Tired after eating, part 2

There is one post on a blog called "Blogging in Paris" that has more than 100 comments regarding "tired after eating." Reading those comments has been very helpful for me, and I recently posted the following long-winded comment:

I am beginning to speculate that, at least in my case, getting exhausted after eating might be largely psychosomatic. After trying to "figure it out" for years, I have noticed that I do not get as tired if I do something fun and/or stimulating after eating. On the other hand, if I go to a boring class or try to study uninteresting material after a meal, I get an intense urge to put my head down and close my eyes. And, in fact, that is what I end up doing on many occasions, much to the chagrin of the professor or the people around me in the library being distracted by my snoring. And, like others have described, I could circumvent the problem either by not eating or by not eating any carbohydrates.

Feeling a little sleepy after eating is actually a normal physiological response. Eating naturally actives your parasympathetic nervous system, which can be functionally described as "rest and digest" (as opposed to your sympathetic nervous system, which is "fight or flight"), and therefore people tend to feel drowsy after a meal. This reaction seems to happen to a substantial portion of the population, as typing in "tired after eating" into Google produces 19,700,000 results. What is perhaps more telling is that many people around the world take naps (e.g. siestas) after meals, although this custom is not typical in the United States because sleep is vacuously associated with laziness.

Notwithstanding the prevalence of this problem, many people who have commented here (myself included) seem to experience postprandial fatigue that is far more severe than the typical drowsiness that the rest of the population deals with. So the question is, why? Well, in my case, I think it might be due to dysthymia or some sort of emotional problem. One day I realized that, even if I somehow found a way to feel alert after eating, I probably wouldn't want to sit down and read some boring textbook or sit in a lecture hall with 300 other people listening to some monotone professor read off of his PowerPoint slides. I also realized that I was enjoying eating way too much. In fact, I didn't really enjoy doing anything other than eating. There were days when I would have a hearty lunch, like a sandwich, side of pasta, and a salad, and then I would eat like 1000 additional calories of packaged cracker and cheese sandwiches when I got back to my room. I absolutely loved carbohydrates and could easily eat half a tray of Fig Newtons, three peanut butter and jelly sandwiches, and so on. Incidentally, eating carbohydrates almost always put me in a "food coma."

Eventually, I noticed that my symptoms (hyperphagia, hypersomnia, feeling of heaviness in the arms and legs, being really sensitive to rejection, loss of interest in virtually everything) were all characteristic of a type of depression called atypical depression. Atypical depression is different from major depression in that vegetative behaviors are exaggerated instead of minimized. People with major depression usually sleep less, eat less, and are anxious, so I guess that's what makes atypical depression so "atypical". So from here, I came up with the following far-fetched and probably wrong explanation (but I'll just mention it for what it's worth). One study from researchers at NIH ("Organization of the stress system and its dysregulation in melancholic and atypical depression: high vs low CRH/NE states") showed that patients with atypical depression have low levels of corticotropin-releleasing hormone, a hypothalamic hormone that stimulates the adrenal glands to secrete glucocorticoids (e.g. cortisol). Such a deficiency could theoretically lead to low cortisol levels, and this could in turn lead to increased insulin sensitivity, since glucocorticoids normally antagonize the effects of insulin. If this were the case, then a person with low cortisol would experience a sudden drop in blood sugar after eating (especially carbohydrates), because insulin's effects would be exaggerated. And this in turn fits with the whole idea of "idiopathic reactive hypoglycemia," a condition in which patients feel tired, irritable, anxious, and/or dizzy after eating. Incidentally, this condition is also associated with emotional problems (see "Suspected postprandial hypoglycemia is associated with beta-adrenergic hypersensitivity and emotional distress") and doesn't seem to have a physiological basis (except in "alimentary reactive hypoglycemia," i.e. dumping syndrome that occurs after gastrectomy or gastric bypass surgery). The paper written by the NIH researchers also said that norepinephrine is somehow affected by low CRH. This suggestion is consistent with the catecholamine hypothesis of affective, which suggests that low catecholamine levels (e.g norepinephrine) are responsible for to mood disorders like depression.

OK, well I don't want this comment to turn into an essay, so here's what I have been doing to fix the tired after eating problem:

- drinking coffee

- always trying to balance carbohydrates with fat and protein

- eating chocolate

- trying to do something else that is enjoyable to relax besides eating

- avoiding the following: Googling "tired after eating" and then wondering if it's being caused by "candidiasis," "mercury toxicity," "fluoride poisoning," "food allergies," "toxic bowel," and so on, and so on...

- similar to the above, not visiting alternative medicine web sites

- doing stretches and deep breathing from time to time

This is just what I have come up with to explain my own particular situation. I would definitely recommend anyone experiencing extreme fatigue to see their doctor to get screened for the usual culprits (e.g. anemia, thyroid disease, diabetes). But, if the lab tests all come back normal, then I would definitely consider emotional problems as the cause of postprandial fatigue. I actually had a doctor tell me a few years ago that my GI problems were being caused by depression. I proceeded to visit several other doctors who looked for some physiological explanation of my non-specific symptoms and came up with nothing. I thought that the first doctor I saw was just being lazy at the time and was making up a diagnosis because he didn't know anything, but now I think that he was right the whole time. It's been difficult to admit to myself that my symptoms probably stem from psychological problems, but now that I've written what is now an essay, it seems like that's a reasonable explanation. And I am willing to bet that at least some people experiencing fatigue after eating also have some sort of affective issue.

At some point I would like to clean this up a bit and appropriately cite references. But I think that what I described in that post is a possible explanation for getting tired after eating. If anyone has any comments, I would love to hear them!

Tired after eating

Did you just eat lunch a few minutes ago, and now you feel like you're going to pass out? You're not alone. The internet is full of sleepy people (myself included) who report overpowering drowsiness and fatigue after eating. Unfortunately, the internet is also full of misleading information on this topic that may evoke frustration or even anxiety. In this post, I will propose some explanations for this problem and some possible ways to alleviate it.

We're all familiar with the image of Uncle Ted sprawled on the couch after Thanksgiving dinner in a "food coma." Indeed, meals tend to have a sleep-inducing effect, and at least part of it seems to be due to increases in the neurotransmitter serotonin after eating (or "postprandially"). It is a common misconception that the high tryptophan concentration in turkey is what leads to the serotonin spike, since the amino acid tryptophan is the precursor to serotonin. Although it is true that turkey is rich in tryptophan, the rise in serotonin is actually a consequence of the insulin that is released in response to carbohydrate consumption. Insulin secretion decreases the amount of glucose and most amino acids in the blood, but it actually raises plasma tryptophan levels and increases the concentration of serotonin in the brain (Fernstrom and Wurtman 1971). Therefore, the foods that put you to sleep at Thanksgiving are more likely to be the potatoes, stuffing, gravy, and cherry pie rather than the turkey.

Thanksgiving dinner is, of course, a very extreme example of this phenomenon, and the reality is that many people experience this sleepiness after eating normal-sized meals. Nevertheless, brain concentrations of serotonin rise whenever you eat carbohydrates, so this effect could still explain postprandial drowsiness that occurs on a day-to-day basis. It is natural to wonder, though, why can some people eat a peanut butter and jelly sandwich for lunch, wash it down with a half-liter of Coke, and feel fine, whereas others (ahem) fall asleep after eating a side of pasta. 

One factor that probably determines your reaction to carbohydrates is your sleep debt. Like it or not, your body needs a certain amount of sleep in order to function properly. Rats that undergo total sleep deprivation experience weight loss, dysregulation of body temperature, hormonal imbalances, and ultimately death (Rechtschaffen and Bergmann 1995), so clearly it is important to get enough sleep to keep yourself healthy. When you don't get enough shut-eye, you accumulate a sleep debt, and your body will make sure that the debt is repaid. When you are sitting through your boring political science class and nodding off, for example, that is a clear sign of sleep debt. Incidentally, falling asleep after eating is also an indication of sleep debt (see Dr. William Dement's Sleepless at Stanford page.) The first step that anyone with postprandial fatigue should take is to ensure adequate sleep over the course of a few weeks.  (That is, don't sleep for 12 hours one day, eat a loaf of bread and still feel tired afterwards, and decide that sleep debt isn't the problem.) By "adequate," I mean that you should be able to wake up without your alarm clock. Personally, after I made getting enough sleep a priority over my other obligations, my postprandial fatigue improved tremendously. If sleeping more does not improve the situation, you might want to consider if you have a sleep disorder. Fourteen hours of interrupted sleep (e.g. sleep apnea, RLS) is just as bad as a curtailed period of uninterrupted sleep, so that could certainly contribute to daytime sleepiness, including after eating. 

While sleep debt is probably the culprit in many cases of postprandial fatigue, there are other physiological conditions that can cause this problem. For example, patients with metabolic syndrome and type 2 diabetes may experience fatigue after eating because their bodies do not respond properly to insulin secretion. As a result, there are wild fluctuations in blood sugar, which often leads to a feeling of exhaustion. It is interesting to note that sleep deprivation, both short-term and long-term, has also been shown to cause insulin resistance in healthy individuals (Knutson et al. 2007). By the same token, metabolic syndrome and obesity are also associated with sleep apnea, so individuals with metabolic syndrome or diabetes should aim to consistently get adequate sleep. Keeping in mind that sleep deprivation can decrease insulin sensitivity, I have had success with eating a low-carbohydrate diet for alleviating postprandial fatigue. For example, eating a salad with grilled chicken, lettuce, and tomatoes for lunch is much less draining than eating a sandwich and pasta salad. 

Other causes of fatigue after eating could be anything that causes fatigue in general, such as anemia or hypothyroidism. Individuals with celiac disease could also conceivably experience fatigue after eating gluten, since doing so triggers an inflammatory response in the small intestine in such patients. It is important to stress that this explanation is only for people that have received a confirmed diagnosis of celiac disease by a physician (e.g. anti-tTg antibodies, genetics testing, biopsy). Unfortunately, the internet is replete with assertions that sleepiness after eating indicates a food allergy (for example, this brochure from the "IBS Treatment Center"). While such an explanation cannot be ruled out completely, it is much more likely that gluten-containing foods cause fatigue because they are typically highly refined carbohydrates. Gluten is found in bread, pasta, pizza, cookies, and so on, all of which have a high glycemic index and cause rapid fluctuations in blood sugar. Since people feel tired after eating these foods, however, it is natural to blame subsequent fatigue on an intolerance to the food, which is very speculative. True food allergies typically produce an anaphylactic response characterized by systemic mast cell degranulation that is mediated by IgE antibodies (i.e. you would probably be well aware if you are having an allergic reaction to food). The food allergy skeptics claim that there are other "hidden" food allergies that do not produce overt symptoms, yet apparently wreak havoc on your intestines. 

Again, such a reaction is not impossible, but to blame sleepiness after eating wheat-containing foods on an "allergy" seems to be completely unfounded. Furthermore, it causes undue anxiety because you will most likely start voluntarily avoiding foods and blaming them for non-specific symptoms. Eventually, you might end up conditioning yourself to respond aversively to a food, even if you are completely tolerant of it, which can lead to nutritional deficiencies and a lower quality of life. I know this because I am saying this from experience. It was getting to the point where I was spending all of my free time reading about "food allergies" and worrying about them. I know that blaming nonspecific symptoms like GI problems and fatigue on an "allergy" sounds tempting, especially when there are so many claims that eliminating "offending" foods will improve symptoms. Do yourself a favor and stop Googling your symptoms and being misinformed by off-beat web sites, because life is too short to be wasted on such meaningless activities.

So if you are feeling sluggish after eating, particularly carbohydrates, try getting more high-quality sleep and exercise regularly. Sleep and exercise will both improve insulin sensitivity, and getting enough sleep will make you less sensitive to the serotonin surge that is caused by carbohydrate ingestion. Also cut back on the amount of refined carbohydrates that you consume and replace them with high protein and low glycemic index foods. And finally, get off of your computer and go do something enjoyable!

References

Fernstrom, J.D., Wurtman, R.J. Brain serotonin content: Increase following ingestion of carbohydrate diet. (1971) Science, 174 (4013), pp. 1023-1025.

Knutson, K.L., Spiegel, K., Penev, P., Van Cauter, E. The metabolic consequences of sleep deprivation. (2007) Sleep Medicine Reviews, 11 (3), pp. 163-178.

Rechtschaffen, A., Bergmann, B.M. Sleep deprivation in the rat by the disk-over-water method. (1995) Behavioural Brain Research, 69 (1-2), pp. 55-63.

Photo credit: http://www.everystockphoto.com/photo.php?imageId=3450711

Chronic candidiasis, “The Yeast Syndrome,” candida, yeast overgrowth

Overview
The microorganism Candida albicans is a unicellular fungus (i.e. yeast) that is present in all humans. Under normal physiological circumstances, its growth is controlled by the immune system and bacteria that live with humans symbiotically. However, in immunocompromised individuals, such as patients with AIDS or cancer, the immune system is weakened and cannot effectively control the growth of C. albicans. Consequently, yeast infections are often seen in such patients. Oral thrush, for example, is often one of the first signs of HIV infection.

A popular book written by Dr. William Crook in 1975, The Yeast Connection, suggests that this problem does not occur exclusively in immunocompromised individuals. In the book, he proposes that environmental factors such as antibiotics, birth-control pills, poor diet, and stress can all cause C. albicans to grow unabated and cause numerous symptoms. This theory originated in 1986 from a book entitled The Missing Diagnosis written by C. Orian Truss, M.D. Both Crook and Truss claim that C. albicans overgrowth is responsible for a variety of non-specific symptoms that include, but are not limited to:

• Fatigue
• Depression
• Craving for carbohydrates (particularly sweets and foods containing yeast)
• Irritability
• Difficulty thinking or concentrating (“brain fog”)
• Recurrent bladder infections
• Sinus infections
  
• Diarrhea
• Constipation
• Bloating
  

Numerous other books have since been published on the topic, and names given to this theoretical disease entity include candida, chronic candidiasis, yeast syndrome, yeast overgrowth, and others. The proposed treatment for this “syndrome” includes a strict diet devoid of foods that “feed the yeast” (e.g. bread, fruit, juice) and the use of antifungal drugs such as nystatin and fluconazole. Proponents of alternative medicine also suggest a number of supplements and herbs to eradicate the yeast, such as probiotics, caprylic acid, garlic, colloidal silver, and others.

Evidence
There is no experimental evidence that shows that C. albicans can growth uncontrollably in healthy individuals as a result of the environmental factors indicated by Crook. Likewise, there is no evidence that shows such an overgrowth cannot occur because it would be impossible to do so. A few studies have been done to evaluate the effectiveness of anti-fungal drugs in relieving symptoms that patients attributed to chronic candidiasis. A randomized, double-blind study published in the New England Journal of Medicine showed that treatment with nystatin did not provide significant improvement in patients with “candidiasis hypersensitivity syndrome” compared to placebo (Dismukes 1990). A randomized, double-blind, placebo-controlled study in Family Practice, meanwhile, showed that patients who received nystatin or a combination of nystain and a yeast-free diet had significant improvement in symptoms compared to patients who received a placebo or a combination of placebo and a yeast-free diet (Santelmann 2001).

Comment
In the introduction of the Santelmann paper, the authors state, "There are also reports of cures of chronic fatigue, allergic conditions including bronchial asthma, pre-menstrual distress, multiple sclerosis and autism with a regimen of diet free from yeasts, moulds and sugars." In the references list, I discovered that the "reports" are actually Truss's book The Missing Diagnosis, Crook's book The Yeast Connection and the Woman, and a commentary by Truss published in the Journal of Orthomolecular Psychiatry. Obviously, none of these sources are supported by any experiments, and using these sources to claim that a change in diet can cure multiple sclerosis is preposterous. The conclusions seemed to be reached by valid data collection and statistical analysis, but there is a high degree of subjectivity involved since the measure of symptom improvement was based on a questionaire. Also, there is absolutely no demonstration that improvement in symptoms was due to the eradication of C. albicans. One could easily argue that the improvement seen with nystatin resulted from, say, altered pain perception caused by the drug.

A lot of people on the web say that their symptoms improve on the "anti-Candida" diet. In the Santelmann paper, their yeast-free diet did not allow "honey, jam, sweets, ice cream, lemonade, fruit juices (except freshly prepared), alcohol, cheese, and breads and pastries containing yeast." These foods are all devoid of nutrition and high in sugar, so obviously people will feel better by not eating them! Eating these foods causes wild fluctuations in blood-sugar that can certainly leave anyone feeling miserable.

Conclusion
The idea of the "yeast syndrome" is highly speculative and is not supported by any evidence. While severely immunocompromised individuals such as cancer and AIDS patients are often affected by systemic candidiasis, there is nothing that suggests this condition occurs in healthy individuals. The suggestion to eliminate sugars and simple carbohydrates from the diet, however, is certainly prudent.

References
Dismukes, W., Wade, J., Lee, J., Dockery, B. & Hain, J. 1990, "A randomized, double-blind trial of nystatin therapy for the candidiasis hypersensitivity syndrome", The New England Journal of Medicine, vol. 323, no. 25, pp. 1717-1723.

Santelmann, H., Laerum, E., Roennevig, J. & Fagertun, H.E. 2001, "Effectiveness of nystatin in polysymptomatic patients. A randomized, double-blind trial with nystatin versus placebo in general practice", Family Practice, vol. 18, no. 3, pp. 258-265.

Photo credit: Amazon

No, doctors are not greedy and selfish jerks

On Dr. Mercola's web site, I stumbled across a cartoon dubbed "The Town of Allopath." I must say, the Flash animation was very well done, but everything else about it was quite offensive. This cartoon portrays a physician as an insensitive, deceptive, and greedy individual who fabricates a disease just so that he and pharmaceutical companies can make money. A hermit (representative of a naturopath, I guess) then says that prevention is the best way to maintain good health and suggests that allopathic doctors only treat symptoms of diseases. At the conclusion, the hermit holds up a sign that says, "Don't be fooled anymore," which of course implies that all allopathic doctors are deceiving their patients so that they can make money.

I am by no means someone who rejects alternative medicine. Unfortunately, some alternative medicine practitioners (like Mercola) make such outrageous attacks on allopathic medicine that it is sometimes difficult to take alternative medicine seriously. One common theme on many alternative medicine web sites is the idea that doctors are money-hungry ogres that don't actually care about their patients. Supposedly, doctors purposely prescribe drugs to their patients that don't work so that patients will need to keep going back to the doctor's office. That way, according to the theory, doctors can afford to make their payments on their Mercedes and golf tournaments.

Such false accusations are both facetious and offensive on several levels. First of all, most physicians are not rich. In fact, many are thousands of dollars in debt because the cost of medical school is somewhere in the area of $200,000. Even if they have paid off their debt, doctors are by no means swimming in money. Primary care physicians, especially, have seen their salaries decline dramatically over the past few years largely due to poor reimbursement from insurance companies. Patients often complain that they do not have enough time with their doctors because they are overbooked. This is certainly a problem, but many doctors have no choice. They are not overbooked because they want to maximize profits, but rather because they need to see a certain number of patients to prevent themselves from going bankrupt. Indeed, doctors are well-paid relative to the rest of society, but they deserve it - 4 years of college, 4 years of medical school, and 3+ years of internship/residency certainly isn't a cakewalk. If anyone should be criticized for being grossly overpaid, it should be athletes, singers, actors, and people who work on Wall Street.

Keeping this in mind, one would have to be pretty stupid to go into medicine for the money, especially now. People choose to become doctors because of an earnest desire to help people and a passion for science. Therefore, it is revolting to suggest that doctors don't care about their patients, because frankly, caring about their patients is the only reason why many doctors remain in their demanding and often overhwhelming careers. Despite malpractice suits, daunting paperwork, insurance companies, and annoying drug company reps, physicians still wake up in the middle of the night to take care of their patients.

Of course, there might be a few exceptions, and there is the occasional surgeon who recommends a more invasive procedure so that he or she can receive a higher reimbursement. The vast majority of physicians, however, do not choose treatments with the intent of maximizing profits. Ironically, many alternative medicine sites that accuse physicians of being greedy are blatantly trying to make money themselves. One of the most popular alternative medicine sites, Mercola.com, has its own online store! You can't even read an article without signing up for their newsletter so that they can inundate you with spam. And what will these emails say? Of course, they'll spend a page convincing the reader that drug companies and prescription drugs are evil and out to get everyone's money. They will continue to say that real way to lower cholesterol is not to take statins, but rather to buy some herbal blend from the Mercola store that is not supported by one clinical study.

The vast majority of doctors are compassionate and do their best to provide the best possible treatments for their patients. Unfortunately, the same cannot be said about so-called health "gurus" on the web.

Photo credit: http://www.mercola.com/townofallopath/index.htm