Introduction

The past decade has seen a boom in sports and energy drink consumption. In 2021, the UK drank 906 million litres of these drinks, up from 740 million litres in 2013, and market sales increased by 8.4% between 2021 and 2022.1,2 There are growing concerns about increasing consumption in children and young people (CYP), with up to one-third regularly drinking caffeinated energy drinks.3

Although often referred to collectively, sports and energy drinks differ in their desired effect and ingredients. Sports drinks are flavoured beverages often containing carbohydrates and other nutrients that aim to replenish electrolytes and fluids and enhance performance of consumers.1,4 Energy drinks aim to stimulate and thus have ingredients such as caffeine and guarana, and may contain carbohydrates, protein, amino acids, vitamins and other nutrients.4

Sports and energy drinks pose a concern to dental professionals. They often have a pH below the critical value for erosive tooth surface loss and free sugar content exceeding the maximum daily recommended intake and thus have cariogenic properties.5 Frequent consumption may also be associated with increased incidence of type II diabetes, poor mental health and obesity.3,4,6

Their growing popularity in CYP may be attributed to the presence of sports and energy drinks on social media. For example, social media has been credited as the key driver of the success of the sports drink Prime, launched in the UK in 2022.7 Although its popularity may be short-lived, it highlights the role of social media, marketing and advertising on the purchasing of sports and energy drinks. To be able to tackle this growing problem, dental and other health professionals should be aware of the harms, consumption patterns and drivers to purchase sports and energy drinks.

Dental and health consequences of consumption of sports and energy drinks

Increased consumption of caffeinated energy drinks in CYP has been associated with a range of health problems, including headaches, stomach pain, sleep problems, hyperactivity and irritation, and reduced wellbeing.3 It has also been linked to high-risk behaviours, such as self-harm, alcohol use, smoking and substance misuse.3 Australian adolescents who reported drinking energy drinks were more likely to be overweight or obese compared with those who did not.6

Many elite and professional athletes regularly consume sports drinks.8 Over 80% of athletes reported consuming them during training, yet less than one-third were high consumers of sugar in their regular diet.9 Despite athletes having positive oral health behaviours, Gallagher and colleagues reported that 49% of athletes had caries and 41% had erosive tooth wear,10 which may be associated with increased sports drink consumption in this group.

In a survey of 12-14-year-olds in South Wales, almost half of participants consumed sports drinks more than once a week, with 14% drinking one or more every day.11 Most (80%) reported purchasing sports drinks from the local shop and half (51%) reported consuming them socially. Differences in sexes were observed: boys were more likely to consume sports drinks during physical activity and mealtimes, while girls were more likely to consume them at home or socially. Taste was the most common reason for consumption. Only 18% of participants reported consuming sports drinks to improve performance.11

The survey also tested participants' knowledge of sports drinks. In free-text responses, participants listed energy drinks they consumed, demonstrating that terms are often used interchangeably and participants could not distinguish between them.11 In a subsequent study, the authors investigated the sugar content of the top five energy drinks on the market at that time: Lucozade, Red Bull, Monster, Rockstar and Relentless.5 The amount of free sugar contained in four of the drinks (Lucozade 380 ml, Monster 500 ml, Rockstar 500 ml and Relentless 500 ml) ranged from 146-187% of the recommended daily free sugar intake for 19-24-year-old men. Although the Red Bull 250 ml serving size was smaller, one can per day still provided more than two-thirds of the recommended free sugar intake.

Despite consumer data suggesting consumption of sports and energy drinks by CYP is increasing, there has been relatively little research in this field and only one study which provides a glimpse of the position of sports and energy drinks in CYP's lives and their contribution to their overall sugar consumption.11

What can be done?

Public health approaches

It has been long established that the determinants of health-related behaviours, such as consuming sports and energy drinks, are complex and operate at different levels. At a population, community and individual level, these can be related to socioeconomic, educational and environmental factors, all of which are impacted by government policy. In addition, the influence of corporate strategies on government policy, social relationships and individual behaviours have been increasingly recognised.12 Consequently, contemporary public health approaches should aim to address determinants operating at all levels, but should particularly focus on so-called ‘upstream' factors rather than focusing purely on changing behaviour of individuals.13

Arguably, the UK Government's obesity strategy launched in 2016 included many such ‘upstream' measures. The initial plan proposed a range of actions, including a number pertinent to sports and energy drinks. This included the Soft Drinks Industry Levy (SDIL) or ‘sugar tax', but also recommended: restrictions on TV advertising of high-fat, high-sugar and high-salt foods until after the 9 pm watershed; preventing the promotion of unhealthy food and drinks in shops by restricting where they can be placed in shops and volume promotions (for example, ‘buy one, get one free' offers); and restricting the sale of energy drinks to adults only.14

Although the implementation of the obesity strategy is incomplete and under threat,15 the SDIL has been in place since 2018. The levy is paid by drinks manufacturers at the following rates: 18p per litre on drinks containing between 5-8 g of sugar per 100 ml and 24p per litre on drinks containing more than 8 g of sugar per 100 ml. Its effect on the consumption of sugar through soft drinks has been significant, with a 10% reduction per household per week, yet with no changes to sales overall, as manufacturers had reformulated their products in response to the levy. Consequently, there has been no deleterious impact on the industry.16 Similar findings have been reported in a range of countries using taxation in this way.17,18

Yet, as described earlier, consumption of sports and energy drinks is increasing,1,2 and measures that may address this have been postponed. Planned bans on pre-watershed and online advertising and volume promotions, due to be introduced in January 2023, have been delayed until October 2025.19 In addition, following a public consultation in 2018,20 plans to introduce a ban on sales of energy drinks containing caffeine to those under 16 years have also been delayed. Although supermarkets and other larger retailers have voluntarily restricted sales to adults, many smaller outlets and some online shops have not.21 Consequently, there may be a three-year period during which no new public health measures will be introduced and damage to teenagers' dental and general health will continue.

Within the relationships, sex and health education curriculum, which has been a statutory requirement in schools in England since September 2021, oral health and healthy eating are both covered within the physical health and mental wellbeing section. It is a requirement for CYP to be taught about the consequences of sugar consumption, including drinks, on dental and general health, and for this teaching to include the adverse effects of consuming too many caffeinated drinks. However, even if all these measures were implemented, it is unlikely that they alone will address the social and environmental factors influencing sports and energy drink consumption and other behaviour change approaches will also be needed.

Role of dental teams

While the role of soft drinks in causing dental disease in children is well-established, it is important dental teams are aware of the increasing popularity of this type of sports and energy drinks and feel able to discuss their consumption with young patients when completing diet diaries and providing dietary advice. However, as noted in the evidence-based toolkit for prevention, Delivering better oral health, there is very little quality evidence about effective interventions to reduce sugar consumption.22 In fact, while a Cochrane review found evidence to suggest dietary interventions delivered by dental professionals can be effective at changing dietary behaviours, it identified only one trial involving CYP as participants and called for more research underpinned by behaviour change theory to develop this area of clinical prevention.23 In future, these dietary interventions should be co-designed with CYP, parents and dental teams to ensure they are appropriate and acceptable.

Conclusion

CYP are regularly and increasingly consuming sports and energy drinks with cariogenic, erosive and other adverse health effects. A combination of upstream legislative changes to help limit sugar intake in CYP and dietary interventions by dental teams are suggested to begin to tackle this worrying trend.