Is Chocolate Milk Really The Best Way To Protect Athletes From Concussion Injuries?

In the United States, a beverage known as Fifth Quarter Fresh chocolate milk is enjoying a surge in popularity due to some clever marketing that promotes it as a health drink for college footballers. This follows a press release in December 2015 announcing the results of a preliminary University study which showed that Fifth Quarter Fresh’s milk helped improve the cognitive and motor functions of high school football players. In a sport renown for its potential to damage brain tissue because of constant collisions, anything that helps the body to recover from these injuries would naturally be very welcome.

Unfortunately, it appears that the announcement of these findings has been premature, with the University now distancing itself from the press release. The University has been widely criticised because the reported results hadn’t been through proper scientific review. There has also been a strong media backlash over the apparent conflict of interest arising from the fact that the University’s research was partly funded by the manufacturers of Fifth Quarter Fresh.

What Does The “Research” Say?

The press release from the University of Maryland claimed that Fifth Quarter Fresh has helped young football players improve cognitive and motor function during the football season even if they suffered concussion injuries.

Professor Jae Kun Shim, who conducted the study, suggested the levels of nutrients in the milk likely contributed to the results. He explained that the chocolate milk contains branched chain amino acids, which are important for energy metabolism and neurotransmitter synthesis in the brain, along with high levels of carbohydrates, calcium and electrolytes.

The study also coincides with the release of the movie ‘Concussion’ which has got people thinking more about the damaging effects of collisions in sport. Concussion is the extreme end of these effects, but constant milder impacts appear to still have an incremental damaging effect on the brain.

It’s exciting to think that there might be a way of reversing damage to the brain that can be caused by the constant jolting of the brain in sports like football.

However the study has been heavily criticised for these reasons:

• It has not been published in any scientific journal for peer review. It’s currently only been published as a press release.
• There are no comparative reports with other chocolate milk drinks – or even plain milk.
• The study was part-funded (10%) by the Maryland Industrial Partnership of which Fifth Quarter Fresh is a member.
• Although the beverage is fat-free, it contains 42 grams of sugar: over half of this is added sugar.

The University of Maryland has now issued a statement saying the results were ‘promising’ and ‘preliminary’ but that their researchers advised more in-depth studies were required to be conclusive.

[Update: The original press release was removed from the website in 2016.]

[Update: The University of Maryland assembled a committee to figure out what went wrong and just released a report on April 1, 2016 detailing its findings and acknowledging the shortcomings of the research. Read more here.]

The Power Of Advertising

The manufacturers of Fifth Quarter Fresh promote their chocolate milk drink as a health drink. [Update: the Fifth Quarter Fresh website has since been taken down, but the product is apparently still available in the US] 

The motto of the beverage is: Rehydrate | Replenish | Reward | Repair. It’s clever alliteration that would certainly appeal to its target audience: athletes and the parents who love them.

Chocolate milk does seem to tick the “Reward” box nicely (although we’d argue that playing a sport you enjoy should be its own reward).

Without peer-reviewed evidence about the ability of the beverage to repair damage to the brain, and with plenty of healthier and more tooth-friendly ways to rehydrate and replenish, the rest sounds very much like it’s fresh out of a marketing 101 textbook.

Not Just Ordinary Cows: ‘Super, Natural’ Cows

Even on its website, Fifth Quarter Fresh makes some interesting claims which might be misleading. They tell us that the source of the milk in the product is ‘super, natural cows’, which refers to the Jersey or Guernsey cows pictured on the home page.

Their website claims that the milk from these cows is better than the Holstein cows usually used in the dairy industry because it contains more protein, electrolytes, calcium and carbohydrates. Interestingly, the article offered as proof of this claim now also has an update stating that further research is required. http://www.mtech.umd.edu/news/press_releases/releases/5QF/

Pure And Natural

Another marketing phrase employed on the website is ‘as Nature intended – pure and natural’ which no doubt appeals to the college generation of athletes who want to take care of their bodies.

Of course, there’s nothing natural about 22 g of extra sugar per serving!

But Aren’t Those Sugars Naturally Found In Milk?

Milk definitely has natural sugar: this is a type of sugar called lactose, so it’s different from the other common forms of sugar which are:

• glucose – a ‘monosaccharide’ (single sugar molecule) that our bodies use for fuel
• fructose – another monosaccharide, the sugar naturally found in fruits
• sucrose – a disaccharide (it contains one molecule of glucose and one of fructose). This is ‘table sugar’, usually harvested from sugar cane, and is the most common form of added sugar in our food supply

The World Health Organisation (WHO) has developed guidelines around the consumption of added sugars in our diets. It recommends that we limit our consumption of added sugars to just 10% of our daily intake of energy (calories or kilojoules) in order to minimise the risk of developing health issues like obesity, dental caries, Type 2 Diabetes, heart disease and some forms of cancer.

It has also recommended that we further decrease our consumption of added sugars to 5% of our daily intake of calories for further health benefits.

Sugars naturally found in milk and fruit don’t fall into the category of ‘added sugars’ (what the WHO calls ‘free sugars’). But table sugar and the many other forms of sugar that we add to our food, such as syrups (like agave syrup), molasses and honey are considered ‘free sugars’ for this definition.

How Much Free (Added) Sugar Should We Be Consuming Each Day?

The easiest way to measure the amount of free sugar in our diet is to know the equivalent in either teaspoons or grams. While the ideal caloric intake will vary according to a person’s size, activity and gender, this table will give you some idea.

 

The American Heart Foundation clearly embraces the WHO recommendation to adopt the 5% level, with a very simple guideline:

But Doesn’t Fifth Quarter Fresh Contain 42 Grams Of Sugar?

Yes, it does, but some of this comes from the sugars naturally occurring in milk, and therefore doesn’t fall into the 5-10% category.

Of course, it’s really difficult to calculate the amount of added sugar in most products we buy. We’ve mentioned before (Identifying Hidden Sugars: Isn’t There A Simpler Way?) that we’d like to see very transparent labelling on foods, so that consumers can easily see how much sugar has been added to the products they are buying.

But let’s show you the method that we use to calculate the amount of added sugar.

Get out your calculator and follow along!

Calculating The Amount of Added Sugar in A Product That Also Contains Natural Sugars

The easiest way to figure out how much sugar is added to a product is to compare the nutrition panel to an unsweetened version of the same food. So in this case, we need to compare Fifth Quarter Fresh’s nutrition panel to the nutrition panel of plain no-fat milk.

Let’s start by looking at the nutrition panel on Fifth Quarter Fresh:

The important bits of information are:

• Serving size (414 ml, or 14 fl oz)
• Total fat (0g)
• Total sugars (42 grams)

We now search Google for an image of the nutrition panel of the same serving size of fat-free milk to see how many grams of sugar the natural product contains. We found a good one from the Bone Builders website:

The first thing we should observe is that the serving size for the skim milk is 8 fl oz, which is considered to be 2 servings! A single serving of Fifth Quarter fresh is 14 fl oz! That’s 3.5 times the normal serving size.

Did I hear someone say ‘supersize me’?

The important bits of information are:

• Serving size (240ml or 8 fl oz)
• Total fat (0g)
• Total sugars (11g)

We’re going to work with fluid ounces for ease of comparison..

• If 8 fl oz of unflavoured skim milk has 11 grams of (natural) sugar, then 1 fl ounce contains 11/8 grams
• Multiply that by 14 to get the amount of natural sugar in a 14 fl oz serve
• The answer is 19.25 grams.

Fifth Quarter Fresh contains 42 grams of sugar. We have just calculated that 19.25 grams are the naturally-occurring sugar in milk. So the amount of added sugar is 22.75 grams (42 grams of sugar minus the 19.25 grams of naturally-occurring milk sugars) , which is around 5.5 teaspoons of added sugar (1 teaspoon = 4.2 grams).

How Much Added Sugar Is This Compared To Recommended Daily Intake?

When you look at the table, you can see that one serving of Fifth Quarter Fresh (5.5 teaspoons of sugar) contains a substantial percentage of the daily allowance of free sugar for all age groups. If you are following the American Heart Foundation’s recommendations, an adult female practically maxes out her daily free sugar allowance with a single serve of Fifth Quarter Fresh, and an adult man only has 3.5 teaspoons of sugar remaining.

 

Children of any age who drink an entire serve of Fifth Quarter Fresh would be almost meeting or exceeding their daily free sugar allowance.

And It’s Not Just Fifth Quarter Fresh That Has This Amount Of Free Sugar

Fifth Quarter Fresh isn’t available on Australia (at least, not to our knowledge). So in a future article, we’ll provide a list of the amount of added sugar in Aussie chocolate milks.

Is Chocolate Milk Good For Teeth?

Milk is often cited as a healthy beverage for teeth. While we’d prefer that water is always the beverage of choice, milk does get a tick of approval from the Australian Dental Association.

But in this context, they are talking about UNFLAVOURED milk.

We want to be very, very clear about this.

Any food or beverage sweetened by added sugar has the potential to damage teeth. This absolutely includes milk.

Added sugar in foods and drinks is consumed by bacteria in your mouth and excreted as acid, which can dissolve enamel. If teeth are frequently bathed in this type of acid, the enamel will dissolve. This will lead to cavities, which are likely to need fillings. A proportion of teeth that have experienced decay will go on to need crowns, root canal treatment or extraction.

Added sugar also has an effect on general health. Peer-reviewed and published research shows that sugar leads to obesity and increases the risk of Type 2 diabetes, heart disease and some types of cancer.

The Dangers Of Promoting Chocolate Milk As A Health Drink

Sugar Content

As dental professionals, we are naturally concerned about the amount of sugar packed into Fifth Quarter Fresh (and other sweetened milk beverages), especially when the product is claiming significant health benefits. It’s difficult for consumers to know, without doing the maths, exactly how much added sugar they are consuming per serve.

Serving Size

We’re also concerned about the serving size. In Australia, the usual serving size of a milk beverage is 250 ml or 300 ml.  At 414 ml, Fifth Quarter Fresh is a significantly larger serving.

Frequency of Consumption

The University of Maryland research described the subject footballers drinking the beverage up to 6 times a week:

“Experimental groups drank Fifth Quarter Fresh after each practice and game, sometimes six days a week, while control groups did not consume the chocolate milk.”

Damage to tooth enamel is more likely to occur when sugar is consumed frequently. If a beverage is consumed all at once, the damage to teeth is less than if the drink is sipped over time. With such a large serving size, it’s quite possible that it won’t be consumed in a single sitting.

Annual Amount Of Extra Sugar Consumed

If the beverage is consumed 6 times per week, that’s an additional 136.5 grams of sugars per week in the diet of these athletes.

If this rate of consumption continues over the six months of a season, that equates to 3.549 kg of additional sugar. If the consumption habit continues throughout a year, 7 kilograms of added sugar will have been consumed.

Why The Promotion of Fifth Quarter Fresh Chocolate Milk As A Health Drink is a Problem

1. Added sugar is contributing to the current worldwide levels of obesity. It’s so bad that the World Health Organisation calls it a pandemic.
2. (As we’ve mentioned) sugar can cause tooth decay, an otherwise entirely preventable disease.
3. Any PR spin suggesting that a particular sugar-laden chocolate milk drink is good for health may lead people into believing that all chocolate milk is healthy.
4. The more milk a person drinks, the less water they are likely to drink.

What If Further Research Shows That Fifth Quarter Fresh Does Protect The Brain?

We’d be very excited to know that there was a natural substance that could be consumed to help the brain to repair damage caused in collision injuries from sports like football. If Professor Shim’s theory that the amino acids, calcium and electrolytes in milk offer this protection is correct, that’s great news for athletes all over the world.

However, to deliver a beneficial mix of nutrients in a sugar-laden beverage seems counter-intuitive, especially if the aim of the research is to promote healthy outcomes for athletes (rather than marketing a particular beverage). We would hope that this theoretical therapeutic compound would be delivered without the sugar, either as an unsweetened beverage or in tablet form.

So How Should Athletes Replenish?

The Australian Dental Association recommends that sporty folk eat nutritious foods like sandwiches with tuna, low fat cheese, lettuce, tomatoes and carrots, pasta and fruit.

And to drink?

Water! Water is the best fluid to drink. It keeps the body hydrated and doesn’t contain sugars and acids that attack your teeth.

What About Protection Against Concussion Injuries In Sport?

If there’s no research yet that upholds Fifth Quarter Fresh’s claims of protection against concussion, what can kids do to protect themselves from concussion and concussion-like injuries on the sports field? Obviously some codes require that players wear protective headwear, and this should be mandatory in all games and trainings.

But in sports where headwear is not required, what options do athletes have to protect themselves?

Wear A Mouthguard

The Australian Dental Association recommends using a mouth guard because, aside from directly protecting teeth from injuries, it acts like a shock absorber for the brain. The Mouthguard Awareness website put together by the Australian Dental Association lists “May help reduce concussion” along with these other benefits of mouthguard wear:

• Cushions teeth against impact
• Protects the jaw against joint injuries
• Protects against soft tissue injuries
• Helps prevent neck and jaw injuries
• May help reduce concussion

Play By The Rules

It’s important for athletes to play by the rules that are designed to minimise trauma to the face, head and brain. As parents, managers and coaches, we all have a role in upholding these rules for our young athletes, and in strongly condemning any high-profile athletes who intentionally cause injury to the heads of other players.

Mouthguards Also Protect Against Dental Injuries

Sports accidents are a common reason for dental injury. If athletes, including children, wore a mouthguard every time they played and trained, many of these injuries could be avoided. It’s estimated that only 36% of 5 -17 years olds wear a mouth guard during sport.

Mouth, teeth and jaw injuries can be very painful, and are often expensive and lengthy to fix. They should therefore be avoided at all costs. A custom-fitted mouth guard from your dentist is an essential item in an athlete’s sports kit.

Your Mouthguard

It’s important to look after your mouth guard. A broken or ill-fitting guard will not protect you from injury.

• Always store it in a rigid container to avoid breakages.
• Keep it away from heat too, so it maintains the correct shape and offers maximum protection.
• Be sure to take your mouthguard in to be examined at your dental check-ups to make sure it’s still fitting well and providing the right level of protection.

If you need any advice on tooth decay, mouth or jaw injuries or would like to talk about keeping teeth safe in sports, make an appoint with your dentist.

And if you’re thirsty after sports, don’t reach for the chocolate milk! Drink some water instead.