C ARBOHYDRATES ,M OOD , AND P REMENSTRUAL S YMPTOMS

13.3.4 C ARBOHYDRATES ,M OOD , AND P REMENSTRUAL S YMPTOMS

The waxing and waning in many women of a variety of physical and psychological symptoms over the course of the menstrual cycle has been known and documented since the time of Hippocrates. However, the importance and the distress accompa- nying these symptoms remained in relative obscurity with, prior to about 1980, much of the research focused on documenting and verifying that affective symptoms

actually do show cyclical changes across the menstrual cycle. 93 The premenstrual syndrome attracted considerable attention in the late 1970s and early 1980s when two women attributed the murder they committed to their premenstrual symptoms. 94 Since that time, this syndrome has generated considerable controversy and debate at every level, from its definition to its diagnostic criteria, and even with respect to the label used to summarize this condition. About four decades ago, the syndrome was referred to as premenstrual tension. Since that time, the term premenstrual syndrome has frequently been used, although the label premenstrual dysphoric disorder is used in the most recent edition of the Diagnostic and Statistical Manual

of Mental Disorders . 95 For purposes of the present chapter, I will use the most common label of premenstrual syndrome (PMS). Regardless of the label used, most definitions and diagnostic criteria emphasize the presence of symptoms only during the late luteal phase, with a change in severity from the follicular to the luteal phase and an impairment in function during the late

luteal phase of the menstrual cycle. 96 There is also little knowledge regarding the etiology of PMS other than the fact that there is a high probability of involvement of the hypothalamo-pituitary-gonadal system, with environmental and psychological factors contributing to the severity and development of the symptoms. 96

Although controversy has existed over the label, definition, and diagnostic cri- teria surrounding PMS, there is consistent evidence indicating that females, both

with and without PMS, demonstrate an alteration in energy intake, with energy intake significantly increasing during the luteal phase of the menstrual cycle. The mean

intake difference between the follicular and luteal phases ranged between 87 and

Dietary Carbohydrates as Mood and Performance Modulators

674 kcal/day, representing a 4 to 35% increase in the luteal phase. 97 While there seems to be agreement on the fact that there is an increase in energy intake during the luteal phase of the menstrual cycle, this increase in energy intake does not seem to be specific to a particular macronutrient in either animal or human studies, although a preference for carbohydrate, protein, and fat has been proposed by

different studies (see Buffenstein et al. 96 for a summary of these studies). Not only is there an increase in energy intake during the luteal phase of the menstrual cycle, but there is also, as might be expected, an increase in appetite. 98 However, the increase in appetite was greater in women with premenstrual symp- toms. Additionally, appetite is correlated with depression in women with premen- strual symptoms, but not in women without premenstrual symptoms, and this correlation exists only during the luteal phase. Depression accounted for 65% of the variance in appetite. This suggests that the existence of premenstrual symp- toms, such as depression, may influence appetite and food consumption, as it has been demonstrated that depression increases during the luteal phase in women

with premenstrual symptoms. 99 This suggestion is supported by research demon- strating that negative affect is correlated with carbohydrate intake during the perimenstrual period. 100

A number of studies have also indicated that food cravings, specifically cravings for carbohydrate-rich foods, increase during the luteal phase of the menstrual

cycle. 101–103 While some studies have not found such an effect, 103,104 the difference between those studies that have identified an increase in carbohydrate cravings in

the luteal phase and those that have not seems to be a function of the research sample used or the time in which cravings are assessed. Studies 104,106 that have not identified an increase in carbohydrate cravings have typically used normal participants or have tested for cravings in the morning, 105 which is wrong time to assess for cravings, as it has been identified that carbohydrate cravings and consumption of carbohydrate- rich foods occur primarily in the afternoon and evening 106 and in the form of snack foods. 106,107 Most of the evidence 101,106,109,110 indicates that the preference is for sweet carbohydrate-rich foods, although there is one study 107 indicating that there is no preference for sweet vs. starch type foods.

The literature reveals that cravings for and consumption of carbohydrate-rich foods in the luteal phase of the menstrual cycle occur primarily for women experi- encing premenstrual symptoms, particularly when the symptom of depression is present. It has been suggested that the increase in appetite and the cravings for and increased consumption of carbohydrate-rich foods may be due to an attempt to ameliorate the heightened level of depression experienced during the luteal phase, 98,108 and suggests that these women engage in a form of self-medication. There are several studies demonstrating just this effect with women experiencing severe premenstrual symptoms. Wurtman et al. 107 compared the mood-altering effect of a carbohydrate-rich meal in a group of women with severe premenstrual symptoms to that in a group of women without symptoms during both the follicular and luteal phases of the menstrual cycle. Results of this study revealed that the carbohydrate meal significantly decreased the depression, tension, anger, confusion, and fatigue experienced by the women with severe premenstrual symptoms, and this effect existed only during the luteal phase of the menstrual cycle. There was no change in

Functional Food Carbohydrates

mood states during the follicular phase or in women without premenstrual symptoms during the luteal phase. The carbohydrate-rich meal had a positive effect only in the women with severe premenstrual symptoms and only in the luteal phase when these symptoms were prominent.

The ameliorative effect of a carbohydrate-rich meal on mood was replicated in

a study 111 investigating the effect of a specially formulated carbohydrate-rich bev- erage in women with severe premenstrual symptoms. This beverage, when admin- istered at a time when the selected women were experiencing a significant worsening of their premenstrual symptoms, was effective in improving these individuals’ overall level of affect and reducing their anger and depression. These two studies reveal that a carbohydrate-rich meal or snack is capable of ameliorating some of the affective symptoms experienced by women with severe premenstrual symptoms and support the self-medication hypothesis. It should be emphasized that this ameliora- tive effect and the appetite increase and carbohydrate cravings that wax and wane with the various phases of the menstrual cycle are most prominent and occur most reliably in women with the most severe symptoms.