Addiction Relapse and Blood Sugar Dysregulation
Addiction Relapse and Blood Sugar Dysregulation
By Christina Veselak, LMFT, CN
Missing a meal or consuming a high sugar diet are primary relapse triggers for all recovering addicts.
Research has clearly shown that low or dropping blood sugar levels lead to cravings, and ultimately, to relapse, in clients with both process and chemical addictions. This blunt fact is substantiated by many years of clinical experience, in my practice and in those of many other chemical dependency clinicians around the world.
Symptoms of low blood sugar, caused by a combination of adrenalin release and a glucose-starved brain, include anxiety, shaking, sweating, heart pounding, and emotional reactivity such as irritability, anger and tears, “brain fog,” fatigue, and insomnia. These symptoms are also in people with “dry drunk syndrome” and premenstrual syndrome (PMS). Fortunately, restoring blood sugar levels through appropriate food and the use of the amino acid l-glutamine often completely eliminates these symptoms.
Clinical experience also confirms that women addicts are much more likely to relapse during the last phase of their monthly menstrual cycle. As estrogen (and progesterone) levels drop towards day one of the cycle, blood sugar becomes more dysregulated, exaggerating all the above symptoms (a drop in serotonin levels, also due to dropping estrogen, often needs to be addressed as well).
How could sugar and low blood glucose exert such strong, negative effects on addiction recovery efforts? The brain absolutely requires glucose to function. Although the brain’s mass constitutes only 2 percent of an average body’s weight, the cerebrum utilizes 20 percent of the carbohydrates that are consumed in any 24-hour period. Moreover, the brain does not have the capacity to metabolize its own source of energy and can store very limited amounts of sugar. Therefore, the brain requires a steady supply of fuel.
Blood sugar level balancing is a metabolic process that is tightly controlled in the body. When we eat food, carbohydrates are broken down into glucose, which passes into the bloodstream and raises blood sugar levels in varying amounts of time, as noted on the glycemic index.
The glycemic index lists how long it takes for the carbohydrates in a particular food to be absorbed into the bloodstream, compared to the amount of time necessary to absorb white, refined table sugar. Sugar is 100 (the highest rank) on the glycemic index, a cup of cornflakes is 84, and apples are 35. Foods with lower scores are absorbed more slowly and produce smoother changes in blood sugar levels.
Protein, fiber, and fats generally slow down digestion and reduce the rate of glucose absorption. Refined sugars and starches typically rank high on the glycemic chart. They raise blood sugar levels rapidly, as does tobacco. Surprisingly, pure alcohol is 0 on the glycemic index and actually lowers blood sugar levels through a variety of mechanisms.
When we eat, sugar is released into the bloodstream and the pancreas releases small amounts of insulin. Insulin attaches to the sugar molecules, escorts them to nearby tissue cells, and metabolically “asks” the cells to store the sugar. In non-diabetic people, the cells readily accept the sugar molecule, and store it for future need. In normal circumstances circulating blood sugar levels then drift downward, and insulin goes away.
When blood sugar levels dip close to baseline, the brain signals us that it is again time to eat, and people find a source of food by which to raise blood sugar levels. This cycle usually takes about four hours, and blood sugar concentration is supposed to rise and fall in a gentle wave throughout the day.
However, at least 80% (if not more) of all alcoholics, premenstrual women, those who habitually eat large amounts of sugar/refined carbohydrates, and those from alcoholic families, have dysregulated blood sugar metabolism, termed reactive hypoglycemia. In these cases, the pancreas appears to release excessive amounts of insulin, leading to a precipitous drop in blood sugar which then may fall below normal baseline.
Two very significant metabolic changes happen when blood sugar is below baseline. First, the adrenal glands release adrenalin in an attempt to slow down this precipitous drop by stimulating the release of some stored sugar back into the bloodstream. Second, as the drop in blood sugar continues, the now starving and unbalanced brain sends out urgent signals for the body to do whatever it takes to bring blood sugar levels back into balance.
This message can easily translate into a powerful craving for quick energy sources such as alcohol or sugar, but this signal just as easily could lead to a craving for any drug or addictive behavior of choice, since an addict’s brain has previously been conditioned to look to its drug of choice to restore comfort and equilibrium. Thus, the alcoholic craves alcohol, the sugar addict craves sugar, the smoker craves a cigarette, and the sex addict craves sex. This relapse-inducing craving especially occurs if a meal is missed, and simply too much time has passed since the brain has last been fed.
What, one may ask, does sex for the sex-addict have to do with low blood sugar, other than a conditioned attempt to restore equilibrium? There are several answers. The first answer has to do with access to the brain’s problem-solving skills. When adrenalin is released, the sympathetic nervous system is activated. One result of this activation is less blood flow to the prefrontal cortex, the cognitive center where plans are made, skills accessed, consequences assessed, and instinctive fight/flight reactions are triggered.
Thus, with low blood sugar, a powerful physiologic trigger for use and relapse is encountered. An addict may be working a strong recovery program and has learned new and helpful skills. However, at that “hypoglycemic moment,” access to those skills is physiologically blocked, and the conditioned response of reaching for the drug behavior of choice is activated to force a release of stress-managing neurotransmitters.
Furthermore, researchers Matthew Gailliot and Roy Baumeister have determined that “self-control relies on some sort of limited energy source.” Their research
“…suggests that blood glucose is one important part of the energy source of self-control. Acts of self-control deplete relatively large amounts of glucose. Self-control failures are more likely when glucose is low, or cannot be mobilized effectively to the brain (i.e., when insulin is low or cells are insensitive). Restoring glucose to a sufficient level typically improves self-control. Numerous self-control behaviors fit this pattern, including controlling attention, regulating emotions, quitting smoking, coping with stress, resisting impulsivity, and refraining from criminal and aggressive behavior. Alcohol reduces glucose throughout the brain and body and likewise impairs many forms of self-control. Furthermore, self-control failure is most likely during times of the day when glucose is used least effectively. Self-control thus appears highly susceptible to glucose.” (emphasis added)
This situation causes more problems. Coping skills are blocked by adrenalin, while self-control is diminished by a lack of energy and blood flow to the brain. So, a stressor that a well-fed addict could successfully cope with, without relapsing, instead leads to a “slip” or relapse, in a person with low or dropping blood sugar. Even more disturbing is the reality that an external stressor is not even needed, for low or dropping blood sugar to lead to cravings, relapse, and addictive use.
Traditionally, in treatment and Twelve Step circles, sugar is touted as the cure for cravings. Candy, chocolate and sweetened coffee abound at recovery meetings. Most residential programs make no effort to limit the amount of coffee, sugar, and refined carbohydrates that are served to their clients. It is common for many people to gain weight after quitting their drug of choice. We all know, for example, that for people who are quitting nicotine their greatest fear is gaining weight. What is actually happening in these situations? Is sugar truly useful for the recovering addict or is the real case just the opposite?
How do we evaluate the AA sponsor’s recommendation that his sponsee should carry a bag of candy for relapse prevention? We believe that this approach actually encourages the switching of addiction from the drug/behavior of choice to sugar. But, researchers have created alcoholic rats by feeding normal rats high amounts of sugar!
Sugar itself is an addictive and dangerous substance. Increased cravings and other physical withdrawal symptoms are common when people swear off sweets. Sugar has been shown to fire and deplete the same neurochemicals as do cocaine, heroin, and ecstasy. As we have seen above, a major problem with this “quick fix” approach is the fact that after eating sugar blood glucose levels are likely to rise too high and too fast, leading to dramatic swings (the “yo-yo effect”) all day. These unpredictable moods and behavior swings can be literally crazy-making and strongly induce relapse.
Furthermore, recent research strongly implicates sugar as a major suspect in the etiology of many cancers. Sugar obviously contributes to obesity and diabetes. Finally, switching addictions may support abstinence from the primary substance, but does not lead to true recovery. People who become “sugarholics” are still addicts.
Therefore, our recommendation is to teach clients how to manage their own blood sugar on a daily basis. Such management is actually quite simple to do, although it might require focus and periodic troubleshooting. We recommend that the day start with a breakfast high in protein and moderate in complex carbohydrates, with protein snacks between meals every four hours. There are many excellent books and articles available which discuss how to make these dietary changes in a healthy and enjoyable way.
Most women who relapse do so within the ten days before bleeding starts. In general, premenstrual women should eat food high in protein every three hours to maintain blood sugar stability. For people who just forget to eat, seem to be too busy to eat, or have trouble finding access to appropriate food (and potato chips definitely falls into the “inappropriate” category!) we recommend carrying better quality protein bars (whose sugar content is no higher than their protein content).
It is advisable to eat protein and complex carbohydrates every three or four hours (and again if you become wide awake in the middle of the night) and limit caffeine to no more than two cups per day. For snacks: a cup of Greek yogurt, half an apple and a stick of string cheese, unsweetened peanut butter on celery or carrots, a handful of walnuts or almonds, half a meat sandwich with lettuce and tomato on whole grain bread, or a higher-quality protein bar (where the grams of sugar listed are no more than the grams of protein).
Placing 1,000 mg of l-glutamine under the tongue for fast absorption can be utilized by the brain as fuel. L-glutamine can eliminate a craving in seconds. It is also a GABA (gamma aminobutyric acid) precursor, so l-glutamine also reduces anxiety-both by raising GABA and by stopping the adrenal response to hypoglycemia. Also, people with unstable blood sugar tend to abruptly wake up in the middle of the night due to an adrenaline surge, and find it impossible to go back to sleep because they feel so alert. Eating a small snack, or using l-glutamine at this time helps to decrease circulating adrenaline and puts people back to sleep easily.
It is often very hard for people, especially those in recovery, to change their unhealthy ways of eating. Tools that we have found to be useful in building motivation and awareness include:
A food/mood/craving diary
A list of hypoglycemia symptoms which clients check off
A 6-hour glucose tolerance test
Using the glycemic index as a food ranking guide
Asking clients who have had a slip into addictive behavior to recall the last time they ate, and what they ate, before the slip occurred
Taking time in each session to find out what a patient is doing to keep his or her blood sugar in balance.
Feeding oneself in a healthy, pro-recovery way, is an act of self-care that is recovery- and life-sustaining. We encourage clinicians to try these approaches themselves and with their clients and track the outcomes.
The Alliance for Addiction Solutions, a nonprofit organization dedicated to promoting natural approaches to addiction recovery, is interested in compiling clinical research on the relationship between hypoglycemia and relapse. Please contact the author if you or your agency would like to participate in this research effort. My office number is 303-888-9617.