I hate to admit this, but I read two recent articles about caffeine, energy drinks and alcohol in JAMA while having my second cup of coffee. And I become just a tad nervous…

Here are some of the physiologic facts that were presented in the first article: When we ingest caffeine, we feel the effect quickly because it’s well absorbed and achieves peak levels in 15 to 45 minutes. And as soon as it gets to the liver, it is metabolized into active stimulants. Alcohol and many medications can also prolong the 5 hour half-life of caffeine. The usual “dose” of caffeine in a cup of coffee is 100 mg and this can raise blood caffeine levels to 1 to 2 picograms per mL. According to Swedish scientists, a known lethal blood level of caffeine is 80 picograms per mL. (If you have read any of the books in ” The Girl with the Dragon Tattoo” series, you’ll remember that coffee consumption is an important activity in that country!) Despite their calculations, it is not totally clear what the exact consumption of caffeine would have to be to achieve this lethal level, but there are some good estimates… probably between 3 to 10 g of caffeine over a brief period of time, depending of course, on a person’s size and metabolism. That means consuming at least 12 highly caffeinated energy drinks within a few hours. This is an unlikely scenario unless mixed with alcohol….it turns out that when combined with alcohol, caffeine becomes much more potent and can cause major morbidity and in some cases the mixture may be fatal!

The second article in JAMA discussed the risk posed by energy drinks mixed with alcohol. The authors presented an alarming statistic; that 31% of young teens and 34 to 55% of 18 to 24-year-olds regularly consume energy drinks whose primary active ingredient is caffeine. As many as 56% of college students have reported mixing energy drinks with alcohol in the past month. They favor ” ready made” cocktails served at bars such as Redbull and vodka as well as premixed caffeinated alcoholic beverages such as four Loco. If not available, they self mix combinations of beverages or drink alcohol and energy drinks separately but within the same drinking occasion. Since caffeine offsets the sedating effect of the alcohol component of the energy drinks, they are less likely to realize that they have become intoxicated. This reduced sense of intoxication induces more alcohol consumption which further impairs judgment and their cognitive function.

The article also points out that other studies have shown that although drivers may feel they’re less drunk if they imbibe alcohol with caffeine, their performance remains impaired. And drinkers who believe that caffeine can counteract impairment from alcohol actually show greater impairment!

So now that we’ve concluded that too much caffeine is bad and that mixing it with alcohol does not make it better (only more dangerous), I want to give you a list of the caffeine ingredients in what many of us consume:

Energy drinks

  • * Five hour energy… 270 mg
  • * Amp, 16 ounce… 143 mg
  • * BAWLS Guarana, 16 oz…100 mg
  • * Full throttle, 16 ounce… 197
  • * Monster, 16 ounce… 160 mg
  • * NOS, 16 oz…260 mg
  • * Redbull, 16 ounce… 152 mg
  • * SPIKE shooter…286mg.


  • * Coca-Cola, 20 ounce bottle… 58 mg
  • * Dr. Pepper, 20 ounce bottle… 70 mg
  • * Mountain Dew, 20 ounce bottle… 90 mg
  • * Pepsi, 20 ounce bottle… 63 mg
  • * Pepsi Max, 20 ounce bottle 115 mg


  • * Black tea brewed, 8 ounces… 55 mg
  • * Coffee brewed 16 ounces, 170 mg
  • * Excedrin extra strength, two pills… 130 mg
  • * NoDoz Maximum Strength, one pill 200 mg
  • * Vivarin, one pill 200 mg


Bottom line: We can have our coffee (let’s keep it at less than 3 cups a day) and yes the occasional energy drink…but too much or trying to use caffeine to “overcome” the effects of alcohol can be harmful to your judgement and health.

 You probably expect this article to be about flu shots. Well, I should reiterate what you probably already know; that the flu shot contains non live flu virus that will instigate an immune reaction against the strains that are causing the current epidemic. The vaccine cannot cause the flu! It takes 2 to 3 weeks to form the specific antibodies to the culpable strains and if you are already infected or exposed the shot won’t have an impact. But for most, it is not too late to get a flu shot since this flu will be around for the next few months. Although not an absolute prevention, the vaccine will significantly diminish (at last count, by at least 62%) the chance of your getting infected and/or having a severe illness. You can still get the shot in many pharmacies…(We finished the last batch that we had received in my office a week ago.) So now I have done my public health announcement, which most of you didn’t need.

I know it took a paragraph to get here, but my intention was to write about an entirely different vaccine this week…the Tdap. This vaccine prevents infection of tetanus, diphtheria as well as pertussis or whooping cough; all spread by bacteria. In 2012 the Advisory Committee on Immunization Practices (ACIP) voted to recommend that it be administered to all adults. They also recommended that it be given to all pregnant women between 27 and 36 weeks of gestation regardless of their prior history of receiving Tdap. Their reason for this recommendation was a new increase in the incidence of pertussis or whooping cough. It’s highly contagious and can be fatal in infants who are too young for immunization. More than half of the infants younger than 1 year who contract pertussis are hospitalized, and up to 2% of hospitalized infants die.

Children begin their vaccination with a series of 3 immunizations called the DTAp at 2 months… The usual course of this vaccine is to administer it at 2, 4, and 6 months. In order for it to fully work it should be repeated at 15-18 months and 4-6 years. DTap immunization is generally required before a child can start school.  Many of us are in contact with infants either as parents, aunts, uncles, grandparents or friends. If we get immunized we, of course, prevent our own illness (which can be severe) and most importantly that of the infants and young children with whom we come into contact.

There are two reasons I want to discuss Tdap immunization in this current newsletter. One is personal…I plan to travel to Mozambique in February to visit a school built by donations from the group I helped found called the LA Associates of Save the Children. When I reviewed my immunization record in order to see if I was up to date for travel to Africa, I discovered that I had not had a tetanus shot in10 years. So I duly went to a local pharmacy and got the Tdap shot. It was easy, and aside from a slightly sore arm two days later I had no reaction. But the better reason to report all this is the article that came out in the  December 26 issue of JAMA in the Medical News and Prospectives Section titled “Study Finds Tdap Vaccine Is Safe For Older Adults”.

Researchers compared 119,573 adults age 65 years or older who received Tdap vaccine with the same number of older adults who were immunized with the tetanus and diphtheria only vaccine (Td) between 2006 and 2010 at seven US health maintenance organizations. They analyzed whether either group had higher rates of mild or severe adverse events. They found that there was no difference and that the most common side effects reported was injection site reactions which occurred in similar rates in both vaccination groups. The investigators concluded that in adults age 65 or older Tdap has the same safety profile as Td in the same age group and to Tdap in younger populations.

The  ACIP now recommends that all adolescents and adults receive a one-time dose of Tdap vaccine. They also state that adults age 65 or older should receive this vaccine instead of TD if they have never been immunized with Tdap. So yes, here is another immunization that you need; not just to protect you  from tetanus and diptheria but also to prevent your getting whooping cough which could spread to an infant and cause severe illness and even death.

The public health statistics that come from the Scandinavian countries are amazing. Each Nordic country has a national registry which includes prospectively collected health and social information on every individual. A Civil Personal Registration (CRP) Number is assigned to each resident at birth or immigration. All clinic and doctor visits, every prescription, and, of course, patients’ hospital records are recorded and centralized using CPRs. This could be considered  “big brother watching over you” or exceptional availability of data which allows for better and more consistent care; I prefer the latter…

An article that appeared in the early January issue of JAMA presented some of the remarkable data that was gathered at the Karolinska University Hospital in Stockholm, Sweden. (My sister did her PhD in cancer research there; I had the opportunity to visit her and can attest to the physical and scientific wonders of the institution.) The article is titled “Selective serotonin reuptake inhibitors during pregnancy and risk of stillborn and infant mortality”. The authors (of which there are 11 authors with either MDs, PhD’s or both) begin the article with the statistic that 7 to 19% of women in economically developed countries suffer from depression during pregnancy and that selective serotonin reuptake inhibitors (SSRIs) are now the most commonly prescribed drugs for depression during pregnancy. They reviewed the information on women with single births (not twins or triplets etc., which could also cause depression) within five Nordic countries which included Denmark, Finland, Iceland, Norway and Sweden from 1996 through 2007. Maternal characteristics, pregnancy and neonatal outcomes were available for 1,633,877 births in the study.  A total of 29,228 of the women in these countries (1.79%) filled  a prescription for an SSRI during pregnancy.

The authors assessed three outcomes: stillbirth (death before delivery after 22 weeks of gestation), neonatal  death (death between 0 and 27 days among live born infants), and postnatal death (death between 28 and 364 days among neonatal survivors). The initial numbers show that women exposed to an SSRI presented with slightly higher rates of stillbirth: 4.62 versus 3.69  per 1000 for women who did not take any antidepressant. There was also a slightly higher postneonatal death rate of 1.38 versus 0.96 per 1000. The rate of neonatal death was similar between the groups (2.54 versus 2.21 per 1000).  However,  they also noted that the mothers who filled prescriptions for an SSRI were generally older, more often smokers, previously hospitalized for psychiatric disease, and more likely to have diabetes and hypertension than mothers not using SSRIs. Each of these factors are known to independently increase mortality rates for fetuses and newborns. When these “confounding factors” we’re  entered into the statistical analysis, there was absolutely no difference in stillbirth, neonatal mortality or post neonatal mortality in women who took SSRIs during pregnancy when compared to women who did not take these drugs.

The most commonly used SSRIs in the Nordic countries were Prozac, Paxil, Zoloft, Luvox, and Lexapro (similar to those prescribed in the US). Studies have show that depression, left untreated in pregnancy is associated with poorer pregnancy outcomes, including increased risk of preterm delivery, and subsequent neonatal morbidity and mortality.  Studies have also shown that discontinuing antidepressant treatment once a woman is pregnant increases the risk of her having a relapse of major depression during the pregnancy.

Although this study does not purport to “clear” an association between SSRI use during pregnancy and potential problems for the exposed fetus, it does reassure us that use of SSRIs during pregnancy does not result in an increase in the risk of stillbirth, neonatal mortality, or postnatal mortality.

Bottom-line: If you, a relative or friend have a history of moderate to severe depression (which can occur to as many as 20 % of women) which has been successfully treated  with SSRI therapy, continuing the medication during pregnancy may be advisable. A major study has shown it will not cause stillbirth, or increase early infant death rates. But of course, as always, you should consult with your physician.

I have to admit that over the holiday I consumed a great deal of chocolate. But in my defense, it was dark and not too sweet. As far as I know (I didn’t read the list of ingredients every time I bit into a piece), it contained sugar, cacao, butter and no corn syrup. And then on my flight home, I read a somewhat reassuring article in last week’s JAMA.

Twenty healthy volunteers at the prestigious medical school at Yale University underwent MRI imaging sessions in conjunction with consumption a 75- mg drink preparation of either pure glucose or fructose. (Please note it was at Yale, which suggests that either the volunteers were smart, or the scientists conducting the tests were, or both… I once dated a very smart student from Yale and hence am prejudiced).

The researchers studied relative cerebral blood flow changes in an area of the brain called the hypothalamus as well as functional connectivity between the hypothalamus and other brain regions in response to fructose and glucose ingestion.  Scientists know that appetite and the sense of fullness are controlled by the hypothalamus as well as (OK I will name them) the insula and stratum. Testing their connectivity helps scientists understand which of these sweet tasting substances (monosaccharides) makes us feel satiated or conversely, want more.

Well you guessed it: from a brain activity point of view the patterns were statistically dissimilar. Ingestion of glucose but not fructose reduced the activity in the specific brain regions that regulate appetite. Glucose caused more satiety and fullness than fructose. Glucose also caused a greater increase in levels of insulin and a hormone called GLP-1, both of which act on the brain to increase satiety and blunt the reward value of food.

I know this all sounds very neurosciency. But in an editorial in the same journal, two authors from The Oregon Health & Science University summed it up in a very understandable fashion: “Products containing fructose are preferred by consumers and cooks over those containing only glucose, owing to the intrinsically greater sweetness of fructose and its ability to improve the appearance and texture of baked goods. As a result, sucrose and high fructose corn syrup are added not just to sodas, energy drinks, and sports drinks flavored by adolescents and adults but also to juice drinks consumed by infants and toddlers and to snacks, processed meats, sauces and many other foods consumed by people of all ages.”  They go on to write that “the consumption of sugar and high fructose corn syrup in the United States has substantially increased in the last few decades and paralleling this increase there has been an increase in obesity, especially among children and adolescents, for whom milk intake has declined … Hunger and fullness are major determinants of how much we eat, just as thirst determines how much we drink. These sensations cannot simply be ignored…The implications of this study as well at the mounting evidence from epidemiologic and animal studies, are that the advances in food processing and economic forces leading to increased intake of added sugar and accompanying fructose in US society are indeed extending the supersizing concept to the population’s collective waistlines.”

It would seem that fructose should be consumed in what I would call “severe moderation”. There are excellent alternatives to foods and drinks that contain this sweetener, namely water, milk and natural foods free of added sugars…and perhaps dark chocolate.