acid 303

e. Diuretics and masking drugs

Furosemide

330

Canrerone

340

HGH

22,400

f. Peptide hormones

LH

30,000

EPO

30,400

More recently, recent research in organic synthesis and genetic engineering has

produced new substances which are similar to natural peptide hormones (f) — a

combination of aminoacids which can stimulate the endogenous secretion of

substances such as androgenous steroids (hCG, LH, etc.) or corticoids (ACTH).

These molecules have a much heavier molecular weight than the others (see table

16

II). They are present in the body at very low levels of concentration, with

considerable variations from one person to the next, and are influenced by

environmental parameters such as effort, stress and/or fatigue. It is thus very

difficult to distinguish between natural and artificial variations.

3. The problem of natural or semi-synthetic or synthetic substances.

A certain number of substances normally used in specific medical circumstances

are now being used in top level sports because of their positive effect on several

physiological functions which play a role in sports. Erythropoietin (EPO) was thus

developed to treat anemia by stimulating the synthesis of red blood cells. Since it

increases corpuscular mass and oxygen transfer capacity, this drug has been used

for the past ten years in aerobic sports and as a rule all intense aero-anaerobic

disciplines, whether practised continuously or alternately. In healthy subjects, it

raises hemoglobin and hematocrite levels and improves staying and maximum

aerobic power. Its use — through injections, as in standard medical practice — is

simpler than transfusions which can cause problems and accidents. For the time

being, anti-doping tests cannot detect EPO. It is commercialized under various

denominations and sold in France at the Pharmacie Centrale des Hôpitaux.

Other drugs, either hardly commercialized or still awaiting market

authorization, are known for their ability to increase oxygen transfer capacity, such

as reticular haemoglobin, developed from a human molecule mainly used in

hemorrhagic emergencies, in order to avoid having to determine the blood type for

selective corpuscle transfusions. This is also the case of fluoro-carbons which are

even more convenient since they keep well. They can also be used as a recovery

activator after intensive effort. So far, no control procedure, in terms both of

prevention and testing, exists for this type of drug. A solution to this problem

should be found before it is commercialized, if possible.

The possibility of increasing muscular mass and acting on the anabolic or

catabolic properties of the metabolism is extremely interesting for top-level sports.

17

The use of androgens and anabolic agents has become increasingly widespread

over the past 20 years, especially with the development of synthetic anabolic

agents whose anabolic power is 30 to 50 times higher than that of natural

androgens. The growth hormone (hGH) developed by genetic engineering has

made it possible to avoid testing positive on synthetic anabolic agents. The

recombinant growth hormone is available on the market. It is used in all sports

where performance is linked to muscular mass, as well as in aero-anaerobic sports,

including team sports. The production of IGF1 (Insulin-like growth factor),

which completes the physiological action of the growth hormone, by genetic

engineering complicates the issue. IGF1 used together with the growth hormone

provides optimal results with smaller doses of both drugs and fewer side-effects.

This may explain the standardization of a certain body shape and the disappearance

of indirect signs of use of the single growth hormone. The availability of a second

IGF2 opens new prospects in the field of energy metabolism.

To a lesser degree, interleukin 3 can be used singly or with another drug to

enhance growth and stimulate corpuscle production. G-CSF is a growth enhancer

which acts mainly on white corpuscles. Although it does not have any known

effect on performance, it may help resist infections.

Analyzing peptide hormone levels in blood, especially the chorionic gonadotropin

hormone (hCG), the growth hormone and EPO is thus of utmost importance.

Synthetic peptide hormones presently in use have a chemical structure which is

identical, or at least very similar to that of natural hormones, and it is impossible to

distinguish their physical or chemical characteristics. Their dosage is at present

determined by immunology techniques, but quantitative standards would be

necessary to determine the exogenous presence of such substances.

4. Organizing the tests

Sports officials organize sports events, but the task of detecting illegal drugs is

devolved to others. If an athlete tests positive, s/he is punished by sanctions. Three

possible cases can occur:

18

- In the first case, tests show the presence of a banned substance which enhances

performance more than would simple training. In this case, there is no question

that this person must be sanctioned.

- In the second case, the tests show the presence of an illegal drug which does not

necessarily enhance performance. Sanctioning the athlete for this would be unfair,

since it would create an unequal situation between athletes and non-athletes, the

latter not being tested.

- In the last case, the test does not reveal any illegal doping substance because it is

"masked", new, or (temporarily) undetectable as an exogenous substance. In this

case, testing is impossible, though justified.

The world of sport is understandably quite ill-at-ease regarding this complex

issue. Indeed, sportsmen are used to dealing with extremely strict rules, in the

sense that all that is not explicitly forbidden is allowable. This principle is actually

what motivates technical progress, which in turn leads to a modification of the

rules.

Another important problem concerns the tests' underlying principle: indeed, sports,

as an institution, focuses on performance, not on the actors, whereas anti-doping

tests focus on the actors, in other words on the athletes as individuals.

Considered necessary, though imperfect, these tests are at the same time perceived

as imposed by external authorities; they are usually criticized and condemned on

principle, and when it comes to the actual testing procedure, attitudes are often

unclear: upon arrival of the physician in charge of carrying out the tests, athletes

and organizers often join forces. If an athlete is tested positive, the entire "family"

falls necessarily under suspicion, which leads to a tightening of group bonds.

When a case of doping is announced, the athlete and his entourage usually protest

loudly. Sports officials thus finds themselves in a contradictory situation: they ban

doping and base their authority on this prohibition, but at the same time, when

doping cases occur and persons are sanctioned, they express surprise, doubt, and

19

minimize the issue. The attitude of sporting authorities is thus far from clear,

especially if we consider that a century ago, doping was a poor man's resource to

earn some profit from sports, and that today, doping has become extremely

expensive. "Scientific" doping, with the accompanying "masking" procedures, is

affordable only to the rich. Improving the efficiency of antidoping tests does not

mean increasing the frequency of testing but carrying them out more efficiently, for

example by monitoring the athlete during the training period, and especially by

improving detection methods and reducing the margin of error on the tested

samples.

The task of laboratories specializing in drug detection is quite complex. To search

for the possible presence of one of 300 illegal drugs and/or their metabolites, at

any possible level of concentration in a selective and small urine sample, without

any chemical diagnosis to help direct the search in any specific direction, requires

extremely precise procedures in terms of sample preparation, methodology and

interpretation of results. Every year, the list of banned substances gets longer and

longer, which means that laboratory researchers must constantly revise and

improve their detection methods. Such a task is almost impossible when results

must be ready within 24 hours.

5. Present detection techniques.

Detection techniques are practically the same in all laboratories with

international accreditation. The first analytical stage, called the "fast" stage, is

based on immunological or radioimmunological methods, separative methods such

as gas chromatography and liquid chromatography (GC and HPLC) and methods

associating two techniques, such as chromatography/mass spectrometry (GS-MS,

HPLC-MS), chromatography/atomic emission detection (GC-AED).

Obviously, it is important to attain a maximum degree of sensitivity at this level,

in order to avoid falsely negative tests.

20

At this initial level of analysis, the samples can be sorted out so as to determine

those containing illegal substances, or, more generally speaking, those which do

not look quite normal.

The second stage of analysis consists in formally identifying the substances

(illegal or not) detected during the first stage and searching for various possible

metabolites, determining their level of concentration and identifying the drug as

precisely as possible by looking for other characteristic active ingredients or

vehicles.

The impact of doping on health.

1. Potentially fatal risks.

In 1886, Arthur Linton died during the Bordeaux-Paris race. In 1904, the

marathon runner Thomas Hicks collapsed after winning the Saint-Louis Olympics:

he had taken strychnine. Dorando Pietri died in London in 1908 for the same

reason. In 1960, the cyclist K. Jensen died during the 100 km road run in the

Rome Olympics. The drug Ronicol was blamed. In 1967, Tom Simpson, a

professional world cycling champion, collapsed and died while climbing the Mont

Ventoux after having taken amphetamines. In 1975, anabolics killed Kangasniesmi,

a weight lifter. His muscles gave in under the weight and the iron bar fell down,

breaking his spine.

These grave accidents, and there are many more, are well-known. It would be

difficult to ignore them, since they happened during competitions, in view of the

public and TV cameras. This, however, is only the visible part of the damage done

by doping: indeed, little is known about its effects once the athlete has left the

sports arena or given up his/her career. We do know for a fact that several great

champions suffered from serious health problems after leaving sport. And we also

know that there is a direct relationship between certain drugs and certain health

problems, such as heart disease or cancer: the existence of a causal relationship

21

between doping and disease thus appears increasingly probable. However, an

additional difficulty resides in the fact that some substances are very often used

together with another, main, drug, that some substances of the same nature (but

bearing different names) are used together, and that these cocktails undeniably

have a positive effect on performance.

1.1.

P

otentially dangerous drug cocktails .

No single drug can satisfy the numerous demands made on athletes to improve

performance, stimulate staying power, sustain effort during training, eliminate

stress. For this reason, s/he can be tempted to use drug cocktails, either as

"scientific doping" and/or as "easy" doping, the latter being used by athletes with

limited financial means. These "cocktails" can be made up of different drugs

whose combined effect increases their power, or of similar drugs with different

names, which, when taken together, bring the dosage to toxic levels. Among these

combinations: amphetamines combined with corticoids, cardio-respiratory

analeptics or cocaine, caffeine or ephedrin; EPO with aspirin and/or an

anticoagulant, or natural or synthetic glucocorticoids; to recover strength, a

combination of glucose-enriched serum added to insulin, IGF1, and as a

supplement, androgens, GH, beta 2-agonists. The list of possible combinations is

much longer, since cocktails are elaborated and adapted according to need.

Pharmacodependency.

Several doping substances used by athletes are considered by psychiatrists as

addictive, leading to drug abuse and dependence, and their psychological effects

and impact on behaviour have been described in the context of the study of

dysfunctions linked to drug use (cf. DSM-IV, American Psychiatric Association,

1994). Caffeine intoxication can lead to nervousness, overexcitement, insomnia, or

attacks of anxiety in certain persons. Cocaine or amphetamine intoxication can

cause hyperactivity, anxiety, stereotyped and repetitive behaviour, anger and

violent behaviour, altered judgement. Their chronic use can cause dulled

22

emotions, fatigue, sadness, social withdrawal, or, as concerns cocaine, persecution

mania and aggressiveness. According to De Mondenard (1991), marijuana, which

is used by some athletes either for its disputed stimulating effect or for the feeling

of calm it provides before an event, can sometimes cause anxiety, dysphoria and

social withdrawal.

2. Clinical and biological signs indicating an iatrogenic disease.

Drug abuse can lead to the development of iatrogenic diseases which must be

diagnosed early and with precision. The drugs used — generally in combination

and at high dosages — provoke changes in the person taking them, modifies in

his/her homeostasis, behaviour, and morphology. As a result, a clinical and

biological semiology of doping with a diagnostic tree should urgently be drawn

up as a diagnostic tool for physicians. Such a medicalized approach to doping

could lead to further investigation of the problem by specialists and to the

establishment of certificates of inaptitude to sport. This approach is only possible

in the framework of a system centered on the long-term monitoring of athletes,

conducted in specialized centers, by teams of clinical specialists in sports

medecine and thanks to sophisticated equipment for the evaluation of the athletes'

functional ability to sustain effort. This medical/athletic monitoring would be

computerized and carried out in close collaboration with the athlete's personal

physician.

3. Psychopathological problems.

Knowledge about the possible psychological and behavioral effects of drugs on

athletes stems exclusively from publications describing isolated cases of

pathological reactions to the use of anabolic steroids, and from experimental

research carried out on animals, voluntary human subjects, either healthy or taking

23

these drugs for therapeutic reasons, or still, from more or less systematic

comparisons conducted within small groups of athletes, both taking and not taking

drugs.

For example, problems linked to body image occur more frequently than

average in body-builders taking anabolic steroids. These subjects often suffer from

"reverse anorexia", feelings of dissatisfaction regarding their body, and bulimia.

Amateur weight-lifters of the male sex taking high doses of anablic steroids are

more aggressive towards objects and verbally aggressive during training. Their

periods of waking are longer and they are more irritable, anxious, suspicious and

negative. Mood changes are more frequent and personal relationships more

difficult when they are "on" drugs than when they are "off", or than in non-users.

4. Numerous determining factors.

Due to rising financial stakes and the toughening of the competition for

recognition and fame, athletes and their entourage tend to search for additional

ways of improving performances, even if it means disobeying the rules established

by the sports federations. Today, science has developed very effective drugs to

enhance performance and hasten the recovery of athletes facing increasing

constraints (schedule, competitions, events, etc.). Many athletes use drugs. The

wealthier athletes use them under the supervision of competent professionals,

while the others, in order to "stay in the race", resort to self-medication on the basis

of advice or information gathered in stadiums ("poor man" doping), unaware of the

risk they run. The analysis of determining factors shows that both sociological and

personal factors must be taken into account.

Calling into question sports institutions: the sociological point of view.

A sociological study of the doping issue must be based on the analysis of

relationships between sports actors holding various positions and whose interests

differ. With the development of sports as a business, the interaction between two

24

different rationales, that of athletic performance and that of profit, has become

increasingly complex, leading us to raise the question of the power of sports.

Competition sports are dominated by a complex system of interdependent

actors:

- the federations, whose aim, among others, is to ensure that rules and traditions

are respected,

- the athletes, who compete mainly for glory; however, through their unions and

associations, they demand recognition as professional players, as well as better

working conditions,

- the educators and coaches who wish to protect their interests, as opposed to those

of their employers (the clubs),

- the referees, employed by federations or professional leagues, who wish to

improve their working environment (professionalization, protection against

violence and pressure, etc.),

- the professional clubs (Unions of professional football clubs, basketball clubs,

etc.) who aim to some profit from their investment in sports, either in financial

terms or in terms of public image, etc.),

- the consultants, sometimes grouped together in multinational firms (International

Management Group, News Corporation, etc.), who manage the athletes' business.

Some of them own TV channels, shares in broadcasting rights for the more popular

sporting events,

- showbusiness companies, which try to reconcile the interests of the public with

those of their clients (sponsors, sports announcers) and those of the actors (the

athletes).

- companies selling sports and leisure equipment (equipment makers, distributors,

service companies, etc.) and sponsors,

- the specialized medical (sports physicians), paramedical, pharmaceutical

professions;

- journalists hunting for pictures, declarations, revelations which could be of

interest to news editors wishing to satisfy their readers'/viewers' demands,

25

- academics and researchers who publish articles and speak out on the subject and

thus wield some influence on public opinion and on the various actors involved,

- persons practising sports or sports fans, who, as consumers (of lessons, images,

clothing, equipment, etc.), support the entire system. Due to their numbers

(evaluated in terms of audience, number of copies sold, etc.), they play a very

important role (events postponed to ensure better attendance, scandals stifled so as

not to shock, etc.). Thanks to them, sponsors, businessmen and professional

athletes are able to earn a living.

When high level sports are governed by federations or olympic bodies, thanks to

state support or because of these institutions' monopoly over the award system

(their titles being the only "noble" titles), the rules of the game remain stable and

more or less protected against attacks of businessmen wishing to adapt the rules of

sport to public demand. However, when federations have little authority, sport can

turn into show business, opening the way for corruption, cheating and rule

changes.

1. Playing with the rules: a risky game.

As the stakes involved in competition sports grow higher, the rule is to get

around the rules. Not to take risks with the rules, or not being able to ensure one's

protection if suspected of cheating can mean being left out of the race. Those who

have nothing or not much to lose are the first to resort to cheating to attain their

goal. Those on the higher rungs of the social ladder are in a much better position

than others to play that dangerous game without getting caught. Persons who have

access to information, to more or less legal ways of getting round the rules

(waivers, corruption, or getting those in charge of enforcing the rules to close their

eyes), and resort to all kinds of loopholes to get around the law, move ahead faster

and remain in dominant positions longer than those who have no way of doing so.

(A "wealthy" club or athlete, in terms of both money and information, has easier

access to the services of physicians, or of laboratories specialized in doping and

masking drugs than "poor" clubs or athletes). To explain why certain athletes,

26

federations, physicians, referees, resort to cheating, it is necessary to question the

entire international sports system, nowadays entirely focused on the tough

competition for medals and money. Not to take drugs when others are taking them

would mean to lose. In this context, a special study on the side effects of the drugs

most used by athletes ought to be commissioned and results publicized among

regularly competing athletes. Players' and athletes' unions or associations would be

in the best position to carry out these information campaigns, since they can

protect athletes who are already locked in the system — forced to take drugs, or

addicted. Of course, athletes are under very high pressure, if only because only the

"best" are selected for competition; the pressure is exerted by actors who have an

interest in seeing "their" athletes win — federations, TV channels, consulting

firms, directors of professional clubs, coaches, event organizers, sponsors, etc.

There is a direct link between doping and the question of power relationships

between these various actors. Internationally recognized associations and unions

(such as in golf or tennis) would thus be the best source of information and

protection for athletes.

2. The declining authority of the federations.

Two processes are responsible for the decline of the power of federations.

In the first place, sports are now practised by all, whereas before World War II, the

working classes, women, and adults over 50 did not practise sports. The growing

TV audience for sports events has generated new sources of profit, leading to the

professionalization of the most popular sports. The sponsors of "show-business

sport" represent a counter-authority for federations, whose power stems from two

main sources: the monopoly on "noble sports" titles, which are a hundred years old

for the more traditional disciplines, and a network of clubs and volunteer educators

who coach millions of athletes and organize their activities. These two elements

are essential to the development of a sports elite, for the benefit of showbusiness

managers, independent professional leagues, sponsors, etc. The recruitment by

private companies of an elite trained in state subsidized clubs (professional clubs

27

or teams) is reminiscent of the transfer to the private sector of graduates of the

French state subsidized grandes écoles system. The second reason for the decline

of the power of federations is the development of other types of sports ("leisure"

sports, "street" sports) which, according to national surveys, draws as large a

public as there are licensed athletes, in other words about 12 million people. Along

with the emergence of these "new" sports, there has been a change of attitude

towards federations, which tend to be considered as service providers rather than

authorities. Athletic excellence is viewed differently from one generation to the

next; nowadays, the winner (according to the rules) is not necessarily the "best"

player. "Excellence" is less a question of measurable, objective performance than

one of self-expression and style, mirroring the aspirations of a generation. "Fun"

sports remain competitive, of course, but creativity and artistic expression are

nevertheless central. These "new" sports include skateboarding, rollerblading,

acrobatic biking, break-dancing, border-crossing, jumping contests, etc.

Demographic and social transformations may explain why the principles which

dominated 19th and 20th-century sports no longer correspond to the expectations

of most members of today's new generations. Though institutional sports have

managed so far to preserve the illusion that their principles were universal, it now

appears that they are not eternal; they only hold true in a world where the values,

beliefs and ideals they represent are shared by all.

Individual factors and the critical age question.

1. Varying degrees of susceptibility.

In addition to sociological factors, individual factors also play a significant

role. Group pressure and financial interests can drive most, if not all, athletes to

28

dope themselves. Nevertheless, doping behaviour — the age at which an athlete

will begin to use drugs and the development of addiction — is also determined by

individual factors. In this respect, it should be noted that there are many former top

athletes among chronic drug users. Heroin or any other drug thus acts a

replacement for sport, which for them was practically a drug in itself.

Several reasons have been suggested to explain this phenomenon. On the one hand,

the daily and mechanical practise of sports blocks unpleasant thoughts and

anesthetizes the mind, in the same way as heroin. Furthermore, when a person

attempts to exceed his/her physical limits, the body secretes endorphin which acts

as an endogenous drug. Although no specific study has been carried out on the

relationship between sports, doping and drug addiction, enough scientific data

exists to show that there is a great deal of inequality among athletes in this respect.

1.1. Temperamental factors.

Personal temperament also determine the choice of behaviour in a given

situation. It is a known fact that differences in behaviour are determined for a large

part by biological factors, in particular as concerns reactivity towards the

environment and need for stimulation. Thus, it has been shown that highly reactive

persons tend to prefer situations which have low stimulating power, and conversely

for persons with low reactivity. The need for strong sensations and new and

intense experiences is governed by the need to reach a high level of sensorial

activation. However, the forms of behaviour aimed at reaching this level of

activation may vary a great deal: drugs and alcohol, danger, adventure (dangerous

sports, mountain-climbing, hang gliding, etc...). In the understanding that each

individual has his/her own personal optimal level of activation and his/her own

way of reaching it, one can see how persons who enjoy taking risks may be liable

to use psychostimulants or drugs.

1.2. Motor activity as a source of gratification.

29

Physical exercise requires the participation of the body's physiological systems

and modifies its homeostasis. In particular, it modifies the activity of several

cerebral neurotransmitter systems. In animals, heavy exercise, prolonged exercise

and overexercising have opposite effects. For most neurotransmitters, the release

increases, then decreases (with slowing down of activity) if the exercising lasts a

long time. Furthermore, it is a known fact that exercising can lead to hormonal

changes, by increasing the secretion of prolactin, of the growth hormone and

corticosteroids. Some of these hormones have a powerful effect on most

neurotransmitter systems. These neurotransmitter systems are both the target of

doping substances and the providers of gratification. As a result, it is easily

conceivable that proneness to addiction should entail doping behaviour, with

doping substances taken together with other drugs. This is all the more true for

persons with a need for strong sensations.

2. Adolescence: a period of major risk.

2.1. Taking doping substances together with drugs: the risk for teenagers and top

athletes.

The subject of doping is usually exclusively related to sports, since doping

drugs are used to enhance performance, as opposed to other forms of addictive

behaviour. In fact, in recent years, the parallel between doping and drug addiction

has become increasingly obvious, and some authors, such as P. Laure (1995), have

been considering whether one should not "regard doping not only as a way of

enhancing performance but also, and most importantly, as a new form of drug

addiction". Indeed, it has long been known that the use of "doping" substances

such as amphetamines, and more recently, anabolic steroids, can lead to drug abuse

and physical and psychological dependence. Between 1980 and 1990, several

epidemiological surveys were conducted in United States high schools. Their aim

was to evaluate teenagers' consumption of anabolic steroids, possibly in

combination with other drugs. This represents a new phenomenon among

teenagers, whether or not they practice sports, and the reason they gave for

30

taking drugs was the wish to improve physical appearance and muscular strength.

According to the surveys, 2 to 4% of teenagers of both sexes, but mostly boys, had

used anabolic steroids. The average age at which they begin is 14 (ranging from 8

to 17), and the proportion of users is slightly higher among those practising

sports. Recent surveys conducted in American and Canadian high schools show

that teenagers practising sports admitted to having taken anabolic steroids in order

to improve their performance, but that they also drank, smoked and used other

drugs, in the same way as those who did not practise sports.

The first surveys conducted on the drug habits of young American

athletes date back to the early 1980s. These surveys showed that athletes took

psychoactive drugs just as did their non-athletic peers. Subsequent studies carried

out in the early 90s do not confirm the generally accepted idea that sports students

use more drugs and drink more alcohol than others. Neither do they confirm the

existence of an anabolic doping "epidemic" in American colleges. Recent studies

carried out in Canada among athletes of both sexes underscore the importance of

alcohol and caffeine consumption. In conclusion, the various epidemiological

surveys conducted in the United States and Canada, in various environments, with

students practising competition sports, or not practising sports, show that there are

not many differences in the choice of drugs in general, whether these are legal,

such as alcohol, illicit, or "doping" substances. The distinction between use and

abuse is not clearly marked.

2.2. Psychopathological disorders underlying the abuse of psychoactive drugs

Certain psychiatric disorders are more frequently observed among young drug

addicts, a fact which raises the question of whether these disorders play a role in

determining a subject's proneness to drug-taking. Depending on the survey,

emphasis is laid on some substances rather than others, but globally, all are

involved (tobacco, alcohol, marijuana, hard drugs such as cocaine). The vast

majority of users are male. However, "externalized" disorders are not the only

explanations for drug addiction among these teenagers. "Internalized" or

31

"emotional" disorders — mood changes, anxiety — are also frequently observed. It

is important to determine whether these observations apply to doping substances as

well.

Important semiological similarities have been observed between the

behavioural and biological characteristics of athletes and those of persons suffering

from eating disorders. Thus, amenorrhea, which often happens in cases of mental

anorexia, is a frequent problem among long-distance runners. These connections

show that the intensive practise of sports is often in itself a form of addiction. In

the same line of thought, one may note that eating disorders are extremely frequent

among young female gymnasts. Another disorder, hyperactivity with attention

deficiency may be an underlying problem in cases of drug abuse. Given its

frequency among children, as well as among teenagers and adults, it would be

particularly interesting to study its incidence in a large sample of young athletes

and correlate this disorder with drug and/or doping substance abuse. This disorder

affects 2 to 3% of the adult population. Drug abuse usually begins during

adolescence or in early adulthood, and affects 10 to 20% of adults.

Energy drinks.

Health hazard data on energy drinks were found to be limited

and therefore the hazard assessment was based on individual

ingredients.

Caffeine was identified as the ingredient with the greatest potential for

intakes of possible health concern. On this basis, excess consumption of

energy drinks would be expected to result in health consequences similar to

those from excess exposure to caffeine. The more mild and transient health conseq

uences could include anxiety, headache and insomnia and these health

consequences can become chronic conditions.

More severe health consequences may include irregular heartbeat, heart attack

and,

very

rarely, death.

Currently,

the

potential

for

taurine

and glucuronolactone to interact with caffeine is unknown and therefore

they

32

may or may not exacerbate the effects of caffeine. In addition, the

health effects of excessive intake of taurine and glucuronolactone are also

unknown.

Using exposure modelling, the potential health risk posed by energy drink

consumption was examined. However, no Canadian intake data for energy

Drinks were available. Therefore, for the purpose of modelling intake, it

was assumed that energy drinks are consumed in a manner similar to

that of caffeinated carbonated soft drinks. In the worst case modelling exposure

scenario, energy

drinks were substituted for caffeinated carbonated

soft drinks on a volume basis. The energy drink caffeine concentration was set

to

320 ppm

(80

mg

of

caffeine/250

ml

serving)

for

modelling purposes. In the most conservative scenario, all caffeinated carbonated s

oft drinks were replaced by a typical energy drink for consumers who drink

these beverages. The results of this conservative estimate showed that

slightly less than 30% of male and female adults, about 15% of pregnant woman an

d more than 50% of the children and adolescents, amongst consumers who

drank

caffeinated carbonated

soft

drinks,

were

above

Health

Canada’s recommended maximum daily caffeine intake.

This extreme scenario only applies to that subset of the population that

consumes caffeinated carbonated soft drinks, which does not exceed 8% of

young children (1‐8 years old), 22% of older children (9‐14 years old), 32% of ado

lescents, 20% of the adult population and 13% of pregnant females.

In critically reviewing the outcomes of this exposure modelling, it

appeared that the corresponding health concerns for children and adults

would be limited to remote, based on this scenario, in view of the

parental control that should exist and would limit access of these products

to to children, as well as the ability of adults and pregnant women to monitor their

own caffeine intake.

This hypothetical scenario and its outcomes could not be as easily excluded for

adolescents, given that energy rinks tend to be marketed to this subset of the

33

population, which is less likely to adhere to consumption recommendations than

adults. The existence of larger volume containers (e.g., 710 ml) increases the

likelihood of exceeding caffeine recommended intakes in one consumption

setting. Specific risk management measures to address potentially high caffeine

levels in larger volume energy drink products would therefore be desirable.

It is acknowledged that various data gaps would need to be addressed

to improve the exposure assessment

and the overall risk

characterization. In particular, data related to the evolving consumption patterns of

these products by the various subsets of the population, in Canada, needs to be gat

hered.

Health Canada’s proposed risk management approach

for energy drinks, announced in October 2011 and updated in 2012, limits the

concentration and total amount of caffeine in these products and requires that

caffeine and nutrition information be displayed on product labels.

These measures support the mitigation of risks related to overconsumption of

caffeine from this type of product that are within the possible areas of

intervention available to a federal food regulator. A more concerted approach

(e.g., education, awareness and regulation) and more research would

be needed to ascertain the effectiveness of the various measures taken

by regulators and other stakeholders.

Defining a typical energy drink.

Defining products known as energy drinks For the purpose of thi

s document, a typical energy drink is characterised

by the ingredients and ingredient levels shown in Table 1. Ingredients include

caffeine, taurine, glucuronolactone, inositol and a variety of B vitamins. The

basis for this characterisation is the formulation of the most commonly sold

products of this category of

beverages, such as the product known as Red Bull.

Although Health Canada does not have a definition or standard for

products

known

as

energy

drinks,

other food regulators have reached a decision on this aspect of these products. For

34

example, Australia and New Zealand categorizes energy drinks as ‘formulated

caffeinated beverages’ which are defined under the Australia New Zealand

Food Standards Code as “a non‐alcoholic water‐based flavoured beverage

which contains caffeine and may contain carbohydrates, amino acids,

vitamins and other substances, including other foods, for the purpose

of enhancing mental performance”.

In Europe, the Ireland Food Safety Promotion Board (FSPB) established a

committee consisting of external experts to research the health effects

of ‘stimulant drinks’ (energy drinks). The committee noted in its final

report that there is no agreed definition in the regulatory framework for

products referred to as energy drinks or ‘stimulant drinks’. For the purposes

of the report, the term ’stimulant drinks’ was adopted. The

committee defined

stimulant

drinks

as

“beverages,

which

typically contain caffeine, taurine and vitamin(s), and may contain an

energy

source (e.g. carbohydrate), and/or other substance(s), marketed for the

specific

purpose

of providing

real

or

perceived

enhanced

physiological and/or performance effects” (FSPB, 2003).

Major components of energy drink products During the preparation of this

manuscript, energy drinks were marketed in Canada under the Natural Health

Products (NHP) Regulations. At the time, it was estimated that over 300 energy

drink product submissions were before Health Canada for consideration as

NHPs. Only twelve were assessed and received a license. Approximately half

of the 300 product submissions

were either refused a license or withdrawn by the petitioner.

either refused a license or withdrawn by the petitioner.

A number of products were also on the Canadian market

under the provisions of the Unprocessed Product Licensing Regulations. Table

below lists the major ingredients and levels typically found in the products

that were in the queue for consideration to be licensed as an NHP.

Substance Formulation of products known as Energy Drinks (mg. per 250 ml

35

serving)

Caffeine 50 – 200 80

Taurine 10 – 2000 1000

Glucuronolactone 600 – 1200 600

niacin 10 – 40 18a

vitamin B6 5 – 10 2

vitamin B12 0.002 ‐ 0.2 0.001

pantothenic acid 5 – 10 6

thiamine 0.5 ‐ 5 2

riboflavin 0.5 ‐ 5 1.65

Inositol 50‐200 50

Serving size is typically 250‐473 ml.