You’re feeling overwhelmed, your body doesn’t listen to you anymore, you’re exhausted but you can’t sleep, you’re gaining weight around the belly, and you have your suspicions that chronic stress is to blame. You may have read my previous blog about adrenal fatigue, and figured that your adrenal glands are likely getting exhausted from working overtime to help you cope in a stressful world.
But the symptoms of adrenal fatigue are wide and varied. How can you test and find out how healthy your adrenal glands really are? Furthermore, how do you find out which stage of adrenal fatigue you may be in?
I use a ranked questionnaire shared by Dr. Tara Scott and Dr. Ken Spiedel at a conference I recently attended, which uses symptom severity and an algorithm to figure out your most predominant hormone imbalances. While this is not a fool-proof test, it allows us to get an idea of what are most likely to be your top 3 hormone imbalances. The results from this simple questionnaire tend to correlate well with the results from hormone testing, helping direct further objective testing. It can help us identify if most of your symptoms are likely from too high cortisol, too low cortisol, both, or something else altogether.
During a physical exam, there are a few specific tests I can do that indicate if you are likely in Stage 3 adrenal fatigue, where your cortisol production goes down. The first test looks at your pupil’s reaction to light. I shine a light in your eye, and see if you can maintain your pupil’s constriction for a short period of time. If you can’t, or your pupil closes and then opens in this time frame, this is one possible indication that your adrenal glands are fatigued, as it correlates with your adrenaline levels (also produced by the adrenal glands).
The second test I do in-office is checking your blood pressure lying down, and then standing up (called orthostatic blood pressure). Generally, when you get up, you should be able to bring your blood pressure up by about 10 points within one minute. If it stays the same or goes down, it could be a sign of hypoadrenia. Again, other factors can affect this, including medications that you’re on.
This test will likely be positive (blood pressure will stay the same or go down when you get up) if you are in Stage 3 adrenal fatigue. However, if you’re in Stage 1 or Stage 2, or even early Stage 3 adrenal fatigue, this test may still look normal.
Salivary Hormone Testing
Salivary hormone testing for cortisol and its precursor, DHEA, is the preferred method for testing adrenal function. Cortisol is the main hormone produced by the adrenal glands during chronic stress. There are several advantages of this method over doing a blood test for cortisol:
1) Salivary testing avoids falsely elevating cortisol levels from doing a blood draw. Pricking or lancing has been shown to increase cortisol levels just because of the anxiety the procedure causes for many people, whereas spitting into a tube in the comfort of your own home usually does not.
2) Salivary testing can be done several times throughout the day, allowing us to see the normal (or abnormal) daily variation of cortisol. Blood is not convenient to test more than once during the day. However, cortisol levels usually are highest in the morning, and then decrease during the rest of the day. Seeing where your levels fall at 4 different time points allows us to more accurately assess which stage of adrenal hypo-functioning you may be in.
3) Salivary testing allows us to identify the level of cortisol that is actually getting to your tissues, where it acts (the active cortisol). Blood levels usually use very large “normal” ranges, and include both bound (inactive) and free (active) cortisol.
Blood Levels of Cortisol
As mentioned above, this is not the preferred method. But, if we want to screen out more serious conditions of the adrenal glands, such as Addison’s Disease (extremely low adrenal function) or Cushing’s Syndrome (abnormally high cortisol), blood tests could be used.
Ready To Test?
If you suspect your adrenals are near or at burnout, or you are under chronic stress, don’t delay in pursuing treatment with a naturopathic doctor. The health of the adrenal glands is intertwined with that of so many hormones, so make sure you take care of these little soldiers before they’re too exhausted to take care of you!
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Rocky Mountain Analytical (2014). Adrenal Function Panel: Clinical Information for Professionals. January 2014.
Scott, TD, Speidel, K. (2017). Essential Elements of Prescription Hormone Compounding. LP3 Network. Conference 2017 Apr 29-30.
We all deal with stress. Stressors such as losses, job interviews, presentations, medical diagnoses, lack of sleep, job and home life balance, or challenging relationships can make us feel overwhelmed. Our bodies should be able to deal with these stressors, for a short period of time. And that’s the key: for a short period of time. The problem is, most of us are chronically stressed!
How Heavy Is The Burden You Carry?
You’ve probably heard of the analogy of holding a glass of water. Hold it for a minute, and it feels light. Hold it for an hour, and your arm will start to ache. Hold it for a day, and your arm will be numb and the glass will feel unbearably heavy. We often don’t remember to put the glass down until it’s too late. Until we have seen the repercussions on our body, mediated primarily by our adrenal glands, these little soldiers that sit on top of our kidneys, trying to fight for us.
Fight Or Flight
Your adrenal glands perceive any form of stress, whether it is a physical, emotional, environmental, biochemical, or spiritual stress, and respond the same way: by trying to produce either adrenaline (short-term) or cortisol (long-term). They are responsible for our fight or flight response: when our body assesses its environment and deems it unsafe, it prepares us for battle, getting our blood pumping, shifting our resources away from digestion and into our muscles and brain so that we can run from danger or fight it head on. But if this goes on for a long period of time, we will get exhausted, as it’s just not sustainable.
How Chronic Stress Affected Me
When I graduated from naturopathic medicine, and shortly after writing my licensing exams, my adrenal glands were in rough shape. I had pushed myself through medical school, but once the stressor was over, it was difficult for me to peel myself off the couch or do any exercise at all. I had survived on insufficient sleep, caffeine, deadlines, and willpower, but in the process, my digestion was a mess, and I was constantly battling fatigue throughout the day. Any new stressor made me feel overwhelmed. Luckily, as a new naturopathic doctor, I knew that my adrenal glands were in need of some tender loving care. I was probably near burnout. It took me a good year before I felt a lot better, and a few years more before I felt better than I had years before, during my undergraduate and naturopathic medical school studies.
You don’t need to be near breaking point before realizing that your adrenal glands need some help, and that stress is affecting your body in various ways. It’s best to catch it in the early stages, when it’s easier to shift back to balance.
Adrenal Fatigue Stages
You may have heard of the term “adrenal fatigue” (or adrenal insufficiency, hypoadrenia) from naturopathic doctors and integrative medical doctors. This term really refers to an older concept founded on Dr. Hans Selye’s research (a Canadian endocrinologist), called “General Adaptation Syndrome”. If we are under stress for long enough, we move through the different stages of adaptation to chronic stress, from the alarm stage, to the exhaustion stage. At the end of the exhaustion stage is burnout. You don’t want to get to the exhaustion stage if you can prevent it!
Stage 1 – Alarm
In this initial alarm stage, the body panics a little and tries to mobilize its resources. You might have a temporary decreased resistance to stress as your body starts to produce more cortisol to deal with the chronic stress, and you mobilize your energy sources from fat and muscle. Some people will lose weight in this stage.
Stage 2 – Resistance
In this stage, the adrenal glands actually grow in size as they try and keep producing more cortisol. But the high cortisol will wreak havoc on the body. Symptoms of high cortisol include:
-feeling tired but wired
-anxiety and nervousness; heart palpitations
-depressed mood; irritability; mood swings
-brain fog, confusion; memory problems; decreased concentration
-decreased sex drive
-hot flashes; night sweats
-weight gain around the middle
-more frequent colds and flus
Stage 3 – Exhaustion
In this stage, the adrenal glands can’t keep up with the production of cortisol and eventually cortisol production goes down. Any added stressor will be more difficult to deal with, as your resilience goes down. While cortisol levels fluctuate throughout the day, your highest levels of cortisol should be in the morning. Morning cortisol levels are also the last ones to drop in hypo-functioning adrenals. Cortisol helps keep us alert. So if you are having trouble peeling yourself out of bed, and you have late afternoon energy crashes, you may be in this stage.
At this stage, you may have symptoms of both low and high cortisol all at once. Symptoms of low cortisol include:
-burned out feeling
-cold body temperature; cold extremities
-cravings for sweets and/or salt
-joint pains; muscle pains
-low blood pressure
At the end of naturopathic school, I was definitely into Stage 3. Luckily, there are things we can do to help you deal with the stress and rebuild the health of your adrenal glands.
Do you need to put your glass down?
Do you think you might suffer from adrenal fatigue? In my next blog, I will discuss testing methods for assessing the health of your adrenal glands, so that you can know which stage you’re in and we can treat more specifically based on your needs.
But if you’ve read this and think you’re in the later stages based on your symptoms, don’t wait! Come on in for a visit, and I’d be happy to help you start to feel better. And don’t forget to put your glass down!
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Selye, H. (1998). A Syndrome Produced By Diverse Nocuous Agents. Journal of Neuropsychiatry, Spring 1998; 10(2): 230-231.
Scott, TD, Speidel, K. (2017). Essential Elements of Prescription Hormone Compounding. LP3 Network. Conference 2017 Apr 29-30.
Fatigue is a very common concern that patients come to see me for in my Nepean and Orleans naturopathic practices. A lot of the time, patients have had a standard workup done with their medical doctor, but were told everything came back as “normal”.
You may find yourself in the same situation. You know you could feel better, but you don’t know what you can do about it. So, you keep dragging yourself from one day to the next with just barely enough energy to get through the day. Chances are, you CAN get better, and a naturopathic doctor can help you figure out what needs to change.
We all feel tired once in a while. If you’re wondering if your level of energy is normal or not, here are some signs that things could be better:
Of course, there are some basic lifestyle factors that can lead to fatigue. These are things that you would easily be able to identify yourself, like lack of sleep, a diet of highly processed food, or lack of exercise (which you may not be able to bring yourself to do if you are feeling very run down). What I’ll share with you today are the top 7 causes that I take into account when assessing a patient with longstanding fatigue. Keep in mind that there are many other causes. If these show up as optimal for you, then I’ll keep digging to find the cause of your fatigue.
#1 – Iron Deficiency OR Iron Overload
Most women who have regular menstrual cycles have sub-optimal iron levels. Furthermore, those who eat vegan or vegetarian diets are at greater risk of an iron deficiency. Even if you are not anemic (where iron levels drop to a minimum), you can still feel low in energy if your storage level of iron (ferretin) is sub-optimal. I generally aim for ferretin to be in the 60-80 range for women. Note that you could be in the “normal” levels with levels of ferretin as low as 10, but obviously you wouldn’t be feeling your best!
Before you go ahead and start supplementing with iron, do get your ferretin levels checked. It is possible to take too much iron, which can cause all kinds of problems long-term. Some people feel unwell because their body stores too much iron, a condition called hemochromatosis. I’ve seen this issue more commonly in men than in women, but it can happen in either.
#2 – Vitamin Deficiencies, Especially VitB12 And VitD
A Vitamin B12 deficiency is very common in vegans and vegetarians, so if you are eating little to no animal protein, you are probably deficient. However, even if you do eat meat regularly, it is possible to be B12 deficient. This can be due to problems assimilating the B12 from your diet due to issues such as malabsorption, food sensitivities, or low stomach acid. As well, if you are prone to depression or anxiety, you may need higher levels of B12.
Vitamin D deficiency is also very common here in Canada. It is very rare for me to measure a patient’s blood levels and find them in the optimal range if they are not supplementing with at least a minimal amount of Vitamin D. Adequate Vitamin D not only helps with energy, but it also helps with hormone balance, immune system support, skin health, and cancer prevention. Most people need prescription levels (i.e. >1000 IU per day) of Vitamin D at least temporarily, and getting your blood levels measured helps to individualize that prescription for you.
#3 – Blood Sugar Imbalances
If you crave carbs or sugary snacks and need that cookie to get your energy back up, a blood sugar imbalance might be behind your fatigue. Sugary foods can bring your energy levels up, but only temporarily. This is soon followed by a crash in energy, which will have you reaching for another quick source of energy. Having more balanced meals with plenty of protein and vegetables can help you keep your energy more even throughout the day. You can test this out by seeing how you feel after pasta dish compared to how you feel after a hearty chicken salad.
#4 – Sub-Optimal Thyroid Function
Hypothyroidism is a condition in which the metabolism slows down, and people generally feel more fatigue. If you’ve been diagnosed with this, you know how it feels. However, even if your doctor measured your thyroid stimulating hormone (TSH) and it was within the normal range, it could be functioning sub-optimally. If you suspect this might be a problem, see my post about the thyroid here.
#5 – Food Sensitivities
Reactions to food can have local effects (such as digestive symptoms of bloating, gas, diarrhea, constipation), but they can also lead to systemic effects, such as brain fog and fatigue. Many patients notice more energy once they go on a detox or elimination diet that removes the most common food sensitivities at once. You can find out if food sensitivities are playing a role in your fatigue either through an elimination diet, or through IgG food sensitivity testing.
#6 - Adrenal Fatigue
If you’ve been under chronic stress for a while, chances are you have adrenal fatigue. Your adrenal glands are little glands that sit on top of your kidneys and help you deal with stress. For short-term stress, they produce adrenaline, but for longer-term stress, cortisol is the prevalent hormone. Your cortisol levels vary throughout the day, so the best way to measure the health of your adrenal glands is through a 4-point salivary adrenal test (taken at 4 times during the day). We typically also test for other hormones in females when running this test, as being chronically stressed can wreak havoc on your other hormones.
#7 - Depression
This one doesn’t have a lab test to rule it out, but careful questioning can help your doctor assess if depression might be causing your fatigue. In this case, the fatigue can be mental/emotional, and you may not feel motivated to do things that used to be enjoyable for you. There are questionnaires, such as the Beck Depression Inventory, that can help us see where you stand. If you do have symptoms of depression, a naturopathic doctor can also see if some of the above factors could be contributing to you feeling depressed.
These are just some of the most common causes of fatigue I have seen in practice. As you can see, finding and treating the cause of your fatigue is key – only then will you be able to see lasting improvement in your day to day energy!
Do you want to wake up in the morning with a spring in your step and energy to last throughout the day? If yes, then I invite you to start your journey towards thriving with me!
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Guest post by Dr. Justin Gallant, ND. See original post here. I have had many patients recently come in with sleep maintenance insomnia, and Dr. Gallant explains very nicely why this may happen.
Almost 80% of the patients who walk through my door wake up around 1-3am. The most common reason for this is hypoglycemia. Once I get them eating a small snack with protein before bed their sleep-maintenance insomnia usually subsides.
There are several other reasons for waking up around this time but clinically I have seen low blood sugar as being the most common. If having a snack before bed doesn’t cut it and you’re still waking up in the middle of the night you should definitely talk to your Naturopath or Medical Doctor about it, especially if you're having other symptoms. Many people say eating before bed will cause you to gain weight but a small snack may actually help you lose weight as I discuss further down.
Protein helps glucose get into your cells more efficiently via insulin and is converted to glucose much slower than if you were to just eat sugar. Fiber slows your absorption rate of glucose so both protein and fiber will help keep your blood sugar stay stabilized while you’re sleeping. Protein also provides amino acids that are necessary for neurotransmitters like serotonin, dopamine and GABA (which I mention below) to be made. Every action has a reaction so if you eat that donut your blood sugar will sky-rocket and then plummet soon after. Your goal should be to keep your blood sugar as close to the midline in the picture above as you can and aim to have blood sugar regulated until cortisol is naturally elevated when it's time to wake up.
A piece of bread with peanut butter
Legumes like chick peas, beans, nuts, seeds
Soup or stew
Protein shake or protein bar
Veggies, crackers or pita dipped in hummus.
Stay away from simple carbs and sugary snacks like fruit before bed as they’ll just temporarily elevate your blood sugar and it will come crashing down soon after, increasing the likelihood of hypoglycemia while you’re sleeping.
Explanation of why you wake up:
During the night your liver is working hard at metabolizing glucose and your brain is actively organizing your thoughts and dreaming. If you eat dinner at 5 or 6pm and then try to go until 8 or 9am without any food you’re going to get hypoglycemic just like you would if you tried to go 14 hours without food during the day. Once our sugar gets too low we pump out cortisol from our adrenal glands. Cortisol is one of our stress hormones. We pump it out naturally to increase our blood sugar but since it’s a stress hormone it wakes us up. Cortisol also inhibits GABA, which is an inhibitory neurotransmitter which helps keep us calm and relaxes our muscles. So now you’re stressed and can’t relax…thanks a lot brain, I thought you were smart? Once our blood sugar gets too low we must secrete cortisol for survival. Our brains use ~30% of the glucose we take in and even though we’re sleeping, each cell in our body needs glucose for fuel.
Eating a snack before bed will actually help you lose weight! Bold statement right? Well think about it. If you’re going 10-14 hours without food your body is going to go into famine-mode. It thinks once it gets breakfast that you could go another 12 hours without food so it’s going to store whatever you put into it as fat to be used for energy later. This is the equivalent of your Uncle Bob carrying a bunch of Jerry cans full of gas in his ol’ pick up so he doesn’t have to keep going to the gas station when he’s running on fumes.
There are plenty of other reasons why we wake up in the middle of the night which can be exacerbated by hypoglycemia as well. For instance, if you have Benign Prostatic Hyperplasia (BPH), you may be waking up around 3am because you have to pee. Most men attribute this to the BPH but once I get these guys eating properly and having a snack before bed the urge to urinate doesn’t wake them up anymore. It’s more of a combo of something is going on in your body that would wake a light sleeper but if you can get into the deep sleep, you won’t be so sensitive to it. This effect can happen with almost any symptom that’s preventing you from sleeping (i.e. bloating, pain, flatulence, snoring, etc…). Our bodies are programmed to turn our senses off while we’re sleeping, but if we pump out cortisol we’re going to wake up and those senses will re-engage. Once our senses re-engage we will be able to perceive those internal and external stimuli that we wouldn't have noticed while in a deep sleep.
Besides feeling terrible, insomnia comes with its complications as well which are too plentiful to discuss in this article but can involve weakening your immune system, emotional strife, poor work performance, side effects from caffeine and poor-decision making to name a few.
Other causes of sleep-maintenance insomnia:
A restless partner
Restless Leg Syndrome (RLS) - I'll be blogging about this soon!
Congestive Heart Failure
Sleep paralysis, hypnopomp, astral catalepsy, whatever you want to call it.
Nutrient deficiency (Iron most commonly)
Respiratory conditions like COPD, Lung cancer, etc…
High or low blood pressure
Segmented sleep, bimodal sleep pattern, biphasic or polyphasic sleep
Pelvic floor weakness
Medication side effect
According to Traditional Chinese Medicine, waking up between 1-3am could indicate your liver needs attention. This could be due to anger issues, dietary, excess alcohol, etc… Sometimes just doing acupuncture, taking Chinese herbs or dealing with diet or anger can completely resolve sleep-maintenance insomnia.
Thanks for reading!
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If you have any questions, comments or contributions feel free to comment below.
If you would like to book an appointment with me please call 905-547-5393 or contact me.
Dr Justin Gallant ND
Dr. Tamar Ferreira is a Naturopathic Doctor in Brampton, Ontario. Her areas of focus include digestive health, hormone balance, and skin conditions.