Thursday, August 18, 2011

Do Carbs Make You Crazy?

Perhaps I should be more circumspect in my title.  After all, there are several popular ideas out there - one that carbohydrates cause blood sugar spikes and crashes, leading to mood swings and general crankiness. The second is that sugar (that special fructosey form of carb) causes everything from ADHD to delinquency to psychosis to bipolar disorder.

(Music selection - Serenade in E Major (right click to open in new tab) by Dvorak, who happened to write what is widely accepted as the most exalted piece of American classical music, though he is in fact from Czechoslovakia Bohemia.)

I think pretty much everyone has heard of these ideas - most recently I saw them in an article I linked a little while ago, "How I Overcame Bipolar II (and Saved My Own Life)"  by Michael Ellsberg.   Here is a quote from the article:

Dr. Hoffman told me there is mounting clinical evidence linking mood swings to blood sugar issues, and that in his experience bipolar patients respond well to cutting out refined sugar, and coffee and alcohol (which affect blood sugar) from their diets. “You should stop eating refined sugar altogether, and stop drinking alcohol and coffee,” he told me.
Apparently, Mr. Ellsberg went to a psychiatrist also:

I asked the psychiatrist I was seeing at the time whether he thought there was any link between nutrition and mental health. He looked at me as though I had just asked whether there was any link between mental health and UFO rectal probes. “There is absolutely no evidence of any link whatsoever between dietary choices and mental health,” he said curtly, and changed the subject.
Besides my wacky UFO rectal probe blog, on the paleo mental health side of things we have Nora Gedgaudas,  who has just released an updated version of Primal Body, Primal Mind.  I have read her book, and though I did not attend her talk at AHS, from my memory of her book and the coverage of that talk, it seems to me she advocates a very low carbohydrate approach, that in effect we are either fat burners or sugar burners, and fat burners are steady and serene, while sugar burners are moody and cranky. (Nora herself! clarifies her very reasonable position in the comments below - in short, her clinical experience has shown her that limiting sugars and starches for most people has been very helpful.)

Then we have the opposite side of the argument, personified by rodent and women's health researcher Judith Wurtman at MIT, and paleo blogger Don Matesz - carbs improve and are essential for good mood, particularly in the case of PMS, atypical depression, and seasonal affective disorder.

What did I learn in psychiatry residency?  Well, that the ideas about sugar causing ADHD were unfounded, and that carbohydrates in general wouldn't be an issue plus or minus unless one had uncontrolled diabetes, in which case, of course, uncontrolled glucose swings could cause all sorts of craziness.  Diabetes is one of those conditions we are supposed to rule out before spending 20 hours talking to someone about his or her mother, or prescribing Prozac.

So whom do we believe?  Orthomolecular Dr. Hoffman?  The Harvard Longwood Psychiatry Residency Training Program?  Nora Gedgaudas?  Parents who have observed their kids after a party with CAKE and ICE CREAM and FACE-PAINTING FAIRY PRINCESSES?  (I'm going to tell you right now that the kids totally spaz out for several hours and then collapse in a twitching exhausted heap of sugar/princess withdrawal.  The confounders are many, I must admit).

What have I learned from Gary Taubes and Peter and Kurt?  Don't believe anyone.  Look it up your own self, and see if it makes sense in the context of physiology and evolution.  But y'all know me at this point - let's put aside the issue of metabolic syndrome for a second.  Most hunter gatherer societies that I'm aware of ate starch when they could get their hands on it, so it doesn't make sense to me that carbohydrates alone would cause craziness.  (We will also leave out alcohol and caffeine which Dr. Hoffman wisely recommends bipolar folks to avoid - both of which will affect SLEEP as well as sugar levels, an obvious confounder in bipolar disorder).

And yet, here on my blog and twitter and elsewhere I've seen reports of folks who feel so much better on VLC diets, and others who feel so much better with zone-ish ratios, and others who do better with more carbohydrates.  My own experience (now documented in several podcasts) is that I had hypoglycemia in my late teens and early twenties.  Of course, I never got an official diagnosis of hypoglycemia, because that doesn't exist outside the context of diabetes or an insulin overdose or insulin-secreting tumor.  If I ate super low fat and high carb, I would get shaky, weak, and cranky about 90 minutes after my last meal.  When I called the doctor about it, I was checked for diabetes (negative), and then I was told not to eat like a jerk.  (Okay, some days I would eat raspberry fig newtons for lunch and dinner, and I was known to eat an entire package of Peeps from time to time - hey, I was 18.)  Eat nuts and avoid sugar, sodas, alcohol, and honey, they told me.  Eat snacks.  And I was careful from then on out to not be such a jerk about eating and to have snacks - packages of peanuts, apples and string cheese, graham crackers stuffed in my bag - and woe befell anyone in my presence who found me snackless two or three hours after a meal… I don't know how I made it through 7-8 hours of sleep… I personally happen to do better eating a bit more fat, though I'm rarely VLC outside fasting days.   I do eat bananas, rice, and potatoes.  Yes, it's true.

But what does the literature say?  Well, let me begin with a very pleasantly retro article from the halcyon days of 1966, when they believed in hypoglycemia outside of insulin tumors and diabetes - tweeted to me by @ambimorph:  Relative Hypoglycemia as a Cause of Neuropsychiatric Illness.

This paper defines "relative hypoglycemia" as my doctor did back in the late 90s - a drop in blood sugar that occurs after eating like a jerk - lots of caffeine or sugar.  Apparently the people of the early 20th century suffered from this condition, which was misdiagnosed sometimes as a brain tumor, diabetes, or cerebrovascular problems, but when you stop eating like a jerk and consume some protein, fat, and get rid of the caffeine and alcohol, your symptoms go away.

In 1966 Dr. Salzer found that:

…patients with relative hypoglycemia have been diagnosed as having psychoneurotic anxiety, psychoneurotic depression, depressive reactions, schizophrenia, manic-depressive psychosis, psychopathic personality, chronic alcoholism, convulsive disorders, migraine, idiopathic cephalalgia, second cervical root syndrome, neurodermatitis, and even hypertensive cardiovascular disease...  Major symptoms from a psychiatric standpoint are depression, insomnia, anxiety, irritability, lack of concentration, crying spells, phobias, forgetfulness, confusion… antisocial behavior, and suicidal tendencies… The major neurological symptoms are headache, dizziness, inward and external tremulousness, numbness, blurred vision, staggering, fainting or blackouts, and muscular twitching...There are also extensive somatic symptoms as follows:  exhaustion, fatigue, sweating, anorexia, tachycardia, cold hands and feet, obesity, chronic indigestion, bloating, abdomnial spasm, muscle and joint pains, backache, muscle cramps, colitis, and convulsions.

Well. That sounds really bad.  It sure does sound like sugar (and caffeine) can make you pretty crazy.  And when I (personally) was pregnant, I did suffer from some frank neurologic symptoms related to hypoglycemia (despite the fact that I was eating like Michael Pollan told me to, not like a jerk) - true vertigo, headaches, severe nausea… the thing was, it was all pretty much instantly cured by eating some instant mashed potato flakes.  Which is why I know I did not have a brain tumor (not typically responsive to mashed potato therapy).  In the modern emergency room we have dextrose IV drips, ginger ale, and instant glucometer measures.  I think perhaps that put the end to the mysterious hypoglycemia masking as a brain tumor era of medicine.

Next time… a discussion of carbohydrates and mood, from the literature.  And a review of the relationship between blood sugar in mood in folks with diabetes, insulin resistance, and women with PCOS.


  1. Body Mind and Sugar
    Written by Em Abrahamson MD and A w Pezet Published October 1951

    This book is your key to understanding alcoholism, neurosis, suicide, allergy, chronic fatigue, insanity... even murder

    Youre sixty years late... What took you?

    ( im being ironic of course, I recognised long ago as a psychiatrist the effect of nutrition and mental health, I got censured for it for speaking out and for discovering vitamin deficiencies masquerading as untreatable depression ( lassitude and bruising easily) Scurvy They hate me.

  2. It is incredibly frustrating at times to read through the dissonance within the paleo community in terms of carb consumption theories. Whether or not carbs and I are meant to be together metabolically I don't know for certain yet, but I do know that personally, eating excess sugar (or even a huge load of natural sugars in a short period of time) can bring on a storm cloud of moodiness that's evened out via carefully reduced carb eating and increased low level activity.

  3. It makes much sense that the hyper->hypoglycemia vicious cycle is very psychologically stressing, I think I see where you're going for next post so I'll keep quite so as not to spoil it.

    Going from a junk-food diet to a high-carb diet featuring lots of grain products was pretty stressful. People should really do some research before jumping into the generally accepted healthy diet amongst Dieticians and save themselves some grief. I honestly felt better eating pizza. It might have been the low fat too, but the symptoms of unstable blood sugar were unmistakable. Never again!

    But interestingly enough potatoes and white rice aren't a problem for most of the world, meaning that it is a glucose regulation problem and in fact we are supposed to be able to metabolize glucose efficiently, or else we would have died out long ago as a species. Nomadic hunter-gatherer tribes do not stop every two hours to forage for Kashi bars.

  4. I like that you write about the conflicting carbohydrate perspectives while remaining objective about it. It is tiring to hear the criticisms from one side or the other.

    My hypoglycemia seemed to be related more to food allergies than to carbohydrates. I was zero carb for a long time because eliminating them worked so well, but I also found that I would crave carbs like crazy every 3 or 4 days and I was just sooo unemotional. It made me want to run away to Mongolia or something. I would try to add in various starches, honey, or other carbs and the hypoglycemia (and craziness - I was very crazy) would return. One day I was eating a cheat - some frozen yogurt - and had no such symptoms. I have since found that table sugar is a great carb for me. After so many years of controlling my seemingly carb induced craziness with a low carb diet, I found that carbs don't seem to be the problem at all.

    I still don't eat a whole lot of carbs - so many years of fear? But they really don't seem to be a huge problem.

  5. This is a fabulous post.

    It's often said that glucose instability can mimic mental illness. "Get ruled out for hypoglycemia relative or absolute before believing you are CRAZ-AY" I've heard this... and it is definitely true.

    However what is often missing from the discussion between blood sugar problems and psychiatric complaints is that blood sugar problems are independently occurring (and exacerbating factors) from real clinical psychiatric illnesses.

    This is because a common biological defect can cause both blood sugar disorders and mental illness. There are a number of underlying biological problems which can cause a blood glucose disorder, and it can also cause a mental illness. They are independent symptoms, which may reinforce each other... but they are ultimately independent. One can have frank hypoglycemia, and frank mental illness like bipolar 1, and both of these symptoms may be caused by the same underlying defect.

    The resultant symptoms of that defect reinforce each other to worsen each condition.

    Uncontrolled blood sugar problems can result in high levels of stress hormones, which worsen both blood sugar problems and mental illness. Stress response is clearly a trigger for mood disorders and psychiosis for some people. Brain energy stability is clearly implicated in some mood disorders and explains the overlap between mood stabilizers/mood disorder and antiepileptics/seizures.

    Then on the other hand, being unstable and mentally ill will result in an inability to afford nutritious food and supplementation that can ameliorate your blood sugar disorder. If you can barely work or live a normal life how can you absorb - and apply - information or expensive supplements and nutrients? It's great that chromium picolinate is clearly effective for many depressives, it's too bad many depressives are too unstable and non-functional to absorb and apply that. Even normal people do a horrible job of controlling their blood glucose problems.

    Though they reinforce, there is probably a common physiologic link to both problems. Energy using disorder at the mitochondrial level, or disorders in regulating the stress response, atypical genetics of glucocorticoid receptors, so on. This will cause glucose intolerance, and it will also cause your brain to freak out with mania or schizophrenia or depression.

    Point I'm making is that we should not always assume the unstable glucose problems is CAUSING the psychiatric complaints... it is entirely possible that these are independent symptoms of the same defect which are only reinforcing each other.

    Speaking personally, my mood stuff is clearly worse when my glucose is totally uncontrolled... but even when my glucose is stable (not eating much carbs - hardly any glucose episodes) ... then I still have mood problems. Only when I attack the problem "from the root" taking magnesium and chromium and inositol and flax seeds and lots of bright light and acetyl l carnitine do I see a near total remission of my mood problems. It's more than just a mood response to hypoglycemia. The underlying defects are causing these problems independently.

  6. @Peggy
    Out of curiosity which foods did you find produced the blood sugar problems?

    Speaking personally I find that MSG messes me up, it is an additional factor that ruins my glucose tolerance.

  7. ItsTheWooo2,

    MSG causes me big problems too as do most vegetables, but I do have a lot of sensitivities. In fact when I eat fiber and do anything to disrupt my digestion - either with or without carbs - hypoglycemia strikes. It is very confusing to me actually because it is not what I have learned to expect from the reading I have done.

  8. Hello there!
    --Nora Gedgaudas here (author of Primal Body, Primal Mind and aforementioned presenter on nutrition and mental health at the recent AHS symposium).

    I'd like to go on record as saying I love your blog posts. Emily--I really respect your work and was very disappointed to have missed both your presentation and especially the chance to meet you there. The AHS was a veritable whirlwind (but what a wonderful experience).

    There's an old saying that if all you have is a hammer then everything looks like a nail. I don't quite think I fit that category. My orientation is foremost clinical and based on what I see (and have seen for many years) in my own clients each and every day. I pay attention to what does and doesn't work and take care not to be blinded by my own ideas and expectations.
    Although I do often see a strong connection between dysglycemia and both neurological and mood instability I also delve into many other key nutritional issues contributing to mental, neurological and cognitive health (as well as physical health). It is also true that I do advocate a low sugar and starch diet. I do offer many well supported reasons for this though it is far from being the only message I have to offer.

    As for Wurtman and Matesz's assertions that carbs can enhance well being...well...let's just say that I get the plasma-tryptophan ratio thing and the temporary effect (and limitations) of that. It's also true that blood sugar surges can interfere with amino acid transport across the blood brain barrier. It's all a matter of perspective and circumstance. Many things can be true within a certain context and I do appreciate this.

    "Managing" blood sugar issues is certainly an option people have. I personally prefer to eliminate blood sugar issues from the mood and cognitive equation by shifting to a long term primary dependence on ketones instead of glucose. Again, the reasons why are detailed in my book. I think I make a valid case for this but don't presume to tell everyone what they must do. I just hate to be pegged as only sending a "low carb" message since I so passionately recognize the complexity of our physiological makeup. Part of the point of my book is making people aware of the fact that things are seldom overly simple or black and white as we would like to see. If you haven't had the chance to look at the updated version of my book I hope you get to do that. It has been substantially updated.

    I do hope we get a chance to connect someday. You are a rare and glowing credit to your profession. The field of psychiatry and the broad realm of the "Paleo" nutrition field desperately needs to hear what it is you have to say. --Just tossing in my two bits.

  9. I think it would be more accurate to say Dvorak (or Dvořak) was from Bohemia, the Austrian Empire, or what is currently the Czech Republic. He died in 1904, 14 years before Czechoslovakia came into existence. /pedant

  10. Ha ha, what's the rule about internet pedantry? With Czech diacriticals it is properly spelled Dvořák not Dvořak. Czech long a.

  11. Nora - how exciting that you read my blog! And thank you for clarifying your position. Though I'm not sure how I'm supposed to set up a false dichotomy to knock down with you being all reasonable… I hope you forgive me for leaning the post in that direction :-)

    I'm giving a little away about the next post but Wurtman's claims are fairly easily scientifically refuted in the context of the real world. In most cases I would say you can't go wrong for the brain by adding a chunk of healthy fat to the SAD diet or even the "healthy" SAD diet of skinless chicken breasts, cereal and skim milk, nonfat yogurt, and salad loaded with soybean oil dressing… though some folks have switched to olive oil and fish...

    My overall tendency (my opinion, not necessarily with an irrefutable evidence base) is to support the ideal of metabolic flexibility - for most folks on SAD or "healthy" SAD that will mean a stretch of VLC to upregulate the machinery. And as with any clinician, one has to take into account my clinical population - with the exception of pediatricians and Ob/Gyns, an adult psychiatrist of my generation will tend to have a younger and healthier population overall than most doctors. I have quite a few geriatric and/or very medically ill patients also, but my overall tendency is to think in terms of comparatively healthy people. When one looks at the Drs. Eades, for example, who worked for decades with obese patients, one can see how their clinical experience with low carb diets compared to high carb would leave low carb as the clear winner in many respects.

    I will definitely have to check out the updated version of Primal Body, Primal Mind!

    Prague - I fear you have stumbled upon my dated musical education (mostly achieved in the 80s and 90s when Czechoslovakia existed).

  12. We recently went paleo in our family and, in one of my children, all KINDS of neurological worries (depression, anxiety... even bipolar-ish symptoms) abated dramatically. Was it the carbs... or was it the gluten >> leaky gut >> brain inflammation? We're going with the latter as most likely, because she had so many of the other physical symptoms of gluten intolerance (GI distress, bloating, joint pain, eczema and on and on).

    I am definitely less prone to hypoglycemic dizziness and crabbiness and mood swings now that I'm paleo...

  13. Modern HGs (except Inuits) eat starches because they have no large mammals in their diet to provide adequate fat. When fats are readily available eg from marine mammals, bison etc starches are generally avoided by HGs.

    Colonic fermentation of carbohydrates causes the overgrowth of colonic bacteria. These produce large quantities of highly toxic bacterial metabolites such as putrescine and cadeverine. Clostridia spp in the colon also produce potent neurotoxins.

    The rate of IBD and Celiac Disease is vastly higher in people suffering mental illness than the general public. Around 80% children with autism have abnormal guts when examined by colonoscopy.

    Dr Abrah Hoffer had very high remission rates treating schizophrenics with B group vitamins in the 1940s and 1950s.

  14. My daughter has autoimmune thyroiditis; we only found out by going to an alt med doc who wasn't afraid to run gobs of tests. Hah. (Found out when she was merely 5)

    Anyway, one symptom is "reactive hypoglycemia." She has Asperger's too. Her most "insane" meltdowns have always corresponded with it having been about 2-3 hours past eating. Late enough when I'd think, uh, maybe she's "getting hungry," but it wouldn't have been long enough for it to be OBVIOUS (you know, nothing like 5-6 hours when a typical person would be hungry!)

    Anyway, for those who are finding that they are really "psycho" when they need carbs, and who are not committed to paleo, you may want to get a full thyroid panel, which includes looking at reverse t3 and thyroid antibodies (two types) If you see a mainstream doctor, he/she will likely poopoo the need for these.

    I had a high rt3 in Dec, and 7 weeks after doing a not 100% attempt at Dr. Kruse's leptin reset, my rt3 levels are way down. I feel much better psychologically and when I slip up and have too many carbs, I am feeling "insane" again.


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