Patient Cases: Using CAR for Tough Cases

Welcome to the Evolution of Medicine podcast! This episode is the third and final installment in our series with Carrie Jones, ND, MPH and DUTCH Test. Dr. Carrie Jones is a force in the functional medicine community, a modern doc with a holistic approach who can appreciate the best of both medical practices. In her own words, she “helps hormonally challenged people feel less crazy” by using testing and her own extensive knowledge to help people understand their hormones so they can feel empowered to take control of their health.

In this episode, Dr. Jones dives into case studies explaining the cortisol awakening response, assessment and treating chronic diseases. Through these explanations, she provides a clear picture of how CAR testing can be practically applied and the opportunities it provides practitioners trying to help patients caught in a cycle of stress. It was a fascinating 30-minute episode, and an excellent way to cap off our series with Dr. Jones and DUTCH Test. I think you’ll really enjoy it, and you can check out our YouTube channel for additional resources discussed in this episode. Highlights include:

• CAR and stress resiliency played out in real-life case studies
• Best practices for testing and assessing CAR
• Why it is critically important to address issues in the HPA axis first
• The one health change patients can make that is totally free and affects all bodily rhythms
• And so much more!

Resources mentioned in this podcast:
goevomed.com/LMRC
goevomed.com/DUTCH
youtube.com/functionalforum
dutchtest.com

James Maskell: Hello and welcome to the podcast. This is the third in the series of a special series that we’re doing with Dr. Carrie Jones about the cortisol awakening response. In the first in the series, we heard about stress and why the cortisol awaking response and stress work so well together. In the last one we talked a little bit about chronic conditions and how to understand how to use it. In this one, we’re going to go specifically into cases. So if you’re listening to this audio, you could check it out on the video, but it was a really great half an hour helpful for anyone who’s dealing with a lot of chronic illness in their practice.

All right, so a warm welcome to the podcast, Dr. Carrie Jones. Welcome back, Doc.

Carrie Jones: Hey, this is great. This is going to be the third one, all about cases.

James Maskell: We’re really excited. The last two months we’ve been talking about cortisol awakening response, why it’s important for assessing patients and their stress and getting into how it affects disease. What I thought we could do for the third one is just go deeper into some case studies that people can see really what this is about. And particularly let’s talk about really chronically ill patients. Because ultimately, for most of the clinics that we’re working with, they’re either seeing those kinds of people or the people who aren’t so chronically ill, you get them doing a little bit of lifestyle modification, you get the meeting better, you get them sleeping properly and the body is so incredible that it can just get us back to health pretty quickly. So I’d love to dive into some case studies. And just as a message, if you’re listening to this on audio, and I know we have a lot of audio podcast listeners, go over to youtube.com/functionalforum if you really want to get the most out of this session because I asked Carrie to put together some slides so that we could see some of these details.

James Maskell: So if you’re listening to this on audio in the car, maybe when you get home you just want to check out the slide. But if you go to youtube.com/functionalforum, we’ll put all the slides up there. So Carrie, welcome and take it away.

Carrie Jones: All right. We’ve been really going into that cortisol awakening response, stress resiliency, autoimmune, memory recall, energy alertness. So let’s tie it all together and let’s summarize it in some cases. I have a handful of cases, some are more on the, not so much simple or basic, but just like what we commonly see. And then I’ve got some autoimmune. So my first case is a woman, she’s in her mid-thirties and she came in because she said I was having extreme morning anxiety. She said, “I have anxiety, I wake up and within seconds I have anxiety and it’s only in the morning.” And she said, “I have really high stress going on my life. But it’s really debilitating. It’s affecting the way I interact with my family. It’s affecting the way that I get ready for work. It’s sort of affecting everything because imagine having debilitating anxiety first thing in the morning.”.

Carrie Jones: So, we ran her cortisol awakening response and on the test, her waking point…so waking is immediately when she opened her eyes, her waking point was fine. It was right in the range where it should be. But within 30 minutes her saliva cortisol shot up. It went from this really high peaked mountain and explained why she was having so much debilitating anxiety to a degree, first thing in the morning. And then it went down through the rest of the day and since she went down into the afternoon, it was actually on the lower end of the range and at night also in the lower end of range. And I would ask her, “Do you have anxiety night before bed?” Nope. None. It was only in the morning. Once she got through her morning, once she pushed through, then it gradually got better and she could do her job and she could move forward.

Carrie Jones: So, when you look at the research when it comes to anxiety and depression, it turns out those people have higher cortisol awakening responses. They have a hyper vigilant cortisol awakening response. So if you’re watching on the YouTube channel and you’re looking at the slide, it’s a study that showed controls, anxiety, depression, and major depression with anxiety. And the reason I chose this case is because so many functional practitioners work with depression, anxiety, right? Mood disorders. Patients come in and they go, “I have really bad depression. I have really bad anxiety and I don’t know what to do. I don’t want to take medication and it’s really affecting my life.”

James Maskell: Yeah. And if it’s not the main complaint, then it’s a sub-complaint. Right? It’s a secondary complaint.

Carrie Jones: Absolutely. And especially because it’s affects so many areas of their life. If you have rheumatoid arthritis and you have anxiety, rheumatoid arthritis and depression, Hashimoto’s and anxiety, it just compounds everything and it just makes you never feel right in your body. So in this study that I’m showing the normal controls with the cortisol awakening response, those with anxiety definitely go up. The cortisol awakening response peak increases. And if you have a major depression and anxiety, it goes up even more, which is really quite interesting. And so it’s really nice to have this data for her to say, “Look, your anxiety is a cortisol driven thing.” And so for her, when I was doing the case review and working with treatment. For her, it was anticipatory stress. She had a very stressful job.

Carrie Jones: She was actually in a very stressful time of her life and her HPA axis, her sympathetic nervous system was already chronically running on fight or flight, either low grade or high grade depending on the time of day. And so we knew what the problem was right there. She did not drink that much caffeine, but she would sometimes just for something warm in the morning or just out of habit or because everybody else does. And so I said, “Hey look, look, be very mindful of your caffeine in the morning and just as a just generally, just avoiding stimulatory medications or supplements,” she didn’t need those. She was already quite stimulated. Addressing sleep hygiene the night before is really important for the CAR. So reminding her to sleep in darkness, dial down before night, getting off her phone, using the blue light blocking glasses will help quite a bit. And then any calming activity or supplement that I did with her, she had to do within the first 30 minutes of waking.

Carrie Jones: So, what people will often do is they will say, “Here patient or client, take this supplement in the morning.” And what do people do? They get up, they check their phone, they deal with their family, they take a shower and they move on with their day and have breakfast and then they take their supplements or they get up, they check their phone because obviously that’s step one and step two for the majority of people. And then they take a shower, then they go to work and then they have their supplements. But if you’re trying to impact the HPA axis when it’s the most active, then you have to do it within the first 30 minutes of waking. And for some of these people, I’m actually trying to substitute sublingual or topical or sprays that will get in and dissolve faster as opposed to a tablet or a pill.

Carrie Jones: It doesn’t always work out that way. But if I can do a tincture, something more liquid-y that they can just get in right away. And it’s also hopefully less likely to cause a nausea. I know a lot of people say, “Well I have to eat in the morning, otherwise I get nausea if I take my supplements.” And for her, breathing exercises right away, any kind of vagal nerve stimulation, humming, singing, cold shower, cold water splashes on her face and just all sorts of things to help lower her sympathetic response and push her into a parasympathetic. Any kind of meditation or journaling, I said you have to do it within the first 30 minutes, which then led to my final point, which was preparedness in the morning. If she’s going to do these things in the morning and she knows she gets this debilitating anxiety that affects the way she can function, then I suggested waking up a little bit earlier and we had to break the cycle of, “When I open my eyes I get anxiety.”

Carrie Jones: Because that was the neuroplasticity, that was the pathway she’s been laying down and we had to break that. So by waking up a little bit earlier and immediately doing either vagal nerve things or doing a five or 10 minute meditation on her phone, taking her calming supplements just broke her pattern of, “When I wake up I have anxiety,” and then boom, she would have anxiety. Or, “When I wake up I hope I don’t have anxiety today.” And so many people do that, right? They wake up and they go, “I hope I don’t.” And then of course by default, that’s what happens. So these are the things we did with her to help.

Carrie Jones: So let’s move on to next patient. Again, like I said, the last one was more of a basic patient with anxiety but such a prevalent symptom along even with depression that I wanted people to realize that the impact of the cortisol awakening response has on that. So the next patient’s a woman in her early forties, she has Hashimoto’s severe fatigue and also has anxiety. And her Hashimoto’s, in her opinion, it was not under control. She felt like she had a lot of symptoms as well. And with her cortisol awakening response, everything was pretty low. So she was just barely riding the range of normal but not really. She was lower than she should have been. And as we know, when you have that lower cortisol awakening response from the earlier podcast, your risk of autoimmune or the autoimmune being worse goes up, because you can’t kill those cells in the thymus gland that fails central tolerance.

Carrie Jones: Plus, when you have a low cortisol awakening response, you’re not alert in the morning and you get all this severe fatigue. And that’s what she had. Now additional information on her that I happen to know about and thought was important to include as we’re talking about her case, she is in her forties and was anovulatory. So she had low progesterone and she did have in the luteal phase, she did have estrogen dominance, not just relative to her progesterone. She actually had higher levels of estradiol than I would have liked to see. She was deficient in adenosylcobalamin, so the B12 that’s more associated with the mitochondria, which of course goes a lot for energy. And on testing, she was higher in VMA, which is a vanillylmandelate or vanillylmandelic acid, which is an indirect marker of norepinephrine and epinephrine on organic acid testing.

Carrie Jones: So, people will say, “Well, we just talked about the last case where the CAR was high, so this person’s CAR is low. So where’s her anxiety coming from?” Well, she has a few things, right? Her progesterone’s low compared to estrogen and her estrogen was actually outright high. And we know that the alpha metabolite of progesterone is actually quite calming to the body. The alpha metabolite, a progesterone, is what crosses the blood brain barrier touches on GABA receptors and helps increase GABA. So by losing progesterone, by not ovulating, she’s losing that GABA support. She also has high VMA, and that’s associated with norepinephrine and epinephrine. Not always, but given her anxiety, I’m assuming probably the case. She probably has higher norepinephrine and epinephrine levels in her body. She has Hashimoto’s and she doesn’t feel it’s very well controlled, so it’s entirely possible thyroid issues are contributing to her anxiety and of course there can be other reasons, we just don’t have time to go into on this podcast besides cortisol.

Carrie Jones: So yes, cortisol can be a cause of anxiety but don’t rule out the other stuff. Make sure you’re doing your due diligence and really looking at her full picture to find out. So for her case, her CAR does have the right peak, but it is definitely way too low. And like I said, it affects Hashimoto’s, which she complains of not being under control. It effects stress resilience, which she complains of, absolutely. Her low energy is likely probably because of that low CAR. In addition, she has low adenosylcobalamin B12, so mitochondrial issues right off the bat. And anxiety, we talked about. Low progesterone, increased norepinephrine, epinephrine and possible fibroid issues. So we would have to work on all of these things. I would want to get her CAR up because I want her stress resilience to go up.

Carrie Jones: I want her Hashimoto’s to be that central tolerance to be properly killed. Right? I want the T-cells that fail central tolerance to go through proper apoptosis versus just sneaking out of the thymus gland. We’d work on why her adenosylcobalamin is low, work on she’s in her forties likely not ovulating, not going to ovulate as she moves closer to menopause. So working on progesterone with her, working on diet, lifestyle, asleep, all the main things. We work on that. And then I’ll show you actually, for those of you watching the slide, I’ll actually show you the her six month follow up first and in six months of doing this work, her cortisol awakening response looks like picture perfect normal. Picture perfect normal. So I’m super proud of her for doing this and really making it happen.

Carrie Jones: So that’s great. But what I wanted to go back and just tell people when I get asked all the time, “Well hers was low. What do you specifically do, Carrie? How do you raise a cortisol awakening response?” And if you listened on the first podcast that James and I did, if you remember, the CAR is directly affected by light. So I tell people, “Go outside and get some sunlight. Open your drapes immediately on waking up or buy full spectrum light boxes,” and they’re very inexpensive. You can find them online. Just read the reviews and get exposure immediately on waking. So instead of waking up and being on your wake up and open your drapes, wake up and go outside, wake up and turn these boxes on. And you want the full-spectrum light to hit your eyes.

Carrie Jones: Don’t stare at the sun, have some common sense, let’s not burn out the retinas, but getting the exposure will help increase your CAR, which is what we’re going for with her. And the CAR starts in the brain. So everything, anything you can do for brain health, do it. So movement and exercise on waking, avoiding EMF and WIFI to the brain, getting regular acupuncture, chiropractic and massage to the neck and back helps blood flow. Getting your blood sugar under control, stopping smoking, all of those things. Anything that helps brain and blood flow to the brain is really, really important. Taking supplements like I talked about with the first patient within 30 minutes of waking, whether they’re calming supplements or stimulatory or adaptogen, you want to do it in the first 30 minutes with those waking supplements because you want to have the biggest impact on the HPA.

Carrie Jones: And then like with anyone, proper sleep hygiene. If the sleep the night before is terrible, then the CAR the next morning is going to be just as terrible. And I actually have a sleep apnea case that might be next. Look at that. Like how well that works out for those of you watching the YouTube video. So in this one, this is a male in his thirties and this is so common and so severely underdiagnosed that getting sleep studies and getting sleep evaluation I think is critical for more people than we realize. So he has severe sleep apnea and he did not have it under control. He was not using the CPAP machine or any kind of device, but he knew he had severe sleep apnea. He was overweight, he had high blood pressure, he had fatigue on waking and a great deal of depression and I think this can sum up a lot of patients.

Carrie Jones: And while this case happens to be male, it doesn’t have to be male, it could absolutely be female. So severe sleep apnea, overweight, high blood pressure, waking fatigue and depression. And there’s a 2018 journal that says, “The hippocampus shows both damage and dysfunction in obstructive sleep apnea, which may contribute to memory, autonomic and depressive symptoms in the disorder.” And that’s exactly what he had. His severe sleep apnea was affecting his weight, it was affecting obviously oxygen to the brain. Therefore things like memory and energy. It was affecting his mood, it was affecting his heart, his cardiovascular system, his endocrine system. It’s affecting everything, which just goes to show please don’t blow off snoring, don’t blow off sleep apnea, don’t blow off, “Oh I don’t want to wear a mask or I don’t want to correct that. That’s too embarrassing.”

Carrie Jones: Because it truly is affecting your entire systemic body for the worst if you don’t get it under control. And so the big takeaway for him is I was like, “You have to address your sleep apnea. You don’t have a choice. No supplement in the world is going to out-supplement the fact that you have severe sleep apnea and you’re not getting oxygen to your brain and it’s just affecting everything downstream.” Because including his cortisol, including as cortisol awakening response. And again, if you’re watching on the YouTube video, I’m going to go back to show his pattern. His saliva cortisol pattern is all over the board. He wakes up really low, which explains his fatigue and then he shoots up…now he goes into the normal range, but it is quite…it’s from below range to a high shoot.

Carrie Jones: And then he crashes back down. So within 60 minutes, he shoots up and crashes back down, which of course is going to affect blood sugar. It’s going to affect inflammation, it’s going to affect energy, it’s going to affect mood, it’s going to affect everything. He spikes up in the afternoon again and believe it or not, the reason he spikes up in the afternoon is he doesn’t eat on a regular schedule. And so on the day of testing he actually completely skipped eating. That’s like, “Well that’s your cortisol actually doing its job, going up to help you break down glucose and then it goes down at night.” And so he’s just all over the board and again, can you give him supplements? Sure. But you know what the problem is? The problem is his sleep apnea and you have to—

James Maskell: Yes. One thing I wanted to ask you about that just with regard to testing, what are some of the best practices? Because I could imagine, my day is not the same every day. Some days I forget to eat lunch and some days I wake up late and sometimes I wake up early and ultimately, is this test…I guess it has the same fallibilities as a one-off test. It’s better in that you’re getting more data points but also depending on what day you test, you’re going to get different results. When you’ve gone through…I know you’ve done some pretty hardcore science on yourself, but have you found that when you do it say a few days in a row that the results are in a zone where any one day is going to give you really good information?

Carrie Jones: Yeah, so on myself, so me as an n of one, for the people who are listening back to the earlier podcast, when I talk about me doing the fasting mimicking diet, my day before, which is my baseline and the my two days after, which is where I’m in baseline again are basically about the same. And my days are basically about the same. My schedule is roughly the same. Obviously, I have stuff if I’m traveling, if I get a migraine, I can screw it up for sure or life can happen and it gets screwed up. But what I tell people when you’re testing, try to test on a typical day. We actually had a practitioner who did their cortisol awakening response and randomly, naturally Murphy’s Law, randomly the night before testing, they didn’t sleep at all.

Carrie Jones: They were like, “It’s one of the worst night’s sleep I’ve had in a really long time.” But it’s when they wanted to do their CAR, and they did it. And of course their CAR was a complete mess. And I said, “Hey look, why don’t we repeat this and let’s try to do what on a normal day when you get normal sleep and let’s see what your normal looks like.” But I had the data now from when you have really bad sleep, here’s what your CAR looks like. And now let’s do the opposite. Let’s take it on a normal sleep night let’s see what your CAR is. And if the car is still whacked out, then that practitioner has problems. But if the car was much more normal, I’d go, “Look at this, sleep has a huge impact and I can prove it right here on your before and afters.”

Carrie Jones: So yes, I tell people whenever you test, please try to do what on a typical day. Don’t do it on vacation, unless you want to know vacation. Don’t do it on a weekend, don’t do it on your day off of work unless that’s what you want to know. But if you want to know your typical day, do it on a typical day. For sure. So James, if you do your cortisol awakening response, I’m going to tell you to do it on your typical day, although I don’t know that you have typical days.

James Maskell: You’d be surprised.

Carrie Jones: So, we’d have to, we’d have to plan that. Okay, this is a female in her fifties. This is a good one because the impact of lifestyle situation and memory because she thought she was having dementia, getting Alzheimer’s is what she said to me. “I think I have Alzheimer’s, Carrie.” Very tired. She’s in a very stressful divorce. And of course, naturally she was having memory issues. So on her cortisol awakening response, her waking point was okay, it was in right in range. And then she went down, and then she went down again. So instead of going up and down, she went down and down. So that explains the fatigue. But if you listen to an earlier podcast, you would know that also affects the memory. So for those of you maybe who are listening to this podcast and haven’t had a chance to go back, I’ll just recap you real quick.

Carrie Jones: So, the CAR has a huge impact on recall. Now recall from the day before, if you don’t get the morning rise in cortisol then what research says, it inhibits free recall of previously learned content in texts and pictures. So if you read something yesterday or you saw something yesterday and you were trying to remember it today but your CAR goes down instead of up, you might have a really tough time. And in her case, she was, she’s like, “I feel like I’m getting Alzheimer’s. I was trying to remember lists, I was trying to remember things I had done the day before. I was even just to remember what I’d eaten. I had texted somebody and then I couldn’t remember who it was that I texted and what I needed to follow up on and I think this is a problem.”

Carrie Jones: I’m like, “It is a problem. But it’s directly related to the fact that you’re not getting the lay down of memory in your hippocampus because you have that flat CAR.” So she’s in a stressful divorce and I’m like, “We just have to keep your head above water. We know what the problem is. We know we know what the problem is.” And just like everyone else, I said, “Whenever our resiliency herbs and nutrients that we’re going to do, we’re going to do first thing on waking,” because again goes down, down, down, and we want her to go up. And then we’re going to improve any kind of blood flow to the brain because the hippocampus, the hypothalamus, the pituitary, that’s where it all kicks off. So as I’ve said before, exercise in the morning, helping getting that blood flow around to the brain. She wasn’t a smoker, but this just is an FYI, stop smoking, normalizing blood sugar.

Carrie Jones: She actually had, because her CAR went down instead of up, she actually had a lot of morning blood sugar problems. The CAR going up will help release blood sugar in your system because you’ve been fasting. So it’s to help stabilize you until you choose to eat. It’s a survival mechanism, which is great. But in her case, she didn’t get it because hers goes down not up. So she was having all sorts of blood sugar irregularities, hypoglycemic in particular. Other great things for the brain, neurofeedback, acupuncture, chiropractic massage for blood flow like I’d said, hyperbaric oxygen therapy, HBOT. Testing for iron overload, I find this a lot, believe it or not, in men and in menopausal women. So make sure that you do test your men for hemochromatosis, test their iron, test their ferritin and make sure you test your menopausal women.

Carrie Jones: Because what happens is when women get their periods, they bleed out their iron and that’s their, that’s their stop gap. But once they become menopausal, they don’t bleed every month. And now the iron starts to build up again. So just especially if they have a family history and you suspect, don’t be afraid to test iron in a menopausal woman or a man. And then like I said before, we do see an EMF, WIFI, cell phone exposure to the head that will just impact the hippocampus, the hypothalamus and the pituitary. The brain-supportive supplements, resiliency type, HPA adaptogens, which there’s a lot of them out there. I’m not going to list them out because they’re specific for her, but they can all be really, really helpful. Especially when done, like I said, within the first 30 minutes. And then remember light is everything, the sun and brightness is everything.

Carrie Jones: So making sure for her I was like, “When you get up in the morning, I know you don’t feel like it, I know you are tired but you have to turn on your light box or you have to sit out on your deck or your patio and open your blinds, get a little sun exposure and retrain your body, retrain your brain that things go up in the morning, you want to go up in the morning. And that can be really helpful.” So I hope that these cases, just touched on a little bit of everything for people like key symptoms in people, key things in people that they walk in your door with. And by knowing the cortisol awakening response, again, you get that huge health insight for both longevity and resiliency, which is what we’re all after.

James Maskell: Yeah, it’s interesting, I’m thinking when a really tough case comes into a clinic, you got a lot of choices about what you could start with. And probably the worst thing to do, just not clinically, but just from a practical standpoint is trying to address everything in the first visit. Right? Because it’s going to be a journey to get people back to health. Given the important role that the HPA axis plays in regulating the whole system seems to be that ultimately making improvements and changes in this area first. One, it embeds a lot of the lifestyle stuff that you’re trying to do anyway that is important for long-term health and building up resilience again. But secondly, if you make changes in the communication system, then the downstream effects of all of those changes will be the body doing a better job of getting back to homeostasis. And I’m always thinking about, what is the simplest way to get people better? What is the simplest, most effective, most consistent, most cost-effective way to get people better? And ultimately it seems to be that because of the central role that is playing in regulating all the other parts of the body, that this might be a significant leverage point.

Carrie Jones: Oh, I think so. 100 percent. When I get asked a lot what I would say my number-one health biohacker health thing is, what’s my favorite thing? I always say sleep. Sleep can affect the circadian rhythm. Because if you can go down at night and up in the morning consistently in a healthy manner, it just sets the domino effect for so many things. Now, I do get the question a lot for those who are on night shift and I understand that you are not down at night and up in the morning, you have a flipped curve and night shift workers, we need you, God bless you. But wow, your circadian rhythm is kind of a mess, so you’re going to have to work with somebody on that. But for those of you who are not night shift workers, if you can go to sleep, get good sleep, get your hit your REM, hit your deep sleep, get your nice melatonin release.

Carrie Jones: I don’t think people realize this, but we didn’t talk about melatonin. But melatonin helps set the circadian rhythm but not only the circadian rhythm, all of your rhythms. So even your reproductive rhythm and your feeding rhythm. And so I find with women, when they say, “I’m having all these reproductive problems, I’m irregular, I’m short cycle, I can’t get pregnant.” I start with sleep and it’s not always that easy. But a lot of times, I find out their sleep is really not as good as they think it is. Or they wake up several times in the night or they can’t fall asleep or they can’t stay asleep or they go to bed way too late.

Carrie Jones: And so that’s directly impacting their cycles. But nobody puts two and two together. Nobody thinks like, “Well, I’m a night owl and I go to bed at two in the morning and I get up at six or seven with my family.” But nobody realizes that shortens your melatonin output, which affects your reproductive rhythm. And sleep is free. I’m not telling you to buy anything with sleep. I’m not telling you to buy supplements or fancy light things just really focus on what you do at night before bed.

James Maskell: Yeah, that’s been a huge piece. Well look, I really appreciate sharing this and I think there’s a lot to learn here from these. If you are listening to this on the audio, make sure to check out the videos on the YouTube channel and you’ll get all of the details there. Carrie, thanks so much for being part of this and for coming through with this series. I really am excited to see that there’s a shift underway from really understanding disease and disease risk and really looking at health and health optimization and they have a lot of things in common but ultimately, it’s a very different conversation and so I’m excited to see just how effective we can be in creating health in the humans that come into our offices.

And I think it’s a lot of good information for everyone. So thank you for this series. If this is the first episode that you’ve heard, there are two more on the YouTube channel and on the podcast and this has been Dr. Carrie Jones. She is the chief medical officer of Dutch Test. If you want to find out more about measuring your cortisol awakening response and getting a lot of other awesome data that can help to flesh out some of the root causes of what’s going on in yourself or in your patients. Check out dutchtest.com but in the meantime, this is been our three-part series on the cortisol awakening response. I hope you’ve enjoyed it. If you want to learn more about it, please feel free to get in touch. Thanks so much for listening and we’ll see you next time.