Thursday, August 25, 2011

Do Carbs Make You Crazy? PCOS and Type II Diabetes Edition

Previously, we discussed the question of Do Carbs Make You Crazy?, reviewed some literature to suggest that a bolus of sugar to a fasting person could certainly make some people crazy (or at least rather rotten-tempered), and yet MIT researchers suggest the same carby bolus will keep people sane with a nice happy squirt of serotonin.  Personally I think the MIT advice to snack on marshmallows and pretzels for serenity's sake to be misguided, whereas I agree with the wise orthomolecular doctor from New York who told the young Mr. Ellsberg, suffering from insomnia, grandiosity, and bouts of suicidal depression, to cut out the coffee, alcohol, and sugar already.

(Music - Beastie Boys/Santigold Don't Play No Games That I Can't Win - right click in new tab)

We all agreed, I think, in the comments of the previous posts, that these studies are weakened by some lack of accounting for confounders (nutritional status, alcohol, sleep, insulin resistance, etc. etc. etc. etc.), and of course one can never just change carbohydrates - one has to alter another variable.  AND of course I think inflammation and industrial food and micronutrient deficiencies cause or increase insulin resistance and violence and depression… so when one just examines blood glucose level and mood state, one is missing the electrified third rail, so to speak.

And I have to say, the state of the literature ain't that great.  Among 15 papers I read for this series, there was one great review paper.  Everything else was rather distractingly haphazard.   And so we go to two more papers (thanks to Jamie Scott, Jackie, Ambimorph, and Zooko for helping me with the paper chase!):  Daily Negative Mood Affects Fasting Glucose in Type 2 Diabetes and The impact of eating behavior on psychological symptoms typical of… (long title - it's about PCOS and blood glucose and mood).

The first paper is about a study following 206 people who kept daily food diaries, morning fasting blood sugar measurements, and daily mood records for 21 days.  What is nice about this study is that the participants were phoned every night to get the data for that day.  They were also paid $35 for the first week, $45 for the second week, and $55 for the third week, so motivation to keep up with the information gathering was pretty good.

After gathering all the data, there was really only one major finding.  There were no real significant correlations between meals, daily mood, and blood glucose - except… if you had a crappy mood one day, you were more likely to have a higher fasting glucose on the morning of the next day.   This makes sense if a crappy mood coincides with cortisol increasing, worsening glucose control that is reflected in the next morning's fasting glucose.  It doesn't seem to say much about a correlation between carbohydrates and mood in diabetics.  There was no relationship between glucose level on day one, for example, and mood on day two.

The second paper with the exhausting title is a little more interesting (well, sort of).  This study looked at women with polycystic ovary syndrome (PCOS - known to coincide with insulin resistance), reactive hypoglycemia symptoms, mood, and diet.   PCOS affects 10% of women, and between 50-70% of women with PCOS (particularly the lean ones) have symptoms of reactive hypoglycemia.  That is, they have a "sugar crash" feeling about 90-120 minutes after a high carb meal.   In this study, 24 women with PCOS, 299 controls, 47 self-reported women with symptoms of PCOS, and 92 men filled out an online survey.

Interestingly, 58% of the PCOS group reported having "binge and/or comfort eating" compared with 32% of the control women.  More of the PCOS women were also reporting being on a "low-GI diet" - presumably at the advice of their doctors or nutritionists to help control PCOS symptoms.  Of the participants, 53% were on no medicines, 13% were on contraception, 5% were on psych meds, 2.2% were on metformin, and 10% were on other meds (typically vitamins or allergy meds).  13% reported psychiatric issues (usually anxiety or depression), and 1.9% reported insulin resistance.  The PCOS group was more likely than the controls to have mood or behavioral issues and to have reactive hypoglycemia symptoms.

In a subset of the study, 12 women with PCOS were matched with 12 healthy controls.  The women with PCOS were, again, significantly more likely to have reactive hypoglycemia symptoms.  Women with PCOS were more likely to have less energy, more tension, less happiness, and more behavioral symptoms associated with hypoglycemia.  These differences remained significant after controlling for age, BMI, and "eating behavior."

So what do we find?   Women with poor glucose control have, well, poor glucose control, and they have moods and fatigue to match, though underlying inflammation and hormonal badness could cause all of the above.  And, not surprisingly, women with poor glucose control have more bingeing and emotional eating - again, perhaps a symptom and a cause wrapped all in one.  There were not enough folks on the "low GI" diet to make any intelligible statistical conclusions.

Here's my conclusion.  If you have PCOS or type II diabetes, do not eat 300 grams of carbohydrate a day.  Don't do it.  Keep it low, keep it nutrient rich*, keep it basic happy natural food.  I'm guessing your moodiness and your glucose control will improve.

* my idea of nutrient rich and the USDA's idea of nutrient rich are rather different.  I think bone marrow and grassfed beef liver are nutrient rich.  They prefer skim milk and whole grains.  You do the math.


  1. Completely agree with you Dr. Deans on this issue. Great blog! I am going to link this in on the MDA leptin reset thread because many of the ladies over there following it need to hear this loud and clear. Dr. Kruse

  2. Although I don't have PCOS, I do have reactive hypoglycemia. Reducing carbs and eating protein at every meal changed my life. I did this for 12 years or so before I swapped out all grain carbs for only paleo carbs - blood sugar control took another huge leap. There is something about grains that really messes with blood sugar. There is no comparison between eating the same glycemic load of carbs in the form of root veggies / fruit compared to grains.

  3. I never had other symptoms of PCOS, but like you Gad hypoglycemia - some grains like oats didn't give me too much trouble in combination with milk proteins, but like you I am a much happier camper with a protein/fat breakfast, some bananas, dates, figs, squash or potatoes for my starch later in the day.

  4. I have PCOS, and I also have mood problems. I do see a relationship to the two, but in my opinion I think that PCOS is a complex neuroendocrine disorder, and women who have PCOS often have defects in neurtransmitter action. It grossly oversimplifies the problem to attribute the mood problems common in PCOS to a simple case of blood sugar instability. Mood problems are quite common in PCOS, more common than in other blood sugar related disorders.

    For example it is found that women with PCOS have slightly higher prolactin levels and low dopamine sensitivity.

    As I said, I believe a major piece of the PCOS puzzle is that it is required to have some sort of imbalance or instability in neurotransmitter function. As you probably know, serotonin, dopamine, NE and epi play crucial roles in the ovulatory process. Serotonin is required to allow for follicle maturation; a surge of catecholamines, primarily epinephrine, allow for the physical process of ovulation to occur. The development of PCOS is easier, if not then it is only possible, when there is a disorder in neurotransmitter function and regulation. This independently leads to disordered mood and anxiety.

    Speaking personally, as someone with PCOS, I do not experience "moodiness" of a sort common to sugar highs and lows. I know that well. Crying from hunger, sleepy and out of it from a huge meal... yes, know that, but even when my sugar is controlled I go through depressions, distinct clinical depressions where my whole body changes. My body becomes heavy, I feel hopeless, I cry often, I think of suicide (I never think of suicide when I am not depressed), the smallest tasks are overwhelming. Life is miserable. It's like being in a tunnel, all at once time is endless enduring, and also impossible to see.

    I see a clear relationship between my mood states and my reproductive capacity - it almost feels as if my neurotransmitter levels control and determine both my mood as well as my reproductive function.

    For example, bright light will improve my depression by raising serotonin and catecholamines, and it will also induce ovulation if I had not ovulated.

    I have also observed this effect from taking extra st johns wort (an increase in st johns wort will lead to ovulation the next few days), and I have observed it from wellbutrin (an increase in dopamine from wellbutrin has also triggered me to ovulate).

    I have observed when I fall into depression, my reproductive funcitoning will slow and stop.

    I don't have evidence to cite right now... but I do think PCOS is a very unique, specific glucose disorder which involved disordered neurotransmitter functioning, which is why the reproductive functioning is so abnormal. A steady and constant flux of neurotransmitters is required for normal ovulation cycling. If you have highs and lows, or insufficient dopamine sensitivity, don't be surprised when your reproductive system fails to work properly.

    I know my depression is definitely related to my PCOS. I feel if I did not have one I wouldn't have the other. I have too often observed my depressions to then cause anovulation, and my mood elevations to lead to ovulation, and taking neurotransmitter stimulants themselves also lead to ovulation (with or without a mood elevation)...

    It's so much more than "well my blood sugar doesn't work properly so therefore I have mood problems".

  5. I used to have bad reactive hypoglycemia years ago. I had to eat all the time, couldn't skip meals, snacks between every meal, etc. I started eating "healthy" and exercising and it got a lot better. It wasn't until I went lower carb paleo that it went away, and can now go for over 24 hours without food and be ok.

  6. I'm sorry I'm not trying to be dismissive, I apologize if my previous post came off that way (in hindsight it may have), I am greatly appreciating these series of blog entries because I do believe there is a significant relationship between blood sugar disorder and mood disorders and explains why both seem to be increasing in the population.

    I just think that describing the problem as simply a result of glucose intolerance and sugar swings is like looking at the first layer of an onion peel and being like "that's all there is". Mood problems in PCOS seem to be far more common than in other blood sugar related problems, it's almost par for the course for a woman with PCOS to have a history of anxiety, depression, bipolar, eating disorder or some sort of abnormal mood issue. You can't say that it is as common for diabetes (although depression is common for diabetes it seems relatively less so than PCOS).

    One statistic I've heard is about 50% of women with PCOS have clinical depression. That is a tremendous number.

    I do very much believe in the central neurotransmitter dysregulation hypothesis of PCOS, with low dopamine sensitivity/relatively elevated prolactin during the anovulatory periods. I look at my history - ovulating after taking neurotransmitter stimulants & bright light, my weeks of depression and then a return to amenorrhea whereas I was cycling normally while euthymic... and for me, depression always goes with anovulation, although I may be experiencing depression while ovulating normally, I am never depressed while also having ovulatory capacity (and usually the very bad depressions are the ones that will stop my fertility totally).

    But then it clearly must be more than surges and lulls in neurotransmitters, otherwise reproductively normal manic depressives and drug abusers would have PCOS, when they do not.

    I just feel that there is more to this than glucose instability.

  7. Hypoglycemia is a sign of food intolerance?

  8. This si something very close to my heart!! I have PCOS and Type 2 diabetes. I am not on any meds (HA1C 5.0 FBS 100 from pre diet readings of HA1C 6.5 and FBS 180)Age 51. because of the Diet I follow called The Metabolism Miracle by Diane Kress, RD CDE. I agree with you Emily, women with PCOS should not be eating 300 grams of carbs. Actually, what is saving my life is that I eat 11-20g of carbs along with veggies and protein every with every 5 hour period throughout the day as recommended by Ms Kress in her book. No other program has this recommendation in the world. Anything under 11 grams of carb with cause the liver to pump out glycogen (about 55 grams of eating a bagel) and anything aboube 20 grams of carbs will cause the pancreas to pump out insulin, the fat growth hormone. This way of eating is after a 2 month "detox" period of eating only 5 gm of carbs after every 5 hours. You lose carb cravings because your brain is better in balance hormonally. This is all spelled out in Kress's book. I also surprised the study does not address the depression and low self esteem issues that comes with sx of PCOS like facial hair, obesity. What woman can feel good about that?

  9. Woo - I guess I was puzzled by the tone of your first comment because I think that is exactly what the blog says - mood did not relate to glucose, except that glucose was higher the day after a bad mood - suggesting the "electrified third rail" of an underlying cause for both the poor glucose regulation and the PCOS and the moodiness.

  10. I think there is so much with PCOS, mood & glucose. I'm into the problem with PCOS is the overproduction of insulin, which makes a person "off" hormonally. Which can also affect emotions and clarity of thinking. Now, in my case with PCOS too much glucose makes too much insulin happen and that may affect mood. Bad moods can also stress someone out, and stress may raise glucose levels too. This metabolic conundrum I deal with everyday is complicated. But I'm so thankful to have plan to follow so that it does balance me out.

    This was an interesting study of Metabolic Syndrome and Depression:

    From what I gathered, it concluded that if someone with metabolic syndrome (PCOS is part of that) gets their Metabolic problems in balance, their depression (and I feel anxiety BTW) improves. Now the big question exactly does one go about getting their metabolism in order? I feel I found what is right for me I feel it, see it in my lab work, see it on the scale and with my moods... but those with this problem should find what works for them because life is so much better when you have PCOS and T2 Diabetes and you're in control and balanced, and even better when you can just go to the grocery store for your medicine and not the pharmacy

  11. "So what do we find? Women with poor glucose control have, well, poor glucose control, and they have moods and fatigue to match, though underlying inflammation and hormonal badness could cause all of the above. "

    It sounded like you were suggesting that the moods/fatigue of PCOS are due to poor glucose control (but you did say it's also possible that hormone imbalances might cause it too).

    I was trying to say that PCOS is distinct from other arms of glucose intolerance (diabetes/hypoglycemia/obesity) because the development of PCOS seems related to abnormal neurotransmitter functioning.

    It's well known that PCOS often causes mood disorders, but generally clinicians assume it's all related to hormone imbalanced, or glucose disorder. .. I agree with the hypothesis that PCOS is so often related to mood problems because of the fact that neurotransmitter dysregulation is involved in the etiology of it. This is the element that links PCOS to depression, at rates significantly higher than diabetics, hypoglycemics, or obese people w/o PCOS.


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