Adrenal Fatigue & HPA Axis Dysregulation In Exercising Athletes

You’ve hit a grove in the gym, you’re smashing personal records and noticing your body composition improving then it starts to rear its ugly head. At first, it’s no big deal, you notice little changes, maybe it takes you longer to fully wake up in the morning despite a good night’s sleep or maybe you start noticing more joint pain. You’re a focused athlete, however, and you push through not realizing that you’re putting yourself in a deeper hole.

Slowly you start noticing that you seem to be taking longer to recover from workout to workout, you seem to need a pot of coffee to get your day started or minor things set you off in your seemingly always anxious state.

These are just a few of the classically defined symptoms of adrenal fatigue. Now I know you may be thinking that what I’m describing isn’t a real condition and you would be right. It’s not a medically defined disease, though your doctor will likely test you for Cushing’s Disease. Adrenal fatigue, or more accurately described as hypothalamic-pituitary-adrenal (HPA) axis dysfunction, is a functional condition implicated in multiple common health conditions such as:

Dizziness when standing from a seated or lying position
Low sex drive and function
Low blood pressure
Frequent headaches
Low blood sugar
Decreased thyroid output “slow thyroid”

Functional, every day symptoms include:

Waking up feeling tired
Having low morning energy, but feeling energized during night time
Blurry vision
Decreased tolerance of stress
Frequent headaches
Low sex drive and function
Increased negative reaction to allergies
Increased muscle soreness

HPA axis dysfunction impacts three endocrine glands from the brain to the adrenals and is essentially a Rubik cube of potential health problems. The best explanation of complex interplay of these three systems is an every day scenario. Maybe someone cut you off on the road or your boss yelled at you for your work performance. Any stressful situation causes a cascade of events that begins with your hypothalamus relating CRH or corticotrophin releasing hormone.

CRH makes its way to your pituitary gland which stimulates the release of adrenal corticotrophin hormone, ACTH, which makes it way to your adrenal glands and tells them to release the stress hormone cortisol. Cortisol is an opposing hormone to testosterone and relies on the same pathway as testosterone for production. You can only have one hormone abundant at a time.

Cortisol has a primary role in the body and that is to keep blood glucose levels high in addition to helping your body retain sodium.

Most articles stop at this point, where cortisol is high.

High cortisol is linked to:
 
Increased blood glucose levels
Decreased conversion of T4 to T3, lower thyroid binding and increased production of reverse T3 (your doctor tells you that you have low thyroid)
Decreased pituitary function
Increased gut inflammation
Insomnia
Decreased brain health including difficulty with memory recall

Don’t get me wrong, high cortisol is bad and using Seyle’s classical definition of stress, high cortisol is a beginning stage of much larger issues. However, we’ve learned that individuals, especially hard training athletes, don’t follow the linear stress path and may go from a beginning phase right to the final, exhaustion phase, which should come as no surprise considering that no two individuals perceive or “clear” stress the same way. Cortisol levels don’t just go up or down, there is also an issue with the metabolism or clearance of cortisol. I’ve seen a wide variety of blood work with different permutations including high cortisol with low metabolism and low cortisol with high metabolism. There’s a lot of different options because there’s a lot of other factors that impact cortisol production besides the hormone itself and we’ll get into those shortly.

This exhaustion phase, where cortisol is low, is when most athletes completely stop training because they feel terrible. When cortisol is low your body cannot release blood sugar efficiently for energy so it increases the release of epinephrine which makes individuals feel anxious during everyday tasks.

Low cortisol has its own host of issues including:

Decreased immune system function
Blood sugar fluctuations and insulin spikes
High catecholamine release
Increased inflammation
Difficult staying asleep
Frequent headaches
Dizziness when standing
Passing out 
Problems with memory recall

Cortisol, as defined by its textbook definition, runs in a normal 24 hour cycle. Cortisol should be high in the morning to wake you up, since it is a low grade adrenaline and progressively gets lower by nighttime so that you can get to sleep, since cortisol and melatonin as opposing hormones, when one is high the other is lower.

At this point I should point out that the only true way to know your cortisol rhythm or any type of HPA axis dysregulation is through medical testing, including an adrenal stress index blood test, a saliva test or a DUTCH test, which is a 24 hour urine test.

Once you know what’s really going on with your body, you need to take the proper steps to address your lifestyle, training and nutrition.

Step One: Be Realistic

When you just don’t feel right and assume you have some degree of HPA axis dysregulation, you need to reevaluate your goals. I was hired by a woman training for a figure contest. She had been dieting a traditional bodybuilding way and was eating roughly 50 grams of carbohydrates per day and doing an hour of cardio on top of her weight training. She was convinced that she had a degree of adrenal fatigue and after some blood testing, she was right. I instantly had her up her carbohydrates and cut back on her cardio. After a week or so, she had gained a few pounds and sent me an angry email.

The point of this story is that you have to be realistic and understand that you’ve been burning the candle at both ends for too long.You can’t expect a PR or to drop 5 more pounds before a contest and manage your HPA axis issues at the same time.

Step Two: Be Mindful

I know this is easier said than done, but mindfulness is the first place to start when you’re attempting to manage your stress load. Everyone perceives stress differently and stress can be emotional, physical, psychological and financial. Anything that stresses you, even training, kickstarts adrenaline production and impacts your HPA axis. It’s important to realize that while every stress is not necessarily bad for us, everyone handles stress differently. Research is even looking into the methylation patterns of different brain neurotransmitters to assess genetic differences in stress tolerance.

Being mindful of how you handle stress is the first step in recovering from HPA axis dysregulation. Meditation falls into this category. As does going for a nice, relaxing walk to be in nature or get sunlight. Anything that you can do that isn’t heavy lifting, strenuous exercise or has you staring at a screen, should be scheduled in your day. It’s easy to say you’ll relax when you’re done with work, but that typically never comes. Schedule your mindful practice into your daily routine.

Step Three: Nutrition

While most people assume that nutrition should be the first step in managing any type of stress 
based dysfunction, I disagree. Situations that cause stress don’t only impair proper hormone function, but they also cause an increased desire for salty or sugary foods. Let’s face it, most people aren’t going to sprinkle pink Himalayan sea salt into some water and call it a day. No, they’ll often grab a bag of potato chips or cookies and triple their ideal caloric intake for the day. As a result, I think mindfulness and understand when you’re in the middle of a stressful situation should come first.
Moving onto dieting specifics, I wish there was one perfect “anti-stress” diet. At this point in my career I’m convinced that a paleo diet with the inclusion of potatoes and rice, if tolerated fine, is the ideal way to go. With HPA axis dysregulation, blood sugar levels may spike leading to abnormal hunger levels and you may feel shaky or unsteady, so stabilizing blood sugar levels with quality sources of carbohydrates is a good starting point.

Like all nutrition approaches, however, you have to continually monitor your symptoms and progress while playing with your levels of carbohydrates. A diet high in processed carbohydrates or sugar is just going to send already whacked out blood sugar levels into a further tailspin. The key is nutrient density.

Knowing how the performance and physique community feels about carbohydrates, I have seen tendencies to attempt to eat ketogenic while experiencing HPA axis dysregulation. A low carbohydrate diet itself is considered a stressor so while a ketogenic diet may have a lot of benefits, it’s not ideal when you’re dealing with some type of adrenal insufficiency.

The same goes for intermittent fasting which is a useful diet approach when things are “normal”, but can be a big stressor when there’s metabolic dysfunction going on.

A paleo approach also decreases inflammation. We’ve talked about the role that stress plays in adrenal health and any stress on the body, combined with blood sugar imbalances also likely result in a varying degrees of inflammation. Even if you have no stress, if you have some type of inflammationary issue then you’re still going to beat up your adrenals and cause a larger problem.

Step Four: Sleep

In healthy individuals if one night of impaired sleep creates levels of insulin resistance similar to diabetics, then you can imagine what chronic sleep deprivation does when you’re in a depleted metabolic state. One symptom of high cortisol is an inability to get to sleep due to a sudden surge of night time energy whereas individuals with low cortisol have no problem getting to sleep, but often wake up during the night as a result of a disrupted circadian rhythm.

Optimizing sleep quality by removing circadian disruptors, limiting the nighttime exposure to light and getting natural sunlight during the day goes a long way to restoring a more natural circadian rhythm. Try to cover or limit your alarm clocks and any other electronic light source, including light coming in from outside by using black out shades.

Step Five: Gut Health

During times of stress your body does not want to digest properly, which not only causes weight gain, gas and bloating but it also leads to nutritional deficiencies. Gut inflammation, whether it be from leaky gut, intestinal permeability or any autoimmune disease will cause extra stressors on the body aside from any external stress. Making sure you’re consuming gut friendly foods such as bone broth and fermented foods is a good idea if those foods are tolerated well.

HPA axis dysregulation can often be a confusion problems because individuals likely also suffer from gut issues. Which came first? Did stress compromise your ability to digest properly or did you ability to digest properly cause undue stress?

Step Six: Smart Supplementation

Most articles on adrenal fatigue or HPA axis dysregulation quickly point to the use of adaptogenic herbs, such as rhodiola and ashwagandha, for managing cortisol. Truthfully, I’ve seen mild cases of high cortisol cleared up when adaptogenic supplements are added after diet and sleep changes occur. For deeper issues, supplements become part of the overall program including:

Ashwagandha, rhodiola and holy basil for adrenal function
Phosphatidylserne for elevated cortisol
Licorice root for low cortisol
Vitamin C, B5 and Pink Himalayan Sea Salt for adrenal health

This article wouldn’t be complete without a brief mention of bioidentical hormones, such as pregeneolne and DHEA. These over the counter supplements should only be used under medical supervision, but they both are indicated in severe HPA axis issues due to their unique position as hormonal “building blocks”.

Step Seven: Your Training

When faced with complete burnout like we’re describing, the conventional wisdom tells you to sit on your couch and do nothing for a while. I’ve been guilty of that myself at times, but now I’m convinced that some type of low stress, outdoor activity is critical for helping you to heal. In my opinion, just sitting on a couch is stressful, as it makes you feel slightly depressed and we all know how easy it is to snack if we’re just laying around the house. So any type of light movement is good in this situation.

The danger lies in when we feel well enough to resume exercise. We assume that since we feel better we can jump right back into what we used to do before. It’s a tough pill to swallow but what we used to do is what got us into our current difficult situation. We need to be very careful to not deplete whatever hormones we have recently rebuilt. It’s easy to fall into the negative trap of thinking you’ll never be as strong or as muscular as you were in the past, but you can’t let that negative mindset enter.

Truthfully you may never get back to pre-burnout levels of training efficiency, but do you have to? Look at it this way, unless you were 100% satisfied with your performance or physique, whatever your metric may be, if you weren’t getting perfect results then this may well be a awkward blessing in disguise. Reevaluating your training and changing things isn’t always bad.

Some notes on training adjustments:

Focus on less overall volume since this is the variable that most people overtrain on historically.
Pay close attention to your overall intensity. An intense deadlift session 48 hours before an intense bench press session factors into the nervous system contribution during the bench press session.
Intensity relates to cardio as well. HIIT is great except when it isn’t, understand when good enough is enough.
It’s okay to not go all out every single workout.
Prioritize your goals. It’s perfectly acceptable to only focus on one goal, not three and a half goals at one time.
You can leave reps on the table.

Step Eight: Live Your Life

Have fun, go meet up with a friend or read a book. While it’s not sexy, social interaction and cognitive tasks are critical for long term stress management. As a society we evolved, in part, due to our community and interactions with others. Make time to have fun.

Jimmy Smith, MS, CSCS is the president of The Physique Formula line of natural supplements. The entire line including artificial sweetener BCAAS can be found at http://www.physiqueformuladiet.com. You can follow him on Twitter @jimmysmithtrain and on Instagram @thejimmysmith, and find his Physique Formula podcast on iTunes.