It is time to ban the sale of energy drinks to children in the UK

Guest post by Prof Amandine Garde, Dr Amelia Lake and Dr Shelina Visram

In 2016 in the UK alone we consumed 679 million litres of high sugar, high caffeine drinks known as “energy drinks”. Described as the fastest growing sector of the soft drink market, they have become a major public health concern and have been subject to both a House of Commons Science and Technology Committee Enquiry (April – December 2018) and a Department of Health and Social Care consultation (which closed on 21 November 2018).

In the report it published on Tuesday (4 December), the Committee found that “the current quantitative evidence alone is not sufficient to warrant a statutory ban”, though it noted that “societal concerns could justify a ban on the sale of energy drinks to children”. This conclusion is puzzling for several reasons.

Energy drinks and children

Firstly, a growing body of evidence has established that energy drinks consumption, particularly by children, is associated with a wide range of harmful effects.

• Whilst childhood and adolescence are periods of rapid growth requiring adequate sleep and good nutrition, energy drinks play a role in disrupting sleep (1 - see references below).
• It is established that energy drinks are highly erosive in terms of dental health: they have low pH and a high non-reducing sugar content (2).
• Consumption is also linked to increased energy intake and therefore obesity (3). Hence the proposal of the UK Government to ban the sale of energy drinks to children in the second iteration of its Childhood Obesity Action Plan, published in August 2018, and the public consultation that followed.
• However, energy drinks consumption is also linked to physical symptoms such as headaches, stomach aches and sleeping problems (with some evidence of a dose-response effect), as well increased risk-taking behaviours, including binge drinking, smoking, illicit drug use, screen time and poor dietary behaviours (4). Moreover, mixing energy drinks with alcohol increases the risk of injury and unsafe driving (5) and 6).

Secondly, the Committee has failed to engage with the fact that gathering “quantitative evidence” on the impact of energy drinks on child health would be unethical (other than the aforementioned studies, which tend to involve large-scale, school-based surveys).

To our knowledge, there have been no experimental studies involving children’s use of other age-restricted products such as alcohol, tobacco, aerosols, solvents, fireworks, knives, crossbows, petrol or even Christmas crackers (sales of which are restricted in England to those aged 12 and over). Why should energy drinks be subjected to a higher standard of evidence than any of these products?

Thirdly, the evidence base has not prevented other countries from regulating the sale of energy drinks to children. In Europe, Lithuania introduced a ban on the sale of these drinks to under 18s in 2016, followed by Latvia, whilst Norway and Sweden are reflecting on similar legislation.

It is therefore unclear why the Committee has concluded that existing evidence is insufficient to adopt a similar law in the UK. The rationale seems to lie in the absence of a “causal link” between energy drinks consumption and childhood obesity, tooth decay and other diet-related diseases. This arguably demonstrates a lack of understanding by the Committee of the strategies required to address complex and multifactorial nature of these diseases.

It is indeed difficult to establish a causal link between the various measures adopted and the burden of non-communicable diseases: no single policy option can realistically tackle broad phenomena, such as growing obesity rates or tooth decay, when taken in isolation.

Governments must ensure that public health is effectively protected, and they can invoke the precautionary principle in the event of any outstanding scientific uncertainty regarding the impact of energy drinks consumption on public health. Hence, probably, the acknowledgement from the Committee that “it would be legitimate for the Government to go beyond the evidence that is available at the moment and implement a statutory ban based on societal concerns and evidence, such as the experience of school teachers and pupils”.

The logic of their reasoning is nonetheless difficult to follow. There is no doubt that the Government should introduce legislation banning the sale of energy drinks to children, following the lead of Lithuania and Latvia. This would not amount to going beyond the evidence; it would be acting on the basis of existing evidence. It is this body of evidence that has prompted very real and major societal concerns of the effects of energy drinks on our children’s health.

Fourthly, the call of the Committee for more effective labelling measures should not be envisaged as providing an alternative to a ban on the sale of energy drinks to minors; it should only be viewed as complementing such a ban. This is all the more so as labelling could increase existing health inequalities. Children and young people from all backgrounds consume energy drinks. However, as the Committee has noted “energy drinks are consumed disproportionately by disadvantaged groups”.

There may indeed be a link between regular consumption of energy drinks and eligibility for free school meals (FSM), which is often used as an indicator of lower socio-economic status. The 2018 Health-Behaviour in School-Aged Children Survey found that, among those who reported that they drank at least one energy drink per day, 23% received FSM, whereas those who said that they never drank energy drinks or did less than once a week, 11% received FSM (compared to 13% of FSM recipients across the whole sample). A study conducted in schools in the South West England also found that being eligible for FSM was significantly associated with drinking energy drinks once a week or more (Richards and Smith, 2016).

Energy drinks have no place in a healthy diet

Finally, the Committee does not seem to be aware that the Government has a duty to protect the rights of all children to the enjoyment of the highest attainable standard of health and to adequate nutritious food. Energy drinks have no place in a healthy diet. Shifting the responsibility of protecting them onto business actors, such as food manufacturers or food retailers, is highly problematic, not only because a voluntary ban will fail to create the level playing field within which all these actors should operate, but also because it will fail to protect child health and their rights and cannot therefore contribute to an effective obesity prevention strategy.

The Responsibility Deal has failed; regulatory measures that apply to all and are duly enforced are required to address the growing burden of obesity, tooth decay and other diet-related diseases. The conclusion that a statutory ban would be too restrictive is ideological rather than grounded in evidence.

A statutory ban is the most likely measure to ensure that children and young people are effectively protected from the many harmful effects of energy drink consumption.


About the authors:

• Professor Amandine Garde, Professor of Law and Director of the Law & Non-Communicable Diseases Unit at the University of Liverpool. 
• Dr Amelia Lake, Associate Director of Fuse - the Centre for Translational Research in Public Health and Reader in Public Health Nutrition at Teesside University. Amelia is a Dietitian and registered Public Health Nutritionist. 
• Dr Shelina Visram, Programme Lead of the Complex Systems Research Programme for Fuse - the Centre for Translational Research in Public Health and Senior Lecturer in Public Health at Newcastle University.

The views expressed here are those of the authors and do not necessarily reflect those of the author's employer or organisation.

References:

1. Do sleeping habits mediate the association between time spent on digital devices and school problems in adolescence?
2. Short Communication: In vitro assessment of Erosive Potential of Energy Drinks
3. Systematic review of the literature on the effectiveness of product reformulation measures to reduce the sugar content of food and drink on the population's sugar consumption and health: a study protocol
4. Consumption of energy drinks by children and young people: a rapid review examining evidence of physical effects and consumer attitudes
5. Alcohol Mixed With Energy Drinks and Risk of Injury: A Systematic Review
6. Alcohol mixed with energy drink use among U.S. 12th-grade students: Prevalence, correlates, and associations with unsafe driving

Young people in the UK drink more energy drinks than any other countries in Europe

Posted by Amelia Lake, Associate Director of Fuse and Reader in Public Health Nutrition at Teesside University and Shelina Visram, Senior lecturer in public health at Newcastle University

It would be a bit shocking to see children and teenagers drinking espressos, yet it’s socially acceptable for young people to reach for energy drinks to give them a quick “boost”.

Energy drink sales in the UK are now worth more than £2 billion a year

Unaffected by the economic crisis, energy drinks are the fastest growing sector of the soft drinks market. Between 2006 and 2012 consumption of energy drinks in the UK increased by 12.8% – from 235m to 475m litres.

These drinks are very popular with young people – despite coming with a warning (in small letters on the back) that they are “not recommended for children”. A survey conducted across 16 European countries found that young people between the ages of ten and 18 in the UK consume more energy drinks on average than young people in other countries – just over three litres a month, compared to around two litres in other places.

More than two-thirds of young people surveyed in the UK had consumed energy drinks in the past year. And 13% identified as high chronic consumers – drinking them four to five times a week or more. Research also suggests that these drinks are more popular with boys and young men.

What goes into energy drinks?

Energy drinks are usually non-alcoholic and contain ingredients known to have stimulant properties. They are marketed as a way to relieve fatigue and improve performance: “Red Bull gives you wings”.

They contain high levels of caffeine and sugar in combination with other ingredients, such as guarana, taurine, vitamins, minerals or herbal substances. A 500ml can of energy drink for example, can contain 20 teaspoons of sugar and the same amount of caffeine as two cups of coffee.

Caffeine stimulates the central and peripheral nervous system. Consumed in larger doses, it can cause anxiety, agitation, sleeplessness, gastrointestinal problems and heart arrhythmias.

In the UK, there are no clear recommendations for caffeine intake for adults or children, although both the Food Standards Agency and the British Soft Drinks Association recommend that children should only consume caffeine in “moderation” and that caffeine content over [150mg/l] should be declared on the packaging. The current scientific consensus is that [less than 2.5 mg a day] in children and adolescents is not associated with adverse effects.

Should we be worried?

The evidence indicates that these drinks do not give you wings – or any other positive benefits. In fact their intake in young people, is associated with adverse health outcomes. There is growing evidence of the harmful effects of these drinks. Teachers are concerned about the detrimental impact these drinks have on pupils in their classrooms. There is also a known association between soft drink intake, dental erosion and obesity.

Lesser known are the effects of the cocktail of stimulant ingredients – such as guarana and taurine – contained within these drinks.

Our recent review of the scientific literature set out to look for any evidence of associations between children and young people’s consumption of energy drinks and their health and well-being – as well as their social, behavioural or educational outcomes.

We found that for young people, drinking energy drinks is associated with a range of adverse outcomes and risky behaviours. They are strongly and positively associated with higher rates of smoking, alcohol and other substance use – and linked to physical health symptoms such as headaches, stomach aches, hyperactivity and insomnia.

Why do young people buy them?

We also spoke with young people about their intake of these drinks. Discussions with our participants aged between ten and 14 indicated just how accessible and available these drinks are. They are also cheap – in some cases significantly cheaper than other soft drinks, as one of the girls we spoke to explained:

"I think it’s because like a normal can of Coke is like 70p, and [own brand energy drinks] are like 35p."

Our research found that energy drinks are often marketed on gaming sites and linked to sports and an athletic lifestyle – and are particularly aimed at boys. Taste, price, promotion, ease of access and peer influences were all identified as key factors in young people’s consumption choices.



Speaking with parents and teachers about these drinks there was confusion. Parents themselves identified the need for more information about energy drinks – and many admitted to not being fully aware of the contents and potential harmful effects on children.

Should they be banned?

Image used in a recent campaign led by Jamie Oliver
to ban the sale of energy drinks to under-16's

Recently there has been a move to restrict the sales of these drinks to under 16’s – an approach which has also been taken by other countries. This saw the self-imposed sales restriction by many larger retailers – including most supermarkets – to not sell to children under 16. But many places still continue to sell to young people – including convenience stores, which offer a wide range of brands, flavours and package sizes.

The Commons Science and Technology Committee’s enquiry into energy drinks called for submissions in April 2018 and will be reviewing in June 2018 – when we will also give oral evidence.

Of course, legislation to prevent the sales of energy drinks to under 16’s would be helpful. But the marketing of these drinks to young people through computer games and their association with sports is also a much wider issue. Far reaching discussions are needed about the direct and indirect marketing of these drinks (and other food and drinks) through multiple platforms other than TV – particularly through computer games.

This article was originally published on The Conversation. Read the original article.

What should we do about children and young people’s consumption of energy drinks?

Guest post by Shelina Visram, Fuse Associate and Lecturer in the Centre for Public Policy & Health, Durham University

Did you know that cigarettes are the only product on the market that, when used exactly as intended by their manufacturers, will kill around half of their users? And yet you can buy them legally in every country of the world, with the exception of Bhutan? But you probably knew that already (except maybe the bit about Bhutan). It’s just one example of the type of paradoxical situation that occurs when public health evidence suggests we should do something and this is then contradicted by the actions of government and industry.

Here’s another example: did you know that energy drink consumption by school-age children is linked to hyperactivity, risky behaviours and health complaints such as headaches and stomach aches? And yet children of any age can buy these drinks in a variety of shops? You may have heard that the supermarket chain Morrisons banned sales of energy drinks to under 16s, but this was a trial that ended in early 2015. Some retailers choose not to sell energy drinks to younger children – often in response to pleas from teachers at nearby schools – but they do this on a voluntary basis and have to accept that they will probably lose revenue as a result.

Regular readers of this blog may be aware that Fuse members have been involved in conducting research on youth energy drink consumption over the past couple of years (you can read previous blog entries here and here). You may have read our Fuse brief, seen us present our findings at a seminar or conference, or downloaded our report from the HYPER! study website. So why the renewed call for action? At a time when the Government’s delayed childhood obesity strategy has been described as "pathetic", we need to take every opportunity to push for clear messages around food and health. We have worked with the Food Research Collaboration (FRC) to produce a briefing paper – published today – that clearly sets out the main ingredients of energy drinks, the current market situation, the scientific evidence base, and existing interventions, ranging from school-based educational activities to country-wide bans. The paper concludes with a series of recommendations on what could (and should) be done by policy-makers and others to address this issue.

To go back to the example of cigarettes, we know that sales and marketing restrictions are key factors in preventing uptake of smoking by children and young people, even if they do not eradicate the problem completely. Obviously energy drinks are nowhere near as harmful as cigarettes. They do not kill one in two consumers. But, like all sugar-sweetened beverages, they do contribute to increasing levels of childhood obesity and type 2 diabetes, as well as poor dental health. By law, energy drink labels must include the following warning: “High caffeine content. Not recommended for children or pregnant or breastfeeding women”. So isn’t it time we stopped sending out conflicting messages and made it clear that these drinks are not suitable for children and young people?

Download the briefing paper Energy Drinks: What’s the evidence? written by Shelina Visram (Durham University) and Kawther Hashem (Action on Sugar).


Illustration: Cathy Wilcox via http://www.essentialkids.com.au/food/nutrition/caffeine-concern-over-teens-and-energy-drinks-20130905-2t6hb

Not just a can of pop: the social meanings of energy drinks

Posted by Mandy Cheetham, Fuse Research Associate at Teesside University

Children and young people can sometimes be conspicuous by their absence in public debates about sugary drinks, so I’ve enjoyed reading the series of blogs posted since September, which describe research and activities involving young people. As children and young people are the predominant consumers of sugary drinks, it is claimed they are one of the groups whose health will benefit most from efforts to control or reduce their consumption (FPH 2015), such as the introduction of a duty on sugary drinks advocated by PHE (2015) and popularised by Jamie Oliver.

Our study on energy drinks showed that cost was one of the major influences on young people’s choices. The mapping exercise we did with Year 6 and Year 9 students in their local area showed walls of cheap, appealing, attractive displays of multiple flavoured energy drinks to tempt young people, with ‘buy one, get one free’ offers to share with friends. As important as the economic considerations are, the social meanings of energy drinks also have a major role to play. These are often misunderstood or ignored by adults planning public health interventions to reduce the risks of obesity.

Young people described the social spaces in which they drink energy drinks, whether consumed at weekend sleepovers, whilst gaming, hanging out with mates in the park, or on the way to or from school. Shared, swapped, and exchanged, energy drinks, and the sponsorship, branding and marketing associated with them, are woven in to the social fabric of young people’s lives. Energy drinks are part of the construction and maintenance of particular gendered identities, associated with extreme sports, alien elimination, looking hard, sophisticated and / or attractive. They offer young people opportunities to conform to certain ideas about what girls and boys like and do, and become part of the currency of young people’s daily interactions. In short, social meanings matter.

In Wendy Wills’ presentation at the Sweetness, Social Norms and Schools seminar in September, (CPPH/Wolfson Seminar - Sweetness, social norms and schools: factors influencing children and young people’s food and drink practices), I was struck by the similarities in young people’s comments about the importance of social relationships, interactions with friends, and the value of friendly respectful exchanges with local retailers, informing their lunchtime decision making. Young people were keen to be involved in efforts to improve the school food environment. Young people in our study were similarly fired up to make positive changes, and questioned why and how energy drinks companies can target young people under 16. They had ideas about what would make a difference and were realistic about the challenges of restricting sales of energy drinks to young people.

In September, Fuse welcomed Professor Helen Roberts, a self confessed fan of evidence informed public health advocacy, to deliver a knowledge exchange seminar prompting debates about our role as academics and advocates. Constrained by restrictions placed on us by funders, some appear nervous about compromising assumed notions of independence. If we want our research to have impact, should we not frame public health debates in ways which make sense to those who participate in our research? Rather than simply highlighting the health risks of energy drinks, this means understanding the social meanings of young people’s food and drink choices and more critical engagement with the industry that promotes them. Our efforts would be further strengthened by encouraging young people and colleagues to connect with other campaigns such as RRED and GULP.

To download the Fuse Energy Drinks report click here, or the Fuse Brief can be viewed here.

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Energy drinks: Don't believe the hype

Guest post by Shelina Visram, Lecturer in the Centre for Public Policy and Health, Durham University

When asked where the idea for our study on energy drinks came from, I usually say it was through discussions with colleagues as part of another project I’m leading on in County Durham. But that's not strictly true. The original spark came from my experience a few years ago of lecturing at Northumbria University in the dreaded Tuesday 9am slot (student night in Newcastle is on a Monday), where I noticed some students regularly downing a couple of energy drinks throughout the lecture. This was my first encounter with these drinks being consumed during daylight hours and I was fascinated by the idea that some people might have them for breakfast. So this got me wondering - why would young, seemingly healthy students feel the need to use an artificial source of energy to get them through the day? Or was it just my lectures sending them back to sleep? (That is if they had even been to sleep).

Over the years I noticed more and more of these drinks appearing in shops, on TV shows, in adverts and as litter on the streets, and assumed that they were used primarily by adults to stay awake. Most cans and bottles state that these products are not recommended for children, given that they contain high levels of caffeine which children are advised to consume in ‘moderation’ [1]. But then I overheard a couple of external partners discussing energy drinks in the context of them being seen as a growing 'problem' in primary and secondary schools in County Durham. They were looking for support in scoping the evidence base and exploring what types of interventions or educational materials could be developed locally. Around the same time, a call was circulated via Fuse for research proposals to The Children’s Foundation [2]. Colleagues from Fuse and the Wolfson Research Institute for Health and Wellbeing at Durham University [3] were keen to collaborate on an application. We developed our proposal, were awarded funding, and the HYPER! (Hearing Young People’s views on Energy drinks: Research) study was born [4]. 

Since June 2014, the HYPER! study team has been busy: reviewing the published literature on children and young people’s use of energy drinks; conducting a series of focus groups and interviews with students, parents and staff from four local schools; and involving young people in a mapping exercise, drawing on their knowledge of the area around their school to identify local energy drink vendors. Here are some of the things we’ve learned:

• If you come across a paper that says ‘energy drinks are good for you’, check to see if the work has been funded by Red Bull or conducted by someone with shares in PepsiCo.
• Most papers that say ‘energy drinks are bad for you’ are based on expert opinion, rather than robust research.
• Young people in the UK drink more energy drinks than those in other European countries, yet there are no published studies from the UK.
• Sales restrictions might seem like a sensible option; they would help to send a clear message but our study participants had concerns that they would be difficult to enforce.
• The strong influence of the marketing activities of energy drink companies should not be underestimated.
• Any interventions should ideally involve children and young people, as well as parents, schools, retailers and the industry.
• There is a lot of confusion around whether energy drinks are safe for children, and parents, teachers and young people need help to make more informed choices.  At least one young person in all but one of our focus groups thought that energy drinks contained bull or horse sperm [5]. They don’t.

There are still lots of unanswered questions. For example, if the government requires energy drinks to carry warnings stating that they are not recommended for children, why are manufacturers allowed to market them so obviously towards young people? What are the long-term health and other effects? Is there a link to health inequalities? And why would anyone knowingly drink something that they thought contained bull sperm? We’re hoping to answer some of these questions by conducting further research so please get in touch if you’d like to collaborate with us or if you’re already involved in work on energy drinks. We would love to hear from you.

You can find out more about this study by reading the new Fuse Brief here.

Shelina spoke about the HYPER! study at the CPPH/Wolfson Seminar - Sweetness, social norms and schools: factors influencing children and young people’s food and drink practices (9 September)

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