one nonfatal MI, abdominal pain, vomiting, tremors, and abnormal heart rate. It was uncertain whether those who experienced adverse events also took alcohol or drugs.(4) The FDA had not yet established a causal link between the energy drink and the deaths. A 24-oz. can of Monster Energy contains 240 mg of caffeine, roughly equivalent to two cups of brewed coffee.

In a Journal of the American Medical Association (JAMA) commentary, a case was made that regular (nonalcoholic) energy drinks might pose as great a threat to individual and public health and safety as those with alcohol.(5) As the authors feel more research is needed regarding these products, they feel it is prudent that health care professionals inform their patients of the risks associated with the use of highly caffeinated energy drinks.(5) They also feel that the community should educate themselves about the risks of energy drink use, especially the risk associated with mixing energy drinks and alcohol. JAMA published a “Patient Page” on energy drinks, outlining the ingredients in them, the risks associated with them, and the caffeine content of beverages and other products. (6) What is not outlined on the “Patient Page” is the damage energy and other drinks do to teeth. A study published 2012 found that an disturbing increase in the consumption of sports and energy drinks, especially among adolescents, and that their consumption is causing irreversible damage to teeth, specifically, the high acidity levels in the drinks erode tooth enamel.(7) The study compared the erosive potential of cola versus non-cola drinks, and regular sugared and diet versions of the same brands. The pH was measured immediately after opening the soft drink can. Enamel slices obtained from freshly extracted teeth were immersed in the soft drinks and weighed at baseline and after 6, 24, and 48 hours of immersion. Non-cola drinks had significantly higher pH values than cola drinks, and sugared versions of the cola and non-cola drinks showed significantly lower pH values. The study showed that prolonged exposure to soft drinks can lead to significant enamel loss. Non-cola drinks are more erosive than cola drinks. Sugared versions of cola and non-cola drinks proved to be more erosive than their diet counterparts. The erosive potential of the soft drinks was not related to their pH value.(7) A Clinical Report from the American Academy of Pediatrics points out that sports drinks and energy drinks are significantly different products.(8) Sports drinks are beverages that may contain carbohydrates, minerals, electrolytes, and flavoring and are intended to replenish water and electrolytes lost through sweating during exercise. The term “energy drink” refers to drinks that also contain substances that act as nonnutritive stimulants, such as caffeine, guarana, taurine, ginseng, L-carnitine, creatine, and/or glucuronolactone, with unsupported performance-enhancing effects.(8)

The authors state that after review and analysis of the literature, they feel that caffeine and other stimulant substances in energy drinks should not be in the diet of children and adolescents. As well, frequent or excessive intake of caloric sports drinks can substantially increase the risk for overweight or obesity in children and adolescents. They point out that dental erosions from sports and energy drinks are of concern in children and adolescents. They base this on a study that found enamel erosion in 57% of 11- to 14-year-olds in a cluster sample of adolescents.(9) Most sports and energy drinks have a pH in the acidic range (pH 3–4). A pH this low is associated with enamel demineralization, as shown from published studies.(10) Citric acid is frequently included in sports and energy drinks and has been found to be highly erosive, because its demineralizing effect on the enamel continues even after the pH has been neutralized.(11)

Soft drink in Brazil

Some drinks also contain guarana, a double whammy! As a dietary supplement, guarana is an effective stimulant, its seeds contain about twice the concentration of caffeine found in coffee beans (about 2–4.5% caffeine in guarana seeds compared to 1–2% for coffee beans).(12) In the United States, guarana has received the designation of "generally recognized as safe" by the American Food and Drug Administration.

It is prudent to educate our patients about the effects of caffeine and energy drinks to their general and oral health. As well, they should be aware of the difference between energy drinks and sports drinks.

References 1. National Research Council. Caffeine in Food and Dietary Supplements: Examining Safety: Workshop Summary. Washington, DC: The National Academies Press, 2014. 2. Meier B. Caffeinated Drink Cited in Reports of 13 Deaths. NY Times. November 14, 2012. http://www.nytimes.com/2012/11/15/business/5-hour-energy-is-cited-in-13-death-reports.html?_r=0. 3. Meier B. Monster Energy Drink Cited in Deaths. NY Times. October 22, 2012. http://www.nytimes.com/2012/10/23/business/fda-receives-death-reports-citing-monster-energy-a-high-caffeine-drink.html?adxnnl=1&ref=business&adxnnlx=1391439953-uYYJVmjbw58kVIPdWjwRyQ. 4. Physician's First Watch. October 24, 2012. 5. Arria AM and O’Brien MC. The “High” Risk of Energy Drinks. JAMA, 305(6): 600-601, Jan 25, 2011. 6. Torpy JM and Livingston EH. Energy Drinks, JAMA. 2013; 309(3):297. doi:10.1001/jama.2012.170614. 7. Jain P, Nihill P, Sobkowski J, and Agustin MZ. Commercial soft drinks: pH and in vitro dissolution of enamel. General Dentistry 55(2):150-4; quiz 155, 167-8. 8. American Academy of Pediatrics. Sports Drinks and Energy Drinks for Children and Adolescents: Are They Appropriate? Clinical Report. PEDIATRICS Vol. 127 No. 6 June 1, 2011, pp. 1182 -1189. (doi: 10.1542/peds.2011-0965). 9. Bartlett DW, Coward PY, Nikkah C, Wilson RF. The prevalence of tooth wear in a cluster sample of adolescent schoolchildren and its relationship with potential explanatory factors. Br Dent J. 1998; 184(3):125–129. 10. Shaw L, Smith AJ. Dental erosion: the problem and some practical solutions. Br Dent J. 1999; 186(3):115–118. 11. Järvinen VK, Rytömaa II, Heinonen OP. Risk factors in dental erosion. J Dent Res. 1991; 70(6):942–947. 12. Johannes, Laura (March 2, 2010). "Can a Caffeine-Packed Plant Give a Boost?". The Wall Street Journal. p. D3.