Introduction
My name is Billy Scantlebury, I am a family doctor in Charlottetown and this is my colleague – also a family physician in Charlottetown, Dr. Jennifer Zelin.  I am the current President of the Medical Society of PEI, and Dr. Zelin and I both serve on the Healthcare and Promotion Committee of the Medical Society.

Good Afternoon, and thank you for the opportunity to speak to you today about concerns we have regarding youth access to highly-caffeinated beverages commonly referred to, and marketed as, “energy drinks.”

What are the issues?
Only since lifting the can ban in May 2007, have energy drinks become widely available in PEI, as compared to the rest of the country.  They are available, without restriction, in virtually every corner and grocery store, at department store checkouts, in bars and taverns, gas stations and convenience stores.

They are advertised for their energy-boosting properties and marketed, predominantly, to youth and young adults – an especially effective strategy and appealing to those who now equate energy drinks with enhanced athletic performance, a way to cram for exams – or all-night partying.

Some consumers have bought into the notion that energy drinks are natural and wholesome – likely based on the fact that energy drink regulations in Canada falls under the jurisdiction of Natural Health Products.

Caffeine doses range vastly. In some energy drinks there is more caffeine, in a single can, than the daily maximum recommended by Health Canada. The drinks have other substances too, some known to have harmful side effects and others not yet researched and therefore their effects are not known.

We have provided a poster highlighting some of the more common additives which, in the lower doses found in most energy drinks, are unlikely to provide any real or proven benefit. On the other hand, even in low doses, in some people the interaction with medications or other supplements taken has caused adverse health effects.

Aside from our concern with ingredients in energy drinks – in particular the concentration of caffeine – there is also the issue of how they are being consumed.
Adverse reactions occur when the energy drinks are consumed more than one at a time – and ‘chugged’ versus sipped as we would a coffee. There is also the dangerous trend with youth and younger adult to mix energy drinks with alcohol. The effect of high doses of caffeine in combination with alcohol enhances alcohol’s dehydrating effects. In short, the cocktail mix allows one to remain alert longer and therefore capable of consuming more alcohol.

At best, this trend is a recipe for a nasty hangover. At worst, it has the potential for serious health effects, injury, and even death. I will examine this concern a little closer later in the presentation.

For these reasons, physicians urge the Government of Prince Edward Island to closely examine energy drinks’ place in the PEI market. As physicians, we see no health benefit and much potential for harmful side effects.

Our minimum request to government is to find a means to restrict access and keep energy drinks out of the hands of children and youth.

MSPEI background on energy drinks:
At the last Annual General Meeting of the Medical Society of PEI, held in September 2008, an internal committee, the Healthcare and Promotion Committee, proposed that the Society support a resolution that highly-caffeinated beverages not be sold to young people.

For the record, the Medical Society did not adopt the recommendation as policy.

The proposed resolution lacked supportive research and physicians being the evidence-based practitioners they are - although wary of the harmful effects of energy drinks - returned the resolution to committee to find out more and to make a recommendation on age restriction.

To this end, much discussion has taken place and research reviewed.  Personally, I believe doctors would be happy to have all energy drinks removed from the shelves for the potential harm they have for all consumers – children and adults.

However, our immediate concern is Island youth; we want energy drinks out of the hands of minors. We appreciate that ultimately this will be an enforcement issue – as with any law - and government will take that into consideration. It is our role as doctors to advise that this product is potentially harmful and potentially lethal. The Medical Society is obliged to state such concerns, provide as much evidence as possible to justify these concerns, and offer a broad recommendation to protect Islanders, most especially youth. 

At this time, I would ask Dr. Zelin to share her thoughts as it was she who first brought the matter to the attention of the committee.

Dr. Zelin
Thank you for this opportunity and your attention to this health issue.

Energy drinks and the potential health effects they can arise first came to my attention about a year ago when I was reading an article about the drinks in the Medical Post. In my health clinic and also as a parent of a young children, I was hearing some very disconcerting tales about so-called ‘energy drinks.’ I brought the issue to the committee to investigate as I was pretty convinced even then – that the arrival of energy drinks to PEI was not something kids should be able to access – more to the point, I was very concerned about potential health effects.

Some of you will appreciate my concern – and curiosity. I am a parent of a 7-year-old. I could not fathom why a product that provided more energy to youth was even marketable! There is a very sane reason most parents would not dream of giving their children coffee.

As a physician, I was certain the product was unnecessary and equally convinced that it could not be healthy – especially when I learned that the prime ingredient for energy was caffeine. Let’s face it, many adults struggle with caffeine dependency - but most, if not all, at least understand that too much is not a good thing. 

The danger I see, and the reason I brought this to the attention of the Medical Society, is that the marketing of the product clearly targets youth. We, as adults and caregivers, instinctively know that caffeine in large doses is not something children and youth should have access to.

In hindsight, it should have been obvious – even predictable - that young people would be drawn to the newness of the energy drink product in PEI especially with no restriction on sales to children and youth.

Public school students of all ages were seen consuming the drinks and teachers observed unhealthy, and unwelcome, side effects. 

To their credit, the Eastern and Western School Districts acted swiftly banning energy drinks from school properties. Teachers had all the evidence they needed to demand they not be allowed in school witnessing first-hand symptoms of caffeine intoxication such as hyperactivity, restlessness, an inability to concentrate, and stomach upsets followed by the inevitable “crash” when the caffeine wore off and students were left struggling to focus – or in some instances even stay awake. As if the demands of teaching were not difficult enough. Imagine the futility of attempting to teach a class where even just a few students were either on a caffeine-induced high or in withdrawal.

Teachers were not alone though. Local media saw the energy-drink-story as one that needed to be told and images of youth downing large cans before heading off to class was viewed and heard about Island wide with most agreeing it was disturbing on many levels.

Coaches and parents spoke candidly about their own observations and concerns. A number of cashiers and even some store owners noted their discomfort selling energy drinks to youth. We understand some have even enforced their own ban on the sale of the product to youth.

It is important to note that with the arrival of energy drinks in PEI, teachers, parents, and coaches – people who spend time with youth – were not aware of the drinks’ composition, yet they felt strongly that kids should not be consuming energy drinks.  Today, the public is somewhat better versed on the potential health hazards - although some would still question why we are making such a fuss.  We hope to justify our concerns - and the use of your time.

So what is an energy drink?
Energy drinks are soft drinks advertised as providing more energy than a typical drink.

While we were not able to find an official definition of what constitutes an energy drink, they typically contain varying amounts of caffeine combined with empty calories - sugar, artificial flavourings and multiple additives touted as healthful like taurine, vitamins and herbs but with no evidence that such ingredients improves energy - as they are aggressively marketed to do.

Unlike sports drinks, energy drinks do not provide the benefit of fluid replacement for hydration. In fact, this is something that needs to be clearly understood. If you are working out and looking for hydration – do NOT reach for an energy drink.  Caffeine creates the opposite affect of hydrating effectively increasing fluid and electrolyte loss.

What an energy drink IS – is a very trendy beverage choice for many young people. A long list of teen celebs provide unsolicited endorsements, the likes of party girls Paris Hilton, Lindsay Lohan, and Britney Spears - all big fans of the beverage.

Last year, Red Bull - one of the original energy drinks - achieved record sales thanks to a strong performance in fast-growing markets in the Far East and Canada. We, apparently, took the prize for the biggest percentage jump in sales. 

Should we be concerned? We think so. Doctors understand that potential health risks far outweigh any perceived benefit that comes from the sales and consumption of energy drinks.

Advertising campaigns, which principally target teens and young adults, promote the performance enhancing and stimulant effects of energy drinks – and in some instances appear to glorify drug use. 

Our suspicion is that energy drink marketers have borrowed a page from the tobacco industry in finding savvy and innovative ways to “advertise” to a youth target.  Things like attending events with lots of free product samples; sponsoring online contests asking youth to create their own online ads featuring their favourite brand of energy drink. We had no problem finding lots of examples in our search. Internet advertising is prolific and accessible – where ever you live. Energy drinks are popular with youth - and sales prove it.

See for yourself:
The following slides include pictures taken yesterday at a couple of local stores in Charlottetown where energy drinks are sold; look at where they are placed. Then, consider the allure of packaging. Packaging is powerful; you only have to be a consumer to understand this reality. It is one reason why, in PEI, tobacco ‘power walls,’ by law must now be hidden from children. And what about the example shown, Monster Energy’s target consumer – geared to a thrill-craved, hyperactive youth culture – look at the teenage graphics and visual themes. Clearly, the cans’ designs are not targeting you or me.

The next presenters are from Refreshments Canada. Their website includes news releases refuting allegations that they target youth; their claim is that energy drink companies do not advertise in any media directed at kids.

There appears to be no lack of creativity when it comes to making money and building a market for products that are inherently unhealthy for consumers. My final comment is to ask this committee, is the exponential growth in sales of energy drinks the kind of economic stimulus we, as Islanders want? Is this something health conscious Canadians should buy into? Perhaps the presentation from Refreshments Canada will address this tempting and lucrative market share and why they believe they are justified in pursuing it? 

Why are doctors worried?
We are here today representing the medical professional. Our main focus is the potential health effects of consuming energy drinks. So what ARE the health risks?

We will not spend a great deal of time describing a litany of health conditions for which the ingredients in energy drinks would most certainly cause adverse reactions – although that is noted. It is important for this committee to know that healthy consumers of energy drinks face potential health risks.

Too much caffeine intake can result in something called caffeine intoxication. It is a recognized clinical syndrome included in the Diagnostic and Statistical Manual of Mental Disorders and the World Health Organizations’ Internal Classification of Diseases.

Coffee-drinkers in this room may have actually experienced varying degrees of this. Caffeine intoxication is marked by nervousness, anxiety, restlessness, insomnia, gastrointestinal upset, tremors, rapid heartbeats (tachycardia), psychomotor agitation (restlessness and pacing) and in rare cases, death.

Caffeine is a drug. Yes, persons have died from too much caffeine.

So how much is too much?
The answer is, ‘it varies’, but your health and even your very life could depend on knowing the answer.

Health Canada sets recommended maximum levels of caffeine intake for various segments of the population:
    •    A maximum of 2.5 milligrams per kilogram of body weight for children aged 12 and under
    •    for pregnant women – or even women who could get pregnant, they say no more than 300 milligrams
    •    For the rest of us, in general, Health Canada says keep your daily intake to no more than 400 milligrams – IF you’re in good health.

This is rather dry information for most, but it is useful in understanding why doctors are so concerned about the caffeine content in energy drinks.

Each of you has a package with a number of articles and research documents for your perusal.

I would like to reference, for a moment, a chart that lists the caffeine content found in popular drinks as compared to energy drinks.  If you examine the list you will see that the caffeine content of energy drinks varies over a 10-fold range, some containing the equivalent of 14 cans of Coca-Cola. 

You’ll also see that almost all energy drinks exceed the recommended caffeine intake for children.

Yet, caffeine amounts in energy drinks are often unlabeled and that is a problem. Consumers have little, if any, idea how much caffeine they are consuming.

As mentioned in my introduction, in Canada, energy drinks are classified as a health product and as such are regulated under the Natural Health Products Directorate. Once approved, they are assigned a Natural Health Product Number or NPN, which is displayed on the container. A number of energy drinks currently available have still not received this approval.

So will it be OK when all drinks are properly labeled?
We would argue that despite best efforts to label, when it comes to a market that is predominantly youth-oriented, labeling will likely not deter youth from buying an energy drink. In fact, because of the risk-taking behaviours which are well-studied and known in this age group, the effect could be just the opposite.

Do we honestly expect, or take comfort in the premise that a grade seven or eight or even high school aged consumer of energy drinks will spend time considering recommended doses of caffeine and make his/her choice accordingly? Do youth pay attention to warning labels on cigarette packages? Does the percentage of alcohol dissuade underage consumption – or encourage it? The jury is out – but we believe there is enough evidence that says some young people will choose risk.

There is speculation that perhaps the only “benefit” (and I use the term loosely) of allowing youth access to energy drinks would be to easily identify those with higher than average risk-taking tendencies; there is research to support this premise. Presumably, interventions to prevent even more dangerous risk-taking behaviour could then take place. 

Based on available research, energy drinks are not healthful or beneficial - unless we consider their profitability to the beverage industry afore mentioned. Further, consumption of energy drinks may cause adverse reactions.

Alternatively, there exists safe and healthful means to achieving sustained alertness and energy, healthy living practices that do not risk side effects, injury or possible death.

John Hopkins report
This past summer, a study was released that confirmed many of our suspicions and justified our need to speak out about potential health risks.

You have a copy of the scientific review released in August 2008 from John Hopkins Medicine, ‘Caffeinated energy drinks – A growing problem.

I would urge each of you to read this paper; it delves into other considerations we are unable to address in detail today. John Hopkins scientists have spent decades researching the effects of caffeine. Today, because of the infiltration of caffeinated energy drinks on the market, these same scientists have concluded that there are potential health risks. The abstract alone is quite enlightening:

Since the introduction of Red Bull in Austria in 1987 and in the United States in 1997, the energy drink market has grown exponentially. Hundreds of different brands are now marketed, with caffeine content ranging from a modest 50 mg to an alarming 505 mg per can or bottle. Regulations of energy drinks, including content labeling and health warnings differ across the countries, with some of the most lax regulatory requirements in the U.S. The absence of regulatory oversight has resulted in aggressive marketing of energy drinks, targeted primarily toward young makes, 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. In children and adolescents who are not habitual caffeine users, vulnerability to caffeine intoxication may be markedly increased due to an absence of pharmacological tolerance. Genetic factors may also contribute to an individual’s vulnerability to caffeine-related disorders including caffeine intoxication, dependence and withdrawal. The combined studies suggest that energy drinks may serve as a gateway to other forms of drug dependence. Regulatory implications concerning labeling and advertising, and the clinical implications for children and adolescents are discussed.

The information is relevant and, for the most part, applicable to PEI. 

Regulations:
In Canada, like the US, soft drinks are limited in the amount of caffeine allowed.
Energy drinks, on the other hand, fall into the category of natural health products – in the US they are marketed as a “dietary supplement.” 

In a letter written in May 2008 from the Canadian Medical Association (CMA), copied to MSPEI, the CMA called on Government to develop regulations regarding the composition and concentration of ingredients in energy drinks.

At that time, the only energy drink that had undergone a review by Health Canada was Red Bull. Today, most energy drinks sold in Canada now carry cautionary labeling stating: Contains caffeine. Not recommended for children, pregnant or breastfeeding women, caffeine sensitive persons or to be mixed with alcohol. Do not consume more than 500 ml per day.

Health Canada’s response to the CMA noted reviewing regulations for products like energy drinks are ongoing to ensure consumer safety and would include appropriate oversight to ensure that consumers have the information they require to measure and control their caffeine intake – should they need or choose to.  Also, that adverse reactions reported occurred when the product was used outside of the approved conditions of use and contrary to the label warnings, e.g. by consuming it with alcohol.

The response also noted unique risks associated with energy drinks when people do not pay attention to cautionary labeling. In other words, cautionary labeling is limited as a means to protect consumers.

What about mixing?
Mixing energy drinks with alcohol is a prevalent and dangerous practice. So what’s the big deal, we do it all the time ‘any one for a rum a Coke?’ I hope by now you have a sense of what the difference is. In PEI, consumers can combine energy drinks with alcohol, or if desired, purchase the combination already mixed and available in liquor stores and bars.

In Sweden, two young healthy people died shortly after drinking Red Bull with vodka. The deaths are still being investigated. France, Denmark, Sweden and Norway have banned energy drinks because of their link to certain deaths.

To bring it back to PEI, aside from my family practice, I occasionally do shifts in Emergency Departments. Since energy drinks arrived in PEI, I take a history of caffeine and alcohol intake in young patients associated with car crashes, sexual assault, anxiety, panic attacks and risky behaviours including suicide attempts.

Canada is interested in what PEI will decide to do about energy drinks.  Why?  Because they are concerned too.

The same day the Medical Society of PEI’s started talking about restricting youth access to energy drinks, as President, I became a sought after interview. I was amazed by the interest and sheer numbers of requests for interviews by media sources across the country. Shortly thereafter we were contacted by your next presenters.  Although never successfully coordinated, Refreshments Canada tried on many occasions to arrange a meeting with the Medical Society. Divisions of the Canadian Medical Association across Canada wait with interest to see how PEI will deal with this health issue. 

Our province has the opportunity to take action and become a leader.

Island doctors believe that the evidence warrants restrictions and that such action should be undertaken not only provincially, but nationally. To this end, MSPEI will propose that the Canadian Medical Association consider including this action as one of their health advocacy initiatives. 

As a Standing Committee, you are tasked to carefully consider the information presented in formulating your recommendations to government.

Physicians speak on behalf of their patients and without prejudice. The documents, research and opinions offered is evidence of the medical community’s support to restrict youth access to highly-caffeinated “energy drinks” in Prince Edward Island.

In addition, we ask you to consider an outright ban given the absence of nutritional and/or other beneficial qualities and well-documented risk of health side effects including possible associated death.

The Medical Society of PEI’s mandate is, in part, to promote high standards of health and healthcare for all Islanders. It is in this vein that we present today using the latest available scientific research – and adherence to the Precautionary Principle:

“When an activity raises threats of harm to human health or the environment, precautionary measures should be taken even if some cause-and-effect relationships are not fully established scientifically.”