Warning: This post contains strong language. If you are offended by strong language, please leave this site now. Ditto if you are one of those bizarre individuals who believes I'm obligated to exhibit saint-like patience and politeness to people who behave like rude assholes towards me.
I’ve written previously about health journalists, and why much of what they write and say is complete nonsense. Despite an implicit duty to present the public with the most accurate possible information, many reporters have little-to-no first-hand knowledge of the subject about which they are reporting on. Instead, they rely on the self-serving statements issued in press releases (which are typically drafted by PR agencies and publicity departments representing vested commercial/ideological interests), and on the opinions of the so-called ‘experts’ they’ve contacted for a quotable quote.
Just how gullible are journalists, exactly?
“Hmmm, a Press Release from Someone Called ‘Luke Sissyfag’ … Sounds Legit to Me!”
Luke Sissyfag was born Luke Montgomery, in 1974. A precocious lad, at 17 he changed his name by deed poll, became a vocal gay rights campaigner, and by the ripe old age of 21 had heckled Bill Clinton six times, disrupted speeches by the Secretary of Health, appeared on The Phil Donahue Show, conducted hundreds of interviews around the USA, and even run for Mayor of Washington in 1994 on the platform, “AIDS is the issue”. Sissyfag was the lipstick-wearing heckler who shouted down Clinton on World AIDS Day, 1993, and was subsequently dragged away by secret service agents.
As often happens when people grow up, Luke Montgomery has changed markedly since his angry heyday of the early 90s. He dropped the Sissyfag surname and in, a dramatic turnaround, became a vocal critic of what he saw as the childish self-indulgence and blatant dishonesty displayed by many in the gay activist movement. In a 1996 interview, Montgomery forthrightly admitted he and his fellow activists deliberately disseminated false claims about the susceptibility of heterosexual women to AIDS, and the prevalence of homosexuality among males.
One especially laughable episode in the early 90s saw articles titled “10% of Men are Gay” feature prominently in newspapers all around the world. The claim was a hoax, one that could’ve easily been identified if the journalists in question had bothered to check even a smattering of the multitude of studies from real researchers showing the true prevalence of male homosexuality to be 1-2%.
When journalist Paul Sheehan asked Montgomery in 1996, “You admit you were cooking the statistics?”, the latter stated outright:
“Absolutely! … We used to skew statistics on a regular basis. We could make one statistic say the opposite of what it really meant, and it’s very simple to do. For example, claiming that AIDS is growing most rapidly among young heterosexual women … It was just scaremongering. Media manipulation.”
So how, exactly, did Montgomery and his former activist colleagues succeed in having patently false statistics reprinted in newspapers all around the world?
“One thing I learned quickly was that if you could write a really good press release, you could write the story,” Montgomery told Sheehan.
“I don’t mean to insult you,” added Montgomery, “but from my experience most journalists are idiots.”
And he’s right.
I don’t know about you, but if I received a press release from someone calling himself “Luke Sissyfag”, you can bet your last dollar I’d research the living shit out of both him and his claims before even dreaming about giving them any print space or airtime.
But journalists all around the world - bless their gullible, unquestioning, scoop-hungry little souls – saw fit to print his claims without so much as even a cursory check of their veracity!
You might think journalists would’ve wised up a little since the Luke Sissyfag era. But they haven’t – reporters still present us with untenable hogwash on a daily basis, and health reporters are certainly no exception.
At this link, you can read all about a 2013 story aired by the Australian Broadcasting Commission (ABC) called “Toxic Sugar?” It featured a litany of patently idiotic claims about exercise, carbohydrates, insulin, and fat loss. The journalist responsible for bringing this feast of fallacious nonsense to Australian screens was Maryanne Demasi, a “medical research scientist” with a PhD and the recipient of “National Press Club of Australia prizes in 2008 & 2009 for … Excellence in Health Journalism”.
After the show aired, I emailed Demasi with abundant evidence showing the claims made by the so-called ‘experts’ on her show were flat out wrong. I asked her why, in light of this evidence, did she include such nonsensical claims in the segment? Her response was to claim that she was busy working on a cholesterol story, and that she would get back to me shortly with a response.
She never did.
But someone from the ABC called Mark Maley wrote me the following month, claiming that in response to my article the organization had conducted an “independent investigation” into the Catalyst segment and had satisfied itself that everything was hunky-dory with the story. In an attempt to explain just how they’d arrived at this decision, Maley proceeded to insult my intelligence with yet more pseudoscientific nonsense.
In addition to apparently not knowing what the word “independent” means (an organization investigating itself is about as ‘independent’ as a criminal presiding as judge over his own trial), Maley clearly had not read the research he cited. In fact, rather than restore confidence in the investigative abilities of his Catalyst cohorts, his email response provided a rather alarming insight into just how hopelessly inept they really were:
I never heard back from Maley, either. I’m guessing that, just like Demasi, Maley knew full well he’d not read the research for himself, and attempting to argue that research with someone who had bothered to read it was going to be a rather futile endeavour.
Clueless Is As Clueless Does
Today, however, you’re going to meet a health writer who harbours no such inhibitions whatsoever. This person boasts (rather loudly) of having penned articles for the Los Angeles Times, Chicago Tribune, TIME magazine, and AskMen. He’s even managed to score a book deal with Random House, one of the world’s largest publishers.
He has a very impulsive, irrational nature, and consequently has a habit of making bold claims in his articles that he hasn’t bothered to verify. He was almost sued by The Biggest Loser trainer Jillian Michaels after making false and malicious statements about her certifications in the LA Times; the newspaper subsequently printed a retraction and Michaels let the matter rest.
As it turns out, this blatant hypocrite is himself a stay-at-home dad – he just conveniently refers to himself as a “work-at-home dad”. But, as you’re about to see, he evidently isn’t very busy – he has plenty of time to troll the internet, making a pest of himself, belittling others in an ongoing quest to big-note himself. A cursory scan of his articles quickly reveals why he has so much spare time on his hands - they involve no research aside from Googling for some ‘expert’ who looks like they’ll furnish a supportive quote.
Meanwhile, his wife is a doctor who consults patients while he spends his days trolling the Internet. I’ll leave it to readers to surmise who the real earner in that household is …
To further add to the oddities, this stay-at-home troll began his ill-conceived attack on stay-at-home fathers by describing Facebook as “the biggest waste of time on the planet" – but, as you’ll see below, continues to suffix all his emails with “I Love: Facebook”.
As you’re about to learn, there’s a lot that’s bizarre about this “syndicated” health writer.
This particular writer has a column called “In Your Face Fitness”, and wears his provocative, belligerent shtick like a badge of honour. Trouble is, when he provokes others who were minding their own damn business and they return in kind, he suddenly starts crying about being “attacked” and being the subject of unwarranted “vitriol”. Yep, like a lot of bullies, our intrepid hypocrite can dish it out, but he can’t take it.
And here’s the real cracker: While most people who argue with me at least make a pretense of referring to the science and having read the research, this guy openly admits he has not read the research, has no intention of doing so, and is instead perfectly happy to rely on the dubious claims of so-called ‘experts’!
The name of this belligerent, reckless, authority-worshipping ignoramus?
The Name is Fell. James Fell. IQ 007.
A few weeks ago, I sent out a newsletter announcing a new feature at my website: A “Recommended Reading” page featuring a list of books I rate highly and that I believe would be of interest to many of my readers:
I’ve since received numerous emails from grateful readers, but not everyone was enamoured with my recommended reads. Within hours of sending out the newsletter, I received a rather curt email from one James Fell, loudly protesting my inclusion of James L. Wilson’s Adrenal Fatigue: The 21st Century Stress Syndrome. It was apparent from the outset Fell had not even read the book, and if I need to explain why attacking a book you’ve never even read is downright idiotic, then you probably work in the health reporting department at Los Angeles Times, Chicago Tribune, TIME magazine or AskMen.
When Fell openly admitted he had not read Adrenal Fatigue, I asked him to cease and desist in emailing me until he had done so and could offer something resembling intelligent commentary on the book. Some seven days later, Fell had still not read the book but stubbornly continued to email me.
I must say, Fell is definitely one of the more bizarre individuals I’ve heard from lately (and as long-time readers will know, I’ve had some real oddballs email me over the years). Fell seems completely devoid of reason, and is utterly incapable – indeed, totally disinterested – in verifying facts and research for himself. Nonetheless – in the long, proud tradition of modern journalistic stupidity - editors at a number of well-known publications have seen fit to give this guy print space.
I’ve reprinted Fell’s emails, along with my replies, below. They serve as a textbook classic example as to why people should be very, very wary of the rot that passes for modern health reporting. Fell’s flippant disinterest in first-hand research, his reliance on ‘top experts’ who in fact are woefully ignorant on the topic they’ve commented on, and his infatuation with superficial indicators of writing ‘success’ such as readership size (as opposed to the quality and veracity of the information he is relaying to his readers), all paint a most unflattering picture.
Fell’s need to resort to pithy little insults to compensate for his woeful inability to deliver intelligent, reasoned commentary on the matter he himself raised also confirm this is one terribly impulsive, insecure sufferer of Little Man Syndrome.
Anyway, ladies and gentlemen, here he is in all his utterly irrational glory … James Fell.
So there it is, folks. Take note of how I promised to elaborate on the science, and the best Fell could do - in addition to issuing yet more pathetic little insults - was threaten to defame me. Yep, after I post this, Fell has vowed to tell his faithful readers – all five of them – that I am crazy.
Yeah, like that’s never been tried before LMAO.
A Quick Stroll Down Memory Lane
There was once a flabby ‘diet guru’ who, just like Fell, delighted in belittling others and making bold and bullshit-laden pronouncements on topics he was woefully ignorant on. With a best-selling book to his name, and a gushing sycophantic audience that uncritically soaked up all the pseudoscientific rot he published on his blog, this diet guru had increasingly lost touch with reality. His blog posts evinced an increasingly arrogant air of superiority, and the uncritical adulation he enjoyed from his blog readers emboldened him with a misplaced sense of empowerment. Our portly diet guru began acting in the manner of what Wall Street traders used to refer as “Big Swinging Dicks”: stockbroking hotshots who made a lot of money and strutted around with the swagger of someone carting a donkey-sized appendage.
Yep, and we all know what happened to those guys in 2008 …
While our flabacious, girdle-wearing diet guru never jumped out of his office window, he did stop blogging after a rather humiliating encounter in which his arrogance finally came back to bite him in the ass.
His name was Michael Eades, and you could read all about his idiotic carry-on here:
Just like Fell, the deluded Eades greatly overestimated his public influence, and earnestly believed he was going to “discipline” me with a series of long-winded posts that claimed I was “MAD” and “a man obsessed”.
All he achieved in the end was to publicly confirm everything I had maintained about him: That he was a hopelessly biased, intellectually dishonest shill who made untenable claims about low-carb diets that had already been repeatedly disproved in tightly controlled clinical research.
Amusingly, Eades eventually recovered enough to return to blogging – only to recently come under heavy fire again, this time from someone who used to be one of his biggest fans.
Yep, Richard “Free the Animal” Nikoley has been repeatedly rubbing Eades’ face in his own hypocrisy, and it truly is a sight to behold:
The Comment Dr. Michael Eades Doesn’t Want You To See
And, as usual, Eades asked for it. When Richard posted some material that blew apart the official Inuit-Eskimo-Universal-Theory-of-Low-Carb-Awesomeness™, Eades took it upon himself to publicly accuse him of suffering confirmation bias.
As Steve Irwin, bless his exuberant soul, would’ve said:
Eades accusing someone else of suffering confirmation bias is like Kim Kardashian accusing someone else of being an attention-seeking slapper.
And then there was the loathsome Janet Brill who, when asked in a public forum what she thought of my book, promptly labelled me a looney.
Things didn’t go too well for her after that:
Note how Brill, despite being the one who made totally unprovoked and uncalled for attacks on my character, proceeds to sanctimoniously whine about having to “defend” herself from my “vitriolic” attack.
I’ll say this about my critics: They’re a boringly predictable and exceedingly hypocritical lot.
As even Fell himself notes, you can tell a lot about a person by the quality of their enemies. And my list of enemies reads like roll call at a lunatic asylum:
Deranged and racist serial troll Razwell
Pathological liar and militant vegan troll Harley Johnstone, whose default response when confronted with criticisms he cannot intelligently refute is to try and defame his critics with blatant and malicious lies. When one former follower of his absurd dietary recommendations started sharing her unfortunate experiences (which included hospitalization) with the world, Johnstone's desperate response was to accuse her of child pornography. When offered $10,000 to furnish proof of this absurd accusation, the money-hungry Johnstone suddenly suffered stage-fright:
The anonymous, cowardly and pathologically dishonest Youtube super-sleaze “Plant Positive”: Another militant vegan sleaze who you can read all about here, here and here.
The hopelessly histrionic Martin Berkhan
Fight-picking loudmouth Danny Albers (who openly admitted to attacking me in an attempt to garner more readership for his crap website)
The irrational, ungrateful and pussy-whipped Don Matesz
Dr Helmet Gohlke, who accused me - without any evidence whatsoever - of writing my book The Great Cholesterol Con simply to make money - all the while selling his own book on heart disease that costs ten times as much as mine...
And now James Fell: The irrational, impulsive, authority-worshipper who loudly boasts about being “In Your Face”, then acts like a petulant little brat when he gets in someone’s face and they return in kind.
Yep, if the quality of one’s character is inversely related to the calibre of one’s enemies, then I must say:
Right now I stand in pretty bloody good stead 🙂
But alas, despite all those who have gone before him and fallen flat on their faces, Fell thinks he’s going to be the one that finally ‘topples’ me. Like Eades, his head has become rather swollen and he’s started to become recklessly overconfident in his abilities. He’s scored a few writing gigs from editors who don’t yet realize what a lunatic they’re dealing with, and he’s managed to score a book deal from a major publishing house that is probably now looking at his measly sales record and wondering why it ever bothered. And his greatest, proudest achievement to date seems to have been defaming The Biggest Loser trainer Jillian Michaels and getting away with it.
Yeah, that’s something to brag about to the grandkids.
And Now, We Interrupt this Hate-Fest to Bring You the Science
As you can see, despite his vehement opposition to my recommendation of Adrenal Fatigue, Fell has not even read the book. Despite my repeated requests for him to actually read the book and then offer some informed commentary, Fell has steadfastly refused to do so – but kept emailing me anyway.
As such, the discussion of Adrenal Fatigue inevitably ceases here. Those who want to learn more about the book are welcome to read my description here, or can go straight to Amazon and read the reviews by others who, unlike Fell, have actually read the book for themselves and awarded it an average 4.5 out of 5 rating.
What I’m going to do now is turn to the topic of mild adrenal insufficiency itself. This is important, because it is a very real condition. One, I should add, that is recognized by researchers with the kind of credentials James Fell, Master of Business Administration and NSCA-certified fitness trainer, and the tiny sampling of cherry-picked ‘experts’ he cites, could not even begin to dream about.
Fell and his band of ‘experts’ at least acknowledge that “things can go wrong” with the adrenals, but they believe the story pretty much begins and ends with overt disorders like Addison’s and Cushing’s. They flatly refuse to acknowledge the well-documented realities of mild adrenal insufficiency.
Mild adrenal insufficiency is pretty much what the name suggests – lower than normal output of adrenal hormones, but not the severe deficiencies seen in Addison’s. This less overt form of adrenal insufficiency, as you shall soon learn, is a common feature of ailments such as Chronic Fatigue Syndrome.
While mild adrenal sufficiency is real and acknowledged by some of the brightest minds in endocrinology, some of the duller minds in that field – for reasons known only to them – prefer to stick their head in the sand and pretend it doesn’t exist. They then issue untenable guidelines and statements that achieve nothing other than fostering further ignorance and confusion on the topic.
The real losers from all this are the patients with disordered HPA function resulting in deficient adrenal hormone output who are suffering unexplained fatigue but remain undiagnosed because their physicians are either unaware of the growing research on mild adrenal insufficiency or have uncritically accepted the dopey guidelines that claim such insufficiency is a “fake” diagnosis.
To help put the alleged ‘controversy’ over mild adrenal insufficiency in context, imagine ‘experts’ who recognized full-blown insulin-dependent diabetes, but labelled diagnoses of non-insulin-dependent diabetes or pre-diabetes as “fake”, and caustically derided those who prescribed metformin or recommended things like exercise, weight loss, and iron-reduction (all shown in RCTs to improve glycemic control) as a bunch of “alt-med” quackopaths.
Anyone with half a brain would realize the entities making these statements were not ‘experts’ but out-and-out idiots.
I’m sorry folks, but I’m really struggling to view those who deny the existence of mild adrenal insufficiency any differently. With over three decades of research showing it is a very real phenomenon, anyone who claims it is a fake diagnosis has simply not bothered to conduct even a cursory examination of the medical literature. Whether this is due to laziness, irrationality, or aversion to information that may refute a preconceived conclusion, I’m not sure.
But the fact remains these people are so obviously wrong it’s not funny.
Do Adrenal Glands Suffer “Fatigue”?
As I’ve noted, I don’t like the term “adrenal fatigue”, because it creates a misleading impression that the adrenals themselves just get “tired”. The term “adrenal fatigue” evidently conjures up, in some people’s minds, images of adrenal glands running to exhaustion then collapsing in a glycogen-depleted heap, or sitting battered on a stool between rounds of a prize fight pleading “Cut me, Mick … cut me!”
An Italian-American adrenal gland suffering severe fatigue. No, wait - that’s Rocky!
And it doesn’t help when some people who’ve written articles on the topic explicitly state the adrenal glands themselves become "fatigued".
In response to this simplistic scenario, we then get folks who loudly proclaim “adrenal fatigue” to be a load of bullshit.
Adrenals don’t “fatigue”, they note.
Correct. And if this is where their argument began and ended, and they were able to subsequently propose a more appropriate term, I’d have no qualms with these folks.
While the adrenal gland “depletion” hypothesis was indeed considered by researchers much smarter than Fell et al in 2000, to the best of this writer’s knowledge there still exists no scientific confirmation that adrenal glands suffer a decline in their hormonal output due to "fatigue" or "depletion".
What is far more likely to be happening is that the adrenals, being the ‘ground floor’ gland of the HPA axis, are secreting less hormones in response to changes higher up in the HPA axis.
To put this into perspective, let’s consider the case of men who suffer from low testosterone. Their levels of the big T didn’t become deficient because their testicles got “fatigued”. While testicular damage (e.g. from radiation) can indeed interfere with testosterone production, in most hypogonadal men the problem originates further up the chain of hormonal command. It could be deficient levels of LH, FSH, or excessive levels of estrogen or prolactin. Perhaps the patient’s total testosterone levels are perfectly normal, but an unusually high level of sex-hormone binding globulin (SHBG) has left him with low levels of all-important free testosterone.
Just like the testes, the adrenals don’t exist in a vacuum, but affect and are affected by what’s happening elsewhere in the body. The term adrenal fatigue may cause some folks to forget that the adrenals are part of the intricate feedback loop that is the HPA axis.
This is why I specifically and repeatedly mentioned hypo-pituitary-adrenal axis dysfunction to Fell, but it’s clear he has very little knowledge of the HPA axis. That’s why he turned to so-called ‘experts’ for an opinion, hoping they would do his thinking for him. Sadly, they were almost as ignorant on the subject as he is.
So the first step to making sense of this whole adrenal fatigue thing is to realize that there is no evidence that adrenal glands ‘fatigue’ per se. That’s a simplistic scenario that ignores the intricate and complex nature of the HPA axis. As Anthony Cleare, one of the leading researchers on HPA abnormalities noted in 2004, “the explanation for lowered cortisol levels [in CFS] is most likely multifactorial.”
We know that in at least some illnesses characterized both by fatigue and low cortisol levels, the hypothalamus releases lower-than-normal levels of corticotropin-releasing hormone (CRH). CRH, in turn, triggers release of adrenocorticotropic hormone (ACTH) in the pituitary, which then stimulates production of hormones such as cortisol in the adrenals. And so low CRH = low ACTH = low cortisol. Yep, a wee bit more involved than simple glandular ‘fatigue’.
It’s not hard to see from this extremely brief overview of the HPA axis why the “fatigue” hypothesis of deficient adrenal output is overly simplistic and provides a misleading impression of how such deficient output arises.
As a consumer of health information, you should always be wary of overly simplistic theories, because, well, they’re overly simplistic. Take the cholesterol hypothesis of heart disease, for example. To this day, journalists, authors and other people without a clue still write stuff like “eating saturated fat causes fatty deposits to build up in our arteries”, as if arterial plaque occurs in the same manner as mud blocking a pipe.
Atherosclerosis begins inside artery walls, not on the surface that is exposed to the bloodstream. It involves the accumulation inside these walls of white blood cells, red blood cells, calcium, scar tissue and yes, fatty acids and cholesterol (the latter being delivered to the site to fulfil its role as a repair substrate). Allowed to continue, this process produces an atheroma that will bulge and narrow the artery. If this atheroma ruptures and its contents spill into the bloodstream, the likelihood of a coronary event or ischemic stroke increases markedly.
Atherosclerosis is not caused by blobs of fat and cholesterol waddling down arteries, pointing to a comfy-looking spot, then settling down and reproducing to the point where the artery becomes blocked.
The cholesterol hypothesis and the mud-inside-a-pipe paradigm of atherosclerosis are hogwash.
But that doesn’t mean atherosclerosis is hogwash. Atherosclerosis is very real, common, and potentially deadly.
It’s one thing to address misunderstandings about the mechanisms behind a medical condition; it’s another thing entirely to deny that condition even exists. And that’s where Fell and his ‘experts’ have screwed up royally – in their enthusiasm to debunk the “adrenal fatigue” mythology, they not only attack misguided perceptions of how the condition arises, but claim that mild adrenal insufficiency does not even exist.
Which is absolute bullshit.
And so if Fell was a non-deranged individual who confined his criticism to the term “adrenal fatigue”, all would be fine and dandy. I would’ve clarified my stance on the issue, he would’ve said “oh, cool, I’m glad you cleared that up!”, and I would’ve said “no worries!” To propagate the burgeoning feeling of goodwill, I might then have said, “listen man, if you ever visit Australia, drop me a line and I’ll make sure I throw another prawn on the barbie!”, to which Fell might have replied, “No worries bro, and if you ever visit Canada, let me know and I’ll buy you a beer!”, to which I would’ve replied “not wanting to sound unappreciative, but I don’t drink beer. I’ve never liked beverages that have a gut named after them, plus that shit tastes too much like what I imagine camel piss would taste like (I’ve never actually tasted camel piss so I can’t be sure) but, hey, a nice malt whiskey will do just fine!”, to which Fell would’ve replied “No problem, malt whiskey it is!”
But, alas, that’s not what happened.
In addition to angrily attacking me for recommending a book he’d never read – a patently absurd action in itself – Fell vigorously attacked the notion that anything other than Addison’s or Cushings could ever go wrong with the adrenal gland.
I clearly explained to Fell my stance on the term adrenal fatigue, and left no doubt I was not talking about adrenal glands being too knackered to do their job properly, but about conditions in which physical - and often mental - fatigue were accompanied by unusually low levels of cortisol release and/or irregular patterns of cortisol release. As Richard Shames, MD, points out, "Any doctor worth his/her salt understands that the term "adrenal fatigue" means mild adrenal insufficiency."
Even the Endocrine Society unwittingly supports this stance when it writes: “While adrenal fatigue is not accepted by most doctors, adrenal insufficiency is a real medical condition that occurs when our adrenal glands cannot produce enough hormones.” The Endocrine Society, of course, maintains the only time this happens is in Addison’s, but as you’ll soon learn there is plenty of research showing impaired cortisol output in people suffering fatigue but who do not have Addison’s.
As the above exchange clearly shows, Fell rejects my (and Shames’) stance outright. His beef is not just with the semantic issues inherent in the term “adrenal fatigue”, but with the very concept of subclinical adrenal deficiency. For maintaining there are health conditions characterized by fatigue and accompanying low/irregular cortisol levels, Fell labels me a mentally insane crackpot that lurks in some “alt-med” swamp with chiropractors (I’m not sure just what his problem is with the bone-cracking fraternity, but Fell evinces a very unhealthy and hate-filled obsession with chiropractors, whom he virulently derides every chance he gets).
Well, one of the parties to the above exchange was indeed a person of highly questionable mental competency, and it sure as hell wasn’t yours truly.
Why James Fell Doesn’t Have the Foggiest Idea About Adrenal Insufficiency
I’m not kidding when I say Fell is oozing so much untenable rot on this topic it’s hard for me to know just where to start.
Tell you what; seeing as Fell has such a hard-on for ‘experts’, why don’t we kick things off with a real quick game of “My-Expert-is-Better-than-Your-Expert”? Being the kind of person that likes to think for himself instead of mindlessly accepting the edicts of ‘experts’, I’ve never actually played it before but, hey, I’m a quick learner. And given his performance so far, I don’t think I’ll have too much trouble triumphing over Fell.
So let’s take a look at Fell’s ‘experts’:
1. His wife. While no doubt a lady of remarkable tolerance, given her ability to live with an obnoxious and immature jackass like Fell, her inclusion as an ‘expert’ on adrenal insufficiency is questionable. When confronted with a patient who suspects they have “adrenal fatigue,” she inquires about things like depression, stress and burnout - as she should. However, she apparently shares Fell's conviction that "adrenal fatigue" is a "non-existent diagnosis", and therefore would appear not to bother herself with checking the patient's cortisol status.
As we shall soon learn, this is most unfortunate for her patients.
Number of peer-reviewed papers she has published on HPA dysfunction: None.
2. Sue Pedersen, an MD and endocrinologist who, like Fell, hails from Calgary, Canada. She completed her endocrinology training in 2005. Her bio states she deals “primarily with diabetes, thyroid, other hormone, and weight management issues” and that her research focus is in obesity management, including “portion control,” diabetes medications” and “gastric bypass surgery”.
Number of peer-reviewed papers she has published on HPA dysfunction: None.
Look, Dr. Pederson sounds like a conscientious and passionate practitioner, but she nonetheless makes some very questionable assertions about “adrenal fatigue” that cannot go without redress.
It also reveals a lot about Fell that, of all the relevant and highly qualified researchers he could have contacted, he instead chose to cite in his article a grand total of one (1) whose research focus lies not in HPA dysfunction and its related fatigue syndromes, but with obesity-related research such as "portion control", "diabetes medications" and "gastric bypass surgery".
3. The Endocrine Society. This is where shit gets real funny. I’m not sure what qualifies a bunch of people to get together and pronounce themselves a “Society”, but clearly getting your story straight isn’t one of them.
The Endocrine Society claims “There is no test that can detect adrenal fatigue”. Well, if you believe in the adrenals-that-are-too-pooped-to-pop paradigm of ‘adrenal fatigue’, then yes, of course there is no test, just like there is no test for ‘testicular tiredness’.
But once we drop the disingenuous semantic bullshit, and acknowledge the substantial volume of research showing insufficient or irregular output of cortisol in people who do not suffer Addison’s, then a number of the Society’s claims can be readily identified for the nonsense they are.
While it admits “Adrenal insufficiency is a real disease”, it believes the story begins and ends with Addison’s. It refuses to acknowledge the numerous studies – many published in its own journal – demonstrating that mild adrenal insufficiency is very real.
In its "Fact vs Myth" sheet it claims "tests for adrenal fatigue are not supported by good scientific studies." By implication it can only be referring to saliva tests, as these are the tests most commonly recommended.
In his article, Fell also quotes Dr Pederson as stating salivary tests are “useless” for detecting “an underproduction of cortisol”.
The Endocrine Society and Pederson are both spectacularly wrong: The claim that saliva tests can't detect subclinical adrenal insufficiency is bollocks. Published, peer-reviewed research shows they can indeed detect such abnormalities. In fact, this study - published in the Journal of Clinical Endocrinology, which is as "respectable mainstream" as you can get in the endocrinology literature - found salivary cortisol as measured by enzyme immunoassay was in fact preferable to blood cortisol testing for research purposes.
The Endocrine Society also has its own journal, the Journal of Clinical Endocrinology & Metabolism, which its members clearly don't spend much time reading. If they did, they might have come across this comment in Volume 95, Issue 10 from last year:
“Late-night salivary cortisol (NSC) is an excellent indicator of the biologically active, free cortisol concentration in the serum, independent of the salivary flow rate (3, 4, 5, 6, 7, 8).”
See those numbers in brackets at the end? They're references for other studies that the authors believe support the contention that late night salivary cortisol is an "excellent indicator" of serum free cortisol. And guess where 5 of those 6 citations were published? Yep, numbers 3 through to 7 were also published in the Journal of Clinical Endocrinology & Metabolism!
To top off the absurdities, the Endocrine Society recommends salivary cortisol testing as part of its adrenal insufficiency work-up guidelines in its Clinical Practice Guidelines for Doctors! Maybe the Society's members do read their own journal after all, but suffer transient memory loss when someone brings up the "alt-med" subject of "adrenal fatigue"?
If the Endocrine Society wants to be taken seriously on this topic, it needs to get its story straight, and pronto. It should also familiarize itself with the true role of the FDA; in its attack on supplements, the Society claims "The U.S. Food and Drug Administration (the government agency that oversees most food and medical products) does not oversee nutritional supplements and vitamins." This is false - the FDA does indeed regulate the supplement industry (often with a jackbooted approach, as many defenders of health freedom are all too aware):
At any rate, I'm not sure why the Society considers the FDA as some sort of hallowed safety guarantor; as fiascoes like the Vioxx scandal showed, the government regulator often does an appalling job of regulating drugs (which I'm sure even the Endocrine Society realizes are under the FDA's jurisdiction). When concerns about the heart attack-causing Vioxx first surfaced, the FDA did not act to protect the public, but instead concentrated its focus on employee and whistle-blower David Graham, harassing and intimidating him in an attempt to keep him silent.
And that, ladies and gentlemen, comprises Fell’s list of experts: His wife, an endocrinologist of nine years who specializes in obesity management, and a Society with a muddled, self-contradictory stance on saliva cortisol testing.
OK, now it’s my turn.
1. Richard Shames, MD. A graduate of Harvard and University of Pennsylvania, who conducted research at the National Institutes of Health with Nobel Prize winner Marshall Nirenberg. Has been in private practice for twenty five years, and has also been a member of the Clinical Faculty of the University of California Medical Center in San Francisco, a founding member of the American Holistic Medical Association, a participant in the Carl Menninger Foundation, and a member of Who's Who in California as well as nationally. He has served as Adjunct Faculty at Florida Atlantic University.
Richard is the interviewee at this link. When I provided this link to Fell, the best our loud-mouthed chirophobe could do was attack the decorated Dr Shames for allowing Mary Shomon to refer to him as an "integrative physician". Apparently, this triggered Fell's violent allergy to anything that sounds like it could in any way, shape or form be related to "alt-med".
Fell had absolutely nothing to say about Shames' discussion of the many flaws in the Endocrine Society's stance on "adrenal fatigue". Instead, he tried to discredit Dr Shames in the same manner he tried to discredit me: By avoiding the facts and instead writing him off as a quack.
He's a real Einstein, this Fell bloke.
2. George P. Chrousos. One of the world’s leading researchers on HPA dysfunction. As in, he’s truly one of the world’s leading HPA dysfunction researchers.
Dr Chrousos is professor and chairman of the Department of Pediatrics at the Athens University Medical School. He was previously Senior Investigator, Director of the Pediatric Endocrinology Section and Training Program, and Chief of the Pediatric and Reproductive Endocrinology Branch of the National Institute of Child Health and Human Development (NICHD), at the NIH. He is also Clinical Professor of Pediatrics, Physiology and Biophysics at Georgetown University Medical School and Distinguished Visiting Scientist, NICHD, NIH.
Dr. Chrousos was the first General Director of the Foundation of Biomedical Research of the Academy of Athens (2001–2002).
He holds the UNESCO Chair on Adolescent Health Care and held the John Kluge Chair in Technology and Society, Library of Congress, Washington, D.C.
Dr. Chrousos is among the 250 most prominent clinical investigators in the world. He has authored more than 1,100 scientific publications, has edited 29 books and his work has been cited over 67,000 times. According to the ISI, he is the highest cited Clinical Pediatrician and Endocrinologist in the world.
Here’s what Dr. Chrousos has to say about HPA dysfunction:
"… potentiators of CRH secretion/action may be useful to treat atypical depression, postpartum depression and the fibromyalgia/chronic fatigue syndromes, all characterized by low HPA axis and LC/NE activity, fatigue, depressive symptomatology, hyperalgesia and increased immune/inflammatory responses to stimuli."
I can just see Fell falling off his chair, succumbing to the violent spasticity of one of his frequent anti-alt-med seizures. I mean, a guy recommending treatments to boost corticotrophin-releasing hormone (and hence cortisol) for things other than Addison’s?!
For things like fibromyalgia and chronic fatigue?!?
Breathe, James, breathe LOL
And once you’ve stopped hyper-ventilating, you need to accept the fact that the man who holds this view – a view you so virulently ascribe to “alt-med” whackos – is in fact one of the most decorated clinical researchers in the world.
I think we can stop this little pissing match right here. Don’t get me wrong, there are plenty more experts who recognize and research subclinical adrenal insufficiency, and you’ll be learning more about their work shortly. But suffice to say, Fell can’t even begin to produce anyone even remotely near the stature of Drs Shames and Chrousos to support his head-in-the-sand stance on adrenal insufficiency.
So let’s get stuck into the research. At the end of the day, that’s what really matters. Maybe not to clueless health columnists like Fell, but certainly to the rest of us who value real science.
A Quick History of the Adrenals and Stuff that Can Go Wrong With Them (It’s Not Just Addison’s and Cushing’s Anymore!)
Unless you’re a creationist (you know, people who believe in ‘Intelligent Design’ despite the occurrence of natural disasters, childhood cancers, flies, and Harley Johnstone), you’re probably aware that human beings as a species are some 2.4 million years old. However, it wasn’t until a mere 500 years ago that we hominids finally became aware of the adrenal glands. Yep, in 1563, an especially prolific Italian anatomist by the name of Bartolomeo Eustachi reported his discovery of the adrenals (Eustachi was also a pioneer in ear and dental anatomy and, along with his contemporary Andreas Vesalius, is credited with having kicked off the science of human anatomy).
Fast forward a few hundred years to 1849, when English physician Thomas Addison discovered what came to be known as Addison’s Disease, a rare disorder in which the adrenal glands fail to produce sufficient hormones. Addison’s can arise due to adrenal damage sustained from the body's own immune system, certain infections, or from other much rarer causes. Characterised by relatively nonspecific symptoms such as abdominal pain and weakness, under certain circumstances the condition may progress to Addisonian crisis, which can result in very low blood pressure and coma.
In 1912, Dr. Harvey W. Cushing reported on a disorder of the pituitary gland which he termed "polyglandular syndrome" but eventually came to be called Cushing's disease. Unlike Addison’s, which is marked by insufficient cortisol release, Cushing's sufferers are afflicted with excessively high production of cortisol, thanks to increased secretion of adrenocorticotropic hormone (ACTH) from the anterior pituitary. This is most often due to a pituitary adenoma or excess production of corticotropin releasing hormone (CRH) in the hypothalamus. Cushing's syndrome can also arise from exogenously administered corticosteroids.
Let’s take a quick breather here and recap: Addison’s and Cushing’s diseases were first reported in 1849 and 1912, respectively. Since then, we Homo sapiens have learned quite a bit more about the adrenals and HPA axis, and the things that can go wrong with them, but Fell and his hand-picked ‘experts’ stubbornly insist adrenal problems pretty much begin and end with the two aforementioned illnesses. Their knowledge, in effect, is 100 years out of date.
Anyways, back to our “Adrenal Glands: This Is Your Life!” timeline.
In 1936, one János Hugo Bruno Selye - more commonly known as "Hans" – observed that in lab rats repeatedly exposed to stressful situations, the adrenal glands were enlarged while the thymus and lymph nodes were shrunken.
From his experimental observations, Hans Selye formulated the classic model for adaptation to stress. He observed that when subjected to external biological stressors, an organism would respond with a predictable pattern in order to restore homeostasis. He termed this the General Adaptation Syndrome or Biological Stress Syndrome, and divided the response into four categories:
1) Alarm reaction, characterized by immediate activation of the nervous system and adrenal glands;
2) Resistance phase, characterized by hypothalamic-pituitary-adrenal (HPA) axis activation;
3) A stage of adrenal hypertrophy, gastrointestinal ulceration, along with thymic and lymphoid atrophy;
4) Exhaustion phase which, if severe enough, may culminate in death.
So What Exactly Do These Adrenal Gland Thingies Do, Anyway?
The adrenal glands sit atop your kidneys and are chiefly responsible for releasing "stress" hormones, including corticosteroids such as cortisol and catecholamines like adrenaline (epinephrine) and noradrenaline (norepinephrine).
The adrenals also produce androgens, mainly dehydroepiandrosterone (DHEA), DHEA sulfate (DHEA-S), and androstenedione (the precursor to testosterone).
The outermost layer of the adrenals, the zona glomerulosa, is the primary site for production of aldosterone, a mineralocorticoid largely responsible for long-term regulation of blood pressure via its effects on the kidneys.
The hypothalamus, located in the brain, is often thought of as the “master” gland; it responds to stress by releasing a hormone called corticotropin-releasing hormone (CRH). This hormone signals the pituitary gland to release adrenocorticotropic hormone (ACTH), which stimulates the adrenal glands to release cortisol. With the rise in stress hormones, a complex feedback system is set in motion, eventually signalling the hypothalamus to stop producing CRF.
There are a wide range of events that can set off this feedback system, including negative emotional states (fright, anger, shock, anxiety, grief, frustration, etc), surgery, sleep deprivation, excessive ingestion of stimulants (caffeine, ephedra/ephedrine, amphetamines, etc) and excessive exercise.
Activation of the stress system heightens arousal, accelerates motor reflexes, improves attention and cognitive function, decreases appetite and sexual arousal, and increases the tolerance of pain. In other words, it gets you ready to either rumble or run when the shit hits the fan.
Cortisol, Who Needs It? (You Do)
Let’s take a closer look at cortisol, as low cortisol levels are a common feature of ailments such as chronic fatigue syndrome. Cortisol is a steroid hormone, but it’s not the kind of ‘steroid’ people have come to associate with massive, pharmaceutically-enhanced bodybuilders.
The muscle-building, voice-deepening, bone-thickening testosterone and its synthetic cousins are anabolic hormones. In contrast, cortisol belongs to the glucocorticoid family and does not trigger muscle hypertrophy, nor does it make women look and sound like men when administered exogenously. In fact, excess levels of cortisol can be catabolic, triggering muscle wasting and decreasing bone formation.
While commonly maligned due to its role as a “catabolic” hormone, the truth is cortisol serves numerous critical functions. As with most things, the key is in the balance. There is an optimal range for cortisol, and both chronically excessive and deficient levels should be avoided.
Here’s a brief list of some of cortisol’s key functions:
--Cortisol is released in response to stress and hypoglycemia. Whether to ensure a supply of quick energy for fight or flight, or to restore sagging blood sugar levels, cortisol raises blood sugar through a process known as gluconeogenesis.
--Cortisol aids the metabolism of protein, fat and carbohydrate.
--Cortisol promotes learning and memory processes.
--Cortisol alters immune function in a manner that seems to prevent an overactive response to infection.
--Cortisol exerts important anti-inflammatory effects.
The abovementioned immunosuppressive and anti-inflammatory actions explain why cortisol is frequently employed as an exogenous medication (hydrocortisone, prednisone) for a wide array of inflammatory conditions.
A couple of other key points are worth noting at this point:
1) The adrenals secrete a basal level of cortisol but can also produce bursts of the hormone in response to ACTH from the anterior pituitary, which sits further up the HPA axis.
2) Chronic activation of the HPA axis results in protective adaptations. In effect, the body is attempting to maintain physiological law and order in a dysfunctional environment. These adaptations usually work just fine in the short term, but when maintained over the longer term can give rise to a whole new set of problems. In the case of mild adrenal insufficiency, those problems can include insufficient levels of key hormones such as cortisol and DHEA.
The Chronic Fatigue Connection
Some of you reading this will be old enough to remember when the term chronic fatigue syndrome first started getting airplay. You’ll remember how, at first, many in the medical profession attempted to dismiss CFS as a purely “psychosomatic” illness (and, regrettably, some still do). The official meaning of “psychosomatic illness” is a disease with physical symptoms but originating in the patient’s mind. More often than not, however, the real meaning is: “We have absolutely no clue what is going on here so we’ll write it off as being all in your head. That saves us from having to admit we have no solution, which in turn allows us to maintain an all-knowing air of superiority.”
As chronic fatigue syndrome not only refused to go away but became ever more pervasive, the whole “it’s all in your head!” gig started to wear a bit thin. And so researchers who didn’t have their heads buried up their ass began taking a closer look at CFS. They quickly confirmed that chronic fatigue was a very real condition whose sufferers evinced a number of commonalities.
One of which was hypocortisolism (low cortisol).
Way back in 1981 – some 33 years ago – UK physician Alex Poteliakhoff compared 25 chronic fatigue patients with 25 age- and gender-matched controls. Blood was drawn from all patients at 9am, and the results showed plasma cortisol levels in the chronic fatigue group were significantly lower than those seen in the control group. Seven of the CF subjects but only 2 of the controls had a plasma cortisol level of less than 100 pg/l.
Each patient was also asked to complete a social readjustment rating questionnaire regarding events in the last twelve months. Social readjustment rating scores were significantly higher in the CF group, indicating their exposure to more severe and frequent stressful experiences.
The incidence of rheumatic disorders was higher in the CF group and these conditions had developed after a period of CF, suggesting that CF and the associated diminished adrenocortical activity had played a role in their causation.
Poteliakhoff didn’t stop there. Previous research had shown a daily rhythm in capillary resistance and circulating eosinophil count; the former being parallel to the daily plasma cortisol curve and the latter inversely related to it. If acute fatigue later in the day was associated with adrenocortical insufficiency, Poteliakhoff postulated, then fatigued subjects should show lower capillary resistance and a higher rise in eosinophils at the end of the day than non-fatigued controls.
And so he gathered up another fifty patients - in this case, otherwise healthy hospital staff – 28 of whom reported no acute fatigue and 22 of whom reported acute fatigue. They were all tested at 9.30am and 5.30pm, and the results confirmed his hypothesis: The acutely fatigued showed on average a greater fall in capillary resistance and a greater rise in the eosinophil count than the latter and this was proportional to their degree of self-rated fatigue.
Dr. Poteliakhoff concluded: “The findings now reported point to adrenocortical insufficiency in both acute and chronic fatigue. This suggests that chronic fatigue should be regarded not just as a harmless subjective symptom but as an important indicator of failure to adapt to stressful events and a justification for prophylactic measures to prevent the development of certain diseases.”
A decade later in 1991, Dr Chrousos and his colleagues compared CRH, ACTH, and cortisol levels in healthy subjects and chronic fatigue patients. Compared to normal subjects, CFS patients demonstrated significantly reduced basal evening glucocorticoid levels and low 24-h urinary free cortisol excretion, but elevated basal evening ACTH concentrations.
As Dr. Chrousos noted in a 1995 discussion: “Patients with the chronic fatigue syndrome have subtle hypothalamic or suprahypothalamic adrenal insufficiency and immune hyperfunction. Urinary cortisol excretion is decreased by 20 to 30 percent, and plasma cortisol responses to corticotropin are diminished.”
In 1995, Dr Anthony Cleare and his colleagues at Maudsley Hospital and King’s College Hospital, in the UK, compared patients with CFS, patients with major depression, and healthy control subjects. They found that baseline-circulating cortisol levels were highest in the depressed, lowest in the CFS and intermediate between the two in the control group.
The authors wrote: “These findings suggest that depression and CFS are characterized by an exaggerated and a deficient stress response, respectively.”
Again, take a look at the dates of these seminal studies. I know new knowledge takes a while to spread around, but for crying out loud … three decades? Yep, over thirty years later and people like Fell, his wife, Dr Pederson and the Endocrine Society still remain blissfully oblivious to the very real phenomena of mild adrenal insufficiency.
Since these seminal studies, many more studies have examined the relationship between CFS and cortisol output, and one of the more consistent findings is a reduced output of cortisol upon wakening (and contrary to the claims of Fell’s ‘experts’, this has also been confirmed with salivary testing). Under normal conditions, the biggest spike in cortisol occurs first thing in the morning, around the time you wake up. The widely-postulated reason is so cortisol can initiate gluconeogenesis in order to raise your blood sugar levels after the extended overnight fast known as sleep. In CFS patients, this response is often attenuated, meaning sufferers aren’t getting enough cortisol right when they need it the most.
In addition to a morning spike in cortisol, healthy people also show a pronounced pattern of variation in cortisol levels throughout the day. A recent review of the literature found this pattern is flattened in patients with CFS.
Chronic fatigue is hardly the only condition marked by hypocrtisolism. As Heim, Ehlert, and Hellhammer from the University of Trier in Germany noted in a 2000 review:
"... a number of studies have now provided convincing evidence that the adrenal gland is hypoactive in some stress-related states. The phenomenon of hypocortisolism has mainly been described for patients, who experienced a traumatic event and subsequently developed post-traumatic stress disorder (PTSD). However, as presented in this review, hypocortisolism does not merely represent a specific correlate of PTSD, since similar findings have been reported for healthy individuals living under conditions of chronic stress as well as for patients with several bodily disorders.
These include chronic fatigue syndrome, fibromyalgia, other somatoform disorders, rheumatoid arthritis, and asthma, and many of these disorders have been related to stress. Although hypocortisolism appears to be a frequent and widespread phenomenon, the nature of the underlying mechanisms and the homology of these mechanisms within and across clinical groups remain speculative. Potential mechanisms include dysregulations on several levels of the hypothalamic – pituitary – adrenal axis. In addition, factors such as genetic vulnerability, previous stress experience, coping and personality styles may determine the manifestation of this neuroendocrine abnormality. Several authors proposed theoretical concepts on the development or physiological meaning of hypocortisolism. Based on the reviewed findings, we propose that a persistent lack of cortisol availability in traumatized or chronically stressed individuals may promote an increased vulnerability for the development of stress-related bodily disorders. This pathophysiological model may have important implications for the prevention, diagnosis and treatment of the classical psychosomatic disorders.”
Interested readers can freely access the Heim et al review here.
As Powell et al noted in a recent review, “There was evidence of reduced CSA [cortisol secretory activity] diurnal variability in fatigued individuals in cross-sectional analyses with nonclinical populations. The one longitudinal study we included indicated that fatigue severity did not predict CSA 2—3 years later, but that some facets of CSA (flattened diurnal slope and low waking cortisol) were predictive of concurrent fatigue, and persistent or new fatigue 2—3 years later (Kumari et al., 2009)”
A team of Swedish and Danish researchers recently reported on 78 working individuals (57 females and 21 males) who they had divided into "exhausted" and "non-exhausted" groups after administering the SF-36 vitality scale. Salivary cortisol was measured three times during the test workday: at awakening, 30 min after awakening, and in the evening. The results showed diurnal cortisol variation was significantly reduced in exhausted individuals. The difference in cortisol variation was mainly due to lowered morning cortisol in the exhausted group. The results could not be explained by age, smoking or BMI, which were similar between the two groups.
Cause or Symptom?
So while Fell and his like-minded cohorts claim the only illnesses involving adrenal irregularities are Addison’s and Cushing’s, the published literature clearly shows otherwise.
So the real question, then, is not whether mild adrenal insufficiency exists, but whether the low and dysfunctional cortisol patterns seen in CFS patients are of a causal or secondary nature. Does HPA dysfunction cause or at least contribute to the fatigue, or does the fatigue cause the HPA dysfunction? Or does one feed the other in a vicious cycle?
A 2004 review by Anthony Cleare, from The Institute of Psychiatry, London, UK, cited two prospective epidemiological studies, one by Candy et al involving Epstein Barr virus sufferers and another by Rubin et al involving patients undergoing surgery. In both studies, there was no difference in daytime cortisol levels between normal and fatigued patients six months after infection/post-surgery. Cleare concluded from their findings that "there are no HPA axis changes present during the early stages of the genesis of fatiguing illnesses ... there is no specific change to the HPA axis in CFS and that the observed changes are of multifactorial aetiology, with some factors occurring as a consequence of the illness."
A couple of problems are immediately apparent with the prospective studies cited by Cleare. Firstly, neither of these studies actually involved CFS patients, but Cleare was nonetheless extrapolating their results to CFS (to their credit, Rubin et al acknowledged this as a limitation in the discussion section of their paper). Secondly, the studies detected no difference in daytime cortisol levels between fatigued and non-fatigued subjects six-months post-infection/-illness, despite the fact that hypocortisolism is a consistent feature of ailments such as CFS and PTSD. While hypocortisolism may still have developed in these subjects after the six-month follow-up, we won’t ever know if this was in fact the case. If they didn’t, then the results of these studies would be of highly questionable relevance to ailments such as CFS and PTSD. After all, no-one is saying all fatigue is caused by or even associated with HPA dysfunction.
Cleare did, however, concede that even if the illness caused the HPA abnormalities rather than vice versa, “the HPA axis might play a role in exacerbating or perpetuating symptoms late on in the course of the illness” and that “raising levels of cortisol pharmacologically can temporarily alleviate symptoms of fatigue.”
Contradicting the small studies cited by Cleare is a much larger prospective study published in 2009. Researchers from the ongoing Whitehall II Study in the UK (the “Kumari 2009” study cited by Powell et al above) observed that, among over 4000 former or current British civil servants, low cortisol at waking predicted new cases of reported fatigue during the subsequent 2.5-years. In other words, hypocortisolism was evident before the onset of fatigue.
Regardless of which comes first, hypocortisolism or fatigue, a number of studies have shown treatments that restore cortisol to normal levels also bring about clinical improvements in fatigue.
Low-dose hydrocortisone produced significant improvements in fatigue and wellbeing scores in CFS patients, compared to those receiving placebo[17,18].
In both adult and adolescent CFS patients, cognitive-based therapy (CBT) has been shown to reduce fatigue and raise awakening and daytime cortisol levels[19,20]. In fact, at this point in time, CBT is one of the few CFS treatments with RCT verification of its effectiveness. No-one is sure yet just how CBT exerts its effect, but enhanced sleep, improved coping, or altered perceptions of stress have been posited as possible mechanisms. The positive results seen with CBT along with these postulated mechanisms have also been cited as evidence that hypocortisolism is a secondary and not primary feature of CFS. Irrespective of whether it is causal or not, doctors who take patient's complaints of “adrenal fatigue” seriously and have them undergo the appropriate hormonal testing will gain a clearer picture of their condition, and will have another marker at their disposal for monitoring their response. Those who prefer to adopt the snide “adrenal fatigue is bullshit!” stance will be in no such position.
What to Do if You Suspect You Have Mild Adrenal Insufficiency
In its "Myth vs Fact" sheet, the Endocrine Society writes:
"Symptoms said to be due to adrenal fatigue include tiredness, trouble falling asleep at night or waking up in the morning, salt and sugar craving, and needing stimulants like caffeine to get through the day. These symptoms are common and non-specific, meaning they can be found in many diseases. They also can occur as part of a normal, busy life."
As an argument against the existence of mild adrenal insufficiency, this line of reasoning scores a massive FAIL.
Because the reality is you could fill a very thick book with the list of legitimate medical conditions evincing - and sharing - "common" and "non-specific" symptoms.
A true doctor's role when presented with a patient complaining of these symptoms, is not to pompously dismiss them, but to conduct the proper evaluation and testing to determine what is causing these symptoms. This process is known as "diagnosis" and, last time I checked, was an integral part of being a doctor.
A doctor who acknowledges mild adrenal insufficiency and is aware of the research dating back some three decades showing it is a very real condition can begin to test for this condition if the patient's symptoms and history point in that direction. If subsequent testing returns evidence of HPA dysfunction such as hypocortisolism, low DHEA, etc, the doctor and the patient can begin working together to institute the appropriate treatment.
In stark contrast, a doctor who believes the waffle published by folks like Fell and the Endocrine Society will be in a position to do no such thing. They might flippantly (or snidely, as is all too often the case) dismiss the patient, and tell them to "stop believing everything you read on the Internet".
Or they might enquire about "things like depression, stress and burnout", and give the patient well-meaning but ultimately useless advice like "try to take it easy". They might wrongly conclude the patient is simply depressed and prescribe them an anti-depressant that won't even begin to address the underlying problem.
Mild adrenal insufficiency is real, and it is treatable.
But before you can begin treating it, you have to confirm you do in fact have it.
Concluding you suffer any ailment without having first conducted the appropriate testing is akin to flying blind.
The following links may help you find a doctor in your area that will test and treat you for mild adrenal insufficiency:
(These links are oriented towards US readers; I can supply the name of a good physician for those living in Melbourne, Australia. I can’t suggest anyone outside of Melbourne, unfortunately).
By the way - contrary to Fell’s rabid anti-"alt-med" rantings – there is no law stipulating you must consult a naturopath, chiropractor, chanting Swami or goat-sacrificing witch doctor when seeking help on diagnosing mild adrenal insufficiency. As we’ve seen, there are indeed bonafide MDs who acknowledge the condition and are happy to test for it and treat if necessary.
If you can’t find an empathetic doctor within a practical distance, then I suggest purchasing Wilson’s Adrenal Fatigue and progressing from there. The book contains abundant information on self-testing and possible treatments. Self-testing is not my preferred avenue of diagnosis, but if all the doctors within traveling distance display the head-in-sand attitude of Fell et al, you’re probably going to have little choice.
The Shames also have a book titled Fat, Fuzzy and Frazzled – I’ve not yet read it but have a copy on the way. If I’m impressed after I’ve had a chance to read it, I’ll be sure to add it to my Recommended Reading list (I’ll let readers know of future additions to the list via my newsletter mailouts).
The following links may also be of interest to readers:
The Truth About Adrenal Fatigue by Dr. Bryan Walsh
This T-Nation article is contrarian in tone, but like yours truly, Dr Walsh’s issue is with the misconceptions surrounding mild adrenal insufficiency. As Dr. Walsh notes: “Adrenal gland dysfunction is real. However, the way it's explained and treated by many integrated practitioners today is an outdated and incomplete model.”
This is the kind of article Fell could’ve written if he was an impartial, intelligent individual capable of independent thought and research - instead of an irrational hothead eager to prove what an "In Your Face!" quackbuster he is.
A Pioneer Researcher Discusses Hydrocortisone
This article is worth reading because it was penned by Dr. William McK. Jefferies, who trained at the Massachusetts General Hospital under Dr. Fuller Albright, a true pioneer in the study of adrenocortical function. It helps provide insight into the adrenal-extract-vs-hydrocortisone debate that still exists. Contrary to the rantings of self-appointed ‘quackbusters’ who claim glandular supplements are useless, the issue with adrenal extracts is not their lack of biological activity – they were in fact a standard treatment and widely used prior to the advent of hydrocortisone (as was thyroid extract prior to the advent of synthetic thyroid hormones). The reason hydrocortisone quickly knocked adrenal extracts off their mantle is because it offered a precise amount of active ingredient per serving, unlike adrenal extracts which were extracted from animal tissues and hence were prone to variation in their constituency.
Hydrocortisone, however, came to suffer its own image problem due to perceptions about side effects. Dr. McK. Jefferies maintains these perceptions are misconceptions and that hydrocortisone has copped a bum rap.
Mary Shomon’s Interview with Dr Shames
Some interesting commentary from a doctor who recognizes and routinely treats mild adrenal insufficiency, and therefore is actually qualified to offer intelligent commentary on the condition – unlike Fell et al.
This was one of the email links I shared with Fell – and the best he could muster in response was to again break out in anti-alt-med hives in response to Shomon’s description of Shames as an “integrative” practitioner.
Fell had no intelligent commentary to offer on the actual content at the above link for the same reason he cannot discuss the science on mild adrenal insufficiency:
He has absolutely no clue about the topic whatsoever.
Folks, it goes without saying, but you really shouldn’t take health advice from people without a clue. If you suspect you might have what is commonly known as “adrenal fatigue”, go find a practitioner with a clue and get the appropriate testing performed. This way, you can either confirm or exclude the possibility based on verifiable test results, rather than the ignorant ramblings of misguided ‘experts’ who don’t even want you to acknowledge the condition exists.
Take Home Points:
--Health reporters, by and large, don't have a clue about the topic they are reporting on.
--The so-called 'experts' they cite often don't have a clue either.
--"Adrenal fatigue" is a questionable name for a very real condition.
--Denying the existence of that condition because you don't like the name, or because some people have a mistaken impression of how that condition arises, is patently idiotic.
Further Take-Home Points for Health Reporters (and the Editors Who Hire Them):
--Don’t write about things you clearly know nothing about.
--Being a Contrarian/Mythbuster/Skeptic/etc is only cool when you know what you are talking about. Loudly proclaiming something to be “bullshit” when it is in fact very real merely serves to demonstrate what an ignorant and inept boor you are.
--Proclaiming a health condition to be “fake” when it is in fact very real automatically makes you part of the problem.
--If you insist on acting like an idiot, don’t complain when people conclude you are an idiot. And if you insist on saying stupid things, don’t complain when people conclude you are stupid.
--How many readers you (think) you have is utterly irrelevant; a decent person who places a premium on truth would much rather report accurate facts to a single person than deliver untenable bullshit to millions.
--Trolling the Internet and starting unprovoked fights with people, and wanking on about what a manly “In Your Face” man you are, but then carrying on like an aggrieved little piss ant when given a dose of your own medicine, is flat out pathetic.
--Arriving at a conclusion and then flatly refusing to even consider conflicting evidence, but instead relying entirely on name-calling, ad hominem arguments and the pronouncements of ‘experts’ who in fact have no idea what they are talking about is especially pathetic. In fact, if you do this, the only people more pathetic than you are the numbskulls who hire you and financially reward you for propagating such out-and-out bullshit.
- Heim C, et al. The potential role of hypocortisolism in the pathophysiology of stress-related bodily disorders. Psychoneuroendocrinology, 2000; 25: 1–35.
- Cleare AJ. The HPA axis and the genesis of chronic fatigue syndrome. Trends in Endocrinology and Metabolism, 2004; 15: 55–59.
- Tsigos C, Chrousos GP. Hypothalamic–pituitary–adrenal axis, neuroendocrine factors and stress. Journal of Psychosomatic Research, 2002; 53: 865–871.
- Selye HA. The Stress of Life. New York, NY: McGraw-Hill; 1976.
- Poteliakhoff A. Adrenocortical activity and some clinical findings in acute and chronic fatigue. Journal of Psychosomatic Research, 1981; 25: 91—95.
- Demitrack MA, et al. Evidence for impaired activation of the hypothalamic-pituitary-adrenal axis in patients with chronic fatigue syndrome. Journal of Clinical Endocrinology & Metabolism, Dec, 1991; 73 (6): 1224-1234.
- Chrousos GP. Seminars in Medicine of the Beth Israel Hospital, Boston. The Hypothalamic–Pituitary– Adrenal Axis and Immune-Mediated Inflammation. New England Journal of Medicine, May 18, 1995; 332 (20): 151-1362.
- Cleare AJ, et al. Contrasting neuroendocrine responses in depression and chronic fatigue syndrome. Journal of Affective Disorders, 1995; 35: 283-289.
- Powell DJH, et al. Unstimulated cortisol secretory activity in everyday life and its relationship with fatigue and chronic fatigue syndrome: A systematic review and subset meta-analysis. Psychoneuroendocrinology, 2013; 38: 2405—2422.
- Papadopoulos A, Cleare AJ. Hypothalamic-pituitary-adrenal axis dysfunction in chronic fatigue syndrome. Nature Reviews Endocrinology, 2012; 8: 22-32.
- Heim C, et al. The potential role of hypocortisolism in the pathophysiology of stress-related bodily disorders. Psychoneuroendocrinology, 2000; 25: 1–35.
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