The bypass-alcoholism connection is worth knowing about. Before I get into it, I should say for the record that my purpose is not to discourage people from considering the gastric bypass. The bypass is a wonderful weight-loss operation. Besides being a safe and fantastically effective treatment for type-2 diabetes and other obesity-related diseases, gastric bypass surgery also results in an amazing 30% to 70% drop in the 10-year all-cause mortality (death rate) of patients who undergo it compared to patients who could have but didn’t.
It’s important to understand just what all-cause mortality is. All-cause mortality is a figure that includes anything and everything that befalls study’s test subjects, includes complications during or after surgery, “natural causes,” and even weird, “Final Destination” type occurrences (e.g., “hit by a bus”). Everything is counted in an all-cause-mortality analysis.
It’s also important to understand that 30-70% is a huge drop in ten-year all-cause mortality. Other than smoking cessation, I can think of no elective health intervention or lifestyle change known to have a benefit that even comes close to it.
How Strong Is the Link between Bypass Surgery and Alcoholism?
The relationship is real, but it’s not super-strong, and most bypass patients won’t ever develop it. The relevant research shows that beginning two or three years after surgery, bypass patients start seeking treatment for alcoholism at a modestly higher-than-expected rate. In absolute terms, it equates to one extra treatment-seeking patient for every twenty to fifty who underwent gastric bypass.
It’s a modest increase, but it’s significant. Because of it, I tend to counsel patients with indicators of addictive potential that they may do better with sleeve gastrectomy, ESG, or medical therapy.
The Cross-Addiction Hypothesis
Why are gastric-bypass patients at risk for alcoholism? In short, we don’t know. In medical circles, speculation centers around the fact that alcohol is absorbed into the bloodstream more quickly after gastric bypass. This absorption hypothesis doesn’t explain how faster absorption increases addiction risk, and it’s not obvious to me why one should follow from the other.
The popular media favors the idea of “cross addiction.” Oprah Winfrey aired an episode about it. Cross addiction posits that when people are thwarted from participating in one addictive behavior, they seek a substitute. Obese patients, thwarted by surgery from indulging in food addiction, supposedly turn to alcohol to fill the void.
I admit that cross addiction is a superficially attractive theory. It is certainly a tidy, logical-sounding explanation for the alcoholism seen in bypass patients. That said, I don’t believe it’s correct. If it were correct, then people who lost a similar amount of weight through other means (e.g., sleeve surgery, injectable medications) should incur the same alcoholism risk. We know that they don’t.
The Hypoglycemia Hypothesis
My personal suspicion is that hypoglycemia (low blood sugar) is the missing piece of the puzzle. Understanding how chronic hypoglycemia leads to alcoholism requires understanding two key aspects of human physiology: how bypass surgery alters absorption of sugar, and how the human pancreas responds to an elevated blood-glucose level.
Simple Sugars Are Absorbed More Quickly After Gastric Bypass
As to absorption, it’s not just alcohol that’s absorbed more quickly after bypass surgery. Sugar absorption is sped up to an even greater degree. Because sugar is absorbed more rapidly, bypass patients experience sharper blood-sugar spikes than non-bypass patients. The rise in blood sugar is sharper, and the peak blood sugar level is higher than anything experienced before surgery.[1] These repetitive spikes in blood sugar are the problem that leads to chronic hypoglycemia later.
Blood Sugar Spikes Induce Rebound Hypoglycemia
Often, the immediate effect of a blood sugar spike is an episode of so-called “rebound hypoglycemia.” Anyone who ever felt jittery and hour after drinking a can of Coke on an empty stomach is familiar with it. Your blood sugar spikes in response to a sugary drink, and your body responds by releasing insulin. Insulin is a hormone that tells every cell of the body to start pulling sugar out of your bloodstream, lowering your blood sugar.
If the blood sugar spikes really high, you release a whole lot of insulin. Too much, in fact. A big blast of insulin doesn’t just return our blood sugar to normal; it causes it to overshoot the target. The cells sucking up sugar under the influence of insulin can’t stop on a dime, and often when the falling blood sugar hits the normal range again … it keeps on going down! The insulin wears off before long, but before it does, the sugar sometimes can fall to levels that are uncomfortably, even dangerously low.
Blood-Sugar Spikes Stimulate the Pancreas to Massively Increase Future Insulin Production
While rebound hypoglycemia is a very noticeable, immediate consequence of a sugar spike, it is not the most important one. The long-term effect of experiencing repeated spikes in blood-sugar has a more ominous effect: It causes the pancreas to massively increase insulin production capacity. Increased insulin production indirectly leads to substance abuse (more on why in a moment).
Evolution Left Humans Unprepared to Consume Refined Sugar
Why do blood sugar spikes cause the pancreas to surge its capacity to make and release insulin? It is because as far as your body is concerned, refined sugar is a dangerous poison. There is no source of refined sugar in nature. Prior to recent times, it was simply unavailable to humans. (There are no trees out there that grow Milk Duds®.) As a result of the unavailability of refined sugars, our bodies are completely unacclimated to dealing with it.
When a normal person drinks a can of Coke®, their blood sugar usually hits 170 mg/dL or higher within about thirty minutes. Prior to the modern, Domino Sugar® era, 170 would have been an extraordinarily high blood sugar for a human being. The diets in any other era of human history did not contain even a tenth of the sugar necessary to produce a blood sugar of 170. If you used a time machine to look back 100,000 years through someone’s family tree, you would not find a single soul prior to, say, 1700 AD who ever experienced a blood sugar anywhere near that high in their entire life (however few decades it probably was).
Your Physiology Considers Elevated Blood Sugar to Be a Life-Threatening Emergency
Your body reacts as though a blood sugar of 180 is a mortal emergency. It pulls the fire alarm. Not only does it release almost as much insulin as it has in store at that moment; the blood sugar spike also sends a strong trophic signal to your pancreas to ramp up its ability to make insulin in the future—tomorrow, and the next day, and the day after that.
Repetitive sugar spikes effectively grow your pancreas’s insulin production in a way quite analogous to how weightlifting grows your muscles. When a bypass patient drinks a Coke®, it’s just like Arnold Schwarzenegger doing another set of bicep curls at Gold’s Gym. Every sugary treat is another blood sugar spike, which is another set of reps to further beef up your pancreas. Before long, your insulin production grows as freakishly out-of-proportion as Arnie’s biceps. Your pancreas becomes a monster.
Excess Insulin Production Leads to Chronic Hypoglycemia
All the extra insulin causes chronic hypoglycemia. You experience rebound hypoglycemia after eating sweets, of course. Over time, it becomes more severe, and you begin to experience distressingly low sugars after eating any kind of carb, like bread. With time, you start experiencing hypoglycemia between meals, because even the baseline level of insulin your pancreas is putting out overwhelms your body’s ability to compensate for it.
We Experience Hypoglycemia as Anxiety
The reason that lower-than-normal blood sugars lead to substance abuse is that we experience low blood sugars as anxiety. Remember how jittery you felt an hour after downing that can of Coke on an empty stomach? Those jitters were the result of adrenaline release. Your body responds to a blood sugar dip by releasing adrenaline, the fight-or-flight hormone, into your bloodstream. Adrenaline makes you feel anxious. It’s where the anxiety comes from. The slow development after gastric bypass surgery of chronic insulin overproduction leads to chronic, adrenaline-induced anxiety.
Hypoglycemia-Related Anxiety Triggers Substance Abuse and Dependence
The link between anxiety and substance abuse is straightforward. If insulin overproduction gets bad enough, anxiety becomes a regular part of life. People who have any inclination to use a substance (alcohol, for instance) to quell an episode of anxiety will start to feel an increasing temptation to do so. The more pervasive and intense the anxiety, the worse the temptation.
Hypoglycemia-Related Anxiety Is Treatable
The patients I’ve known who have developed chronic hypoglycemia after bypass surgery have almost always pulled out of it through diet modification. In 20+ years of treating bypass patients with this problem, there are only two exceptions that I can recall. Those two patients felt badly enough that they wanted to proceed with bypass reversal, which reliably solves the problem. Both of the patients in question experienced complete relief from the anxiety problem more or less immediately after reversal surgery.
Dietary Modification Is a Rapid and Effective Solution to the Hypoglycemia Problem
The treatment I recommend to most patients is a dietary adjustment that I have come to call the “carb hygiene” diet (for lack of a better idea). Carb Hygiene entails two pieces: (1) comprehensive exclusion of all sweet things from their diets, and (2) implementation of the “50% rule” with respect to starchy foods. The 50% rule dictates that whenever they eat anything—meal or snack—they need to ensure that no more than 50% of the net, incoming calories will come from carbs. At least 50% needs to be fat and protein.
Your Pancreas Is Like Conan the Barbarian.
For most patients, the anxiety begins getting better after a few days of carb hygiene. For things to get completely back to normal, however, it takes about a year. To understand why, we return again to the Arnold Schwarzenegger’s biceps analogy (which is very apt, by the way). If, during Arnie’s prime, we managed to persuade him to skip the gym for a week, he wouldn’t look appreciably different. We’d still be looking at Conan the Barbarian. If, on the other hand, he skipped the gym for a year, then we would be looking at a basically normal-appearing guy. As with biceps, it is with pancreases.
My advice to all my bypass patients—and any other weight-loss patients, for that matter—is that they should avoid sugar and sweeteners like the plague. Those things are (for all practical purposes) poison. They’re just slow poison, like cigarette smoke. Smoking a cigarette won’t kill you today, but smoking regularly for thirty years will change your appearance in a way that people can see from across a room. Sugary food also changes you, too. It’s a different change, yet you can still see it from across the room.
[1] These changes to absorption are why the standard test for gestational diabetes, the three-hour glucose tolerance test, cannot be used in gastric bypass patients.