H1N1 (pandemic flu)

What does the science say: H1N1

Joshua DeWald (josh at 40two org)
November 29, 2009
As usual, an easier to read and printable version can be found at:
Update (April 2012): Added portion (and link to) useful infographic on the cost of getting the flu vs the small cost of a vaccine. 

Introduction

It seemed like a good idea to do a quick entry addressing the H1N1 “swine flu” strain as well as the vaccine for it. A friend of mine suggested adding it to my previous entry on vaccines, but I thought I’d do a separate one instead so people’s eyes don’t glaze over from an already over-long article.

I have no intention of promoting the quack H1N1 claims that are floating around the Internet, so I won’t be linking to them. What you will find here is the official information that is available about the disease and the vaccine. As usual, if you are convinced that the government is lying to us about the flu, then you may as well stop reading now, as I am really just summarizing CDC and FDA  data.

As always, I welcome comments on my blog (https://whatdoesthesciencesay.wordpress.com) or to my email address (josh at 40two org). If anything in here seems factually inaccurate to you, please let me know, but cite your sources. I’m truly not interested in what “Mr. Fit” or any number of random Internet flu scare sites have to say unless they have any genuine science to back them up.

Summary

The “pandemic” H1N1 (aka “swine flu”) is a very serious strain of flu. It is separate from the standard seasonal flu and to be protected for both you have to vaccinate from both. The actual effects are similar to the normal flu, which kills about 36000 people a year. The expected combined deaths of seasonal flu (3 strains) and H1N1 is about 65000 deaths. The H1N1 vaccine has been shown to be as safe and effective as the normal seasonal vaccine that people take yearly.

Disclaimer

I am not a doctor. None of my words should be construed at medical advice. If you still have questions about H1N1, speak with your own doctor. You may safely ignore any statements that appear to be opinion from me or not directly supported by any research or authority I cite.

The H1N1 virus

So what is H1N1 any way?

There actually is already a different version of H1N1 that circulates as part of the seasonal flus.
From the CDC’s Q&A about H1N1 (http://www.cdc.gov/h1n1flu/qa.htm):

This virus was originally referred to as “swine flu” because laboratory testing showed that many of the genes in this new virus were very similar to influenza viruses that normally occur in pigs (swine) in North America. But further study has shown that this new virus is very different from what normally circulates in North American pigs. It has two genes from flu viruses that normally circulate in pigs in Europe and Asia and bird (avian) genes and human genes. Scientists call this a “quadruple reassortant” virus.

Symptoms:

The symptoms of 2009 H1N1 flu virus in people include fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills and fatigue. Some people may have vomiting and diarrhea. People may be infected with the flu, including 2009 H1N1 and have respiratory symptoms without a fever. Severe illnesses and deaths have occurred as a result of illness associated with this virus.

Severity, risk, infection rates:

In seasonal flu, certain people are at “high risk” of serious complications. This includes people 65 years and older, children younger than five years old, pregnant women, and people of any age with certain chronic medical conditions. About 70 percent of people who have been hospitalized with this 2009 H1N1 virus have had one or more medical conditions previously recognized as placing people at “high risk” of serious seasonal flu-related complications. This includes pregnancy, diabetes, heart disease, asthma and kidney disease.

With seasonal flu, we know that seasons vary in terms of timing, duration and severity. Seasonal influenza can cause mild to severe illness, and at times can lead to death. Each year, in the United States, on average 36,000 people die from flu-related complications and more than 200,000 people are hospitalized from flu-related causes. Of those hospitalized, 20,000 are children younger than 5 years old. Over 90% of deaths and about 60 percent of hospitalization occur in people older than 65.

Is anybody really dying from H1N1?

Sadly, yes.
As of October 17th (so a month before this writing), the CDC estimates that there have been 2500 to 6100 deaths. 63,000 to 153,000 people have been hospitalized. And the season is really just getting started.
If you’re curious about why it’s an “estimate”, it mainly has to due with the fact that states don’t have to report all flu-related deaths, or the person might day later from complications. Specifically:
  • First, states are not required to report individual seasonal flu cases or deaths of people older than 18 years of age to CDC.
  • Second, seasonal influenza is infrequently listed on death certificates of people who die from flu-related complications.
  • Third, many seasonal flu-related deaths occur one or two weeks after a person’s initial infection, either because the person may develop a secondary bacterial co-infection (such as a staph infection) or because seasonal influenza can aggravate an existing chronic illness (such as congestive heart failure or chronic obstructive pulmonary disease).
  • Also, most people who die from seasonal flu-related complications are not tested for flu, or they seek medical care later in their illness when seasonal influenza can no longer be detected from respiratory samples. Influenza tests are most likely to detect influenza if performed soon after onset of illness.
  • For these reasons, many flu-related deaths may not be recorded on death certificates.

The Vaccine

Was the vaccine rushed?

The key thing to know is that from a vaccine point of view, this is just another (better targeted) strain.
“The flu” vaccine changes every year because of the evolution and recombination of the strains. Or from the CDC’s “key facts” about the seasonal flu1:

The viruses in the vaccine change each year based on international surveillance and scientists’ estimations about which types and strains of viruses will circulate in a given year. About 2 weeks after vaccination, antibodies that provide protection against influenza virus infection develop in the body.

My readers will probably agree that we don’t hear yearly conspiracy theories about the “rush” to create the current year flu vaccine. Or maybe they do and, rightfully, ignore them.
The ones that circulate seasonally are:
  • H3N2
  • seasonal A (H1N1)
  • seasonal B
“pandemic” H1N1 is the new version.
Additionally, the FDA has a Q&A about the 2009 H1N1 which addresses this concern2.

Vaccines used in the United States must be licensed by FDA. FDA approved these vaccines as a strain change to each manufacturer’s FDA-approved seasonal influenza vaccine. Each of the manufacturers will make the Influenza A (H1N1) 2009 Monovalent vaccines using its well-established, licensed egg-based manufacturing process that is used for seasonal influenza vaccine.

There is considerable experience with seasonal influenza vaccine development and production and influenza vaccines produced by this technology have a long and successful track record of safety and effectiveness in the United States. The safety and effectiveness demonstrated for seasonal influenza vaccine also support the licensure of the Influenza A (H1N1) 2009 Monovalent vaccines produced using the same process as for seasonal vaccine.

The Influenza A (H1N1) 2009 Monovalent vaccines will undergo the same rigorous testing and lot release procedures that are in place for seasonal influenza vaccines.

Summary

Every year, it takes approximately 6 months to make the current season’s batch of flu vaccine. The pandemic H1N1 strain (an earlier version of which circulated in 1976) vaccine is being produced using the same process as the seasonal flu. To call it rushed is to also claim that every year the seasonal flu vaccine is “rushed”. I see no evidence of truth in that claim.

But I heard that I might get Guillain-Barré?

What is Guillain-Barré?

From the CDC’s “Fact Sheet” on Guillain-Barré3:

Guillain-Barré syndrome (GBS) is a rare disorder in which a person’s own immune system damages the nerves, causing muscle weakness and sometimes paralysis. GBS can cause symptoms that last for as little as a few weeks, or go on for several months. Most people recover fully from GBS, but some people have nerve damage that does not go away. In rare cases, people have died of GBS, usually from not being able to breathe due to weakness of their breathing muscles.

A key item in there is the fact that “most people recover fully”.

And the risk from the swine flu vaccine?

Continuing in the same Fact Sheet:

In very rare cases, someone may develop GBS in the days or weeks after getting a vaccination. In 1976, there was a small increased chance of GBS after getting a flu (swine flu) vaccination. This means about 1 more case per 100,000 people who got the swine flu vaccine

Since 1976, many studies have been done to see if other flu vaccines may cause GBS. In most studies no link was found between the flu vaccine and GBS. However, two studies did suggest that about 1 more person out of 1 million people vaccinated with seasonal flu vaccine may develop GBS. This continues to be studied.  For the most part, the chance of getting very ill from flu is far higher than the chance of getting GBS after getting the flu vaccine.

This 1976 increase is the part that scares people. In fact, as soon as the increase was noticed, they stopped doing mass vaccinations that year as a precaution (yes, despite what people would like to claim, the CDC is very concerned about the safety of vaccines and takes seriously any indication they they haphazardly vaccinate).
Despite a continued lack of real risk in subsequent flu vaccination programs, the CDC definitely monitors for any illness following vaccination [from Fact Sheet above]:

During the 2009-2010 flu season, CDC and FDA will be closely looking at reports of serious problems, including GBS, which may be linked to the use of the 2009 H1N1 flu vaccine and to the seasonal flu vaccine. These systems already include some vaccination safety systems, such as the Vaccine Adverse Event Reporting System (VAERS), and new systems, such as the CDC Emerging Infections Program and a partnership with the American Academy of Neurology, which includes doctors who are most likely to see people with GBS. None of these systems existed in 1976.

If you’d like to take a look at some of the actual studies, the ones I found were:
One study found the risk after swine flu vaccine in 1976 to be approximately 11.7/1M (or 1.7/100K)[4 ]. Another found 13.3/1M (or 1.3/100K) using a different methodology[5 ].
Researches continued to look at the risk from the seasonal flu vaccine. I believe these are relevant because the process of creating the vaccine for seasonal and “pandemic” flu is the exact same. Nobody is quite sure what happened in 1976, but it has not been repeated and could have been a random blip.
A study in Great Britain found no real evidence of increased risk from 1990-2005 following seasonal flu vaccine, but “greatly increased” risk following flu-like illnesses[6 ].
There was a slight increase in the 1993-1994 season above the 1992-1993 which elicited a study that found: “There was no increase in the risk of vaccine-associated Guillain–Barré syndrome from 1992–1993 to 1993–1994. For the two seasons combined, the adjusted relative risk of 1.7 suggests slightly more than one additional case of Guillain–Barré syndrome per million persons vaccinated against influenza.”[7]

Other insights

In what I saw as a great example of a person really looking at the science and weighing the risks, even after recovering from Guillain-Barré, Laura Claire Price submitted an editorial (not a clinical study) published in the September 2009 British Medical Journal. After summarizing much of the findings (some I have quoted above), she closes8:

In view of the potential risks of and likely exposure to flu infection as a health care professional, the lack of relapse of the syndrome in a sizable number of people who have had the flu vaccine, and the lack of a persistent causal association, my current view is to consider “having the jab” when it becomes available.

In terms of the relative risks themselves, two statisticians did an analysis of relative risk and whether it necessarily indicates an actual association. The analysis seems generic to me, but it was specifically in response to a civil case regarding Guillain-Barré and flu vaccine (in tort law, 2.0 relative risk is used). They concluded9:

The scientific connection between a relative risk of 2.0 and specific causation is doubtful. Large relative risks argue for general causation, while small ones argue against. If the relative risk is near 2.0, problems of bias and confounding in the underlying epidemiologic studies may be serious, perhaps intractable. Problems created by individual differences may be equally difficult. Bias and confounding affect the estimation of relative risk from the underlying data. By contrast, individual di fferences affect the interpretation of relative risk:namely, the application to any specific individual.

In short, when the relative risk indicates an increased risk, but that relative risk is still low, then it is not necessarily indicative of an actual association.

Summary

Guillain-Barré Syndrome is rare to get and generally a person recovers fully. Guillain-Barré appears to be triggered from many illnesses (including the flu) as well as other factors that affect the immune and nervous system. In rare causes (1/1,000,000) the flu vaccine itself can be this cause (as obviously the intent of the vaccine is the trigger an immune reaction). During the 1976 swine flu vaccination program, there appeared to be a 1/100,000 extra cases for those who were vaccinated. The health risks (as well as the incidence) of H1N1 itself is much higher and easily outweighs the risk of Guillain-Barré.

But what about the crazy ingredients?

General Overview

Because people are unnecessarily scared, none of the US approved vaccines have adjuvants (basically they help to “annoy” the immune system into producing more antibodies) such as aluminum in them. But for some of the more “controversial” ingredients (for all US vaccines, not just flu), the FDA has produced a nice FAQ[10].

They specifically cover formaldehyde, preservatives, amino acids, sugars, etc.

I’ll quote from a portion of the section on formaldehyde (emphasis mine):

Although high concentrations of formaldehyde can damage DNA (the building block of genes) and cause cancerous changes in cells in the laboratory, formaldehyde is an essential component in human metabolism and is required for the synthesis of DNA and amino acids (the building blocks of protein).  Therefore, all humans have detectable quantities of natural formaldehyde in their circulation. In addition, quantities of formaldehyde at least 600-fold greater than that contained in vaccines have been found to be safe in animals.

Additionally, some of the sugars, proteins and amino acids:

These materials may be added as stabilizers.  They help protect the vaccine from adverse conditions such as the freeze-drying process, for those vaccines that are freeze dried.  Stabilizers added to vaccines include: sugars such as sucrose and lactose, amino acids such as glycine or the monosodium salt of glutamic acid and proteins such as human serum albumin or gelatin.  Sugars, amino acids and proteins are not unique to vaccines and are encountered in everyday life in the diet and are components that are in the body naturally.

The approved H1N1 vaccines for usage in the United States

You can see this same list at the FDA’s “2009 Monovalent Descriptions and Ingredients” site[11].


CSL Limited

http://www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM182401.pdf

A single 0.5 mL dose of Influenza A (H1N1) 2009 Monovalent Vaccine contains:
  • sodium chloride (4.1 mg)
  • monobasic sodium phosphate (80 mcg)
  • dibasic sodium phosphate (300 mcg)
  • monobasic potassium phosphate (20 mcg)
  • potassium chloride (20 mcg)
  • calcium chloride (1.5 mcg)
From the manufacturing process, each 0.5 mL dose may also contain residual amounts of:
  • sodium taurodeoxycholate (≤ 10 ppm),
  • ovalbumin (≤ 1 mcg),
  • neomycin sulfate (≤ 0.2 picograms [pg]),
  • polymyxin B (≤ 0.03 pg),
  • beta-propiolactone (< 25 nanograms)

ID Biomedical Corporation of Quebec

Influenza A (H1N1) 2009 Monovalent Vaccine, for intramuscular injection, is a homogenized, sterile, colorless to slightly opalescent suspension in a phosphate-buffered saline solution formulated to contain:
  • 15 mcg hemagglutinin per 0.5-mL dose of the influenza A/California/7/2009 (H1N1)v-like virus.
  • Thimerosal, a mercury derivative, is added as a preservative. Each dose contains 25 mcg mercury.
Each dose may also contain residual amounts of:
  • egg proteins (≤1 mcg ovalbumin)
  • formaldehyde (≤25 mcg)
  • sodium deoxycholate (≤50 mcg)

No doubt the first thing you will notice is the use of Thimerosal, which has absolutely not been found to be linked to Autism. However, this vaccine is still only used for adults over 18 years of age. I repeat, children do not receive this vaccine.

MedImmune LLC

Each 0.2 mL dose contains 106.5-7.5 FFU of the live attenuated influenza virus reassortant of the pandemic (H1N1) 2009 virus: A/California/7/2009 (H1N1)v.
Each 0.2 mL dose also contains:
  • 0.188 mg/dose monosodium glutamate
  • 2.00 mg/dose hydrolyzed porcine gelatin
  • 2.42 mg/dose arginine
  • 13.68 mg/dose sucrose
  • 2.26 mg/dose dibasic potassium phosphate
  • 0.96 mg/dose monobasic potassium phosphate
  • <0.015 mcg/mL gentamicin sulfate.

Novartis Vaccines and Diagnostics Limited

Influenza A (H1N1) 2009 Monovalent Vaccine is a homogenized, sterile, slightly opalescent suspension in a phosphate buffered saline. Influenza A (H1N1) 2009 Monovalent Vaccine is formulated to contain:
  • 15 mcg hemagglutinin (HA) per 0.5-mL dose of the following virus strain: A/California/7/2009 (H1N1)v-like virus.
The 5-mL multidose vial formulation contains thimerosal, a mercury derivative, added as a preservative. Each 0.5-mL dose from the multidose vial contains 25 mcg mercury.
Each dose from the multidose vial or from the prefilled syringe may also contain residual amounts of:
  • egg proteins (≤ 1 mcg ovalbumin)
  • polymyxin (≤ 3.75 mcg)
  • neomycin (≤ 2.5 mcg)
  • betapropiolactone (not more than 0.5 mcg)
  • nonylphenol ethoxylate (not more than 0.015% w/v)
The multidose vial stopper and the syringe stopper/plunger do not contain latex.
Again, notice the Thimerosal in the multidose version. This vaccine is itself only for children over 4 years of age. Also I suspect that due to the unnecessary fears, the single dose version is what is given to those under 18.

Sanofi Pasteur, Inc.

Influenza A (H1N1) 2009 Monovalent Vaccine is formulated to contain:

15 mcg hemagglutinin (HA) of influenza A/California/07/2009 (H1N1) v-like virus per 0.5 mL dose.
Gelatin 0.05% is added as a stabilizer.
Each 0.5 mL dose may contain residual amounts of:
  • formaldehyde (not more than 100 mcg),
  • polyethylene glycol p-isooctylphenyl ether (not more than 0.02%) [Note: this is not anti-freeze, or even related to anti-freeze. Antifreeze is made from propylene glycol or ethylene glycol. It is non-toxic. It’s also in laxatives!]
  • sucrose (not more than 2.0%)
There is no thimerosal used in the manufacturing process of the single-dose presentations of Influenza A (H1N1) 2009 Monovalent Vaccine.
The multi-dose presentation of Influenza A (H1N1) 2009 Monovalent Vaccine contains thimerosal, a mercury derivative, added as a preservative.
Each 0.5 mL dose of the multidose presentation contains 25 mcg mercury.
Anything crazy? Didn’t think so.
For those wondering why no adjuvants are present, it’s because they aren’t. Again, from the FDA’s Q&A about the swine flu vaccine:

No, these vaccines are manufactured according to the same processes as the licensed (approved) seasonal influenza vaccines, which do not contain adjuvants.

Summary

Except for the formaldehyde, which the CDC addresses, and the Thimerosal (which no valid scientific study has demonstrated has any causal link to Autism), which is only in vaccines meant for people over 18 (and possibly over 4 in one case), there are no ingredients which seem to me even worth looking up. Some of the online scare sites will attempt to link polyethylene glycol with “anti-freeze”, but this is a dishonest tactic.
One sad side effect of the scare tactics are that there is actually less vaccine available because adjuvants aren’t being used (as they are in other countries). This means more attenuated virus and virus proteins must be used rather than a combination of proteins and adjuvants to stimulate the immune system. So less can be made and less live material is available for worldwide vaccines. Score one for pseudoscience.
Another personal comment is that are people genuinely more trustworthy of random “herbal cures” that they find on the internet (or even a health food store) that is unregulated and not demonstrated to have any natural effect, then regulated and tested vaccines? Seriously?

Is it safe for pregnant women?

The Recommendation

As usual, let’s go straight to the CDC’s statements about pregnant women and the flu vaccine[12 ]

Additionally, because the vaccine cannot be given to babies less than 6 months old, the antibodies will protect the baby after it is born until they can get themselves vaccinated.

Yes. Besides protecting her from infection, the shot may also help protect her infant. Flu shots are only given to infants 6 months of age and older. Everyone who lives with or gives care to an infant less than 6 months of age should get both the seasonal flu and 2009 H1N1 vaccines. A woman can get either the shots or the nasal spray after she delivers.

It is true that the current swine flu vaccine has not been tested for pregnant women, as doing any clinical testing with pregnant women is not frequent.
They are actually doing some clinical trials currently to be sure, which you can look for at the US Government’s clinicaltrials.gov. There is currently a study in Phase II being done specifically for pregnant women[13].

The studies

A 2009 study (a literature review I believe, I can only get to the abstract) continues to find no risk to pregnant women from flu vaccines[14]:

No study to date has demonstrated an increased risk of either maternal complications or adverse fetal outcomes associated with inactivated influenza vaccination. Moreover, no scientific evidence exists that thimerosal-containing vaccines are a cause of adverse events among children born to women who received influenza vaccine during pregnancy. In this article, we review the evidentiary basis for the recommendation of vaccination of all women who will be pregnant during the influenza season and safety data of influenza vaccination during pregnancy.

A study done in 2004 comparing pregnant women getting vaccines with those who hadn’t between 1998 and 2003 and found no important statistically significant difference between them [15]:

Among 7183 eligible mother-infant pairs, only 252 pregnant women (3.5%) received the influenza vaccine. Women with medical insurance were more likely to be vaccinated, although the rates for women with chronic underlying conditions were similar to those of healthy women, regardless of insurance status. The mean gestational age at the time of influenza vaccination was 26.1 weeks (range, 14-39 weeks). No serious adverse events occurred within 42 days of vaccination, and there was no difference between the groups in the outcomes of pregnancy (including cesarean delivery and premature delivery) and infant medical conditions from birth to 6 months of age.

I dove into the study a bit and it should be noted that “abnormal glucose tolerance” test was just at the 95% CI p-value of .05, but there was no increased gestational diabetes. Additionally there was increased “transient hypertension”, but no additional preclampsia (which is what would normally follow). There was non-statistically significant increase in acute respiratory illnesses in the unvaccinated women, especially during the peak of flu season. And at the p-value of .05 (1.8% of cases), the children of unvaccinated women had congenital anomalies reported. The point here is really that there is no meaningful difference, as both as statistically insignificant increases in one form or another. They authors note: “Overall, a greater variety of pathologic conditions was observed in the group of infants of unvaccinated mothers throughout the first year of life.

Miscarriages

There is some unfortunate anecdotal stories of women who miscarry following flu vaccination. This is heartbreaking, but is a case of correlation without causation. There are thousands of spontaneous miscarriages a month (possibly daily), so it is not surprising that there will exist expectant mothers who will have happened to have gotten a vaccine recently (just as they might have had Burger King that morning, or gone to the gym, or been around a smoker, or any number of events that might correlate but are not the cause).

I had a section where I attempted to calculate how many miscarriages might be occurring per day to demonstrate how likely it is. I’ve deleted this section because a) my math is probably wrong b) no matter the number it is heartbreaking. Instead I will simply provide the numbers of how many live births there are and the miscarriage rates.
Every month there are approximately 320,000 successful live births (obviously depends on the year, this is from 2000)[16].
While about 10-15% of pregnancies after the first few months end in spontaneous miscarriage, the rate is about 3% once in the 3rd trimester (unfortunately, I can’t seem to find a reliable source for this number, just various pregnancy sites mentioning it. The normal number is 10-15%, but that is across the entire pregnancy and not specifically for the 3rd trimester, which is what the anecdotal claims are about).
Summary
Pregnant women should really speak with their physician. The CDC’s recommendation is for them to get vaccinated, due to the high risk of complications from the flu itself and as there is no indication that the vaccine would cause harm. There is anecdotal evidence, as there is for many things, of women who get a vaccination and then shortly afterwards miscarry. No study has been able to find this linkage.

Further Resources

The government’s flu information center: http://flu.gov/

CDC’s “key facts” about the flu vaccines: http://www.cdc.gov/flu/protect/keyfacts.htm

As usual, Brian Dunning of Skeptoid manages to make the same topic entertaining: http://skeptoid.com/episodes/4180
Additionally, the bloggers are Science-Based Medicine are in fact real doctors and genuinely know what they are talking about: http://www.sciencebasedmedicine.org/?p=2733
Jason from Frugal Dad made a great infographic going over the “true cost” of the flu (in general), as it compares to the relatively low cost of getting vaccinated. Here is a small portion of it, I recommend you take a look at the whole thing. It covers both the cost to the individual as well as the a company, the economy as a whole and even the world overall.

Cost of the Flu (source:frugaldad.com)

notes

1 “CDC: Seasonal Influenza Key Facts”. http://www.cdc.gov/flu/protect/keyfacts.htm Visited 11/26/2009

2 US Food and Drug Administration. “Influenza A (H1N1) 2009 Monovalent Vaccines Questions and Answers.” http://www.fda.gov/BiologicsBloodVaccines/Vaccines/QuestionsaboutVaccines/ucm182335.htm. Published September 15, 2009. Visited 11/28/2009

3 http://www.cdc.gov/h1n1flu/vaccination/factsheet_gbs.htm CDC. “Fact Sheet: Guillain-Barré Syndrome”. Published 11/2/2009. Visited 11/27/2009.

4 Breman, Joel G. “GUILLAIN-BARRÉ SYNDROME AND ITS RELATIONSHIP TO SWINE INFLUENZA VACCINATION IN MICHIGAN, 1976–1977”. American Journal of Epidemiology Vol. 119, No. 6: 880-889 http://aje.oxfordjournals.org/cgi/content/abstract/119/6/880

5 Marks, James S. “Guillain-Barré Syndrome in Recipients of A/New Jersey Influenza Vaccine”. JAMA. 1980;243(24):2490-2494.http://jama.ama-assn.org/cgi/content/abstract/243/24/2490

6 Stowe, Julia et a. “Investigation of the Temporal Association of Guillain-Barré Syndrome With Influenza Vaccine and Influenzalike Illness Using the United Kingdom General Practice Research Database”. American Journal of Epidemiology 2009 169(3):382-388; doi:10.1093/aje/kwn310 http://aje.oxfordjournals.org/cgi/content/abstract/169/3/382

7 Lasky T, Terracciano GJ, Magder L, Koski CL, Ballesteros M, Nash D, Clark S, Haber P, Stolley PD, Schonberger LB, Chen RT. The Guillain-Barré syndrome and the 1992-1993 and 1993-1994 influenza vaccines. N Engl J Med. 1998 Dec 17;339(25):1797-802. PubMed PMID: 9854114. http://content.nejm.org/cgi/content/full/339/25/1797

8 Price, Laura C. “Should I have an an H1N1 flu vaccination after Guillain-Barré syndrome?”. BMJ 2009;339:b3577. http://www.bmj.com/cgi/content/full/339/sep09_1/b3577. Visited 11/27/2009

9 Freedman, D. A., Stark, P. B. (1999). The Swine Flu Vaccine and Guillain-Barré Syndrome: A Case Study in Relative Risk and Specific Causation. Eval Rev 23: 619-647

10 “Common Ingredients in U.S. Licensed Vaccines”. fda.gov. http://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/VaccineSafety/ucm187810.htm. Visited 11/27/2009

11 US Food and Drug Administration. “Influenza A (H1N1) 2009 Monovalent Vaccines Descriptions and Ingredients”. FDA.gov.  http://www.fda.gov/BiologicsBloodVaccines/Vaccines/QuestionsaboutVaccines/ucm186102.htm Visited 11/27/2009

12 Center for Disease Control. “2009 H1N1 Influenza Shots and Pregnant Women: Questions and Answers for Patients”. http://www.cdc.gov/h1n1flu/vaccination/pregnant_qa.htm Updated November 2, 2009. Visited November 28, 2009.]:

13 ClinicalTrials.gov. “H1N1 Vaccine in Pregnant Women”. http://www.clinicaltrials.gov/ct2/show/NCT00963430?term=NCT00963430&rank=1 Updated 11/25/2009. Visited 11/28/2009

14 Tamma PD, Ault KA, Del Rio C, Steinhoff MC, Halsey NA, Omer SB. Safety of influenza vaccination during pregnancy. Am J Obstet Gynecol. 2009 Oct 20. [Epub ahead of print] PubMed PMID: 19850275.

15 Flor M. Munoz, MD et al. “Safety of influenza vaccination during pregnancy”. American Journal of Obstetrics and Gynecology (2005) 192, 1098–106. http://www.i-lumens.com/DOCUMENTS/VACCINATION%20ET%20GROSSESSE.pdf

16 CDC National Center for Health Statistics. “National Vital Statistics Reports. Births:Final data for 2000”. Vol:50,Number 5. February 12, 2002. Visited 11/29/2009.

8 glasses of water a day

Introduction

Impetus

This is part of my ongoing series of articles looking into the science around various popular claims (in the same vein as Brian Dunning of Skeptoid). My goal is not necessarily to “debunk” (though that will often be the result) but more to see what the actual scientific consensus is which may be different from what we are often told from friends or news sources. This is the third in the series, I previously discussed some anti-vaccination claims and energy drinks. In this case, a friend of mine suggested I look into the truth of the need for at least eight 8 ounce (“8×8) glasses of water a day.

Methodology

I have used the same method as in my previous entries. Namely, I do a quick search for the top sites making the claim(s). When they refer to their sources, which is itself infrequent, I look take a look at those studies (as well as others that cite them) to see if the studies actually match the claim. At times, the studies might turn out to have been superseded my newer research or discredited for one reason or another. Additionally I make heavy use of Google Scholar to locate studies on the topic. Wikipedia will often be a jumping off point, but will not itself be used as a source (for obvious reasons). Also, blogs and non-scientific sites are not considered sources for the side of “science” but will be used for the claim side. In this particular case, I did not end up using the “claim” sources as this topic is pop culture enough to not need to take up space with specific quotes.

Summary

I was actually surprised to find out that the recommended intake of water was in fact in the range of 90 ounces (2.7L) for women and 120 ounces (3.7L) for men (really it depends on age and weight). In other words, more than 64 ounces. However, at least 20% of this will come from your daily food intake. More importantly it is incorrect to claim that tea, soft drinks and coffee don’t count toward the intake, when in fact they do. Mildly alcoholic beverages have been found to show a small increase in the time it takes to rehydrate from exercise. So there is absolutely no need to feel obligated to down 2 full liters of plain water daily. The average person gets pretty well within range of the recommended intake without trying too hard.

Disclaimer

None of what is written here should be construed as medical advice, as I am certainly in no way qualified to provide that.

The Claims

Claim 1: An adult requires 64 ounces (“8×8”) of water a day

What the science says

Intriguingly, the recommendation of the Institute of Medicine (IOM) is actually a bit higher for a normal adult. Taking a look at the “Dietary Reference Intakes: Electrolytes and Water” published by the Institute of Medicine’s (IOM) Food and Nutrition Board, female adults should have 2.7L/day and males should have about 3.7L. However, they state that “about 20%” of that will come from food, leading to about 2.16L (73oz) and 2.96L (100oz), respectively, that should be consumed in liquid form[1].

This is technically an average, as the actual recommendation is really based on your weight (so bigger folks like myself actually need more). The best number I can find is about 35 mL/kg[2], which translates to about .5 oz/pound. So someone around 170lbs would “need” about 80 or so ounces, while someone closer to 200 pounds would go for 100 ounces.

What I found cool was that even in the “original” source for the recommendation, it mentions that most of the fluid intake would come from food, but that people ignored that part. From a very comprehensive review of the available literature done by Heinz Valtin of Dartmouth[3]:

According to J. Papai (65), P. Thomas has suggested a different origin for 8 × 8. Thomas reminds us that in 1945 the Food and Nutrition Board of the National Research Council wrote (31): “A suitable allowance of water for adults is 2.5 liters daily in most instances. An ordinary standard for diverse persons is 1 milliliter for each calorie of food. Most of this quantity is contained in prepared foods.”

Thomas suggests that the last sentence was not heeded, and the recommendation was therefore erroneously interpreted as eight glasses of water to be drunk each day.

Summary

The current recommendation is in fact to consume about about 2.5-4L of water a day, of which at least 20% will come from food and that soft drinks and mild alcohol count toward (discussed below). If you look for it, there is also some controversy that the suggested amount is higher than necessary.

Claim 2 : Soft drinks, coffee and alcoholic beverages don’t count

So we’re supposed to have at least 2L of water a day, but that has to come from plain drinking water. Or does it?

What the science says

Let’s start with the IOM Food and Nutrition’s board actual recommendation (previously quoted above as well)[4]:

The AIs provided are for total water in temperate climates. All sources can contribute to total water needs: beverages (including tea, coffee, juices, sodas, and drinking water) and moisture found in foods. Moisture in food accounts  for about 20% of total water intake. Thirst and consumption of beverages at meals are adequate to maintain hydration.

So right off the bat the most official recommendation that I’m aware of contradicts popular knowledge.
The reasons are probably related to studies that were done such as that by Ann C. Grandjean and others. In “The Effect of Caffeinated, Non-Caffeinated, Caloric and Non-Caloric Beverages on Hydration“, they concluded[5]:

This preliminary study found no significant differences in the effect of various combinations of beverages on hydration status of healthy adult males. Advising people to disregard caffeinated beverages as part of the daily fluid intake is not substantiated by the results of this study. The across-treatment weight loss observed, when combined with data on fluid-disease relationships, suggests that optimal fluid intake may be higher than common recommendations. Further research is needed to confirm these results and to explore optimal fluid intake for healthy individuals.

Additionally, in a controlled study where one group consumed a standard diet (except with no water, but other beverages) and another had a diet including plain water they concluded “Inclusion of plain drinking water compared to exclusion of plain drinking water in the diet did not affect the markers of hydration used in this study.“[6]

The exception appears to be (at least) for those who are just now restarting to drink caffeine after having abstained for a week or so. Basically the body very quickly adapts to counteract the diuretic effects. In a literature review published in the Journal of Nutrition and Dietetics, the authors found [7]:

The available literature suggests that acute ingestion of caffeine in large doses (at least 250–300 mg, equivalent to the amount found in 2–3 cups of coffee or 5–8 cups of tea) results in a short-term stimulation of urine output in individuals who have been deprived of caffeine for a period of days or weeks. A profound tolerance to the diuretic and other effects of caffeine develops, however, and the actions are much diminished in individuals who regularly consume tea or coffee. Doses of caffeine equivalent to the amount normally found in standard servings of tea, coffee and carbonated soft drinks appear to have no diuretic action.

In terms of alcohol, in a study looking at fluid balance recovery after exercise, there appears to be no difference in recovery from dehydration whether the rehydration beverage is alcohol free or contains up to 2% alcohol, but drinks containing 4% alcohol tend to delay the recovery process.” [8]

Summary

The actual IOM recommendation specifically mentions that non-water beverages fully contribute to the intake. At least one study indicates that mildly alcoholic beverages have a mildly net diuretic effect. One study found no difference in hydration of folks who did not intake any plain water.

Final Note and Further Reading

If you’re interested in some of the other dietary guidelines for vitamins in nutrients, a good jumping off point is the USDA’s National Agricultural Library DRI tables.

Also, the article I referenced by Heinz Valtin is very interesting and significantly more thorough than mine.
I always invite readers to comment on any of my “articles”, suggest new topics or provide additional resources. I’m available by email (address above) or at my blogs (https://whatdoesthesciencesay.wordpress.com and http://quay.wordpress.com).

References

1 Institute of Medicine’s Food and Nutrition Board. “Dietary Reference Intakes : Electrolytes and Water”. http://www.iom.edu/Global/News%20Announcements/~/media/442A08B899F44DF9AAD083D86164C75B.ashx Visited 11/18/2009

2 Ann C. Grandjean, EdD, FACN, CNS, Kristin J. Reimers, RD, MS, Mary C. Haven, MS and Gary L. Curtis, PhD. “The Effect on Hydration of Two Diets, One with and One without Plain Water”. J of Am Coll Nutr. Vol 22, No. 2, 165-173 (2003). http://www.jacn.org/cgi/content/full/22/2/165

3 Valtin, Heinz. “‘Drink at least eight glasses of water a day.’ Really? Is there scientific evidence for ‘8 × 8’? Am J Physiol Regul Integr Comp Physiol 283: R993-R1004, 2002. First published August 8, 2002; doi:10.1152/ajpregu.00365.2002 – I would highly recommend my readers take a look at this if they want a more comprehensive look into this topic.

4 Institute of Medicine’s Food and Nutrition Board. “Dietary Reference Intakes : Electrolytes and Water”. – See above.

5 Ann C. Grandjean, EdD, FACN, CNS et al.”The Effect of Caffeinated, Non-Caffeinated, Caloric and Non-Caloric Beverages on Hydration”. Journal of the American College of Nutrition, Vol. 19, No. 5, 591-600 (2000). http://www.jacn.org/cgi/content/abstract/19/5/591

6 Ann C. Grandjean, EdD, FACN, CNS, Kristin J. Reimers, RD, MS, Mary C. Haven, MS and Gary L. Curtis, PhD. “The Effect on Hydration of Two Diets, One with and One without Plain Water”. J of Am Coll Nutr. Vol 22, No. 2, 165-173 (2003). http://www.jacn.org/cgi/content/full/22/2/165

7 R.J Maughan.”Caffeine ingestion and fluid balance: a review”. J Human Nutr. 16:6. p411-420 (2003). http://www3.interscience.wiley.com/journal/118888724/abstract

8 Susan M. Shirreffs and Ronald J. Maughan.”Restoration of fluid balance after exercise-induced dehydration: effects of alcohol consumption”. Journal of Applied Physiology. Vol. 83, No. 4, pp. 1152-1158, October 1997. http://jap.physiology.org/cgi/content/abstract/83/4/1152

Energy Drinks

What does the science say:Energy Drinks

A printable and potentially easier to read version of this can be found at http://www.40two.org/What_the_science_says_about_Energy_drinks.pdf

In general I am still trying to figure out the best way to present this information, so bear with me 🙂

Introduction

Impetus

I really enjoy drinking (mostly for the taste) energy drinks, especially Monster Lo-Carb. However, I am often told how bad they are for me, much much worse than regular soft drinks! I have been told that not only are they absolutely filled with caffeine, but sugar. And I will also die of a heart attack if I drink them.

My goal in this was to look into into these claims, especially in terms of how energy drinks might compare with other popular soft drinks and caffeinated beverages. I knew that these drinks probably wouldn’t be considered “healthy”, but is it true that energy drinks represent a significantly worse health hazard then everything else we’re drinking?

This article is part of an ongoing series, I have previously addressed some specific anti-vaccination claims1. They all have the dual purpose of allowing me to learn more about these topics as well as the inform others (and provide references) about them. I firmly believe that the spread of bad information is worse than no information at all. If you find anything in here that is not based on fact (or at least scientific studies), please let me know.

NOTE: I plan on addressing Diet drinks in a separate one of these, in case you have comments/questions specifically regarding diet energy drinks. Also, I will not specifically address pesticide concerns about any herbal ingredients here, as that is planned for another essay.

Methodology

As I am not a scientist or doctor, I have done no original lab-based or statistical research as part of this article. Rather I have tried to find studies which may be an intended response (or investigation into) a claim, simply a study that contradicts the claim, or even science that completely confirms the claim. I will generally just quote from the studies in those cases. Occasionally I will use Wikipedia if I don’t think the particular piece of information is controversial but is rather descriptive in nature (such as describing what a chemical might be). For the controversial bits, I will always look to find the source studies.

I have done my best to accurately present the data in an objective way. If you are reading this on the internet, all sources can be reached (as of writing here in November of 2009) via clicking on the links. If you are reading this via a printout, then the citation and URL for all sources is available in the footnotes sections for later checking.

If the reader disagrees with the results, I would definitely appreciate some feedback with other (preferably peer-reviewed) evidence they have. As always, anecdotal stories are not scientific evidence and do not contribute to the debate.

Audience

I’ve been asked a couple of times who a document like this is meant for. Part of it is for me (basically documenting my journey of finding out about the topic). The second audience is really for those other followers of science who may have a friend or relative making a claim about the topic (in this case energy drinks) and want some resources to be able to back up with actual numbers or studies. Or perhaps they themselves are simply unsure about whether a claim is true or not (in some cases, they might be true). The final audience are those who are convinced of the truth of what is a, I believe the science shows, false claim. To those, I hope that you are open minded enough to consider the data. In some cases, your views might even get strengthened (for instance, there’s no denying that non-diet energy drinks contain as much or more sugar than other soft drinks).
And it is for those reasons that I try to have so many references and links (perhaps to the point of ridiculousness). Through that I can hopefully be able to address even minor details of claims that could come up (“yes, but did you consider… ?”).

I’m also looking for ways to make this more interesting…

Disclaimer

I am not a doctor, research scientist or medically trained in any way. Nothing in this document should be construed as medical advice.

The Claims

There are a variety of claims leveled against energy drinks, which can be grouped in a variety of ways. As far as I can tell (from speaking with people and searching the Internet), the main claims are:

  • They have much higher levels of caffeine than other drinks
  • They have much higher levels of sugar than other drinks
  • They are filled with mysterious ingredients, including the unstudied herbal ones
  • When they are mixed with alcohol, chaos ensues
  • They destroy your teeth

An example that encompasses most of these can be found at the “Quality Health” site2:

Caffeine content in energy drinks range between 50 and more than 500 milligrams (for a 12-ounce cola drink it’s 35 milligrams, and it’s about 80 to 150 milligrams for a brewed 6-ounce cup of coffee). However, energy drinks are marketed as “dietary supplements” and the Food and Drug Administration’s caffeine content limit of 71 milligrams per 12-ounce can doesn’t apply. As a result, consumers remain in the dark about the dangers of energy drinks, which include:

• Dental decay. A study published in the journal General Dentistry revealed that high energy drinks have the potential to erode tooth enamel more than other drinks we’re usually     warned about such as sodas, sports drinks and root beer.

• Energy highs and crashes. In a study that investigated the energy drink consumption by college students (the key target demographic for energy drinks), 29 percent reported experiencing weekly jolt and crash episodes.

• Headaches and heart palpitations. In the same college study, 22 percent reported having headaches, and 19 percent had heart palpitations related to drinking the energy drinks.

• Poor perception of intoxication. Mixing an alcoholic beverage with an energy drink may help fight fatigue, but it reduces your ability to tell that you’re drunk – even more than drinking alcohol on its own, according to a study out of Brazil. This puts you at a higher risk of problems such as driving while intoxicated.

• Higher risk of injury. In a Wake Forest study that also investigated energy drink consumption by college students, researchers found that combining alcohol with energy drinks dramatically heightened the risk of injury and other alcohol-related problems.

• Increased risk taking. If you consume six or more energy drinks a month, you have a three times greater risk of smoking cigarettes, abusing prescription drugs, or engaging in a serious physical fight. You’re also twice as likely to abuse alcohol and smoke marijuana compared to people who don’t drink energy drinks.

This article is one of the very few that actually cites their sources, which I have used as a basis to start.

Their sources (last updated 9/11/2009):

Wake Forest University Baptist Medical Center press release, “Study Shows Energy Drink ‘Cocktails’ Lead to Increased Injury Risk,” Sept. 2007.

Academy of General Dentistry press release, “New Study Indicates That Popular Sports Beverages Cause More Irreversible Damage to Teeth Than Soda,” Feb. 2005.

Drug and Alcohol Dependence, 2009 Jan 1;99 (1-3):1-10 “Caffeinated energy drinks–a growing problem.” Reissig CJ, Strain EC, Griffiths RR.

Nutrition Journal, Oct. 2007 6(35) “A Survey of Energy Drink Consumption Patterns Among College Students.” Brenda M Malinauskas, Victor G Aeby, Reginald F Overton, Tracy Carpenter-Aeby and Kimberly Barber-Heidal

Alcoholism: Clinical and Experimental Research, 2006 30(4):598 – 605 “Effects of Energy Drink Ingestion on Alcohol Intoxication.” Sionaldo Eduardo Ferreira, Marco Túlio de Mello, Sabine  Pompéia, and Maria Lucia Oliveira de Souza-Formigoni

I was able to locate all of these and reference them within the main body of the article.

And now on to the specific claims.


Claim 1: Energy Drinks have significantly higher levels of caffeine than other drinks

Sample claims

Again from the Quality Health article mentioned above3:

Last year, scientists at Johns Hopkins University called for prominent labels to warn consumers of the possible dangers of energy drinks. “The caffeine content of energy drinks varies over a 10-fold range, with some containing the equivalent of 14 cans of Coca-Cola,” says Roland Griffiths, Ph.D., a co-author of the article published in Drug and Alcohol Dependence. “Yet the caffeine amounts are often unlabeled and few include warnings about the potential health risks of caffeine intoxication.”

From sixwise.com ‘s “The 6 Top Dangers of Energy Drinks, and 5 Healthy Energy-Boosting Alternatives4:

1. Caffeine Intoxication

Energy drinks contain anywhere from 160 mg to 300 mg of caffeine, compared with 80 mg for a typical cup of coffee. While most adults can safely drink up to 200-300 mg of caffeine a day, many teens drink several energy drinks a day, sometimes in a short period of time.

Not surprisingly, a study by Johns Hopkins School of Medicine found that energy drinks can lead to caffeine intoxication, a condition that can cause nervousness, heart irregularities, increased blood pressure, insomnia, neurological symptoms and anxiety.

“The caffeine content of energy drinks varies over a 10-fold range, with some containing the equivalent of 14 cans of cola, yet the caffeine amounts are unlabeled and few include warnings about potential health risks of caffeine intoxication,” the study’s author said.

Sidebar comment: As far as I can tell, all of sixwise.com’s article end with with a “solution” or “alternative” product to solve the problem listed in the article, which they conveniently link to so the person can buy it. It strikes me that all of the articles are written specifically with this in mind, but this is just my personal opinion.

What the science says

Reading those quotes you’ll notice that both quote from a Johns Hopkins article, co-authored by Roland Griffiths. So it seemed like a good idea to locate this article and see what it had to say.

The article is:

Reissig, C.J., et al., Caffeinated energy drinks—A growing problem. Drug and Alcohol Dependence (2008), doi:10.1016/j.drugalcdep.2008.08.001

The only version I could find that did not require purchase was a Google scholar cache of http://www.keyetv.com/media/news/7/f/c/7fc1accb-5d80-4993-9e78-e985920e6762/caffeine_study.pdf, which is no longer available. I apologize for any strange formatting. I’ve tried to correct bits that the Google conversion missed.

The study is a review and commentary on other studies (sort of a meta-study). For the most part, it’s a review of the literature on caffeine in general.

With regards to caffeine levels (emphasis mine)5:

These drinks vary widely in both caffeine content (ranging from 50 to 505 mg per can or bottle) and caffeine concentration (ranging from 2.5 to 171 mg per fluid ounce) (Table 1). For comparison, the caffeine content of a 6 oz cup of brewed coffee varies from 77 to 150 mg (Griffiths et al., 2003).

This all looks to be factual information, but I would like to make some points about it. First, while they show the caffeine concentration for the energy drinks, they neglect to show it for coffee. If you do the math (77 to 150 mg for 6oz) you end up with 12.8 to 25 mg/oz. Yet, the caffeine concentrations they mention for energy drinks start as low as 2.5 mg/oz (but go up to 171, but more on that in a bit). Secondly who, outside of breakfast diner patrons who drink only a single cup, have ever consumed only 6 ounces of coffee? A Tall at Starbucks is already 12 oz.

I have reproduced a portion of the table they included in the study below (but I have added in ‘brewed coffee’ based on their information, though it is left out of their actual table):



Ounces per bottle/can Caffeine Concentration (mg/oz) Total caffeine (mg)
Red Bull 8.3 9.6 80
Monster 16 10 160
Rockstar 16 10 160
Full Throttle 16 9 144
No Fear 16 10.9 174
Wired X505 24 21 505
Fixx 20 25 500
Coca Cola 12 2.9 34.5
Mountain Dew 12 4.5 54
Brewed Coffee 6 12.8 to 25 77 to 150

The first thing that probably strikes you is that 6 ounces (a very small cup) of coffee, can have nearly twice the caffeine as Red Bull! And it can have about equivalent to a standard 16 oz can of Monster or Rockstar, the other popular energy drinks. The actual concentration for brewed coffee is more than any standard caffeinated drink, so it seems to me slightly disingenous and misleading to use it as an example of something with less caffeine.

And what about the huge volumes they mention (up to 505 mg, or 14 cans of Coke)? Well, those are in drinks known as Wired X505 and Fixx. Ever heard of them? Neither have I. So while nobody could actually disagree about the fact that numbers are true for them, they in no way represent the norm for energy drinks.

For more details on Starbucks (which I am using as representative of mainstream coffee shops) as well in tea (which people often bring up in caffeine conversations), I have produced portions of tables available at the Energy Fiend site. They are their “caffeine database6” and “the complete guide to Starbucks coffee7“:

Drink drink ounces concentration (mg/oz) total caffeine (mg)
Starbucks Brewed Coffee (Tall) 12 21.6 260
Starbucks Brewed Coffee (Grande) 16 20.625 330
Starbucks Brewed Coffee (Venti) 20 20.75 415
Latte (Tall) 12 6.25 75
Latte (Grande/Venti) 16/20 9.375/7.5 150
Coca Cola 33 (1 liter) 2.9 95.7
Tea (Brewed) 8 3.1 47
Tea (Green) 8 3.1 25
Tea (Brewed, Imported) 8 7.5 60

If you compare this to the previous table, you’ll find that Starbucks brewed coffees (as with any brewed coffee) just blow energy drinks (except for the crazy 500 mg ones) out of the water. Espresso/latte is of approximately the same concentration and amount as standard energy drinks.

I have combined these tables and produced a chart which hopefully makes the comparison even more obvious

Caffeine Content of Popular Drinks

Continuing from the same study, with regards to caffeine toxicity8:

Concern regarding the caffeine content of energy drinks is prompted by the potential adverse consequences of caffeine use. One such adverse effect is caffeine intoxication, a recognized clinical syndrome included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) and theWorld Health Organization’s International Classification of Diseases(ICD-10)(American Psychiatric Association,1994;World Health Organization, 1992a,b). Caffeine toxicity is defined by specific symptoms that emerge as a direct result of caffeine consumption. Common features of caffeine intoxication include nervousness, anxiety, restlessness, insomnia, gastrointestinal upset, tremors, tachycardia, psychomotor agitation (American Psychiatric Association, 1994) and in rare cases, death (Garriott etal.,1985;Kerrigan and Lindsey,2005;Mrvosetal.,1989).The symptoms of caffeine intoxication can mimic those of anxiety and other mood disorders (Greden, 1974).The consumption of energy drinks may increase the risk for caffeine overdose in caffeine abstainers as well as habitual consumers of caffeine from coffee,soft drinks, and tea.

Basically, caffeine can make you hyper and could also have some other negative effects in same cases. So in this case energy drinks are not the culprit here any more (and in fact less in many cases) than other frequently consumed caffeinated beverages.

The full cite for the Garriott study referenced above is: Garriott, J.C., Simmons, L.M., Poklis, A., Mackell, M.A., 1985. Five cases of fatal overdose from caffeine-containing “look-alike” drugs. J. Anal. Toxicol. 9, 141–143

From the abstract9:

Five cases of death from ingestion of “look-alike” dose forms are reported. “Look-alikes” are widely used non-prescription drugs sold as appetite suppressants or stimulants. Three of the cases had taken caffeine/ephedrine combinations, and two had taken caffeine only. All had lethal concentrations of caffeine detected in the blood (130 to 344 mg/L), and three had high ephedrine concentrations from 3.5 to 20.5 mg/L. Caffeine and ephedrine were measured in body fluids and tissues (when available) by SIM gas chromatography/mass spectrometry (GC/MS) after extraction with diethyl ether.

So in these already rare cases, 3 were because they had taken ephedrine along with the caffeine and the other two had taken lethal level doses of caffeine. In other words, they did not just have a Red Bull and die.

And finally (from the Ressig study above):

The absence of regulatory oversight has resulted in aggressive marketing of energy drinks, targeted primarily toward young males, for psychoactive, performance-enhancing and stimulant drug effects. There are increasing reports of caffeine intoxication from energy drinks, and it seems likely that problems with caffeine dependence and withdrawal will also increase.
One limitation of the present review is that the great majority of the knowledge about caffeine intoxication, withdrawal, and dependenceis derived from studies of coffee consumption. However, studies that have examined these phenomena in the context of caffeine delivered via soft drinks or capsules have shown similar results (e.g. Juliano and Griffiths, 2004; Strain et al., 1994).
Thus, there is no reason to suppose that delivery of caffeine via energy drinks would appreciably alter these processes.

Drinking too much caffeine can be bad, regardless of its source. My can of Monster actually contains the warning:

Consume responsibly – Limit (3) cans per day. Not recommended for children, pregnant women or people sensitive to caffeine.

Lest you think that the only thing beneficial from caffeine is the energy boost, a WebMD article has the following10:

After analyzing data on 126,000 people for as long as 18 years, Harvard researchers calculate that compared with not partaking in America’s favorite morning drink, downing one to three cups of caffeinated coffee daily can reduce diabetes risk by single digits. But having six cups or more each day slashed men’s risk by 54% and women’s by 30% over java avoiders.

In recent decades, some 19,000 studies have been done examining coffee’s impact on health. And for the most part, their results are as pleasing as a gulp of freshly brewed Breakfast Blend for the 108 million Americans who routinely enjoy this traditionally morning — and increasingly daylong — ritual. In practical terms, regular coffee drinkers include the majority of U.S. adults and a growing number of children.

Overall, the research shows that coffee is far more healthful than it is harmful,” says Tomas DePaulis, PhD, research scientist at Vanderbilt University’s Institute for Coffee Studies, which conducts its own medical research and tracks coffee studies from around the world. “For most people, very little bad comes from drinking it, but a lot of good.”

Consider this: At least six studies indicate that people who drink coffee on a regular basis are up to 80% less likely to develop Parkinson’s, with three showing the more they drink, the lower the risk. Other research shows that compared to not drinking coffee, at least two cups daily can translate to a 25% reduced risk of colon cancer, an 80% drop in liver cirrhosis risk, and nearly half the risk of gallstones.

Summary

Energy drinks contain caffeine in varying numbers. If your goal is to get a boost of energy, they are one path to that. But coffee is actually a much “better” source of caffeine to get the extra kick. The average energy drink does contain a good amount more caffeine (4-5x) than the average soft drink (Coke, Pepsi, etc). So they are somewhere in the middle. So if the argument you are making or are hearing is that energy drinks represent “worse” caffeine levels than anything else, the argument really does not hold water.

The many thousands of Americans who start their day in a coffee shop are getting as much or more caffeine than those who start their day with an energy drink such as Red Bull or Monster. The high-caffeine (400+ mg) energy drinks do exist, but it is my view that they don’t represent the mainstream assuming you can even locate them.

In terms of the the caffeine itself, there have been medical studies demonstrating that it can raise your heart rate and make you restless or anxious and in extremely rare cases of high doses, lead to death. It has also been shown to be very beneficial for helping to prevent some diseases. So partake wisely.


Claim 2: Energy Drinks have significantly higher levels of sugar than other drinks

Sample claims

Somewhat surprisingly, I found it difficult to find many popular articles addressing the sugar content in energy. One of the few that I happened to see is from the previously mentioned sixwise.com “6 Dangers of Energy Drinks” article:

Dependence

Energy drinks contain a lot of sugar (at least 7 teaspoons for each can)

So I guess suffice to say is that the claim is that energy drinks have a lot of sugar.

What the science says

There isn’t much to dispute here. Non-diet energy drinks contain similar concentrations of sugar as other standard soft drinks.

I have reproduced a portion of another table from the ever-useful “Energy Fiend” site11:

Drink Ounces Sugar Grams g/oz
Cherry Coke 12 42 3.50
Chocolate Milk 8 24 3.00
Clearly Canadian daily ENERGY 20 30 1.50
Club-Mate 16.9 27 1.60
Coca-Cola Blak 8 12 1.50
Coca-Cola C2 12 18 1.50
Coca-Cola caffeine free 8 27 3.38
Coca-Cola Classic 12 40.5 3.38
Cocaine Energy Drink 8.4 18 2.14
Monster 16 54 3.38
Monster Lo-Carb 16.9 7 0.41
Red Bull 8.46 27 3.19
Rockstar 16 62 3.88
Starbucks Bottled Frappucino 9.5 33 3.47
Starbucks Double Shot 6.5 17 2.62
Starbucks Grande Caffe Latte 16 20 1.25

Assuming this table is accurate, energy drinks are about average when compared to Coke or even bottled Frappucino. An individual can of Monster will have more sugar due to its higher volume, but the concentration is the side (i.e. someone having a liter bottle of Coke would actually get more caffeine than from a standard can of Monster).

There is also interesting diagram of calorie and sugar content of different drinks available at http://www.flickr.com/photos/25541021@N00/3770804689/sizes/o/

Summary

Energy drinks have about the same sugar by volume as other soft drinks. Because most energy drinks (other than Red Bull) come in 16 oz cans, an actual can will tend to have more actual sugar than a can of Coke or Pepsi.. So if sugar is your worry, then you can have the sugar-free versions (the “dangers” of which I will address in a later article), which is the path I tend to take.

In other words, it is not true that energy drinks contain significantly more energy then other soft drinks. The effects of too much sugar are well known and I don’t see any reason to go into them here.


Claim 3: The “herbal” and otherwise mysterious ingredients in energy drinks have unknown side effects

Sample Claims

From ezinearticles.com’s “The Dangers of Energy Drinks” (emphasis my own)12:

The problem with many of these energy drinks is not what you know is in them but what you don’t know or aren’t familiar with. While one of the most common ingredients in energy drinks is caffeine, this is only the tip of the iceberg as far as problems go … But what about the other common ingredients in energy drinks, the ones you probably never heard of? We are just beginning to learn of the problems associated with some of these ingredients, especially when mixed with other things, such as drugs.

To give you an example of what I am talking about, guarana, which is a very popular ingredient in many energy drinks, is a central nervous system stimulant. What you don’t know is that consuming these drinks and then mixing them with drinks containing ephedrine or diet pills can be very dangerous.

Another popular ingredient in energy drinks is taurine, which is actually something that we naturally get from foods that contain vitamin B6. We normally get more than enough taurine in our diet and the extra amount that we get from these energy drinks, depending on how much we consume, can become toxic in our systems.

But even worse than what we know about the ingredients in these energy drinks that can be harmful, especially if mixed with other items, is what we don’t know. The FDA has all but admitted that many of the ingredients in most popular energy drinks have not been fully tested as to their degree of “safeness.” This is not to say that these ingredients are good or bad, simply that we don’t know. When you combine these factors with what we do know, that caffeine and some ingredients in these energy drinks can be harmful, it is almost like playing Russian Roulette with a fully loaded revolver to your head, especially if you’re like most people who consume energy drinks. It is common knowledge that most energy drink consumers are not casual users and consume large quantities of these drinks. This fact just makes the consumption of these drinks that much more dangerous.

The article is somewhat balanced, but the writer does something misleading by talking about guarana and then immediately going into caffeine dangers, which I guess is supposed to lead us to make a connection between the two.

It seems a bit unfair to bring up ephedrine and diet pills in combination of energy drinks, as they are dangerous even without mixing them with drinks. I believe they are referring to the incidents (mention in the caffeine section) of 3 people dying after having consuming a lot of diet pills mixed with caffeine. That same study mentions the 2 deaths where were reported to be exclusively from a large amount of caffeine.

And from a blog called Global Healing Center, an entry entitled “The Health Dangers of Energy Drinks13:

My main concern with the use of the herbs in these drinks is their source. The mass manufacturers of energy drinks are not required by law to list whether or not the herbs they use, have been sprayed with toxic pesticides, irradiated or watered with contaminated water supplies, so there is no telling what other toxins are contained in these drinks and whether or not these herbs will have a negative effect on the body.”

“The bottom line concerning energy drinks is that medical professionals simply do not know the long-term effects of consuming these beverages. It is known, however, that large amounts of sugar and caffeine are harmful to our bodies. For people to utilize energy drinks during exercise or other strenuous activity compounds the problem of dehydration, and does nothing to provide the body with any necessary nutrients or fluids.”

It’s hard to comment on this specifically as the entire “argument” is “eh, we dunno… they might or might not be dangerous, so you should be afraid of them”. We already know you shouldn’t take vast quantities of caffeine and sugar. But it doesn’t require energy drinks to do that, just use common sense.

What the science says

Addressing this is made somewhat more difficult by the fact that most of the actual scientific articles sounds remarkably like the claims above. Namely, the main gist is “we don’t know” what the effects of guarana, etc are but express a general sense of dis-ease about them.

From the previously quoted Reissig et al study14:

The main active ingredient in energy drinks is caffeine, although other substances such as taurine, riboflavin, pyridoxine, nicotinamide, other B vitamins, and various herbal derivatives are also present (Aranda and Morlock, 2006). The acute and long-term effects resulting from excessive and chronic consumption of these additives alone and in combination with caffeine are not fully known

But a much less wish-washy conclusion can be found in the 2008 study “Safety Issues Associated With Commercially Available Energy Drinks“, published in the Journal of the American Pharmacists Association, which concluded15:

Conclusion: The amounts of guarana, taurine, and ginseng found in popular energy drinks are far below the amounts expected to deliver either therapeutic benefits or adverse events. However, caffeine and sugar are present in amounts known to cause a variety of adverse health effects.

The approach I will take is to try to take each of the ingredients in turn, and see if there are any known dangers of them or what their purpose is.

Ingredients of example energy drink (Monster Lo-Carb in this case)

I have highlighted in orange the chemicals brought up in the “claim” section.
  • acesulfame potassium41 [Wikipedia link]
    • Another non-caloric sweetener (aka Acesulfame K)
    • See the reference for the 5th bullet on sucralose for safety studies
  • sodium chloride
    • Standard table salt (NaCl)
  • glucuronolactone
    • Considered one of the “active” ingredients in energy drinks (along with caffeine and taurine)
    • It’s unclear to me what it is exact function is, but it might be a stimulant (apparently it’s part of what produces a “high” feeling with tea)
    • It’s mentioned specifically in studies that looked42 at the efficacy43 of energy drinks.
  • inositol (most likely myo-inositol)
  • guarana46 [Wikipedia link]
  • seed extract (presumably grapefruit) [Wikipedia link]
  • pyridoxine hydrochloride51 [Wikipedia link]
    • A version of vitamin B6 (about 4mg in 16oz can)
    • Helps promote red blood cell production
    • Most comes from milk and meat products
    • Most beneficial at levels between 101 and 150 mg, but at chronic daily levels starting at 200mg (50 cans) but really around 1000 mg (250 cans) can cause temporary sensory and nerve damage52.
      • So to directly address the original claim… yes this can be “toxic” but only in very very large doses.
      • There was a study that claimed doses of 10mg could be dangerous, but this study has been discredited
  • riboflavin53 [Wikipedia link]
    • A version of vitamin B2 (about 4mg in 16oz can)
    • Common in milk, cheese, leafy green vegetables, liver, kidneys, soybeans, yeast, almonds
    • Not very fat soluble, so not toxic via ingestion (unabsorbed amounts over 20mg or so come out as bright yellow urine)
  • maltodextrin54 [Wikipedia link]
  • cyanocobalamin56 [Wikipedia link]
So that’s that… it does not appear that any of these would represent some shocking health hazard based on the science. Some of them in very large levels could prove toxic, but the same can be said of anything including water. In the cases of things like guarana and taurine, the study above found that most likely the levels (regardless of the potential benefits of the chemical itself) in energy drinks are not high enough to have any noticeable effect.
There was an additional claim about pesticides in the herbal ingredients or them being watered with toxic water. This is one of those that is difficult to address because it is simply thrown out there as a “what if!?” hypothetical. So on that note I will leave it for a later essay devoted to pesticides (kind of a cop out I suppose, but I think it would take quite a bit more time to find any evidence either way).

Summary

Hard to say here. I did not find anything in the research about the ingredients that would lead me to believe they are dangerous (especially in the levels in an energy drink). In fact, most are more beneficial than I was aware of. And this is without actually attempting to specifically look for benefits of the ingredients or energy drinks in general. It does seem true that the “long term” effects of the full complement of ingredients has not been done, but I don’t know that it is seen as being warranted by the scientific community. Red Bull was introduced in Austria in the late 80s, so that could be the place to look.
For the cases where the original claim said that some of the herbal and amino acid ingredients could become toxic, the levels are significantly higher than a person could reasonably consume in a day via energy drinks. For taurine specifically, it is a damn crucial chemical!


Claim 4: The dangers increase when mixed with alcohol

Sample Claims

From the sixwise article mentioned previously:

Heart Failure

Energy drinks are commonly used as mixers for alcoholic drinks in bars and nightclubs, and there are now new pre-mixed alcoholic energy drinks on the market.

The dangerous combination of mixing energy drinks, a stimulant, with alcohol, a depressant, has proven deadly. “It is scary to think that these energy drinks are being used as a mixer with vodka and whiskey,” said David Pearson, a researcher in the Human Performance Laboratory at Ball State University. “You are just overloading the body with heavy stimulants and heavy depressants.” The resulting mix can lead to cardiopulmonary and cardiovascular failure.

What the science says

Also again from the Reissig article mentioned above in the section on caffeine, but this time relating to alcohol consumption:

There is an association between the heavy use of caffeine and the heavy use of alcohol (Istvan and Matarazzo,1984;Kozlowski et al., 1993), and the ingestion of energy drinks in combination with alcohol is becoming increasingly popular (O’Brien et al.2008; Oteri et al., 2007), with 24% of a large stratified sample of college students reporting such consumption within the past 30 days (O’Brien et al., 2008). In the previously mentioned survey of 496 college students, 27% reported mixing alcohol and energy drinks in the past month. Of those that mixed energy drinks and alcohol, 49% used more than three energy drinks per occasion when doing so (Malinauskas et al., 2007). In a survey of 1253 college students, energy drink users were disproportionately male and consumed alcohol more frequently than non-energy drink users (Arria et al., 2008)

And from a 2006 study “Effects of Energy Drink Ingestion on Alcohol Intoxication” which looked to see if energy drinks actually had any effect on the intoxication (versus perception of intoxication)58:

Conclusions: Even though the subjective perceptions of some symptoms of alcohol intoxication were less intense after the combined ingestion of the alcohol plus energy drink, these effects were not detected in objective measures of motor coordination and visual reaction time, as well as on the breath alcohol concentration.

And from the discussion section (emphasis my own):

Riesselmann et al. (1996) suggested that users of alcohol plus energy drinks might have their judgment affected by the reduced subjective sensation of intoxication, thus increasing the probability of their becoming involved in accidents after the combined ingestion of these drinks. Besides, the increase in the alcohol palatability reported by many users of energy drinks could lead youth toward a higher consumption of alcoholic beverages

The Riesselmann study referenced above appears to be of single case study of a DUI in Germany
From the abstract (PubMed translation of the original German)59:

In the case discussed here-both the 20-year-old car driver and his passenger suffered not inconsiderable injuries-an alcohol concentration of 1.2 per mille was found at the time a blood sample was taken. Furthermore, a caffeine content of 1.5 micrograms/ml was noted. A value also reached after drinking a cup of filter coffee. In contrast, values of 2 to 10 micrograms/ml are reached when caffeine is used for therapeutic purposes. Values of more than 15 micrograms/ml are considered toxic. The measured caffeine content was thus fully insignificant. The same also applies to the “active ingredients” (taurine, glucuronolactone) contained in the beverage “Red Bull”. Another assumption that, namely, the effect of alcohol can be offset by such beverages could lead to a situation in which young people incorrectly assess their ability to drive after imbibing alcohol and fitness drinks.

The 1.2 per mill, would correspond to .12 per cent, certainly over the legal limit but not ridiculously so.

So the general idea here is that if you consume some number of energy drinks with alcohol, you will feel less impaired than you actually are and so might either consume more alcohol or otherwise make dangerous decisions (DUI).

I suspect the majority of energy drink consumption is not in combination with alcohol and that generally the alcohol will be in larger volumes than in this test. But that is purely my own conjecture.

Summary

This seems to be scientifically valid concern (though to what extent it is not clear). If you are going to consume energy drinks with alcohol, be aware that your subjective experience of “being drunk” may be affected. Granted, once you have reached a certain point in your alcohol consumption that ability to judge will go out the window anyhow. I think the danger is more going to be at those borderline (~.10%) cases where the person is not ridiculously drunk but is in the range of DUI.

 


Claim 5: Energy drinks destroy your teeth

Sample Claims

From the “Quality Health” article referenced above:

Dental decay. A study published in the journal General Dentistry revealed that high energy drinks have the potential to erode tooth enamel more than other drinks we’re usually     warned about such as sodas, sports drinks and root beer.

And from the “Yale-New Haven Children Hospital” general info site60:

According to the study cited in General Dentistry, the Academy of General Dentistry’s clinical, peer-reviewed journal, enamel damage caused by non-cola andsports beverages was 3 to 11 times greater than cola-based drinks.

A study by the University of Maryland revealed that regular long-term use of these beverages may cause irreversible damage to dental enamel – the thin, outer layer that helps preserve the tooth’s structure and prevent decay.”

Lead author Dr. Anthony von Fraunhofer, professor of biomaterials science at the University of Maryland Dental School, exposed tooth enamel from cavity-free molars and premolars to a variety of popular sports beverages including energy drinks, fitness waterand sports drinks and cola and non-cola beverages – such as bottled lemonade and canned iced tea. The tooth enamel was steeped in the drinks for a total of 14 days, and weighed every 24 to 48 hours. The solution’s acidity was checked, and solutions were changed daily. The exposure timewas intended to simulate the effects of normal beverage consumption over about 13 years.


While all the drinks produced some enamel damage, von Fraunhofer found the most wear occurred, in descending order, from lemonade, energy drinks, sports drinks, fitness water (often with citrus flavors), ice tea and cola. Von Fraunhofer said most cola drinks contain acids, but energy and sport drinks also contain other organic acids that can speed up damage to the enamel.

To be balanced, they also include a response to that study:

“The study from Maryland uses an experimental approach that takes the tooth out of the mouth and uses a non-real-world situation to see if beverages have an impact on tooth weight,” said Craig Horswill, senior research fellow at the Gatorade Sports Science Institute. He pointed to another study, published in the European journal Caries Research in 2002, that found no relationship between sports-drink consumption and dental erosion in more than 300 athletes.

What the science says

The study being referenced is:
von Fraunhofer JA, Rogers MM. Effects of sports drinks and other beverages on dental enamel. Gen Dent. 2005 Jan-Feb;53(1):28-31. PubMed PMID: 15779219.

From the actual study summary61:

Enamel dissolution occurred in all of the tested beverages, with far greater attack occurring in flavored and energy (sports) drinks than previously noted for water and cola drinks. No correlation was found between enamel dissolution and beverage pH. Non-cola drinks, commercial lemonades, and energy/sports drinks showed the most aggressive dissolution effect on dental enamel. Reduced residence times of beverages in the mouth by salivary clearance or rinsing would appear to be beneficial.

I found it interesting that actually lemonade was the worst of the bunch. The response above should also be noted (taking into account that the guy is from the “Gatorade Sports Science Institute”) that in the real-world, your teeth are not bathed continuously in the drink for 14 days days (this type of study is known as an “in vitro” study), and that at least one other study has actually found no relationship in the world world with tooth decay by sports drinks.

Furthermore, although there is much in vitro evidence that acidic drinks such as wine, fruit juices and carbonated soft drinks have erosive potential and there are relationships between consumption of these drinks and erosion, only one study has reported an association between sports drinks and dental erosion. Other factors such as drinking habit and salivary production may be more important determinants of dental erosion.

Basically, this one in vitro study has found a dental erosion correlation, but when looking at actual people there isn’t much there.

Summary

This one seems somewhat inconclusive. Basically, studies testing direct bathing of teeth in energy and sports drinks show tooth decay. Evaluations of actual do not appear to relate equivalent amounts of decay due to other factors. So, swallow regularly I suppose.


Conclusion

As part of my research, I was not looking to prove that energy drinks were “good” for you, only that they were not as bad as some people claim. The look into the ingredients did have the side effect of definitely making want to continue drinking them (even if the quantities of the ingredients might not be enough to offer their claimed benefit). In any case, it seems unfair to say that they are any worse than the beverages (coffee, soda, etc) consumed by the same people making the claim the energy drinks represent something akin to a narcotic. And depending on which axis their claim is about (i.e. caffeine levels, sugar, acidity, etc), energy drinks are actually better/lower than commonly consumed drinks that are considered more mainstream, such as a coffee from Starbucks or a Coke. Unless all you drink is water…

In a sense, even the naysayers have been swayed by the marketing (“it gives you wings!”) into believing that energy drinks are full of mysterious substances wreaking havoc on the body. The claims don’t appear to me to hold much water and in some cases are exactly the opposite as claimed. I’m going to continue to drink my much-loved Monster Lo-Carb with knowledge that soft drinks in general are not the best thing in the world, but that energy drinks are really no worse.

The reader can decide if they agree with my conclusions.

References

1 http://quay.wordpress.com/2009/11/03/a-response-to-some-vaccination-concerns/ My previous article about anti-vaccination claims.

2 http://www.qualityhealth.com/dieting-articles/dangers-energy-drinks – Quality Health’s “Dangers of Energy drinks”. Visited November 8, 2009

3 http://www.qualityhealth.com/dieting-articles/dangers-energy-drinks See above.

4 http://www.sixwise.com/Newsletters/2008/October/31/The-6-Top-Dangers-of-Energy-Drinks.htm – The 6 Top Dangers of Energy Drinks, and 5 Healthy Energy-Boosting Alternatives. Visited November 8, 2009

5 http://74.125.155.132/scholar?q=cache:V83mdSTMd4QJ:scholar.google.com/+author:griffiths+%22Drug+and+Alcohol+Dependence%22&hl=en Reissig, C.J., et al., Caffeinated energy drinks-A growing problem. Drug and Alcohol Dependency (2008).

6 http://www.energyfiend.com/the-caffeine-database Energy Fiend “caffeine database” list of caffeine content of popular drinks

7 http://www.energyfiend.com/2007/10/the-complete-guide-to-starbucks-caffeine Energy Fiend guide to Starbucks coffee

8 http://74.125.155.132/scholar?q=cache:V83mdSTMd4QJ:scholar.google.com/+author:griffiths+%22Drug+and+Alcohol+Dependence%22&hl=en Ressig et al (see previous footnoets)

9 http://www.ncbi.nlm.nih.gov/pubmed/4010239 Garriott, J.C., Simmons, L.M., Poklis, A., Mackell, M.A., 1985. Five cases of fatal overdose from caffeine-containing “look-alike” drugs. J. Anal. Toxicol. 9, 141–143

10 http://men.webmd.com/features/coffee-new-health-food Visited November 8, 2009.

11 http://www.energyfiend.com/sugar-in-drinks Energy Fiend table of sugar levels.

12 http://ezinearticles.com/?Dangers-Of-Energy-Drinks&id=501337 e-zine article with claims about energy drinks

13 http://www.globalhealingcenter.com/natural-health/the-health-dangers-of-energy-drinks/ Blog entry called “The Health Dangers of Energy Drinks”

14 http://74.125.155.132/scholar?q=cache:V83mdSTMd4QJ:scholar.google.com/+author:griffiths+%22Drug+and+Alcohol+Dependence%22&hl=en

15 http://www.medscape.com/viewarticle/583831

Kevin A. Clauson; Kelly M. Shields; Cydney E. McQueen; Nikki Persad. Safety Issues Associated With Commercially Available Energy Drinks. Published: 11/24/2008

16 http://www3.interscience.wiley.com/journal/118653682/abstract – Human enamel erosion in constant composition citric acid solutions as a function of degree of saturation with respect to hydroxyapatite

17 http://www3.interscience.wiley.com/journal/121677439/abstract “Taurine deficiency is a cause of vigabatrin-induced retinal phototoxicity”

18 http://www.mjn.com/app/iwp/HCP/Content2.do?dm=mj&id=/HCP_Home/Product_Information/Product_Descriptions/EnfamilProSobeeLIPIL&iwpst=B2C&ls=0&csred=1&r=3435187961 – Enamfily ProSobee description

19 http://www.ncbi.nlm.nih.gov/pubmed/3909770 “Taurine: Its biologic role and implications”

20 http://www.ncbi.nlm.nih.gov/pubmed/3251249 Ferko AP, Bobyock E. Effect of taurine on ethanol-induced sleep time in mice

genetically bred for differences in ethanol sensitivity. Pharmacol Biochem Behav.

1988 Nov;31(3):667-73. PubMed PMID: 3251249.

21 http://www.anyvitamins.com/taurine-info.htm#Best%20used%20with – Anyvitamins.com notes on Taurine

22 http://ec.europa.eu/food/fs/sc/scf/out22_en.html European Union, Scientific Community on Food. “Opinion on Caffeine, Taurine and D-Glucurono – g -Lactone as constituents of so-called “energy” drinks”. 1999 – This is actually a pretty interesting article, which seems to have been written in with a similar goal to mine to address concerns.

23 http://www.alkaseltzer.com/as/as_original.html – Alka Seltzer (for sodium citrate)

24 http://www.ncbi.nlm.nih.gov/pubmed/6892267  Banerjee U, Izquierdo JA. Antistress and antifatigue properties of Panax

ginseng: comparison with piracetam. Acta Physiol Lat Am. 1982;32(4):277-85.

PubMed PMID: 6892267.

25 http://www.jstage.jst.go.jp/article/jphs/93/4/458/_pdf Rai Deepak et al. Anti-stress Effects of Ginkgo biloba and Panax ginseng: a Comparative

Study. Journal of Pharmacological Society. 93, 458 – 464 (2003)

26 http://en.wikipedia.org/wiki/Sorbic_acid

27 http://dermnetnz.org/reactions/contact-urticaria.html  Contact reaction (with reference to sorbic acid)

28 http://care.diabetesjournals.org/content/19/9/1004.abstract N H Mezitis. Glycemic effect of a single high oral dose of the novel sweetener sucralose in patients with diabetes. Diabetes Care September 1996 vol.19 no. 9 1004-1005 doi: 10.2337/diacare.19.9.1004

29 http://dx.doi.org/10.1016/S0278-6915(00)00029-6 S. W. Manna. A combined chronic toxicity/carcinogenicity study of sucralose in Sprague–Dawley rats. Food and Chemical Toxicology Volume 38, Supplement 2, July 2000, Pages 71-89

30 http://www.shac.net/HLS/research_papers/Paper%204%20-%20HLS%20sucralose%20mice%20and%20monkeys.pdf    Neurotoxicity Studies on Sucralose and its Hydrolysis Products with Special Reference to Histopathologic and Ultrastructural Changes

31 http://www3.interscience.wiley.com/cgi-bin/fulltext/118607158/PDFSTART (see section called “Sucralose”). Manfred Kroger et al. Low-calorie Sweeteners and Other Sugar Substitutes: A Review of the Safety Issues. Volume 5 Issue 2. pp35-47.

32 http://dx.doi.org/10.1111/j.1526-4610.2006.00543_1.x Rajendrakumar M. Patel. Popular Sweetner Sucralose as a Migraine Trigger. Headache: The Journal of Head and Face Pain. Vol 46. Issue 8.

33 http://en.wikipedia.org/wiki/Benzoic_acid

34 http://www.inchem.org/documents/cicads/cicads/cicad26.htm#SectionNumber:6.1 CONCISE INTERNATIONAL CHEMICAL ASSESSMENT DOCUMENT NO. 26: BENZOIC ACID AND SODIUM BENZOATE. INTERNATIONAL PROGRAMME ON CHEMICAL SAFETY

35 http://www.inchem.org/documents/cicads/cicads/cicad26.htm#SectionNumber:11.1  (Same as above)

36 http://en.wikipedia.org/wiki/Carnitine#Food

37 http://www.ingentaconnect.com/content/adis/cpk/2003/00000042/00000011/art00002 Evans A.M.1; Fornasini G.2. Pharmacokinetics of L-Carnitine. Clinical Pharmacokinetics, Volume 42, Number 11, 2003 , pp. 941-967(27)

38 http://www.springerlink.com/content/k62135r76p0m716k/ l-Carnitine and the recovery from exhaustive endurance exercise: a randomised, double-blind, placebo-controlled trial

39 http://en.wikipedia.org/wiki/Nicotinamide aka Niacinamide

40 http://dx.doi.org/10.1007%2Fs001250051536 M. Knip et al. Safety of high-dose nicotinamide: a review. Diabetologia. Vol. 43, Number 11. Oct 2000. doi:10.1007/s001250051536. Full text available at http://www.springerlink.com/content/h18qd6rr27hxeljt/fulltext.pdf

41 http://en.wikipedia.org/wiki/Acesulfame_potassium

42 http://www.ncbi.nlm.nih.gov/pubmed/11310933 Horne JA, Reyner LA. Beneficial effects of an “energy drink” given to sleepy drivers. Amino Acids. 2001;20(1):83-9. PubMed PMID: 11310933.

43 http://www.ncbi.nlm.nih.gov/pubmed/11713623 Warburton DM, Bersellini E, Sweeney E. An evaluation of a caffeinated taurine drink on mood, memory and information processing in healthy volunteers without caffeine abstinence. Psychopharmacology (Berl). 2001 Nov;158(3):322-8. PubMed

PMID: 11713623.

44 http://www.ajcn.org/cgi/reprint/33/9/1954.pdf Myo-inositol content of common foods: development of a high-myo-inositol diet

45 http://www.ncbi.nlm.nih.gov/pubmed/8780431 Fux M, Levine J, Aviv A, Belmaker RH. Inositol treatment of

obsessive-compulsive disorder. Am J Psychiatry. 1996 Sep;153(9):1219-21. PubMed

PMID: 8780431.

46 http://en.wikipedia.org/wiki/Guarana

47 http://jop.sagepub.com/cgi/content/abstract/21/1/65

Haskell CF, Kennedy DO, Wesnes KA, Milne AL, Scholey AB (January 2007). “A double-blind, placebo-controlled, multi-dose evaluation of the acute behavioral effects of guaraná in humans”. J. Psychopharmacol. (Oxford) 21 (1): 65–70. doi:10.1177/0269881106063815. PMID 16533867

48 http://dx.doi.org/10.1016/S0378-8741(97)00141-4 R. Matteia,R. F. Diasb, E. B. Espínolab, E. A. Carlinia and S. B. M. Barrosc. “Guarana (Paullinia cupana): toxic behavioral effects in laboratory animals and antioxidant activity in vitro”. Journal of Ethnopharmacology. Vol 60. Issue 2. March 1998. pp111-116 From abstract.

49 http://www3.interscience.wiley.com/cgi-bin/abstract/10007270/ABSTRACT. Armando C, Maythe S, Beatriz NP (December 1997). “Antioxidant activity of grapefruit seed extract on vegetable oils”. Journal of the Science of Food and Agriculture 77 (4): 463–7. doi:10.1002/(SICI)1097-0010(199808)77:4<463::AID-JSFA62>3.0.CO;2-1.

50 http://dx.doi.org/10.1093%2Fcarcin%2Fbgi318 Vanamala J, Leonardi T, Patil BS, et al. (June 2006). “Suppression of colon carcinogenesis by bioactive compounds in grapefruit”. Carcinogenesis 27 (6): 1257–65. doi:10.1093/carcin/bgi318. PMID 16387741

51 http://en.wikipedia.org/wiki/Pyridoxine (for pyridoxine hydrochloride – B6)

52 http://www.orthomolecular.org/library/jom/2003/pdf/2003-v18n02-p065.pdf – Aliya N. Chaudary, Adam Porter-Blake. Patrick Holford. “Indices of Pyridoxine Levels on Symptoms Associated with Toxicity: A Retrospective Study”

53 http://en.wikipedia.org/wiki/Riboflavin

54 http://en.wikipedia.org/wiki/Maltodextrin

55 http://glutenfreeliving.com/ingredient.php#maltodextrin – Gluten Free Living site addressing fact that maltodextrin is gluten-free

56 http://en.wikipedia.org/wiki/Cyanocobalamin

57 http://bloodjournal.hematologylibrary.org/cgi/content/abstract/24/5/502 – BERNARD A. COOPER and LOUIS LOWENSTEIN. “Relative Folate Deficiency of Erythrocytes in Pernicious Anemia and its Correction with Cyanocobalamin”. Blood, 1964, Vol. 24, No. 5, pp. 502-521.

58 http://www.cepebr.org/PDF/artigos/23.pdf Sionaldo Eduardo Ferreira, Marco Túlio de Mello, Sabine  Pompéia, and Maria Lucia Oliveira de Souza-Formigoni. “Effects of Energy Drink Ingestion on Alcohol Intoxication.” ALCOHOLISM: CLINICAL AND EXPERIMENTAL RESEARCH. April 2006 Vol. 30, No. 4

59 http://www.ncbi.nlm.nih.gov/pubmed/8924273 Blutalkohol. 1996 Jul;33(4):201-8.

[Alcohol and energy drink–can combined consumption of both beverages modify automobile driving fitness?]

PMID: 8924273

60 http://www.ynhh.org/healthlink/pediatrics/pediatrics_07_06.html

61 http://www.ncbi.nlm.nih.gov/pubmed/15779219 – von Fraunhofer JA, Rogers MM. Effects of sports drinks and other beverages on dental enamel. Gen Dent. 2005 Jan-Feb;53(1):28-31. PubMed PMID: 15779219.

62 http://www.ncbi.nlm.nih.gov/pubmed/15973827 – Coombes JS.”Sports drinks and dental erosion”. Am J Dent. 2005 Apr;18(2):101-4.

Welcome, and a response to some anti-vaccination claims

Hi there. This is the first of what I hope to be a weeky or bi-weekly series of entries on what the science actually has to say about certain topics.

My intent is not to dissuade those who have already decided that some form of pseudo-science is true. Instead, I want to address those who for the most part believe that modern science is right, but have perhaps heard about a claim about a scientific topic and are curious about what the current scientific consensus is.

In essence… I try to debunk pseudoscience but realize I will not convince anyone who has already made their decision.

To get things started, I am linking to something I recently wrote on another of my blogs, which made me decide to start this one.

The article is a response to some anti-vaccination claims that were presented to me:

http://quay.wordpress.com/2009/11/03/a-response-to-some-vaccination-concerns/

I invite anybody to send questions or comments to wss@40two.org

And comments will be open on any posting.