Laura Schoenfeld: This is kind of a … I don’t want to say a complicated question, it’s not that complicated, but there is a lot of different information that I can’t really go into in this question-and-answer session, and the main reason for that is because you guys are going to learn from Chris how to interpret the DUTCH test that he is going to teach you. I don’t know if you guys are using DUTCH tests right now. We just started using them—and when I say “we,” I mean me and Kelsey—not only for our individual patients, but also in our adrenal fatigue or HPA axis dysfunction program that we’ve created. We’ve been doing a ton of changes to our program to make sure that we’re using the information that you get from that DUTCH test as opposed to the saliva panel that most people used to use. If you’re already using the DUTCH test, you know that it has a lot of complicated information that can really change why a person is experiencing HPA axis dysfunction, so I don’t like to give one-size-fits-all recommendations for this kind of issue since there are a lot of different things that can affect a person’s HPA axis function. But what I will say is the most typical thing that I see in my patients is people that are either undereating total, in terms of the amount of food that they’re eating, not eating enough carbs for the amount of activity that they either are or were doing, so I get a lot of patients that used to do intense activity, like CrossFit or bootcamp classes or lots of Spinning or something like that, where they’re trying to lose weight because all women are trying to lose weight all the time, apparently, and so they ended up overexercising and then undereating either carbs or just in general. The reason why that’s an issue is because a lot of the exercise that people end up doing, things like CrossFit, things that are higher intensity, maybe heavy weight training, sprinting, that kind of stuff, that all uses glucose as its primary substrate during the actual activity, and if you aren’t eating that much glucose or if the glucose that you’re eating is really going to support basic functions, like your brain and your red blood cells and the things that really do need the glucose, then you’re not going to have the glucose you need for that type of activity. What happens is then your adrenal glands have to put out stress hormones like cortisol and adrenaline to make sure that your liver is getting the signal to create new glucose from protein. That’s gluconeogenesis. That is driven by those stress hormones. It basically turns on that process so that way your body can get the glucose it needs to have what it needs for that type of activity. A little bit of that is normal. It’s not pathological for the body to occasionally have some stress hormone-released glucose, but if that’s happening chronically, that’s when you start to have that HPA axis dysfunction. When somebody is exercising a decent amount and they’re not eating enough carbs and they’re not eating enough calories in general over the course of the long run, so they’re not just doing a short-term weight loss, they’re in that chronic dieting mentality, which is super common these days for women especially, that is a big contributor to HPA axis dysfunction.
That’s the typical pattern that I see in my patients, and that’s just because that’s kind of my niche, working with specifically women, especially athletic women, that have HPA axis issues or hormonal issues. That doesn’t mean that every single person you see with HPA axis dysfunction needs to be eating more or needs to be eating more carbs, and that’s why I was hesitant to give any sort of one-size-fits-all recommendations here. Just because the clients that I see typically tend to be the undereating, overexercising, type A, chronically stressed type of person, that doesn’t mean you won’t see the same type of HPA axis dysfunction in people who are overweight, maybe they have insulin resistance, maybe they have some kind of inflammatory condition that’s causing issues with cortisol release because cortisol is antiinflammatory, and if the body is always inflamed and always needing to use cortisol to keep inflammation down, there may be a point where the body starts to downregulate cortisol production, and then the inflammation comes back. For that kind of person, if somebody is insulin resistant and obese, I might also … I don’t work with these clients necessarily, but if I was working with someone like that, I’d probably make sure they’re not overeating carbs. I’d make sure that they’re exercising appropriately. It’s possible that they’re not exercising at all, and doing a little bit of exercise would help. I might focus even more on lifestyle for them.
I know this person didn’t specifically ask about lifestyle factors that affect HPA axis function, but as Kelsey and I teach in our program, I would say stress management and sleep and circadian rhythm entrainment and making sure exercise is appropriate are actually far more important to HPA axis function than having the perfect diet. I think people often are looking for a diet and supplement treatment for HPA axis dysfunction, and they don’t always take the lifestyle factors as seriously as they should.
If you guys aren’t familiar with what circadian rhythm disruption is, it’s basically that you have a 24-hour clock system in your body that orchestrates a lot of the hormonal release. Cortisol is on a circadian pattern, so you get a high cortisol amount in the morning when you’re waking up, and it drops throughout the day, and it’s lowest at night. You have a lot of different hormones that run on circadian cycles. Melatonin is an example of one that runs kind of the opposite of cortisol. You have a melatonin rise in the evening, and then it drops in the morning when you wake up. The circadian rhythms are really driven primarily by light-and-dark cycles. There are other things that can affect circadian rhythms, but the biggest impact on circadian rhythms is getting bright light during the day and getting no light in the evening, which I’m sure as many of you understand, that’s very uncommon for a lot of Americans these days. A lot of Americans are in an office all day or they’re inside all day, not really getting a lot of sunlight, not getting the full spectrum of light that the sun would be providing compared to artificial light. Maybe they’re in an office that doesn’t even have windows, so they’re having artificial light all day, and maybe they’re there for, like, 10 hours or 12 hours. Then they get home and they have artificial light on when it’s dark out. Especially over the winter, when the sun is going down at 5:30 or 6:00, you’re getting home and it’s time to cook dinner at 6:00, and you have all your lights on. All the lighting that we use in the evening when it should be dark, that’s a problem.
Then the biggest problem, I think, for Americans and Westerners, in general, these days—unfortunately, I have a little bit of a problem with this, too, but I’m sure some of you can relate—is using bright-light-emitting devices, so either your phone or your laptop or a Kindle that has lighting, or you’re watching TV. Doing that in the evening in the 9:00, 10:00, 11:00 hours or later, that is one of the biggest impacts on circadian rhythm function. Unfortunately—like I said, myself included—a lot of us tend to use these electronic devices way later than we should, and I actually think that that is really, really important to HPA axis function. It’s something that we don’t necessarily prioritize when it comes to HPA axis dysfunction, but it is something that, again, could make more of a difference to someone’s wake-and-sleep cycles than their diet, specifically.
With this patient that Leslie was asking about, saying that they’re waking up at 3:00 or 4:00 in the morning every day for the last several months, but they’ve had this issue for a few years, first of all, make sure that their circadian rhythms are being addressed. What that means is getting some sunlight during the day, maybe if they have a desk job, they can go outside for lunch or go take a 15-minute walk twice a day when they have the opportunity to take a break, maybe using a light box at work, so if you are indoors and you are not getting sunlight in your office environment, then having a light box at your desk so you can use that midday to get that light exposure and that light stimulation in the daytime.
Then when you get home, there are a couple of different options. One option that a lot of my clients use is a little goofy, but it is to put on orange goggles when the sun goes down. Right now for us in North Carolina, I’d say the sun goes down around 7:00 or something, I’m guessing, maybe a little earlier, and hypothetically, if I was really good about doing this, I would be putting my orange goggles on basically as soon as the sun goes down. In the winter, it’s earlier. In the summer, it’s a little bit later. The orange goggles will block blue light, and blue light is one of the main drivers of melatonin suppression, I should say. Suppressing melatonin also can affect … or I’m sorry. I should say … well, actually it might affect your cortisol release, but the light itself can actually affect your cortisol release, so getting rid of that artificial light at night as much as possible by using those orange goggles, installing programs like f.lux on the devices that you’re using. On an Android phone, I have one that’s called Twilight. That’s another option. It turns your screen kind of orangey and it dims it, so it doesn’t give you as much stimulation from the light. Make sure you use the goggles if you’re doing any sort of laptop work or watching TV or anything like that. Then if you’re reading, maybe use an orange light bulb for your reading light instead of using a regular light bulb. Then finally, which is usually the hardest part for most of us, myself included, is just turning the electronics off after a certain time, not using your phone or your laptop after 10:00 or after 9:30 or whatever the time is that works for a particular person. I would definitely make sure that this person is not messing up their circadian rhythms.
One really interesting study—and I’ve actually recommended this to some of my clients that have what I think is circadian rhythm disruption—is that going camping for a couple of days can actually help reset your circadian rhythms. It’s kind of interesting because it seems a little silly to recommend camping to somebody as a recommendation for their health, but if you suspect that someone’s circadian rhythms are really messed up, then doing something like a couple of days of camping with no electronics or limited electronic use would actually potentially be helpful. Like I said, I’ve recommended it to some patients before. I’ve had, I think, one or two people actually follow through and do it, but it is a possible reset for the circadian rhythms.
Like I said, I would definitely make sure that those are being dealt with. With the diet, if it is that typical undereating, overexercising, stressed-out person that is trying to lose weight, then making sure they’re eating enough and eating, I’d say at least 20 to 30 percent of their diet from carbs. It depends on how much they’re exercising. If they’re doing something like high-intensity interval training or CrossFit or powerlifting or something like that, I would even go higher, maybe like 40 to 50 percent of calories from carbs. But if they’re not super-active or if they’re so fatigued that they really can’t be active right now, then around 30 percent should be plenty. Definitely getting rid of caffeine and alcohol is a great, important strategy for the diet. Sugar I would say to generally avoid with the caveat that if somebody is, like, terrified of sugar and won’t touch it ever and is even afraid of eating fruit sugar, that’s probably not a great situation for someone with HPA axis dysfunction. Yes, you don’t want to be adding a ton of sugar to things. You don’t want somebody to be addicted to sugar. You don’t want somebody to have really bad blood sugar swings because of the sugar that they eat. But if somebody, on the flipside, is completely terrified of sugar and won’t touch, like, a banana, which I’ve had multiple clients in that situation, it’s kind of insane, but you want to make sure that their diet is not so restrictive that it’s avoiding anything that even contains natural sugar. Use your judgment there. Just be careful and don’t allow your patients to go overboard with the sugar avoidance, because a lot of times, especially if you’re on a Paleo diet, a lot of the carb-containing foods do also have sugars in them. Fruit and even sweet potatoes and other sweet starches like that, they’re going to have some sugar in them and it’s OK.
As far as the supplements are concerned, that’s something that I think you want to wait until Chris talks about the DUTCH testing because Kelsey and I have really spent a lot of time creating basic supplement guidelines for the different patterns of adrenal dysfunction that you guys are going to learn about. With adrenal dysfunction, there are a lot of different things that can affect what somebody’s supplements are going to be. First of all, just their total cortisol output, their amount of cortisol compared to cortisone, if they’re under-producing cortisol or if they’re over-converting cortisol or over-excreting cortisol, there are a lot of different things that will affect somebody having “adrenal fatigue symptoms,” and so there isn’t a one-size-fits-all supplement protocol that we use for just the average person.
There are a few general supplements that we like to use, things like vitamin C, magnesium, the B vitamins. Make sure that those are methylation appropriate, depending on what the person’s genetic profile is. If you know what their 23andMe test says, then make sure you’re not using folic acid or cyanocobalamin for the B12. Try to make sure you’re not over-methylating them if they have COMT mutations because that can cause a lot of symptoms. I usually like to do a combination of some methylfolate and hydroxy- or adenosylcobalamin and not use the methylcobalamin with a lot of people, especially if I don’t know what their methylation function is, just because I’ve had a lot of clients with that COMT mutation and HPA axis dysfunction react poorly to over-methylating using methyl B12. You kind of have to play around if you don’t know someone’s actual genetics and you can’t necessarily test for their current methylation status, but I find that that methylfolate and non-methylated B12 combo tends to work pretty well and doesn’t cause people to have extra anxiety from the methylated folate.
The as far as the specific supplements for adrenal function and HPA axis regulation, adaptogens generally tend to be helpful. Again, this depends on the patient because some adaptogens don’t work super-well depending on the person’s situation. An example of that is ashwagandha, which usually works pretty well for a lot of people, but it is a nightshade, so if somebody is on an autoimmune Paleo diet and they react poorly to nightshades, then you wouldn’t want to use ashwagandha. And if somebody has, say, a high production of cortisol, but it’s being excreted really quickly or it’s being converted to cortisone instead of cortisol really quickly, then you don’t necessarily want to be using things like adrenal glandulars or licorice and that kind of thing because that person doesn’t need more cortisol; they may just need to deal with any sort of health conditions that are causing their cortisol to be excreted more. Again, it gets kind of complicated, and you guys are going to learn all this in the HPA axis module with Chris, but those test results will determine what kind of supplements you would use. If somebody does have low cortisol or if they’re over-converting cortisol to cortisone, then a little bit of licorice might be helpful. This person having issues with waking up, they may not need the licorice, and that might actually make it worse, but like I said, you’ll learn the specific supplements that would go along with the specific patterns of HPA axis function.
Again, this is something that Kelsey and I have created an entire program for, and the program is called Paleo Rehab: Adrenal Fatigue, so if you guys are interested in that, I can share some information about that. We’re actually going to be relaunching the program next week with Chris, so keep an eye out for that if you have any patients that might benefit from going through the program. It basically just covers all the diet questions, making sure people are doing a diet that is blood-sugar stabilizing, so a decent amount of protein, higher protein in general, a moderate amount of carbs, adequate fat, adequate calories, eating three meals plus a snack or two during the day, eating breakfast, making sure they’re not skipping meals, and really focusing on the lifestyle component. Again, stress management, sleep, circadian rhythm entrainment, exercising appropriately, and then dealing with some of the emotional side of the HPA axis function. I’m sure you guys have seen a lot of clients with either perfectionist tendencies or they take on too much work either at work or home, maybe they have some past trauma in their life, so that’s another component of the program as well. That can make a huge difference to somebody’s outcomes. If they are feeling really stressed about life, but they’re doing all these other things right, like the diet and the sleep and the stress and that kind of stuff, they’re possibly not going to get the full benefit of the program.
I didn’t mean to do a plug for the program. I just wanted to make sure you guys knew that this is pretty complicated as far as there being different recommendations for different people. Again, basically, the diet just needs to support blood sugar control, avoiding stimulants, and making sure that they’re not overly restrictive to the point where it’s causing anxiety about what they’re eating.
I will say that Kelsey and I love talking about HPA axis dysfunction, for obvious reasons, so if you guys have more questions about specifics with patients that are dealing with HPA axis issues, please feel free to ask questions about that either here or in the Facebook group. Like I said, we’ve done a lot of work self-educating and educating clients on how to deal with this problem, which is pretty rampant in a lot of the functional medicine patients we see. It’s definitely a really important topic. The good news is that you don’t technically have to have test results to really implement the diet and the lifestyle factors that are going to be helpful, so if somebody can’t afford a DUTCH test or they just don’t want to pay for a DUTCH test, then you can just do the diet and lifestyle and basic supplementation and not worry about all the extra little special supplements that are going to more fine-tune the cortisol production as opposed to really making any sort of major differences.