The Functional Medicine Protocol For Beating Burnout with Adrenal Support

In today's fast-paced world, burnout has become an increasingly prevalent and pervasive concern, with some studies indicating prevalence rates higher than 50% in some professions (1, 28). Characterized by chronic physical and emotional exhaustion, burnout often arises from prolonged exposure to stressors in the workplace and personal life. Adrenal health becomes central to addressing burnout, as the adrenal glands play a vital role in the body's response to stress. Understanding the intricate interplay between chronic stress and adrenal function is essential for preventing and managing burnout.

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Understanding Burnout and Its Symptoms

According to the APA Dictionary of Psychology, burnout is "physical, emotional, or mental exhaustion accompanied by decreased motivation, lowered performance, and negative attitudes toward oneself and others." This physical and emotional exhaustion results from prolonged and intense stress, often related to one's work or personal life. It is characterized by feelings of cynicism, detachment, and a sense of reduced accomplishment. Unlike general stress or fatigue, burnout is a more profound and enduring condition that goes beyond the normal ups and downs of daily life. It typically arises when individuals consistently face overwhelming demands that exceed their capacity to cope, leading to a gradual erosion of emotional resilience and a sense of diminished personal efficacy. Burnout can manifest in various aspects of life, impacting professional performance, overall well-being, and interpersonal relationships. (44, 46) 

Burnout can present differently for everyone but typically manifests as a combination of physical, mental, and emotional symptoms (44, 46):

• Exhaustion 
• Feelings of apathy and dissatisfaction
• Headaches
• Changes in sleep and appetite patterns
• Reduced performance capacity

The Adrenals and Stress Response

The body's stress response is intricately orchestrated by the nervous system and the hypothalamic-pituitary-adrenal (HPA) axis. The nervous system's rapid response is initiated by the sympathetic division, which releases neurotransmitters like adrenaline, triggering the "fight or flight" reaction. This leads to immediate physiological changes such as increased heart rate, heightened alertness, and redirection of blood flow to critical organs. Simultaneously, the HPA axis plays a key role in the prolonged stress response. When the brain perceives a stressor, the hypothalamus releases corticotropin-releasing hormone (CRH), signaling the pituitary gland to release adrenocorticotropic hormone (ACTH). ACTH then prompts the adrenal glands, one located above each kidney, to release cortisol, a stress hormone that modulates various physiological processes. Cortisol increases blood sugar levels, suppresses the immune system, and aids the body's adaptation to stress by regulating metabolism. (11) 

While these responses are essential for survival during acute challenges, chronic activation of these pathways without adequate recovery can lead to endocrinological miscommunication. HPA axis dysfunction refers to an imbalance or dysregulation in the functioning of this signaling system due to prolonged, chronic stress. HPA axis dysfunction can manifest as either an overactive or underactive stress response, leading to a range of symptoms such as fatigue (often described as "tired by wired"), brain fog, sleep disturbances, cognitive difficulties, mood swings, and weight gain.

The term "adrenal fatigue" is often used colloquially to describe a similar set of symptoms, implying that the adrenal glands are exhausted and unable to produce sufficient hormones, primarily cortisol, leading to a state of chronic fatigue. However, this term lacks scientific validity, as robust scientific evidence does not support the concept of the adrenal glands becoming fatigued. HPA axis dysfunction is a more accurate and accepted term within the medical community, acknowledging the broader systemic dysregulation involving the entire HPA axis. It recognizes that the issue is not solely due to adrenal gland fatigue but involves complex interactions between the brain and adrenal glands in the body's stress response.

The Functional Medicine Approach to Adrenal Health

If you've ever consulted a functional/integrative medical provider, they've likely mentioned the need for adrenal support as part of a holistic wellness plan. The reason is that optimal adrenal function is crucial to almost every aspect of health. Conversely, adrenal dysfunction can have expansive health consequences, extending beyond the emotional perception of feeling stressed. 

Fortunately, a comprehensive lifestyle approach encompassing nutrition, exercise, and stress management effectively supports adrenal health and combating HPA axis dysfunction. We will discuss the specifics of these interventions in detail later on, but it is also important to note that holistic adrenal support must also include identifying and remedying underlying causes of HPA dysfunction. This entails identifying, modifying, and managing everyday stressors for many of us. But other factors are responsible for causing HPA axis dysfunction, so identifying and addressing underlying causative factors, such as inflammation, malnutrition, alcohol consumption, sleep disorders, and infections, is critical for the long-term health and function of the adrenal glands.

Functional Medicine Lab Testing for Adrenal Function

Lab testing for adrenal function is not straightforward, and there isn't a single definitive test to diagnose HPA axis dysfunction. Many doctors will use tests to measure cortisol, the cortisol awakening response, and DHEA to assess HPA axis activity. 

Salivary Cortisol

Cortisol's diurnal rhythm is a natural pattern of cortisol secretion that follows a 24-hour cycle. Cortisol levels typically peak in the early morning and then gradually decline throughout the day, reaching their lowest levels in the evening and early night. The HPA axis regulates this rhythmic pattern. HPA axis dysfunction impacts this cortisol curve, causing cortisol levels to be irregular in amount and timing. Multiple-point salivary testing, such as the Diurnal Cortisol Profile by Doctor's Data, measures free cortisol levels throughout the day to assess the cortisol curve as a marker of HPA axis activity. (40, 43) 

Cortisol Awakening Response (CAR)

The CAR is a distinct aspect of the cortisol secretion curve marked by a natural and transient surge in cortisol levels by 50-160% within the first hour upon waking in the morning. The CAR reflects the responsiveness of the adrenal glands to signals from the HPA axis and is influenced by psychological factors. Therefore, CAR has become a standard measure of HPA activity, and deviations from the normal CAR pattern indicate HPA axis dysregulation. CAR can be measured independently, with a test like the DUTCH CAR test by Precision Analytical, or alongside cortisol, such as with the ASP with CAR panel by Genova Diagnostics. (12)

DHEA

DHEA, short for dehydroepiandrosterone, is a steroid hormone primarily produced by the adrenal glands. Like cortisol, the adrenal glands secrete DHEA in response to ACTH signals, and short-term increases are measurable during acute stress. However, in situations of chronic stress, the body may prioritize cortisol production over DHEA, leading to changes in the DHEA-to-cortisol ratio. Monitoring this ratio can theoretically enhance the predictive value of HPA axis dysfunction. This is why DHEA is generally included in panels, like the HPA Profile by Sanesco & NeuroLab, designed to assess HPA axis activity.

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Dietary Strategies for Adrenal Support

What we eat influences the amount of circulating cortisol in the body. For example, several studies have linked high intakes of simple carbohydrates and sugars with sustained cortisol elevations upon waking and throughout the day (16, 29). Consuming excessive sugar can lead to dysglycemia, which has been shown to heighten perceived stress levels. Consequently, the body initiates the stress response, releasing cortisol, further exacerbating elevated blood sugar levels. This establishes a harmful loop where high sugar intake intensifies stress, cortisol secretion, and HPA axis dysfunction, perpetuating the negative cycle. Therefore, one of the key dietary strategies for adrenal support is balancing blood sugar and making careful decisions regarding the types of carbohydrates you eat. Evidence suggests that adopting the Mediterranean diet may be beneficial in regulating the HPA axis and promoting stable blood sugar levels (24, 26). 

The Mediterranean diet is also beneficial for adrenal health because it promotes high intakes of nutrient-dense foods. Many micronutrients important for adrenal health, including B vitamins, vitamin C, magnesium, and zinc, are at risk of depletion under chronic stress. Following a Mediterranean diet, or one similar to it that promotes eating a diverse range of fruits, vegetables, nuts, seeds, legumes, and lean proteins rich in these (and other) essential vitamins and minerals, prevents nutritional deficiencies from occurring. (25)

Lifestyle Modifications and Stress Management

Along with diet, there are many other lifestyle strategies for managing stress and its associated symptoms and preventing burnout. 

Exercise is shown to be an effective stress management tool through its ability to modulate the body's HPA and nervous system response systems to stress. However, a word of caution – high-intensity exercise does stimulate cortisol secretion. People experiencing adrenal overactivity (i.e., elevated cortisol levels) may benefit from limiting high-intensity activity until HPA axis dysfunction has been corrected. Additionally, to coincide with the healthy circadian rhythm, engaging in high-intensity exercise in the morning and low-intensity exercise later in the day is generally recommended. (8) 

Incorporating mind-body therapies into daily practices can be a valuable approach to managing stress and supporting adrenal health. Techniques such as mindfulness meditation, deep breathing exercises, and yoga have been shown to reduce stress levels and positively impact the functioning of the adrenal glands. These practices promote relaxation, improve resilience to stressors, and may contribute to a balanced activation of the HPA axis. 

Poor quality sleep negatively impacts how your body responds to stress. Inadequate sleep is linked to HPA axis dysfunction, elevated cortisol levels, and nervous system hyperarousal. The National Sleep Foundation recommends that adults get 7-9 hours of sleep per night. To support optimal sleep, it's important to establish a regular sleep schedule and sleep hygiene habits, along with treating any underlying sleep disorders. 

Herbal and Nutritional Supplements for Adrenal Support

Adaptogens, a class of herbs renowned for their stress-modulating properties, play a significant role in supporting adrenal health and aiding recovery from burnout. Simply stated, these herbs regulate the HPA axis, modulate the release of stress hormones, and promote adrenal homeostasis. Ashwagandha and Rhodiola, for instance, have been shown to reduce cortisol levels. Conversely, licorice has more stimulating effects by inhibiting the enzyme that breaks down cortisol, extending its half-life; this would benefit people whose HPA dysfunction has resulted in low cortisol output. 

Phosphatidylserine is a phospholipid found in high concentrations in cell membranes. Research suggests that phosphatidylserine may help normalize the HPA stress response by modulating ACTH secretion and, thereby, normalizing cortisol levels. (19) 

The adrenals are one of the organs in the human body with the highest concentration of vitamin C. As mentioned above, stress (more specifically, adrenal stimulation by ACTH) leads to a vitamin C-dumping effect, increasing the risk of vitamin C inadequacy and deficiency. In one study, vitamin C supplementation improved stress responses and salivary cortisol recovery in healthy subjects undergoing acute psychological stress.

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Beating Burnout: Key Takeaways

Addressing adrenal health is paramount in the context of burnout, as chronic stress can lead to dysregulation of the adrenal glands and the HPA axis. Adopting a comprehensive approach grounded in functional medicine principles is essential to navigate burnout effectively. This includes personalized dietary interventions that prioritize nutrient-dense foods, lifestyle modifications to incorporate stress-reducing practices, and targeted supplementation. This holistic strategy aims to alleviate symptoms and address the root causes of adrenal dysregulation, fostering resilience and restoring the intricate balance within the body's stress response system.