Bulls, Bars and Brawls

May 7, 2009, 9:30 a.m.

Red Bull: "the non-stop party-animal's hot secret"
(brought to you by FromDC2Iowa.blogspot.com*)

"[A] 21-year-old Grand Valley State University student found dead in her off-campus apartment, died from complications due to over-consumption of alcohol, university officials reported . . .."

"Alcohol over-consumption is cause of death for Grand Valley nursing student . . .," The Grand Rapids Press, April 28, 2009.

However tragic yet one more student death from alcohol might be, what caught my attention was a comment posted by a Press reader on this story's Web site:

Posted by flipper2 on 04/29/09 at 3:25PM

You know what part of the problem is when the kids mix liquor and the red bull drinks.....all that caffeine and their system can't tell them when to slow down. Used to be drink alot and pass out.......now keep going.

Red Bull is neither a new product nor a new story, but it is a deadly story worth the retelling.

Here is a similar story two months earlier from England:

[The death of a] student who died on a nightclub dance floor [around 3:00 a.m.] . . . may have been triggered by caffeine in the Red Bull she had been drinking . . . around four cans . . . and several VKs - a vodka based drink which also contains caffeine . . . despite efforts from staff and paramedics to revive her. . . .

[H]ours before the night out on which she died . . . she went to a friend's house, where she drunk a bottle of wine together with two cans of Red Bull because she "felt tired". She then drank approximately two more cans of the energy drink and a couple of VK drinks. . . .

Dr Stephen Morley, a consultant pathologist, said of Miss Leach's Red Bull consumption: "She may have had as little as two cans, she may have had as many as six. It was more probably about four." . . .

"Red Bull 'may have triggered heart condition that killed student' an inquest heard," London Telegraph, February 3, 2009.

I could give you more like that. After all, if you put "'red bull' death" into Google it will provide you 1.2 million links. But those stories, plus the reports of research that follows, should be enough to get us started.

And where did it start?

"Introduced in Europe in 1987, Red Bull is the creation of Austrian businessman Dietrich Mateschitz." David Noonan, "Red Bull's Good Buzz; Why Coke Pepsi and Other Heavyweights Are Chasing the Edgy Upstart," Newsweek, May 14, 2001 (pdf available from the Red Bull Web site). It was introduced to America in 1997 in the San Francisco Bay Area, and three or four years later was in 40 states. (As Noonan's story explains, other drink manufacturers soon entered the "energy drink" market as well.)

Nor is the relationship of Red Bull-plus-alcohol to increased injury and death a new phenomenon.

The London Times followed the news that "A young woman died of alcohol poisoning in a nightclub in Dublin this year after consuming numerous cocktails of Red Bull and vodka" with its report of an academic study at Wake Forest University involving over 4000 students at 10 U.S. colleges and universities:

People who drink Red Bull or other “energy drinks” mixed with alcohol during a night out are twice as likely to be injured or otherwise come to harm than those who have alcoholic drinks on their own, . . . more than twice as likely to take advantage of someone else sexually, and almost twice as likely to accept a lift from a drink-driver or to be taken advantage of themselves . . .. An estimated 330 million litres of energy drinks were consumed in Britain last year, a market worth £1 billion. The study suggests that products such as Red Bull, which contain stimulants such as caffeine and taurine, may allow drinkers to consume more alcohol without noticing its negative effects."

David Rose,"Drinkers who mix Red Bull with alcohol ‘twice as likely to suffer harm,’" The Times [London], November 5, 2007.

The problem is considered sufficiently serious, the Times continues, that "The Swedish National Food Administration has warned people to avoid drinking Red Bull with alcohol or after heavy exercise, while France and Denmark have banned the drink. Health departments in Ireland, Turkey, Sweden and the United States have all expressed concern."

Because I do not recall seeing mention of "energy drinks" in discussions by University and City officials of Iowa City's binge drinking problems and their consequences I thought it worth a little exploration. (The City's latest effort, reported this morning, Chris Rhatigan, "Council Passes Alcohol Measure," Iowa City Press-Citizen, May 7, 2009, p. 3, reflects its conclusion that downtown Iowa City may, finally, have enough bars. I'm sure that seeing to it that those 50 bars within walking distance of the campus need not worry about additional competition will do a lot to reduce alcohol abuse by students. As Mayor Regenia Bailey is reported to have said, "This would have been a much more beneficial zoning code 10 years ago.")

Near as I can figure out Red Bull is more bull than red -- maybe 99 percent marketing and one percent caffeine and taurine (a crystalline acid of nitrogen and sulphur, C2H7NS03, first found in the bile of oxen).

Although it would never occur to me to ask if anyone had put bull semen or testicles in my food or drink, Red Bull thought it necessary to reassure its customers (especially those who are vegetarians) with this exchange in its "FAQs":

IS TAURINE MADE FROM BULLS' TESTICLES? IS TAURINE A DERIVATIVE OF BULLS' TESTICLES OR SEMEN?

The taurine in Red Bull® Energy Drink is a purely synthetic substance produced by pharmaceutical companies and is not derived from animals or animal materials.
All ingredients for Red Bull® Energy Drink are synthetically produced by pharmaceutical companies. This guarantees the highest quality.

www.redbull.com.

The FAQ site continues with equivalent assurances regarding the healthful attributes of this product for those who might wonder:

IS RED BULL ENERGY DRINK SUITABLE FOR VEGETARIANS?
IS RED BULL ENERGY DRINK KOSHER?
IS RED BULL ENERGY DRINK HALAL?
IS RED BULL ENERGY DRINK GLUTEN-FREE, VEGAN, WHEAT-FREE, DAIRY-FREE?

The answers, it won't surprise you to discover, are Yes, Yes, Yes, Yes, Yes, Yes, and Yes.

It's a very clever bit of marketing positioning -- clearly aimed at the late teens, early twenties college students, and providing all things to all potential customers. The drink is represented to be both as environmentally friendly as organic kale, and of "highest quality" because it is "produced by pharmaceutical companies." It's designed to appeal to both serious students studying for exams and athletes engaged in "extreme sports." "Red Bull's prime customers are young adults, better known as kids in their twenties. . . . The company works hard courting the college crowd, and has also established itself in the black and blue world of extreme sports." It has sponsored, for example, a kayaker who paddled over a 98-foot waterfall (from Noonan's article, quoted and linked above).

The manufacturer says that Red Bull is good for you; it has vitamins, and "reduces harmful substances" -- while enabling you to engage in damn fool behavior well beyond the hour you would otherwise have been in bed (alone). But it's not an elite drink; it's also the taxi drivers' favorite -- according to the company's high energy Web site:

"Red Bull® is an Energy Drink that works. Red Bull ® Energy Drink supplies tired minds and exhausted bodies with lost substances and reduces harmful substances. It provides immediate energy and vitamins. Red Bull ® Energy Drink has always been and always will be more than just a hot secret for the night owl and the non-stop party-animal. It is appreciated by a wide range of people, such as the overworked taxi driver, . . .." "Benefits/Red Bull - More Than Just a Myth," www.redbull.com.

Of course, it has to be highly profitable. It provides less caffeine than a single cup of strong coffee (though more than Mountain Dew). It's mostly water. I don't know what all those "highest quality" pharmaceuticals cost, but it can't be much. And my guess is that a month's supply of "NoDoz" tablets (also a caffeine source) would cost no more than a can of Red Bull. (A "maximum strength" NoDoz dose is one-half a 200 mg tablet -- at 100 mg of caffeine that's more than Red Bull supplies. At one a day that's about 7 cents a day, or $2.10 a month -- and store brands may be cheaper. Search Google for NoDoz.)

[Not knowing the price of Red Bull when writing this, I subsequently inquired, while in a drug store, as to whether the store handled the product. It did, and a clerk directed me to the cooler. There, along with milk and soft drinks, were a variety of sizes of Red Bull. Clearly the most economic container was the 16-ounce at $3.99 -- especially since if you considered yourself man enough (or fool enough) to buy and consume three cans they were discounted to $10.00. Because that's close to a 20% discount, anyone still sober enough to do some simple math would have a significant financial incentive to down 48 ounces of the stuff -- rather than an 8- or 12-ounce can.]

Here is an abstract of the study to which the Times of London story refers:

OBJECTIVES: The consumption of alcohol mixed with energy drinks (AmED) is popular on college campuses in the United States. Limited research suggests that energy drink consumption lessens subjective intoxication in persons who also have consumed alcohol. This study examines the relationship between energy drink use, high-risk drinking behavior, and alcohol-related consequences. METHODS: In Fall 2006, a Web-based survey was conducted in a stratified random sample of 4,271 college students from 10 universities in North Carolina. RESULTS: A total of 697 students (24% of past 30-day drinkers) reported consuming AmED in the past 30 days. Students who were male, white, intramural athletes, fraternity or sorority members or pledges, and younger were significantly more likely to consume AmED. In multivariable analyses, consumption of AmED was associated with increased heavy episodic drinking (6.4 days vs. 3.4 days on average; p < p =" 0.027).">

O'Brien MC, McCoy TP, Rhodes SD, Wagoner A, Wolfson M., "Caffeinated cocktails: energy drink consumption, high-risk drinking, and alcohol-related consequences among college students," Acad Emerg Med., 2008 May;15(5):453-60 [Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA. mobrien@wfubmc.edu].

Here is a summary of one of the studies done at Johns Hopkins:

Since the introduction of Red Bull in Austria in 1987 and in the United States in 1997, the energy drink market has grown exponentially. Hundreds of different brands are now marketed, with caffeine content ranging from a modest 50 mg to an alarming 505 mg per can or bottle. Regulation of energy drinks, including content labeling and health warnings differs across countries, with some of the most lax regulatory requirements in the U.S. The absence of regulatory oversight has resulted in aggressive marketing of energy drinks, targeted primarily toward young males, for psychoactive, performance-enhancing and stimulant drug effects. There are increasing reports of caffeine intoxication from energy drinks, and it seems likely that problems with caffeine dependence and withdrawal will also increase. In children and adolescents who are not habitual caffeine users, vulnerability to caffeine intoxication may be markedly increased due to an absence of pharmacological tolerance. Genetic factors may also contribute to an individual's vulnerability to caffeine-related disorders including caffeine intoxication, dependence, and withdrawal. The combined use of caffeine and alcohol is increasing sharply, and studies suggest that such combined use may increase the rate of alcohol-related injury. Several studies suggest that energy drinks may serve as a gateway to other forms of drug dependence. Regulatory implications concerning labeling and advertising, and the clinical implications for children and adolescents are discussed.

Reissig CJ, Strain EC, Griffiths RR, "Caffeinated energy drinks--a growing problem," Drug Alcohol Depend., 2009 Jan 1;99(1-3):1-10 [Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA]. For full text of article, click here.

Although not specifically focused on Red Bull, here is a summary of research regarding the adverse consequences of our University-City lax approach to 17-to-19-year-olds' (and high school students') binge drinking that concludes, "Compared with respondents first drunk at age 19 or older, those first drunk prior to age 19 were significantly more likely to be alcohol dependent and frequent heavy drinkers, to report driving after any drinking, driving after five or more drinks, riding with a driver who was high or drunk and, after drinking, sustaining injuries that required medical attention."

OBJECTIVES: This study explored whether college students who were first intoxicated by alcohol at ages younger than 19 are more likely to become alcohol dependent and frequent heavy drinkers, drive after drinking, ride with intoxicated drivers and be injured after drinking. It also investigated whether these results occur because these students believe they can drink more and still drive legally and safely. METHOD: In 1999, 14,138 of 23,751 full-time 4-year students from a random sample of 119 college and universities nationwide completed self-administered questionnaires (response rate: 60%). This analysis focused on 12,550 who were aged 19 or older. Respondents were asked the age at which they first got drunk, as well as questions about recent alcohol-related behaviors and consequences. RESULTS: Compared with respondents first drunk at age 19 or older, those first drunk prior to age 19 were significantly more likely to be alcohol dependent and frequent heavy drinkers, to report driving after any drinking, driving after five or more drinks, riding with a driver who was high or drunk and, after drinking, sustaining injuries that required medical attention. Respondents first intoxicated at younger ages believed they could consume more drinks and still drive safely and legally; this contributed to their greater likelihood of driving after drinking and riding with high or drunk drivers. CONCLUSIONS: Educational, clinical, environmental and legal interventions are needed to delay age of first intoxication and to correct misperceptions among adolescents first drunk at an early age about how much they can drink and still drive safely and legally.

Hingson R, Heeren T, Zakocs R, Winter M, Wechsler H., "Age of first intoxication, heavy drinking, driving after drinking and risk of unintentional injury among U.S. college students," J Stud Alcohol., 2003 Jan;64(1):23-31 [Social and Behavioral Sciences Department, Boston University School of Public Health, 715 Albany Street, T2W, Boston, Massachusetts 02118, USA. rhingson@bu.edu].

I've never thought that "educating" college students with regard to the potentially adverse consequences of alcohol abuse would do much to slow down those youngsters determined to expend their new-found "freedom" on drunkenness. But I have to admit I don't know; I don't know what's in the educational materials the University of Iowa offers them, nor do I know what the data show as to the effects of that education. I do hope, however, that to the extent we are trying to provide some useful guidance that at least some mention is being made of "energy drinks," how they interact with alcohol, and what the consequences of that interaction can be.

There is, of course, much more research along this line available through Medline, NIH, and other sources. My thanks to Brett Cloyd for putting me onto this material.
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* Why do I put this blog ID at the top of the entry, when you know full well what blog you're reading? Because there are a number of Internet sites that, for whatever reason, simply take the blog entries of others and reproduce them as their own without crediting the source. I don't mind the flattering attention, but would appreciate acknowledgment as the source -- even if I have to embed it myself. -- Nicholas Johnson

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