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Supplement Article

Legitimacy of concerns about caffeine and energy

drink consumption
Nancy J Wesensten

Whether caffeine and energy drink consumption presents a critical emerging health
problem is not currently known. Available evidence suggests that energy drink
consumption represents a change in the ways in which individuals in the United
States consume caffeine but that the amount of caffeine consumed daily has not
appreciably increased. In the present review, the question of whether Americans are
sleep deprived (a potential reason for using caffeine) is briefly explored. Reported
rates of daily caffeine consumption (based on beverage formulation) and data
obtained from both civilian and military populations in the United States are
examined, the efficacy of ingredients other than caffeine in energy drinks is
discussed, and the safety and side effects of caffeine are addressed, including
whether evidence supports the contention that excessive caffeine/energy drink
consumption induces risky behavior. The available evidence suggests that the main
legitimate concern regarding caffeine and energy drink use is the potential negative
impact on sleep but that, otherwise, there is no cause for concern regarding caffeine
use in the general population.
Published 2014. This article is a U.S. Government work and is in the public domain in the USA.

INTRODUCTION
Over the past several years, there has been a rising
number of television and newspaper reports of a
so-called epidemic of energy drink use in the United
States; this has been supplemented by reports of energy
drink-related illnesses and deaths and concerns about
energy drink usage in vulnerable populations. The extent
to which such reports are evidence-based and reflect
legitimate concerns is unclear.
Perhaps the first question to ask is “Why are energy
drinks consumed?” The answer seems straightforward: to
increase energy. But what kind of energy is desired? Is it
physical energy (e.g., strength, endurance, stamina)? Is it
mental energy (e.g., alertness, mental acuity)? And what is
the purpose (e.g., to work longer, harder, or better; to play
longer and later into the night)? The answers to these
questions may reveal both the nature of the problem that
energy drink users wish to overcome and the extent to
which the use of energy drinks (or the caffeine that many
of them contain) represents an effective solution to the
problem.
The present review is focused on caffeine’s alertness-
enhancing effect as one reason for its use; investigations
of other reasons (e.g., improving mood or cognition) that
fall within the construct “mental energy” can be found
elsewhere.1 Numerous articles pertaining to the impact of
caffeine and energy drink use on physical performance
have been published recently.2–5 The use of caffeine and
caffeine-containing energy drinks to restore or maintain
alertness may reflect attempts to get by with insufficient
daily sleep and/or overcome the brain’s biological clock
(e.g., to stay awake during nighttime hours when alertness
is waning). These concerns are likely shared by a diverse
population group in terms of age, occupation, and other
demographics, but the present review is focused on the
adult US population (18 years of age or older), including
military personnel.

Affiliations: NJ Wesensten is with the Behavioral Biology Branch, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA.
Correspondence: NJ Wesensten, Behavioral Biology Branch – Room 2A–26, Walter Reed Army Institute of Research, 503 Robert Grant
Avenue, Silver Spring, MD 20910, USA. E-mail: Nancy.j.wesensten.civ@mail.mil.
Key words: alertness, caffeine, circadian rhythm, energy drinks, sleep

doi:10.1111/nure.12146
78 Nutrition Reviews® Vol. 72(S1):78–86
Daily reported sleep amounts
Do individuals in the United States suffer from a chronic
sleep debt that they attempt to override by using caffeine-
containing energy drinks to maintain alertness and mental
performance? There appears to be inconsistency in the
published literature regarding this issue.By some accounts
(for example, the United States Bureau of Labor and Sta-
tistics’ 2012 American Time Use Survey,6 average daily
sleep amounts, even on weekdays, appear to be within the
7−9 hours per 24 hours range that is currently recom-
mended by the United States National Heart, Lung, and
Blood Institute,7 which are also used in the recommenda-
tions of the United States Centers for Disease Control and
Prevention. Results from the 2012 American Time Use
Survey indicate that both men and women aged 15 years
and older reported obtaining at least 8 hours of sleep per
day (when averaged over all days of the week).6 However,
results from a poll conducted by the National Sleep Foun-
dation, when disaggregated along demographics such as
type of employment, indicate substantial sleep deficits in
certain populations – notably, shift workers who attempt
to sleep during the day.8 Results from another survey
disaggregated by age indicated that over 30% of adult
respondents aged 45 years or older reported sleeping 6 or
fewer hours per 24-hour period.9 In short, whether most
Americans obtain sufficient sleep or not appears to vary
depending on which survey results one considers.
Daily reported amounts of sleep in young adults
(who are thought to be the main consumers of energy
drinks) have received some attention. In a recent cross-
sectional questionnaire study of college students
(N = 561), respondents reported sleeping an average of
6.71 hours per night on weekdays and 8.30 hours per
night on weekends (weekly average, 7.16 h).10 The Spring
2013 National College Health Assessment (N = 123,078
respondents) included several items pertaining to sleep
quality and waking alertness (but not actual sleep
amounts).11 Few respondents indicated that they
obtained sufficient sleep to feel rested upon awakening on
6 or 7 nights per week (suggesting sleep debt). In contrast,
the percentage that reported having to go to bed on 4 or
more nights because they could not stay awake any longer
also was relatively low (20.07% total). Only 6.61% of
respondents reported that sleepiness was a problem
during daytime activities. These results appear to cor-
roborate those from Melton et al.,10 suggesting that sleep
debt among college students is mild (and possibly
restricted to weekdays).
Daily reported caffeine use
What is the evidence, if any, that daily caffeine consump-
tion is on the rise? Results from the 2001 through 2010
Nutrition Reviews® Vol. 72(S1):78–86
National Health and Nutrition Examination Surveys
(NHANES) indicated that caffeine use among those who
reported it remained relatively stable over that 10-year
period for most age groups except for 35–39 years.12 In
the latter age group, daily caffeine intake significantly
decreased by 19 mg from 2001 to 2010. For the period
2007–2010, average daily reported caffeine intake was just
under 150 mg for the 18–29 year age group, just over
200 mg for the 30–34 year group, just under 200 mg for
the 35–39 year group, just under 250 mg for the 40–49
year group, just over 250 mg for the 50–59 year group,
and just under 200 mg for those 60 years and older.
Results by percentile indicated that average reported daily
caffeine intake for those at the 90th percentile (i.e., highest
reported caffeine intake) also was highest in those 40–49
years of age (just under 500 mg) and those 50–59 years of
age (just over 500 mg). Average daily caffeine intake for
those at the 90th percentile was just over 300 mg for 18–29
year olds (young adults). Evaluation of the sources of
caffeine intake from the same NHANES data sets indi-
cated that the amounts of caffeine consumed from differ-
ent beverage types did not change significantly, except for
a small but statistically significant increase in the amount
of caffeine consumed in the form of energy drinks (1 mg
per 2-year survey cycle or approximately 0 mg in 2001 to
approximately 8 mg in 2010) and a statistically significant
decrease in caffeine consumed in the form of sodas
(approximately 55 mg in 2001 to just under 45 mg in
2010).Across all adult age groups, the main form in which
caffeine was consumed was coffee.
Results from a 2010–2011 large-scale (N = 37,604)
survey of caffeinated beverage intake (7-day diary)
among US consumers appeared comparable to the
NHANES data set, although direct comparisons are not
possible since different age ranges were used.13 For indi-
viduals in the 18–24 year age group, daily reported caf-
feine consumption was 122.1 mg; for the 25–34 year
group, daily reported caffeine consumption was
137.3 mg, which is approximately 60 mg lower than the
daily intake for the 30–34 year group from the NHANES
study. Similar to the NHANES results, the highest
amount of reported daily caffeine consumption was
found in the 50–64 year age group (225 mg/day). Con-
sumption was also reported as a function of product type
(see Fig. 1). Consistent with the NHANES results, for all
age groups the main form in which caffeine was con-
sumed was coffee. However, the amount of coffee relative
to other beverage types was lower in younger adults than
in older adults: for example, the 18–24 year age group
consumed an average of 60.1 mg of coffee per day,
31.4 mg caffeinated soda drinks per day, 23.1 mg tea per
day, and 6.2 mg energy drinks; in comparison, the 50-64
year age group consumed 158.6 mg coffee, 28.0 mg soda,
37.1 mg tea, and 1.3 mg energy drinks per day.
79
Figure 1 Reported daily caffeine use as a function of age
and caffeine formulation. Adapted from Mitchell et al.
(2014).13
Caffeine and energy drink use in the United
States military
Currently, no yearly survey of caffeine use is conducted
among the active-duty US military population. However,
some descriptive statistics are available from several dif-
ferent sources, one of which consists of in-theater (i.e., in
deployed troops) surveys conducted by the United States
Mental Health Advisory Teams. Such surveys are con-
ducted at the request of a given military branch’s senior
operational leadership and executed through the Office of
The Surgeon General of the Army with support from
military branch Command Surgeon Offices. In the most
recent survey, US Soldiers and Marines deployed in
support of Operation Enduring Freedom (Afghanistan
theatre of operations) completed a detailed survey that
included an item regarding energy drink use. Participants
were asked, “How many energy drinks (e.g., Red Bull,
Monster, 5-Hour Energy) do you use per day?” Possible
responses ranged from 0 to “5 or more” in one-integer
increments. Results are shown in Figure 2 (data from14).
The relationship between the percentage of individuals
reporting daily use and the reported number of energy
drinks consumed per day followed a saturating exponen-
tial function: the percentage reporting consumption of a
given number of energy drinks decreased as the number
of energy drinks increased. This pattern was evident
among junior enlisted (approximate age range, 18–24
years), senior enlisted (approximate age range, 25–39
years), and officer/warrant officer (approximate age
range, 28–46 years) personnel. Interestingly, 55.2% of all
respondents indicated that they used no energy drinks. It
is not clear whether this response means that these indi-
viduals used no caffeine at all, since the survey did not
contain additional questions about consumption of other
forms of caffeine (e.g., coffee, sodas).
80
Figure 2 Percentage of participants reporting daily
energy drink use as a function of reported number of
energy drinks consumed per day and military rank.
Adapted from Toblin et al. (2012).14
Jacobsen et al.15 described energy supplement use in
military volunteers participating in the 2007–2008 Mil-
lennium Cohort Study. The Millennium Cohort Study is
a longitudinal assessment of various health factors in
military members that was initiated in 2001 and is admin-
istered every 3–4 years. In the 2007 assessment, volun-
teers were asked whether they had taken energy
supplements such as energy drinks, pills, or energy-
enhancing herbs in the last 12 months. Odds ratios for
reporting energy supplement use were higher in the fol-
lowing groups: 1) men and women who reported less
than the recommended 7–8 h of sleep per night; 2) men
and women who also reported using body-building
supplements or weight-loss supplements; and 3) men and
women reporting trouble sleeping. Overall, the odds
ratios for reports of energy drink usage were slightly
higher among those who reported deployment experi-
ence, regardless of gender.
Lieberman et al.16 conducted a detailed caffeine use
survey of the active duty military population in 2007.
Their survey included a question listing 31 caffeine-
containing items (e.g., beverages, foods, dietary supple-
ments) and respondents reported the amount and
frequency of consumption. Respondents could also enter
caffeine-containing products that were not listed on the
survey. Total average daily caffeine consumption
(summed across all caffeine formulations) was 285 mg,
ingested mainly in the form of coffee (127 mg/day) and
energy drinks (79 mg/day). Total caffeine consumption
differed as a function of gender (males, 365 mg; females,
216 mg), race (other, 334 mg; white non-Hispanic,
318 mg; Hispanic, 280 mg; black non-Hispanic, 139 mg)
and tobacco use (current use, 421 mg; former use,
327 mg; never used, 190 mg). The amount of caffeine
Nutrition Reviews® Vol. 72(S1):78–86
ingested in various formulations differed by age group:
coffee consumption was higher in respondents aged 40
years or older (312 mg) compared to other age groups,
and the amount of caffeine consumed as “other soda” and
as “energy drink” was higher in respondents aged 18–24
years (42 mg and 120 mg, respectively) and 25–29 years
(36 mg and 125 mg, respectively) compared to older
respondents. The latter results correspond to those
reported above for a civilian population and suggest that
younger adults are more likely to consume their daily
caffeine via formulations other than coffee.
In sum, results from surveys of the US population
overall, as well as subgroups comprised mostly of young
adults (e.g., active duty military), indicate that the main
consumers of caffeine are not young adults but rather are
older adults over 40 years of age.
Other energy drink ingredients
The list of ingredients in energy drinks that are advertised
to confer some kind of benefit is daunting (even to sci-
entists and physicians). The most frequently listed are
caffeine, taurine, sugar, B-vitamins, and guarana (see table
1 in McLellan and Lieberman17). Which of these compo-
nents, if any, possesses demonstrated biological activity
that could be construed as conferring “energy”?
Caffeine. Caffeine leads the inventory of energy drink
ingredients – and with good reason: results from numer-
ous studies show that caffeine at dosages of 100 mg or
more improves neurobehavioral performance and alert-
ness, most notably under conditions of insufficient sleep
and at or near the circadian alertness trough.18 Although
caffeine exerts several biological actions, its neuro-
behavioral effects are mainly mediated via antagonism of
brain adenosine receptors (specifically, the A1 and A2A
receptor subtypes, with variants in the latter also playing
a role in caffeine sensitivity).19 As adenosine itself modu-
lates various neurotransmitter systems, antagonism of
adenosine receptors via caffeine administration poten-
tially affects neurophysiological systems that are involved
in neurobehavioral performance. Caffeine’s abuse liability
is relatively low compared to other psychostimulants,20
most likely because doses above approximately 300 mg
have been reported to cause side effects including nausea,
anxiety, jitteriness, heart palpitations, etc.21,22
Taurine. Taurine is an amino acid found naturally in
dairy, meat, and seafood. As reviewed by Mahoney and
Lieberman,23 limited results from animal model studies
suggest that taurine acts as a GABA receptor antagonist
and, thus, might be predicted to enhance learning and
memory, decrease anxiety, and improve mood, suggesting
a rationale for its inclusion in energy drinks. However,
Nutrition Reviews® Vol. 72(S1):78–86
evidence that taurine exerts any of these neurobehavioral
effects is notable for its absence. Results from several well-
controlled experiments (summarized by Mahoney and
Lieberman23) failed to demonstrate that taurine possesses
utility as an energy-enhancing compound.
B vitamins. Various combinations of the B vitamins (B1
thiamine, B2 riboflavin, B3 niacin, B5 pantothenic acid, B6
pyridoxine, B7 biotin, B9 folic acid, and B12 cobalamin) are
among the next most frequent constituents of energy
drinks. In their review of energy drink components,
McLellan and Lieberman17 determined the following:
“There is no experimental evidence showing that the
addition of multivitamins to a caffeinated energy drink
will cause greater improvements in physical and cognitive
performance than can be attributed to the effects of caf-
feine alone” (p. 736). A broad-based PubMed search
(“vitamin” AND [“cognitive performance”] OR [“neuro-
behavioral performance”] OR [“alertness”] OR [“mood”])
failed to reveal well-controlled, peer-reviewed reports of
studies in which an objectively measured benefit on
neurobehavioral performance was derived from admin-
istration of B vitamins in an otherwise healthy, adult
population.
In addition to the above constituents, energy drinks
contain various kinds of sugars. These contribute to the
overall caloric load but have no demonstrated
neurobehavioral-enhancing effects in healthy adults.
Safety of caffeine dose
Caffeine is arguably one of the most studied psychoactive
compounds, with literally thousands of articles published
to date regarding its side effect profile and safety. It is
beyond the scope of this article to comprehensively
review that literature; therefore, what follows is a brief
description of caffeine guidelines followed by a brief
overview of several publications in which caffeine’s side
effects are described.
The U.S. Food and Drug Administration (FDA)
draws a distinction between caffeine occurring naturally
in coffee and tea and caffeine as an additive to cola-type
beverages. In the former, caffeine is classified as GRAS
(generally recognized as safe) whereas for the latter, the
FDA indicated the following: “While no evidence in the
available information on caffeine demonstrates a hazard
to the public when it is used in cola type beverages at
levels that are now current and in the manner now
practiced, uncertainties exist requiring that additional
studies be conducted.”24 (The exact nature of the “uncer-
tainties” was not specified in the FDA report.) The
FDA lists 400 mg per day as the “amount not generally
associated with dangerous, negative effects.”25 This
amount is consistent with guidance from the World
81
Health Organization, which defines acute or chronic
“overuse” as a daily intake of caffeine of 500 mg or more;
adverse consequences are referred to as “caffeineism.”26 It
is not clear from the World Health Organization defini-
tion of “caffeinism” whether ingestion of caffeine at levels
at or above 500 mg that does not cause adverse effects
(i.e., caffeineism) is considered safe. The International
Classification of Diseases manual further lists caffeine as
a potential cause of mental and behavioral disorders,27
but specific caffeine amounts are not indicated, and it is
not clear whether “caffeinism” and caffeine as a potential
cause of mental or behavioral disorders are considered
synonymous. Several caffeine-related disorders are listed
in the most recent Diagnostic and Statistical Manual of
Mental Disorders (DSM-5), to include caffeine intoxica-
tion.28 The dose of caffeine causing intoxication is speci-
fied only as “typically a high dose well in excess of
250 mg.” Similarly, fatal doses of caffeine are specified
only as “extremely high.” Caffeine withdrawal is listed as a
separate disorder, with the dose unspecified other than
“caffeine withdrawal symptoms may occur after abrupt
cessation of relatively low chronic daily doses of caffeine
(i.e., 100 mg).”
A distinction (perhaps artificial) can be drawn
between caffeine’s effects on the central nervous system
(e.g., mood alterations to include increased anxiety –
briefly described below) and caffeine’s effects on the
peripheral (sympathetic) nervous system (blood pressure,
heart rate, and body temperature). Of these, caffeine’s
impact on cardiovascular function could, perhaps, be
considered the most likely to adversely affect safety
(although it is recognized that caffeine’s other effects may
negatively impact health in certain subpopulations; for
example its impact on blood glucose in diabetics29). In a
recently published meta-analysis, it was concluded that
caffeine at or above 400 mg does not increase risk of atrial
fibrillation.30 In another meta-analysis, caffeine at or
below 300 mg was determined to be safe even in those
with high blood pressure.31 These results corroborate
published guidelines described above regarding the gen-
erally good safety profile of caffeine at doses below
approximately 400 mg per day. Cases of caffeine overdose
have been reported in the open scientific literature,32,33
but such cases involved ingestion of caffeine doses far
exceeding the 400 mg cutoff (and generally exceeding
5 g). Although some overdoses resulted in death,34,35 indi-
viduals have survived overdoses as high as 50 g.36
Subjective side effects of caffeine
Whether caffeine’s subjective side effects pose a safety
hazard is perhaps debatable. Nonetheless, side effects are
widely reported, may impact objective performance, and
also serve as the basis for DSM-V diagnoses. Subjective
82
side effects evaluated in several select studies (in which
more than one dose level of caffeine was evaluated, thus
allowing for determination of dose-response effects) are
described below to illustrate those side effects commonly
resulting from caffeine use.
Side effects of caffeine in
non–sleep-deprived volunteers
Side effects of caffeine have been reported in studies of
non–sleep-deprived volunteers. In one such study, a
dose-dependent increase in reports of jitteriness/
nervousness/shakiness (caffeine doses = 0, 100, 200, 400,
and 600 mg) in non–sleep-deprived volunteers was
found, and even the lowest caffeine dose (100 mg) was
statistically different from placebo.37 Dose-dependent
effects also were found for ratings of “dislike effects,” but
the difference from placebo was significant only for the
400 and 600 mg doses. In another study of habitual
smokers, effects of repeatedly administering caffeine in an
ascending dose schedule (i.e., caffeine 200, 400, or
800 mg) were examined.38 In that study, one volunteer
experienced shakiness and an upset stomach after 200 mg
of caffeine and was therefore not tested at higher caffeine
doses. Caffeine was associated with a dose-dependent
increase in ratings of tension-anxiety that was statistically
significant from placebo for all three doses. In addition, a
scale associated with dysphoric and somatic symptoms
was dose-dependently increased, but only the 800 mg
dose was statistically significant from placebo. The
800 mg dose also significantly increased ratings on a scale
measuring general drug-induced euphoria, compared to
placebo. Because the volunteers were allowed to smoke
following caffeine consumption, it is possible that the
symptoms reported at high caffeine doses may have been
due to nicotine. No other adverse effects of caffeine at
800 mg were reported for any of the 5 study volunteers
who received all doses. Results from these studies indicate
that in non–sleep-deprived volunteers, doses of caffeine
that exceed the recommended daily total intake are gen-
erally well tolerated.
Side effects of caffeine in sleep-deprived volunteers
Because caffeine often is used to overcome sleepiness
associated with insufficient sleep, its impact on perfor-
mance and alertness in sleep-deprived individuals has
received much attention. Caffeine has been administered
in sleep-deprived volunteers in single bolus doses of up to
600 mg. In one such study, frequency of reports of anx-
iousness, irritability, jitteriness/nervousness, sleepiness,
talkativeness, pounding heart, headache, sweatiness, and
upset stomach following caffeine at doses of 150, 300, or
600 mg/70 kg body weight, administered after 48 h of
Nutrition Reviews® Vol. 72(S1):78–86
wakefulness; although the authors reported that these
effects showed a dose-dependent function, the minimal
caffeine dose at which these effects were found was not
reported.39 In another study, 600 mg of caffeine adminis-
tered following 41 hours of sleep deprivation resulted in
reports of pounding heart and nausea, and 2 of the 10
volunteers receiving the 600 mg dose vomited approxi-
mately 2 h after caffeine administration.21 Caffeine at
doses of 1.5–3.0 mg/kg (approximately 100–200 mg for
an average adult male) was associated with increased sys-
tolic and diastolic blood pressure, although neither was
raised by more than 6 mm/Hg, and all values were within
normal ranges (systolic below 140; diastolic below 90).
As noted above, in a portion of the numerous human
use caffeine studies published to date,volunteers who were
totally or partially sleep-deprived and ingested a bolus
(single) dose of up to 600 milligrams experienced no
serious adverse consequences and few nonserious side
effects. It is possible that this generally low rate of caffeine-
related adverse effects is a function of self-selection, with
those individuals who have experienced negative reactions
to caffeine choosing to not volunteer for participation in
studies involving caffeine administration. However,
although results from the literature available to date indi-
cate that, at doses up to 600 mg, caffeine causes few untow-
ard effects, the generally agreed upon safe upper limit of
daily caffeine dosing is 400 mg, likely ingested as several
smaller doses (e.g., 50–100 mg) across the day.
Association of caffeine with behavioral and other
health problems
To what extent is caffeine use, including that in energy
drinks, linked (most notably in a causal fashion) to behav-
ioral or other health problems? The answer is that there is
presently no evidence causally linking caffeine or energy
drink use to any behavioral or other health problem.
However, there is a growing amount of literature
linking insufficient sleep with behavioral and other health
problems. Over the past two decades, evidence that
chronic sleep disturbance is associated with mood disor-
ders,40 impaired immune function,41 age-related cognitive
decline,42 metabolic syndrome/obesity/diabetes,43 heart
disease,44 and even cancer45 has steadily accrued. Thus,
insufficient sleep is a more plausible cause of behavioral
and other health problems that, on the surface, appear to
be directly linked to energy drink/caffeine usage. For
example, Toblin et al.14 correlated the reported number of
energy drinks consumed per day with frequencies of
reporting that the following disrupted sleep on more than
50% of the past 30 nights (selection of one cause was not
mutually exclusive of others): 1) stress related to combat,
2) stress related to personal life and problems, 3) poor
sleep environment (too noisy, bright, hot, cold, etc.), 4)
Nutrition Reviews® Vol. 72(S1):78–86
high operational tempo, 5) nighttime duties, 6) off-duty
leisure activities (video games, movies, etc.), 7) illness, and
8) other. Of these eight causes of disrupted sleep, only
three (stress related to combat, stress related to personal
life, and illness) were reported as occurring on more than
50% of the past 30 nights by individuals who also
reported consuming 3 or more energy drinks per day.
Although it could be construed that the relationship was
causal in nature (i.e., that caffeine use disrupted sleep), an
equally likely explanation is that insufficient sleep
increased sleepiness, and that sleepiness was the driver of
both the caffeine use and reports of stress. It is possible,
depending on timing of caffeine use (discussed below),
that, as suggested by Toblin et al.,14 caffeine directly
impaired sleep. However, the timing of caffeine con-
sumption was not addressed in the MHAT survey; in fact,
such information is generally not collected in caffeine use
surveys although it is critical for determining the extent
to which caffeine use could be driving sleep disruption
(discussed further below).
It also has been reported that adolescents and young
adults who consume excessive amounts of energy drinks
also engage in other risky behaviors.46 Although it has
been hypothesized that excessive caffeine use causes risky
behavior, the most parsimonious explanation for this
relationship is that excessive energy drink use is simply
another manifestation of risk-taking expressed by indi-
viduals who are already predisposed to engage in risky
behaviors. Results from a January 201347 report from the
Drug Abuse Warning Network lend some support for the
latter hypothesis. That is, although the overall number of
emergency department visits related to energy drink use
increased from 10,068 visits in 2007 to 20,783 visits in
2011, almost half (8,652) were associated with another
psychoactive compound. Because it does not appear that
urine drug tests were conducted, it may be that the
number of energy drink–related visits associated with
other psychoactive compounds may be larger than that
reported. Consistent with other results showing that ado-
lescent males engage in more risk-taking behavior than
do older males and females of any age (which appears to
be at least partly explained by gender differences in brain
development48), results also showed that males and indi-
viduals aged 18–25 years comprised the bulk of energy
drink-related emergency department visits.
Caffeine’s impact on tasks that are purported to
measure aspects of risk-taking has received some atten-
tion. In one recently published study, volunteers were
administered alcohol only (0.5 g/kg), an energy drink
only (3.57 mL/kg; caffeine content not reported although
the authors indicated that Red Bull 250 mL/70 kg was
used), an alcohol-containing energy drink, or placebo.49
The researchers performed the computerized Balloon
Analogue Risk Task (“BART”) at 30 and 125 min post-
83
administration. The BART involves pumping a balloon to
earn money. For a given trial, each pump earns money
but it also fills the balloon further. Volunteers choose
when to stop inflating the balloon and “cash in” to start
the next trial. However, volunteers do not know when the
balloon will explode, so each press of the button to inflate
the balloon is associated with risk. Compared to placebo,
energy drink consumption marginally (p = 0.05)
increased the mean adjusted average number of pumps
(40.3 for placebo versus 44.5 for energy drink). No other
BART outcome metrics differed between the placebo and
energy drink groups.
The BART has also been utilized in two separate
investigations to evaluate the impact of caffeine on risk-
taking during sleep loss. In the first study, volunteers
(mean age, 25.4 years; range, 20–35 years) remained
awake for 75 h and were administered repeated doses of
caffeine (200 mg) or placebo across nighttime hours
(total caffeine dose per night, 800 mg; total cumulative
dose, 2,400 mg).50 Caffeine did not increase risk-taking as
measured by the total number of exploded balloons or a
cost-benefit ratio metric (which quantifies risk taken rela-
tive to amount earned). In the second study, volunteers
(mean age, 23.5 years; range, 18–36 years) received
600 mg of caffeine administered after 44 h of sleep loss
and no effect on risk-taking was found, as measured by
either the BART or the Iowa Gambling Task (IGT).51,52
The volunteers included those who were older than a
typical college student; nonetheless, no evidence that caf-
feine induced risky behavior was found.
To summarize: there is no evidence that the caffeine
(or any other ingredient) contained in energy drinks
directly causes behavioral or other health problems. In
the adolescent/young adult population, the most likely
explanation for co-occurrence of excessive energy drink/
caffeine use and risky behaviors is the well-known age-
and gender-related neurophysiological vulnerability to
engage in risky behaviors.
Future trends in caffeine use
A distinction should be drawn between evidence that
caffeine use is on the rise and speculations or predictions
that caffeine use may be currently on the rise and/or
continue to increase over the next few years. As shown in
the sections above, there is presently no evidence that
caffeine use is on the rise. Rather, the evidence suggests
that the forms in which Americans consume their daily
caffeine has changed.
However, it seems reasonable to speculate that 21st
century lifestyle changes (e.g., increased availability of
electronic social media, affordability of communication
devices such as cell phones) and work habits (longer work
week in the United States) will drive Americans to
84
increasingly forego sleep for social and work-related
activities.When work or social activities delay sleep times,
the resulting neurobehavioral deficits have been referred
to as “social jetlag.”53 It is, therefore, not surprising that
individuals would choose to use energy drinks to boost
feelings of alertness or physical energy. The available evi-
dence does not indicate there is any inherent danger asso-
ciated with using energy drinks within daily limits (below
400 mg/day) to support mental or physical energy, so are
there any reasonable causes for concern?
Caffeine and sleep impairment
Most of us are familiar with the morning routine of
waking up with a cup (or several cups) of coffee. This
practice of consuming coffee upon waking is widespread
for good reason: it represents an effective use of caffeine
to overcome reduced alertness at our usual circadian
trough (which coincides with habitual awakening time)
and post-awakening sleepiness (i.e., sleep inertia).
Because caffeine is so effective at blocking sleepiness, a
reasonable concern associated with its use would be its
potentially disruptive impact on subsequent sleep.
Indeed, results indicate that caffeine consumption
reduces total sleep time.54–58
CONCLUSION
The only ingredient in energy drinks that has well-
documented, psychoactive (alertness and performance-
enhancing) effects is caffeine. At daily doses below
400 mg, caffeine is a safe, temporary means of improving
mental and physical energy. There is no evidence that
caffeine itself causes risky behavior. Caffeine can nega-
tively impact sleep, however, and this represents a legiti-
mate concern regarding its use in any age group and in
any form. Therefore, educational efforts that focus on the
deleterious effects that caffeine and caffeine-containing
energy drinks exert on sleep, rather than on other unsub-
stantiated concerns, would be the most beneficial.
Acknowledgments
Funding. The author acknowledges the United States
Army Medical Research and Materiel Command Military
Operational Medicine Research Program Directors for
financial and scientific support of the ideas presented in
this article.
Declaration of interest. The author of this paper maintains
no financial or personal relationships that bias the infor-
mation presented in this manuscript. No individuals
other than the author participated in writing or providing
other assistance during preparation of this manuscript.
Nutrition Reviews® Vol. 72(S1):78–86
Disclaimer. This material has been reviewed by the
Walter Reed Army Institute of Research, and there is no
objection to its presentation and/or publication. The
opinions or assertions contained herein are the private
views of the author(s) and are not to be construed as
official or as reflecting the position of the Department of
the Army of the Department of Defense.
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