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.