Nutrition Articles by Richard Kunin, MD

It’s All About Dose

Modern medicine is still at the early stages of research regarding the optimal intakes of nutrients. The field is controversial and subject to revision and the best advice available at present is the warning to beware of over-eating all types of food. This is based on considerable research that shows protein excess is bad for the kidneys; fat excess is bad for the blood vessels and sugar excess causes a long list of complications, ranging from dental cavities to hyperactivity and influencing both diabetes and hypoglycemia in between.

With that in mind, how should one react to a research report that tells us that sugar intake has no effect on children's behavior, that it is essentially of no effect?! The sweet truth is that sugar got a reprieve from the New England Journal of Medicine. Before you go on a sugar binge, however, I think there is also a bitter truth in this report: that the research design of this study was faulty and the conclusions are therefore invalid.

Mark Wolraich and his colleagues at Vanderbilt University, studied the effects of sweets on the behavior and mental acuity of a group of 23 children, who were selected because their parents said they were sensitive to sugar. (http://www.ncbi.nlm.nih.gov/pubmed/8277950) In the study the children were fed either sucrose, aspartame or saccharine in successive 3 week periods. The diets were otherwise standard for all and they were evaluated by their parents and teachers as well as the authors, who concluded: "Even when intake exceeds typical dietary levels, neither dietary sucrose nor aspartame affects children's behavior or cognitive function." In other words, there were no behavior changes, no hyperactivity, and no interference with attention or school performance in these children who were supposedly sugar-sensitive.

Because this research is featured in the New England Journal of Medicine it will probably convince health professionals around the world that sugar intake has little or nothing to do with behavior, not even in children. This flies so much in the face of everyday experience that it begs for rebuttal.

After the discovery of the hormone, insulin, in 1921 we came to understand diabetes as a hormone deficiency disease. Insulin catalyzes enzymes that make sugar available to cells; hence it regulates the energy supply at the cellular level. Deficiency of the hormone causes blood sugar levels to rise and some sugar spills over into the urine. Once the hormone became available as a treatment, the phenomenon of low blood sugar became familiar. Patients complained of weakness, dizziness, chills, sweats, nervousness, excess hunger and weight gain. The worst cases might go on into insulin shock, which could prove fatal.

Within a few years of the discovery of insulin, it occurred to one astute physician that similar symptoms also afflict patients not on insulin treatment. That physician, Dr. Seal Harris, introduced the diagnosis of hypoglycemia in his classic paper on hyperinsulinism, based upon finding low blood sugar readings in five of his non-diabetic patients. Unlike diabetes, which has been known since ancient times, hypoglycemia is a new disease, never before recognized!

My interest in nutrition and orthomolecular medicine became a commitment in 1967, at a time when hypoglycemia was beginning to take on the status of a lay-movement. The Hypoglycemia Foundation was very active in support of research and education, with a particular emphasis on adrenal cortex weakness, which went by the unwieldy diagnosis, hypo-adrenocorticism. Dietary treatment, particularly a low carbohydrate, low sugar, high protein diet, was the major recommendation, along with injections of adrenal cortex extract and a medication, Bellergal, to relieve nervous symptoms of hypoglycemia. In fact, many patients who tried the diet reported substantial benefits, eg. increased well being and energy and, for those who were overweight, remarkably easy weight loss. This paved the way for the Atkins Diet.

The popularity of the Atkins Diet, introduced in 1972, was directly connected to the well-known health benefits of the low carbohydrate diet for hypoglycemia. However Atkins went a step further in promoting the use of Ketostix to monitor the urine for acetone and ketone bodies, those by-products of fat, which appear in the urine of most of those who are actively losing weight. I recognized this as a worthy innovation, an improved mode of behavioral reinforcement for obese patients who otherwise must rely on the inconsistencies of body weight to guide and motivate their progress.

I was equally impressed by Dr. Atkins' use of Ketostix test strips to determine a "Critical Carbohydrate Level," the transition point at which the Ketostix no longer turned purple on being dipped in the patient's urine. It seemed plausible that this might be an optimal carbohydrate intake, since it was sufficient to avoid ketosis, while at the same time not so much as to over stimulate production of hormones (eg. insulin, glucagon, adrenaline and cortisone), hence likely to protect against both diabetes and hypoglycemia.

With that in mind I designed a test diet for my patients based on carbohydrate titration, increasing intake from low to medium and then to high levels over the course of a week. The results were so beneficial and instructive that this technique, the Balance Point Test Diet™ has become a mainstay of my nutrition education program for patients.

The following tabulation summarizes the effects of the carbohydrate Balance Point Test Diet on mood and energy in 73 of my adult patients, who were troubled by anxiety, depression, fatigue and irritability.

As you can see, 28 percent of these patients felt best at very low carbohydrate intake; but over half felt worse. Over two thirds of these patients felt their best at the medium or optimal carbohydrate level and over 10 percent felt their best at the high carbohydrate intake, over 120 grams per day. On the other hand, over 80 percent felt worse after high carbohydrate intake. Beyond that level there was no further increase of symptoms.

These findings shed a new light on the study by Wolraich, for all his control subjects received no less than 202 grams per day and up to 271 grams (with added sucrose). His experimental group received no less than 251 grams and up to 326 grams per day with added sucrose. It is possible, even probable, that the high carbohydrate intake in his study masked the neurological effects, either by means of a blanket dysfunction in all subjects or, more likely, an adaptation of some sort, such as more frequent eating or a change in the internal hormonal milieu. My patients were not adapted, since they started at very low carbohydrate and titrated their intake over a period of only 8 days.

Dr. Wolraich represents a medical profession that has forgotten about the historic use of the low carbohydrate diet and fasting to the point of ketosis in treating epilepsy. The ketosis diet for epilepsy went out of fashion fifty years ago when Dilantin (phenytoin) turned out to be more convenient, (though not always more effective). Until then most neurologists knew that seizure disorders were made worse by carbohydrate and especially by sugar intake. Low carbohydrate diet was often successful in controlling seizures, even when drug therapy failed! And the clinicians of that day also knew that the behavior and mood states of these patients, particularly children, also improved dramatically upon carbohydrate restriction.

The recent popularity of high carbohydrate diets to lower cholesterol and, maybe, to protect against heart and blood vessel disease, should not cause us to abandon the valuable observations of yesteryear. Researchers must design their studies so that carbohydrate effects are observed across the entire range of dietary effects, not limited to the higher intake levels only. Carbohydrate effects are more obvious to patients consuming less than 4 ounces, ie. 120 grams per day. Above roughly 150 grams the symptoms seem to fade.

The truth seems to be that researchers are limited by their own theories. The determination of optimal intake of sugar for the total person has been neglected in the midst of tons of basic research about sugar in relation to cells, enzymes and receptors.

What needs to be done is to identify optimal doses and new treatment applications for every one of the approximately 50 nutrients that are the keys to our health and survival. That is the core issue of Orthomolecular Medicine, a just-emerging discipline. In the meantime, it remains a personal matter: you have to find out what works for you and without much help from the medical profession. The Balance Point Diet Test™ is the best way so far developed.

If you want to balance your carbohydrates, proteins and fats for optimal energy, well-being and mental focus you can find the details AT THIS PAGE.

Copyright @ Dr. Richard A. Kunin, 1994

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