A recent story in the New York Times titled “Drowning in a Sea of Prescriptions” by Alan Schwarz outlined the sad story of Richard Fee, a 24-year old pre-medical student who hung himself after getting hooked on the prescription stimulant Adderall. It is truly a tragic story. According to his parents, Richard never showed any signs of ADHD during his early school years, but in college he started using Adderall to cram for tests. This appears to be a common practice among college students, especially over the past few years.

Several years later when he was studying for his medical school entrance exams, Richard started obtaining prescriptions of Adderall from various physicians. ADHD is a “clinical” diagnosis based on taking a careful history of past and present symptoms that must start before the age of seven to qualify for a diagnosis. This can lead to problems because any intelligent person can study the typical symptoms of ADHD and then present them to a clinician. In today’s world of rushed medical visits, a diagnosis of ADHD is often quickly made and a drug like Adderall is then prescribed. Once a diagnosis of ADHD is established, other clinicians are more likely to refill the medications without doing their own diagnostic workup.

In Richard’s case he soon became addicted to Adderall and over several years he began to demonstrate paranoid and psychotic behavior. Despite his parent’s attempts to keep him off Adderall, he always managed to find a clinician who would prescribe the drug. He eventually hung himself in his closet—a tragic end to a promising life.

A True Epidemic of ADHD
Over the past few decades the number of young people diagnosed with ADHD has risen dramatically. After the story of Richard Fee was published, clinicians who diagnose and treat this condition were quick to point out that any medication can be abused or cause problems if it is taken improperly. They spoke out because they are concerned that closer scrutiny of drugs like Adderall might make it more difficult for patients with ADHD to obtain medications that might improve their ability to function.

As a scientist, I tend to take a more global perspective. Before we discuss medication issues, we need to understand the reasons why ADHD is increasing at such a dramatic rate. Some say we have become more skilled at diagnosing the condition, but I disagree with this perspective. Over my many years of practicing medicine, I have noticed that in recent years many more of my patients have typical ADHD symptoms than just a few decades ago. If you talk to any schoolteacher who has been in the profession for years, they will tell you the same thing.

ADHD is characterized by symptoms of inadequate amounts of key neurotransmitters in the brain—mainly dopamine and norepinephrine. When the levels of these neurotransmitters are low, people tend to have trouble focusing, concentrating and paying attention. Their thoughts seem to wander and they often have poor impulse control. Some are restless and fidgety and others are more quiet and withdrawn into their own world.

Diet and Brain Function
When incidence of a disease is rapidly increasing, we need to figure out what environmental influences might be in play. After observing thousands of patients of all ages with typical ADHD symptoms over the years, to me the answer is clear—it’s our standard American diet (SAD). Recent research has suggested that certainly dietary elements may have an adverse affect on brain function. The most likely suspects come from three sources:

1. Excessive fructose–mainly from sugar and high fructose corn syrup.
2. High glycemic carbohydrates–mainly from grains.
3. Omega 6 fatty acids–mainly from vegetable oils and partially hydrogenated vegetable oils (trans fats).

A great deal of research has shown that excessive consumption of food and beverages loaded with added simple sugars is the driving force behind insulin resistance, central obesity and type II diabetes. In other studies these metabolic conditions have been strongly associated with impaired brain function. Our modern diet is now loaded with added sugar and high fructose corn syrup. In the early 1800s, the average sugar consumption per person was about 5 pounds per year, whereas today the average person consumes over 120 pounds of sugar per year. To learn more about the adverse affects of excessive fructose, I recommend reading Richard Johnson’s books “The Sugar Fix” and “The Fat Switch”.

Refined sugars are often added to grain-based high glycemic carbohydrates like white flour to make popular highly processed foods. When a person has insulin resistance from eating too much fructose and they consume high glycemic carbohydrates, their brain is bathed in a blast of glucose. Although neurons depend mostly on glucose for their energy needs, too much glucose is harmful for nerve cells. That’s one reason why over time, diabetics sometimes develop a form of reversible cognitive dysfunction.

Processed foods are often loaded with vegetable oils, especially corn or soybean oil. These highly processed oils contain relatively large amounts of omega 6 fatty acids. Although we do need some omega 6 fatty acids for optimal health, our ancestors evolved in an environment where they consumed equal amounts of omega 6 fatty acids and omega 3 fatty acids. Both of these polyunsaturated fats are essential for health, but for optimal health and brain function they must be in balance. The standard American diet is completely out of whack when it comes to these essential fats. The omega 6 to omega 3 ratio in the SAD has been estimated to be anywhere from 16 to 1 to 30 to 1.

The omega 6 fatty acids in our diet mainly come from vegetable oils like corn oil, soybean oil, sunflower oil, safflower oil and other plant based oils. These oils are commonly used in many processed foods or for frying at home. These vegetable oils can become completely hydrogenated through further processing to create trans fatty acids. Trans fatty acids have been associated with an increased risk of heart disease, so many manufacturers have reverted to using plain polyunsaturated vegetable oils. When you combine excessive fructose, high glycemic carbohydrates and excessive omega 6 fatty acids, you have created a real brain-frying food bomb.

Excessive omega 6 fatty acids can trigger a long list of pro-inflammatory reactions in your body and this inflammation can have an adverse affect on your brain function. Recent studies have shown that the high amount of linoleic acid found in vegetable oils promotes fat storage by stimulating certain hunger centers in your brain. The bottom line is that consuming excessive amounts of vegetable oils will make you hungry and fat, and will also lead to impaired brain function.

 Adderall in the Headlines
Now let’s get back to the issue of Adderall and ADHD, a very popular topic in recent news stories. A recent article by Brown and White college student Emma Diehl titled “Students Resort to Study Drug Adderall” outlines how Adderall has become the go-to study drug on college campuses. Over 30% of students have used it for this purpose. Adderall is relatively cheap and easily available on virtually any college campus. Students who use the drug as a “performance enhancer” are seen to have a clear academic advantage over those who choose not to use the drug, putting further pressure on students to take the drug just to keep up.

Tom Ashbrook from “On Point” recently aired a story called “Adderall on Campus: Use and Abuse” where he interviewed Emma Diehl and several ADHD experts.

It seems like everyone is talking about Adderall. A recent blog in Scientific American took another perspective on the Richard Fee story by stating: “But there is a delicate balance to be struck here between serving the needs of the ADHD population, many of whom benefit tremendously from the regulated use of stimulants, and potential drug addicts, like Richard.” The writer is trying to make the case that over-restricting medications like Adderall might harm patients with ADHD.

As a scientist I believe we first need to answer the following questions if we hope to make any sense of the Adderall mess:

Do Adderall and other similar stimulant medications clearly improve mental performance in otherwise health individuals?

1. Are there significant risks associated with using drugs in this manner?
2. Could it be possible that a large number of individuals who choose to use stimulants for performance enhancement might actually have some type of subtle brain impairment?
3. Why is the incidence increasing at an epidemic rate?

If Adderall and similar drugs significantly enhance performance in healthy individuals without significant risks, then our society needs to make some type of judgment about how these medications should be integrated into our culture. If there are significant risks associated with using these medications in this manner, then we must decide whether the benefits outweigh the risks.

In my opinion the third question is largely ignored. We assume that when individuals without obvious ADHD use these drugs, it is simply to get an academic jump on their fellow classmates. I have a different perspective that also relates to question number four.

Food Induced Brain Dysfunction
ADHD is characterized by symptoms indicating low levels of the key neurotransmitters dopamine and norepinephrine. Over my years of practice, I have noticed that individuals who eat the standard American diet seem much more prone to developing these symptoms. They are also more prone to insulin resistance, obesity and type II diabetes. Is it possible that excessive fructose, high glycemic carbohydrates and excessive omega 6 fatty acids are affecting brains in a way that makes people look like they have classic ADHD? I believe the answer is clearly yes.

Decades ago ADHD was a relatively rare disorder with a strong hereditary component. For these individuals stimulant medications can provide dramatic improvements in their ability to function. I believe that in recent decades most people who appear to have ADHD actually have a form of food-induced brain dysfunction called Carbohydrate Associated Reversible Brain syndrome or CARB syndrome. After years of careful observations, I am convinced that CARB syndrome is triggered by these three dietary elements when they somehow interfere with the production and functioning of the key neurotransmitters dopamine, norepinephrine and serotonin. That’s why so many people with CARB syndrome have both ADHD symptoms indicating low dopamine and norepinephrine, and symptoms associated with serotonin deficiency like fatigue, carbohydrate cravings, anxiety, depression and insomnia.

Now let’s go back to the case of Richard Fee. He clearly didn’t have classic ADHD because by definition symptoms must be present by age 7 to make a valid diagnosis, and his parents and friends confirmed that he never had such symptoms. In people with CARB syndrome, the ADHD like symptoms are often initially mild and are often overlooked in adults. Let’s assume that Richard Fee had early CARB syndrome. Like most people his age, he likely consumed a diet loaded with sugar, HFCS, high glycemic carbohydrates and omega 6 vegetable oils. People with CARB syndrome who take drugs that enhance dopamine, norepinephrine or serotonin almost always immediately feel better—at least for a period of time. These drugs act by enhancing the effects of these neurotransmitters.

The problem is, after a period of time the medication effects wear off and the person feels even worse. They need even more of the drug to have the same effect. Because they don’t understand that their dietary choices are driving their condition, they continue to eat a standard American diet. This is a perfect setup for addiction and further brain dysfunction. This is also a pathway to becoming a Richard Fee.

Diagnosis and Treatment of ADHD is a Colossal Mess
Because the medical and scientific communities have yet to recognize the CARB syndrome concept, they assume that anyone who feels and functions better on the medications must have ADHD. Thus many people who have CARB syndrome rather than true ADHD are receiving these medications. Many ADHD experts are now questioning the criteria that symptoms must be present before the age of 7 because they are seeing so many patients with “late-onset” ADHD. In my opinion most of these folks have CARB syndrome, not true ADHD.

If they fail to make appropriate changes to their diet, this group will experience a further decline in brain function down the road, yet ADHD experts rarely discuss dietary issues with their patients. In my experience people with totally normal brain function who are consuming a healthy diet lacking these toxic dietary elements, do not experience an improvement in brain function by taking these medications. They are already alert and energetic and are functioning at a high level, so they see no need to enhance their performance.

People with true ADHD often have some hyperactive symptoms and Adderall typically has a calming affect for them. People with CARB syndrome usually have physical and mental fatigue, difficulty concentrating and focusing and some degree of internal restlessness where they tend to fidget. When they take drugs like Adderall, they immediately feel more energetic and focused and their tendency to fidget often disappears, making it much more likely they will quickly learn to rely on the medication to function. In my opinion the reason that so many college students use Adderall to “enhance” performance is because most of them already have some degree of CARB syndrome from eating a standard American diet.

Coffee–a Great Performance Enhancer When Brain Function is Normal
If a person with normal brain function needs a little jolt to help them study, a cup of coffee will often do the trick. I can speak from personal experience. Years ago when I was in college and medical school, I certainly spent a great deal of time studying. Because my diet was typical for a college student, there were times when I was tired and couldn’t focus or concentrate very well. I compensated by putting in more hours, but it wasn’t easy. Who knows–if Adderall had been available back then, I might have been tempted to take it for cognitive enhancement.

At the age of 64 I work seven 12-hour days in a row in an intense and high stress environment. During my week off I blog, write and pursue other activities with vigor. My ability to think, concentrate and focus is better now than it was 35 years ago. I am also very careful with my diet. Today I can’t imagine taking a drug to improve my performance. My co-workers already accuse me of functioning a little bit too well! If I need a little boost, a cut of coffee always does the trick.

Some patients with advanced CARB syndrome do seem to benefit from short-term use of certain medications like stimulants or antidepressants to help control bothersome symptoms and improve compliance, but this only works in a medical environment where the clinician understands the importance of eating a healthy diet and using the non-medication elements of a proper CARB syndrome treatment protocol. Unfortunately, this type of clinician is as rare as hen’s teeth. Even when medications are initially helpful for patients with CARB syndrome, they can be quickly tapered and discontinued as brain function improves from eating a healthy diet.

The real tragedy of the Richard Fee story is that he might be alive today if somebody had understood the reason why he felt the need to take Adderall. If college students like Richard understood the importance of eating a healthy diet for optimal brain function, they wouldn’t need to resort to taking medications to improve their performance. In my opinion we are facing a national tragedy and very few seem to understand the true nature of the problem.

 Fix Your Brain–Paleolize Your Diet
The good news is that you don’t have to wait for everyone else to get up to speed. If you have trouble focusing and concentrating or if you are having trouble with your schoolwork, you can start fixing your brain today. One of the easiest ways to quickly improve your diet is to move to a Paleo style diet. A Paleo diet eliminates all the triggers of CARB syndrome and in my opinion it is the healthiest way to eat for just about everyone. To learn more about this type of diet, I recommend reading Loren Cordain’s book “The Paleo Answer” or Robb Wolf’s book “The Paleo Solution”. Cut out sugar and HFCS. Greatly reduce your intake of grain-based carbohydrates and vegetable oils and replace them with healthy fats like coconut oil, grass fed animal fats, olive oil or avocados. There are also several safe, targeted supplements that can be useful for treating CARB syndrome. I discuss these supplements in detail elsewhere on this web site.

How do you know whether you have true ADHD or the more common CARB syndrome? If you had typical symptoms before the age of 7, go to a competent health care provider for an evaluation. If you have true ADHD, medications may greatly improve your ability to function in the world. Even if you do have true ADHD, unless you are already eating a Paleo style diet, it’s very likely that you have added some CARB syndrome to your underlying ADHD. In other words these dietary recommendations can be very helpful for both true hereditary ADHD and the CARB syndrome variety. If you are struggling with mental performance and you don’t have classic ADHD, you don’t need to enhance your performance—you need to change your diet.

If enough young people follow this path, the tragic story of Richard Fee will be much less likely to repeat itself in the lives of our future generations. I dedicate this blog post to the memory of Richard Fee and his grieving family and friends.