The Cortisol Awakening Response: How It Became the Go-To Stress Test

Welcome to the Evolution of Medicine podcast! This episode is the first 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. It was an energizing, educational 25 minutes, and I think you’ll really enjoy it.

In this episode, we dive into a cutting-edge topic: the cortisol awakening response (CAR). We discuss how it became the default test for assessing stress and how you can capitalize on this information in your practice. Highlights include:

• Understanding the cortisol awakening response, and how it became the default test for assessing stress
• How testing the cortisol awakening response answers the question, “How resilient are you?” and changes the conversation from testing for disease risk to testing for health opportunity
• How the cortisol awakening response influences alertness and blood sugar management
• Resources for getting up to speed on the cortisol awakening response and implementing this testing in your practice
• And so much more!

Resources mentioned in this podcast:
goevomed.com/LMRC
goevomed.com/DUTCH
dutchtest.com
dutchtest.com/dutch-fest-2019

James Maskell: Welcome to the Evolution of Medicine podcast, the place health professionals come to hear from innovators and agitators leading the charge. We cover the latest clinical breakthroughs and health technology as well as practical tools to help you transform your practice and the health of your community.

This podcast is brought to you by the Lifestyle Matrix Resource Center, who provide a range of options to help you deliver successful, effective, functional and integrative medicine. To find out more and to get started, go to goevomed.com/LMRC. That’s goevomed.com/LMRC.

Hello and welcome to a new special series that we are doing with DUTCH Test. We’re going to be talking about the cortisol awakening response. I’m super excited to share. In this session, you’re going to learn about the cortisol awakening response and sort of how it became the default test for stress and how you can take advantage of this information in your practice. And so check out the segment. I think you’ll really like it.

A warm welcome back to the podcast, Dr. Carrie Jones. Welcome, Doc.

Carrie Jones: Thanks, James, appreciate being back here.

James Maskell: Great to have you back here on the podcast. I’m excited for this series that we’re going to do really getting into stress and we’d be doing a whole a series on stress in the brain. This is going to be a series of three and I guess the question that we really wanted to ask today was just about the cortisol awakening response, which is kind of become the default tool in a certain way for assessing stress. How did we get here and can you sort of for our audience give us sort of a baseline of why that test became the tool for doing that?

Carrie Jones: Yeah, I’d have to say it’s like quickly becoming my new favorite topic to talk about the cortisol awakening response, just because it gives so much insight into stress response, stress resiliency. I’m sure as you know, the number of people out there who just don’t have a lot of really good resiliency. They’ll tell you, I don’t feel resilient. I wake up in the morning, I can’t get going, or the opposite, they’re like hyper-resilient, they’re hypervigilant, they’re anxious, they go from zero to 10 their heart races and they can’t figure out what’s going on. That’s all centered around that cortisol awakening response. That is for sure what I want to talk about. But before we do let’s back up a step, let’s talk about the basics, just to remind people that it all comes out of the HPA axis.

It comes out of the hypothalamic-pituitary-adrenal axis. Any kind of stress response, stress signal, from anywhere in the body, anywhere outside the body comes up to the brain, to the hypothalamus, and then that triggers the release of CRH, goes down to the anterior pituitary that triggers ACTH, which then triggers cortisol release. And then within the stress response, you get your norepinephrine, which is noradrenaline and your epinephrine, which is adrenaline release at the same time. Because people want to test this, they want to know like, well, how stressed out am I? I’m tired or I’m not tired or in fact, I’m anxious. Where do I really look? That’s what really drove people to doing saliva testing. They would do saliva testing because they could get that saliva test first thing in the morning on waking and then they could collect again maybe later in the morning or maybe at lunch.

Then they will collect again in the afternoon and then they will collect again at nighttime and they’d get this nice pretty four-point curve through the day to see if they go up down like they’re supposed to or if they’re more flat-lined or if they shoot through the moon. That then led us to the cortisol awakening response and it became this super big deal. Why do we care about the cortisol awakening response? We’ve already got this pretty four-point picture and it tells you what’s going on. But the cool thing about the cortisol awakening response, there’s this great quote that I read that says the cortisol awakening response or the CAR occurs upon wakening in the absence of any apparent stressful situation or imminent danger. It’s this spike in cortisol whether you want it or not.

The body is doing it for a number of reasons and it’s supposed to go up and then it’s supposed to come down. I’ve been saying, some people don’t, they just don’t have the stress response. They don’t have to stress resilience or, or they’re hypervigilant, they’re too much. Within that first part of their day, it’s just not healthy and they don’t feel healthy. They tell you that. They tell you, I wake up and feel terrible or I wake up and I feel anxious or I wake up and I feel depressed or I wake up and I hurt, my joints hurt. What’s going on here? The thing about the CAR is it’s influenced by so many things, it’s influenced by our health status, our behaviors, our stress perception.

If we think it’s going to be a really stressful day, if we’re anticipating a lot at work or we wake up and we check our text messages and immediately it’s just awful things coming at us, which is maybe why we constantly tell people don’t check your phone first thing on waking cause it just sets off the cortisol awakening response. Now that we’ve kind of moved forward, we know how cortisol is made, we know how cortisol was tested. How does the actual cortisol awakening response work? It’s this process where the body knows you’re about to wake up. The body’s like, okay he or she is getting closer and so the pituitary is releasing ACTH and a pulsatile manner, but the adrenal glands are like, no, not yet, no, not yet.

It puts this blunting on. Until the person opens their eyes in their morning and light enters in to the super cosmetic nucleus, the SCN in the brain, and then it goes into the brain, then the blunting releases, you get what’s called this flip-flop in the brain and cortisol shoots up and it’s supposed to shoot up about 50% over baseline, at least in the first 30 minutes. You’ve got about 30 minutes that your cortisol is going to get up there and you know, get your butt out of bed and get you moving and get you doing all these things. Then it gradually declines through the day down, down, down so that you can be nice and low before you fall asleep at night. I mean, that’s how it’s supposed to work. Again the light that enters into the SCN, into the retina, into the eyes, is really critical.

People will say to me, well, I sleep with blackout curtains or I sleep with a sleep mask. Or maybe people don’t. They’re like, well, I sleep with a lot of light around. Could that be affecting it? Absolutely, sleeping with or without light helps set your circadian rhythm. I tell those people who wear sleep masks, who sleep in with the blackout curtains, I said when you wake up in the morning immediately, obviously, take your mask off but open the curtains, get some light exposure in and that will help to address your cortisol awakening response. Then I get asked a lot about this flip-flop. What does this flip-flop mean for the cortisol awakening response? I remind people when you open your eyes, you’re conscious but it takes about 20 to 30 minutes for you to go from consciousness to about to full alertness, ready to go.

It’s different parts of your brain where you flip from an area where you’ve been asleep to an area that’s more sort of alert and ready to make executive decisions. The big question always is, are you alert in the morning? This is where having the cortisol awakening response can answer this question for people. Really just sort of dial into that first 30 to 60 minutes and say, are you alert? Can you go from consciousness to alertness? Can you get up in the morning? Are you so fatigued because your awakening response goes down? Are you anxious because you go up too much? By knowing the cortisol awakening response, CAR, we can answer these questions.

James Maskell: Do you think it’s maybe one of those things where, because you don’t feel 100% alert, you think that that needs some sort of intervention? You take on some sort of intervention because you…but you don’t realize that’s actually probably normal and that’s just the body warming up. Actually, if you didn’t do anything your alertness would go up either. The coffee first thing in the morning is doing part of it. But actually, it’s just the fact that you just woke up.

Carrie Jones: Honestly, the only way to know is to test. Right? Let’s say you wake up and you’re just completely exhausted and you think, well, I need to have my coffee right away or I need to have whatever you do right away. Or you might think it’s wrong. You just, like you said, you might think it’s a problem. You might tell your functional practitioner. When I wake up in the morning, I’m tired. It’s like, you should be, you just opened your eyes. You’re only conscious. It takes about 20 to 30 minutes for you to move into alertness. Now it can take some people longer and some people, they don’t ever feel alert. Unfortunately, they’re the people that are like, I desperately need coffee. If I don’t do any coffee at all in the morning or any kind of caffeine, I’m never alert.

Or maybe they do caffeine and they’re still not alert. By testing, knowing their cortisol awakening response, they can really see this and then they can address it, which we’ll talk about in subsequent podcasts. But I want people to know what really influences the cortisol awakening response because it’s not like something you’re born with, it’s not set in stone and once you’ve got your CAR that’s it. It’s not like once it’s low, it’s low or once it’s high, it’s high. Your cortisol awakening response changes with age, it changes with things like anticipatory stress for the day, your sleep habits. Obviously, people who have sleep apnea or disordered breathing or their mouth breathers at night, which is so common, that’ll affect the way your CAR goes up or down in the morning.

If you wake earlier than normal. People who are waking up 4am to catch a flight, obviously, that day is going to be different. People with infections, overt or stealth. We talked a lot about stealth infections that can have a huge influence on the CAR in the morning. Autoimmune, which we’ll talk about in a later podcast, that the CAR in autoimmune are very tightly intertwined. It’s one of my favorite things. If you can get the CAR dialed in, it can really help those with autoimmune. Psychological burnout, big one, we know that the workplace burnout is a new ICD 10 that’s coming out and is now being recognized by the WHO, but psychological burnout right there, chronic fatigue, PTSD, fluorescent lights. There was a study about fluorescent lights. People who sat under fluorescent lights for six to eight hours, it greatly suppressed their cortisol awakening response, which I would bet most people could just tell you that you don’t even need to study for that.

People will say, I know when I go into stores with bright fluorescent lights, when I sit at my office, I feel actually more tired after a while. It’s draining after a while. Any kind of traumatic brain injury that affects the hippocampus, which the CAR is directly set off, I should say, by the hippocampus. Then the hypothalamus and pituitary. A lot of people are on medications that are suppressive. Think your steroids, whether it’s oral, inhaled nasal sprays, topical steroids or stimulatory. People who are on maybe ADD medications or any kind of…they’re taking cortisol to replace missing cortisol. Obviously, that’s going to have a big impact on the CAR. Caffeine, people who drink caffeine immediately upon waking, people who set the alarm on their coffee maker so it’ll have coffee brewing when they wake up.

Really lucky people who have their significant other bring them coffee in bed that will affect the CAR. Then where a woman is in her cycle, in ovulation, her CAR is a lot higher. If she’s testing and she’s ovulatory, just know that it’ll probably be quite a bit higher. What’s interesting is I ask women this if they already have a hypervigilant CAR, do they feel more anxious around ovulation? When women start tracking, it’s amazing to see what they say. Oh my gosh, around ovulation I do have these feelings. I do get heart racing. I do feel more stress in the morning. I’m like, well, you’re ovulating, everything’s going up and the CAR goes up with it.

Now on the flip side, those are all the things that can influence a CAR. What does the CAR influence? Well, like so many things, energy levels, obviously it goes up to get your butt out of bed and to put you into alertness. It affects your stress response and really your resilience. There’s so much research out there on the CAR and resilience that it’s a really good indicator of are you resilient or are you not. Basically, are you stressed or are you stressed out? That’s why I really like running it.

James Maskell: Can I ask you a question about that? Because one of the things that I’m focused on a little bit with some of the stuff that I’ve been doing with Jeff Bland and some of the stuff that we’ve been talking about is just literally thinking very differently about the numbers that we associate with our health. Because so many numbers in healthcare are actually all about disease risk. This seems to be a number that is starting the conversation towards health. How resilient are you? Do you feel part of the reason may be why this is becoming more of a thing is just because people are looking for markers that will determine the bounce-back ability of the body? This seems to be something that is sort of moving in that direction.

Carrie Jones: 100 percent. What’s really cool about the CAR is not only is it a marker of, like you were saying, resiliency instead of a disease risk, what’s actually happening in real-time in your body. But it is also a marker of disease risks. For example, which I actually will sort of cover in a later podcast, but research shows if you have breast cancer and a low CAR, your mortality risk goes up. You have a disease risk just by looking at your CAR, but on the flip side, if you’re stressed out and you have a low CAR, I know that your resiliency is low real-time. I know real-time your resiliency is so not only can I say real-time you’re stressed out and it’s showing all over your body cause it’s in the CAR, but also in the future, I can tell you that you have a higher risk of mortality if you develop breast cancer. But research is also in prostate cancer as well, so you can actually get both out of the cortisol awakening response, which is why I love it, it’s a really cool marker.

Other things, the CAR influences alertness, which I said, blood sugar management obviously. As cortisol goes up, it’ll help you break down glucose because you’ve just been fasting all night. It affects your mood, it’ll make you more anxious. It can induce panic. It actually can be a cause of depression and worry, hypervigilance, autoimmune development and progression, which we’ll talk about. Inflammation regulation, of course, cortisol’s anti-inflammatory to a point. If you don’t have that rise in the CAR, then you may be more inflamed than the average bear in the morning. Tons of people wake up and they’re like, I wake up with migraines, I wake up with joint pain, I wake up, my shoulder hurts so I wake up and my stomach hurts. It could have to do with the CAR’s ability to regulate inflammation, infection regulation, memory and recall because the hippocampus is so tied into the CAR that if the CAR doesn’t occur then that memory and recall from the prior day can be affected.

How many people say to you that their memory is not what it used to be? They can’t recall things they used to. Especially when they’re stressed out. I have so many patients who say to me, my stress is a 10 out of 10 and I think I’m developing Alzheimer’s because I can’t remember anything. I’m like, yeah, the cortisol absolutely affects the hippocampus. You have to be careful and in cancer outcomes, like I said, with health risk when it comes to a low CAR and increased risk for mortality in the future. What they say, what the experts say, is it’s the mini stress test of your day. If you know your CAR, then you get all this insight and the ability of your HPA access and the associated regions and structures. You know if your CAR is good that you probably had decent sleep, your hypothalamus is probably talking to your pituitary.

Your pituitary is probably talking down to your adrenal glands. You have decent stress resiliency if you have a normal CAR. If you don’t, then you know that a lot of those things have fallen off the tracks and you have to do something about it. I tell people if you can’t get your CAR right, then how do you expect to get the rest of your stress response right. Because if you can’t even do the most basic first thing in the morning thing, you’re not going to get your blood sugar right. You’re not going to get your autoimmune right. You’re not going to get your inflammation right. You’re not going to get your stress resiliency right. You’re not going to get any of that right. You’re not gonna be able to fight infections correctly because you can’t even get your cortisol awakening response right.

It’s super important. It’s super important as a biomarker. When people ask me, how does the CAR look different than like a traditional four-point sort of adrenal test, I tell them it’s actually five collections. It’s more collections, more data points, because you do it first thing in the morning on waking. You do it 30 minutes later, you do it 30 minutes after that and then around dinner and before bed. So you want that waking 30, 30 so boom, boom, boom test right away. Because we want to really hyper-focus on that first hour for the CAR. We want to really make sure that you look right there because if you let it go too long, if you do it in the morning then at lunch like, oh you missed it. You have got to focus on that first 30 minutes.

With elevated CARs, examples of elevated CARs, people will say, Carrie, how do I know if it’s high or not? Well, the only way to know is to test, but usually what will happen is that their 30-minute, maybe their 60-minute point will be really high, and they’ll tell me, I feel anxious in the morning. I feel my heart racing in the morning. I can hear my heart rate or my heartbeat in my ears in the morning. I get nervous in the morning. I feel like a chicken with my head cut off in the morning. I’m like, I would imagine you probably have an elevated CAR. On the opposite side, the low CAR people are the ones who tell me I hit snooze six times. I need a lot of caffeine to get going. It takes a while to open my eyes. I don’t feel human until about 10am maybe 11.

We have so many of these people. We have so many clients and patients that come in and say one of these two things all the time and we know either way their resiliency, their long-term health effects is probably not that good, unfortunately. We want that CAR to be dialed in. Those are all my key things when it comes to sort of the basics of the cortisol awakening response and why I love it so much because it’s supposed to naturally occur in the morning within minutes of waking. It’s supposed to push us into full alertness in about 20 to 30 minutes. And if it doesn’t, then you’re going to have problems with all sorts of systemic things, blood sugar, inflammation, infection, autoimmune. It’s influenced by so many things. I know it’s not set in stone and I know that it’s affecting other areas of my life. Key areas like autoimmune, like cancer risk, I want my CAR to be pretty perfect.

James Maskell: I know one of the things that we’re sort of moving away from if you look in a meta-level, we’re moving away from single measures to more regular measures. Look at blood glucose monitoring versus continuous glucose monitoring. You get a lot more information when you have more time in there. Is that kind of…I would imagine that that’s sort of one of the benefits here is that you’re getting one data point and so you can start to make inferences about a physiological process, not just based on one number that could be high, could be low for a range of reasons.

Carrie Jones: Yeah, absolutely. Think about traditional testing of saliva and adrenal glands. You do it in the morning and you do it at noon and so if in the morning you’re low and at noon you’re low, you don’t know what happens in between there. You don’t know if you shoot way up and then come down, you don’t know if you stay low the entire time. By going on waking, 30 minutes later, 30 minutes after that, you get a really clear picture of, can you go up and down, or do you just stay low, or do you just keep going up? Just like you said, having all those data points for some people can be challenging to collect, but I’m like, look, more data points means more health information; I have to really be very personalized to what I’m going to do for your case.

James Maskell: Absolutely. Well, look, I’m super excited for our community to bring this. We’re going to focus on this for a few podcasts here. But for practitioners who are either not using this already or think that they’d like to be able to access this kind of information, what are some other ways that they can get up to speed with this kind of learning?

Carrie Jones: Well, definitely I’m slightly biased, but I would look at www.dutchtest.com. Everything on there, all their webinars, information videos are free, and we do have an upcoming functional endocrinology summit, October 4th and 5th in Portland, Oregon. Check out dutchtest.com if you’re interested in learning all things DUTCH, but also just again, cortisol awakening response hormones, endocrinology on October 4th and 5th.

James Maskell: Amazing. All right, well, Carrie, thanks so much for this podcast. We will do two more. This month, we are looking at how CAR became this tool. In future sessions, we’re going to talk about what you learn from patients and we’re going to get deeper into that resilience conversation and then we’re also going to go deeper into chronic health patients because ultimately, that’s the majority of who’s showing up in the practices of our community. Thanks so much for being a part here and sharing such great information and I hope you enjoyed it. Let us know what you thought in the comments and we’ll see you next month.

Thanks for listening to the Evolution of Medicine Podcast. Please share this with colleagues who need to hear it. Thanks so much to our sponsors, the Lifestyle Matrix Resource Center. This podcast is really possible because of them. Please visit goevomed.com/LMRC to find out more about their clinical tools, like the Group Visit Toolkit. That’s goevomed.com/LMRC. Thanks so much for listening and we’ll see you next time.