By Robyn Norwood, Special for USA TODAY
The Gatorade cooler and the coffee pot in the locker room have competition.
From youth playing fields to major league clubhouses, caffeinated energy drinks such as Red Bull and its scores of cousins have become a familiar presence in sports.
"The bottom line is, it's a long season. You're going to do what you have to do, whether you feel like you have to jump into a cryogenic freezing tank or a hyperbaric chamber or drink a Red Bull," said Texas Rangers pitcher C.J. Wilson, a World Series starter who says he has never used alcohol or drugs but consumes energy drinks socially and to prepare himself to pitch. "I see nothing wrong with drinking Red Bull."
Some athletes and industry officials compare the beverages to a cup of coffee.
But doctors and other experts increasingly warn of misunderstandings about energy drinks' contents, lax labeling requirements and the risks of high doses of caffeine - particularly to young athletes.
In June, a clinical report in Pediatrics, the journal of the American Academy of Pediatrics, warned that "stimulant-containing energy drinks have no place in the diets of children or adolescents."
In October, the National Federation of State High School Associations cautioned that caffeinated energy drinks - often confused with such products as Gatorade, a fluid replacement drink - should not be consumed before, during or after physical activity because they could raise the risk of dehydration and increase the chance of potentially fatal heat illnesses. The organization also warned of possible interactions with prescription medications - including stimulants used to treat ADHD, or attention-deficit hyperactivity disorder.
In Orange County, Calif., at least four high school football players were taken to the emergency room last season with persistent tachycardia, or rapid heartbeats, said Michael F. Shepard, a team physician and member of the California Interscholastic Federation's state medical advisory board.
"All four had had supercaffeinated drinks," Shepard said. "If you add dehydration or flu or muscle-building supplements like creatine to that, there can be an increased risk of fatal cardiac arrhythmia.
"These four kids all did fine. But the heart's a muscle, too."
At issue is a dizzying array of products with widely varying levels of caffeine, sugars, carbohydrates and other additives, including herbal supplements.
Red Bull, the first such drink on the U.S. market, in 1997, has been surpassed in national sales volume by Monster energy drinks in what is now a $7.7 billion industry, according to the trade publication Beverage Digest. Rockstar energy drinks rank third.
Most best-selling energy drinks contain about 80 milligrams of caffeine per 8 ounces, though they are often sold in containers as large as 20 to 24 ounces. Other more extreme products abound, some of them in mix-your-own powders or concentrates, in strengths researchers say range from about 50 to 500 milligrams per serving. At their maximum strength, energy drinks contain about 300 milligrams more than the 2-ounce shots of 5-hour Energy frequently seen near checkout counters.
Beverage industry officials contend their products are not dangerous when used in moderation by healthy people.
"Regulatory agencies around the globe agree that caffeine is a safe ingredient to use in food and beverages," said Tracey Halliday, a spokeswoman for the American Beverage Association. "When it comes to energy drinks, the amount of caffeine in most mainstream energy drinks is about half that in a cup of coffee in a coffee shop, if you compare ounce to ounce."
A 16-ounce can of the top-selling energy drinks contains about 160 milligrams of caffeine. A 16-ounce cup of Starbucks' robust Pike Place Roast contains 330 milligrams, though critics say a hot drink is sipped more slowly than a cold beverage.
Researchers complain that identifying caffeine content and other ingredients is difficult for consumers because U.S. Food and Drug Administration regulations do not require products marketed as dietary supplements - as many energy drinks are - to adhere to the same labeling requirements as food and beverages.
Canada moved last month to limit the caffeine in energy drinks to no more than 180 milligrams in containers up to 20 ounces.
In the USA, cola-type drinks are limited by the FDA to 71 milligrams of caffeine per 12-ounce serving. But no such limit applies to energy drinks marketed as dietary supplements, and manufacturers are not required to list the caffeine content or all ingredients on the label, sometimes opting for the term "energy blend" or "proprietary blend."
"They regulate a can of cola," said John P. Higgins, a sports cardiologist at the University of Texas Health Science Center at Houston and co-author of a 2010 article on energy drinks published in the Mayo Clinic Proceedings. "These are like a free-for-all."
Additives including the herbal supplements guarana, green tea and yerba mate can boost the effective level of caffeine. Less common additives such as yohimbine and bitter orange can increase heart rate, cause changes in blood pressure and interact with certain antidepressant medications, according to the National Institutes of Health.
Monster, the U.S. leader in sales, does not list the amount of caffeine on its can, although independent sources place it at about 80 milligrams per 8-ounce container, or 240 in Monster's 24-ounce can. The drinks are manufactured and distributed by Southern California's Hansen Beverage Co., which declined to comment, saying it does not respond to news media inquiries.
Causes, effects debated
The FDA, which quashed the controversial practice of manufacturers including caffeine in alcoholic drinks such as Four Loko by issuing warning letters to four companies in 2010, has not acted on petitions by academics and other experts to limit caffeine or change labeling requirements for energy drinks. (Four Loko is now sold as an alcoholic beverage that does not include caffeine.)
"Those petitions are still within the FDA and still under consideration, and the agency can't comment," said Susan Carlson of the FDA's office of food additive safety.
Nationally, emergency room visits associated with energy drink use increased more than tenfold from 1,128 in 2005 to 13,114 in 2009, according to a report released last month by the federal government's Substance Abuse and Mental Health Services Administration. Forty-four percent involved combinations with other substances such as alcohol, pharmaceuticals or illicit drugs, which the American Beverage Association said made energy drink consumption "potentially irrelevant." However, more than half of the visits didn't involve another substance.
Most adverse reactions involve people who consumed two to eight energy drinks or more than 200 milligrams of caffeine, said Higgins, co-author of the Mayo Clinic report.
The exhaustive review of studies on energy beverages by Higgins and Houston exercise physiologist Troy D. Tuttle noted the risk of such effects as insomnia, nervousness, nausea, rapid heartbeat - and in more rare cases, seizures, cardiac arrhythmias and cardiac arrest, particularly in people with underlying medical conditions. The review also cited four documented cases of caffeine-associated deaths involving individuals who had consumed energy drinks.
"For a healthy person, probably one is not going to kill you. But we don't know," Higgins said. "I think it's the combination of things in these energy beverages," he added, cautioning about interactions. "A lot of athletes drink coffee."
Marketing to the young
Yet another issue raised by doctors and researchers is the marketing of energy drinks to young people, particularly through sponsorships of athletes and extreme sports.
New York's Major League Soccer team is the Red Bulls, owned by the drink company. NASCAR driver Kyle Busch endorses the drink NOS, and Monster has a stable of lesser-known athletes, bands and celebrities.
"Unfortunately, it starts at this level, where kids in college, high school and even younger see these athletes promoting it," said Cindy J. Chang, president of the American Medical Society for Sports Medicine and chief medical officer for the 2012 U.S. Olympic team. "It's like thinking, 'Wow, I need that shoe,' or whatever. It's a brand associated with a personality, and they think, 'He's cool. She's a superstar. They're drinking it.' "
A parent of two teenagers, Chang was at her daughter's club soccer tournament in Palo Alto, Calif., last spring when she saw energy drink samples being distributed.
"All the girls took one, and here I am embarrassing my daughter by telling them, 'You can achieve just as much if you drink a glass of milk,' " said Chang, previously head physician for athletes at the University of California-Berkeley.
Tuttle, co-author of the Mayo Clinic Proceedings article, has seen the drinks at events for even younger children.
"What shocked me was I've seen it at 8- to 10-year-olds' soccer games, seen parents providing it and kids drinking it at that level," he said. "When I grew up, I was eating oranges and drinking water."
The American Beverage Association advises its members not to sell their products in K-12 schools, not to market to children younger than 12 and to voluntarily list the amount of caffeine from all sources and include a label advising that the drinks are not recommended for children, pregnant or nursing women or people sensitive to caffeine. Red Bull said its policy is not to sample its products to children under 15.
Older athletes, particularly in professional and college sports, typically have more access to information about energy drinks or supplements through trainers, strength and conditioning coaches and team doctors.
In addition, the National Center for Drug Free Sport offers a subscription-based Internet service available to athletes affiliated with organizations including the NCAA, NFL, Major League Baseball and USA Track and Field that allows athletes to receive reports on products and their ingredients, including whether they contain banned substances.
Another group, NSF International, an independent non-profit, conducts product testing for a "Certified for Sport" designation. John Travis, a research scientist in NSF's chemistry laboratory, said NSF checks for banned substances and accurate labeling, and it will not certify any product that contains more than 150 milligrams of caffeine per serving. (Red Bull was the first energy drink to earn the NSF certification, in 2006, which accounts in part for its common presence in professional locker rooms.)
Part of the landscape
At other levels of sports, young athletes and their parents are often on their own.
In 2010, Dakota Sailor, a 17-year-old high school football player in Carl Junction, Mo., drank two 16-ounce NOS energy drinks containing a total of 520 milligrams of caffeine during an offseason school day. He was later discovered on his family couch, blue after aspirating, and his stepfather, a nurse by training, performed CPR.
Sailor spent five days in the hospital recovering from what his neurologist, Taylor Bear, said evidence indicated was probably a seizure, though no one witnessed it.
"We know stimulants can lower the seizure threshold in those with predispositions," Bear said. "We're always dealing with gray areas, but in his case, because he had had a few energy drinks in a relatively short time, and who knows, may have had sleep deprivation or other factors, we surmise maybe the drinks were a contributing factor to his event."
Sailor said he hasn't had another similar event and no longer drinks energy drinks.
"I'd drink several in a day, no problem. I drank them before the games or in the locker room," he said. "Maybe they gave you, like, more adrenaline, or it might have been a placebo effect. We saw older athletes sponsored by them, and a lot of events, like after graduation, were sponsored by them. We never heard of any risk."
NOS, which like Full Throttle is owned by The Coca-Cola Co., issued a statement saying the company was aware of the incident:
"None of our beverages, including energy drinks, contain any harmful substances. All of the ingredients in our energy drinks are safe and suitable for use in the product. Energy drinks, like all food and beverage products, should be consumed responsibly and not to excess."
The drinks remain part of the everyday sports landscape.
NFL defensive end Adam Carriker of the Washington Redskins said he drinks an energy "shot," similar to 5-hour Energy, before each game.
"When I take it, what I feel is I'm a lot more mentally clear, I'm aware and don't get as tired as quickly," Carriker said. "I've made the mistake of taking too many in a game and having an out-of-body experience, and that's not good.
"I've known guys that took a lot at games, and it was a scary situation in the locker room because they took too much stuff. The way I look at it, if you take the right amount and consult somebody who can tell you what to do, I think it's beneficial. Now, if you take too much, it can obviously hurt you."
Teemu Selanne, a 41-year-old player for the Anaheim Ducks who is one of the top 15 goal-scorers in the history of NHL, said he has one energy drink before each game with teammate Ryan Getzlaf.
"I think it's like coffee. You feel a little lift, but maybe it's a little more mental," Selanne said. "It's just a habit."
He does not look on them so lightly for his children. When Selanne's youngest son, Leevi, was about 9, he drank energy drinks without permission at the family's annual summer party.
"I think he had three or four," Selanne said. "He was so hyper, it was not even funny. He was up until 3 or 4 o'clock."
His oldest son, Eemil, is a teenage hockey player, but Selanne doesn't advise him to follow the same pregame routine he does.
"His friends and stuff, they're drinking more Monster and Rockstar. I tell my kids, 'You know what? You guys don't need that.' They have enough energy."
Contributing: Jorge Ortiz from Arlington, Texas, and Gary Graves from Ashburn, Va.