Burnout: Part 4: Resolving the Controversy

Richmondchironeu • August 26, 2019

Hello again:

Thanks for staying tuned for Part 4, as this subject is important and lends an understanding as to how chronic health conditions evolve and what to do about them…so this newsletter is a bit longer than usual.

If you have not read this link, please do so to understand the issues, it is not that long and is pretty good:

From this article: “A  recent review  of 58 studies concluded that there is no scientific basis to associate adrenal impairment as a cause of fatigue. The cortisol level, when checked four times in a 24-hour period, was no different between fatigued and healthy patients in 61.5% of the studies…. In summary, there is no formal criteria to define and diagnose adrenal fatigue.”

However, repeatedly and commonly on labs, it can be observed that there are states of adrenal function that are not normal, but not Cushing’s or Addison’s. This is where you can see changes in adrenal function that are not pathologically based. An example would be high morning cortisol, that trends to normal the rest of the day. Or a normal morning cortisol, that drops low during the day but goes up too high at night. Another example is that cortisol is a low normal all day. Currently within allopathic medicine, the term adrenal fatigue is not a recognized condition until the cortisol production becomes too low, then this is called adrenal insufficiency.

Additionally, within functional medicine concepts, adrenal fatigue can be the state that precedes insufficiency that is not brought on by an autoimmune disorder or hypothalamic-pituitary failure but the  KEY  is that adrenal dysfunction can be a result of chronic stress that stems from mental/emotional stress, nutritional stress, chronic illness of any type, autoimmune conditions, latent or hidden infections, poor food choices, lack of sleep or a combination of all types of stress facing any individual. This type of disorder  IS  recognized within standard medicine (see below).

How do we reconcile these observations?

First  of all, this study seems to assume that adrenal issues are part of all fatigue states, yet it is widely recognized that fatigue often/usually has  MULTIPLE  causes. Even the Harvard blog mentions that. So, there is no reason to make the broad assumption that  all  fatigue/burnout states have adrenal dysfunction at the root of the fatigue. Indeed, in the above referenced study, there were 38.5% of the patients that may have met the criteria for adrenal fatigue. Why were those individuals not explained, in other words, if 38.5% of the cases had some form of match up to adrenal fatigue, why not investigate that and come up with criteria and definitions? Perhaps adrenal fatigue affects every 2 out of 5 cases of fatigue or burnout and it is not an all or nothing case. Or maybe this is part of HPA axis dysregulation (see below).

Secondly,  there are other organs that are recognized that become fatigued, such as the pancreas, kidneys, heart, brain and even joints…why not the adrenals in some cases?

Thirdly,  it depends on how you read lab tests, and that means, are you looking for pathology (Cushing’s and Addison’s) or for disturbances of function (adrenal fatigue). It simply can be a matter of gradation that does not fit the standard way of looking at lab results. Standard evaluations have a range of normal, and ANYTHING in the normal range is usually considered Ok, even if the patient has symptoms. In other words, it is a Black or White situation, there is no room for Grey. This way of looking at things has been enormously useful and has greatly benefited humanity. However, when it comes to chronic, multi-system health issues where no clear pathology can be found in the usual way of looking at lab results, it is often useful to look at lab tests where you narrow the normal range (which can be called an Optimal range) and those numbers that are not Optimal but not Black, can be considered to be Grey.

The Grey zone is where there is a lack of normal function that precedes pathology and is often called a disturbance of FUNCTION as opposed to pathology. In Grey zone issues, there are usually no prescription medications or standard treatments recognized…in other words, if you do not have a tool for it, you may not look for it, therefore it may not be considered to be real or exist. This may apply to adrenal fatigue, which is not a disease but a functional condition, and for the most part, functional (Grey zone) conditions often respond best to comprehensive natural supportive therapies, which the author kindly acknowledges when he states: “Alternative and complementary clinicians often have better results, because the appointments tend to last longer and they view patients through a more holistic lens.” The functional medicine approach tends to look at multi-system interconnectedness and seek to support and balance those dysfunctional relationships, and certainly acknowledges, respects, recommends and employs standard methods right alongside functional measures to assist and support optimization. In other words, in my opinion, there is no controversy, but there are two distinct conditions supported by clinical observations and they are Black (Addison’s & Cushing’s) and Grey (adrenal fatigue or over-activity).

Lastly, and  most likely, what we are all really looking at is HPA axis dysfunction or dysregulation, which means that adrenal fatigue states should be viewed from this perspective and as a part of a larger issue. This means that adrenal supplements ALONE will seldom get the results we would all like to see. This makes sense of the abnormal cortisol lab tests that we see even when there is no adrenal or pituitary pathology such as seen in Cushing’s and Addison’s.

Bottom Line:  If you are having unreasonable fatigue, any type of chronic condition(s) or the symptoms that were listed in the previous newsletters,  part  of the investigation should include a morning cortisol test. If that is high or low, then depending of the results, it may be prudent to follow up with a salivary cortisol rhythm test. We often run these lab tests, and the vast majority of the time, we find functional problems, and rarely find pathologically low or high cortisol that requires the immediate referral to an endocrinologist.

HINT:  It is usually more important and useful to find the  underlying causes  of the ongoing stress response that led to the overactive state (high cortisol), then later the crashed state (low cortisol) than it is to simply support adrenal function by itself. This is why the scientific literature  DOES  recognize HPA dysregulation or dysfunction as a real entity:

In the next newsletters, we will go over HPA axis dysregulation and it’s causes, then self-care methods relating to functional disturbances in the HPA axis that include nutrition, stress reduction and lifestyle support for elevated morning cortisol or low cortisol patterns and why I seldom use adrenal supplement protocols.

Do You Know Where 80 to 90% of Your Health Comes From?

By Mark Smith • September 15, 2025
New Title

What You Eat Can Save Your Life…or Not

By Mark Smith • September 8, 2025
New Title

To Avoid Chronic Disease, Watch What You Eat

By Mark Smith • September 1, 2025
To Avoid Chronic Disease, Watch What You Eat

Health News Update: Inflammaging is Bad News

By Mark Smith • August 25, 2025
Hello everyone: I think I have mentioned inflammaging before but never really focused on it. So, let’s dig into this interesting topic. Inflammaging is when chronic, low-grade inflammation develops with age as dietary and environmental stress accumulates, contributing to the development of all of the various age-related diseases and health issues. It results from a loss of control over systemic inflammation, which tends to come from an unbalanced and dysregulated immune system. One of the key drivers of inflammaging is diet…which means that one of the key tools to slow and reduce aging is our what we eat as well as what we don’t eat. In this paper, the authors reveal that the typical Western Diet (what science calls the Standard American Diet or S.A.D.) is the best example of a pro-inflammatory diet pattern. “ Conclusion: Inflammation is a key physiological process in immunity and tissue repair. However, during aging it becomes increasingly more chronic. In addition, we found that certain foods such as saturated fats have pro-inflammatory activity. Taking this into account, in this review we have proposed some dietary guidelines as well as a list of compounds present in foods with anti-inflammatory activity. It must be taken into account that the amounts used in the studies that detect anti-inflammatory activity of these compounds are very high, and the intake of a single food to achieve its anti-inflammatory power is not feasible. (My Comment: what this means is that it is the overall dietary pattern that matters the most.) However, the combination of foods rich in compounds with anti-inflammatory activity could exert beneficial effects during aging and in pathologies associated with inflammation and in reducing the detrimental effects of foods with pro-inflammatory activity. Therefore, we can conclude that the compounds in our diet with anti-inflammatory activity could help alleviate the inflammatory processes derived from diseases and unhealthy diets and thereby promote healthy aging. Thus, we can use diet not only for nourishment, but also as medicine.” https://pmc.ncbi.nlm.nih.gov/articles/PMC8389628/ anti-inflammatory diet and health aging https://www.healthline.com/health/5-minute-guide-to-inflamm-aging Bottom Line: We all must age, and how we do so is largely under our own control. To create an anti-inflammatory lifestyle is not that difficult, especially if you put it all together in stages. Start with a clean, whole-food, unprocessed plant-based food plan. And to begin, first focus on what you can add into your menus and use those additions to sort of crowd out the things that are more inflammatory…sugar, refined grains, processed and pre-packaged things. Set realistic goals such as going plant based one or two days a week, or even one meal…just start and gradually work up. It has to be doable so don’t stress. Next, start moving and doing regular exercise at least three times a week…and find what you enjoy doing and focus on that. Then add activities that de-stress you, whether that is socializing, church, meditation, prayer, yoga, etc. Overall, shift your attention to giving love to things that love you back. Sugar, drive-thru and processed food like thingies do not love you back but apples or kiwis or berries or veggies do. Sitting around does not love you back but going for a short walk after a meal does love you back. Hang out and give love to the people you really like to be with, they will most always love you back. Create a love you back lifestyle and see how you feel.

Health News Update: Blocking Internet on Smartphones Improves Mental Health

By Mark Smith • August 18, 2025
Hello everyone: I frequently hear about mental health issues with the people in our practice. They could be experiencing depression, or anxiety, feel flat, can’t focus or sustain attention, or may not feel well in general. These comments can come from anyone of any age…I can hear from parents about their kids, or it may be themselves experiencing these feeling. So, when I read this paper, it felt important to share it because we all seem to have mobile phones. Here is how the paper is summarized: “Concern about how smartphones affect users is widespread: half of American smartphone users—and 80% of those under age 30—worry that they use their device too much, and correlational research suggests that smartphone use is negatively related to mental health and cognitive functioning. However, few large-scale experiments have tested for causal effects. We report such an experiment, finding that blocking mobile internet for 2 weeks reduces smartphone use and improves subjective well-being (SWB) (including life satisfaction and positive affect), mental health (more than antidepressants), and sustained attention (as much as being 10 years younger). Despite the many benefits mobile internet offers, reducing the constant connection to the digital world can have large positive effects.” https://academic.oup.com/pnasnexus/article/4/2/pgaf017/8016017?utm_source=klaviyo&utm_medium=email&utm_campaign=%28Email%20-%20Chris%20Kresser%20General%20News%29%20Chris%27s%20Friday%20Favorites&utm_term=randomized%20controlled%20trial&utm_content=randomized%20controlled%20trial&_kx=fARhTo_gi8X3B_2-MaeO_RyzUl9tvT3tr4re-Dy7cNQ.my75y6 Bottom Line: It seems like a smartphone ‘timeout’ can be very beneficial for mental, emotional, physical health and can be an important part of stress reduction. The world today, with nearly instant communications, the almost constant bad and anxiety promoting news, and the fast pace of data consumption can add up to significantly stress us out and pull us down…or just simple keep us distracted. From what I can see, a ‘timeout’ may be just what the doctor ordered.

Health News Update: Diet can Alter Your Disease Trajectory

By Mark Smith • August 11, 2025
Hey there everyone: As you know, inflammation causes, perpetuates, and/or aggravates every known human condition, including aging. As we age, we become more vulnerable to non-communicable diseases such as heart attack, stroke, high blood pressure, cancer, diabetes, dementia, arthritis and more. How we eat can massively reduce our inflammatory burden and promote health as we age. It is your choice. One reason that I keep writing on this is that I keep running into the mindset that these diseases are inevitable and that there is nothing we can do about it. Plus, because there are so many different diets for sale out there, it becomes hard to know what to eat. What is important for you to know is that there is a growing scientific consensus about what to eat, but the media rarely mention it and our public health authorities don’t either. It definitely seems like money is more important than our health. So…consuming an overall low-inflammatory diet is what the science is adding up to show it is the healthiest way to go, plus it actually gives you power over your future. This is a great article worth the time it takes to read it as it is pretty comprehensive. Bottom Line: “To adopt an anti-inflammatory dietary pattern, it is recommended to replace refined grains with whole grains, substitute healthy fats (such as nuts, seeds and fatty fish) for saturated and trans fats and increase the consumption of colorful fruits and vegetables while reducing the intake of sugary and processed foods. Additionally, choosing lean protein sources like fish and legumes over red and processed meats, using herbs and spices (such as turmeric, ginger, garlic and cinnamon) in place of excessive salt and sugar and consuming probiotic-rich foods (such as yogurt and kefir) instead of processed and sugary snacks are advised. These dietary adjustments can help mitigate inflammation and promote overall health.” https://www.cambridge.org/core/journals/british-journal-of-nutrition/article/overview-of-antiinflammatory-diets-and-their-promising-effects-on-noncommunicable-diseases/AA3166846841DCC1B219C063F52E2A7F (anti-inflammatory diet)

Health News Update: When We Eat is as Critical as What We Eat

By Mark Smith • August 4, 2025
New Title

: Dietary Inflammation Drives Diseases and Death

By Mark Smith • July 28, 2025
Health News Update: Dietary Inflammation Drives Diseases and Death 7.28.25 Hello again everyone: Here are two papers of tremendous interest because they reveal the link between dietary inflammation and health. Bear in mind that the two leading causes of death in our country are cardiovascular disease (CVD) and cancer…directly caused by chronic inflammation. Conclusion Chronic inflammation appears to play a key role in the development of CVD and certain cancers. The results from the present study suggest that eating a diet high in sugar, saturated fat and other pro-inflammatory foods promote inflammation, which may increase the risk of a variety of chronic diseases. The next logical step would be to use the DII (the Dietary Inflammatory Index) to predict CVD outcomes, such as atherosclerosis, and indicators of CVD including intimal thickening, plaque formation and cardiac output in the Asklepios Study. https://www.academia.edu/29422691/Associations_between_dietary_inflammatory_index_and_inflammatory_markers_in_the_Asklepios_Study?email_work_card=view-paper And here is the follow up study they suggested: Conclusions To conclude, an anti-inflammatory diet may diminish the risk of CVD in healthy individuals but may be impossible to reverse the results of several years of exposure to oxidative stress among participants with established MetS (Metabolic Syndrome). Thus, the presented findings suggest that favoring anti-inflammatory diet at early stages of life could be found to act preventively as regards to the development of CVD and challenge us to evaluate potential antioxidant therapies that could be applied on public health action plans. https://www.academia.edu/80264311/Anti_inflammatory_diet_and_10_year_2002_2012_cardiovascular_disease_incidence_The_ATTICA_study?email_work_card=view-paper Bottom Line: Consuming a diet with low inflammatory potential and high anti-inflammatory ingredients shows real and significant protection against the two leading causes of death. Furthermore, other more recent studies with different interventional designs do show the possibility of overcoming the cumulative damage from Metabolic Syndrome, which is an inflammatory condition associated with high cardiovascular risk. The following links show how the whole-foods, unprocessed plant-based Mediterranean diet reduces Metabolic Syndrome and inflammation. It is never too late to eat right to beat disease!! https://www.mdpi.com/2673-4540/6/1/4 https://dmsjournal.biomedcentral.com/articles/10.1186/s13098-023-01052-7 “In this study, participants with MetS with adherence to high-quality and moderate-quality Mediterranean diet were significantly associated with lower all-cause mortality as well as cardiovascular mortality during the follow-up period. Furthermore, in joint analysis of the Mediterranean diet and sedentary behavior or depression, we found that high-quality or moderate-quality Mediterranean diet could attenuate, even reverse the adverse effects of sedentary behavior and depression on all-cause and cardiovascular mortality in participants with MetS. Among the components of the MED diet, greater intakes of vegetables, legumes, nuts and high MUFA/SFA (Mono-unsaturated fats like olive oil/Saturated Fats mostly animal based foods) ratio were significantly associated with lower all-cause mortality and greater vegetables intake was significantly associated with lower cardiovascular mortality, while more red/processed meat intake was significantly associated with higher cardiovascular mortality in participants with MetS.”

Plant-Based Diet Quality is Essential

By Mark Smith • July 21, 2025
Health News Update: Plant-Based Diet Quality is Essential 7.21.25 Hello everyone: While science now recognizes that going plant-based is critical to prevention and recovery from any illness, dietary quality is a must…not all plant-based foods are healthy. Please read these highlights carefully: “A new study confirms that healthy plant-based foods can be beneficial for the heart. However, not all plant-based foods qualify as healthy, and the study finds that those foods can be just as damaging to the heart as their non-plant-based counterparts. For many people who choose not to eat animal-based foods for moral reasons, the potential health benefits of a plant-based diet may be considered a happy byproduct or even a reward. The study suggests that this is not necessarily incorrect, as long as one considers that the rules that apply to healthy eating in general also apply to plant-based foods. This study’s biomarkers of concern were cardiac troponin T, cardiac troponin I, and N-terminal pro-B-type natriuretic peptide. Troponins are indicators of cardiac muscle damage, which is a sign of myocardial infarction or heart attack . The peptide is associated with heart failure. Up to 50% of individuals with no apparent history of cardiac issues have subclinical levels of troponins. While these levels are not of immediate concern, they may be interpreted as an (early) warning sign of potential future issues. (Especially cardiac troponin I elevations.) The analysis revealed that adherence to a healthy plant-based diet was associated with a 49% lower likelihood of having elevated levels of cardiac troponin I. People following an unhealthy plant-based diet had a 65% greater chance of elevated levels of cardiac troponin I.” https://www.medicalnewstoday.com/articles/unhealthy-plant-based-diets-may-significantly-raise-heart-disease-risk?utm_term=feature&utm_source=Sailthru%20Email&utm_medium=Email&utm_campaign=MNT%20Daily%20News&utm_content=2025-06-18&apid=41304130&rvid=a32216b5e1c0c5df3c84080e2b2e161318206dbce6fd663dd747aa557a4753cd https://www.sciencedirect.com/science/article/pii/S2666667725001047 To clarify this observation, increasing cardiac troponin I levels reveal very early heart damage from systemic inflammation, which if allowed to continue can lead to cardiovascular disease progression…the number one killer on the planet. Thus, consumption of a predominantly unprocessed, plant-based whole-foods diet is largely anti-inflammatory and heart protective, while a diet that may be plant-based but is processed, fried, sugar laden, etc., is what contributes to systemic inflammation and sets the stage for heart, arterial and immune damage. https://pmc.ncbi.nlm.nih.gov/articles/PMC5419814/ https://www.ajconline.org/article/S0002-9149(02)02253-1/abstract Bottom Line: Quality really matters, so please avoid processed foods from all sources, plant or animal. Be wary and minimize or avoid processed or ultra-processed food products…stick with unprocessed whole-foods such as vegetables, fruits, beans, nuts, seeds, lentils, etc. to protect your health and your heart. Food is foundational to all aspects of our lives, so please…eat as if your life depended on it…because it truly does. “While many plant-based diets can reduce cardiovascular risk due to their nutritional profile, such as being low in saturated fat, high in fiber , high in potassium , magnesium, calcium, and antioxidants , not all plant-based foods share these benefits,” she added. ( Michelle Routhenstein , who is a registered dietitian specializing in heart disease.)

: Plants Can Save Your Life

By Mark Smith • July 14, 2025
Health News Update: Plants Can Save Your Life 7.14.25 Hello everyone : I am working to give you information that you can easily put into your daily life that can massively improve your health and wellness, as well as speed recovery and promote prevention. Because inflammation can cause, aggravate, and/or perpetuate every known human ailment (including aging), my goal is to empower us all towards our best life by managing our inflammatory and anti-inflammatory biology. Because food is foundational to health, it is important to know what the best dietary approach to health is, and currently the data is all pointing to plants…the only source of phytonutrients adequate to upgrade your health. “Phenolic compounds including phenolic acids, flavonoids and proanthocyanidins are widely distributed in plants as a protective mechanism against biotic and abiotic stresses. Fruits, vegetables, grains, spices and herbs are the richest source of dietary polyphenols. High intake of these foods has been linked to lowered risk of most common degenerative and chronic diseases that are known to be caused by oxidative stress . This review intends to summarize briefly recent progress on the chemistry and biochemistry of dietary polyphenols, their antioxidant and anti-inflammatory activities, and the underlying molecular mechanisms of their involvement in inflammation mediated metabolic diseases are also discussed.” https://www.sciencedirect.com/science/article/abs/pii/S2214799316300133 Bottom Line: Be sure to eat lots of a lot of different plant-based foods. Make it an integral part of your day and personal health plan. Read what the science says that can lead us all to make the best choices when it comes to fueling our body, our Temple, our only home. We all have nothing to lose and everything to gain by being smart about what we choose to consume day in and day out. Shoot for 90% of your food to be from unprocessed, whole-foods, plant-based sources and watch your health improve. “Dietary polyphenols are one of the most important groups of natural antioxidants and chemo preventive agents found in human diets including fruits, vegetables, grains, tea, essential oils and their derived foods and beverages. Epidemiological, clinical and nutritional studies strongly support the evidence that dietary phenolic compounds enhance human health by lowering risk and preventing the onset of degenerative diseases including cancers, cardiovascular diseases and metabolic disorders.” If you want to be really impressed, and super informed, at the bottom of the paper take a look at the references…click on a few and read the beginning introductions/abstracts…this should help convince you that our present day Standard American Diet is truly S.A.D and empower your shift to a predominantly plant-based lifestyle. Friendly-tip : to make the upgrade to a predominantly plant-based whole-foods plan and to make it easy, start with one meal per week…then move to 3 meals per week, then one per day…or just start with breakfast or lunch…think about and focus on what you can add to your daily food intake…that makes it easier to know what to avoid.
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