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Ask the RD: Adrenal Fatigue


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Join Kelsey Kinney, MS, RD and Laura Schoenfeld, MPH, RD, as they answer your questions about ancestral and Paleo nutrition. A must-listen for anyone new to the Paleo diet or looking to improve their current Paleo diet based on their personal needs and health goals.

The content on this show reflects the opinion of Kelsey and Laura and does not represent the opinions of Chris Kresser, who has not reviewed the content of this podcast.

This week in our first ever Ask the RD podcast, we’re focusing on adrenal fatigue. We’ve received a lot of questions about this topic so we’re going to try to condense it into one podcast. We have two major questions that have come up frequently that Kelsey will be addressing in this podcast:

  1. What is adrenal fatigue and how do you get it?
  2. What are the dietary recommendations for treating adrenal fatigue?

About Laura: Laura is a Registered Dietitian with a Master’s degree in Public Health from UNC Chapel Hill. She is passionate about making traditional diets healthful and accessible for all her clients. You can learn more about Laura by checking out her blog or visiting her on Facebook.

About Kelsey: Kelsey is a Registered Dietitian with a Master’s degree in Human Nutrition and Functional Medicine. She works in private practice and recommends individualized dietary therapy focusing on biologically appropriate diet principles to aid her clients in losing weight, gaining energy, and pursuing continued health. You can learn more about Kelsey by visiting her website.


Thanks to Andy Brown for volunteering to transcribe this episode!

LAURA: Hi everyone. Welcome to the first episode of Ask the RD. I’m Laura, and I am a Graduate Student at UNC Chapel Hill, studying public health and nutrition, and I’ll have my RD at the end of 2013.

KELSEY: And I’m Kelsey, a registered dietician in private practice specializing in whole food and ancestral diets. And I am working on my masters in nutrition and functional medicine.

LAURA: Thanks for joining us for our first ever public podcast. We are really excited that this will be a new feature on Chris’s website, and we hope that you will enjoy learning about nutritional related topics. As a reminder, this is just general advice, and it should not be used in place as medical advised from a licensed professional. So you ready to get ready for our first podcast Kelsey?

KELSEY: Yeah, Let’s do it!

LAURA: Awesome, lets get it kicking. OK, so this week, on our first podcast, we are focusing on adrenal fatigue, which we have received several questions about, so we are going to try and condense it into one podcast. And we have two major questions that have come up frequently. So the first question is: What is adrenal fatigue, and how do you get it?

KELSEY: This is a really good question because its one of those terms that we really hear a lot in the Paleo world: “Adrenal Fatigue.” I guess the short answer to that is, adrenal fatigue is when the body starts to not be able to produce enough cortisol. Cortisol is our major stress hormone, and so when we can’t produce enough of it you know, we get really tired because it keeps us awake, in the earlier stages, you might have trouble sleeping at night. Just having trouble getting to sleep and waking up multiple times throughout the night. A lot of people will experience blood sugar crashes, so they sort of get that “Hangry” feeling, where they are sort of hungry and angry at the same time. You know a lot of just mood and anxiety sort of symptoms because of the blood sugar crashes. Basically, these are going to be the main symptoms you are going to get from adrenal fatigue. So that is how you can sort of know if you have it, or if you should get checked out for it.

But adrenal fatigue is caused by too much stress, for the short answer. Because our body can handle short bouts of stress, it is sort of made to be able to handle that. Our ancestors had to catch food to eat, they would have had these shorts bursts of stress. Then they would have had time to sit and relax, you there are these two extremes where one is the “Fight of Flight Mode”, where the body is stressed out, you are producing lots of cortisol, you are having that stress reaction. And then other times you know, you are really relaxing and taking it easy so your body can digest food, and do all that kind of thing. So, I would really like to call, instead of referring to it as Adrenal Fatigue, I usually like to refer to it as HPA axis dysfunction. That sounds really complicated, so, a lot of people don’t use that term, because it’s not a very good search term. And if you are trying to figure out what the heck is going on with your adrenals, you probably to not know much about the HPA axis.

But, the HPA axis is basically the axis between the hypothalamus, pituitary, and the adrenal glands. All of them are connected. So what happens when we get stressed is, first: The HPA is the role center for the reaction to stress, and it regulates a lot of other body functions like digestion and immunity. So when we are in contact with a stressor, like being in traffic, the first thing that happens is something called CRH, which is Corticotrophin-Releasing Hormone, is released from the hypothalamus. CRH travels within the blood, to the interior pituitary gland, and stimulates the production of adrenal corticotrophin-hormone, also known as ACTH for a shorter way of saying it. ACTH goes through the blood to the adrenal cortex, which it ultimately stimulates the release of cortisol, which is the body’s main stress hormone (which we have already talked about), as well as some other hormones, like DHEA and others.

So that’s a brief biochemistry lesson as to how the body reacts when we get stressed out. That’s what’s going on behind the scenes in the body. Cortisol works to help keep blood glucose levels elevated, and to help the body retain sodium so that our blood pressure stays high, and so that our blood glucose can keep up with the fuel demands of the brain and other vital organs during times of stress.  So you know how blood glucose and high blood pressure do not sound like a good, but when you are talking about being in a stressful situation, those are the things that the body actually wants to prioritize, you know, you want to have that energy to keep going. Because if you are running away from a bear of something, that’s what you want!

LAURA: Yeah. Not necessarily if you are driving behind a pickup truck or something…

KELSEY: Exactly

LAURA: …on a high traffic day.

KELSEY: Unfortunately, that it is sort of the problem. We have a lot of all the little stressors that unfortunately, cause the same reaction in the body.

LAURA: Right, and I was just going to say, you know, we talk about things like traffic as being a stressor. And I think a lot of people are aware that that is something that is stressful, but I think one of the big problems of people’s lifestyles is that there is a lot of sub-conscience stress if you will. Something like staying up to late to watch TV until one o’clock in the morning, that is a stressor. Granted that if you are listening to this podcast, you probably eat pretty well. But people that eat junk food, that is a stressor. You may not see that as being stressful. Even things like over-exercise, cross fit six times a week, that’s a stressor. So even if it is something that you do not think is a stressor, and you think it is actually healthy, it can actually be contributing to this response to making you more at risk for something like adrenal fatigue, or HPA axis dis-regulation.

KELSEY: Exactly, and that’s a really good point. Even though many times you may not feel overtly stressed, the body has already begun that reaction, and that is something a lot of us don’t really think about. You were right, we are sitting in traffic, or our boss yelled at us. We think of stress as being major things, but it can also be something really small.

LAURA: Just as a disclaimer, Kelsey and I, our boss, he doesn’t yell at us! So that is not a stressor in our lives right now!

KELSEY: No, Chris is great, of course!! So under normal circumstances, the HPA axis is only activated when it’s really necessary. Negative feedback cycles actually start to reduce the CRA and ACTH production so we don’t start to produce a ton of cortisol again because we just had that HPA axis stimulated. SO when it happens, and you have good HPA axis function, you will only get stressed when the body needs to, and then you come down and it’s a normal function, because it’s suppose to happen that way. But unfortunately, in the modern world today, with all these little tiny stressors all the time, or chronic stress, it kind of places this really negative effect on health because we are chronically activating that HPA axis. So we really don’t want that. What happens in the beginning, it’ll just be activated sort of chronically, and the body is able to deal with that. But, overtime, as it keeps happening, you will basically first go into what’s called an alarm reaction, where the body has increased levels of glucose, high blood pressure, cortisol is too high, and overtime, the body cannot keep up with all that activation. Basically you will end up with too low of cortisol over time

LAURA: So would you say someone who has high cortisol is technically not experiencing adrenal fatigue?

KELSEY: Right, I would not necessarily call that adrenal fatigue. That’s why I like the term HPA axis dysfunction better. It is a dysfunction, but they are not having that fatigue that is definitely related to low cortisol. They are not in that stage yet.

LAURA: Right. I think it is important for people to know what stage they are in. Because if they have high cortisol, and are using specific treatments that are typical for adrenal fatigue, like licorice or something like that, those supplements are used to actually make cortisol more effective. So if you’re in the stage where you have high cortisol all the time, taking something like licorice is probably not going to help you, where as is you are in the fatigue stage, and you are not producing enough cortisol, this is where something like licorice would help.

KELSEY: Exactly, and that’s a good point to bring up.

LAURA: We will get to the treatments; it is just something that popped in my head as you were talking about this. I think adrenal fatigue, in general, being such an unknown disease in the standard medical field. We don’t hear about that thing, and it’s not something people talk about in conventional medicine, so it’s hard enough to talk about it as a phenomenon. But then, understanding how in can be different between people and how different levels of adrenal fatigue and stress can manifest as symptoms. It’s a very complicated topic, and Kelsey is doing a great job at giving you guys the basics, but you all need to remember that it’s complicated and there are a lot of different factors that play in.

KELSEY: Absolutely. That’s a good point you brought up. And you can get tested for your adrenal and cortisol levels by doing a salivary test. Basically you spit in a couple tubes over the course of a day and they measure how much cortisol you are producing at certain times. A normal cortisol curve is, you’ll have the highest amount of cortisol in the morning, like right when you wake up, because that is what wakes you up (because you are producing a lot of cortisol), it’s like your natural coffee in the morning keeping you awake. Then over the day, you will start producing less and less of it. And by the time you are ready to go to bed, it’s at its lowest point there, so you’ll fall asleep easily. It stays low for the night so you stay asleep, and like I said, it comes back up in the morning. This is what it looks like normally, and sometimes, as you go through these certain stages of HPA axis dysfunction, the first stage you’ll be too high. So in the morning, you’re cortisol levels will be high, but then they will stay high basically when it should be going down.  And then, when you are sort of more advanced, you’ll have lower cortisol in the morning, and higher cortisol at night. This is when you will feel pretty tired during the day, and wired at night so you can’t fall asleep. You will also have trouble staying asleep once you did fall asleep. Finally, in some severe cases of adrenal fatigue (And this is when I would now call it Adrenal Fatigue), the body just really can’t keep up at all, and it has very low cortisol production throughout the entire day.

LAURA: So would you count issues of people’s cortisol issues being low in the morning and high at night as being under this terminology of HPA axis dysfunction?

KELSEY: Yes I would. It sort of like the rhythm is off, so it is “dysfunctioning” in that regard. So yeah, I would definitely count it there. The only place where I would really call it adrenal fatigue however is really in that last stage.

LAURA: Its good to know because people have such different symptoms and cortisol output, you want to lump it into one condition because it’s easier to talk about, but its really difficult for that to be useful for people who are dealing with cortisol issues. It’s important for people to get stuff tested if they can.

KELSEY: Right, absolutely. One of the things to think about too is, the earlier you catch this, it’s much easier to go back. Once you are at severe adrenal fatigue, where you are really not making much cortisol, it can be a long hard process to get back to normal.  So if you are recognizing the symptoms because you are wired all the time because you have such high cortisol, you are always stressed, that is the time to make time to heal yourself, and to take time for some stress release activities. All these things we have been talking about, that’s when you want to do it.  Of course its going to be helpful at the end stage as well because we would like to get the adrenals backing to working well, but catching it early is definitely better.

LAURA: Right. It’s not a terminal illness. So, if you have end stage adrenal fatigue, do not freak out. But, it’s more challenging to rebuild the adrenals, than to prevent them from getting to that stage in the first place.

KELSEY: Yeah, absolutely. Laura, does that sort of give you an idea of what it is?

LAURA: Yeah. I think we are saying it’s complicated because people can have such different issues when it comes to cortisol issues and stress response, so its useful for people to know what the definition of adrenal fatigue is, and what kind of variations there might be in an HPA axis dysfunction. That way, if you are able to get a cortisol test, which I think is pretty inexpensive, and you do not need a prescription because it is a saliva test…

KELSEY: It’s usually about $100.

LAURA: Right, which obviously isn’t really cheap, but if you are having major issues, it is something that is worth having, and you do not need to go to the doctor to get it.

KELSEY: Depending on what state you are in…

LAURA: Really? I thought a saliva test was something you were allowed to do…

KELSEY: New York is really strict about them.

LAURA: Oh I see…

KELSEY: So its something I have to deal with. In a lot of other states, RD’s can get tons of tests ordered, but here, we can’t order any actually.

LAURA: Yikes! I’m in New Jersey right now, and normally I am in North Carolina, and in New Jersey is similar. But, I think we can order a saliva test, but if you have a good doctor, or even certain medical professionals, like a chiropractor, they can order these tests. So if you are in the worst-case scenario, and you really need it, you may be able to find someone that can order it for you.

KELSEY: Right, absolutely. So if you suspect it, definitely get it tested, and I think people would be surprised to see their adrenal functioning. Because, like I said before, there are so many little stressors that we do all the time, and I think an important thing to mention to the Paleo audience is often people tend to restrict a lot of carbohydrates when they are doing a Paleo diet, or at least when they first start, because that is what you see on a lot of websites, that it’s a really low carb that tends to be the idea of Paleo. But, that actually is a stressor too. So if you do that for too long, that can potentially push you into HPA axis dysfunction too. With that, make sure you are eating enough overall, and not exercising like crazy.  Just taking general precautions and common sense to keep your body healthy too.

LAURA: Yeah, and certain people are obviously at higher risk. Somebody that works a 50-60 hour a week desk job, or has a stressful job, is going to have more issues with diet and exercise induced stress than someone who, I do not know, is a college student who is spending a lot of time hanging out and not working as much as other people.

KELSEY: Exactly.

LAURA:  It’s one of those situations where people are very individual with their responses, I think, generally, some people respond more strongly to stress. I know I am one of those people, a “type A” personality that freaks out if I am under too much stress. I think this is why testing is so important. Not only can you figure out if this is a problem for you, but you can also figure out how you might solve it.

KELSEY: Exactly. Basically, from here on out, we are going to talk about some of the things you can do for adrenal fatigue. I am going to be more focusing on actual adrenal fatigue, that sort of last stage. Or you know, where you have some times where you have too low of cortisol. Because that tends to be most of the time where most people catch it and they know that something is going on. A lot of times its just this fatigue that people will experience, and then they can determine something may be wrong, and they can get tested at that point.

So, I just want to mention something about if you are thinking this might be you. I know we discussed excessive fatigue, and that you might have trouble sleeping at night, or you might feel like you get this second wind of energy in the evening, and the blood sugar crashes. But I wanted to mention a couple other symptoms that you might be experiencing if you are experiencing adrenal fatigue.  One of them is something called Postural Hypotension which is a fun way of saying: When you are laying down to standing up, basically you get light headed, maybe a little dizzy, sometimes your eyes will black out. That’s because when you stand up your blood pressure is actually dropping instead of staying the same or rising a little bit, which is the normal reaction.

LAURA: Right. I have had that in the past, but more when I was an athlete and I was exercising and sweating a lot. For me, the symptom was that I was getting up from a chair or from laying down, and I would get really dizzy and get tunnel vision, like around the field of vision, it would get dark and it felt like things were closing in. It’s definitely not fun, and there were a few times where I almost passed out, but I tend to have low blood pressure, but that’s a symptom people should definitely be watching for.

KELSEY: Yeah, it’s actually specific to a few things, and adrenal fatigue is one of them. Like Laura mentioned, if you have low electrolytes, like if you are sweating a ton, or low blood pressure, those could be explanations. But if you don’t have either of those things, and that’s happening to you, it’s definitely worth checking out your adrenal status.

LAURA: Unfortunately, if you have adrenal fatigue, than things like low blood pressure and inadequate sodium are actually symptoms, so you know, even if you have not been tested for adrenal fatigue, those might be two major symptoms that you might be experiencing from it.

KELSEY: Exactly. Other things too would be increased allergies or asthma symptoms. Some people will sort of just, start getting allergies if they never had them before, or start having asthma if they have never had it, and it kind of went away but now its come back. Or they have just increased in severity. So if you have that symptom too, along with some of the other ones, than definitely consider having your adrenals tested.

LAURA: Do you know what that is from? Is it maybe like a hypersensitive immune system?

KELSEY: Basically, cortisol helps the immune system, but it also helps to calm inflammation. So basically, the allergy reaction can’t happen if there is enough cortisol as long as it wasn’t happening before, and now you have too low of cortisol to prevent the reaction. That could definitely be a part of it. I think this is why that happens. But this is not a really common one, but it does happen in some people

LAURA: I feel like, I know I always bring this back to my own experience, but I definitely deal with stress related health problems admittedly. And actually, just as you mentioned this, the last couple years, I have never had seasonal allergies before, than in the last few years, I have experienced short bouts of them, not so much lately, but a couple years ago. I had never had allergies before, and I had just randomly got them one year. I thought to myself: Oh, I had been abroad and just got back to the United States, so that’s the reason why. But who knows, maybe it was a stress response.

KELSEY: I will give my personal story too. I recently tested my adrenal status, and mine was out of whack. I had some low values, which I had suspected because a couple years ago I had gotten this really nasty cold, and upper respiratory infection. That’s actually a common instigator of adrenal fatigue too: Some upper respiratory infection that lasts for a really long time. I think I had mine for about 6 weeks. You know, they didn’t give me antibiotics or anything like that, and it was really a horrible cough, I got bruised ribs from coughing so much. And I had actually that spring before, done a half marathon, which although really fun: I think, often times, over training a little bit can lead to upper respiratory infections too.  So there was a little bit of too much going on in my life, and that definitely caused some issues for me. One of the things that I noticed too was the increased allergies and asthma too.

LAURA: Yeah. This is definitely something people should be looking out for.

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KELSEY: A couple other things too are recurrent infections. If you constantly getting sick, or any other kind of infection that is going around, and you tend to catch everything, this is definitely something to look into. Again, this sort of ties into the immune system or cortisol. What else you can get sometimes is cognition and brain problems, like memory issues. So if you are kind of feeling brain fog or you are forgetful all the time, that can be a sign of adrenal fatigue, especially if you see it in combination with a lot of these other symptoms too.  Finally, if you have a lot of cravings for salt, that can also be a sign of this as well, and we will talk about why in a second.

LAURA: So, is that generally the most common symptoms that you see?

KELSEY: Yes, this tends to be the majority of them. So if you have a lot of those, definitely consider asking for an adrenal fatigue test, or a cortisol test: They will probably know what you are talking about.

LAURA: What about things like weight gain? I know that’s common with people with high cortisol. But if you get to the point where you are not producing enough cortisol, are there changes in weight?

KELSEY: Some people can lose weight. But, really, I do not notice a huge difference in weight, unless it’s with the high cortisol, where they are getting belly fat. Because if you are producing a lot of cortisol, you will start putting on a lot of belly fat.

LAURA: Yeah. I just didn’t know if (ha: not that this is a good weight loss technique or anything), but if you were in the actual fatigue stage, and you were having high cortisol symptoms, that maybe it would switch over to…

KELSEY: Yeah, I just haven’t had all that much experience with people having severe weight changes in that stage personally.

LAURA: Right. Okay. Well, so we can move on to the second big question of adrenal fatigue: What are the dietary recommendations for treating adrenal fatigue?

KELSEY: Sure. There’s a lot you can do actually for adrenal fatigue. We are talking about adrenal fatigue, or “hypo-adrenalism” which you know, you are having low cortisol, or at least of couple of low cortisol moments throughout the day. So just to explain that, when you get a cortisol test, you will usually do 4 cortisol tests throughout the day. One is usually around 8AM in the morning, one is around noon, one is around 4PM, and one is around midnight. Of those four, if you have one or two areas of low cortisol, like generally it tends to be in the morning or afternoon, than that’s what we are talking about. Or if you have low cortisol across the board, just to clarify. In terms of diet, you know, basically a Paleo diet is a really good place to start. There are a couple tweaks that you can make to it to help with low cortisol. One of those things, like we talked about: one of the symptoms of low cortisol is having blood sugar issues, meaning you get blood sugar crashes. This is where your blood sugar goes way too low, you feel cranky, you might get shaky, anxiety, mood swings, that kind of thing. What you want to do for that is to keep a relatively lower carbohydrate diet. I do not mean low carbohydrate in the way most Paleo people think low carbohydrate. Probably, a general ‘just’ Paleo diet with maybe 150-200 grams of carbohydrate would be ok. I do not like seeing people go too low, because again; that can increase cortisol production.

LAURA: Some people might think that 150-200 (grams of carb/day) would actually be a high carbohydrate diet.

KELSEY: Right. Exactly. This is why I do not mean it in terms of what we may think of as “low”, like 100-50. That to me is really low. And it depends on how much activity the person is doing. So, really, I go somewhere between 100 and 200, and it depends really on the person. Often times people will tell me that if they go lower than 100, or even at 100, they do not feel like there blood sugar stays quite as stable. So it really depends on the person and what activity they are doing at that time, if anything. If you have really low cortisol, something that goes a long with that is exercise intolerance. So you feel really crappy when you are doing exercise, where you are getting that postural hypotension, where you are blacking out, etc. It is just not a fun experience. But, if you are including some activity, make sure you are getting enough carbohydrate to sustain that level.

LAURA: Sounds good!

KELSEY: So with that in mind too… You just want to make sure you are eating on a regular basis, so you avoid getting those blood sugar crashes. Often what you’ll want to do is stick to that “5 to 6 method” of eating, where you are eating 5-6 times a day. This is often beneficial with people who have blood sugar issues. Because if they go any longer than 2 – 3 hours, they sort of get in that cranky, anxious mode. So you want to make sure you are eating pretty often, even if it is just a snack. Make sure you always have some type of food on you, so you can eat if you feel an episode coming on.

LAURA: That’s important for people with low cortisol output. Especially because, as you mentioned before, one of the functions of cortisol is to help released stored blood sugar. So we store glucose as glycogen in the liver, and when our blood sugar drops (which is totally normal), cortisol is one of the hormones that is released to help release that glycogen as glucose. Then our body can use it, and you know, it brings our blood sugar back up to normal. But if you have inadequate cortisol output, when your blood sugar drops, you are not going to have that rebound release of glucose the way a normal person would, and than you are going to feel real, REAL crappy!

KELSEY: Exactly. So it’s not fun, and you sort of have to play with that a little bit to figure out what method of eating works well for you. But generally, for most people with low cortisol, eating every 2 to 3 hours, and definitely something that has some protein in there, that tends to help get blood sugar pretty stable. Really I try to get people to eat a little bit of carbohydrate, some protein, and some fat. So it’s pretty balanced. That’ll keep your blood sugar pretty stable throughout the day.

LAURA: Right.

KELSEY: In terms of what you actually eating in terms of macronutrient ratios, and when and how much? That’s what I really recommend. And we talked about one of the symptoms being that you crave salty foods. That’s because the adrenals kind of need salt to function well. So often times, if the adrenals are struggling, it’s a good idea to give them some extra, high-quality, salt. So, you definitely do not need to restrict salt, and you might actually want to increase your salt. Some people put it in their water because they need a lot of it to keep at a good energy level.

LAURA: Yes. That is definitely something that I do. Not the salt in the water, but eating a lot of salt. Because as I mentioned, dealing with things like hypotension and excess sweating and that kind of thing; I am the kind of person that needs salt all the time. So something that I like to do is certain days, if I am going to work out a lot, or if I have already worked out a lot, I’ll add salt to chicken broth or something, which I find to be more palatable that just straight water. I find that this makes a big difference to how I feel, and my blood pressure. I get really dizzy if my blood pressure drops too low, so I am very good about adding salt to everything! Even when my friends make fun of me and say, “that’s so gross, you’re eating so much salt!!” And I say, Yeah well…

KELSEY: Well, you need it! I agree with that. It does make a pretty significant difference.

LAURA: Right. And as you mentioned before, one of the main functions of the adrenals is to retain salt. In the past, salt was not something that was found easily in natural foods (which is one argument why people think we shouldn’t be eating so much salt). With that said, sodium is a required element, and we have a very tight range of sodium that needs to be kept stable for us to function and to be able to survive to keep or neurons and muscle fibers firing. So, with the adrenal being in control of your blood-sodium levels, if you have a poorly function adrenal gland, that could potentially cause you to have blood-salt, called Hyponatremia. Beyond just feeling better from eating salt, but eating enough salt when you are in some type of adrenal stress or adrenal fatigue just takes some of the load off of your adrenal glands for their requirement to help retain sodium in the blood.

KELSEY: Exactly. Some other nutritional factors that we could make sure that we get through the diet would be: Vitamin C for one. The adrenal gland, actually, contains a high concentration of vitamin C, compared to all other organs. And vitamin C is required for catecholamine biosynthesis and adrenal hormone production.

LAURA: It’s funny, I remember Chris Masterjohn saying that the reason why traditional Eskimos and Inuit and Native Americans who were eating really low carb / no fruit diets…The reason that they didn’t get scurvy was because they ate the adrenal glands of animals.

KELSEY: Right! That makes sense.

LAURA: That is kind of crazy. I would not have known that before.

KELSEY: Yeah, and what happens is Vitamin C is actually released from the adrenals in response to ATCH, which is that beginning of that HPA axis reaction. Every time we get stressed, the adrenals are actually loosing Vitamin C. To make sure we can have that HPA axis function correctly, you need to make sure you get enough Vitamin C in the diet. Or if you need to take supplements to do that: Take the supplement.

LAURA: I think this is another reason why you wouldn’t want to be on a really low carb diet with adrenal fatigue. Because it’s hard to get enough vitamin C if you are not eating enough “carby” foods. Things like: citrus fruits, and kiwis may have sugar in them, but they are so high in vitamin C, that for someone with adrenal fatigue, it’s definitely a good thing to be eating.

KELSEY: Absolutely. Another thing you want to make sure that you are getting enough is magnesium. During chronic stress, plasma magnesium is just depleted. Magnesium affects the adrenal gland’s sensitivity to ACTH, which we talked about is that “start” of the activation of the HPA axis. We need to make sure we are getting enough so when we do get stressed, we can produce that cortisol. For example, low blood sugar, that’s a stress, and we want to be able to produce cortisol in response to that, so we can get our blood sugar back up. So you need to have magnesium to be able to start that reaction. So many of us do not consume enough magnesium in the diet. Supplementation, especially for someone with adrenal fatigue, is useful in terms of magnesium.

LAURA: Yeah. Magnesium is hard to get enough of just by eating foods. And it’s not even about your food choices. It’s actually that our soils are so depleted from magnesium that it’s really hard to get enough.

KELSEY: Exactly. So definitely consider supplementing with that if you do have low cortisol, because it’s so hard to get.

LAURA: Magnesium is one of those supplements that Chris recommends as a maintenance supplement for everyone really. So even if you are not having adrenal fatigue issues, magnesium is definitely a great supplement to use, and it’s relatively, I don’t want to use “harmless”, you can definitely over do the magnesium, but if you are taking ‘normal’ amount, meaning a serving of the RDA, you’re probably OK.

KELSEY: Something else that is really important for adrenal function is pantothenic acid. That’s required for the structural integrity of the adrenal glands. Actually, they have done some studies on mice where they make them be pantothenic acid deficient, and those mice have decreased adrenal function. So it’s kind of interesting. And of course, there have been limited studies in humans because it would not be really nice to do this to humans!

LAURA: It’s actually really hard to not eat pantothenic acid as far as a normal amount of food. Pantothenic acid is one of those vitamins that is in everything. That’s why it’s called pantothenic, because I think it’s Latin or Greek, the root word of “Pantothenic” is “pan” which means it is everywhere. But, that said. I think I have definitely seen recommendations for people with adrenal fatigue to take more, well above the RDA.

KELSEY: Right. And a B complex vitamin is a good idea to take because, actually, vitamin B6 being quite important, because what happens in animals that are vitamin B6 deficient, the glucocorticoid action of cortisol is decreased. So it is just not working as well, and vitamin B6 is important to creating cortisol in its function.

LAURA: And B6 is a vitamin that is found in both plants and animals. But the problem with B6 is that it is very heat sensitive, so, if you are cooking most of your food and cooking for a long time, this might be good for some nutrients, but bad for B6.

KELSEY: One other thing to consider with B6 is women that are on birth control pills should get extra vitamin B6 or supplement with it because they have shown to have lower stores of that too. Especially if you’re on the pill, think about that as well. Lastly, in terms of diet, getting some probiotics in. Either through the diet, like in fermented foods, or if you are supplementing with a probiotic supplement. Either one is going to be beneficial because gut health is really important in overall health. What has been shown, recently, is actually that the gut-flora of rats has an effect on the HPA axis. So they did a study with rats that had no exposure to microorganisms, they called them germ free rats. They actually had significantly higher ACTH and corticosterol responses to stress than rats with normal gut bacteria.


KELSEY: Right! So it’s pretty interesting that the gut – you know we always hear about the gut brain axis, and that those are tightly related – but the gut has a connection to the HPA axis as well.

LAURA: The new “gut adrenal axis”, I guess Chris needs to do a series on that next.

KELSEY: Yeah! And stress also alters the gut micro-biome. So if that change is happening, than that is probably where this change in the HPA axis is coming from.

LAURA: It’s like a vicious cycle. Stress harms your gut, and a bad gut makes you stressed.

KELSEY: Another thing that we have already talked about (or at least which you have already mentioned) is licorice root, or other ‘adaptagenic’ herbs. An adaptogen is basically can help to normalize or stabilize the HPA axis function. If you have too low of cortisol, it can help to increase cortisol. And if it’s too high, depending on the adaptagenic, it can help lower it too. Licorice is actually an interesting one because it is an HPA axis “potentiator”, meaning it doesn’t increase cortisol production, but it increases how long it’s active. There is an enzyme called “11-Beta hydroxysteroid dehydrogenase.”

LAURA: I have actually heard about that one in our biochemistry class!!!

KELSEY: What licorice does is it inhibits that enzyme. What this enzyme does is it converts active cortisol into inactive cortisol. So when the enzyme is inhibited, it enables a ‘potentiated’ effect of cortisol, so it stays active longer.

LAURA:  So there is a condition that comes with excessive intake of licorice. It’s actually the compound is ‘glycyrrhetinic acid’ I am pretty sure…


LAURA:  I am not sure if I am pronouncing it right. But, that compound, if you eat too much of it, or if you take too much as a supplement, can cause something called “pseudo-hypercortisolism”.  We learned about it in our biochemistry class, and this is all off of the top of my head, so I am butchering this really bad. But basically, you don’t have too much production of cortisol (as you said), but the cortisol that you are producing is much more active.

KELSEY: Right. So it just stays there for way longer. Definitely think about this: if you already have high blood pressure, which is unlikely for someone who actually has adrenal fatigue. But if you do have high blood pressure, it’s contra-indicative to take licorice because it can cause even higher blood pressure in some people. Usually this is if you are taking a lot of it, but just to be safe, either talk to your doctor about it, or do not take it if you have high blood pressure.

LAURA: Yes, definitely. Sorry, I am really working on what that word is…Hyper…corta…” Oh my gosh, I can’t do it!

KELSEY: Sounds like a tough word!

LAURA: Yeah! Well I am looking it up, and it’s either “hyper corticism, cortiscims”, or hypercortisolism. Basically, it’s specifically “pseudo….hyper…corta…” Oh my gosh, this word is going to kill me!

KELSEY: We get what you mean!

LAURA: Yeah!  That is definitely something people need to be paying attention to because these herbal supplements are not ‘harmless’, and if someone has high cortisol, taking something like licorice is just not going to help, its just going to make it worse

KELSEY: Exactly. That’s a really good point. I don’t know Laura, if you have heard of this supplement called DGL…? Which is De-Glycercin…

LAURA: Right, it takes the glycyrrhetinic acid out of the licorice.

KELSEY: Yeah! A lot of people take that to help heal the gut, and you take a much higher dose of it when you are using it for that purpose. SO they take that compound out so that people aren’t getting so much of that and causing high blood pressure.

LAURA: Right. There are also a lot of different herbs that have been used for adrenal fatigue. It’s a little bit outside the scope of this podcast to really go into all the different ones. As you being an RD and me being a nutrition student (soon to be RD), unfortunately, herbs are one of those things that may or may not be something that we can really use technically. Especially on a podcast, making recommendation on herbs is really difficult because, as we were mentioning earlier, it really depends on the person’s symptoms and what their situation is. There is definitely a lot of herbs that can be successfully used, but as a disclaimer, if people are going to be using that stuff: Don’t just read a LiveStrong article about adrenal fatigue, and then go buy a bunch of adrenal supplements.

KELSEY: Figure out where you are, in terms of what stage, and I would definitely recommend speaking to a practitioner about (especially with herbs and adaptagens), just figuring out what things you should use, and what might be beneficial for your case.

LAURA: Right. And certain things like adding salt, getting extra B6, pantothenic acid, and vitamin C, those are going to be relatively benign, and it’s always good for people to get adequate amounts of those nutrients. But once you start playing around with herbs… Herbs are basically a form of medicine. A lot of pharmaceutical medicines come from herbs. So they can be very effective if used in the right way. But they can also be very damaging if they are used or misused under false pre-tenses of what you think your problem is. So if you are going to be getting into that stuff, I think it’s a really a good idea to find a knowledgeable practitioner that can help you make those decisions, and guide you through the process of figuring out of what’s going to help you get better and not cause you additional harm.

KELSEY: Exactly. So I hope that this gives people a good background.  Obviously, this is a really complicated topic like we mentioned before. But you at least know now what it is, some of they symptoms of it, and how it happens (especially in the modern world) and some dietary recommendations to help deal with it. There are certainly a lot of lifestyle recommendations that we could talk about, but maybe we will save that for another time because obviously those are really important to. But this at least gives you a start with your diet.

LAURA: Right. I think overall, things like exercise and stress relieving activities (especially for people with adrenal fatigue) it’s really mostly about taking it easy. Getting lots of rest, maybe even taking some time off from really intensive exercise, or even moderate exercise! Maybe you need to just not do any strenuous activities for a while until you can get your adrenals back on track, and then you can get back into running, swimming, weight training, and that kind of stuff that is stressful. In a normal person, it’s great, it’s good stress. But in a person that is in stage 4 adrenal fatigue, even a simple couple mile jog is probably too much.

KELSEY: Right. You have to take it where you are. Do not be ashamed to have to take it easy. It’s something that we, in this country, almost look down upon. It’s horrible. We expect people to be going all the time, be doing a million things, and it’s actually a really unhealthy way to live.

LAURA: Just prioritizing sleep! Obviously, getting good, quality sleep. I think for somebody with adrenal fatigue, even letting themselves sleep in as much as they can. I mean, if you are a healthy person, you do not want to be sleeping 10-12 hours a night. But if you adrenal fatigue, I think sleeping as much as you can is really important, and napping if you have the opportunity to.

KELSEY: I agree with that.

LAURA: Like you said there are a lot of different lifestyle changes that can be made to help deal with this condition. Like you said, maybe we will answer some more about that if people would like to know on the next “Ask the RD” section.

KELSEY: Yeah, definitely.

LAURA: Great! Well thanks everyone for listening to our first “Ask the RD” podcast. Be sure to post your questions on Chris’s Facebook page whenever we send out call for questions here and there. Feel free to add a comment and ask whatever questions you want and we will do our best to answer it on our next podcast!

KELSEY: You can ask questions too on the comment section of this page as well if you want to.

LAURA: And we will try to get through as many as we can. This was a little bit of a shorter one, because it’s our first. But we are hoping that this will be a regular feature on Chris’s blog. Anyways, it was great to talking to you Kelsey, and I am looking forward to the next one!

KELSEY: Yeah you too!! Sounds good. Bye Laura!

LAURA: All right, bye Kelsey!

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Join the conversation

  1. Thank you for the very informative podcast. Do you have any additional specific recommendations for people with Autoimmune Diseases and Adrenal Fatigue? I have Hashimoto’s Disease and have seemed to have gotten it under control through medication and diet (Autoimmune Paleo Diet) only to discover that I am also suffering from Adrenal Fatigue. With hypothyroid and adrenal fatigue having many overlapping symptoms it seems as one is “fixed” I notice another issue that needs to be addressed. My main fatigue/exhaustion comes in either during or post exercise and will last another 12 to 24 hours (down from 4 days so I am making progress). I have really scaled back my exercise from a pretty high level and have been trying to rest more but this still persists. I enjoyed the podcast and will start incorporating the supplements you recommend, but wanted to ask if there is anything else specific to this condition I should address. Thanks!

    • Maybe a book on this topic by Dr. Wilson will be useful to you. And the website by Dr. Lam. They both specialize in adrenal fatigue.

  2. If one’s diet allows him to stay in fat burning mode, wouldn’t that make the task of keeping blood glucose level stable easier?

  3. Hi,
    Thank you so much for sharing with us your knowledge! I am pretty sure that my adrenal glands are not working properly a lot time ago! due to the usage of salbutamol… and I just can’t beleive the lack of knowledge that doctors have. Hardly ever do they know what happens in the body.
    I am willing to test myself, but the price is much higher here in Mexico (unfortunately).
    But well, thank you so much!! I highly appreciate your help.
    Santiago de la Mora

  4. I found this podcast very interesting, though it left me wondering what I should do in my own case. I have secondary adrenal insufficiency caused by long-term steroid use (3 years) due to an autoimmune disease. I’ve eaten a Paleo diet for 16 months now, which has improved my autoimmune issue.

    However, I also have pre-diabetic blood sugar issues. If I eat a normal amount of carbs with a meal (about 1/2 small sweet potato and a small fruit, around 30-40 grams), my blood sugar usually goes up to over 150 – even if I eat the carb with fat and protein. This issue is worse when I eat 5-6 times a day.

    However, when I eat to control my blood sugar (3-4 meals/day with about 15 gm carb per meal), I start developing significant low cortisol symptoms – even when I’m taking my full normal replacement dose of hydrocortisone. I almost never experience low blood sugar issues, though.

    So, my ears perked up when you were recommending 5-6 small meals a day for adrenal fatigue, though my adrenal insufficiency is a more serious condition. I just can’t figure out how to eat enough carbs for my adrenal condition, without messing up my blood sugar. My endocrinologist is pretty worthless about this issue, and being on disability, I haven’t been able to afford a functional medicine doc. 🙁 Any suggestions? (knowing that you might just have to say – consult a doctor!) Thanks!

    • I have a similar mechanism. I had to increase carbs and saw that 2 hr bs was higher than I wanted. Two things that help me: to have protein at every meal and be sure to eat a little of it as the first thing. Apparently the body kicks in the insulin as soon as it senses carbs and if you have the protein first there is not such a strong kick in. The other is to have sufficient fats at every meal so that it slows down the travel time of the food so the absorption of the carbs is slowed down. If you are paleo you are probably doing that. I have a tbsp of coconut oil in my broth or on my veggies or just eat it at every meal.

      • Linda, have you tried adding acidic foods to your meals to lower glycemic index? See my reply to Debra.

      • Kelsey, why don’t you mention the usefulness of adding acids to lower glycemic index to keep the blood sugar more stable?

  5. Thanks for this podcast! I’m wondering about the connection of adrenal fatigue and autoimmune disease with the connection of cortisol and inflammation. I’m thankfully in remission now from Crohns, but I had to take corticosteriods several times to help myself get out of flares. How do corticosteriods play into adrenal fatigue? I’m sure it’s case dependent, but do you have an idea of how long it takes to get over adrenal fatigue? Also are you more susceptible to getting it again if you’ve had it once, or if you have an autoimmune disease (even if in remission)? I realize this is a lot of questions, but it would be great if you could cover these at some point if you can’t answer them here.

    I appreciate your sharing your knowledge and hope this becomes a regular addition. Take care.

    • Taking steroids can definitely play into this, though it’s usually with long term use that it becomes an issue (see Debra’s comment on this post). It’s tough to say how long it takes to recover since it really depends on what stage you’re in and how intense you go with the therapy. It’s truly difficult (if not impossible) to fully recover without adding in some mind-body/stress relieving activity, and this is tough for a lot of people. However, if you can get really into the therapy (supplements + diet + stress relief) it can be as quickly as a few months for a fairly simple case. But again, it really depends on the person.

  6. I have done and taken absolutely everything for 2 years that you spoke about for adrenal fatigue and still feel the same. What could I be missing? I also saw a hormone specialists and got my hormones balanced. I am 51 and feel so tired all the time. My thyroid is under control. Thank you

    • Laney, do you practice conscious relaxation? See http://askwaltstollmd.com/articles/relax.php for details.

      Do you tend to react to things too intensely? If so, you would probably benefit from using various techniques perhaps, with a facilitator, to desensitize yourself to common stressors in your life. Techniques such as EFT, Sedona Method, etc.

  7. Great podcast. I’m a doc. For future: Id love to hear clinical pearls how you persuade people on the most nutrient dense foods that are very important for this type of diet, that these days are unfamiliar or harder to prepare. Liver of course, but even more mundane things that people tend to avoid like fish, shellfish, seaweed, soup, adding extra fat, eating more than 2 eggs a week, even the idea of cooking etc etc etc
    Also how do you work with people that dont know or are fearful of cooking. Where do you start.

    • Great question Dr. Gray. You start by first meeting the patients where they are with their food, nutrition and the lifestyles that they live, and then support and guide them make gradual but sustainable changes in these areas. Lifestyle means far more than your exercise habits. It also includes the way we live, think, act and handle stress, all of which affect how your body utilizes the foods you eat. In other words you consider the whole person – body, soul and spirit.

      In addition, there is need to consider the principle of bio-individuality, meaning that the best specific biological balance is unique to each individual in such a way that, the foods and the drinks one consumes, and the lifestyles that one lives, are specific to one’s own body. In other words, there is no one-size-fits-all food intake as far as concerns ration and/or lifestyle.

  8. Thank you for your informative podcast, Kelsey & Laura. Some months ago I had blood work done and learned that I have very low estrogen, progesterone, and testosterone, though my cortisol level is normal (but it was only tested in the mid-afternoon and not several times in a day). I’m 46, and though I haven’t had a period for nearly two years, my doctor doesn’t think I’m in menopause. I don’t have hot flashes, and I don’t have a problem with low energy levels, though I generally get 6 hrs’ sleep during the week, 8 Friday night, 7.5 Saturday night, and back to six on Sunday night. I’m really tired by the end of the week, but I can’t sleep more than 6 hrs after a few nights of longer sleep. I’ve been forgetful for over 5 years now, and I’ve had problems with chronic nausea for nearly 2 years, though that comes and goes these days. On Monday I had an upper GI scope done, and they told me right off that I have esophageal thrush. I haven’t been able to eat any kind of sugar (refined or natural, such as honey) or many fruits for over a year, or licorice root and some other things. Sugar gives me sores on my tongue almost immediately, and that plus the others burn my mouth and throat. I live in Canada, and the medical system is very slow here, and the alternative practitioners I’ve gone to haven’t helped me at all. Could this be an issue of cortisol after all, or do you have any ideas?


  9. Sorry . . . just listened to your podcast. Understood about the concern that ketosis requires too low a level of carbs. Phinney and Volek as well as other authors contend that the high fat element of the ketogenic/paleo diet resolves the blood sugar issues as well as a host of other issues.

    I’m using coconut oil, MCT oil, avocado, etc. . . keeping fat around 75-80%.

    I am experiencing BFS (Benign Fasiculation Syndrome w/ cramping) . . . using potassium . . . and just added salt. What dosage of salt do you recommend? Too much seems to result in edema w/ my anecdotal experience.
    again Many thanks

  10. Had an MRI a few years ago and pituitary stopped producing aldosterone . . saliva text confirms low cortisol in morning/during day and up at night~thinking it may be flatlining at this point . . . . As of 2/3/2013 I adopted the ketogenic diet in thinking some of *my* stress came in the form of ingesting carbs. The digestive/bloating has gone . . . weight came off . . . and a host of other physiological improvements. Would you agree with my line of thought regarding the ketogenic diet? Hopkins uses it ~actually has a support group/personnel/dept for patients with epilepsy and numerous other neurological ailments.

    I do lead a very high stress lifestyle. Think medical, major responsibility of a number of people,
    many thanks

  11. There are some very good adaptogenic formulas out there, like Vital Adapt. They often contain licorice but the licorice is used as a harmonizer in the formula to coordinate the way all the herbs work together and is not at such a dose usually to affect blood pressure. You would need to experiment. Licorice by itself would be too strong if you are hypertensive. Another interesting twist is that you can have adrenal fatigue and hypertension. I have a genetic mutation that affects the way my body works with aldosterone, thus retaining sodium and losing potassium. I’m sure there are other genes that affect the adrenals. If there is a strange set of symptoms probably a good idea to get the genes tested. @Mike When I was reversed (low in the morning and high in the night, my doctor recommended Seriphos at night and adrenal supplement in morning. It took about 6 months to reverse. Good overview today.

  12. You mentioned many treatment options for the low-cortisol side of adrenal fatigue, but I didn’t hear many recommendations for the high-cortisol version of adrenal dysfunction. Any tips? Been having a very rough time falling asleep — feel like my mind won’t stop racing and I’m thinking this could be stress-induced hypercortisolism. Aside from de-stressing and eating enough carbs, do you have any suggestions for those of us dealing with high cortisol at night?


    • Avoid strenuous workouts within 3 hours of going to bed. Use blue light blocking goggles to prevent excessive exposure to artificial light in the evening. Practice light yoga/meditation in the hour before going to bed. Avoid caffeine after noon.

      Do any of these recommendations apply to you?

    • My husband had that problem for years and we recently found a couple solutions. The first was Seriphos at bedtime, which worked, but within a couple weeks he stopped needing it because we found solution #2 for him. We started doing more circadian rhythm stuff, specifically taking daily walks outside in the “sun” (in quotation marks because we’re north of Seattle–it apparently doesn’t take cloudless days for this to help) fairly soon after sunrise and at some time in the afternoon. It was based on Paul Jaminet’s recs for the timing.

  13. RD’s are not nutritionists, they are dieticians, big big difference. They bring you the wonderful food in hospitals, etc. I would not seek advice from a RD! about nutrition. How about using Clinical Nutritionists?

  14. Perfect, exactly the information I needed. I have been thinking a lot about adrenal fatigue and if that is something that I have problem with.