A (12:55)
Let'S talk about the metabolism of caffeine. You know, whatever you put in your mouth is generally very much absorbed by your stomach and your digestive system. So it all the milligrams are going to go into your body. It's metabolized by your liver and the paraxanthine is the name of the enzyme that's not important. The really important thing is that it is metabolized at different rates by different people which we, we kind of know. Like we all know people who can drink like six cups of coffee and be totally fine. And we know people who drink six sips of coffee and are like, wired, right? So what that means is that the people who can drink lots of coffee and not have much effect of it or much side effects from it, those people have a high amount of that paraxanthine enzyme in the liver. So their liver is really, really good at metabolizing caffeine. So it's hard to get much caffeine in their bloodstream because their liver is just, you know, get getting rid of it really fast. The people who are very sensitive to caffeine, their liver enzymes are slow and, you know, a little bit is taken in and their bodies don't break it down very fast. So it's very effective for mostly, like, it works well because it's not being broken down. They may also have more side effects because, again, it's present in their body. This concept of metabolism is true for caffeine. It's true for medications for people. Just like different people are sensitive to different amounts of Adderall because their metabolism of Adderall varies with different enzymes. And we all have our unique combination of enzymes. You know, some people are super sensitive to Adderall, and some people, you could back up the Adderall truck and have them just take a whole bunch of it and they'll be like, what am I taking? Anything? So, and those people have good enzymes for Adderall. And I should say, if you're good at metabolizing one thing, that doesn't mean that you're going to be good at metabolizing another thing. So, for example, I'm a pretty good drinker. I could drink a lot of alcohol and not feel it very much. However, with caffeine, I'm super sensitive. If I have any caffeine after about 10, 30 or 11, I will feel it that night. So everyone metabolizes different things differently. And certainly everyone has their own specific and unique metabolism. Metabolism for caffeine, I will say that people who smoke generally can metabolize caffeine faster. I kind of was looking around and I just was wondering if metabolism of caffeine can change depending on different parts of a woman's cycle. And no, that doesn't seem to be the case. So the big, the big take home from this particular slide is that different people metabolize caffeine differently, so are affected by it differently. How does caffeine work? Kind of an interesting thing, caffeine, you take it in your mouth, it gets absorbed by your stomach. Or GI tract. It goes into your blood, and from your blood it goes to your brain. This is generally how all medications work. And in your brain, it's floating around in your blood, and it may or it will kind of float by some receptors that are on the brain cells called adenosine receptors. What they normally do is they decrease the amount of dopamine that's released in your brain. So what these caffeine molecules do is it blocks these receptors, and so it increases the amount of dopamine release in your brain. So a whole other topic is ADHD and dopamine, and we can't really get into that. But one of the theories of why some people have ADHD is that there's too little dopamine in certain areas of your brain. Dopamine is a super complicated chemical. It's involved in Parkinson's, it's involved in breastfeeding. It's involved in a lot of things. So it's not just a matter of too low dopamine or anything like that. But in certain areas of your brain, in adhd, there may be less than average dopamine release. So the caffeine could be increasing dopamine in those areas. I wish we had better tools to study this. It's hard to study a brain. We can't see those little receptors in living human beings. So, you know, what I'm telling you is a simplified version, a simplified theory. But that's what we think is the way caffeine works. I should also say that the medications for adhd, specifically the stimulant medications like Adderall and Ritalin, also increase the amount of dopamine in certain areas of your brain as well. So caffeine, as we said, goes into your bloodstream. We talked about what happened when it hits your brain. When that blood hits your brain, however, that blood is going all over your body. And so it hits your heart. Right? And so one of the things that happens is heart rate goes up and there's effects on inflammation. There's effects on your kidneys. You know, you kind of have to pee more after caffeine hits your kidneys. So those are some side effects that we're talking about, but that's how the caffeine works. What does it do when it's going around your body? Well, one of the good things is that multiple studies have shown that it increases mental performance on certain tasks and physical endurance. So it seems like with athletes, for example, they kind of are even more coordinated and they're able to do their sports better. Than without caffeine. It's not on all kinds of cognitive tasks, but it does enhance performance on cognitive tasks and some aspects of your mood. So it can make people a little bit more happy for some people. And specifically in terms of the cognitive tasks, it seems to increase the rate at which you can kind of gather information about the outside world and the speed and accuracy of using that information. It definitely helps with the cognitive task of being awake. So, you know that's the most common use of caffeine, right? Because it really helps you be awake. It hits parts of your brain that say, okay, it's daytime, let's turn on. It helps with vigilance. Vigilance is another word, sort of looking around and being aware that things can happen. It is not a, it's not helpful for long term memory. So in terms of cognitive tasks that it does not help, it does not help people remember things from a long time ago. And you know, one of the things that people complain of when they don't get enough sleep is that they can't remember things. You know, when, when you get less sleep than you need, the way your brain functions is worse. And the thing about it is that people always overestimate, you know, how well they underestimate, I should say, the effects on them. So they'll get like six or seven hours of sleep when they need eight, and they'll be like, no, I'm fine, I can do it, I'm great. Or they might do that several nights in a row. But when they take tests of how their brain is thinking and performing, those tests generally show that they're not doing as well as they think they are. So we all fool ourselves is what I'm trying to say regarding the sleep deprivation. And to fix that, sleeping works better than taking your coffee in the morning. So what I'm trying to say is that if you don't get enough sleep, you are probably underestimating how well you are performing. And the way to fix that is to get more sleep. The way to fix things that is not to have more coffee in the morning or to have your coffee in the morning. Coffee has definite side effects. So one of the things that it does is make sleep worse. And that's even for some people, if you take it in the morning. So you can measure caffeine in your bloodstream even if you just had it in the morning, at least for nearly everyone who takes it. But it affects people's sleep, especially if they are slower metabolizers of the caffeine. As I Mentioned before, it increases heart rate and blood pressure as it's floating around in your blood. And that's most often in the first two hours after it's ingested. And I'll say a little bit more about the blood pressure soon. We talked about effects in the brain. So as it's floating around your brain, one of the things it does is increases your anxiety. Some people, I think when it increase their, increases their heart rate, that makes them feel more anxious as well. But sort of everything in your body is kind of a little bit amped up. There have been some studies now this is not well studied, but as recently as this month, there was a study that came out that showed that doses over 100 milligrams per day and that is sort of like a little less than the average coffee. Probably it can worsen kids behavior. People are more irritable, meaner, other things, and that would be in kids and adolescents was that the last study was in adolescents. I think that that's true in adults too. But I'm referring particularly to the study that came out this month, which was in adolescence. It causes headaches for some people. And as a neurologist, which is what I am, so I treat headaches. And one thing I can tell you is that caffeine withdrawal headaches are real like they are really bad for some people. And that means that if you're used to having caffeine every day and you don't have the caffeine, you can get a really raging headache. I had somebody who had been having coffee and also a medication that contained caffeine. She was taking it every day. It was a medicine that was for pain and headaches and she took it for like 30 years. But because the medicine also contained aspirin, she had upcoming surgery and she had to get off the medicine. And she was just absolutely miserable with these headaches. So I can tell you it doesn't usually take 30 years of taking a medicine, but even for some people a couple of weeks. Again, people metabolize this differently. So it could be different amounts of time. But you can get a headache either from direct effects of caffeine when it is in your body or if you suddenly stop taking the caffeine. Also for people, caffeine can cause diarrhea, nausea and vomiting from effects on your GI system. So I mentioned in the slide before that I was going to address blood pressure. One of the things about stimulant medicines that a lot of providers are like, oh my God, we don't want to give you stimulant medicine, because it could raise your blood pressure, which is absolutely true. But when you look it up, on average, stimulant medicines don't raise your blood pressure very much, maybe a few points, three to five points, basically. So if your blood pressure is normally 120 over 80 on the stimulant medicine, it could be 124 over 84 or something like that. When you look up the effects of coffee or caffeine on your blood pressure, it's probably about the same. Now, we're dealing with very few studies and very average numbers. And what matters is not necessarily the average, but it matters for what it, what effects they are on you as an individual. But on average, you know, we should be worrying about caffeine as much as we should be worrying about the stimulant medicines. Of course, some people take both, and we'll get into that in, in a little bit. So, you know, if you take a look at caffeine versus ADHD medications like the stimulants, boy, on paper, they look about the same. They have this alertness factors, they help with attention, they help with. Or they have side effects on your heart rate and blood pressure, and they also have effects on your sleep, negative effects on your sleep. So all of these things, you can't tell whether we're talking about caffeine or stimulant medicines. So then the question gets to be, well, if they're pretty similar, why don't we use caffeine for adhd? And the thing is that it is less specific for the receptors. So it's floating around and it's hitting lots and lots and lots of different receptors in your body. Yes, it does hit your brain and make you more awake and more vigilant or attention attentive. But does that, it does lots of other things too that are side effects that you're not looking for. And it doesn't work as well in your brain as the stimulant medicine. So this, you basically need lots more of the caffeine to get the mental benefits. But with that, you get lots and lots of side effects. So you get effects on your sleep, you get the headaches, you get the negative behavior, the blood pressure, heart rate, feeling kind of anxious. So that's the major difference here. So if you want to kind of visualize it, the stimulant medicines are much more specific and effective for your brain. So you basically are putting all of it in your brain. They have fewer side effects on average. And with the caffeine, while you can get the same effects on your brain, and it has. You need much more of it to equal the stimulant medicines. And with more of it, you get more side effects. So remember that caffeine and stimulant medicines work in different ways. So both of them do achieve some increase in dopamine. But caffeine, as we said earlier, blocks these adenosine receptors. And by doing that, that's how they increase the dopamine. Stimulants tend to block dopamine transporters, and they increase dopamine in a different way, in a way that seems to be more effective for many people. It's not. And here I'm talking about adults in general. Mostly it's the adults that are going to be combining caffeine and ADHD medications. And, you know, I had to learn to ask about this because that's not something that I was really taught when I was prescribing stimulants, was to ask about other things like caffeine. But in the real world, that is a huge issue. I have a lot of people who I give a small dose of Adderall or Ritalin to them, and they have way more than affected side effects or way more than expected side effects, I should say. And some of them can then tolerate the stimulant medications if they reduce or eliminate their caffeine in the morning. And so what we're doing is we're basically, instead of sort of giving a whole thing of coffee and stimulant medicines, we are shifting to the stimulant medicines, which are more specific for the benefits and give fewer side effects per benefit, basically. And that definitely helps your helps some people tolerate their ADHD medicines. Then they're like, well, I can just drink decaf if I'm drinking for the taste. If I'm drinking for the benefits of the caffeine, they might decide to increase the amount of stimulant medicine because they're getting their benefits without as many side effects. So if you are taking ADHD medicines and drinking coffee and having side effects, one way to solve that problem would be to reduce the amount of coffee you take in the morning, or tea, whatever you're taking that has the caffeine or or energy drinks, if you're young and drinking those. But what we want to do is then maybe increase the amount of ADHD medication that you're taking. And that might be your solution. Okay, and I'm going to go back to that last slide for a second, too, and just say, what about the non Stimulant medications. There are non stimulant medications for adhd. The most common ones are Kelbri and Strattera. Strattera has been around for a very long time and Kelbri is a little bit newer, however works very similarly to Strattera. Some people are on clonidine too, but I'm going to get off that. And Wellbutrin is a non stimulant, but it is not FDA approved for adhd. What I want to say about the non stimulant medicines is that they don't work on the dopamine pathways as much as the stimulant medications do. So you probably will have fewer interactions of these medications. So, you know, instead of all piling on the dopamine, you might be piling on some increasing norepinephrine with the non stimulants and the dopamine with the coffee. You know, you probably will have fewer side effects with that combination in terms of things that dopamine can do as a side effect. But you know, the stimulant medicines do tend to be the most widely used and the most effective for adhd. So that's, that's why I sort of focus on combining adhd, stimulant medicines and caffeine. Talk about caffeine and exercise for a minute. So caffeine helps people exercise, it makes their stamina increased, it makes them more able to be sort of coordinated in what they're doing with their exercise. If coordination is a part of your exercise and the, you know, different sports governing bodies have looked at these things. But so whether it's legal or not in a particular sport, I'm not going to get into that. But studies have definitely shown that caffeine helps you physically with exercise. I will also mention that exercise helps with adhd, that's for dang sure. And so what exercise does is it increases certain good substances in your brain like brain derived neurotrophic factor or BDNF, which improves neuron growth, IGF1 and all these things, they improve blood vessel growth, brain cell growth. When I don't feel like exercising, I might kind of think about this. I'm like, oh, you're doing good things for your brain to increase your nerve cell growth and your blood vessel growth ward off dementia. All these things that exercise is supposed to be good for. Exercise also helps people sleep better. So that's a really good thing for ADHD and cognition in general. Exercise is one of the best things you can do to help you with your mood and, you know, it's one of those positive reinforcement cycles. It probably directly affects the brain chemistry effect that is associated with mood, but it also makes people feel accomplished, and that's a good thing for your mood. So, you know, if you wanted to combine caffeine and exercise, both of those things could be really good things for your adhd. But, you know, watch out for the side effects of caffeine. Most people don't need caffeine to exercise. So this has been a really, really interesting topic for me to think about and to learn about and to talk to you guys about. I really have enjoyed, you know, thinking about caffeine, and I think about it a little bit differently. You know, long story short, your body doesn't know the difference between what comes in a cup and what comes in a pill. Just gets into your body and your body reacts to it. So how we think about caffeine may be something that we think differently about after this webinar. But you let me know it's time for me to stop being the talker and start being somebody who takes your questions. So I'm going to hand it back to the moderator, Nicole.