I certainly agree with most of the points in this recent New York Times Op-Ed article “Sugar Season. It’s Everywhere and Addictive.” I communicate frequently with my friend Dr. DiNicolantonio and we share many views about the dangers of refined sugars. Pioneers like Richard Johnson, Gary Taubes and Robert Lustig have been warning about the dangers of sugar and refined carbohydrates for years, so it’s good to see others piling on. In 2011 Gary Taubes made a similar argument in the New York Times Magazine in his article “Is Sugar Toxic?”. Sometimes it’s good to sound like a broken record.
Sugar Takes Another Hit
In this most recent tale of woe for sugar, Dr. DiNicolantonia and Dr. Lucan make a strong case that refined sugar is addictive in the same way that some drugs are addictive. Thus lab animals and us poor slobs who are exposed to excessive refined sugar become hooked and we can’t stop eating it. According to this article and others who favor a “sugar is addictive” model, we then demonstrate the classic triad of addiction: cravings, tolerance and withdrawal. There’s only one problem with this somewhat simplistic viewpoint—it doesn’t quite fit what we are seeing in the real world. At the small hospital where I work, during the Holidays it becomes a virtual “candy land” for patients and staff alike. Every square inch of space on the ward is piled high with every imaginable form of goodies and sweets and patients are often inundated with similar fare from relatives and friends.
Pay Attention to the triad
When it comes to the triad of addiction, I certainly observe a lot of cravings for sweet and starchy foods in both the hospital staff and patients. Because of these cravings many individuals simply can’t resist eating this type of food if it is available. Because most people are exposed to large amount of refined sugar often combined with highly refined carbohydrates and omega 6 fatty acids, you would expect everyone to have strong cravings for processed food, but this simply isn’t the case. Many people “like” sweets or other forms of processed food (myself included), but they don’t have strong cravings for them.
Bring it on
I also don’t think the issue of tolerance plays much of a role when it comes to sugar, starch and bad fats. People who appear to be addicted to sugar and starchy foods get their dopamine surge whether they eat a bite of a donut or the whole box. Withdrawal also doesn’t seem relevant when it comes to sugar and starch. I don’t see people having sugar withdrawal seizures or other serious symptoms associated with the withdrawal of addictive substances when they stop eating processed foods. Although some animal studies suggests that under controlled circumstances sugar can be addictive for rats, I don’t think we can automatically assume that the same is true for humans.
The addictive triad
People who are addicted to heroin, cocaine, alcohol, nicotine and other addictive substances clearly have all three components of the addictive triad. They also don’t have a lot of the other symptoms of brain dysfunction that can eventually be associated with consuming highly processed foods. Even though they are addictive, caffeine and nicotine have been shown to have some brain enhancing characteristics, making the situation even murkier. To get to the bottom of this dilemma I think we need to go back and observe those folks with strong cravings for sweet and starchy foods. I have been doing so for decades and years ago I noticed that these folks also tend to eventually develop a long list of other brain dysfunction symptoms that unfold in a predictable manner, fitting the criteria of a disease. To date we have identified 22 brain dysfunction symptoms that define this disease. We have also noticed that these folks with brain dysfunction also tend to be a metabolic mess even if their weight and BMI are normal. They have insulin resistance and excessive body fat and many eventually develop type II diabetes.
Some are protected but don’t press your luck
I have also noticed that some people seem to be able to eat a moderate amount of processed sugar, highly refined carbohydrates and bad fats, yet they never develop strong cravings or other brain dysfunction symptoms. Is there another model that explains these observations other than the simple addiction model outlined in this article? I think the answer is yes. To me it is crystal clear that the long term consumption of highly processed food can eventually trigger a form of food-induced brain dysfunction that we now call Carbohydrate Associated Reversible Brain syndrome or CARB syndrome. Your likelihood of developing CARB syndrome depends on a complex combination of genetic, epigenetic and environmental factors. Thus if I were writing this article I would change the title to:
The Sugar, Starch and Bad Fats Season
The hallmark symptom of this brain dysfunction is craving sweet and starchy food. To make it more palatable food processors usually add an unhealthy fat to the sugar and starch. Although humans evolved to prefer sweet food under some circumstances, when someone develops CARB syndrome, this natural preference is kidnapped by a disease process. Our primitive ancestors never had these intense cravings because they were never exposed to Twinkies and similar fare.
It’s also important to point out that this pathological process isn’t just driven by refined sugars. High glycemic carbohydrates, especially from grains and omega 6 fatty acids mainly from vegetable oils seem to round out this deadly dietary triad of foods. Of course this combination defines modern processed food.
Is the addiction model really the best we have?
So why do we need the CARB syndrome concept when we already have the addiction model as outlined in this article? Many others have also promoted this addiction model and it has become widely adopted. As with any scientific model, you want to use the one that reflects the real world in the best possible way. If you ignore the brain dysfunction associated with cravings for sweet and starchy food, you are going to miss a heck of a lot of pathology and your treatment approach will lead to a lot of dead ends (and dead patients). Let me give you a few examples.
Weight and depression
Years ago all patients with major depression felt depressed and down and they universally lost their appetite and lost weight—it was a defining symptom of the disease. In the past few decades many depressed patients have an increased appetite and weight gain. From a scientific standpoint this makes no sense. If any level of appetite or weight qualifies you to have depression, then appetite and weight completely lose their diagnostic power and should be ignored! If you use the CARB syndrome model it makes complete sense. People with true major depression always lose their appetite and lose weight. Major depression was somewhat uncommon years ago and it still is today. Those who feel depressed and have an increased appetite and weight gain have CARB syndrome, not true major depression. Why is this distinction important? If you treat patients with CARB syndrome with high dose SSRI medications—the most effective treatment for major depression, patients almost always get worse over time rather than better.
It’s also instructive to consider eating disorders like anorexia. I don’t think too many people are worried that someone with anorexia is “addicted” to sugar. As a mater of fact, most people would be happy if the person indulged in some sweets just to get a few calories on board. If you really talk to someone with anorexia, they virtually always have cravings for sweet and starchy food but they rarely eat them. They force themselves into ketosis through starvation and this damps down both their appetite and sweet cravings. When people with anorexia do eat it is almost always highly refined processed food loaded with refined sugar. They also have all the other brain dysfunction symptoms found in people with CARB syndrome. In other words they often have the same brain problems as someone who weighs 300 pounds but they just aren’t eating as much food, keeping their weight and BMI low despite their excessive body fat.
Bipolar disorder II is another example of this type of food-induced brain dysfunction. Years ago we only had one form of bipolar disorder. People with bipolar disorder fluctuated between severe depression and psychotic mania. Over the past several decades we started to see a lot of folks who sometimes seemed down and at other times seems a bit hyper—a condition we call hypomania because they don’t become fully psychotic with these episodes. They “sort of” look like bipolar disorder but don’t quite make the cut so they decided to call it bipolar II. For example Catherine Zeta Jones apparently has bipolar disorder II. They are now diagnosing bipolar II in young children! Give me a break—in my opinion if they change their diet, all of this will go away. I also believe that bipolar II is virtually always CARB syndrome. These folks don’t need more medications—they need to change their diet and fix their brain.
In clinical practice today we see many patients diagnosed with multiple conditions including depression, anxiety, ADHD, irritable bowel syndrome, fibromyalgia and obesity. In my experience most of these patients with “labelitis” only have one disorder—CARB syndrome. Even though these folks might appear to be addicted to processed food because they crave it and prefer to eat it, I don’t think that this “addictive model” is very helpful in managing these patients. In a similar fashion to this article, David Kessler in his book “The End of Overeating” also focuses on the addictive nature of processed food. He also believes that eating this food changes your brain and I completely agree with him except he doesn’t go much beyond processed food stimulating the pleasure centers of the brain. Thus his solutions to the problem are superficial and unlikely to be helpful for many people. He focuses mainly on behavior changes but this does little to suppress the cravings that are driving the pathological eating patterns in the first place.
Michael Moss takes a similar approach in his book “Salt, Sugar, Fat: How the Food Giants Hooked Us”. He focused on how the food industry has manipulated processed food to make it more addictive. I agree with Moss that the food industry simply wants to sell more food but once again I think his perspective is too simplistic and one-dimensional. I also don’t agree with him that salt plays much of a role in the diseases he discusses in his book. I would replace salt with high glycemic carbohydrates, especially from grains, giving us the true toxic dietary triad. Long ago the food industry realized that when they combined sugar, refined carbohydrates and bad fats together they ended up selling more food regardless of whether or not people fit the pattern of an addiction. In my opinion that’s because once someone starts to develop CARB syndrome, they will increase their intake of highly processed food driven by their cravings. Of course this does make the food companies very happy.
The pathology of CARB syndrome
The CARB syndrome model doesn’t concern itself with whether or not processed food is “addicting”. It is based on the idea that the long-term consumption of processed food can trigger an illness characterized by up to 22 brain dysfunction symptoms that can interfere with your ability to function and promote the tendency of your body to store excessive body fat regardless of caloric intake. Processed food somehow triggers this disease process by adversely affecting three interconnected nodes—the central nervous system—the one between your ears, the enteric nervous system that controls your gut and the bacteria in your gut or the “gut biome”. With CARB syndrome we know that all three nodes begin to malfunction even if we don’t understand exactly how processed food leads to these changes. As Gary Taubes has so eloquently pointed out in his books “Good Calories, Bad Calories” and “Why We Get Fat”, highly processed food has adverse affects on cellular metabolism and fat storage and I believe that these metabolic changes can in turn adversely affect these three nodes. We also believe that highly processed food can directly adversely affect these three nodes and these nodes also play a role in controlling cellular metabolism and fat storage. Thus the pathology involving cellular metabolism and the dysfunction of the three nodes is likely a two way street.
I know–this is getting complicated. In medicine we often learn how to effectively treat a disease long before we unravel all the details of the underlying pathophysiology. I don’t see how calling sugar or other food components “addictive” helps in this process. The group Overeaters Anonymous has been focusing on eating and addictive for years using a 12-step program similar to AA. Although this approach may benefit some individuals, many others fail to make any real progress. In my opinion that’s because the addition/behavioral approach isn’t based on the type of disease model that can be used to craft effective treatments.
Suppress the cravings—the key to effective treatment
The lead symptom of CARB is having strong cravings for sweet and starchy food. In order to successfully treat CARB syndrome you need to suppress these cravings. Eating a low carbohydrate, moderate protein, high healthy fat diet automatically reduces these cravings. There are several safe supplements that also help to suppress these cravings, including the amino acid L-glutamine and a fixed dose precursor supplement called CARB-22. Certain combinations of low dose medications can be useful in suppressing cravings and the other symptoms of CARB syndrome, helping to improve compliance and outcomes. Although the details of the treatment of CARB syndrome are beyond the scope of this article, after treating thousand of patients I can assure you that it is a treatable and reversible disease if managed properly. Once you successfully suppress these cravings a person no longer acts like they have an addiction, so the concept of addiction loses much of its relevance.
It’s time to swap out models
In summary substances like heroin, cocaine, narcotics, nicotine and alcohol clearly fit an addictive pattern for many people who consume them. They develop the typical addiction triad of cravings, tolerance and withdrawal. I don’t think that processed food fits this addictive template as outlined in this article very well. I propose that the CARB syndrome model is much more useful from a clinical standpoint, so until something better comes along we should adapt it to better help us understand the complex relationship between processed food and health. In my experience using it also leads to much better clinical outcomes. If someone has a disease models that fits what we are seeing in our patients better than the CARB syndrome model, I’m all ears.