A Man Died After Consuming a Bag of Black Licorice Each Day

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A Man Died After Eating a Bag of Black Licorice Every Day

He has not had any heart problems in the past. He regularly went for walks with his dog and, according to his doctors, worked as a physically demanding construction worker.

Then, in January 2019, he collapsed at a McDonald's and died.

The likely culprit? Black licorice, according to the doctors who treated it, who this week published their results on the unusual case in the New England Journal of Medicine.

According to the report, the man, an unidentified 54-year-old from Massachusetts, had consumed one or two large bags of black liquorice a day for three weeks. This habit caused his potassium levels to drop sharply, which, according to the study, led to cardiac arrest. He never regained consciousness after his collapse and died about 24 hours after arriving at Massachusetts General Hospital.

"We almost didn't believe it when we found out," said Dr. Jacqueline B. Henson, who treated the man when she was in the hospital. "We were all shocked and surprised."

Aspiring doctors in medical school are learning that black licorice contains glycyrrhizic acid, a plant extract often used as a sweetener in candy and other foods that can lead to dangerously low potassium levels if consumed in sufficiently high doses. But it rarely happens that someone dies from ingesting too much candy, said Dr. Henson.

The Massachusetts man had a poor diet and, according to his friends and family, smoked a pack of cigarettes a day, his doctors said. But it was a switch from red to black liquorice three weeks before his death that doctors labeled fatal.

Dr. Henson said she interviewed the man's friends and family members, and doctors ran several laboratory tests that confirmed the man's potassium levels were well below normal.

They studied his medical history, which included heroin use even though he had not used opiates for three years. There was no family history of heart disease or any other medical condition that led to low potassium levels, said Dr. Henson, who is now a Fellow at Duke University School of Medicine in Durham, NC.

"We had no other clear reason why his potassium levels were so low," she said.

The case "poses a public health problem that consuming large amounts of licorice can be harmful," said Dr. Neel M. Butala, one of the authors of the study and a contributor to the Interventional Cardiology Department at Massachusetts General Hospital.

Dr. Butala said consumers need to be informed about the level of glycyrrhizic acid in their products from candy and other food manufacturers.

He also reported the case to the Food and Drug Administration.

In a statement, the F.D.A. declined to comment specifically on the report and noted its policy of not discussing individual cases.

"The FDA is committed to protecting public health and ensuring the safety of our country's food supplies," the agency said in an email. "We understand that the naturally occurring compound in black licorice can have adverse health effects . "

The F.D.A. warns people 40 and over that consuming two ounces of black liquorice per day for at least two weeks can cause "heart rhythm or arrhythmia".

The agency warns consumers of the dangers of an overdose of black liquorice on its website. The compound glycyrrhizin, which is extracted from licorice root, can cause potassium levels in the body to drop and, according to the agency's warning, lead to abnormal heart rhythms, high blood pressure, edema, lethargy and heart failure.

The doctors' results have been carefully researched and should serve as a public health warning, said Dr. Keith C. Ferdinand, an unrelated cardiologist at Tulane University Medical School, who read the article in the New England Journal of Medicine.

While it seemed "a very unusual case", it should serve as a warning to the public to "be aware that any substance taken into the body, especially in excess, can have real physiological effects" said Dr. Ferdinand, who is also the Gerald S. Berenson Endowed Chair for Preventive Cardiology.

"It is always difficult to find a cause and effect when a person has a sudden catastrophic event," he said.

But the factors in this case – the patient's low potassium levels, the patient's arrhythmias, the fact that he was fine until he collapsed – all signal that the licorice was "likely the source" of his ultimately fatal condition, said Dr. Ferdinand.

Other studies have raised the alarm about overeating licorice. In 2012, doctors at Mercy Hospital and Chicago Medical Center published a study entitled "Licorice Abuse: Time to Send an Alert." It advised doctors to warn patients against ingesting too much licorice and urged the F.D.A. regulate the use of it.

"Daily consumption of licorice is never justified because its benefits are small compared to the adverse effects of chronic consumption," the study says. The case of a 35-year-old Egyptian man with no underlying health problems has been identified who temporarily lost control of his motor functions after drinking a liter of liquorice-flavored water during Ramadan.

"There are numerous licorice-containing products that are readily available in everyday use and that can be inadvertently consumed by the public in generous amounts, putting them at risk of complications," she noted.

Dr. Henson said people who want to eat a piece of licorice on occasion shouldn't be alarmed by the Massachusetts case.

Black liquorice isn't poison, she said.

"It's okay to take in small amounts, rarely," said Dr. Henson. "But when taken regularly, it can lead to these problems."

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