Postprandial Adrenergic Syndrome: “Post Meal Anxiety”

Patients often tell me they feel hopeless, crazy and just down right scared. They have made multiple trips to the doctors feeling as though they have developed food allergies yet testing reveals nothing. Leaving those visits fuels frustration and has one questioning their own mental health.

“How can I feel so poor and my exams so normal, labs are normal, and images are normal—nothing can be found. It has to be in my head. How can all these doctors be wrong?”

Unfortunately, the doctor often offers up the usual cocktail of anti-anxiety meds, no answers, and the all so comforting sentiment, “this is just something you’re going to have to deal with”. Great, not only do you feel horrible but now your only fix is to slip into a zombie– like state, just so you can eat a meal without feeling like you are dying.

Imagine every time you ate, no matter what it was, you felt like the weight of 1000 men were standing on your chest and getting heavier with every breath. Like someone slipped a zip lock bag over your head and was slowly sealing it shut. Your vision is tunneling in, your heart is racing— you want to scream for help but you’re afraid you’ll use your last breath. Sounds a lot like anaphylaxis but in these patients it is actually anxiety. I’m thankful that I’ve never experienced this but this is the feeling that has been described to me. The idea that this feeling could be triggered by a meal, in the absence of an allergic reaction, was new to me as of just a few years ago. Luckily I had first hand experience with a family member (patient zero) that I was able to monitor closely as well as experiment on with different diagnostics and treatments.

So once we ruled out an allergic reaction to food, we needed to answer 2 questions: How and why?

 

The first thing I thought that had to be ruled out was a legitimate immunologic reaction to food-stuffs. Some comprehensive immunoglobulin testing (antibodies to food) revealed nothing in patient zero. Immunoglobulin A, G and E were all ran for the foods that they ate. No positive results. This confirmed that the anaphylactic type response was not a physical emergency situation. Anaphylaxis is a very serious state that requires immediate emergent care. On one hand, relief, but on the other, confusion. We still had no answers…what else could it be? A living organism? Something like a parasite or some sort of yeast feeding off the contents of the food, thus becoming more metabolically active for a short period of time? This was ruled out with various testing strategies that included stool, blood and urine tests. The patient also tried a short stint on a ketogenic diet (high fat and low carb). Most living organisms have a hard time rapidly using fats and proteins for energy so once the patient was in ketosis (a state of utilizing fat for energy) and still experienced the symptoms—the living organism theory was out. So what next?

 

I wanted to revisit what foods they were eating since their symptoms surrounded food, yet I have seen these reactions in patients after eating anything ranging from a single apple to a loaded hamburger. No rhyme or reason, no patterns, no commonality other than anything you eat has you in an anxiety fueled panic. Sounds like something that is made up right? Something people may say to get attention? It is not.

 

You can see how confusing this is to the doctor and downright scary this can be for the patient. How could you be allergic or sensitive to everything you eat? Well, it really isn’t possible, but I am here to tell you that if you are experiencing this, you are not crazy. You’re not making this up and it is absolutely NOT all in your head. The bad news: No two people are the same and the causes and treatments can be radically different from one to another. The good news: There are modifiable factors and reasons as to why you feel this way. With the information I am going to present this should allow you to take control of your health and I highly recommend finding a practitioner that can help guide you through this process, as there can be many ups and downs.

 

If you have never heard of postprandial adrenergic syndrome (PPAS) do not be surprised, it is commonly mistaken for other conditions. The symptoms that a patient presents with are often confused for reactive hypoglycemia and even allergic reactions. Reactive hypoglycemia is a sharp decline in blood glucose that leads to the symptoms mentioned previously such as shakiness, rapid pulse, nausea and anxiety. Allergic reactions are similar with the additions of symptoms like hives, swelling of the face, throat and tongue. Reactive hypoglycemia can quickly be ruled out by measuring the patient’s blood glucose. If the blood glucose is not low during an episode then that rules out hypoglycemia. In fact, often times you’ll find the patients’ blood sugar high. This is likely due to the stress response or for the simple fact that they just ate.

 

After a meal in a healthy individual we see a concert of hormonal action. Insulin, cortisol, leptin, endorphins etc. are all released based off the make-up of the meal as well as the size. The exact mechanisms are beyond this article but suffice it to say that the overall purpose of these hormones is to relax the system and trigger enzyme activity to allow digestion to take place. This gives the body its greatest ability to extract nutrients we need from food. This is why you may get tired after a large meal. The nervous system has switched over to the ‘rest and digest’ function.

Now you can see how being excited or anxious following a meal is perplexing. After all, this is the exact opposite of what we would expect. Our original thought that food was the culprit was not entirely false. At this time I have yet to find a patient suffering from postprandial adrenergic syndrome with a simple combination of food sensitivities. I have run and reviewed hundreds of food sensitivity tests and in these patients never to find the culprit. If we do have positives of within these tests, removing them from the diet, unfortunately, provides little to no benefit.

 

How about the size of the meal? Ah ha! Some success. Altering the size and feeding times of the patient does improve their status, tremendously actually. Now normally this would be a blood sugar stabilizing tactic. Smaller meals higher in proteins and lower in starches, but as we discussed improper blood sugar levels (for the most part) are not involved. Larger and higher starch meals negatively affect nearly every single patient that suffers from this syndrome. Finally, we had a commonality that could provide some relief. So now we turn our attention to the hormones. Cortisol in particular.

Cortisol has been vilified for decades with conversations heavily weighted to discussing high cortisol levels. What about low cortisol levels? Let us look at a comparison of some of the symptoms between the 2 states:

  • inability to cope with stress
  • shakiness
  • nervousness
  • anxiety
  • sweating
  • chills
  • clamminess
  • irritability
  • impatience
  • confusion, including delirium
  • a rapid heart rate
  • lightheadedness
  • dizziness
  • hunger
  • nausea
  • sleepiness
  • blurred or impaired vision
  • tingling or numbness in the lips or tongue
  • headaches
  • weakness
  • fatigue
  • anger
  • stubbornness
  • sadness
  • a lack of coordination
  • low libido

Confused? Only see 1 list? It is not a typo…high and low cortisol symptoms are nearly the same! What you see above is termed a clinical paradox. Cortisol levels MUST be tested. You cannot just assume they are high or low. For those doctors reading this, you may be surprised on your results. Pooled, averaged or 24 hour cortisol tests are not ideal. I prefer multiple tests ran throughout the day. There are many great labs that can perform this test.

In PPAS patients, nearly unanimously, cortisol is low which would match the timing of their complaints where they indicate that later meals affect them the most. Cortisol starts high in the morning and slowly drops off as the day progresses. This dropping of cortisol is exaggerated in patients suffering from postprandial adrenergic syndrome. In fact, I have some patients that tell me they feel completely normal after breakfast but every other meal is the nightmare.

 

Treatments

The treatment for PPAS can vary and may not be as straightforward as others. The underlying issue is the improper response from the adrenal glands after feeding. This is NOT “adrenal fatigue” as the adrenals are not constantly in a low functioning state—rather they will fluctuate from a low to a high. Rarely patients with PPAS ever feel really good, rather they always feel elevated (anxiety and inner tension) or low (fatigued and depressed). That is the difficult part, the transient states from hypo to hyper do not allow you to just “ramp up” or “calm down” the adrenal response. Adaptogenic herbs appear to have the greatest benefit. Astragulus, aswhaganda and eleuthero root are some that I find most effective. Compounds like rhodiola should be avoided in the beginning, as they appear to have more of a stimulating effect and contraindicated in those with anxiety.   Licorice root may also be a viable option but like rhodiola could have the opposite effect and needs to be monitored.

If a patient is in a crisis state there are things that can be done to help alleviate the symptoms. Remember although this presents as an allergic reaction to the meal that was just consumed, it is more of a hormonal/emotional issue. Kavalactones (kava) is a GABA agonist, which will trigger the ‘calming’ side of the nervous system. Phenylbutyric acid (phenibut) is another fast acting compound for anxiety. Inositol is perhaps one of the most successful nutrients for anxious attacks- its mechanism of action is unknown but suspected to affect the strength of serotonin release in the central nervous system. It is relatively safe and has benefits in a myriad of other diseases such as PCOS (poly cystic ovarian syndrome) and diabetes.

  • Kava kava
  • Ashwagandha
  • Eleuthero
  • Licorice
  • DHEA
  • Pregnenolone
  • Phenibut

It is important to discuss these options with your doctor- dosage, timing and even combining different compounds are important.

Let us not underestimate the power of deep methodical breathing. Try it now. Close your eyes, take a deep breath in through your nose. Fill your belly with air and now slowly release to a 4 second count through your mouth. You can enhance this by adding some calming oils like lavender, sandalwood, citrus and chamomile. Place them in a jar or sprinkle on a cloth and breath them in.

Writing this article from the beautiful state of Colorado, I would be remiss not to mention the effects of marijuana on these patients. There is no doubt that marijuana can be an effective anxiolytic (stopping anxiety) and may be sought out by patients suffering. Marijuana, in this instance, can make the anxiety worse. Once again, another perplexing response. Most of the symptoms come on as the “high” wears off but some have stated even during their “high” they have felt a heightened state of anxiety and panic.

Avoiding caffeine is something else that is important, and it needs to be all forms of caffeine- from tea, soda, coffee etc.

Reducing stress, (yes I know, easier said than done) is absolutely paramount to the healing process of this condition. Either through meditation, prayer, therapy, exercise; it doesn’t really matter, everyone is unique. Find something you like and keep it consistent. Reducing emotional stress is key.

There is not a single health issue that cannot benefit from a change in diet. Here you will find a few alterations that will benefit PPAS patients. This is the only time I really recommend smaller, more frequent meals to my patients (I am a huge proponent of short term fasting otherwise). Low starchy carbohydrates, high protein, and moderate fat meals appear to be best. These meals should be small enough to not make the person feel full but large enough to provide the daily nutrition they need. Look into performing a ketogenic diet or a modification of it. I would avoid introducing newer foods into your diet as you go through this process, (but if you must) I would try newer foods earlier in the day like breakfast or lunch when cortisol is naturally higher. Keep in mind this will not be forever.

  • Low starchy carbohydrate
  • High protein and high fat
  • Smaller meals
  • Bowel rest dieting
  • Low FODMAP diet
  • Low histamine foods

Testing

As stated previously, traditional chemistries are often inconclusive. Whether it be due to the transient nature of not collecting the blood at the right time, or that the fluctuations in these hormones are not strong enough to flag any current reference ranges. I have tested patients during an “attack” and there wasn’t any significant, conclusive data to gather. Cortisol/hormone testing has been by far the most beneficial. Females are affected by this syndrome more than males so there may be an estrogen/progesterone component that has yet to be unearthed.

Final thoughts

As I go back and review these patient cases I realized that these patients either currently or in the past have complained of many features common with mast cell activation disorder or histamine burden. Could this be a possible co-morbidity or sequela? This is a truly horrible syndrome and no way to live. I hope this article finds those in need and provides some guidance through the process of healing.