Energy drink cocktails: a dangerous combination for athletes and beyond.

Energy drink cocktails: a dangerous combination for athletes and beyond. ABSTRACT The combined-use of alcohol and energy drinks (EDs) on collegecampuses and in communities has become a considerable public healthconcern. Among college students, intercollegiate athletes have beenidentified as being particularly at-risk for excessive alcoholconsumption and resultant health and behavioral consequences. The mainpurpose of this study was to measure patterns of alcohol, combined-use,and ED-only use among men and women student-athletes (N = 401; 257 male,144 female), and to investigate whether or not significant differencesexisted within combined-users on risk-taking and consequences whencomparing alcohol-only to the combined-use of alcohol and EDs. Amongalcohol drinkers (n = 315), 92% participated in alcohol binge drinking binge drinkingAn early phase of chronic alcoholism, characterized by episodic 'flirtation' with the bottle by binges of drinking to the point of stupor, followed by periods of abstinence; BD is accompanied by alcoholic ketoacidosis–accelerated lipolysis and and 150 (47. 6%) combined alcohol and EDs. Within combined-users, 68 of107 males (63.6%) and 24 of 40 (60%) females reported participating in"energy-binge" drinking episodes (i.e., having 3 or moreenergy drinks on one occasion) when combining alcohol and EDs. Whencomparing alcohol-only use to combined-use within athletes who did both,results indicated that the combined-use of alcohol and EDs lead to asignificant overall increase in reported risk-taking. There is acritical need to include more information about the effects of EDs andcombined-use in existing substance abuse treatment and preventionprograms. TERMINOLOGY Energy Drink (ED): An 8 ounce serving of drinks containingcaffeine, taurine taurine/tau��rine/ (taw��ren) an oxidized sulfur-containing amine occurring conjugated in the bile, usually as cholyltaurine or chenodeoxycholyltaurine; it may also be a central nervous system neurotransmitter or neuromodulator. , B-vitamins, and other ingredients. Not coffee ordrink simply high in caffeine. Energy-Binge: 3 or more EDs on one occasion--can be with or withoutalcohol. Combined-user: Used both alcohol and EDs together and alcohol-onlyon separate occasions. Alcohol-only use: Drinking only alcohol on that occasion and notconsuming EDs. Since the introduction of Red Bull in the United States in 1997,the energy drink (ED) market has grown exponentially. ED sales haveincreased from an estimated $200 million in the U.S. in 2002(Agriculture & Agri-Food Canada, 2008), to $5.4 billion in 2006(Reissig, Strain, & Griffiths, 2009). To reduce alcohols'depressant depressant,any one of various substances that diminish functional activity, usually by depressing the nervous system. Barbiturates, sedatives, alcohol, and meprobamate are all depressants. Depressants have various modes of action and effects. effects people have mixed stimulants with alcohol fordecades, and evidence suggests that this behavior is increasing due tothe proliferation of energy drinks (Malinauskas, Aeby, Overton,Carpenter-Aeby, & Barber-Heidal, 2007; O'Brien, McCoy, Rhodes,Wagoner, & Wolfson, 2008). As witnessed by widespread use andpositive athlete testimonials (e.g., 5-hour energy), EDs appear to beperceived as safe. However, EDs are unregulated by the Food and DrugAdministration and have not been 'recognized as safe' (FDA,2003). The Power of Advertising Strategic advertising campaigns claiming improved performance,alertness, concentration, and mood have been influencing the increaseduse of EDs (Miller, 2008a; 2008b). To further promote increased use,college students are regularly given free samples during nightclubpromotions or during times of increased stress such as finals week(Woolsey & Kensinger, 2009). The objectives of these strategies aresimple, give students free samples to get them using. Then, once theyare hooked, charge high prices ($2-4 per can) and take full advantage ofthe products addictive properties. Miller (2008c) suggested that EDcompanies exploit the 'jock identity' of athletes and useenticing marketing ploys to attract young people. Historically, EDadvertising has targeted young males and glorified glo��ri��fy?tr.v. glo��ri��fied, glo��ri��fy��ing, glo��ri��fies1. To give glory, honor, or high praise to; exalt.2. the risk-takinglifestyle (Miller, 2008a; 2008c). More recently however, companies haverealized the tremendous sales growth potential of targeting women. Forexample, VPX VPX Virtual Path Cross-ConnectVPX Vector Product ExchangeVPX Video Post SequenceVPX Video Pixel Decoder Sports Nutrition (2010) created a product called RedlinePrincess in bright pink bottles with flavors such as peach mango.According to the VPX Redline Princess product description (2010),"The biggest concern women seem to have with most "energyproducts" is that they don't want to feel totally jacked up!Redline Princess however, provides women with the same level of energyas original Redline, but with the added bonus of appetite suppressionand mood enhancement, which is nothing short of euphoric." Energy Drink Ingredients The main ingredients found in Red Bull are sucrose, glucose, sodiumcitrate, taurine, glucuronolactone (i.e., synthesized metabolite ofglucose), caffeine, inositol inositol(ĭnō`sĭtōl): see vitamin. InositolThe generic name for hexahydroxycyclohexanes, which are classified as carbohydrates. , niacin niacin:see coenzyme; vitamin. niacinor nicotinic acid or vitamin B3Water-soluble vitamin of the vitamin B complex, essential to growth and health in animals, including humans. , D-pantothenol, pyridoxine HCL pyridoxine HCl (pir´idok´sēn),n (vitamin B6),brand names: Beesix, Nestrex;drug class: vitamin B6, water soluble;action: ,Vitamin B vitamin Bn.1. Vitamin B complex.2. A member of the vitamin B complex, especially thiamine.vitamin B, vitamin B complexa group of water-soluble substances described separately. 12 and B6. Other popular EDs contain N-Acetyl tyrosine,L-camitine, milk thistle, and herbals such as panax ginseng Panax ginseng,n Asian ginseng. See ginseng and ginseng, Asian. , guarana guarana/gua��ra��na/ (gwah-rah��nah) [Tupi-Guarani] the Brazilian woody vine Paullinia cupana, or a dried paste prepared from its seeds which is used as a stimulant and tonic in folk medicine and for the treatment of headache in ,yerba mate, yohimbine hydrochloride yo��him��bine hydrochloriden.An alpha-blocker drug that is derived from the bark of a tree, Corynanthe yohimbe, and is used as a mydriatic and as a treatment for erectile dysfunction. (HCL HClhydrochloric acid. ), and evodamine. A concern withED use is that one 8 ounce serving contains mega-doses of vitamins andherbals that are well above dietary recommendations, and many peopleregularly consume multiple servings. In the more than 500 brands of EDsnow available, several contain over 4 times the amount of caffeine asRed Bull as well as powerful herbal stimulants such as evodamine andyohimbine yohimbine/yo��him��bine/ (yo-him��ben) an alkaloid chemically similar to reserpine, from the bark of the yohimbe tree; it possesses alpha-adrenergic blocking properties and is used as the hydrochloride as a sympatholytic and mydriatic, and (Walker & Woolsey, 2009). Yohimbine HCL and evodamine posea greater immediate danger to consumers than caffeine because thesesubstances are more potent, and most people do not have tolerances tothese stimulants (Woolsey, 2009). Redline and Spike are examples of EDscontaining these substances and are popular among strength trainingathletes. As a result of these stimulant increases, the risks of usingEDs are now greater than they were just a few years ago. The followingparagraphs will describe some of the common ingredients in EDs and howthe metabolic and neurological effects of these ingredients couldinfluence the results of this study. Glucose & Glucuronolactone. Unlike other carbonated beveragesmixed with alcohol, EDs contain glucose and a synthetic product ofglucose metabolism glucose metabolism,n the process by which simple sugars found in many foods are processed and used to produce energy in the form of ATP. Once consumed, glucose is absorbed by the intestines and into the blood. known as glucuronolactone. Hypoglycemia hypoglycemia:see diabetes. hypoglycemiaBelow-normal levels of blood glucose, quickly reversed by administration of oral or intravenous glucose. Even brief episodes can produce severe brain dysfunction. is an effectof alcohol metabolism in humans due to alcohol's inhibiting theliver's ability to convert newly ingested food and sugar (sucrose)into glucose through its normal process known as gluconeogenesis gluconeogenesis/glu��co��neo��gen��e��sis/ (gloo?ko-ne?o-jen��e-sis) the synthesis of glucose from molecules that are not carbohydrates, such as amino and fatty acids. glu��co��ne��o��gen��e��sisn. (Freinkel & Arky, 1966; Shelmet et al., 1988). Some of the sideeffects Side effectsEffects of a proposed project on other parts of the firm. of alcohol induced hypoglycemia include problems with thinkingand memory, brain damage, dizziness, clumsiness, rapid heartbeat,difficulty sleeping, and hangovers. EDs directly contain glucose andglucuronolactone so the liver does not have to convert anything intoglucose, which should be considered when examining the effects ofcombining EDs with alcohol. Taurine. Taurine is an amino acid amino acid(əmē`nō), any one of a class of simple organic compounds containing carbon, hydrogen, oxygen, nitrogen, and in certain cases sulfur. These compounds are the building blocks of proteins. naturally found in the body atlevels between 40 to 400 mg (Laidlaw, Grosvenor, & Kopple, 1990),whereas most EDs contain 1000 mg per 8 ounce serving. Studies have foundthat taurine increases dopamine dopamine(dōp`əmēn), one of the intermediate substances in the biosynthesis of epinephrine and norepinephrine. See catecholamine. dopamineOne of the catecholamines, widely distributed in the central nervous system. production, improves locomotor activity,reduces symptoms of alcohol induced amnesia, and reduces toxic effectsof alcohol metabolism on the liver (Aragon, Trudeau, & Amit, 1992;Dahchour, Quertemont, & De Witte, 1996; Kerai, Waterfield, Kenyon,Asker, & Timbrell, 1998; Vohra & Hui, 2000). Microdialysisstudies have shown that when alcohol is consumed it raises extracellularlevels of taurine in numerous brain regions (Olive, 2002). Taurinecrosses the bloodbrain barrier (Tsuji & Tamai, 1996; Salimaki,Scriba, Piepponen, Rautolahti, & Ahtee, 2003) and has severalimportant roles in physiological processes including inhibitoryneurotransmission. Olive (2002) found that taurine exerted positivemodulatory affects on GABA GABA?. GABAabbr.gamma-aminobutyric acidGABA (gamma-aminobutyric acid)A neurotransmitter that slows down the activity of nerve cells in the brain. (i.e., gamma-aminobutyric acid gamma-aminobutyric acid/gam��ma-ami��no��bu��tyr��ic ac��id/ (gam?ah-ah-me?no-bu-tir��ik) ?. gam��ma-a��mi��no��bu��tyr��ic acidn. Abbr. ) and glycine glycine(glī`sēn), organic compound, one of the 20 amino acids commonly found in animal proteins. Glycine is the only one of these amino acids that is not optically active, i.e. receptors and had inhibitory effects on N-methyl-D-asparatate (NMDA) andpositive calcium channels (Ca2+). Taurine generally acts as anantianxiety agent because of its effects on GABA, but it can produceboth anxiolytic anxiolytic/anx��io��lyt��ic/ (ang?ze-o-lit��ik)1. antianxiety.2. an antianxiety agent.anx��i��o��lyt��icn.A drug that relieves anxiety. and stimulating effects in a strong dose dependentmanner (Chen et al., 2004; Olive, 2002; Zhang & Kim, 2007).Therefore, taurine has regulatory effects on the central nervous systemand can help stabilize heart rhythm when used with stimulants. Caffeine. Caffeine is the most commonly used psychoactive substancein the world ranking second to alcohol (Hsu, Chen, Wang, & Chiu,2009). Standardized caffeine content calculations m top selling EDs aregenerally only 80 mg per serving; however, among the hundreds of brandsnow available many contain caffeine contents between 250 and 500 mg(Energyfiend, 2009). Additionally, EDs do not include unstandardizedherbal forms of caffeine such as guarana and yerba mate in theircaffeine content calculations. The half-life and user tolerance level ofcaffeine vary widely among individuals and are dependent on multiplefactors including liver functioning and other substances in the body(Griffiths, Juliano, & Chausmer, 2003). In healthy adults,caffeine's half-life is generally 4-6 hours with the average forwomen taking oral contraceptives increasing to 5-10 hours (Meyer,Canzler, Giers, & Walther, 1991). Additionally, when higher dosesare consumed (250-500 mg), caffeine's half-life increases, and itselimination from the body is significantly slowed (Kaplan et al., 1997).Caffeine readily crosses the blood-brain barrier blood-brain barriern. Abbr. BBBA physiological mechanism that alters the permeability of brain capillaries so that some substances, such as certain drugs, are prevented from entering brain tissue, while other substances are allowed to and works by binding toadenosine adenosine/aden��o��sine/ (ah-den��o-sen) a purine nucleoside consisting of adenine and ribose; a component of RNA. It is also a cardiac depressant and vasodilator used as an antiarrhythmic and as an adjunct in myocardial perfusion imaging receptors as a nonselective adenosine antagonist (Fisone,Borgkvist, & Usiello, 2004). Like alcohol is with GABA, caffeine ismolecularly similar to adenosine which allows it to occupy adenosinereceptor sites, primarily A1 and A2a (Fisone et al., 2004). These tworeceptors have important roles including regulating the release of otherneurotransmitters such as dopamine and nor-epinephrine (Fuxe, Ferre,Genedani, Franco, & Agnati, 2007; Schiffmann, Fisone, Moresco,Cunha, & Ferre, 2007). A2a receptors are located in the dopaminerich pleasure-reward areas and A 1 receptors are located in all parts ofthe brain with heavy concentrations in the hippocampus hippocampusfabulous marine creature; half fish, half horse. [Rom. Myth. and Art: Hall, 154]See : Monsters (learning),cerebral cortex cerebral cortexLayer of gray matter that constitutes the outer layer of the cerebrum and is responsible for integrating sensory impulses and for higher intellectual functions. , and cerebellar cortex cerebellar cortexn.The thin gray surface layer of the cerebellum, consisting of an outer molecular layer and an inner granular layer. (Fredholm, Battig, Holmen,Nehlig, & Zvartau, 1999). Increasing evidence indicates thatcaffeine interacts with the neuronal systems in the brain involved inreinforcing the use of alcohol and other drugs (Griffiths et al., 2003;Hsu et al., 2009). Ginseng ginseng(jĭn`sĕng), common name for the Araliaceae, a family of tropical herbs, shrubs, and trees that are often prickly and sometimes grow as climbing forms. . Ginseng is an herbal stimulant compound commonly found inEDs such as Monster. Research shows ginseng can reduce the sedative sedative,any of a variety of drugs that relieve anxiety. Most sedatives act as mild depressants of the nervous system, lessening general nervous activity or reducing the irritability or activity of a specific organ. effects of ethanol due to its stimulating affects (Koo, 1999). Animalresearch by Koo (1999) indicated that ginseng reduced blood alcoholconcentration blood alcohol concentrationn.The concentration of alcohol in the blood, expressed as the weight of alcohol in a fixed volume of blood and used as a measure of the degree of intoxication in an individual. which was partially attributed to ginseng slowing gastricemptying (p. 153). Interactions of additional ingredients will beaddressed further in the discussion section. Alcohol Metabolism Differences between Men and Women Previous research indicates large differences between men and womenin the amount of alcohol consumed, drinking motives, and consequences ofalcohol use. A recognized trend is that college age males drink moreoften and more per occasion than females (Baer, Kivlahan, & Marlatt,1995; O'Malley & Johnston, 2002; Taylor et al., 2006). Evenwhen differences in body mass (muscle and fat composition) have beenconsidered, men have been found to consume 38 percent more alcohol thanwomen (Dawson & Archer, 1992). Despite the large differences inconsumption, women still have a greater sensitivity to the negativeeffects of alcohol due to lower bodyweights or less total body water(i.e., muscle mass) or both, and fewer alcohol metabolizing enzymes suchas alcohol dehydrogenase alcohol dehydrogenase/al��co��hol de��hy��dro��gen��ase/ (ADH) (de-hi��dro-jen-as) an enzyme that catalyzes the reversible oxidation of primary or secondary alcohols to aldehydes; the reaction is the first step in the metabolism of alcohols by (NIH "Not invented here." See digispeak. NIH - The United States National Institutes of Health. , 2002). Frezza et al. (1990) found thatgastric alcohol dehydrogenase activities were 70-80% higher innonalcoholic men than nonalcoholic women which would have a significantimpact on how fast alcohol is metabolized. Combined-use and Energy Drink Studies Studies on the combined-use of alcohol and EDs show that it canlead to increased alcohol use, risk-taking, and consequences(O'Brien et al., 2008; Oteri, Salvo, Caputi, & Calapai, 2007;Thombs et al., 2010; Woolsey, Waigandt, & Beck, 2010). Miller(2008a) found that the frequency of ED consumption was associated withincreased marijuana use, sexual promiscuity, fighting, and taking risks.ED use has also been linked to increased smoking, alcohol use/problems,and illicit prescription drug prescription drugPrescription medication Pharmacology An FDA-approved drug which must, by federal law or regulation, be dispensed only pursuant to a prescription–eg, finished dose form and active ingredients subject to the provisos of the Federal Food, Drug, use (Miller, 2008a; 2008b; O'Brien etal., 2008). Woolsey & Kensinger (2009) found that ED use amongcollege students was significantly correlated with the illicit use ofamphetamine amphetamine(ămfĕt`əmēn), any one of a group of drugs that are powerful central nervous system stimulants. Amphetamines have stimulating effects opposite to the effects of depressants such as alcohol, narcotics, and barbiturates. based medications such as Adderall. O'Brien et al.,(2008) found that when alcohol was mixed with EDs it lead to significantincreases in alcohol related consequences including being takenadvantage of sexually, riding with an intoxicated driver, and being hurtor injured. Mounting evidence suggests EDs are not safe as they havebeen linked to increased drinking and driving (Thombs et al., 2010;Woolsey et al., 2010), seizures, strokes, arrhythmias/heartpalpitations, and even deaths (Iyadurai & Chung, 2007; Kapner, 2004;Walsh, Marquardt, & Albertson, 2006; Worrall, Phillips, &Henderson, 2005). The Current Study Among college students, athletes have been identified as beingamong the heaviest users and to be susceptible to experiencing seriousalcohol related consequences (Leichliter, Meilman, Presley, &Cashin, 1998; Martens, Dams-O'Connor, & Beck, 2006; Nelson& Wechsler, 2001). Research indicates that college athletesparticipate in more alcohol related risk-taking and experience moreconsequences from alcohol when compared to other college students (Ford,2007; Leichliter, Meilman, Presley, & Cashin, 1998; Martens,Dams-O'Connor, & Beck, 2006; Wechsler, Davenport, Dowdall,Grossman, & Zanakos, 1997). Therefore, the current studyinvestigated how EDs affect the existing problems among NCAA athletes.This study measured alcohol-only, combineduse, and ED-only consumptionrates and was the first to explore differences between men and womenathletes when comparing alcohol-only to combined-use. METHODS Participants In the Fall of 2006, a total of 401 of 456 registered NCAAstudent-athletes (257 male and 144 female) from a large Division-IMidwestern University voluntarily participated in this study. The sampleconsisted of 18 to 23+ year olds with an average age of 19.80 from everysport offered at the university. Descriptive statistics descriptive statisticssee statistics. from the QuickDrink Screen (QDS QDS Questionnaire Development System (trademark of NOVA Research Company)QDS Quarter Degree SquareQDS Quote Dissemination System (NASD)QDS quater die sumendus ) instruments indicated that 150 athletes combinedalcohol with EDs. Combined-use was defined as using an ED within plus orminus four hours of using alcohol. The time determination was made byexamining previous ED studies and the half-life of caffeine and otheringredients. After data screening, 18 cases of combined-users wereremoved for missing or incomplete data on the expectancy measures. Thecombined-use sample (n = 132) contained 91 men (68.9%) and 41 women(31.1%) with an average age of 20.0 (SD = 1.30) years. Permission wasobtained from the campus Institutional Review Board and theintercollegiate athletics department. Participants were recruited asentire teams at designated meetings. All coaches and personnel wereremoved from the area to protect athletes' privacy. Participationwas confidential and voluntary with no consequences for notparticipating. Measures This study used the Quick Drink Screen (QDS) for alcohol use(Sobell et al., 2003) and a modified QDS for combined and ED-only use.The QDS is a quantity-frequency and daily estimation measure thatprovides a retrospective estimate of a person's average alcoholconsumption. The QDS contains four drinking variables and has been shownto be highly reliable and consistent when compared to the 12-monthTimeline Followback (TLFB TLFB Timeline Followback Method (alcoholism); Roy et al., 2008). In comparison to the TLFBthe QDS produces highly reliable aggregate drinking data and only takes3-5 minutes to administer versus 20-30 for the TLFB, making the QDSbetter when multiple measures are used. Two modified versions of the Brief Comprehensive Effects of Alcohol(B-CEOA; Ham, Stewart, Norton, & Hope, 2005) compared male andfemale athletes' reported risk-taking and negative consequenceswhen using alcohol-only and combining. The B CEOA CEOA Commercial Executive Online AdvertisingCEOA Central European Operating AgencyCEOA Center for Earth Observations & Applications (Scripps Institution of Oceanography, UCSD)assessesdrinkers' risk-taking and consequences of alcohol consumption. Itcontains a subset of 15 items that measures expectancies and valuationswhile using alcohol (Ham et al., 2005). At the time ofthis study, noexisting measures were available to assess combined-use. Therefore, 12additional questions were added to the end of the original B-CEOA withadvisement Deliberation; consultation.A court takes a case under advisement after it has heard the arguments made by the counsel of opposing sides in the lawsuit but before it renders its decision. ADVISEMENT. from well established alcohol researchers. This resulted in amodified B-CEOA instrument and a combined-use instrument that theresearchers named the Brief Comprehensive Effects of Combined Use(B-CEOCU). Participants indicated if the particular effects would happento them while under the influence of both alcohol-only and combined-useon a scale ranging from 1 (disagree) to 4 (agree) and whether the effectwould be good or bad on a second scale ranging from 1 (bad) to 4 (good).For more details see Ham et al. Data Analysis Possible differences in risk-taking and consequences wereinvestigated. One independent samples t test was used to compare meanscore differences between men and women on the alcohol-only (B-CEOA) andcombined-use (B-CEOCU) scales. To check internal consistency of eachscale, Cronbach's Alpha was performed and the risk-taking andconsequence scales were internally consistent with a Cronbach'sAlpha of .726 for risk-taking and .737 for consequences. Each scaleconsisted of 10 preselected risk-taking and consequence variables (SeeAppendix A). The variables for these scales were selected with help froman expert committee of well established alcohol researchers. To test thehypotheses, the means of the 10 variables were summed to create a totalrisk-taking and consequence score. Participants selected a numericalscore of 1-4 for each question (1 = Disagree, 2 = Slightly Disagree, 3-- Slightly Agree, 4 = Agree). The total possible score for each scalewas 40 points, with higher scores indicating increased potentialrisk-taking and consequences. The additional variables not used forhypothesis testing were used in data screening to cross check theconsistency of answers. RESULTS Descriptive statistics from the total QDS sample (N = 401)indicated that 48% of college athlete drinkers (n = 315) combinedalcohol with EDs in the past year. 315 of 401 athletes (78.6%) usedalcohol, 150 combined alcohol and EDs, and 194 (48.4%) used EDs withoutalcohol. Twenty-two of 86 (25.6%) non-alcohol drinking participantsreported using EDs in the past year. 290 (92.1%) reported alcohol bingedrinking with binging defined as "5 or more drinks on oneoccasion." The gender specific alcohol binge measure was not usedin order to keep the QDS instrument intact and to avoid confusion withmultiple measures being used (Sobell et al., 2003). Descriptive statistics for the combined-use sample (n = 132)indicated that 104 or 78.79% of athletes reported using EDs withoutalcohol. Alcohol binge drinking was very high among combined-users with103 of 105 males (98.1%) and 39 of 40 (97.5%) females reporting alcoholbinging in the previous year. A high percentage also participated in"energy-binge" drinking while using alcohol with 68 of 107male (63.55%) and 24 of 40 (60%) female respondents using 3 or more EDson one occasion. The "energy-binge" is considered a high-riskdrinking behavior because of the mega doses of vitamins/herbals andstimulants when consuming multiple ED servings (Woolsey, 2007; Woolseyet al., 2010). Without using alcohol, only 43 athletes (32.58%) consumed3 or more EDs in the previous year. Additionally, the average number ofenergy-binge episodes with alcohol was 8.21 (SD = 16.5) times in thepast year compared to 2.69 (SD = 8.83) without alcohol. Interestingly,only 31 combined-users [16 male, 15 female] reported consuming EDswithout alcohol and Among athletes who abstained from alcohol use (n =86), 17 of 57 (29.8%) males and 5 of 29 (17.2%) females reported usingEDs (See Table 1). Significant differences were found between men and womencombined-users on the average amount of alcohol consumed while drinkingalcohol only, t(126) = 7.33, p < .001 and during combined-use, t(122)= 5.32, p < .001. Males consumed an average of 10.12 alcoholic drinks(SD = 5.33) per occasion when drinking alcohol only compared to anaverage of 7.31 alcoholic drinks (SD = 4.75) while combining alcoholwith EDs. Females consumed an average of 5.17 drinks (SD = 2.28) whendrinking alcohol only compared to 3.91 drinks (SD = 2.23) duringcombined-use. Contrary to other reports, combined-users consumed morealcohol when they used alcohol without EDs (see discussion). Significantdifferences were also present on the average amount of EDs consumedduring ED-only episodes, t(131) = 2.14, p = .029 compared tocombined-use episodes, t(131) = 2.23, p = .028. When combining EDs andalcohol, males consumed an average of 2.39 EDs (SD = 2.49) per occasioncompared to 1.70 EDs (SD = 1.10) for females (See Table 1). The first hypothesis tested differences in combined-use risk-takingbetween men and women. Levene's test of equality of variance wasperformed and was not significant, indicating that equality of varianceassumption was not violated. One t test on the risk-taking scaleindicated that gender on combined-use risk-taking was highlysignificant, n = 130, t(128) = 4.45, p < .001, with an effect size of.85. The average mean score on the combineduse risk-taking scale was27.66 for males (SD = 5.11, SE = .54), and 23.31 for females (SD = 5.10,SE = .82), with a mean difference of 4.35, indicating that men reportedmore risk-taking. After testing the research hypothesis, separate exploratory t-testswere performed to examine differences on the individual items within therisk-taking scale. Men reported higher scores than women on all 10risk-taking variables, with significant differences on 4 questions: (1)I would enjoy sex more t(129) = 3.19, p = .002 (2) I would actaggressively t(129) = 3.37, p = .001 (3) I would drive a motor vehiclet(116) = 4.04, p = .001 (4) I would be more likely to fight t(129) =4.82, p = .001. Results indicated that under the influence of alcoholand EDs men reported that they would enjoying sex more, act moreaggressively, be more likely to drive a motor vehicle, and be morelikely to fight than women. Table 2 summarizes exploratory t-testresults for the 10 risk-taking variables. The second research hypothesis examined differences in combined-useconsequences. One t test on the consequence scale indicated that genderon combined-use consequences was not significant, n = 131, t(129) =-1.80, p = .074, with an average mean score of 25.54 for males (SD =5.70, SE = .60), and 27.45 for females (SD = 5.23, SE = .83). Thishypothesis was not significant but is mentioned, because women reportedoverall higher consequence scores after consuming considerably lessalcohol and EDs than men. Separate exploratory t-tests after hypothesistesting revealed that women reported higher mean scores on all tenquestions within the consequence scale; however, only one item "Iwould feel guilty" was statistically significant t(129) = -2.48, p= .014. DISCUSSION It should be noted that previous studies on the main ingredients ofEDs have shown positive effects when mixed with alcohol includingreductions in alcohols' intoxicating and sedating effects (Ferreiraet al., 2004). B-vitamins have been evaluated for their effects onalcohol and have shown to reduce alcohol intoxication and hangovers,particularly at high dosages (Kelly, Myrsten, & Goldberg, 1971;Moretti, Ciceri, & Suchowsky, 1969; Muir, Pollitt, & Rooney,1973). Glucose has been shown to aid in alcohol metabolism and act as astimulant by accelerating heart rate (Kennedy & Scholey, 2000).Liguori and Robinson (2001) observed improvements in psychomotor psychomotor/psy��cho��mo��tor/ (si?ko-mo��ter) pertaining to motor effects of cerebral or psychic activity. psy��cho��mo��toradj.1. performance under the influence of alcohol in individuals after theingestion ingestion/in��ges��tion/ (-chun) the taking of food, drugs, etc., into the body by mouth. in��ges��tionn.1. The act of taking food and drink into the body by the mouth.2. of 400 mg of caffeine. It may be considered counterproductive to discouraging the practiceof combined-use, but EDs do have real positive effects when used withalcohol. Therefore, practitioners should not ignore this when addressingcombined-use. Whether or not EDs reduce alcohol intoxication in humansreally remains to be seen. The doses tested with alcohol previously onhumans were relatively low compared to the amounts consumed by athletesin this study (Ferreira, Mello, Pompeia, & Souza-Formigoni, 2006).Additionally, the high levels consumed by athletes would be closer tothe amounts that it took to show significant reductions in animals(Ferreira et al., 2004). In this study, the average greatest number ofEDs on one occasion was 3.77 (SD = 3.42) for males and 2.59 (SD = 1.50)for females and it was not uncommon for men to report consuming 5 ormore EDs with alcohol. Bodyweights and hours of consumption were notmeasured, because athletes are an IRB IRBSee: Industrial Revenue Bond specially protected group.Therefore, adjustments could not be made to measure the extentdifferences between men and women were due to blood alcohol, caffeineand other ingredient amount differences. However, in recent studies, wehave measured and began examining these variables. Beyond differences inalcohol metabolism, differences in caffeine metabolism and othercompounds should be considered as birth control is known to considerablyextend the half-life of caffeine to 5-10 hours (Meyer et al., 1991). EDs contain mega-doses oftaurine, B-vitamins, and other substanceswhich could be toxic to users through prolonged use. A major concern isthat there have not been enough long term studies to determine thesafety of ED ingredients. In the United States, ED manufacturers areable to avoid FDA regulation because they are classified as"dietary supplements" and therefore are not subject to thesame safety guidelines as other drinks such as soda (FDA, 2007).However, this has not stopped ED manufacturers from marketing theirproducts as drinks. Perhaps people would be more cautious if theyunderstood that EDs are not regulated or "recognized as safe"(FDA, 2007). According to the current FDA standards, "other thanthe manufacturer's responsibility to ensure safety, there are norules that limit a serving size or the amount of a nutrient in any formof dietary supplements" (2010). Notice the use of the words"dietary supplements." Most EDs use the wording "energysupplements" in fine print. Therefore, companies selling billionsof dollars of EDs each year are the ones making the safety decisions forconsumers. Clearly, consumer health interests are not the main focus.Everyone should be aware that the amounts of ingredients in EDs do notrequire FDA review or approval. Essentially EDs (even 5-hour energy) work like drugs by causing aneurotransmitter high followed by a low a few hours later. Due to EDsneurotransmitters effects and links to increased use of alcohol andother drugs, EDs have been considered as gateway-drugs (Woolsey, 2010).Health reports since the introduction of EDs indicate substantialincreases in depression and anxiety disorders, both of which are highlyrelated to the neurochemical neu��ro��chem��is��try?n.The study of the chemical composition and processes of the nervous system and the effects of chemicals on it.neu systems EDs effect (Strine et al., 2008).We are already seeing more physical and psychological health problemsamong our youth from ED use, and we can expect this to continue unlesschanges are made. Neurological & Psychological Implications of Energy Drink Use Due to the pharmacodynamics pharmacodynamics/phar��ma��co��dy��nam��ics/ (-di-nam��iks) the study of the biochemical and physiological effects of drugs and the mechanisms of their actions, including the correlation of their actions and effects with their chemical of ED ingredients and the adverseneurological adaptations to prolonged use, people who regularly use EDsare likely to suffer from neurotransmitter imbalances that increase thechances of developing anxiety and depressive disorders. Describing theingredients and complex neurological and biochemical cascades resultingfrom ED use is a complete paper in itself; however, one can start byexamining the pharmacological actions of ED ingredients (includingstimulant and anxiolytic effects) on the brain's stress (amygdala amygdala/amyg��da��la/ (ah-mig��dah-lah)1. almond.2. an almond-shaped structure.3. corpus amygdaloideum.a��myg��da��lan. pl. )and neurotransmitter systems. Several ingredients such as taurine andinositol are known for their modulatory or regulatory effects onneurotransmitters and the CNS See Continuous net settlement. CNSSee continuous net settlement (CNS). . Taurine acts like an anti-anxiety agentby effecting GABA and glycine receptors (Olive, 2002; Zhang & Kim,2007). Inositol is a serotonin modulator ModulatorAny device or circuit by means of which a desired signal is impressed upon a higher-frequency periodic wave known as a carrier. The process is called modulation. The modulator may vary the amplitude, frequency, or phase of the carrier. and has successfully been usedas an anti-depressant medication (Nick, 2004; Fux, Levine, Aviv, &Belmaker, 1996). Like drugs of abuse, stimulant ingredients in EDs(evodamine, yohimbine, ginseng, caffeine, et al.) work by causing alarge release or prolonged action, or both, of pleasure-rewardneurotransmitters (dopamine and serotonin) and stress hormones(nor-adrenaline and adrenaline), which in turn provide a short term highfollowed by a low. There are ingredients in EDs such as L-tyrosine thatare precursors to producing neurotransmitters such as dopamine andnor-epinephrine (Rasmussen, Ishizuka, Quigley, & Yen, 1983).However, these will not replenish or balance out the deleteriousneurotransmitter and negative neurological effects of regular ED use(Miller & Carroll, 2006, Ch. 3). As a result, over using EDs raisesusers' neurotransmitter thresholds and can damage pleasure-rewardreceptor sites, which results in more drug craving, thrill seeking, orboth, to satisfy homeostatic homeostaticpertaining to homeostasis. deficiencies in brain chemistry (Miller& Carroll, 2006). These negative neurological adaptations result inmore time feeling tired and greater future chances of developing anxietyand depressive disorders. This is important because research indicatesthat significant brain modeling occurs to age 20, and those under 25 areat-risk for addictions due to incomplete development of the memory(hippocampus), stress, and pleasure-reward systems of the brain (Lubman,Yucel, & Hall, 2007; Miller & Carroll, 2006). Effective Brief Behavioral Interventions There are effective alcohol interventions available such as theBrief Alcohol Screening and Intervention for College Students BASICS(Dimeff, Baei, Kivlahan, & Marlatt, 1999). BASICS programs currentlydo not have an ED component which would be a good addition. BASICS drawsheavily from both cognitive-behavioral skills training and MotivationalInterviewing (MI). MI is a patient-centered brief behavioralintervention behavioral interventionBehavior modification, behavior 'mod', behavioral therapy, behaviorism Psychiatry The use of operant conditioning models, ie positive and negative reinforcement, to modify undesired behaviors–eg, anxiety. that applies well to substance abuse and a wide range ofhealth behaviors (Rollnick, Miller, & Butler, 2008). MI is a highlyeffective tool for managing resistance and ambivalence toward change.Metaanalyses and other reviews have supported the efficacy of MI-basedinterventions versus control conditions (Burke, Arkowitz, & Rivara,2003; Larimer & Cronce, 2007). The focus of MI is using a positivecommunication style to build clients' self-efficacy by helping themachieve their goals in a nonjudgemental and collaborative way. Thisprocess involves the clinician eliciting change talk from the client andallowing the client to present personal reasons for a desired change(Rollnick et al., 2008). Based largely on the Transtheoretical Model ofbehavior change, MI focuses on personal needs and motivations and hasbeen shown to be particularly effective when people are in theprecontemplative and contemplative stages of change (Rollnick et al.,2008). The great benefit of using MI is that it meets people at theircurrent readiness or stage of change and builds from there. Thus, MIeffectively reduces peoples' natural ambivalence and resistance tochange and allows the practitioner to actually help people they want tothe most. MI is an effective way to build stronger beliefs in one'sabilities to make good autonomous decisions to maintain long-termchanges. RECOMMENDATIONS To develop more effective prevention programs positive motivationsfor ED use should be explored further. By better understanding how usersexpect EDs to positively impact their alcohol drinking experience, wecan better predict their future drinking behavioral choices. Programsneed to focus on how to achieve desired positive outcomes throughalternative methods such as the utilization of cognitive controlstrategies. Practitioners should assess what students already know aboutEDs and selectively share information when given permission or whenpeople indicate they are ready to change (Rollnick, Miller, &Butler, 2008). Clinicians should acknowledge that there are positives ofusing EDs which is why people continue to use them despite knowing manyadverse consequences. In order to achieve regulation of EDs, researchers should move awayfrom placing such a large emphasis on caffeine. Because of theubiquitous sale of other caffeine containing drinks such as coffee,continuing to focus on caffeine as we have previously, will likelyresult in further regulatory delays. However, since ED manufacturerstarget young populations, it is a good idea to continue to focus on thepharmacology of caffeine (e.g., effects on dopamine receptors), and howcaffeine use negatively affects adolescent and young adult hippocampal hip��po��cam��pus?n. pl. hip��po��cam��piA ridge in the floor of each lateral ventricle of the brain that consists mainly of gray matter and has a central role in memory processes. and amygdala brain development. Previously there has not been enoughemphasis placed on how the other ingredients in EDs affect brainchemistry and the neurological implications for those under the age of25. Placing an emphasis in these areas and focusing less on caffeinewould help in obtaining swift regulation of these beverages. Specialprecautions need to be taken to protect people from the growing trend ofenergy shots and newer herbal ingredients such as evodamine.Furthermore, consumers need to be made more aware that caffeine contentson EDs labels do not accurately include herbal forms of caffeine. EDs contain drugs and several ingredients that work like drugs.Therefore, energy drinks should be required to be marketed and sold as'supplements containing drugs' to more accurately representthe risks of these products to consumers. When combining EDs withalcohol, it is not uncommon for students to partake in"energy-binge" drinking episodes (Woolsey & Kensinger,2009). Therefore, manufacturers should be required to disclose thepotential dangers of consuming multiple servings of these supplementscontaining drugs that are already well above daily required nutritionalvalues. This wording change would help consumers make better beveragechoices and to be more aware of the potential dangers. CONCLUSIONS With increases in ED strength and the introduction of energy shotssuch as Redline Power Rush containing 350 mg of caffeine in 2.5 ounces(Energyfied, 2009), the dangers of EDs are greater than just a few yearsago. Multiple studies indicate that adolescents and young adults have ahard time seeing future consequences and can be easily enticed by theimmediate pleasures and rewards of mind altering substances (Miller& Carroll, 2006), particularly in reinforcing social environmentssuch as college bars (White, 2008). Adolescents and college students areat a prime age for developing physical and psychological dependencies toalcohol and EDs due to incomplete development of the stress,pleasure-reward, impulse control impulse controlPsychology The degree to which a person can control the desire for immediate gratification or other; IC may be the single most important indicator of a person's future adaptation in terms of number of friends, school performance and future , and addiction centers of the brain(White, 2008; Miller & Carroll, 2006). Therefore, specialprotections should be put in place to protect our youth. Within college students, athletes have already been identified ashaving increased problems from alcohol. Results of this study indicatethat athletes have even greater problems from combined-use. To betterserve clients, it is important for practitioners to understand how theingredients of EDs effect brain chemistry and development and resultantclient motivations. Practitioners need to study and understand theneurological and biochemical behavioral influences that these substanceshave on human decision making and well being (See Figure 1). Alcohol anddrug prevention programs will be improved by more people being able toeffectively and accurately communicate how these substances work. Given the physical and psychological health risks, it is time torethink ED use and for regulatory changes. People need to be more awarethat EDs are only a quick fix for energy, and that regular use willeventually lead to more time feeling tired, anxious, or depressed. EDsdo not actually "supplement energy" but instead cause therapid and/or extended release of neurochemicals and stress hormones fromwithin our bodies. Therefore, long-term or regular use, or both, willeventually result in more time feeling tired, anxious, and depressed dueto deficiencies and/or increased pleasure-reward neurotransmitterthresholds. With every high there comes an inevitable low or crash, andthe more artificial 'highs' one experiences by using EDs themore at-risk they are to develop brain imbalances or deficiencies inneurotransmitters that influence how we think, feel, and perform. [FIGURE 1 OMITTED] This image is a work of the National Institutes of Health, part ofthe United States Department of Health and Human Services United States Department of Health and Human Services (USDHHS),n.pr a cabinet-level government organization comprising 12 agencies, including the Food and Drug Administration and the Centers for Disease Control and Prevention. . As a work ofthe U.S. federal government, the image is in the public domain.APPENDIX A.Risk-Taking and Consequence Scale Variables by Item NumberRisk-Taking Variables1. I would enjoy sex more 1 2 3 46. I would be brave and daring 1 2 3 47. I would be courageous 1 2 3 48. I would act 1 2 3 414. I would take risks 1 2 3 416. I would be more alert 1 2 3 417. I would feel stronger 1 2 3 422. I would sober up quicker 1 2 3 423. I would drive a motor vehicle 1 2 3 424. I would be more likely to fight 1 2 3 4Consequence Variables:2. I would feel dizzy 1 2 3 43. I would be clumsy 1 2 3 44. I would be loud boisterous or noisy 1 2 3 49. I would feel guilty 1 2 3 411. I would feel moody 1 2 3 418. I would not sleep well 1 2 3 420. I would be nervous or jittery 1 2 3 425. I would get a hangover 1 2 3 426. I would experience a rapid heartbeat 1 2 3 427. I would be more likely to get injured 1 2 3 4 REFERENCES Agriculture and Agri-Food Canada The Department of Agriculture and Agri-Food, also referred to as Agriculture and Agri-Food Canada (AAFC) (French: Agriculture et Agroalimentaire Canada), is the department of the government of Canada with responsibility for policies governing agriculture . (2008). The energy drink segmentin North America. The Government of Canada The Government of Canada is the federal government of Canada. 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Correspondence concerning this article should be addressed to:Conrad Woolsey, PhD, CHES; Assistant Professor and Sport PsychologyConsultant; School of Applied Health & Educational Psychology;Oklahoma State University Oklahoma State University,at Stillwater; land-grant and state supported; coeducational; chartered 1890, opened 1891 as Oklahoma Agricultural and Mechanical College, renamed 1957. ; 2107 Main Hall; 700 North Greenwood Avenue,Tulsa, OK 74106; Phone: (918) 594-8368; Email:conrad.woolsey@okstate.edu. Conrad Woolsey, Ph.D., CHES Oklahoma State UniversityTABLE 1Alcohol-only, Combined, & Energy Drink QDS Statistics (n = 132)Quick Drink Screen Variables Male Female N M SD N M SDAlcohol-only days/week 91 1.94 0.93 41 1.38 0.90Combined-use days/week 91 0.88 0.78 41 0.79 0.93Energy drinks only days/week 91 1.52 2.49 41 0.63 0.99Average # alcoholic drinks 88 10.12 5.33 39 5.17 2.28Average # alcohol drinks 85 7.31 4.75 38 3.91 2.23 comb.Average # EDs Combined 91 2.39 2.49 41 1.70 1.10Average # EDs-only 91 1.06 0.92 41 0.56 0.65Greatest # of alcoholic 91 21.76 10.42 41 10.38 5.38 drinksComb. greatest # alco. drinks 91 12.88 8.42 41 6.29 4.05Combined greatest # EDs 91 3.77 3.42 41 2.59 1.50ED-only greatest # EDs 91 2.59 3.57 41 0.98 0.99TABLE 2Risk-Taking Exploratory t-test Results Comparing Males (n = 91)and Females (n = 40)Variable (I would ...) Male Female M SD M SDEnjoy sex more 2.81 1.05 2.18 1.06Be brave and daring 3.09 0.94 3.00 0.91Be courageous 3.12 0.84 2.80 0.99Act aggressively 2.97 1.07 2.28 1.11Take risks 3.24 0.79 3.15 0.86Be more alert 2.79 0.96 2.48 1.13Feel stronger 2.77 1.04 2.43 1.17Sober up quicker 2.12 1.04 1.85 0.96Drive a motor vehicle 1.95 1.12 1.30 0.69Be more likely to fight 2.80 1.14 1.80 0.99Variable (I would ...) Independent Samples t test [M.sub.dif] ES t df sig.Enjoy sex more 0.64 0.58 3.19 129 .002 *Be brave and daring 0.09 0.11 0.50 129 .619Be courageous 0.32 0.38 1.90 129 .059Act aggressively 0.69 0.58 3.37 129 .000 **Take risks 0.09 0.13 0.59 129 .554Be more alert 0.32 0.30 1.64 129 .103Feel stronger 0.34 0.31 1.67 129 .097Sober up quicker 0.27 0.27 1.41 128 .161Drive a motor vehicle 0.65 0.70 4.04 116 .000 **Be more likely to fight 1.00 0.94 4.82 129 .000 *** n < .01, ** n < .001