You said generally there are three primary areas that you tend to address with most patients when they come initially. I think one of them was HPA axis dysregulation, which we haven’t gotten to yet. What are the things that you typically run out of the gate on most people when you’re doing that initial consult?

Chris:​ Yes. The three areas are the gut, which you you’re deep into now, and then HPA axis, which is the next section of the functional medicine track that we’ll go into, and functional blood chemistry, which of course is not a particular aspect of physiology as gut and HPA axis is, but it just generally contains a lot of those markers that will do. For example, our case review blood panel will have blood sugar markers that will have metabolic profile. It will have thyroid. It will have a lot of the nutrients like vitamin D, magnesium, iron, B12, and folate. You’ll have some of the immune markers. Those are the three core things that wel tend to do for most people that come in finance and time permitted.

Dr Justin: “What type of testing does the HPA axis stuff include?”

Chris: ​We primarily use the DUTCH test, which is DUTCH test for dried urine— what’s the T, I’ve forgotten the T-something comprehensive hormone. It’s a relatively new way of completely assessing not just HPA axis but also sex hormones like progesterone, estrogen, testosterone, etc. It tests both free cortisol and total cortisol, and you’ll learn the importance of that when we get to that module, and also DHEA and the steroid hormone metabolites as well. It’s a really good starting place with the comprehensive. We have lots of talk about other kinds of HPA axis assessments there, but that’s the root of it.

Dr Justin: ​I’ve been using some testing from DiagnosTechs to assess a lot of the same things. I know there’s a philosophical debate between what’s better with the saliva versus using the urine. ​“What is the rationale that you’ve come across that makes you choose to use the DUTCH testing versus using saliva?”

Chris:​ DUTCH combines saliva and urine. Saliva is a great way of assessing free cortisol levels, and it’s also the only way of testing for the cortisol awakening response, which actually if you look in the research, it connects cortisol levels to disease. Almost all of that research is done on the cortisol awakening response, which is just what happens in the first half-hour basically after you open your eyes in the morning. It’s not done using the four-point saliva analysis that labs like Diagnostic and BioHealth have been offering for many years. I still think you will have some benefit, but the cortisol awakening response I think is the best way of assessing what we’re trying to get at. DUTCH offers that. BioHealth offers the cortisol awakening response test now. I’m not sure if DiagnosTechs does at this point. Urine allows us to look at things that saliva doesn’t. As I mentioned, it lets us look at total cortisol production, and that’s important because it represents about 97 percent of the cortisone in the body. Free cortisol is much more potent, but it’s only about 3 percent of the cortisol being produced, and free and total cortisol are not always concordant, so you can have a situation where someone has high free cortisol and low total cortisol, and using strategies in that case to boost or to lower cortisol might not actually be a good idea because their overall cortisol is already low and actually free cortisol when it’s high and low and total cortisol as low is often a sign of a thyroid problem. If you approach that as an HPA axis issue, you’re going to be missing the boat. There are a lot more examples like that that will go into detail on, but that’s one thing. Then, you also can get the steroid hormone metabolites, which give you additional information, and then you get not only the sex hormones but the sex hormone metabolites, not just E1, E2, and E3, but all of the estrogen metabolites, and that can be useful. We’re not covering that in this course, but that’s useful as well.