Gym, eat, repeat: the shocking rise of muscle dysmorphia

‘Every muscle could be bigger. I could be leaner. I have no chest muscles; I have no arm muscles ... you’re judging yourself against an impossible standard.’

‘Every muscle could be bigger. I could be leaner. I have no chest muscles; I have no arm muscles … you’re judging yourself against an impossible standard.’ Photograph: Posed by model/Getty/iStockphoto

It is difficult for Miles to pinpoint the moment his muscle dysmorphia started. It was just always there, a background hum. “As far back as I can remember, I wanted a better-looking body,” says the 35-year-old US soldier, now stationed in Mons, Belgium. When he was 13, Miles spent a summer cutting grass to save up for a secondhand Soloflex exercise machine. The machine cost $1,000 (£800), but as Miles was too young to join a gym, it was worth the expense. With the help of the Soloflex, Miles started weight training and never looked back.

When he returned from a posting to Afghanistan at 24, things spiralled. He began obsessively working out and regimenting his meals. “I went all in … it was full, hardcore dedication to the lifestyle.” Miles set his watch to beep every three hours, to remind him to eat. If it beeped when he was driving, he would pull over. Slowly, he whittled his body into shape. His muscles became striated, every fibre visible. Not big enough. At 95kg (210lbs) and 1.8 metres (6ft 2in), Miles wanted to be more muscular; leaner. He lost 22kg and started competing in amateur bodybuilding competitions. There was virtually no fat on him. “You pinch your skin and it just stays pinched.” His girlfriend left him. “She began to realise that my body dysmorphia was like dating another person.” The pursuit of muscularity took over his life. “I just thought, I am so lean, and shredded, and veiny, and masculine – I don’t ever want to go back to how I was before.”

Yet by 33, single again – the dysmorphia had claimed yet another relationship – it had all become too much and he was in a dark place. “I did not enjoy life in any way, shape or form.” All day long, he would starve himself, struggle through punishing workouts, go home and binge-eat before throwing it all up. One evening, waiting in line at the burger chain In-N-Out for more food to purge, Miles finally decided enough was enough. “I woke up so happy the next day, knowing it was over.”

A subset of body dysmorphic disorder, individuals with muscle dysmorphia feel they need to become bigger or more muscular, regardless of their size. Sometimes referred to as “bigorexia”, it typically affects men. About 30% of people with muscle dysmorphia will also have a medically diagnosable eating disorder, as those with the condition may follow extremely restrictive diets. Because men with muscle dysmorphia rarely seek treatment, estimating its prevalence in the general population is hard, but it is believed that about 10-12% of professional male weightlifters meet the criteria.

And muscle dysmorphia may be on the rise. A study published in June found that 22% of men aged 18-24 reported muscularity-oriented disordered eating. “The drive for a bigger, more muscular body is becoming very prevalent,” says the lead researcher Dr Jason Nagata of the University of California, San Francisco. Not everyone who benches 180kg has muscle dysmorphia. It is when working out takes over your life, occluding all else – work, family, friends – that you have a problem. “Their entire day is spent at the gym trying to bulk up,” says Nagata. “They may also be taking illicit supplements like steroids.”


What drives a generation of young men to slavishly pursue this physical ideal? “Over the past decades, the idealised male body image has got bigger and bulkier,” says Nagata.

This body type even pressed its way into our children’s bedrooms: studies show that action figures have become brawnier over the past 25 years.

This wasn’t always the case. “In the 70s, we saw very slim, almost androgynous men, like Mick Jagger and David Bowie … to be muscular was to be defined as to be militaristic, at a time when, in the US, there were protests against the Vietnam war,” says Dr Roberto Olivardia of Harvard Medical School, an expert in male body image. “So that build was really frowned on and rejected by youth culture.

“But then the 80s came about, with figures like Ronald Reagan, who was pro-military, and men like Arnold Schwarzenegger and Sylvester Stallone.” This ideal male – hyper-masculine, militaristic, strong above all else – was exported globally through films such as First Blood (1982), Predator (1987) and The Terminator (1984). WWE wrestling was founded in 1980, and the likes of Hulk Hogan became celebrities. In the late 90s, a leaner but still very muscular aesthetic – popularised by Brad Pitt in the movie Fight Club – became fashionable.

Today’s muscle men stare down at us from the billboards of superhero films featuring stars such as Chris Hemsworth or Jason Momoa, the latter only last week body-shamed online after photographs emerged of him enjoying himself on holiday in fractionally less-than-superhero condition. On the small screen, the current crop of Love Island contestants mug for the cameras in tiny swimming trunks, all the better to display their perfect six-packs.

However, just as fashion magazines don’t cause anorexia, but contribute to a toxic environment in which extreme thinness is celebrated, Hulk Hogan, Dwayne ‘the Rock’ Johnson and Chris Hemsworth are not to be blamed for the disordered behaviours sweeping our gyms. According to the NHS, we do not yet know what causes body dysmorphia disorders but genetics, a chemical imbalance in the brain or a traumatic experience in your past may play a part. You are also more likely to develop it if you were bullied or abused as a child, something student Nathaniel Shaw knows well. The 28-year-old was bullied at secondary school – they called him a Borrower, on account of his slender frame.“I was always the small kid in the corner that no one wanted to speak to.” Social acceptance came one squat press at a time. “From where I’m from in Nottingham, because it’s a very rough place, you’re training to protect yourself. The bigger guys are the serious people that no one wants to mess with. That was the main thing at the start – get big and be taken seriously.”

When Shaw went to college at age 17, he had a plan: work out all winter and reveal his buff body come summer. But when he took off his T-shirt playing football one afternoon, a girl said that Shaw “had no chest”. He instantly put his top back on. “I still wasn’t good enough.” The unkind comment laid waste to Shaw’s fragile self-esteem; he walked away from the wreckage determined to become even more shredded.

Shaw’s life became: the gym, home to eat enormous portions of tuna, pasta and cheese, move as little as possible to conserve energy and repeat. Shaw detached from the contours of normal life. He stayed in bed longer, later and missed exams. He was depressed. “The pursuit of this muscular ideal takes over people’s lives,” explains Nagata. “They become obsessed with it. They can’t function in their daily life outside of pursuing this ideal and it can lead to depression, missing school or work, and losing their ability to do basic living tasks.”

To an observer, Shaw – who weighed 80kg at 1.7 metres – was tank-like. But that wasn’t how he saw himself. “I would be in the gym and say: ‘I look like shit.’ Everyone would be like: ‘No you don’t, you’re huge, I wish I could look like that.’” Muscle dysmorphia is a disease of perception. Although its sufferers live in the material world – a place of grunting exertion and weighted bags and scoopable protein powders – they spend most of their time in an imagined reality, where they are incalculably huge. Their biceps are swollen watermelons; each muscle as finely striated as the delicate contours of a seashell.

But even if they eventually achieve that physique, it is not enough. As soon as one muscular ideal is achieved, a new goal appears. “There’s a saying: ‘Once you step into a gym, you’re forever small,’” says 27-year-old Rich Selby, an amateur bodybuilder from Cardiff. Miles agrees. “Every muscle could be bigger. I could be leaner. You look at yourself and feel like everything is small and weak. I have no chest muscles; I have no arm muscles … you’re judging yourself against an impossible standard.”

Social media reflects this standard back at you. “You’re being sold a false reality,” says Miles. “I can get into really good shape, right before I’m doing a bodybuilding competition, and use lighting and angles and filters to make my physique look even crazier than it already is, and save a bunch of pictures and upload them to make it seem that I always look like that, all year round.”

Some turn to illegal substances to attain this ideal. Tony, 23, works for a pharmaceutical distributor in Dallas. He started taking illegal performance-enhancing drugs, including testosterone, equipoise and nandrolone, two years ago. The drugs created a dangerous feedback loop: the more he injected, the more his body changed and the more he took. “People are like: ‘Wow, that guy’s a tank.’ They have more respect for you … I thought, heck yeah, I’m going to take more so I can get even bigger.”

Up close, you can see the havoc muscle dysmorphia wreaks. “Your interpersonal relationships fall apart – but you are so caught up in the endorphin rush of affirmation from your gym buddies, you barely notice,” says Miles. “You’re kind of an asshole. You don’t realise it … you just become this all-around grouch. It consumes not only all of your time and focus, but also the human part of you.” It’s also a lonely existence. All your time is spent preparing protein-rich food, but because you are over-exercising, you are often “hungry, and cranky, and don’t sleep well”.

Among the young men Nagata surveyed, 2.8% had used illegal steroids, and it is estimated that up to 1 million Brits take performance-enhancing drugs.“Steroids can lead to heart disease, kidney problems and liver damage,” says Nagata. There are also mental health risks. “People may have extreme irritability, aggression, paranoia and can be violent.”

Tony was one young man who used drugs to bulk up. He knew what he was doing was dangerous: he would even donate blood to get his blood pressure down. “I just genuinely didn’t care.” As he cycled on and off drugs, he experienced dramatic mood swings. He got fired from his job at a hardware store for screaming at a coworker in the break room. Eventually, his mental health deteriorated so much that he came off all the drugs in May last year.

What makes someone play Russian roulette with a steroid-filled syringe? Selby thinks people are driven to desperate measures because they cannot disassociate who they are from how they look.

It’s an obsession that can prove fatal. Freddie Dibben, 28, died in March 2017 after his heart became enlarged by the stimulant Clenbuterol. His father Clifford, 69, found him. “The hardest part was going back through to the kitchen and telling his mum what I found. It’ll never go away.” Like Tony, Freddie experienced mood swings. “He would snap at you,” Clifford says, recalling an incident where Freddie was “stroppy” with him as they tinkered with his car. He put the moodiness down to work stress – Freddie had been pulling a lot of night shifts at Wilton carpet factory, where colleagues referred to him as a “forklift”, on account of how much he could carry.

But Clifford felt blessed to have a health-conscious son; he didn’t see anything to be alarmed about. A keen gym-goer, Freddie even gave up smoking at his parents’ request. “He used to cook all his own food! He’d cook a meal before he went to work … he had two sets of scales, and he weighed all his vegetables, everything. He even kept notes of what he was eating and what he was doing.” Clifford laughs, bitterly. “Except for the bloody drugs.”

And that is one of the issues of muscle dysmorphia – you can hide in plain sight. A pair of weighing scales in the kitchen; tupperware boxes of chicken and broccoli in your backpack. Most people view these as harmless, if idiosyncratic, behaviours. And when you look like you are hewn out of marble, it is hard to consider anything is amiss. It is only when you step past the facade that you realise these statue-like men are slowly destroying themselves.

It is a silent epidemic – Olivardia estimates as many as 10% of men working out in gyms may be suffering, but never seek help. Lately, Tony has started taking illegal substances again, insisting “it can be done safely”. Clifford still has Freddie’s weighing scales in the kitchen. Looking at them, he would probably disagree.

Cardiovascular and Cerebrovascular Safety of Testosterone Replacement Therapy Among Aging Men with Low Testosterone Levels

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We assessed the risk of ischemic stroke, transient ischemic attack, and myocardial infarction associated with testosterone replacement therapy (TRT) among aging men with low testosterone levels.


Using the UK Clinical Practice Research Datalink, we formed a cohort of men aged 45 years or older with low testosterone levels and no evidence of hypogonadotropic or testicular disease, between 1995 and 2017. Hazard ratios (HRs) and 95% confidence intervals (CIs) of a composite of ischemic stroke/transient ischemic attack and myocardial infarction were estimated using time-dependent Cox proportional hazards models, comparing current use of TRT with nonuse.


The cohort included 15,401 men. During 71,541 person-years of follow-up, 850 patients experienced an ischemic stroke/transient ischemic attack/myocardial infarction (crude incidence rate 1.19 [95% confidence interval (CI), 1.11-1.27] per 100 persons per year). Compared with nonuse, current use of TRT was associated with an increased risk of the composite outcome (HR 1.21; 95% CI, 1.00-1.46). This risk was highest in the first 6 months to 2 years of continuous TRT use (HR 1.35; 95% CI, 1.01-1.79), as well as among men aged 45-59 years (HR 1.44; 95% CI, 1.07-1.92).


TRT may increase the risk of cardiovascular events in aging men with low testosterone levels, particularly in the first 2 years of use. In the absence of identifiable causes of hypogonadism, TRT should be initiated with caution among aging men with low testosterone levels. 

Lachlan Foote, 21, dies after drinking protein shake containing enough ’caffeine for FIFTY coffees’

Lachlan Foote, protein powder

Lachlan Foote, 21, was set to celebrate his 22nd birthday the following day but instead his family were grieving their son’s death.

His body was found on the bathroom floor of the family’s home in Blackheath, New South Wales, Australia after he downed the muscle building drink.

But they have only just discovered the cause of death, and are sharing the heartbreaking story in the hope of “saving someone else’s life”.

The lad’s dad Nigel said the coroner’s report revealed Lachlan had died as “caffeine toxicity” after adding caffeine power to his protein shake.

“Dawn and I have finally received the Coroner’s findings regarding Lachlan – he died of ‘caffeine toxicity’ (not from a dodgy batch of protein powder as we had first thought). There was nothing else in his system except a small amount of alcohol (.043).”It turns out that Lachlan came home after celebrating New Year’s Eve with his friends and made a protein shake, innocently adding too much (caffeine powder) – a teaspoon is lethal (the equivalent of 25-50 coffees).”

Nigel added: “We think Lachlan obtained the caffeine powder from a friend or work associate as a thorough search of his computer and bank statements, by both myself and the police, revealed no mention of caffeine powder, only related protein powder products.

“Therefore, it appears the pure caffeine powder was bought by someone else and shared, so it’s very likely that Lachlan never got to read the warning label on the packet and was unaware of its potency.

“And the fact that he kept the caffeine powder in our kitchen pantry (where one of us might have mistaken it for flour or sugar) proves the point – Lachlan would never have kept it there had he known it was a threat to the family. He was a bright, imaginative young man.

Lachlan Foote

“We’re concerned that there might be other young people in his circle who bought or shared in this batch of pure caffeine powder and, like Lachlan, be unaware of the danger… hence this post.”

Just hours before Lachlan’s death, the young man had sent a Facebook message to friends saying his protein shake tasted “off”.

He wrote: “I think my protein powder has gone off. Just made an anti hangover / workout shake and it tasted awful”.

When a pal asked “how?”, Lachlan replied: “Dunno, was kinda bitter though… anyway night lads.”

Describing the tragic events that following, Nigel added in his Facebook post: “Morning never came for Lachlan. We found him, dead and cold on the bathroom floor (New Year’s Day 2018)… the day before his 22nd birthday.

“It has been an excruciating wait for the Coroner’s findings, but the love and support we have received from our family, friends and this fabulous Blue Mountains community has seen us through. We can never thank you enough.

“The investigation is finally over and we are not left wondering what exactly happened to Lachie any more – we now know. The original autopsy revealed caffeine but not the precise levels, so another, more specialised test had to be done, hence the delay. The Coroner’s forensic team and counselling staff have been wonderful.

“We bear no ill feeling toward whoever shared the caffeine powder with Lachlan as we’re sure this was just a tragic, innocent mistake.

“It’s just insane that something so dangerous is so readily available. Please warn your friends, talk to your children… and perhaps check your kitchen cupboards…pure caffeine powder looks just like any other white powder… but a heaped teaspoon of it will kill you.

“I’m not going to go on a crusade about caffeine powder – we need to move on – but I do want to warn Lachlan’s friends and the Blue Mountains community.

“I will post some special ‘Lachlan moments’ now and then – perhaps on his birthday – for I know how much he meant to so many of you. He lives on in our hearts… our photos… and in the stars…”

Younger Guys ‘Bulking Up’ May Face Dangers of Disordered Eating

Young adults who see themselves as scrawny and who exercise to gain weight may be at risk of muscularity-oriented disordered eating behaviors, according to a new study led by researchers at the University of California- San Francisco (UCSF) Benioff Children’s Hospitals.

These behaviors include one or more of the following: eating more or differently to gain weight or bulk up and/or using dietary supplements or anabolic steroids to achieve the same goal.

The findings, published in the International Journal of Eating Disorders, reveal that 22 percent of young men and 5 percent of young women, ages 18 to 24, exhibit these disordered eating behaviors.

Left untreated, these behaviors may escalate to muscle dysmorphia, characterized by rigid dieting, obsessive over-exercising and extreme preoccupation with physique, say the researchers.

“Some eating disorders can be challenging to diagnose,” said first author Jason Nagata, M.D., of the UCSF Division of Adolescent and Young Adult Medicine.

“Unlike anorexia nervosa, which may be easily identified by parents or pediatricians, disordered eating to increase bulk may masquerade as healthy habits and because of this, it tends to go unnoticed.”

At its most extreme, it can lead to heart failure or overexertion, as well as muscle dysmorphia, which is associated with social withdrawal and depression, Nagata said.

For the study, the researchers evaluated the data of 14,891 young American adults, who had been followed for seven years. The researchers wanted to see if the early data, when the participants’ average age was 15, revealed something about their perceptions and habits that may serve as warning signs.

They found that male teens who exercised specifically to gain weight had 142 percent higher odds of this type of disordered eating; among female teens, the odds were increased by 248 percent. Boys who perceived themselves as being underweight had 56 percent higher odds; in girls the odds were 271 percent higher. Smoking and alcohol use in boys, and smoking in girls, increased odds moderately.

In addition, being African-American boosted the odds by 66 percent in boys and 181 percent in girls. Non-heterosexual identity, which the participants had been asked about when they reached adulthood, was not found to be a risk factor, the researchers said.

In young adulthood, 6.9 percent of males reported supplement use to gain weight or build muscle and 2.8 percent said they used anabolic steroids. Use by young women was significantly lower at 0.7 percent and 0.4 percent respectively.

“Supplements are a black box, since they are not regulated,” said Nagata. “In extreme cases, supplements can cause liver and kidney damage. Anabolic steroids can cause both long-term and short-term health issues, including shrunken testicles, stunted growth and heart disease.”

According to Nagata, some behavioral clues that may indicate muscle dysmorphia risk include a highly restrictive diet that omits fats and carbohydrates, compulsive weighing and checking of appearance, and extensive time dedicated to exercise that may cut into social activities.

Source: University of California- San Francisco

Braves host kids as part of PLAY Campaign

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ATLANTA — Catching coach Sal Fasano and bullpen coach Marty Reed were among the members of the Braves’ organization who welcomed nearly 100 kids to SunTrust Park Tuesday afternoon to participate in the National PLAY Campaign.

“I think there are a lot of good and bad ways these kids can be influenced,” Fasano said. “We wanted to influence them on the good side.”

The Professional Baseball Athletic Trainers Society (PBATS) has spent the past 15 years coordinating the PLAY (Promoting a Lifetime of Activity for Youth) Campaign, which was formed to raise awareness about childhood health issues and disability inclusion in the United States. More than 350 events have been held in Major League ballparks to promote making healthy decisions and living a more active and healthy lifestyle.

Children from the National Down Syndrome Society were among the members of local Atlanta youth groups that took part in this event, which is supported by the Ruderman Family Foundation, Major League Baseball Charities, the Taylor Hooton Foundation and the Henry Schein Cares Foundation.

The PLAY Campaign became the first program in professional sports to include children with disabilities. PBATS partnered with the Ruderman Family Foundation and National Down Syndrome Society in 2017 to enhance this effort.

Rain prevented the kids from partaking in hitting activities, but Fasano provided outfield instruction and Reed offered pitching advice. Braves assistant athletic trainer Mike Frostad conducted a relay race station. As the children ate lunch in the Chop House, they received information about the dangers of performance enhancing drugs.

“They got a few different messages today,” Fasano said. “You want to do anything you can to influence the youth of the area.”

Mark Bowman has covered the Braves for since 2001.

Federal officials seize adulterated dietary supplements from Life Rising Corporation due to poor manufacturing practices

For Immediate Release:  June 14, 2019

At the request of the U.S. Food and Drug Administration, U.S. Marshals seized more than 300,000 containers of dietary supplements, including tablets, capsules, and teas from Life Rising Corporation. The seized goods, which were held by Life Rising or manufactured in the company’s facility located in Willowbrook, Ill., consisted of more than 500 products bearing brand names Life Rising, Holicare, or HopeStream, and are valued at approximately $3.5 million. The U.S. District Court for the Northern District of Illinois determined there was probable cause that the company prepared, packed, and/or held dietary supplements under conditions that do not conform to the dietary supplement current good manufacturing practice (CGMP) requirements.   

“This seizure underscores the agency’s commitment to taking aggressive action when manufacturers distribute adulterated dietary supplements that have the potential to put consumers at risk,” said Melinda K. Plaisier, the FDA’s Associate Commissioner for Regulatory Affairs. “The FDA has a variety of enforcement tools at its disposal, and when products don’t comply with FDA regulations, we will not hesitate to take appropriate action.” 

The FDA inspection at Life Rising found that its dietary supplements were prepared, packed, and/or held under conditions that violated CGMP regulations. Among other observed deficiencies, the company failed to establish product specifications for the identity, purity, strength, and composition of each finished batch of dietary supplement, and for limits on certain types of contamination, to ensure the quality of the supplement. The company also lacked written procedures for pest control and for maintaining, cleaning, and sanitizing equipment and/or surfaces that came in contact with the dietary supplements, among other violations. Based on these CGMP violations, last month, the FDA issued an Administrative Detention Order to prevent these products from reaching consumers until they could be seized.

Last month, the FDA also issued a safety alertExternal Link Disclaimer for three Life Rising products (Life Rising Holder-W Holder Warmer capsules, Life Rising NECK-ND Neck Clear capsules, and HoliCare Metabolism Cleansing (MET-CLS) tablets) because those products may be contaminated with lead. These products were recalled by the company on May 2, just before the FDA’s safety alert. Lead exposure is extremely dangerous and can cause extensive damage to the nervous system and internal organs. 

In 2016, Life Rising recalled certain dietary supplement products because of elevated lead levels, and in May 2017, the agency issued a warning letter to Life Rising citing CGMP violations. This action stems from a follow up inspection the FDA conducted to evaluate the company’s CGMP compliance. In light of the recalls and safety alerts, as well as the continuing violations of CGMP, the FDA discourages consumers from purchasing or using dietary supplement products bearing brand names Life Rising, Holicare, or HopeStream.

Consumers and health care professionals should report any adverse events related to products from Life Rising to the FDA’s MedWatch program by:


The FDA, an agency within the U.S. Department of Health and Human Services, protects the public health by assuring the safety, effectiveness, and security of human and veterinary drugs, vaccines and other biological products for human use, and medical devices. The agency also is responsible for the safety and security of our nation’s food supply, cosmetics, dietary supplements, products that give off electronic radiation, and for regulating tobacco products.


Energy Drinks: Another Tragedy

I wanted to share my husband’s story, Darryl Lefler.

He would drink 2-3 energy drinks daily. One day he began seeing double vision and his eyes were not tracking correctly. Then he started having small seizures every 3-4 minutes to where he could not talk and would lose movement in his right side.

He had an MRI, and they found a lesion on his brain. We found Dr. Okuda in Dallas by the grace of God! He is studying the brain and what energy drinks do to your brain.

Most energy drinks have taurine and high caffeine. When these two are mixed it causes quick shifts in blood pressure and damages the brain.

Thank God we caught it when we did.  My husband had to take seizure meds at first, but over time his brain healed. He still has the lesion but the seizures have almost stopped. His vision has not improved though.

I have attached the study that our doctor is doing regarding energy drinks causing brain lesions. 

–Joyce Lefler, Wife



Pontine myelinolysis following excessive consumption of commercial energy drinks!po=3.12500

New-onset seizures in adults: possible association with consumption of popular energy drinks.

Energy drinks may have unintended health risks

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(CNN)  Energy drinks may promise a boost, but experts are increasingly concerned that their cocktails of ingredients could have unintended health risks.

A study published Wednesday in the Journal of the American Heart Association found that caffeinated energy drinks altered the heart’s electrical activity and raised blood pressure.
The extent of these electrical changes — which signal the heart’s chambers squeezing and relaxing — is “generally considered mild,” according to study author Sachin Shah, a professor of pharmacy at the Thomas J. Long School of Pharmacy and Health Sciences at the University of the Pacific. However, people who take certain medications or have a specific type of heart condition could be at increased risk of a fatal arrhythmia, or irregular heartbeat, he added.
“Unlike drugs, supplements and consumer products do not necessarily get tested for safety,” Shah said in an email. 
The American Beverage Association stands by the safety of energy drinks, indicating that many of their ingredients are also found in common foods and have been rigorously studied for safety.
But health experts like the World Health Organization say they “may pose danger to public health.” Children “should not consume” them, cautions the American Academy of Pediatrics.
Still, the global energy drink market continues to grow. It was worth $39 billion in 2013 and is forecast to reach $61 billion by 2021.
So what exactly is inside these drinks, and how do they impact your body?

‘A black box’

Over the years, concerned experts have been getting closer to answering those questions, said Dr. John Higgins, a sports cardiologist with McGovern Medical School at the University of Texas Health Science Center in Houston.
Most energy drinks typically contain large amounts of caffeine; added sugars; vitamins, such as B vitamins; and legal stimulants, such as guarana, a plant that grows in the Amazon; taurine, an amino acid that’s naturally found in meat and fish; and L-carnitine, a substance in our bodies that helps turn fat into energy.
“Overall, the concern is that these vitamins, amino acids and herbals are often in higher concentrations than naturally in food or plants, and the effects when combined especially with caffeine may be enhanced,” Katherine Zeratsky, a clinical dietitian at the Mayo Clinic in Rochester, Minnesota, previously told CNN.
Higgins, who has led multiple studies on energy drinks and health impacts, agreed.
With the caffeine, sugar and stimulants, Higgins previously told CNN that more research is needed to determine how those ingredients could interact to cause negative health effects.
“They’re sort of a black box. We really don’t know a lot about them,” Higgins said of energy drinks.
“People need to be aware of that,” he said. “For certain groups, it could be potentially dangerous, like for those under 18, women who are pregnant, people who have a caffeine sensitivity, people who don’t consume caffeine on a regular basis and people who are taking certain medications, like Adderall for attention deficit (disorder).”
Rachel Hicks, a spokeswoman for the American Beverage Association, previously issued a statement from the group that said many people around the world have safely consumed energy drinks for more than 25 years.
“Many of the ingredients in energy drinks, such as B vitamins and taurine, are found naturally in many foods,” the statement said.
“The fact remains that energy drinks have been extensively studied and confirmed safe for consumption by government safety authorities worldwide including a recent review by the European Food Safety Authority. America’s leading energy drink manufacturers voluntarily go beyond all federal requirements when it comes to responsible labeling and marketing practices, including displaying total caffeine content — from all sources — on their packages,” the statement said. “As recently as 2015, EFSA again concluded that it is unlikely that energy drink ingredients such as taurine interact adversely with, or enhance the effects of, caffeine.”
Here’s a look at how certain parts of your body may be affected after guzzling more than the recommended amount of energy drink, according to experts.

‘Arteries of his heart were completely locked up’

After chugging an energy drink, you might notice your heart rate increase.
Your rapidly beating heart could pose a health risk, as “energy drinks not only have been shown to raise stress levels, increase heart rate, increase blood pressure, they’ve also been shown to make the blood a little bit thicker,” Higgins said.
Study: Energy drinks can harm teens

Taurine, a common amino acid, can affect the levels of water and minerals in your blood. Bits of guarana, the plant from the Amazon, are commonly added to energy drinks and already contain caffeine, which can increase a drink’s total caffeine amount.
“There’s been several cases described of people that have gone into cardiac arrest after consuming more than one energy beverage, and when they’ve done sort of further analysis on these individuals, they haven’t been able to find anything abnormal other than the very high levels of caffeine and taurine in the toxicology,” Higgins said.
“In one case, a young 28-year-old who drunk eight cans of an energy drink actually went into cardiac arrest, and they found his arteries of his heart were completely locked up. When they were able to open them up, all the testing revealed nothing wrong with this person other than he had high levels of caffeine and taurine,” he said.
The possible interaction of caffeine with the other ingredients in energy drinks may impact the function of your arteries by inhibiting them from dilating properly, especially during exercise, Higgins said.
“The blood vessels in the heart during exercise have to get larger; they dilate and get larger so that more blood flow can get to the heart,” he said.
Large amounts of caffeine, however, might affect not only your body, but also your brain.

Energy drinks and the brain

Depending on how many energy drinks you consume, doses of caffeine equal to or above 200 milligrams can be linked to caffeine intoxication, according to a paper published in the International Journal of Health Sciences in 2015. Symptoms include anxiety, insomnia, gastrointestinal irritation, muscle twitching, restlessness and periods of inexhaustibility.
“To give you an idea of products containing caffeine, Java Monster contains 100 milligrams per serving; 5 Hour Energy contains 200 milligrams per serving, and keep in mind that does not include amounts of other stimulants found in energy drinks that can enhance the effects of caffeine,” said Sheri Zidenberg-Cherr, nutrition specialist and vice chairwoman in the department of nutrition at the University of California, Davis.
The US military has even warned against troops consuming too many energy drinks since doing so has been associated with sleep disruption, leading to periods of fatigue during briefings or on guard duty.
Service members who drank three or more energy drinks per day were more likely to report about four hours of sleep or less, on average, per night than those who drank two or fewer a day, according to a study conducted in 2010.
Army warns of new threat: Energy drinks

The Consortium for Health and Military Performance recommends that service members, from sailors to Marines, limit their caffeine intake to no more than 200 milligrams every four hours and no more than 800 milligrams throughout the day, according to the Navy and Marine Corps Public Health Center.
Some papers and research have linked energy drink consumption to an increased risk for symptoms ofmental health problems. However, a review paper published in the Journal of Caffeine Research last year suggests that there is not enough evidence to determine causation or direction of effect.
Now that energy drinks have grown in popularity, especially among adolescents, many health experts are concerned about the impacts they could have on young consumers.

How much ‘energy’ kids, adults could drink

The copious amounts of caffeine that energy drinks tend to contain are why the American Academy of Pediatrics has recommended that children avoid consuming them.
Kids & Energy Drinks
For adolescents, 12 to 18, the academy recommendsthat they should not exceed 100 milligrams of caffeine a day, according to the CDC.
An intake of caffeine greater than 100 milligrams a day has been associated with elevated blood pressure in adolescents, Zidenberg-Cherr previously told CNN.ome 1,145 Americans ages 12 to 17 were admitted to emergency rooms for energy drink-related health emergencies in 2007, according to the CDC. That number climbed to 1,499 in 2011.
As for most adults, up to 400 milligrams of caffeine a day appears to be safe, according to the Mayo Clinic.
“Healthy adults who choose to drink energy drinks should not exceed one can per day,” the Mayo Clinic’s Zeratsky said.
Concerns over energy drink marketing

Some parents and children may not even be aware of the potential health risks associated with energy drinks due to the way they are marketed, Zidenberg-Cherr said.
“There is no regulation of the marketing of energy drinks targeted at young adults,” she said.
Energy drinks are popular among young athletes, especially for an extra energy boost. Yet the National Federation of State High School Associationsrecommends that they not be used for hydration prior to, during or after physical activity.
Furthermore, a common ingredient in energy drinks, guarana, is mentioned in the NCAA’s 2016-17 banned drugs list, which is provided online.
Higgins, the Houston sports cardiologist, said that while shopping at a grocery store on a recent Saturday morning, he saw a woman with a 12-pack of Red Bull. Her son, who Higgins said appeared to be about 11 years old and who was wearing soccer gear, stood nearby.
They were waiting in line at a checkout counter.
“She was having a conversation, and the boy said, ‘Oh, yeah, gee, our team will really do well today when we’re having the Red Bull at the halftime.’ And I was just thinking, wow, back in our day, we used to have oranges, bananas, water and juice, and they’re doing energy drinks,” Higgins said.
“That just sort of told me, the mom obviously didn’t understand that these are not like oranges or bananas or even juices,” he said. “These are a completely different beast, and that’s part of the confusion that people have.”

Harmful effects of energy drinks – it’s not the caffeine

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(Reuters Health) – Drinking 32 ounces of energy drink is associated with potentially harmful changes in blood pressure and heart function that are beyond those seen with caffeine alone, according to a new study.

There are more than 500 energy drink products on the market, and their increased popularity is matched by a significant rise in energy drink-associated emergency department visits and deaths.

Manufacturers and fans of these products claim they are as safe as caffeine, but there is little evidence to support that claim.

Caffeine in doses up to 400 mg (about five cups of coffee) is generally recognized as safe by the Food and Drug Administration. While energy drinks usually contain caffeine, little is known about the safety of some of their other ingredients the study team writes in the Journal of the American Heart Association.

To see what effects these other components have, researchers compared physical changes in a group of 18 healthy men and women after consuming a commercially available energy drink and after drinking another concoction with the same amount of caffeine but none of the other ingredients.

Besides 320 mg of caffeine – the amount in about four cups of coffee – the energy drink contained 4 ounces of sugar, several B vitamins and a proprietary “energy blend” of taurine and other ingredients that are often found drinks like Monster Energy, Red Bull and 5-Hour Energy.

Sachin A. Shah of David Grant Medical Center on Travis Air Force Base and University of the Pacific in Stockton, California, and colleagues measured the participants’ blood pressure and used an electrocardiogram (often called an ECG or EKG) to measure heart electrical activity for 24 hours after the subjects consumed the drinks.

An ECG change known as QTc prolongation and sometimes associated with life-threatening irregularities in the heartbeat was seen after drinking the energy drink, but not after drinking the caffeine beverage, the study team reports.

Several drugs have been withdrawn from the market just for causing ECG changes of a similar magnitude, the authors note.

Blood pressure increased by close to 5 points after drinking the energy drink, but by just under 1 point after drinking the caffeine beverage. Blood pressure also remained elevated six hours later.

These changes are by no means worrisome for healthy individuals, the researchers say, but patients with certain heart conditions might need to exercise caution consuming energy drinks.

Larger studies are needed to evaluate the safety of the noncaffeine ingredients contained in energy drinks, they conclude.

“The energy drink industry claims that their products are safe because they have no more caffeine than a premium coffee house coffee,” said Dr. Jennifer L. Harris from University of Connecticut’s Rudd Center for Food Policy and Obesity in Storrs, who wasn’t involved in the study.

“However, energy drinks also contain a proprietary ‘energy blend,’ which typically consists of stimulants and other additives. Some of these ingredients (including taurine and guarana) have not been FDA-approved as safe in the food supply, and few studies have tested the effects of caffeine consumption together with these ‘novelty’ ingredients,” she said by email.

“On top of that, energy drinks are highly marketed to adolescent boys in ways that encourage risky behavior, including rapid and excessive consumption,” she said. “As a result, emergency room visits by young people in connection with energy drinks are rising.”

Any research that compares the effects of consuming energy drinks versus caffeine alone provides important evidence for public health advocates who have urged the energy drink companies to stop targeting youth with these potentially harmful products, Harris added.

SOURCE: Journal of the American Heart Association, online April 26, 2017.

Case report: The long‐term effects of anabolic steroids on the female voice over a 20‐year period

Key Clinical Message

Anabolic steroids and androgenic steroids (AAS) can have long‐term effects on the female voice. These changes are clinically relevant since they are difficult to treat and therefore should be disclosed to patients using AAS or receiving androgenic steroid therapy.



A 27‐year‐old female bodybuilder presented with an androgenized voice (F0 = 110 Hz) after 6 weeks of androgenic anabolic steroid. She was followed for 20 years, requiring multiple surgical interventions to increase her pitch and presented with delayed severe vocal fold atrophy, with concurrent abnormal low testosterone levels.

Androgenic anabolic steroids (AAS) can have virilizing effect in women. The most common side effects include weight gain, acne, and increased libido, which are usually reversible. However, the masculinized voice change associated with AAS, including decreased pitch, reduced F0, and vocal fold thickening, has been reported as irreversible12 despite discontinued use.

A new entity, anabolic steroid‐induced hypogonadism (ASIH), described by Jarow,4 suggests AAS can have an inhibitory effect on the hormonal axis long after discontinuing their use, including hypotestosteronism. Several authors have since described this condition in men,5but there has been no reported case of ASIH in woman or description of vocal symptoms due to this condition.

This is a case report on the effect of AAS in a 27‐year‐old woman who ingested AAS when competing as a bodybuilder. This patient experienced disabling side effects due to androgenization of her voice and required surgery to increase vocal pitch in order to be identified as female. She has been followed for 20 years and experienced further unanticipated changes in vocal function many years after discontinuing anabolic steroid use, concurrently with abnormally low testosterone levels.


K. A, a 27‐year‐old woman, formerly a bodybuilder, sought treatment at our tertiary voice center for “masculine” voice in 1998. The patient had developed a gradual husky and low‐pitched voice change over a period of months, two years prior to presentation (at presentation—VHI = 40, F0 = 110 Hz, Jitter = 0.64%, Shimmer = 2.6%, pitch range = 2 semitones). The patient was more often than not perceived as male, and the gender misidentification was disabling in her personal and professional life including the loss of employment due to her voice quality. The patient had taken nandrolone, 50 mg/wk for 6 weeks as part of a muscle enhancement bodybuilding program. The voice change developed within 8 weeks of starting the androgenic steroids, and despite discontinuing the drug, the voice did not improve. No other previous voice issues or general health problems were reported. The patient was no longer bodybuilding and denied any other hormone replacement or medical therapy. She was fully evaluated by an endocrinologist (at presentation, normal female hormone profile) and was followed long‐term by her specialist.

Videostroboscopy at initial evaluation showed thick vocal folds, with blunting of the free edge bilaterally. A dull pink color was noted throughout the full length of the membranous vocal folds. There was no glottis gap with mucosal wave present bilaterally (Figure 1). Mild aperiodicity was also noted, and the fundamental frequency (F0) was 110 Hz, clearly in the lower range for a male and below the normal range for females.

Endoscopic evaluation of the larynx at initial presentation showing thickened, dull, pink vocal folds with blunting of the free edge bilaterally

A trial of 3 months of pitch increasing speech therapy (1998) and a type 4 thyroplasty 6(1999) resulted in very minimal improvement.

A novel endoscopic 1/3 anterior web creation procedure was then performed (2000)7 (Figure 2), resulting in an increased F0 = 215 Hz with normal perturbation measures. The patient was able to return to normal premorbid vocal function and was perceived as a female with habitual voice use.

Direct laryngoscopy showing an anterior web creation to create a 1/3 membranous vocal fold web using microlaryngoscopy, anterior vocal fold mucosal resection, and Gelfoam paste injection (Pfizer, Michigan)

The patient had no voice complaints for ten years but returned 13 years later with new symptoms of pitch and phonation breaks, inconsistent and “weak” voice quality without change in pitch. A Voice Handicap Index‐10 (VHI‐10) questionnaire revealed a score of 40 (severe disability).

Videostroboscopy revealed an unchanged anterior web. However, both VF now showed marked bowing and significant spindle‐shaped glottis gap with moderate aperiodicity (Figure 3).

Stroboscopic evaluation of the larynx 13 y after withdrawal from AAS showing marked bowing of the vocal fold bilaterally and spindle glottic gap

The patient denied new medical treatment or surgery, hormone therapy, or irregular menses. Repeat hormonal serum profile ordered by her endocrinologist now showed low level of free testosterone (Table 1). At that time, she also reported symptoms of generalized fatigue. She was then started on testosterone replacement therapy, which improved energy level without any impact on perceived voice handicap.

Table 1. Hormonal serum values for patient K.S from 2008 to 2016
Date TSH (U/mL) TT (nmol/L) FT (pg/mL) DHEA (nmol/L) SHBG (nmol/L) LH (U/L) FSH (U/L) PrL (ng/mL)
2008/02 2.71   11.0 1.8     <1 9.0
2012/06 3.52   <0.3          
2012/08     1.3          
2013/07 3.03   <0.3          
2014/01   <0.1 <0.3     6.0 6.0 5.0
2014/05   0.2            
2014/07   0.6 <0.3 4.1        
2014/08 2.87              
2014/12   0.8 <0.3          
2016/01 2.19 0.2 2.0   61.5      
2016/02   0.3 4.0   57.9      
2016/03     18          
  • DHEA, dehydroepiandrosterone (normal range: 1.8‐7.7 nmol/L); FSH, follicular‐stimulating hormone; FT, free testosterone (normal range: 0.3‐6.9 pg/mL); LH, luteinizing hormone; SHBG, sex hormone‐binding globulin (normal range for adult female: 20‐180 nmol/L); PLC: prolactin (normal range for nonpregnant female: <26 ng/mL); TSH, thyroid‐stimulating hormone (normal range: 0.3‐5.0 U/mL); TT, total testosterone (normal range: <1.8 nmol/L). All values since 2008 were taken after more than 9 y of withdrawal from AAS. The year of 2012 coincides with the patient presenting back to our clinic 13 y later with vocal fold atrophy.

The patient underwent bilateral type 1 medialization thyroplasty (MT) under local anesthetic with silastic blocks to augment vocal fold mass (2015), which resulted in a significant improvement in vocal function reflected by an reduction in her VHI.


The larynx and the vocal folds are often described as secondary sexual characteristic due to their distinctive role in puberty and gender identification.8 Many authors have studied this phenomenon by demonstrating the presence of hormonal receptors within the laryngeal tissue.910

It is therefore not surprising that our patient developed an androgenized voice with the fundamental frequency and stroboscopic appearance of male vocal folds. Several authors have reported AAS associated dysphonia in woman but described it as irreversible changes, up to 4 years after discontinuing the drugs.12 To explain these irreversible changes, Amer and al. demonstrated structural and immunophysiological changes in an animal model after 2 months of systemic anabolic steroid treatment.3 The rat model vocal folds showed thicker epithelial layers with increased mitotic figures, thicker lamina propria, and thicker muscle fibers. Moreover, more recent evidence (2015) suggests a dose and concentration dependent decrease in vocal pitch in woman receiving androgenic steroid therapy after hysterectomy. Although the changes are thought to be permanent, the follow‐up period in these studies does not exceed 1‐4 years.11

The findings that differ from the existing literature are the late changes in her voice 13 years later as well as the objective findings that correlate her symptoms on laryngoscopy. Instead of showing signs of androgenized vocal fold changes (thickening, edema, and shortening), she presented with thinned and atrophied vocal cords with significant impact on her voice. Although the previous literature describes androgenic effects of AAS to be permanent, no study has ever provided more than 2‐ to 4‐year follow‐up. There are a few hypotheses that should be mentioned to explain the late changes and others that should be excluded.

Firstly, the patient was 40 years of age at the time these late changes occurred and still had regular menses. Therefore, presbyphonia and menopause should not have contributed to the changes. The surgical interventions the patient underwent 10‐15 years earlier are not known to cause drastic vocal cord atrophy. The superficial laminal propria of the cords and the body of the cords were never instrumented during these procedures.

One of the plausible hypotheses could be related to anabolic steroid‐induced hypogonadism (ASIH), a recently described entity. Jarrow and Lipshultz first reported ASIH in 1990, by describing two cases of men with low testosterone levels 3 months and 2.5 years after discontinuing use of AAS.4 Rahnema et al5 published a comprehensive review of this phenomenon in 2014, describing the secondary hypogonadotropic hypogonadism by feedback suppression of the hypothalamic‐pituitary‐gonadal (HPG) axis via inhibition of pulsatile GnRH. Only male patients were described, and there was no mention of vocal symptoms. Interestingly, our patient did have low free testosterone levels as well as generalized fatigue which both improved after testosterone therapy by her endocrinologist. It is to be noted that she did not have complete suppression of her HPG axis since she did not suffer from amenorrhea.

Another explanation of these late changes could be that the effect of AAS are not permanent after all and wear off after several years leaving the vocal cords atrophied from the resorbed edema throughout the years. This hypothesis could not explain the low testosterone levels. Testosterone levels have been shown to have an impact of voice pitch and quality in recent literature studying transgender therapy.12

In both cases, late changes to the voice and larynx have not been described in the past due to lack of long‐term follow‐up in literature.


To the best of our knowledge, this is the first report of the long‐term effects of anabolic steroid on a female voice over a 20 years period. This challenging case suggests that effects of anabolic steroids on the female voice previously thought to be permanent could potentially change years after withdrawal. These changes are clinically relevant since they are difficult to treat and therefore should be disclosed to patient using AAS or receiving androgenic steroid therapy.


None declared.


Yael Bensoussan: performed the chart review and developed the manuscript. Jennifer Anderson: involved in the care of patient in this case report as a surgeon and reviewed the manuscript and literature.