Optimizing Adrenal Health An Interview With Carrie Jones, ND, MPH
Carrie Jones is a Naturopathic Physician with a Master’s in Public Health, having over 12 years experience in the field of functional and integrative medicine. As Adjunct Faculty for the National University of Natural Medicine, Dr. Jones has taught courses in both Gynecology and Advanced Endocrinology. She is currently the Medical Director for Precision Analytical, Inc., creators of the DUTCH hormone Test.
Perched atop each kidney, the adrenal glands sit ready to respond to the stresses, strife, and adversity we face on a daily basis. They release hormones that play a role in maintaining the balance of blood sugar and blood pressure, as well as digestion, energy metabolism, immune function, mood, and more.
Even slight variations in adrenal function can influence health. Subtle changes in adrenal hormone release may lead to a cascade of physiologic activity—affecting everything from thyroid function to metabolism. These subclinical changes in adrenal function are extremely relevant to integrative patient care.
Recently Element Senior Writer Sarah Cook, ND, sat down with hormone health expert Carrie Jones, ND, MPH, to discuss the latest strategies integrative practitioners can use to assess and optimize adrenal health.
SARAH COOK:
Before we jump into the details of adrenal health, tell us a little bit about your own story and the focus of your career today.
CARRIE JONES:
I’ve known since I was a young girl that I wanted to be a women’s health and hormone doctor. I went to medical school with that focus and completed a residency in women’s health. I’ve worked for 12 years in the field of integrative medicine, and have been a faculty member at the National University of Naturopathic Medicine and the medical director for two large, integrative clinics in Portland, Oregon. I am now on sabbatical from clinical practice and am the medical director for Precision Analytical, creators of the DUTCH hormone test. I consult with practitioners around the world to help them make sense of their patients’ symptoms and hormone patterns.
I love to teach the hard stuff on a basic level. Hormone health is complicated. My job is to break down the complexities so that everyone can understand. It makes people feel empowered. I want patients to know how to support their own hormone balance. I also want clinicians to confidently make sense of adrenal, thyroid, and sex hormone interactions.
Although I have focused my career on women, I see in my consults every day that men are equally affected by hormone imbalances. This is undoubtedly true for the adrenal hormones. Men and women of all ages and walks of life struggle with maladaptive stress responses and imbalances in adrenal function. Empowering people to nourish their adrenal health is fundamental to overall hormone balance.
COOK:
Why is evaluating adrenal health an important part of integrative patient care?
JONES:
The adrenal glands produce more hormones than most people realize. The inner portion of the glands (the adrenal medulla) produces epinephrine and norepinephrine so we can react quickly to danger and avoid things like car accidents. The outer portion (the adrenal cortex) produces cortisol to boost our blood sugar levels, get us out of bed in the morning, and fight inflammation. The adrenal cortex also makes aldosterone to regulate salt and water balance and manage blood pressure. Even androgen hormones, including dehydroepiandrosterone (DHEA) and testosterone, are produced by the adrenal glands.
All of these hormones have such varied physiologic effects that suboptimal adrenal function manifests differently in everyone. Some people experience fatigue, hot flashes, or low libido. Others may have blood sugar dysregulation, headaches, mood changes or blood pressure changes. Many people experience an aggravation of symptoms upon waking in the morning, or have water retention and bloating.
In a conventional medical workup, unless a patient shows signs of pathologic adrenal disease (like congenital adrenal hyperplasia or Addison’s disease), the adrenal glands are mostly ignored. Integrative medicine looks at subtle patterns of adrenal function. Subclinical changes in adrenal hormone production can influence metabolism, immune function, thyroid health, heart health, and more. Because of its effect on all body systems, adrenal function should be evaluated as a foundational part of integrative patient care.
COOK:
Some patients refer to their exhaustion as “adrenal fatigue.” Is this an accurate term?
JONES:
The symptoms that people identify as adrenal fatigue are 100 percent real. I don’t deny that people feel fatigued, achy, sluggish, and burnt out. But we need to debunk adrenal fatigue as a diagnosis. It is not a diagnosis. Patterns of adrenal hormone release can deviate from normal in several different ways, and the adrenal glands do not function in isolation. They participate in the bigger hormonal cascade of the entire hypothalamic-pituitary-adrenal (HPA) axis.
Most people who think they have adrenal fatigue actually have psychological and physical stress that activates a cascade of events from the brain down. The hypothalamus produces corticotropin-releasing hormone (CRH), which informs the pituitary to produce adrenocorticotropin-releasing hormone (ACTH), which binds receptors on the adrenal cortex to trigger a release of cortisol. If cortisol production is triggered chronically or excessively, precursors are shunted toward cortisol and away from DHEA and other androgens.
Evaluating cortisol levels in isolation is reductionistic. We need to evaluate multiple adrenal hormones in the context of the HPA axis. It doesn’t have the same ring to it as “adrenal fatigue,” but “HPA axis dysfunction” is a more medically correct term.
COOK:
Which methods do you recommend for evaluating adrenal health?
JONES:
I am a big believer in “test, don’t guess.” The reason is that somebody can feel tired but have either high cortisol or low cortisol. I want to know if a patient can make cortisol and if they can make it at the right time of day. I also want to know if they are circulating free cortisol in its active form or if they’re deactivating it to cortisone. And I want to know how cortisol levels relate to other hormones, like melatonin and DHEA.
There are a few options for testing. Hormones and their metabolites can be tested in the blood, saliva, or urine. I collect saliva and dried urine to assess cortisol, cortisol awakening response, cortisone, DHEA, and melatonin.
Many clinicians are not using cortisone tests, however, cortisol is deactivated to cortisone in the colon, salivary glands, and kidneys, and then reactivated to cortisol in the liver and peripheral tissues. If someone is heavily shunting cortisol toward cortisone, you might see high cortisone and normal cortisol in the urine. A cortisone test gives a more comprehensive picture. Only looking at the cortisol test may underestimate cortisol production.
Another unique biomarker we can test in urine is a melatonin metabolite called 6-hydroxymelatonin-sulfate. This metabolite correlates with overnight melatonin production. Melatonin is not part of the HPA axis (it’s produced by the pineal gland), but it should be produced on a circadian rhythm that’s opposite of cortisol.
The cortisol awakening response is another underutilized test of HPA axis function. The patient collects saliva first thing in the morning on waking, and then 30 and 60 minutes after waking. Cortisol should rise rapidly on waking and then decline gradually throughout the day. The cortisol awakening response tells us if a person is efficiently spiking cortisol in the morning.
COOK:
What are some common patterns on saliva or urine hormone tests?
JONES:
The healthy pattern of cortisol production is a spike in the morning on waking, followed by a decline throughout the day, with the lowest point in the middle of the night. People who feel chronically tired expect to see their cortisol low across the board, but that’s only sometimes the case.
Another pattern could be flatlined cortisol but elevated cortisone, which tells me a patient is deactivating their cortisol. Sometimes we see cortisol elevated both day and night. Another typical pattern is low cortisol in the morning and high cortisol at night. I call this a reverse curve, or the “parent pattern,” because it’s so often seen in parents of young children—they get the kids to bed and then get a burst of energy when they finally have time to themselves.
The cortisol awakening response pattern test is particularly helpful for evaluating people who feel worse in the morning. If the body is not producing that burst of cortisol within the first hour of waking, any number of health concerns can be aggravated on waking.
If a person has low melatonin production (as seen by its metabolite in morning-dried urine), it might be more helpful to support melatonin than to suppress cortisol at night. Altered melatonin production can create similar symptoms as altered cortisol production, such as difficulty sleeping or sluggishness in the morning. Again, this test helps us evaluate the bigger picture of hormonal balance.
If a person has low DHEA, it’s often because of precursors being shunted to cortisol. This explains why a person might have low mood, low motivation, and low libido. DHEA is also protective for the brain, so this test informs us if we need to provide more support for ongoing brain health.
COOK:
What are some of the biggest threats to adrenal health?
JONES:
The HPA axis is triggered by psychological, physical, and environmental stressors.
Psychological stress could come from work, relationships, finances, or anything a person perceives as stressful.
Physical stress activates the same response as emotional stress. Lack of sleep is a huge stressor. Sleep keeps our circadian rhythm balanced and is when the body is repaired. Consuming sugary foods is also extremely hard on the adrenal glands. Low blood sugar triggers cortisol production, cortisol raises blood sugar, and metabolic chaos ensues. Eating allergenic foods triggers inflammation, which in turn triggers cortisol production. Excessive exercise is also perceived as a stressor, as is dehydration. And of course, injury and illness are physical stressors.
Environmental stressors are sometimes not within our control (like pollution in the air) but can often be minimized. Environmental stressors include chemicals in personal care products (like parabens), plastics (like BPA), hand sanitizers (like triclosan), and foods (like pesticides). Many of these chemicals are endocrine disruptors, interfering with the action of our endogenous hormones.
COOK:
What are your top lifestyle recommendations to support adrenal health?
JONES:
The idea is to focus on lifestyle habits that support a healthier stress response. Social support from family, friends, loved ones, and professionals has a huge impact on how a person handles stress. Good sleep hygiene and sufficient sleep help support a balanced circadian rhythm. Exercise in moderation-if the body is already responding as if it’s running from a tiger, then running on a treadmill can make things worse. I tell people to dial back on the aerobic exercise and instead add in yoga or walking.
We can also teach habits that stimulate parasympathetic nervous system (PSNS) activity. Meditation and guided relaxation are good options. Singing or humming activate the PSNS, so I tell people to sing in the shower or the car. Finishing the shower with a cold rinse or washing the face with cold water are other easy ways to trigger the PSNS response.
COOK:
Which dietary patterns best support adrenal health?
JONES:
Now that I work for a lab and consult with hundreds of different clinicians, I see hormone patterns of patients following all kinds of diets. I see results from patients following ketogenic diets, paleo diets, vegan diets, you name it. And do you know what I’ve found? Every person is unique. Some people following a ketogenic diet have perfectly healthy cortisol patterns, while others have flipped or flatlined curves. No single diet is best for everyone.
Sure, certain habits will set off the stress response. Sugar, alcohol, and allergenic foods trigger cortisol release. A whole-foods diet with plenty of vegetables provides the nutrients needed for hormone production, but I stop short of recommending any specific dietary pattern. It depends on the person. The beauty of testing adrenal hormones is that we can observe how the body responds to dietary and lifestyle change.
COOK:
What are some dietary supplements to support adrenal health?
JONES:
Some herbs and nutrients are helpful in supporting adrenal health no matter what patterns are seen on testing. Vitamin C acts as an antioxidant to protect the mitochondria in adrenal cells, and is necessary for the conversion of norepinephrine to epinephrine. Pantothenic acid (vitamin B5) is needed for cortisol production, as well as for adrenal receptors to respond appropriately to ACTH.
Adaptogenic herbs can be used in most situations because they have a balancing effect. If cortisol production is high, adaptogens help to lower it. If cortisol production is low, adaptogens help to boost it. Some of my favorite adaptogenic herbs are ashwagandha (Withania somnifera), rhodiola (Rhodiola rosea), and Siberian ginseng (Eleutherococcus senticosus).
Additional supplements can be targeted to the pattern of cortisol production, DHEA, and melatonin. If a person has a low cortisol awakening response or generally flatlined cortisol, we use more stimulating supplements. These include adrenal glandulars, brain glandulars, and licorice (Glycyrrhiza glabra). For those who have elevated cortisol in the evening, I use l-theanine, phosphatidylserine, skullcap (Scutellaria lateriflora), or holy basil (Ocimum tenuiflorum). If there is a reverse curve, we can give tonifying herbs in the morning and calming herbs at night.
COOK:
For new practitioners supporting the adrenal health of their patients, are there any pitfalls or final words of wisdom you would like to share?
JONES:
Yes, absolutely. I always tell new practitioners that you have to ask a lot of questions. What are the patient’s current or past stressors? Do they have current or past trauma? How did they handle the trauma? How do they practice self-care? What do they do to relax? Do they snore? Do they have sleep apnea? Are they happy? Do they have friends? What are their favorite foods? These questions inform us about how they manage life and how they respond to adverse events. You cannot treat only the lab results. You need to treat the individual.
I’ll share one last clinical pearl. Oxytocin has an inverse relationship with cortisol and can quell the stress response. Oxytocin is produced by the hypothalamus and released from the pituitary hormone during sex, childbirth, and lactation, but we can also boost this “love hormone” by the simple acts of hugging or petting an animal. Petting a dog or a cat raises oxytocin levels, puts us into a parasympathetic mode, and calms us down. Pets give us unconditional love. So add that to your prescription pad for the next patient who needs a little more adrenal support.
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