Monday, April 2, 2012

Adrenal Dysfunction: An Intro Primer, no go?

Adrenal Fatigue.  Adrenal Dysfunction.  The first time I actually heard these words, immediately my bullshit radar went off.  I figured these were the excuse labels folks placed on themselves when they didn't want to work hard, didn't want to change a shitty diet, or didn't want to alter their destructive lifestyle habits.

Wow, was I ever wrong.  And I have really awesome bullshit radar.  But I missed the target by a mile on this one.

What lies below is a seriously cut-down primer on adrenal dysfunction; a bit of anatomy, causes, classifications, and potential treatment.  


You only wish your adrenals were that big, sucka.

If you've had even a smidgen of high school biology, then you probably have an idea where your adrenal glands are and what they do.  Sitting on top of both kidneys, these endocrine glands measure about 2x2x1cm; about the size of one of those small old-school pink erasers.  

What the lack in size them make up for in power.  Think of these as the nitrous-oxide boosters of the human body; when shit gets heavy and actions needs to happen, these kick on.  Responsible for secreting stress (fight-or-flight sympathetic stimulation) hormones such as cortisol and epinephrine, aka "adrenaline", the HPA (hypothalamus-pituitary-adrenal) axis, pictured above, signals the adrenals to secrete these hormones, and others, in times of ACUTE (this is key, remember this) stress.  While getting beyond the scope of this brief article, the adrenal medulla is actually innervated and receives direct transmissions, while the cortex acts via hormonal response.

I got news:  This Ain't News.

In a nutshell, adrenal dysfunction results directly from the impact stress has on our body.  Yeah, I wish it was that simple, period.  The human body is amazingly adaptable, but generally only thrives under conditions of infrequent, acute stressors.  What is a stressor?  These can be categorized into Internal and External.

External Stressors: Anxiety, Lack of Sleep, Excessive Exercise, Pain, Injury

Internal Stressors: Bacterial/Viral/Parasitic infection,  Toxin intake (alcohol), Inflammatory Dietary Items

It's pretty easy to identify external stressors---for the most part.  Modern society has basically put a death sentence on our adrenals; we are "turned on", aka Fight-or-Flight dialed, aka constantly in a sympathetically stimulated state.  What can be accurately described as a stessor is now the "norm" for most people---5hrs sleep, bright lights until 2 AM, cranked on coffee and shitty-ass nutrition, sitting on your ass all day, then driving like mad to get to the gym to work on your CAR-DEE-OO.  If you're cool, you put on knee high socks, rip your shirt off, and do a WOD.  And the chicks dig it.

Y'all know I love Crossfit.  You also all know how I love to bash it, at the same time.  Did you ever read my article on Dose-Dependent Individuality? Well, imagine the above scenario, then douse it in the gasoline fire of HIIT group programming.  "What was that crunching sound?  Oh, just your adrenals drying up.  Now let's do this 20 min AMRAP followed by Murph and then throw in some core, homie"

My sarcastic point here is that in today's society, we really can't get away from chronic stress---it's the world we've created.  We make it worse by lifestyle and dietary habits, and we try to fix those issues by doing more.  Just like trying to out-exercise a shitty diet, you can't un-fuck your adrenals by working harder.  And, to top it off, internal stressors are much harder to identify, and this is where diagnostic FUNCTIONAL lab values comes into play---not necessarily the same labs your doc would run.  Conventionally clinical testing doesn't look for the same sub-clinical values that FDN does.  Ok, I'm spewing forth my opinion.  Back on target, Gold Leader.

Stages Of Adrenal Dysfunction

A Chart = Shit Just Got Real. Pay Attention.

While there's a LOT of differing opinions on adrenal dysfunction/fatigue and categorization, there's no doubt it's a quantifiable disorder.  My angle on all this, of course, comes through Functional Diagnostic Nutrition.  Via lab testing from Biohealth Labs out of San Diego, accurate, real time testing can be done to track cortisol throughout the day.  Now, you've probably heard of cortisol, as it's been thrown around a lot in relation to stress/diet/insulin/ etc.  This would be ONE of the parameters in a tentative diagnosis of adrenal dysfunction; other criteria, such as DHEA, Cortisol/DHEA ratio, and how the different 4 cortisol points are trending.

 For brevity, I've just included the cortisol sum as the definitive value in categorization; keep in mind I'm describing these stages from an athletic point of view; sedentary individuals and athletes are essentially, two different beings in how their body will handle stress, and how much.

Stage 1 Adrenal Dysfunction:   Elevated Daily Cortisol Sum, > 42nM.  Duration of Stage 1 AF is dependent on various factors; these include type of stress, duration of stress, lifestyle factors (positive vs negative), and probably most important, genetic potential.  With the maximum cortisol sum reported in excess of 2000nM and knowing a person's potential is an unknown variable, time in Stage I cannot be determined. As far as Stage I goes, this would be OPTIMAL to be found in; in all honesty, few few people will be tested here, because they are still feeling goddamn great, so they don't need testing.  This is where one has a healthy H/P/A axis to stressors.  Just HOW long one stays here, or can stay here, is the issue. 

From an athletic coaching point of view, this is most likely one of the main variables that determines why one athlete can excel and adapt under stress, when another will succumb to overtraining (adrenal dysfunction).  Think Annie T.  Think Nate Schrader.  Froning.  Spealler.  Howell. Meredith.  While there's lots of reason's these people will kick your ass, adrenal stamina is one.  And you can't train that shit.  Well, not yet.  But I'm working on it. ;)

Stage II Adrenal Dysfunction: Daily Cortisol Output 23-42nm.  This is an interesting stage of dysfunction---this is where symptoms start to occur, but vague stuff; sleep issues, mild loss of performance, old injuries might flare up, pretty bagged in the morning, slightly delayed recovery.  Go to your doc, and he'll say "Don't train".  If he's on the ball, he'll cortisol test; might be a one-shot serum test, or maybe a AM/PM blood draw.  Comes back "normal".  He tells you your fine.  And, the story goes, shit gets worse, performance hits the toilet, and you fall apart.  Why "normal"???

If you look at the chart above, you'll see actual physiological normal and Stage II are in the same range---the difference is, your adrenals are on the downslide.  They aren't compensating to the same degree that they would be going from normal to Stage I.  This is where dysfunction can be more accurately described as "fatigue".  And, in my opinion, this is where the Annie Ts get separated from the soccer moms. As it stands, a LOT, and I mean a LOT, of athletes sit here.  I won't even begin to throw an estimation.  The data will speak for itself soon enough.

Stage III Adrenal Dysfunction: Daily cortisol sum <23nm.  Big time fatigued adrenals, symptoms of C/DHEA ratio affecting other systems (chart below).  Lots of self-medicating w/ OTC supplements and/or stimulants.  While is sounds like the end of the world, it's not---I personally know a few folks sitting here, me being one of them; my cortisol sum came back at 22.2, and this was last October, PRIOR to my daughter being born (and my sleep getting blasted into oblivion).  AT that time I was still putting up good numbers for strength, and felt pretty much normal...but that's also an indicator of how dysfunction can appear normal.  I've probably felt shitty for so long that it has become "normal" for me.  A shiftworker that likes coffee and Crossfit?  Well hellooooo,  Stage III.  There's other athletes out there with lower levels still compensating quite well, and performing at high levels.  If anything, it's a testament to how much abuse the human body can take---and how much potential is there.

Wheels, man.  It's all connected.

I'm not going to go into great depth on this chart, but it's a good illustrator of how the cortisol to DHEA ratio, and dysfunction with (low cortisol, low DHEA, high cortisol, low DHEA, etc) can affect different body systems.  This is also where genetic individuality kicks in; while an athlete may have a cortisol sum that's sitting in his boots, his performance is holding---but he's developing injuries (Musculo-skeletal health) and becoming noticeably moodier (Neural Tissue Health).  Another athlete might develop symptoms of hypothyroidism despite the fact no obvious dietary offenders are taken in, and no previous family history (Endocrine Function).

The Human Endocrine System and Pregnenolone Steal

The Red Arrow Ain't The Bus You Wanna Ride

I know, there's a lot of shit here.  Don't freak out and snort a whole bottle of GABA, it's pretty basic.  Just focus on the bigger boxes---Pregnenolone, specifically.  Not a hormone we hear about a lot, but it's the "Master" hormone of this cascade---everything else is made from it (well, vitamin B5 and cholesterol.  This is why I tell you to eat f-ing eggs and take New Root's Ultra B 100). When we enter a state of prolonged cortisol demand, we need substrate to create cortisol---pregnenolone.  The demand becomes so great that it's stolen from the DHEA pathway---hence the issues with low testosterone and low estrogen.  I'm talking loss of libido and lean muscle mass in males under 30, and women well under 40 entering post-menopausal states.  This is exactly how stress affects us---cortisol demand stealing from essential hormone pathways.


I'd be a liar if I said the treatment was easy; the hardest part, as is with any clinical issue, is figuring out what the problem is; this is where astute assessment skills, patient evaluation, and accurate lab testing come into play.  I'm extremely fortunate that I have the background in paramedicine that I do; trust me, the last 17 years haven't been all car accidents and cardiac arrests.  A vast majority of the medical calls received are for vague complaints that could either be mild and benign in nature, or symtptomatically related to the onset of a severe medical condition.  Don't get me wrong, I'm by no means tooting my own horn---what I'm saying is that treatment lies in finding the cause.  You can't treat what you don't understand.

Ok, so we've got a patient history, we've got assessments done, and we have some lab what?  Treatment will vary and be highly individualized, depending on a wide range of factors. 
  • Nutrition.  The base.  You knew it would be.  Pointless to throw supplemental DHEA at someone that eats cereal and milk.
  • Exercise.  But aren't we talking about athletes?  Yup.  What did I say earlier?  You can't un-fuck your adrenals by working harder.  Less is more, in this case, and severely fatigued individuals need to back off, big time, and get some smart recovery programming happening.
  • Lifestyle Factors.  Probably the biggest one, and hardest to change.  You can't make stress disappear.  But you can quit boozing and get your ass to bed early.  Except if you're reading this blog, 'cause it's cool.
  • Supplements.  Ahhh, the panacea for all ills, the magic bullet for everything.  Everyone---and I mean everyone---loves supplements.  Something is wired in humans in that they WANT the magic to be in the pill and drop.  And, I'm not saying it isn't---but you HAVE to have the above shit in order. Like I said earlier, it's pointless and a waste of money unless the first three points are taken care of.  So, assuming you DO have your ducks in a row,  how do we fix some busted up adrenals?  In no particular order:
  1. Adaptogens.  These are a class of supplements that influence how stress affects us.  Ashwaganda.  Rhodiola.  Ginseng.  
  2.  Anti-Oxidants.  Lots o' controversy with these, and, for the record, I'm NOT a fan of throwing these at everyone.  If lipid peroxides are elevated, these can be indicated.
  3. Liver support.  If UBAS (urinary bile acid sulfates) are elevated via lab testing, supporting the liver via specific supplements (milk thistle, glutathione, n-acetyl-cysteine, methionine) is indicated.  If your liver is dysfunctional, this carries over into every other system
  4. GI specific supplements:  A huge one---GI dysfunction means nutrients are not being utilized, even if diet is dialed.  Low melatonin scores (75% is secreted in the GI epithelial cells) and positive Indican (dysfunctional protein digestion) can indicate further testing and use of HCL and enzymes.
  5. Hormonal support, via DHEA, pregnenolone, licorice root, and progesterone.  If indicated via lab values, supplemental support is given to the hormonal pathways; this can have a profound effect in clients with adrenal dysfunction, but systemically healthy & fit (read: athletes).  A big questions I get asked:  Is this NCAA and WADA compliant?  Yes.  Treatment of this nature isn't supra-physiological in origin---it's supportive.  I'm not looking to create monsters like Conte.  I just wanna fix the broken ones. :)
This is just the tip of the iceberg; there's a plethora of different treatment modalities depending on the issues at hand.  As I have alluded to before, THIS is the missing link in the next level of athletic training: quantifiable lab data, on how training is, or isn't affecting athletes.   In the next month or so I'll be starting a small-scale project with James to collect data on high-end athletes.

Test. Implement.  Re-test. Apply. This is the path to the podium.