Sunday, August 4, 2013

The Adrenal Glands, Part 1 - Why You Have Hit the Proverbial Wall

"Adrenal fatigue" is a sexy phrase floating around in the blogosphere these days.  It has come to our attention in the fringe medical community that stress is driving a lot our health woes, and your adrenals are at the heart of the matter.  In this article, we'll discuss the role of the adrenals in human physiology and why it's a mistake to not address chronic stress in your pursuit of well-being.

At Sweat and Butter, we maintain a heavy black line between our company and the standard health and wellness industry.  We have all heard that stress is bad for our health, but what does this mean?  To answer this, you need to ask "why" and "how".  Telling you to worry less or live a stress-free life is easier said than done.  It's important to us that we back up our specific advice with logic, science, and experience.  You've likely tried many of these implements without success.  At Sweat and Butter, we work with clients to personalize their plan of action because each client responds slightly differently to various methods of stress reduction.  Keep this in mind as you work through this material.

I'm going to break this topic up into two posts.  In Part 1, I'll discuss the biochemistry that justifies the recommendations that I make in Part 2.  Keep in mind that this is a vast topic that is covered by many authors over hundreds of pages.  I'm only trying to cover the basics in these two posts.  Not all of the entries to the Sweat and Butter Journal will be this long, but this topic is so important that it deserves some quality attention.

THE SKINNY: natural selection has ensured that our bodies are exquisite experts in managing acute stressors, but exposure to chronic stress is not something for which we have been equipped.
We will delve deeper into the specifics in concept-focused posts on the Sweat and Butter Journal down the road since, as you'll soon find out, your stress levels are likely at the root of many of your health problems.  Stress is making you sick, tired, and fat.

Let's get to it...

The Definition of Stress

Before we can continue, it's important that we define "stress", mostly so that we can quit using "quotation marks".  A stressor is defined as any action that attempts to shift a system from a state of equilibrium.  Your body's number one goal - whether you like it or not - is to maintain this equilibrium at all costs.  Wellness companies and your doctor often preach stress reduction, and this is good advice.  Coping with a stressor requires energy to keep you within the normal parameters of equilibrium.  An apt metaphor for this is the process of heating your house.  As the air temperature drops inside your house, your thermostat, which is given strict orders to maintain the temperature inside your house at, say, 70 degrees, signals the furnace to pump out more heat.  The transfer of heat to the cold outdoors every time a person enters the house is a stress on the thermostat, and the furnace is called upon to pump out more heat in order to prevent the temperature from shifting too far away from equilibrium (70 degrees).  In order to maintain this temperature, the furnace must burn fuel.

Our body responds the same way to a stress as your household thermostat.  When equilibrium is threatened, our body responds.  In nerd world this is called homeostasis, and it requires energy.  As you probably know, our body largely relies on sugar for fuel.  When we are stressed out, our body does everything in its power to increase glucose in the bloodstream.  This is where cortisol and the adrenals come into play.

At this point, take a moment to have a break and get some sunshine.  This is heavy stuff, so take your time with it.  I'm going to nerd out for a little bit.  If you find yourself getting lost, you can skip past this section to dig into my recommendations for fixing this issue.   If you are a fellow nerd, read on!

What the bleep is an adrenal? Biochemistry for beginners.

The adrenals (there are two of them) sit atop your kidneys.  They look like this:
 ('s from Wiki, but it's as clear a picture as I can get you without grossly dissecting somebody to show it to you in the flesh.  This will have to suffice.)

The adrenals secrete a number of hormones when they are told to do so by other hormones - from other glands - floating around in the blood.  I want to focus on one in particular: adrenocorticotropic hormone (ACTH), which is secreted by the anterior pituitary, a gland found in the brain.  The anterior pituitary is furthermore stimulated to release ACTH by another hormone called corticotropin-releasing hormone (CRH), which is secreted by the hypothalamus (also found in the brain).  These interactions can be clumped together into what is known as the Hypothalamic-Pituitary-Adrenal axis (HPAA).

So...the adrenals secrete hormones in response to other hormones which are secreted by glands in the brain.  These hormones include aldosterone, cortisol, sex steroids (e.g. DHEA, androstenedione), and catecholamines (e.g. epinephrine, norepinephrine), whose roles are blood pressure maintenance, blood sugar maintenance, sexual maturity and fertility, and "flight or flight", respectively.  The one that we are going to focus on in this piece is cortisol, the "stress" hormone.

Cortisol's Role In the Body

Cortisol has multiple functions in the body, but I only want to focus on a few:
  •  Blood sugar: Cortisol helps to maintain your blood sugar throughout the day at a baseline value.  It accomplishes this by carefully regulating processes such as gluconeogenesis in the liver as well as the breakdown of proteins (proteolysis) and fat (lipolysis).  Under extra-stressful events, cortisol can shoot your blood sugar through the roof!  The bottom line is that you need sugar to function throughout the day, and cortisol makes it happen.  When you're really stressed out - whether you're doing a workout or your mom is nagging you about your finances - more cortisol is pumped out to cause a temporary jump in blood sugar in order for the body to fuel the according physiological adjustments.  If these adjustments aren't made, your body goes out of equilibrium.  This is a no-no.
  • Blood pressure: Because cortisol is produced in the same gland as aldosterone (also from the adrenals, remember?), an important hormone in the regulation of blood pressure, it shouldn't be a surprise that cortisol also has some effects on blood pressure.  It does so through a direct effect - albeit weaker than aldosterone - at the kidneys to hold onto salt.  It also sensitizes your blood vessels to catecholamines (e.g. epinephrine), which, as you should recall, drive the "flight or fight" response.  This is to say that they directly stimulate heart rate and vasoconstriction (narrowing of your blood vessels) in order to send blood screaming through your body to fuel the muscles you need to run from saber-toothed tigers.
  • Inflammation: Cortisol has an anti-inflammatory effect through the inhibition of arachidonic acid production.  Arachidonic acid is the precursor for leukotrienes and prostaglandins, both of which drive inflammation.  
  • Immune function: Cortisol directly inhibits proliferation of CD4 T lymphocytes, which are critical in your body's defense of viruses and fungal infection.  Cortisol also down-regulates B lymphocytes but to a lesser degree.  When you're stressed out all the time, you are more susceptible to infection.
  • Sleep/Memory: Cortisol decreases REM sleep and disrupts memory formation through direct effects on the brain, namely through the hippocampus and limbic system.  This might explain why stressed out students that pull all-nighters have trouble remembering information on a test the next morning.  

The Stress Hormone

It makes sense that one hormone serves all of these functions.  It's the stress hormone!  In the days of our prehistoric ancestors, they relied on all of these functions to escape that tiger that has decided that they are its next dinner.  Cortisol essentially shuts down other processes in the body in order to conserve energy for you to run like hell!  You don't need your immune system while running from the tiger.  You will be served better in that moment for your heart to pump harder and your blood to flow to working muscles.

Cortisol is released in response to stress.  We previously defined stress as any action that threatens a system's equilibrium.  In your daily life, cortisol is literally being pumped out all day long at a low level to keep you going.  It works sort of like the accelerator in your car.  You normally need to give a little gas to keep it going, although there are occasions when your fuel injector gets reprieve on the occasional down hills.  If you want to go really fast, you slam your foot down on the accelerator.  The largest stressors in our lives put the pedal to the metal.  When you accelerate, cortisol is released from the adrenals.  When you let your foot off the pedal, the adrenals get to rest.

The problem is probably already becoming clear to you.  In our daily lives, we are constantly rushing around trying to do more, lift heavier, run faster, get more finished before lunch, etc.  This GO! GO! GO! signal is putting great demands on your adrenals, and they're sick and tired of it.

Put Your Adrenals to Sleep

At Sweat and Butter, we see sleep and stress as equally important in optimizing your health, and now we know that they are related.  But sleep is so critical to our health that I feel it deserves its own section.  Optimizing your sleep pattern is critical in maintaining your adrenal health.  While you are sleeping, your cortisol levels are low because your adrenals get to rest.  While awake, your adrenals are at full attention and cortisol levels are high.  In fact, the brain responds to UV light stimulation by activation of the HPAA (CRH-->ACTH-->cortisol, remember?), so when light graces your eye balls in the morning, your body prepares your body for the day's war by pumping you full of cortisol and thus fuel (glucose).

So what if you aren't sleeping?  Let's look at the classical example of a busy American life.  You sleep less because you feel the need to get more done.  Your days are spent stressing out over every detail. It's constant.  Then, after we decide to make some changes in our lives, we start obsessing over our healthy habits.

The point I'm trying to make is that we worry all day long about what we want to accomplish for the day, then we cut ourselves short on sleep.  Unfortunately, because of our efforts to meet the demands of every day stressful life, we fail to achieve sufficient sleep.  Not allowing for sufficient sleep is like jogging up behind a first time marathoner at mile 25 and whispering in their ear: "Just kidding!  We're running a hundred miler today."  The adrenals have been loyal to you for your entire life, but, eventually, they're going to jump ship.

The Consequences of Squeezing Your Adrenals to Death

When you force your adrenals to work beyond their capacity, they do what an over-trained athlete does.  They plop down on the curb: "I'm not budging until you let me rest!"  When your adrenals are fatigued, you consequently feel like crap.  Under normal circumstances, cortisol levels are highest in the morning.  This makes sense: you are coming out of a sleep state and you need your blood sugar to spike in order to fuel your daily activities.  If you're hammering your adrenals all day and only sleeping minimally at night, when are your adrenals supposed to rest?  In adrenal fatigue, your circadian cortisol secretion is out of whack. Your adrenals don't pump out enough cortisol in the morning to get your moving, so you compensate by drinking coffee.  This kick starts your day.  If you require caffeine to get moving in the morning, your adrenals are screaming for a break.

The process leading to adrenal fatigue is gradual.  Evolutionarily speaking, our bodies' abilities to adapt  are incredible.  Many of us will have to go for short bursts of heavy activity in order to accomplish specific tasks in our lives.  If you fly from Pittsburgh to Los Angeles, the clock reads 10:00pm in LA, but your body thinks it's 1:00am.  By the time I settle onto a buddy's couch, it's midnight in LA, but my body feels like it's 3:00am.  If it only occurs once a month, my body responds accordingly, and there are no long-term effects.  Cortisol is pumped out at a higher daily rate than if I hadn't flown across the country, but no long-term harm done.  This is an example of acute stress, and our bodies have been fine-tuned to accommodate these occasional circumstances.  On occasion, your prehistoric ancestors had to work extra hard for food.  Sometimes they struggled to get a full night's rest because of nearby predators.  These were occasional occurrences, and, a few days later, after allowing their bodies to recover from the stressor, they would be back to feeling healthy and vital.

Now imagine your body in a state of stress indefinitely.  You wake up at 5:30 in order to have enough time to drop your three year-old off at daycare before heading to work.  Your boss is on your butt all day about deadlines.  You rush home, pick up the kid, head to the gym for a high-intensity workout - after all, you are trying to lose weight.  You rush home start chopping vegetables in the kitchen and try to manage conversation with your partner who had a PTA meeting at your thirteen year-old's school immediately after work.  You've been arguing lately, and the workload of life has left you both feeling too exhausted for much of a sex life.  You live like this day in and day out, and, as citizens of the great United States of 'Merica, you are fortunate to get two weeks reprieve each year from the grind.  And that sucks to your adrenals.

You Are Stressed Out, and Your Health is Suffering

The life described in the passage above is vastly different from the occasional stressors of our prehistoric predecessors.  Cortisol's great at driving the physiologic changes that your body requires to respond to an acute stressor.  But your adrenals weren't adapted for the 24/7 stress demanded by contemporary life.  If you recall from our biochemistry lesson, your adrenals secrete cortisol, and cortisol increases blood glucose by breaking down fats and glycogen, the body's glucose storage molecule.   When blood sugar is up, your pancreas secretes a hormone called insulin to drive it back into tissues.  In this way, insulin and cortisol - along with a host of other hormones -  are constantly battling it out for long-term regulation of blood sugar and consequently our body's energy stores.  The medical community has studied the effects of hypercortisolemia, hyperglycemia, and hyperinsulinemia for years.

If you are chronically stressed out, you can and will eventually experience many of the following:

In fact, you could go on to PubMed, type in "hypercortisolemia" or "hyperglycemia" and find a connection to stress and thus the derangement of blood sugar and energy metabolism to virtually any illness or disease process that you can think of!  But this article isn't about long-term high blood cortisol or sugar levels.  We're concerned with what happens when your adrenals put their foot down and declare: "Enough is enough!" Over time, you effectively go from a state of hypercortisolemia (high cortisol) to hypocortisolemia (low cortisol), a state in which pressing down on the accelerator gets you little or no response.

When the Sh*t Hits the Fan

At this point, we've discussed the effects of stress on your body.  It's all bad news if you're chronically stressed out.  Tapping your adrenals once an hour is like making a purchase with your credit card without ever checking the balance.  You may pay the minimum amount due every month, but the interest stacks up and eventually you reach your credit limit.  With your credit card maxed out, you can either seek out an additional credit card to achieve an extra few thousand dollars in credit or you could accept defeat and reduce your spending until the balance is paid off.  Modern medicine hasn't developed the equivalent to additional "adrenal credit" [yet], so for now, you'll have to start watching your spending.  This means minimizing your daily stress levels.

Here is an incomplete list of stressors that you may or may not have considered up to this point:
  • anxious people in your life
  • deadlines
  • food to which you may have an allergy or insensitivity
  • your commute to work
  • a stressful work place
  • poor sleep hygiene
  • sweating the small things
  • excessive exercise (or anything for that matter)
  • always putting the feelings of others before your own
  • insufficient sleep
  • procrastination
  • avoiding responsibility
  • passive aggression
  • infection
  • illness
  • school exam preparation
  • finances

The most obvious item on this list is weight gain.  The majority of our clients come to us looking to lose weight.  The majority of our problems revolve around food and exercise, but chronic stress complicates these matters.  Cortisol drive up blood sugar by breaking down glycogen, fat, and protein and the pancreas pumps out insulin to try to drive it back into working cells so that it can be used for fuel.  Tissues all over the body respond to insulin, namely liver cells (e.g. hepatocytes), muscle cells (e.g. myocytes), and fat cells (e.g. adipocytes).  When insulin is elevated over the majority of your day, the hepatocytes and myocytes get overwhelmed and they flip the signs on the front doors to "Closed", a condition known as "insulin resistance".  This leaves only one remaining cell type to accept sugar for storage: fat cells.  I think you're probably putting the pieces together by now.

[ You keep your body stressed out.  Cortisol levels are kept high throughout every waking hour.  The chronic blood sugar elevation leads to insulin resistance.  Everything that you eat in excess of what you burn immediately gets stored in fat cells. ]

To make matters worse, cortisol also interferes with leptin signaling in the brain.  This is a hormone produced by fat cells that tells your brain: "I'm full!" The physiology and biochemistry is quite confusing, and the Sweat and Butter Journal will be covering it in much greater detail down the line, but suffice it to say for now: if you are stressed out, losing weight or maintaining your weight is infinitely harder.  This might explain why clients come to us baffled as to why they can't lose weight despite their greatest efforts despite exercising four hours per day.  And we haven't even touched on the other health detriments listed above.  Ay carumba...

YOLO, Baby!

At this point, you might be thinking: "But Nathan, I'm the most productive peacock at the party when I load up my schedule!  I don't want any day to go to waste!  YOLO, Baby!"  Many of us indeed crave stress. We thrive when deadlines are in place, we seek out exercise programs that feel like a kick in the face (and return the next day happily for more!), and we get annoyed when we don't cross all of the items off of our to-do list each day.  But, as the science above describes, this behavior is driving our adrenals into the dirt resulting in your liver and muscle cells gradually becoming resistant to insulin.   This leaves your fat cells to take on the burden of fuel shortage, thus packing pounds around your waist.  Furthermore, certain foods cause an acute stress reaction in your body and high-intensity exercise (HIT) does the same.   You feel chronically tired, you need coffee to get moving in the morning, you feel like a pile of crap when you try to work out, and you struggle to focus on tasks at work.

The whole picture is beginning to come together.  Ladies and gentlemen, this is the face of adrenal fatigue.  Eventually, you will push your adrenals to the point of exhaustion, and you need to give them a break if you want to become optimally healthy.  This stuff matters!  Your health and longevity depend on the health of the various systems driving your body.

What You Can Do About It

At Sweat and Butter, this is our bread and...butter.  Food and movement are critical to your longevity and short-term health, but doing more is not always the answer, despite what the fitness industry leads you to believe.  Getting stress under control is the single most important thing you can do for your health, and this requires paying close attention to your food, sleep, relationships, and exercise levels.  In Part 2 of this post, I'll give detailed explanations as to how you can mitigate the effects of chronic stress.
Since you've been so kind as to grin and nod throughout this long-winded post, I'll leave you with a nice list of things you can begin working today to give your adrenals a rest:
  1. Add on one more hour of sleep per night.  This requires that you...
  2. Shut down your laptop at 10pm (sooner if possible) and make other sleep hygiene improvements
  3. Minimize interactions with people that seem to be chronically stressed
  4. Consciously minimize your stress response to that guy that cut you off in traffic 
  5. Immediately before bed, write down 3 things that made you happy throughout your day
  6. Focus on a nightly routine in preparing for bed rather than what happened throughout your day. 
  7. Workout less or at least at a lower intensity
  8. Practice meditating.  Go to a room by yourself where you can block out as much sound as possible.  Start a timer for five minutes and focus only on your breathing. 
  9. Incorporate some starchy vegetables back into your diet.
  10. Simplify your life
  11. Spend more time outside
  12. Quit being a slave to your electronic devices
  13. Play with your kids
  14. Make time for friends
In the second part to this piece, we'll dig a little deeper into these recommendations for correcting adrenal fatigue. 

Nathan Riley is a 2014 MD candidate at Temple University School of Medicine; He writes about food, movement, sleep, relationships, and stress in order to bridge the gap between his patients and evolutionary theory and clinical evidence. You call follow him on Twitter @BeyondtheMD. He can be reached at

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