Adrenal Testing with Dr. Nick Hedberg

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Yes, Where Do I Start?

Adrenal Testing – When You Should and What It Tells You with Dr. Nick Hedberg

Adrenal testing is one of the most recommended tests in functional medicine, but unfortunately, most of the tests recommended are antiquated.  Furthermore, most test results are not used correctly.  Today Dr. Nick Hedberg joins us to discuss which adrenal tests make sense and, more importantly, how to use them.

In This Episode

Episode Intro … 0:42
Different Aspects of the Adrenal Glands and Cortex … 3:04
Adrenal Cortex … 12:40
Adrenal Testing … 16:33
When to Use Adrenal Tests … 27:12
Organic Acids Testing … 34:10
How Do Test Results Change Treatment … 37:26
Episode Wrap-up … 41:24

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Episode Intro

Dr. Michael Ruscio: Hey, everyone. Welcome to Dr. Ruscio Radio. This is Dr. Ruscio. I am here with my good friend Dr. Nicholas Hedberg, who has been on the show before. And today, we are going to talk all about adrenal testing. And I think he might be able to provide some really nice perspective as someone I respect.

He is, unfortunately, one of the few clinicians that I think is responsible and doesn’t excessively test. So I value what he has to say. And with that, Doc, welcome to the show.

Dr. Nicholas Hedberg: Dr. Ruscio, thanks for having me again.

DrMR: Of course. It’s always good talking with you, my man. Last time you came on, we talked about viruses. And one of the things we kind of got tangentially pulled into was the topic of adrenal testing.

And I think we have a similar overarching philosophy of trying to get patients well, and efficiently, and not getting sucked into testing that’s not going to change the treatment outcome.

In fact, I think you were one of the first people who I really heard say very clearly and directly that testing is only useful if it has a marked impact on the treatment. Testing is only really useful if it helps you or if it changes, guides or dictates treatment.

And that is something that I think, of course, we’re on the same page with philosophically. So I thought it might be interesting to talk about the adrenals. I think we maybe have different approaches with the adrenals. But we have that similar philosophy.

So I think people kind of know what my take on the adrenals is. Why don’t you tell people a little bit about how you’ve been using it? And we can kind of flow from there.

And I just want to quickly throw out there that I think we’ll probably have some differences in how we’re using this in practice. And I just want to get this out there right away. We have a good enough rapport that we can have a polite difference of opinion.

But if I ask Nick questions, it’s not because I’m doubting anything that he has to say. I know Nick does an excellent job with checking his references and being very evidence-based. It’s more for my own curiosity in terms of how I satisfy the questions I hear in my own mind.

So with that, Doc, why don’t we jump into wherever you want to start with the adrenal piece? And we can kind of go from there.

Different Aspects of the Adrenal Glands and Cortex

DrNH: Sure. Sure. So one of the things — before we get into the testing — is the difference between the two aspects of the adrenal gland and the cortex. And the other side of it — usually, it’s the cortisol side, the DHEA, the aldosterone, all those glucocorticoids that are really the things that are really focused on.

DrMR: Sure.

DrNH: But the autonomic nervous system is one thing that’s usually overlooked. A lot of practitioners will just do a salivary hormone profile and make some clinical decisions based on that without really looking at the autonomic nervous system.

So just to lay some of the bedrock that we’re going to get into, I spend a lot of time sort of digging, figuring out what’s going to be disrupting the autonomic aspect of the adrenal gland, which is just as important.

So just so everyone understands, the sympathetic is the so-called fight-or-flight. It’s the stress response. It kind of revs everything up. And it’s a way for the body to prioritize things. So for example, digestion is just not that important when you’re running from a saber-toothed tiger.

So when someone is sympathetic dominant, that’s going to really affect their digestion, for example. So it’s going to shut down the gallbladder. So you’ll have less bile flow. It inhibits the activity of the pancreas. So your pancreatic enzymes are going to suffer, hydrochloric acid [lividity of the upper GI? 05:01]. So all those things are going to be affected, for example, when someone is in chronic stress.

And the interesting thing that I’ve been reading a lot about recently is the difference between men and women and then also the effects of trauma and [adversity] as a child and as an adult. So a few examples would be — one of the things we know is that if a child has been through significant trauma and [adversity] like abusive parents, molestation — which is quite common. I’m sure you found that. And abusive parents, death of parents, all the things that kids can go through.

What they found is that they’re going to be much more inflamed as adults. They’re going to be much more likely to have chronic illness. And all those things that happened as a kid and even into adulthood, they create new pathways in the brain. And they kind of get stuck in a sympathetic dominance state as opposed to parasympathetic.

So the parasympathetic, for those listening, is just kind of the opposite. It’s the rest and digest. It really stimulates the activity of the digestive organs, the pancreas, the gallbladder. And a lot of people just aren’t in that state very much. And that causes significant adrenal dysfunction and adrenal adaptation issues.

Now, the areas that are specifically caught in these new loops in the brain, those are going to be the hippocampus, the amygdala, and then the prefrontal cortex. And those three areas in the brain are intimately related to mood — so depression, anxiety, insomnia.

And they’re also going to have a significant impact on how someone actually responds to stress. So for example, it may not be what we would consider a serious stressful event.

DrMR: Sure. But to them, it is.

DrNH: Yeah. So for example, let’s say you have a woman whose uncle molested her as a child. She may actually have more inflammation as an adult. And some of these stress loops are going to be built in. And so she might have an argument with her spouse. And she’ll actually become very inflamed. Her HPA axis will over-respond to that. And she’ll have a lot of devastating effects just from those conflicts in the relationship.

So going back to what I was saying, that whole autonomic aspect of the adrenals is something that I dig for. And we may have to have them work with someone in, say, cognitive behavioral therapy, some kind of counseling. And then I talk to them a lot about things like meditation and journaling and things like that that can really help to get the autonomic nervous system back in balance. Did you have anything you wanted to add to that autonomic component?

DrMR: Well, actually, as you’re saying that, I’m reminded of how there is some annals data showing that perturbations in the microbiota early in mouse models show a heightened stress response of the HPA axis and then also correlates with the heightened inflammatory response.

So the early development of your microbiota and immune system can impact, at least from some of the mouse models, maybe you could term it their autonomic balance or how sensitively they respond to stress. And I’ve heard of some of the same literature that you’re citing that early life events that are more psychological, I guess you could say, in nature and not necessarily microbiota. Inputs can also make one have a very exaggerated stress response.

So, yeah, I think these are definitely very important foundational pieces, yeah.

DrNH: Right. So, yeah, I’m glad you brought that up because the other thing that I would add to that category is the overall antibiotic load. And that’s something that I always kind of dig as well and talk to people about. I just ask them, “What would you say is the total number of antibiotic rounds you’ve taken in your entire life?”

DrMR: Sure.

DrNH: And we usually see a pretty strong correlation there with some major issues, not just gut-related, obviously, but outside of the gut. And we’ll see a heavy antibiotic load.

And then if it’s a woman, if we kind of compound that with oral contraceptives, birth control pills, those can compound those issues as well related to the gut microbiota.

So I was talking about the autonomic component and really addressing that because you’re just not going to really get the adrenals back in balance unless you’re really working on that. And that’s one of the things that’s really overlooked. And so that’s—

DrMR: And maybe one of the things — not to cut you off, Nick.

DrNH: Yeah.

DrMR: But maybe just to paint this backdrop for the audience to make sure that I’m interpreting some of this the same way that maybe you are and how you’re advising your patients: Part of how I interpret this is some people are going to have to be more or less diligent with how much of a priority they make their lifestyle — how much meditation they have to do and how much down time they need and how much relaxation they need.

Some people seem to be able to do better with some stress. And it doesn’t seem to really kind of break them down, so to speak. And these maybe are people that just have had a healthier, childhood so they have a healthier stress response so they can handle a heavier dose of stress, whereas other people are going to have to be a little more diligent with trying to mitigate that. Would you agree with that or tweak that in any way?

DrNH: Oh, yeah. Yeah, definitely.

DrMR: Okay. Cool.

DrNH: Because a good treatment plan is a plan that doesn’t create additional stress or anxiety.

DrMR: Sure.

DrNH: And that’s another big issue in the alternative medicine world.

DrMR: Completely agree.

DrNH: You have a lot of fanatics out there, fundamentalists, kind of a one-size-fits-all. And the patient just gets overloaded, overwhelmed with too much to do.

DrMR: Right.

DrNH: You look at some of these treatment plans. And it’s okay, you have to go gluten-free, dairy-free, sugar-free. You have to exercise. You have to meditate. You have to do this. You have to do that. You have to take these supplements. It’s just kind of ridiculous sometimes. And I’ve seen a lot of treatment plans that actually created additional stress and worry and anxiety, which actually will just set somebody back.

DrMR: Yeah.

DrNH: But sort of shifting, so that was the adrenal medulla that I was talking about, the part that makes the adrenaline.

Adrenal Cortex

And then the other part, the cortex, that makes the cortisol and the DHEA.

I found that testing cortisol and DHEA gives me a lot of indirect information. I’m actually not overly concerned about the levels themselves, so to speak. I’ll give you a couple of examples. I run into this quite a bit where I’m really talking to the patient for a long time and talking about a lot of things. And how much stress do you have in your life? How would you rate your stress on a scale of 1 to 10? And they might say, “Well, I don’t really have that much stress. It’s more like maybe a two.” One being no stress, ten being really high stress.

And I just get the feeling that that’s not really true based on what they’re telling me.

DrMR: Right.

DrNH: And this can be due to a number of things: Genetics, will, the way their parents were, what they taught them. So there are going to be individuals who just don’t really perceive the amount of stress that their body is really under. And so sometimes the adrenal tests can be very useful in showing someone on paper how much stress they’re really under and what it’s doing to their body.

So for example, someone might say, “Well, my stress level is nothing. It’s like a two out of ten.” And then we’ll find that that just isn’t true biochemically. And it really helps them understand what they need to do as far as stress reduction and really doing these things once they see that on paper. What do you think about that?

DrMR: I think that’s one of the major utilities that the adrenal testing has, and maybe two aspects within what you said. One is if you need some way of motivating someone to chill out, and maybe someone who is clearly — this doesn’t exactly speak to what you’re saying.

But maybe someone who, when they’re telling you about what they’re doing and they have an hour commute five days a week each way. And they’re getting five hours of sleep a night. And they’re doing four CrossFit classes a week. And they’re also volunteering at their child’s school. And they’re having some relationship stress.

You’re listening to all this. And you’re saying to yourself, “Geez, how is this person even holding it together?” And you can kind of get the sense that they’re in denial of the fact that their allostatic load is too high, or whatever you want to call it. They’re under too much general stress.

Then I think testing can be nice to help show them, “Hey, this is something that’s happening physiologically that shows that you’re probably under too much stress.” So I would definitely agree from that standpoint.

And there’s something that has been piquing my curiosity, which is heart rate variability as a method for getting a gauge on that. And what I like about the heart rate variability is it’s very inexpensive. And it can be assessed daily. So, yeah, do you have any thoughts on the heart rate variability as another way of looking into this same stress overload piece?

DrNH: Yeah, there are going to be direct connections there, especially with the autonomic component.

DrMR: Sure.

DrNH: The sympathetic component. And I haven’t gone as far as using a monitor or pulse oximeter or things like that. But yeah, I can see how that can be very useful.

DrMR: Right, right.

Adrenal Testing

And how are you defining — because I guess the one thing that people are probably curious about is, how do they know when they’re under too much stress in terms of looking at an adrenal test? And I know it may be beyond the scope of this call to go into a highly specific answer to this question.

But the more traditional salivary cortisol tests aren’t fully representative because there are fractions that you’re missing. I know you’re an advocate of the Dutch testing. And maybe you want to use this as a transition to talk about that. But how are you looking at these tests and using that to tell if someone is under adequate stress or too much stress?

DrNH: Yeah, so let’s dig into that. So free cortisol is about 1% of cortisol output from the adrenal gland. And metabolized cortisol is 80%. So that’s one of the reasons why the Dutch method would be preferable, because you’re just seeing a much greater output of the adrenal gland. So that’s the first thing.

And even in the urine testing, you’re still getting the free cortisol as well, just like you would in saliva. So you’re kind of getting the best of both worlds.

But talking a little bit more about this indirect connection with adrenal testing and helping someone.

So cortisol, just let’s go over some basics. Cortisol is active. And then cortisone is inactive. So in the urine, you get to see both. And that conversion, the cortisol into cortisone, that’s happening in the kidney, the colon, and the salivary gland.

And then cortisone can actually be converted back into cortisol. That’s happening in the liver, testicles, brain, muscle, and fat. Now, where this is really helpful because the preference towards cortisol is shifted when someone is hypothyroid, if they’re inflamed, if they’re insulin-resistant, if they have a lot of fat. And then if they’ve made the mistake of using licorice as a supplement.

And then the other aspect is cortisone. There’s a preference towards cortisone, which, remember, is inactive. It shifted that from growth hormone, coffee (especially too much coffee), hyperthyroidism, and estrogen.

Now, you can see there are two things that come up there, the thyroid in both cases. And as you know, thyroid testing is highly ambiguous. And sometimes, these tests can be extremely helpful in really figuring out if it’s truly a thyroid issue or if there are other issues at play that are disrupting the thyroid.

The insulin resistance, that’s going to be fairly straightforward. If they’re inflamed, that’s going to be fairly straightforward. But it is helpful to see the preference in the two. And then, like I said earlier, you can see massive amounts of metabolized cortisol coming out in the urine in certain cases.

The other example would be if I’m working with a Graves’ patient. We’re trying to get things under control. And in hyperthyroid, we’re going to have a preference towards cortisone. We’re going to have very high metabolized cortisol output, for example.

So those are just some of the examples of how I would use some indirect information with that particular type of testing.

DrMR: I like that. I like the piece about using that to get a window into other conditions indirectly. And I think that’s important for people to realize. And correct me if you don’t agree with this, but I think we’re probably in general agreement on this.

The adrenal tests don’t really tell you what the cause of adrenal stress is, which is one of the reasons I haven’t made them foundational in my practice because I try to look rather directly at the things that might be causing or contributing to the adrenal stress.

But I do like, and I see their potential utility with using it to get an indirect gauge as to, “Okay, there’s a major imbalance here. What else might we want to look more closely at as being the underlying contributor to that?”

DrNH: Exactly. And then the DHEA component. Again, a lot of my practice is thyroid. And DHEA is actually extremely vital for the utilization of T3. For those listening, T3 is the most active form of thyroid hormone. It’s about ten times more biologically active than T4. And if we find DHEA levels that are bottomed out, a lot of times, that can be helpful in improving T3 performance.

And then the cortisol does have significant impacts on not just the thyroid but the rest of the body. And too much cortisol is going to be highly catabolic. It’s going to break down gut lining, muscle tissue, bone, skin, and things like that.

But I do want to bring up something again that’s usually overlooked. And that’s called glucocorticoid resistance. And glucocorticoid resistance is basically when there’s just been too much cortisol output for too long. Those receptors have downregulated. They’re just not really responding anymore like they should.

This creates a lot of inflammation because cortisol can be anti-inflammatory. And so you’ll start to see a lot of things like food sensitivities, allergies, inflammation, a lot of difficulty controlling autoimmunity, suppressed immune function. These are the people that pick up everything around them — colds, the flus. They just keep getting infections over and over again.

DrMR: Sure.

DrNH: And that can be in women too, getting urinary tract infections over and over again. And you’re kind of searching. So unfortunately, there’s no treatment for glucocorticoid resistance other than time and getting that stress physiology under control.

DrMR: Right. And I like the way you say stress physiology because I think this ultimately comes down to ameliorating this stress physiology. And I think this is important to mention especially in the context of adrenal fatigue.

And this year, I was at the Ancestral Health Symposium. And I caught a few snippets of Chris Kresser’s talk. And he said something that I’ve been thinking for awhile and saying in different contexts which is we should abandon the term adrenal fatigue because it’s very misleading. It almost implicates the adrenals as the sole source of the problem when the problem is really the excessive stress or the chronic stress physiology.

And that’s really what needs to be addressed rather than looking at the adrenals like something that there’s going to be this miracle type of support. And then [*snaps*] the whole problem goes away. It’s broader than that. It’s more holistic than that.

So something that I’m wondering, Nick — or I guess, let me pitch this as an idea. And then we can figure out maybe the ideal time to intervene with a test because I’m sure people listening are wondering that — when to test, when not to test.

So for me, of course, we want to start with diet and lifestyle. It goes without saying. But if someone’s eating Standard American Diet, let’s get them on a healthier diet, maybe a paleo-type diet or maybe a low FODMAP diet if they have a lot of IBS-type symptoms. Or just get them, to put it very simply, off anything processed, get them cooking all their own food at home, and eating only whole foods. That’s a great step in the right direction.

Make sure they’re getting some exercise, but not too much—maybe three to four days a week. Again, that’s going to depend person to person, but just to throw something out there quantifiable. Make sure they’re getting some time in the sun, some low-level activity like walking.

They have something enjoyable that they’re doing in their life like music or art or what have you and not spending all their time on the Internet, which has been shown to cause depression. The longer someone spends on the Internet or on social media, that has correlated with increased scores of depression, whereas when people go outside in nature for a walk, that’s been shown to prevent all-cause mortality and increase subjective feelings of wellbeing. So make sure we have these dietary and lifestyle foundations in place.

I would also say again with, perhaps, a bit of a biased opinion on this, if those things have been done and a suboptimal response has been obtained, then consider a good gut evaluation to make sure there is no gut problem that could be contributing to this chronic stress physiology like we’ve been talking about trying to undo.

And then from there, there are other things that they may want to look into, like look more closely into the thyroid or for another inflammatory issue. But I would say if we’re getting to the point where we’ve got the diet and lifestyle addressed and we’ve done at least a fundamental gut checkup and we’ve cleared any problems there and we’re still seeing a suboptimal response, now this is when I see the cortisol testing or whatever we want to term it — Dutch testing — having a little bit more utility.

When to Use Adrenal Tests

So what I’m hinting at there and wondering how you would critique this is, when do you do this testing in terms of the greater clinical process? And when do you withhold it?

DrNH: Right. So I definitely don’t do the testing on everyone. It’s going to be a very specific, case-by-case basis. It’s going to depend on the individual, what disease process they have. Are they on prednisone? Are they on this? Or are they on that?

I would say that the more chronically ill they are, then the more likely I’m going to run the test, the longer they’ve had an issue. So for example, if it’s only been a couple years compared to 10 or 20 years, I’m going to be much more likely to run it on the 10- or 20-year case.

And then a lot of that is going to depend on their symptoms, especially if there are some major issues with insomnia, depression, anxiety. And again, what’s going on with their autonomic nervous system is going to be an indicator.

And then if we’re just seeing a lot of signs that they’re extremely catabolic. For example, if they’re having an extremely difficult time gaining muscle mass, that can be a good indicator to do the test, severely osteoporotic, osteopenia at a younger age.

If there has been a lot of difficulty in figuring out their thyroid dose for their medication, then that can be extremely helpful. So for example, if they’re kind of on the edge and they’re hypothyroid and they’re on medication, you’re going to see an increased metabolized cortisol if their thyroid dose is too high. And so that can be kind of an indirect indicator.

So for example, if their TSH looks fairly normal or low normal but their dose is actually too high, then it can be valuable in that regard. There’s a lot there to cover as far as how we would make that decision. But that would just kind of be the general overview.

DrMR: Yeah, I like that point you make about the thyroid too because — and I’m sure you see this also — you have some patients who maybe read in some of these heretical circles on the Internet that thyroid hormone deficiency is the cause of every symptom under the sun. And they get roped into this hyper-dosing of thyroid hormone.

And for some people, that really does make them feel worse. And one of the things it can cause is fatigue, which would seem so ironic. But I’ve seen maybe two general ways a thyroid overdose can manifest in terms of energy. And one can be fatigue and probably because it increases the clearance, or metabolism of adrenal hormones and thus creates kind of this pseudo adrenal hormone insufficiency.

And then the other, of course, is more kind of a textbook effect on energy which is this jittery, “I feel wired. My heart’s kind of racing sometimes. I feel jittery.” And that’s the other way I see the hyper-dosing being able to manifest.

But I think the fundamental, important point that you make — or at least one of the points — is that more thyroid hormone is definitely not always better.

DrNH: Right. Right. And I want to go back to what you were saying earlier about what you heard at the conference. And there’s definitely still some lingering education out there in the functional medicine world that still looks at glands as the issue. The thyroid is the issue, or the adrenals or the gut or things like that.

DrMR: Right.

DrNH: That’s been an antiquated view for quite awhile now. But again, it still kind of seems to linger. And as you were saying—

DrMR: And where you see it linger—sorry, not to cut you off. But unfortunately, I think you see it linger the most in the companies that have the most products that are glandular based.

DrNH: Right. Right. There’s an entire model built on glandulars.

DrMR: Yeah.

DrNH: But the idea of testing glands, that can provide some useful information, obviously, if it’s thyroid and adrenals and things like that. But as far as the way that you orchestrate the treatment plan, it’s really not going to be targeting a gland, like you were saying, especially something like the adrenal gland, which has not only an endocrine aspect but also an autonomic aspect.

DrMR: Yep, I completely agree.  Completely agree, especially because — are you still there, Nick? Did we lose our connection?

DrNH: Yeah. Yeah, I’m still here.

DrMR: Okay. Yeah, I often will see, especially with thyroid, people who have their thyroid levels in the normative range but, again, are convinced that they need to get them higher because they think that that’s where the problem is. And a lot of times, it’s not actually the gland that’s dysfunctional.

But it’s that the gland is part of this system that has a high stress or a high inflammatory load. And that affects all sorts of things that happen after the gland. The gland makes hormone. It’s doing a fine job with that. But now, how the hormone is getting distributed throughout the body, how it’s getting into cells, how the cellular receptors are working, how other hormones that are part of this kind of global response that we have in the body — of course, it’s not just one hormone that affects something like energy or sleep.

It’s multiple hormones acting in concert. A lot of that is really what the problem comes down to and not just this gland pathology like someone having overtly high or low thyroid or Graves’ or Hashimoto’s or Cushing’s, for example. It’s more of a subtle, functional problem than that.

DrNH: Yeah, that’s exactly right.

Organic Acids Testing

And I just wanted to bring up organic acids testing, which we kind of have to talk about if we’re talking about adrenal testing. And I find the organic acids extremely useful in a number of ways. And it does give a little bit of information regarding the other aspect of the adrenal gland, at least as far as how the body is metabolizing adrenaline, the norepinephrine, the epinephrine, the dopamine, and then even the serotonin.

But with that particular test, the organic acids test, we get a good look at mitochondrial function. We have to remember that these glands are made up of cells that contain mitochondria. And so we have to look at that, especially with the thyroid when we’re talking about metabolism.

You were talking about finding the right thyroid dose. And you can get into a situation where, if there are a lot of mitochondrial issues — and for those who don’t know, basically the mitochondria are just little factories in your cells that make energy. And they’re driven by thyroid hormone. That’s where you burn all your sugar and your fat and even amino acids in some cases.

But if those are dysfunctional because of a lot of other issues that are going on, you’re basically getting into a situation where you’re just whipping a dead horse. You’re trying to force metabolism in a system that is just completely broken down. And that’s just not going to work.

DrMR: So you’re using, is it the Dutch test in concert with the organic acids as a general rule? Or do you only add the organic acids sometimes? What does that look like?

DrNH: So the organic acids, I’m going to be utilizing in the vast majority of patients just because it’s going to give me the most information about their biochemistry, the best overall picture. And I would say that there are very few out there who really know how to interpret an organic acids profile correctly.

And so for those listening, the organic acids test, the lab provides this strange analysis with a list of nutrients that are supposedly required to address these imbalances on the test. And that just isn’t really how it’s interpreted. And unfortunately, that’s a lot of the way practitioners are interpreting it. So as long as you know to really interpret organic acids, it is going to give you a tremendous amount of information about the patient.

DrMR: So you’re using the Dutch with the organic acids.

How Do Test Results Change Treatment

And here’s another question I understand may be complicated. But the question I want to ask is, how do these test results change treatment?

And I get — and I think we’re in, again, agreement on the fact that the most important part of the treatment is identifying what the contributing inflammatory or stress issue is. And that’s really where the treatment has to be targeted. So it’s not necessarily treating the levels on the test. But as you said, you can use the test results indirectly to guide you to examine where the problem might be coming from.

But I’m wondering if there are some pearls we can pull from these results that may suggest this person is going to do better on an adaptogen. This person is going to do better on Pregnenolone and DHEA. This person needs cofactors like B vitamins. Are any of those pearls able to be extracted from the results?

DrNH: Yes, let’s just talk about a couple of specifics. So number one, you mentioned B vitamins. That, you can actually get some very, very specific recommendations and information from the organic acids. So that would be number one.

DrMR: But that’s not based upon the printout that they give you. You have to know how to interpret this beyond that, correct?

DrNH: Right, exactly.

DrMR: Okay. Okay. Just want to clarify.

DrNH: The second one would be branch chain amino acid metabolism and if those levels are deficient. So it’s kind of nice. You can get that without doing an amino acid profile. And so as someone who uses branch chain amino acids quite a bit, it’s extremely helpful in that regard. So that would be number two.

Number three would be the level of insulin resistance. And so we’re looking at pyruvate and lactate and the ratio there. And so let’s say we’re looking at someone who, fasting glucose looks okay. A1c looks okay. Fructosamine is okay. Even the glucose tolerance test, if anybody goes that far, is not that bad. We can really get a really deep picture of what’s going on with the organic acids test in that regard.

And the other thing is that it helps me choose if I’m going to use a ketogenic diet or now because you get ketone metabolites. And so we might see someone who is severely insulin resistant. And one of them might actually look okay as far as their ketone metabolites.

And then the other individual might have no real ketone production at all, and there should be. Those particular cases, those patients respond extremely well to a short term ketogenic diet. Sometimes, it can almost be revolutionary, so to speak, in their case, especially someone who has been sick for many, many years and nothing has really worked. So that would be one example.

And then the kynurenine pathway is just really important for me to look at in certain cases, especially if there’s a mood disorder or insomnia. And so that’s going to be very helpful in if I’m specifically going to use, say, niacinamide combined with melatonin because there are things going on with those enzymes that are involved in the kynurenine pathway that I need to know about.

There are more examples than that. But those are some very specific examples for you.

DrMR: All right, so I have one or two closing questions.

Episode Wrap-up

But before we transition to a close, is there anything else on this issue that you think is important to mention that we haven’t covered yet?

DrNH: Not that I can think of at this point. I think you did a good job of talking about all the things that kind of need to be done first before necessarily looking at these things, especially related to just the specific adrenal testing. So that would be my closing message — just make sure that every single aspect of your health, your case, is being looked at and addressed because if one thing is missing, then you’re going to have a hard time getting the stress physiology back in balance.

DrMR: Sure. Sure. Now if someone wanted to learn more about the Dutch testing and how to interpret that or the organic acids and how to interpret that, I know you do some practitioner training. I’m not sure if you’ve done something on both these issues or if you’d recommend a combination of some of your literature in combination with someone else’s. But where can people learn more about these things?

DrNH: Right. So my website,, I do have a number of articles about these things that we’ve talked about. And then the Hedberg Institute — that’s — that’s practitioner training. And in the Functional Medicine Fundamentals course I have up there, we do cover adrenals and autonomics and allostatic load and all these things that can contribute to adrenal dysfunction.

The lab, Precision Analytical, has some good videos that are out there put together by Mark Newman, the lab director. Those are excellent foundational things to look at.

And then I would say Dr. Jeff Moss at Moss Nutrition. He is kind of in the middle of it right now. But he’s running a very long organic acids course that is really the best out there on organic acid testing and interpretation.

DrMR: Good. I was wondering if you were going to mention his course because I’ve seen bits and pieces of it come through. And I know that Dr. Moss does a pretty excellent job with most everything I’ve seen him do. So I was assuming that that course was going to be pretty spot on, too. Cool.

All right. So your two websites are and The Hedberg Institute?

DrNH: Right.

DrMR: Hedberg Institute. So we’ll put those links in the transcript for people. And hopefully, this will help people kind of contextualize the whole adrenal fatigue, adrenal testing piece. I think there are definitely some areas here, as Nick and I have been discussing, that really need to be updated.

We had some good hypotheses that were generated from practitioners from a generation or two ago. But we need to update because a lot of these things are based upon a very antiquated model.

And that’s a lot of what we’ve been talking about today is a better way to look at this that’s not, I guess you could say, reductionistic because just to blame the adrenals, even though we may think that’s a very holistic model — if we’re just looking at the adrenals and blaming the gland, that’s kind of a reductionistic model as opposed to being a little bit more holistic in our thinking and looking at the total stress physiology.

So, Nick, always a great talk. Thanks again for coming on. And until the next time, keep fighting the good fight. And we’ll talk soon hopefully.

DrNH: Hey, thanks for having me. Appreciate it.

DrMR: My pleasure.

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