On a basic level, adrenal fatigue (sometimes called adrenal insufficiency) is a condition that results when the adrenal glands cease to meet the demands placed upon them. It occurs following a period of excessive stress. Reduced energy, mental function, libido, hypoglycaemia, poor sleeping patterns and difficulty in losing weight are typical of those suffering from adrenal fatigue and, while there are no formal figures, it is estimated that adrenal fatigue affects one in 10 of our clients to varying degrees. So why haven't you heard of it?
More than seven decades after Hans Selye first began to identify an autonomous reaction of the adrenal glands to external stressors, adrenal issues are still largely ignored by the pharmaceutical industry. Unlike thyroid conditions, which are treatable with various combinations of the many T3 and T4 replacements that have been developed and patented, there have been no equivalent drugs that can restore adrenal function to its natural level. Put simply, there is no profit available for any pharmaceutical companies. What's more, as the pharmaceutical giants are the biggest contributors to the costs of educating new doctors, adrenal fatigue is destined to remain omitted from the agenda for the foreseeable future.
The function of the adrenal glands is a complicated science. There are a number of important substances secreted by these pyramid-shaped glands, which include aldosterone from the adrenal cortex (which affects body hydration) and adrenaline from the adrenal medulla (responsible for energy and alertness). However, most diagnosis of adrenal fatigue center around the more measurable steroid hormones cortisol and DHEA, produced in the adrenal cortex. These hormones should rise in the morning to wake a person and then progressively fall from mid afternoon to allow unwinding and sleep. They work together to balance your decision making, your energy levels, your blood sugar, your immune system function, your sex hormones and almost every system you care to mention. Because cortisol has major effects on the immune system and blood sugar levels, and because DHEA is the base substance from which your body makes estrogen and testosterone, the effects of adrenal imbalance can be difficult to pin down and categorize.
For the reasons mentioned above, it is still the medical view that adrenal function comes in just three flavours: normal, Cushing's Disease (extreme excess of both cortisol and DHEA) and Addison's Disease (extreme, potentially fatal deficiency of both cortisol and DHEA). The reality is that adrenal dysfunction does not respect the textbooks that try to compartmentalise it. Cortisol and DHEA sometimes do excessively rise and fall together, but this is rarely the case. Different tissues within the adrenal glands can fatigue at different rates. Thus, there is no reliable path to recognize. This is why the adrenal medulla (responsible for the release of adrenaline) can still be over active while the adrenal cortex (responsible for the release of cortisol and DHEA) is seriously under active.
So how does this occur? Firstly, adrenal fatigue is a consequence of the external environment and one's response to it. This especially refers to the stress response. When we detect a stressful situation, the brain sends a hormone called ACTH to the adrenal glands, which stimulates secretion of adrenaline, followed by cortisol and DHEA. This system increases alertness, increases the heart rate and generally prepares the body for action. It is the “fight or flight” reaction.
This reaction works fine, unless it is activated too regularly. If this is the case, the reaction becomes over exaggerated. The adrenal glands over release adrenaline and then cortisol whenever they receive a signal from the brain. This is Adrenal Fatigue Stage One, and almost all of us enter this at various points during periods of stress, such as a week of prolonged and consecutive stressors. This would typically result in increased tiredness at the end of each day, becoming flustered quickly and being shaken easily by loud noises. Affected individuals remain thoroughly functional and, provided the stressors are removed, adrenal function reliably returns to normal.
However, if it is not, an individual will enter Adrenal Fatigue Stage Two. This is characterized by a constant over secretion of stress hormones, especially cortisol. The stress switch is permanently flicked to the “on” position. While still able to function in the working world, clients in this state will often find they are tense, forgetful, unmotivated, constantly suffering with colds, have wounds/ulcers that heal slowly, may struggle to digest food and will notice an increase in blood pressure and in bodyfat (especially around the abdomen). The higher stress hormones will keep the body alert later into the evening, and typically these clients will take considerably longer to fall asleep, despite how tired they feel. To overcome this now ingrained response at the adrenal glands, a total removal of stressors must be maintained to allow hormonal secretions to slowly return to ideal levels.
If the stressors are not removed, then the individual will inevitably move into Stage Three Adrenal Fatigue. This could take weeks, months or even years, but this is defined by a sharp fall in the secretion of adrenal hormones. The tissues that are responsible for their manufacture “burn out” from sustained overuse. While more often than not it is cortisol production that is effected, DHEA levels can also collapse in this way (confusingly enough, the symptoms this produces mimic a crash in cortisol). An excess of stress hormones will seriously drain the resources of any individual and yet, as they are essential for energy production, a deficiency leaves a person even more tired. “Death warmed up” is often a phrase used by clients in this state. Noticeable dark rings around the eyes tend to accompany this condition. Blood pressure will also be lowered in most cases, allergic reactions may occur with more frequency, and salt cravings are likely. The overworked tissues responsible for the production of stress hormones cannot keep pace with the requirement, which sees cortisol (or DHEA) levels remain deleteriously low all day. Often, these overworked tissues will compensate for under performing by continuing to release stress hormones well into the night. This creates a paradox whereby your client cannot summon enough energy to function properly during the day, and yet he or she cannot sleep at night. Rather than having assumed an unhealthy response, the tissues are now unable to perform their role. This is naturally a more serious condition.
The good news is that it is possible to fully restore healthy adrenal function. In theory, it is a simple case of resting the damaged tissues to allow them to heal, which means reducing the load placed on them (reducing stressors and increasing rest) and assisting them to meet the load (supplementing with liquorice root, hydro-cortisone or DHEA). If you are going to suggest supplements that effect adrenal hormones, this should only be done following suitable testing and under the supervision of someone familiar with adrenal function.
Circulating cortisol levels can be fortified by liquorice root as it extends the half life of the hormone and boosts its potency. The active component of the plant glycyrrhizic acid does this by inhibiting the steroid dehydrogenase enzyme. The best results have come from liquorice root extract (standardized to 20 percent glycerrhizinic acid). Cortisol can also be fortified through hormone replacement (using bio-identical hydrocortisone), with different doses required for different situations. DHEA can also be replaced with bio-identical hormone replacement. Note that these interventions should never be used without prior hormone testing or without sufficient expertise with adrenal fatigue, especially since there are so many similarities to cortisol/DHEA insufficiency.
After a period of time, normally six to eight weeks, the supplements can be decreased in small intervals and, providing there is no return of malady, discontinued altogether. This normally occurs over several months. Supporting adrenal function with Vitamin C, Vitamin B5 and liquorice root can be extremely important, as is the removal of psychological stressors. Caffeine, alcohol, tobacco and sugar should all be removed. (It would be unwise to dismiss the benefits of acupuncture and reflexology on helping to restore adrenal function. The limited feedback I have had from clients on this matter has been entirely anecdotal but positive nonetheless.)
In practice, boosting adrenal function with supplements can prove very successful but is often bereft with problems. The affect this has on blood sugar levels, mental response, sex hormones and all of the other bodily systems means that intervention can have multiple interactions. Disturbances in stress levels over any period of time will reliably affect many different areas of metabolism, especially digestion. Digestion is intrinsically linked to the function of the liver, and I very rarely see any client recovering from adrenal fatigue that would not benefit from a liver cleanse. The affect that cortisol:DHEA ratio has on estrogen and testosterone levels should also not be overlooked, especially in females whose hormonal interaction is more complicated.
Another crucial factor is exercise. Too little leaves insufficient outlet for stress, but since exercise is a stressor in itself, too much can compound the problems. In these situations, all heavy or prolonged exercise is totally outlawed for at least six to eight weeks and approached with extreme caution thereafter. Trainers should avoid training that is stressful on the nervous system (e.g., neural training, 1-6 rep range) and equally, aerobic exercise of more than half an hour (which is enough to push most clients into a catabolic state). I generally plan weight training sessions totalling just seven to eight sets, using larger compound exercises in the 10 to 15 rep range and long rest periods of around three minutes. This leaves plenty of time for stretching or any overdue postural work. While all clients are different, it is always better to underwork a client than risk overworking them.
Don't expect clients to feel satisfied with their new, “easy” workout, especially as clients with adrenal fatigue will be used to overloading their system on a regular basis. Educating clients as to the reasons behind their low stress workout is very important to obtain continued cooperation with this approach.
With a firm understanding of both adrenal function and the interactions in and around the human body, it is possible to navigate an efficient route back to optimum health. There are a number of difficulties I regularly face in restoring the adrenal function in various individuals, primarily bio-chemical individuality and obtaining the cooperation of client's doctors (who are typically very cautious when in unfamiliar territory), but the approach that is best suited to dealing with adrenal fatigue is to assess everything that is possible (through blood/saliva tests as well as client questioning). Analyze this with a holistic mindset that takes into account the whole body but to always “treat the patient, not the test.”
Naturally, prevention is better than any cure, and the increasing incidence of adrenal fatigue only serves to show how important it is for any health and fitness professional to prioritize the reduction of stress in the lives of all the clients they deal with on a daily basis.
In summary, when a client presents with symptoms of adrenal fatigue...
- Do send your client to an experienced nutritional therapist who can provide an overall health screen and conduct a four-point adrenal stress index test.
- Do moderate your client's workload and look for regular feedback as to what feels best.
- Do keep track of your client's sleep patterns, stress levels, food cravings (especially salt and sugar) and general moods.
- Do keep track of your client's responses to workouts, and make sure you are not pushing too hard.
- Do give your client generous rest periods (3 mins+) between resistance exercises.
- Do encourage your clients to reduce their stress load and address work/relationship/etc issues that are causing them psychological stress.
- Don't assume that your client has reached a plateau due to poor diet.
- Don't exceed a training time of more than 30 minutes.
- Don't train clients in the more stressful one to six rep range.
- Don't use fat burners/stimulants.
- Don't train your client too early in the day or too late at night.
- Don't warn your clients off salty foods if this is what they are craving. Individuals who are suffering from adrenal fatigue rarely hold onto salt in the normal way.
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