Active Voice: Just Say No to Energy Drinks for Vulnerable Groups

By John P. Higgins M.D., M.B.A., M. PHIL., FACC, FACP, FAHA, FACSM, FASNC, FSGC

Viewpoints presented in SMB commentaries reflect opinions of the authors and do not necessarily reflect positions or policies of ACSM.

Dr. John P. Higgins is a professor of medicine at McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth). He is chief of cardiology at Harris Health System’s Lyndon B. Johnson General Hospital and serves as director of exercise physiology for the Memorial Hermann IRONMAN Sports Medicine Institute-Texas Medical Center. Dr. Higgins also works as a sports cardiologist, providing team physician services for both the Houston Rockets NBA basketball organization and the Rice University Athletics Department.

This commentary presents Dr. Higgins’ views on health and performance implications of consuming energy drinks in association with physical activity and exercise. Notably, he and three other experts addressed this topic in a “Contemporary Issues” (CI) paper that was published in the February 2018 issue of ACSM’s clinical review journal, Current Sports Medicine Reports (CSMR). Their paper represents the first in a new class of official ACSM pronouncements that express an opinion from an expert group on a scientific or clinical question of emerging importance in the field. The CI is based on examination of available published research and includes both consensus recommendations and identification of research gaps. For more on the CI pronouncement, see ”Science Spotlight” in the February 13, 2018 issue of SMB.


As energy drinks become more and more popular, questions about their safety and efficacy are growing.

Safety concerns associated with energy drink consumption include adverse effects on the cardiovascular, neurological, gastrointestinal, renal and endocrine systems, as well as psychiatric symptoms. For example, cardiovascular complications associated with consumption include elevated blood pressure and heart rate, arrhythmias, endothelial dysfunction, coronary artery spasm/thrombosis, myocardial infarction and sudden cardiac death. Further, all the actual ingredients – names, quantity and quality – are often not listed on the labels. Some groups are especially susceptible (see “vulnerable populations” below).

Efficacy concerns are that the data are inconclusive. Some studies suggest energy drinks may improve physical or mental performance; others show that these drinks degrade performance. Poor study design, nonrandomized/inadequately blinded studies, selection bias, variable dosing and manufacturer sponsorship and execution of studies are main issues. Because energy drinks are frequently classified as supplements or nutritional products, they are not subject to the scrutiny that the FDA and other regulatory bodies ordinarily apply to other food, beverages and drugs.

In summary, we have a weakly regulated product that anyone can buy and consume — a product of questionable efficacy that is associated with significant adverse events, especially in vulnerable populations.

In our ACSM Contemporary Issues Paper (February 2018 issue of CSMR), we have highly encouraged consumers, parents, physicians, athletic trainers, personal trainers and coaches to follow these ACSM-endorsed recommendations. These energy drinks:
  • Should not be consumed by children or adolescents
  • Should not be used for hydration by children and adolescents, and information about the absence of benefit and potential adverse effects should be provided to those who interact with young persons
  • Should neither be available for sale in K-12 schools nor advertised to children who attend such schools
  • Should not be marketed to (nor consumed by) vulnerable populations, including:
    • those younger than 18 years
    • pregnant or breastfeeding women
    • caffeine naive or sensitive individuals
    • those taking stimulant or caffeine-based medications
    • those with certain cardiovascular or medical conditions.
  • Should be avoided before, during, or after strenuous activities, until such time that proper safety and efficacy data are available
  • Should not be marketed premixed with alcohol or consumed with alcohol
  • May contain high levels of carbohydrates and calories, which can contribute to obesity
  • Should not be consumed close to bedtime
Also, of great importance:
  • Energy drink manufacturers should not promote excessive or rapid consumption of their energy drinks, as this pattern has been associated with increased adverse events
  • Education about energy drinks and their potential adverse events should be encouraged, especially in schools and universities
  • Health care providers, athletic trainers, sports medicine physicians, and personal trainers should educate their patients or clients about energy drink use and potential adverse events
The bottom line: until sufficient safety and efficacy data on energy drinks is available, avoid these products! Safer alternatives include water, milk, juice, or sports drinks.