Adrenal Fatigue & Overtraining in the Athlete: a Nutritional Perspective on Pathology and Treatment of Overtraining Syndrome: an exhaustive review

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1 Adrenal Fatigue & Overtraining in the Athlete: a Nutritional Perspective on Pathology and Treatment of Overtraining Syndrome: an exhaustive review By, BA (Hons) Dip ION NTCC CNHC MBANT Although the term adrenal fatigue is used frequently these days, the term adrenal insufficiency is more accurate, as complete adrenal fatigue is a very serious condition which would need immediate medical attention. The only difference between adrenal fatigue and over-training syndrome in an athlete is the root cause of the condition. In essence we are talking about exactly the same state with a different series of causal factors. Many athletes I see exhibit symptoms of adrenal insufficiency and over training although few go on to develop over training syndrome or adrenal fatigue requiring medical intervention it is nonetheless a very debilitating experience. The failure of the adaptive mechanisms means progression and adaptation take a back seat whilst rest and recuperation are the order of the day. In the accompanying case study I have suggested interventions which can help an athlete recover quickly whilst still maintaining performance. This is not always the case though, and left unchecked without adequate support and infrastructure some athletes will take up to a year to recover or persistently dip in and out of over-training and as a result never quite make the grade in terms of performance improvement. Overtraining has been described as an imbalance between training and recovery which, in turn, leads to decreases in performance 1. There is no single biochemical or physiological definition of overtraining, although many different criteria are used to assess the level to which an athlete has compromised their physical and psychological abilities to adapt to training stimuli. Chronic Overtraining Syndrome can be differentiated from the transient state of overreaching which may be alleviated with rest. Over-trained individuals often take far longer to recover and usually display associated hormonal, biochemical and inflammatory imbalances and psychological impairments that may take months to correct. These imbalances have a nutritional underpinning allowing the possibility of a nutritional approach to treatment. An initial consultation aims to: Conduct a full assessment and screening process with the athlete Withdraw and lower trigger factors Increase supporting factors Two very useful spreadsheets I ve used include adrenal stress causes (view online) and adrenal stress indicators (view online) when these are combined with an adrenal stress index test proper evaluation can be made, and then an intervention plan adjusted to the individual s requirements. The Nutrition Practitioner Spring 2010

2 Figure 1: Stages of Fatigue, taken from Adrenal Fatigue Presentation 2006 Cortisol Normal Rested Stage; Peak of super compensation DHEA high Cortisol raised ALARM STAGE DHEA high Cortisol raised RESISTANCE STAGE 1 DHEA normal Cortisol raised RESISTANCE STAGE 2 DHEA low Cortisol normal / low RESISTANCE STAGE 3 DHEA very low Cortisol low / EXHAUSTION DHEA in it s boots NERVOUS BREAKDOWN Typically, overtraining is associated with symptoms of performance incompetence, immune suppression, glycogen depletion, high perceptions of fatigue and negative impacts on mood 2. The profile of mood states questionnaire (POMS), a scoring system, is also a valid method of assessing the mental state which may lead to or may be a symptom of the hormonal and neurotransmitter changes which result from over training. It is a state of dysregulation between anabolic and catabolic processes, which has been associated with chronically decreased circulating levels of testosterone, growth hormone, follicle secreting hormone (FSH), luteinising hormone (LH), as well as decreased neuromuscular activity 3,4. Hormonal dysregulation is a unifying factor in most documented cases of overtraining, although the specific nature of such impairment can vary from case to case depending on the overtraining subcategory, demands of the sport and stage of overtraining. Two subcategories have been defined, being the sympathetic and the parasympathetic types of overtraining 5. These are usually exemplified by explosive-type athletes and endurance-type athletes respectively, although this categorisation is far from consistent. Many other factors involved in overtraining serve to complicate attempts at simplification and classification. In theory at least, a sympathetic dysregulation in over trained individuals is manifested as restlessness and hyperexcitability, with anxiousness also contributing to performance incompetency and inadequate recovery. This is by far the rarest subtype 1. Parasympathetic overtraining would be typified by decreased sympathetic activity, such as impaired adrenal function 6. However, not only are the associations between athletic types and overtraining category inconsistent, but the symptom described as impaired adrenal function may describe both increased levels, or decreased levels of hormones as seen in the phases of over training listed in Figure 1. Deficits may occur in hormone levels as well as at the receptor level (insensitivity despite high hormone concentrations), or due to other, related metabolic processes. The Catecholamine Response and pre cursor therapy This review will focus mainly on what could be described as the parasympathetic type of overtraining, also referred to as adrenal fatigue or adrenal insufficiency. Essentially, this is a state of impaired sympathetic function due to decreased circulating levels of stress hormones, or perhaps more frequently, decreased sensitivity to them 7. This has been supposed to be a defence mechanism against the catabolic and deleterious effects of training and stress-hormone release 8. The fact that overtrained individuals may display either excessive, or reduced levels of adrenaline(e) and 2 The Nutrition Practitioner Spring 2010

3 noradrenaline (NE) at submaximal exercise intensities, can be reconciled by considering the effects, rather than the volumes, of catecholamine release. In addition, one must consider whether the individual is in the early, or advanced, stages of overtraining. It is now thought that early stages of overtraining are typified by an increased catecholamine release in response to exercise, coupled with a decreased biological sensitivity to their effects. This may be coupled with decreased resting levels 7,9. However, reductions in circulating catecholamine levels are exhibited in the later stages of overtraining. 10 In an athlete struggling with higher levels of body fat this can often become a vicious cycle of over training in order to achieve weight or skinfold targets. The increased training exacerbates the adrenal issues and compounds the problems in addition thyroid activity will lower in medium to longer term over training and excess exposure to stressors. The tendency in this case can be to administer thyroid hormone replacement therapy, which may worsen the adrenal fatigue as the whole system is pushed further by upregulating thyroid activity, when in reality the body s defensive mechanisms are slowing the whole process down. Furthermore, supplementation with stimulant fat burning supplements will compound this problem and if taken with excess carnitine can down regulate thyroid activity in receptors. 37 Whilst decreased circulating levels of NE have been reported in male footballers following weeks of overtraining 11, as well as in female endurance athletes 7, elevated submaximal catecholamine release is in fact a consistent observation in overtrained athletes. Male swimmers who displayed significantly reduced maximal performance following 4 weeks of overtraining however, actually showed increased resting levels of NE 12, while increased nocturnal E levels were seen following overtraining resulting from resistance exercise 4. The unifying factor in these pathologies is a lack of catecholamine sensitivity. Combined with a chronic rather than acute release of stress hormones, in essence the individual is becoming catecholamine resistant. Not only have such increased E levels been seen to coincide with decreased density of β-receptors at the neuromuscular junction 4,13, but a decrease in submaximal heart-rate (HR) is frequently observed to accompany such hormonal elevation 14. This reduction in HR is in marked contrast to appropriate endurance training adaptations, as it is not accompanied by a reduction in resting HR, and is associated with decreased performance. Decreased maximal HR is also a symptom of overtraining that may be explained by ineffective sympathetic tone 14. Decreased sympathetic activity is therefore likely to be induced by a reduction in β -receptor density. This would explain not only observations of submaximal bradycardia (HR reduction), but lower levels of neuromuscular excitability (NME) shown from EEG measurements following overtraining. Such desensitisation to catecholamines in resistance trained athletes has been explained by some as a possible defence mechanism in response to undertaking high-intensity loads and is associated with frequency of maximal efforts 4. Thus an athlete becoming desensitised to catecholamines may represent a biological fail-safe whereby the body attempts to prevent further excessive exertion which could lead to damage. The coach who doesn t understand his athletes within a team environment where there is less time for individual contact and coaching than in individual based sports could see this situation as a player lacking drive becoming lazy and generally not pushing themselves as hard. Monitoring processes need to be in place to assess daily levels of energy, sleep patterns and how this relates to performance in fitness and power as well as field based sessions. Late stages of overtraining have been proposed to coincide with reduced exercise-induced catecholamine release at all intensities. Some have proposed that this may be to do with adrenal fatigue, or depletion in endogenous levels, while others would argue against this logic. It could be argued unlikely that catecholamine precursors could become depleted when one considers that tumour induced hormonal elevations are often tenfold higher and sustained for decades in cancer patients 15, and that no other protein synthesis processes are overtly impaired by amino-acid deficiency in overtraining. That other impaired metabolic processes may be aided by supplementary The Nutrition Practitioner Spring

4 amino-acids, and that such supplementation may act via amino acids stimulatory roles, rather than by providing precursors, keeps open the possibility that supplementation may offer benefits. Overtraining and the Hypothalamic Pituitary Response Dysregulated cortisol metabolism, caused by overtraining, is a major pathological inhibitor of training adaptations. During exercise, corticotrophin releasing hormone (CRH) from the hypothalamus stimulates growth hormone and adrenocorticotropic hormone (ACTH) release from the pituitary gland. ACTH subsequently stimulates the adrenal gland to release cortisol particularly following exercise at high intensities. Acute elevations in cortisol are integral to training adaptations and actually go on to reduce inflammation via a negative-feedback mechanism 16. Cortisol causes subsequent alleviation of catabolic stress responses when released acutely following high intensity exercise 17. However, chronic elevations in basal cortisol levels only serve to act as a continual catabolic stimulus and are involved with muscle wasting and a plethora of adverse health outcomes 18. As with the decreases in sensitivity to adrenaline, overtraining is also frequently observed to induce a decrease in ACTH sensitivity, depending on the stage of overtraining. In the early stage of overtraining, despite increased circulating ACTH concentrations, subsequent cortisol release is reduced 19. In later stages, this decreased sensitivity to ACTH is further exacerbated by impaired pituitary ACTH release 20. Both effects have the outcome of reducing the acute cortisol response to exercise. Figure 2: The Hypothalamic Pituitary Response in Different Stages of Overtraining. Taken from Lehman et al (1997) The overnight cortisol/cortisone ratio has been seen to increase in overtrained marathon runners 21, also highlighting the possibly increased potential for nocturnal hypercortisolism to damage health. Increased basal cortisol has been seen in wrestlers, footballers and runners suffering from overtraining syndrome and is associated with impaired performance in overtraining. In contrast, reductions in acute cortisol elevations following intense exercise have been observed in strength athletes, as well as in world class endurance cyclists 3 despite unaffected ACTH levels. Fortunately there are many interventions aimed at balancing excess cortisol levels in these cases and allowing the adrenal glands some respite. Adaptogens work extremely well in this regard but the tendency can be for an athlete to carry on training excessively using the adaptogens as a buoyancy or training crutch. At later stages in overtraining, resting cortisol elevations may finally become reduced, putting forward the possibility that this dysregulation in hypothalamo-pituitary action may also be a defence mechanism to prevent frequent and consistent elevations in cortisol. However, the prevailing effect is to attenuate the acute, anti-inflammatory actions of cortisol and to reduce the facilitation of training adaptations. Inflammation is also a catabolic collection of biological signals that is impacted by overtraining. 4 The Nutrition Practitioner Spring 2010

5 In this state, where the stress system cannot manufacture enough cortisol, profound tiredness will be a symptom with difficulty waking and getting out of bed. The best nutrient for this situation is liquorice, a potent substance which can prolong the half life of cortisol. Possible roles of Serotonin The central-fatigue theory postulates that serotonin (5HT) may exert a determinant role in instilling feelings of exhaustion from exercise. The theory goes that serotonin synthesis and release in certain areas of the brain is associated with feelings of tiredness. Indeed, a chronic imbalance in neurotransmitter levels has been reported in overtrained marathon runners, which may not only highlight a role for 5HT, but also its interaction with catecholamines and acetylcholine in overtraining 22. This serves to demonstrate the complexity of neurotransmitter relationships, and argues against the over-simplified definition of overtraining as simply being hormonal/neurotransmitter deficiency. In animal studies, levels of 5HT were seen to be elevated in the midbrain, unchanged in the striatum and decreased in the hippocampus compared to rest at the onset of fatigue 23. It is rather dysregulation then, as opposed to a specific deficiency, which may link neurotransmitter biochemistry with overtraining. This may reflect impairments in metabolic processes, as well as deficits in endogenous hormones/neurotransmitter precursors. Other factors that may affect these metabolic pathways include the presence of circulating fatty-acids and amino acids. 5HT is synthesised from the amino acid tryptophan. Lipolysis is stimulated by exercise, and competition from fatty acids for albumin-binding, causes an increase in circulating free tryptophan. Simultaneously, branched chain amino acids (BCAAs) are taken up for use as fuel by muscle cells. This decreases circulating levels. The circulating tryptophan/bcaa ratio has been seen to be affected by dietary fat and exercise 17. Following this line of reasoning, normalising levels of fats, BCAAs and tryptophan, and supporting the proper function of involved metabolic processes may aid the treatment of overtraining. In addition, supplementation with BCAAs during exercise will blunt the cortisol response, potentially increasing the effectiveness of anabolic hormones on the adaptive mechanisms. The Cytokine Theory of Overtraining Another, and not necessarily unrelated, theory of overtraining puts cytokine activity at the centre of the problem. Overtraining is described as primarily an inflammatory disorder whereby trauma to muscle tissue causes an increase in circulating inflammatory mediators. These would stem from both immune-cells, as well as muscle cells themselves 24. Like the theories regarding a hormonal basis to overtraining, the cytokine hypothesis can also go some way to explain the psychological impairments that accompany physical symptoms. Cytokines are known to be able to cross the blood-brain barrier and impact on behaviour, being frequently associated with depression Indeed, many similarities between the psychological aspects of overtraining and depression can be seen. Behaviours such as withdrawing from social contact, and lethargy, are often described as sickness behaviour and are believed to be linked to the physiological phenomenon of systemic inflammation 27. The hypothalamopituitary/adrenal-fatigue theory of overtraining would explain psychological impacts as resulting from dysregulation of endocrine hormones which also act as neurotransmitters, thus affecting behaviour. Resting elevations in the proinflammatory cytokines IL1b, IL-6 and TNFα are a common symptom in overtrained athletes 27. Such proinflammatory environments cause muscle-wasting and are also associated with catabolic hormonal environments 28. Yet more links and similarities with the hormonal theory of overtraining can be seen when one considers the elevations in resting cortisol seen in overtraining. Acute post-exercise cortisol responses of the magnitude that would decrease inflammation by negative feedback are reduced however. Rather than subscribing to one or the other theory of overtraining, it is perhaps more useful to think of overtraining as a great number of interrelated and integrated pathologies, which affect many physiological and psychological processes. Dietary nutritional strategies and supplementation protocols The Nutrition Practitioner Spring

6 As we outline the various pathological processes involved in overtraining, potential strategies regarding nutritional intervention become apparent. The problem can be tackled from one of several angles: 1. Supporting recovery processes around training sessions through the use of amino acids, herbs and macronutrient selection. 2. Supporting HPA axis through the use and rotation of certain adaptogenic compounds. 3. Supporting neurotransmitter/endocrine metabolism by ensuring adequate levels of dietary precursors. 4. Supporting neurotransmitter metabolism indirectly (e.g. cofactors/competitors in synthesis). 5. Addressing inflammation from a nutritional perspective. BCAAs BCAAs compete with tryptophan for the same transport proteins in order to cross the blood-brain barrier. The BCAA/free-tryptophan ratio has been seen to impact upon 5HT synthesis 23. Therefore branched chain supplementation has been theorised to offer relief from central fatigue and overtraining. 26,29 Tyrosine Tyrosine supplementation has been proposed as a method of regulating and maintaining adequate catecholamine levels. Supplementation may have an impact on mood regulation by aiding the synthesis of dopamine (DA), noradrenalin and adrenalin. 30 Omega-3 Fatty Acids Omega-3 fatty acids are the precursors for the series 3 prostanoids and series 5 leukotrienes, as well as resolvins. Prostanoids are inflammatory mediators, while resolvins help mediate their inflammatory action. The series 3 prostanoids and series 5 leukotrienes are less inflammatory than their omega-6 derived counterparts, the series 2 prostanoids and series 4 leukotrienes. By skewing the precursor supply to favour omega-3 derived inflammatory-mediators and resolvins, omega-3 supplementation has been seen to exert anti-inflammatory effects. Supplementation two grams per day or more of EPA has been observed to decrease inflammatory aspects of overtraining in swimmers and aid exercise induced broncho-constriction, while their anti-catabolic properties have shown encouraging results in preventing muscle-wasting 28. From a psychological standpoint, supplementation has also been seen to be effective in the treatment of depression 31, supporting cognitive function 32, and increasing measures of emotional well-being. 33,34 Adaptogens Adoptogen is the name given to a wide and unrelated collection of herbal preparations that seemingly have the ability to adapt in treating a great many different ailments. This has been put down to the fact that these herbs commonly contain a great many different active components which can address different deficits depending on the condition. Valerian is one such adaptogenic plant which in addition to accepted anti-oxidant and immuno-stimulatory properties 35,36 has been used for treatment of overtraining-like symptoms, making use of its regulation of sympathetic neural activity. 30 Summary Overtraining can have severe detrimental effects, impacting upon the physiological and psychological workings of the body and mind. Top Adrenal Supporting Factors: 1. Balance systemic factors 2. Remove Trigger factors 3. Support mental health through cognitive therapy 4. Support adequate recovery through nutrition and lifestyle 6 The Nutrition Practitioner Spring 2010

7 5. Increase CNS supporting amino pre cursors 6. Supporting HPA adaptogen cycling and glandulars Case Study of an Elite Rugby Player Player 1 Symptom Presentation Fatigue especially in the afternoon Difficulty sleeping Under-recovery following training sessions Excess body fat despite following a strict dietary regime A number of psychological symptoms including low grade depression In his words he was just not feeling right. Ragland s sign was positive, 120/80 followed by 103/70, as was pupil dilation test. Player 1 also reported feeling dizzy on standing. (Ragland s sign is an abnormal drop in systolic blood pressure when a person arises from a lying to a standing position. There should be a rise of 8 10 mm in the systolic number. A drop or failure to rise is indicative of adrenal fatigue.) Adrenal stress index test showed low afternoon cortisol levels reflecting fatigue based symptoms initial stages of over-training were apparent. Player 1 s diet was as follows: Time 7-8am 8-9am 12-1pm 2-4pm pm 7-9pm 10pm Action Training (cardio/w eights) Post Training Recovery Lunch Rugby Skills/ Metabolic Session Nap Uncontrolled grazing Dinner Intake Nil BCAAs + Proteinshake Meat + Vegetables (no starch) Protein Shake (during/ post) Table 1: Lifestyle and daily diet on presentation, player 1 Player Supplementation: green drinks (Jarrow green defence, multi nutrients, and omega complete) taken in a sporadic and unplanned manner. Family history: both parents overweight, father had significant problems with cholesterol and was taking statin medication. Nil High GI CHO (Cereals, breads etc) High GI CHO (potatoes) with meat and vegetables. Possibly desert (bakery product) Hypothesis and Nutritional Interventions The initial hypothesis centred around a likely case of over training combined with an inadequate intake of quality carbohydrates in sufficient amounts to allow full muscle recovery and protein synthesis. Strategy The Nutrition Practitioner Spring

8 The key elements were feeding little and often to reduce insulin drive. Whole protein foods were therefore advocated instead of whey shakes, incorporating good fats, fibrous vegetables, and starchy wholegrain foods and root vegetables in measured amounts to support carbohydrate requirements for training. The interventions stressed the importance of taking in nutrients prior to morning training sessions (table below). Symptom Hypothesis Intervention Rationale Fatigue especially in the afternoon Challenge to HPA system through intensive, fasted, Adrenal optimiser (2 on rising with b/fast) Precursors support adrenal function Difficulty sleeping training sessions - possible B-vitamin need, mineral need, and blood-sugar dysregulation ZMA (4 capsules with supper) combination of Zinc l-methionine, zinc aspartate and magnesium aspartate, B-6 Supporting metabolism involved in neurotransmitterregulated sleeping patterns Under-recovery following training sessions Possible impaired protein absorption/metabolism Multi nutrients (2 with each main meal) Address bloodsugar/insulin with frequent small meals Glucose optimiser Address potential shortfall in B vitamin status Assists with proper blood glucose regulation Excess body fat despite following a strict dietary regime A number of psychological symptoms including low grade depression Mis-timing nutrient intake/overconsumption and dysregulated fatty acid Amino acid supplementation changed to PREtraining as opposed to post-training Omega plus EFAs (3 capsules with each main meal) metabolism Green tea extract (1 capsule with breakfast) Challenge to HPA system and possible mineral needs impacting on neurotransmitter function. Under-recovery influencing mental well-being Table 2: Strategy for intervention, player 1 All above Support protein synthesis/repair Regulates fatty acid metabolism Support antioxidant status and fat metabolism As above Lifestyle Interventions Psychological and habitual strategies included 1. Eating earlier in the evening ideally finish eating 3 hours before bed time 2. Introducing raw vegetables celery, peppers, etc 3. Having a broth based soup before the main meal 4. Eating protein foods and cooked vegetables first 5. Eat chosen sources of starch only if still hungry 6. Stopping eating if more thirsty than hungry and return to finish leftovers if desired All recommendations and were clarified with player 1 before initiating the intervention. 8 The Nutrition Practitioner Spring 2010

9 In essence what presented here in the athlete was not at all uncommon a high degree of impact based and resistance training complemented by an inadequate intake of nutrients. Body composition targets were being met through calorie restriction in and around exercise exactly when a higher intake of nutrients is required. The body s defence mechanism excess stress hormone production will eventually deplete the adrenals and result in insufficient adrenal hormone production. The provision of blood glucose stabilising nutrients and frequent feeds suppresses cortisol production and allows the adrenals to begin restoring. This combined with adrenal nutrients pantothine, cycling adaptogens and non stimulant based fat burners allows the athlete to remain lean whilst increasing calories in and around training. As I continue to work with player 1 we now pay more attention to cycling supplementation and to supplementing according to test results as opposed to what we feel a client may need. Overall I learnt that the simple things normally work the best eating slowly, proper digestion, sleep and taking time to relax as an athlete are critical to success. Without these even the most comprehensive supplementation and testing protocols will not assist performance or help with an athlete s health and wellness. For the full unedited version of the case study please About the Author is director of Perform and Function Ltd. From a personal training background, he graduated from ION and ran a personal training company in the City of London where he gained wide experience in body composition change and physical preparation for general and elite level sports. This has led to specialisation in performance based nutrition and diet applications for elite athletes, female hormonal health and body composition management. Currently Matt s day to day work includes elite rugby players, footballers and professional boxers. He holds monthly clinics for the general public to maintain a broader spectrum of applied clinical nutrition. This includes female hormonal health and weight management. He is the author of several ebooks; References 1. Lehmann, M., et al., Autonomic imbalance hypothesis and overtraining syndrome. Med Sci Sports Exerc, (7): p Kreider, R.B.F., A.C.; O'Toole, M.L., Overtraining in Sport. 1 ed. 1998: Human Kinetics. 3. Lucia, A., et al., Hormone levels of world class cyclists during the Tour of Spain stage race. Br J Sports Med, (6): p Fry, A.C., et al., beta2-adrenergic receptor downregulation and performance decrements during high-intensity resistance exercise overtraining. J Appl Physiol, (6): p Lehmann, M., et al., Training-overtraining. A prospective, experimental study with experienced middle- and longdistance runners. Int J Sports Med, (5): p Lehmann, M., C. Foster, and J. Keul, Overtraining in endurance athletes: a brief review. Med Sci Sports Exerc, (7): p Uusitalo, A.L., et al., Hormonal responses to endurance training and overtraining in female athletes. Clin J Sport Med, (3): p Meeusen, R., et al., Brain neurotransmitters in fatigue and overtraining. Appl Physiol Nutr Metab, (5): p The Nutrition Practitioner Spring

10 9. Uusitalo, A.L., Overtraining: making a difficult diagnosis and implementing targeted treatment. Phys Sportsmed, (5): p Hartmann, U. and J. Mester, Training and overtraining markers in selected sport events. Med Sci Sports Exerc, (1): p Lehman, M.F., C; Netzer, N, Chapter 2; Physiological responses to short and long term training in endurance athletes, in Overtraining in sport, R.B.F. Kreider, A.C.; O'Toole, M.L., Editor. 1998, Human Kinetics. p Hooper, S.L., et al., Hormonal responses of elite swimmers to overtraining. Med Sci Sports Exerc, (6): p Kraemer, W.J., et al., Acute hormonal responses to a single bout of heavy resistance exercise in trained power lifters and untrained men. Can J Appl Physiol, (6): p Provenza de Miranda Rohlfs, I.D.M., LS; and W. De Lima, Relationship of the overtraining syndrome with stress, fatigue, and serotonin Rev Bras Med Esporte, (6). 15. Thoren, M. and M. Anniko, Glucocorticoid incubation of human ACTH-producing pituitary tumours in vitro. A study on ACTH secretion and cell morphology. Arch Otorhinolaryngol, (2): p Wellhoener, P., et al., Elevated resting and exercise-induced cortisol levels after mineralocorticoid receptor blockade with canrenoate in healthy humans. J Clin Endocrinol Metab, (10): p Huffman, D.M., et al., Effect of n-3 fatty acids on free tryptophan and exercise fatigue. Eur J Appl Physiol, (4-5): p Huang, Q., et al., Hypoleptinemia in gastric cancer patients: relation to body fat mass, insulin, and growth hormone. JPEN J Parenter Enteral Nutr, (4): p Urhausen, A., et al., Ergometric and psychological findings during overtraining: a long-term follow-up study in endurance athletes. Int J Sports Med, (2): p Urhausen, A., H.H. Gabriel, and W. Kindermann, Impaired pituitary hormonal response to exhaustive exercise in overtrained endurance athletes. Med Sci Sports Exerc, (3): p Wittert, G.A., et al., Adaptation of the hypothalamopituitary adrenal axis to chronic exercise stress in humans. Med Sci Sports Exerc, (8): p Conlay, L.A., L.A. Sabounjian, and R.J. Wurtman, Exercise and neuromodulators: choline and acetylcholine in marathon runners. Int J Sports Med, Suppl 1: p. S Chaouloff, F., D. Laude, and J.L. Elghozi, PHysical exercise: evidence for differential consequences of tryptophan on 5-HT synthesis and metabolism in central serotonergic cell bodies and terminals. J Neural Transm, (2): p Pedersen, B.K., et al., Role of myokines in exercise and metabolism. J Appl Physiol, (3): p Pedersen, B.K., The diseasome of physical inactivity--and the role of myokines in muscle--fat cross talk. J Physiol, (Pt 23): p Armstrong, L.E. and J.L. VanHeest, The unknown mechanism of the overtraining syndrome: clues from depression and psychoneuroimmunology. Sports Med, (3): p Smith, L.L., Cytokine hypothesis of overtraining: a physiological adaptation to excessive stress? Med Sci Sports Exerc, (2): p Fearon, K.C., et al., Double-blind, placebo-controlled, randomized study of eicosapentaenoic acid diester in patients with cancer cachexia. J.Clin.Oncol., (21): p Gastmann, U.A. and M.J. Lehmann, Overtraining and the BCAA hypothesis. Med Sci Sports Exerc, (7): p Balch, J., Balch, P., Prescription for Nutritional Healing 2nd ed ed. 1997, NY: Avery Publishing Group. 31. Hallahan, B., et al., Omega-3 fatty acid supplementation in patients with recurrent self-harm. Single-centre doubleblind randomised controlled trial. Br.J.Psychiatry, : p Helland, I.B., et al., Effect of supplementing pregnant and lactating mothers with n-3 very-long-chain fatty acids on children's IQ and body mass index at 7 years of age. Pediatrics, (2): p. e472-e Lucas, M., et al., Ethyl-eicosapentaenoic acid for the treatment of psychological distress and depressive symptoms in middle-aged women: a double-blind, placebo-controlled, randomized clinical trial. Am.J.Clin.Nutr., (2): p van de, R.O., et al., Effect of fish-oil supplementation on mental well-being in older subjects: a randomized, doubleblind, placebo-controlled trial. Am.J.Clin.Nutr., (3): p The Nutrition Practitioner Spring 2010

11 35. Neill, M. and P.S. Dixon, Effects of a preincisional 14-day course of valerian on natural killer cell activity in Sprague- Dawley male rats undergoing abdominal surgery. Holist Nurs Pract, (4): p Zaffani, S., L. Cuzzolin, and G. Benoni, Herbal products: behaviors and beliefs among Italian women. Pharmacoepidemiol Drug Saf, (5): p (Jeffrey Bland) The 14th International Symposium on Functional Medicine, 21st Century Endocrinology: Thyroid and Adrenal as Sentinel Organs The Nutrition Practitioner Spring

12 Adrenal Stress Causes ( ASC ) ADRENAL CAUSES TOTALS MENTAL / EMOTIONAL SUB-TOTAL ENVIRONMENTAL SUB-TOTAL Copyright 2008 Healthexcel & Functional Diagnostic Nutrition LIFESTYLE SUB-TOTAL Version 1.1 METABOLISM SUB-TOTAL Hit "<Ctrl>Shift X" to SORT tables by NOW column Hit "<Ctrl>Shift Y" to SORT tables by Symptoms Please rate any condition that applies to you NOW and in the PAST, using the following scale: 5 = Severe 4 = Strong 3 = Moderate 2 = Mild 1 = Weak 0 = Not Present Start by going through and marking in the NOW column only the symptoms that apply to you currently Then go back and respond in the PAST column to the symptoms you marked in the NOW column Rate your response in the PAST column based on how you felt when the symptoms were at their WORST KEY: Red numbers indicate worsening since last test. Green numbers indicate improvement. MENTAL / EMOTIONAL NOTES & COMMENTS acute stress or crisis anger often anxiety often autism bi-polar disorder chronic, unrelenting stress depression often despair or hopeless often don t take enough time for myself experienced long periods of stress that effected my well-being experienced one or more stressful events or traumas that effected my well-being fearful often financial stresses prevalent grief feelings often guilt feelings often impatience often irritable often mental strain for prolonged period(s) nervous often no or too little down time often exercise to exhaustion often work until I m exhausted overwork, work long hours panic attacks post traumatic distress syndrome push too hard until exhaustion relationship conflict or stress (family, work, romantic, friendship, marriage, etc.) sad often, no apparent reason type A personality went through a major mental or emotional trauma in last 5 years (death in family, divorce, lost job, lost home, moved, etc.) work stress (unhappy, boss problems, co-worker disputes, deadline pressures, etc.) work too much, I m a workaholic worry about things too much (money, future, relationships, kids, world affairs, health, etc.) MENTAL / EMOTIONAL ENVIRONMENTAL NOTES & COMMENTS air pollution exposure chemical exposures electromagnetic fields (computers, etc.) geo-physical stressors heavy metal accumulation in hair metal fillings in teeth mold exposure at work or home noise pollution non-organic foods processed foods and drink radiation (airplanes, computers, x-rays) root canals in teeth smoking or second hand smoke exposure toxic exposures in air (smog) water pollution wear a dental splint on teeth wear braces on teeth ENVIRONMENTAL LIFESTYLE NOTES & COMMENTS dieting (calorie restriction) excessive exercise lack of exercise late hours (not in bed before 10 p.m.) light cycle disruption ( grave yard shift) long work commutes overscheduled life overwork (physical strain) physical injury, trauma, accident poor diet serious falls or blows to the head sleep deprivation - insufficient quality or duration (less than 8 hours per night) surgery temperature extremes too much to do, not enough time whiplash LIFESTYLE ASC 1 of 2

13 METABOLISM NOTES & COMMENTS acute infections alcohol abuse antibiotic use often bacterial infections bacterial infections-bacteroides fragilis bacterial infections-clostridium perfringens bacterial infections-e. coli bacterial infections-e. enterococcus bacterial infections-helicobacter pylori birth control pills caffeine abuse candidiasis, candida overgrowth chronic fatigue (CFS) chronic illness chronic indigestion chronic infections chronic inflammation chronic pain colitis, mucous colitis, ulcerative diagnosed degenerative condition/disease drug abuse environmental sensitivities food allergies, reactivities, sensitivities fungal infections gingivitis gluten intolerance GSE Gluten Sensitive Enteropathy GSE-celiac disease, sprue GSE-dermatitis herpetiformis hyperthyroid hypothyroid inhalant allergies injury to head, neck, or back insulin resistance kidney problems lactose intolerance liver toxicity or other problems low blood sugar (hypoglycemia) lung or respiratory problems mal-absorption mal-digestion nutritional deficiencies oxidative stress - high free radicals revealed in lab tests parasites protozoa, flatworms, roundworms parasites-cryptosporidium parvum parasites-entamoeba histolytica parasites-giardia lamblia parasites-toxoplasma gondii protein digestion insufficiency pyorrhea structural problems, misalignments sucrose intolerance TMJ stress viral infections (ebv, cmv, herpes) yeast infections METABOLISM Please list any use of Presciption Drugs: Please list any use of Over-the-Counter drugs: ASC 2 of 2

14 Adrenal Stress Indicators ( ASI ) NAME: HEIGHT: SEX: TEST WEIGHT AGE DATE TEMP * What is your Main Health Complaint? 1st Test How often does this bother/affect you? 2nd Test How long has it been present? 3rd Test What have you tried that has NOT worked? 4th Test What does it prevent you from doing that you love to do? 5th Test On a 1-10 scale, what is your level of commitment to getting well? 6th Test Females Only - What is your menstrual status? Mentruating? Perimenopausal? Menopausal? * TEMP - Take your Oral Temperature upon awakening before getting out of bed for 5 days (not necessarily consecutive). Add them up. Divide by 5. Enter your result. ADRENAL INDICATORS TOTALS ENDOCRINE FUNCTION SUB-TOTAL NEURAL TISSUE HEALTH SUB-TOTAL Copyright 2008 Healthexcel and Functional Diagnostic Nutrition MUSCULO-SKELETAL SUB-TOTAL Version 1.4 CARBOHYDRATE SUB-TOTAL EICOSANOID MODULATION SUB-TOTAL DETOXIFICATION SUB-TOTAL FAT & PROTEIN SUB-TOTAL Hit "<Ctrl>Shift N" to SORT tables by NOW column Ratings Hit "<Ctrl>Shift S" to SORT tables by Symptoms Please rate any condition that applies to you NOW and in the PAST, using the following scale: 5 = Severe 4 = Strong 3 = Moderate 2 = Mild 1 = Weak 0 = Not Present Start by going through and marking in the NOW column only the symptoms that apply to you currently Then go back and respond in the PAST column to the symptoms you marked in the NOW column Rate your response in the PAST column based on how you felt when the symptoms were at their WORST KEY: Red numbers indicate worsening since last test. Green numbers indicate improvement. ENDOCRINE FUNCTION asthma bright light/sunlight bothers me bruise easily chronic illness cold often crave salt decreased ability to handle cold diarrhea diminished sex drive, low libido dizzy or light-headed upon standing dry skin edema, fluid retention (around ankles, under eyes, etc.) endometriosis energy low excessive facial or body hair exercise exhausts, makes me feel worse fatigue easily fatigue not relieved by sleep fibrocystic breasts hair brittle hair loss hay fever headaches heart arrhythmia heart palpitations heartburn, reflux, or GERD hot flashes hyperthyroid (medically diagnosed) hypothyroid (medically diagnosed) impotence increased effort to perform daily tasks indigestion when stressed or tense low blood pressure NOTES & COMMENTS ASI 1 of 5

15 low body temperature (below 98 degrees orally) menstrual irregularities/problems migraines nails brittle, break easily nausea need my daily coffee, tea, or cola (caffeine) need to wear sunglasses in bright sunlight night sweats no energy to exercise often awake between 2-3 a.m. (not because I m hungry) oily skin PMS (cramps, nausea, headaches, irritability, etc.) rashes, dermatitis, itching skin, or hives often sleepy, drowsy during the day slow to get going in a.m. and/or like to sleep late sodium retention (medically diagnosed) spider veins swelling or puffiness under eyes tender breasts thin or delicate skin thyroid disorders (medically diagnosed) tire easily, low stamina/endurance tired/low energy, especially in afternoon unable to get pregnant unable to maintain pregnancy urinate frequently uterine fibroids vaginal dryness wake up feeling tired or unrested ENDOCRINE SUB-TOTAL NEURAL TISSUE HEALTH absentminded ADD/ADHD angry often anxiety, anxiousness (can be for no apparent reason) apathetic avoid emotional confrontations or situations best sleep often between 7 9 a.m. can t think clearly concentration difficult decreased ability to handle stress or pressure decreased tolerance of others depression, sadness, melancholy despair emotionally stressed fearful (can be for no apparent reason) feel best in the evenings feel overwhelmed often feel unwell often foggy thinking forgetful get confused often hard to do tasks quickly hard to get out of bed or get going in a.m. hard to think or act quickly have little control over how I spend my time hopelessness feelings inability to calm down insomnia - hard to fall asleep insomnia - wake up & can t go back to sleep irritability just don t feel right, not myself lack drive, motivation learning is difficult less productive than in the past loud noises bother memorization difficult memory poor mentally stressed mood swings, emotional ups and downs must force myself to keep going nervous breakdowns NOTES & COMMENTS ASI 2 of 5

16 nervousness panic attacks procrastinate often shake or feel nervous under pressure sleeping pills needed for sleep spacey, hard to focus startle easily stress or pressure causes me to lie down and rest suddenly run out of energy tearful, could cry easily thinking gets confused when under pressure thinking not as clearly as in the past thoughts too many, too rapid timid, overly cautious upset easily work best late at night worry NEURAL TISSUE SUB-TOTAL MUSCULO-SKELETAL HEALTH arthritis, osteo arthritis, rheumatoid circulation poor difficulty building muscle losing muscle mass low back pain muscle weakness osteopenia osteoporosis pain in jaw (TMJ) pain in joints (not due to injury) pain in low back area pain in lower neck pain in sciatica pain in shoulders pain in upper back sprains or strains occur easily or often stiffness or achiness, especially in morning MUSCULO-SKELETAL HEALTH SUB-TOTAL CARBOHYDRATE METABOLISM alcohol intolerance anger, irritability relieved by eating craving for sweets diabetes, Type I diabetes, Type II excessive hunger feel faint often feel weak hyperglycemia high blood sugar hypoglycemia low blood sugar insulin resistance light-headed often nausea, eating relieves often awake between 2-3 a.m. and need to eat something shakiness, nervousness relieved by eating CARBOHYDRATE METABOLISM SUB-TOTAL EICOSANOID MODULATION allergies - food allergies other inhalants allergies seasonal (hay fever) allergies are worsening (severity, frequency, or to more things) autoimmune diseases-als autoimmune diseases-crohn s autoimmune diseases-graves autoimmune diseases-hashimoto s autoimmune diseases-lupus autoimmune diseases-ms autoimmune diseases-other bacterial infections cancer cardiovascular disease NOTES & COMMENTS NOTES & COMMENTS NOTES & COMMENTS ASI 3 of 5

17 catch colds easily CFS-chronic fatigue syndrome chemical sensitivities coughs or colds usually last for several weeks environmentally sensitive, reactive food intolerances, reactivities, or allergies fungal infections get sick easily or often gum infections (gingivitis) headaches immune deficiency inflammation (not due to injury) often get colds or flu pain (not due to injury) parasite infections sensitive to odors, flowers, or chemicals sick more often, takes longer to get well sinus problems tooth infections (pyorrhea) urinary tract infections viral infections (cmv) viral infections (ebv) viral infections (herpes) yeast infections (candida) EICOSANOID MODULATION SUB-TOTAL DETOXIFICATION CAPACITY acne alternating constipation and diarrhea aversion to certain foods bloating burping or belching constipation (b.m. less than once a day) dark circles under eyes diarrhea exposure to environmental toxins heavy metal accumulation intestinal gas irritable bowel kidney disorders leaky gut liver disorders loss of appetite lung disorders often have nightmares rashes, hives often skin problems, bad skin, bad coloring strong body odor sweat burns my skin DETOXIFICATION CAPACITY SUB-TOTAL NOTES & COMMENTS FAT & PROTEIN METABOLISM digestive disorders mucosal surface integrity problems (ulcers) slow healing sweat has an ammonia odor unable to lose weight weight gain - waist, hips, thighs weight loss FAT & PROTEIN METABOLISM SUB-TOTAL NOTES & COMMENTS ASI 4 of 5

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