All About Cortisol

1. I have been on a very low carb diet for more than five years but my blood glucose is slowly rising with time. Now my fasting blood glucose is consistently in the upper 90's mg/dL. My doctor told me this was a "borderline" result and seemed concerned. I am proactive with my health care so I immediately knew this wasn't diet related since my diet hasn't changed. From what I have read on your blog, I figured this could be some kind of stress response. I decided to get my cortisol levels checked and they were through the roof. Before I went low carb, I was never diabetic nor prediabetic but I was hyperinsulinemic for decades as my fasting insulin levels were abnormally high before starting my diet. I also had metabolic syndrome. I would like some insight on what's happening and if there is anything I can do to stop it. 

This is a great question and I want to dive deep into this so it will be a long read. This is where most of the misconceptions of what diabetes is and how it occurs lies, so even though I want to keep it simple, I need to be thorough. Even though you have not been diagnosed with type II diabetes or even pre-diabetes, metabolic syndrome is the non-clinical manifestation of diabetes. So what pertains to diabetes, also pertains to metabolic syndrome as metabolic syndrome leads to diabetes. 

First, I want to remind everyone that diabetes is a syndrome. This means it is a set of symptoms which occur together. This doesn't mean they occur in the same order, at the same rate or in the same way for everyone. This is why everyone's diabetes is slightly different and responds differently to different interventions. 

Secondly, when I refer to "stress" in this post, I am not referring to emotions. I am referring to the body's stress response which is mitigated by the hypothalamic/pituitary/adrenal axis (HPA). This axis doesn't care about your meditation or your "grounding" practices. These things might help you feel emotionally better but the axis continues on with its trajectory until it's interrupted by something that actually affects it. The part of this axis that we will be discussing here is the adrenals. 

I am going to give a very brief summary as to what the adrenals are and what they produce. 

The adrenals are a set of glands that sit on top of each kidney. Each gland is composed of two parts - the adrenal cortex and the adrenal medulla. The adrenal cortex produces three hormones - mineralocorticoids, glucocorticoids and adrenal androgens. Our primary concern for this discussion is the glucocorticoids of which cortisol is the predominant one. 

The adrenal medulla produces the catecholamines. These include adrenaline, noradrenaline and small amounts of dopamine. Adrenocorticotropic hormone is secreted by the anterior pituitary gland and it primarily affects the release of glucocorticoids and adrenal androgens. It also stimulates aldosterone release to a lesser degree. 

This HPA axis is dysregulated in people with metabolic dysfunction. This is because metabolic syndrome is an adaptation towards hyperglycemia so all glucoregulatory systems are primed for one thing and one thing only - keeping blood glucose high. This occurs at all stages of metabolic dysfunction, from metabolic syndrome all the way to diabetes, and is a main catalyst in the development of pathology. 

This is the point where diet becomes irrelevant in obtaining remission and why doctors do not put much weight on diet when it comes to the treatment of diabetes, though they make recommendations for an overall healthier lifestyle. This is also why diabetes is described as a chronic and progressive "disease", as diet is only a palliative treatment. The glucose dysregulation, which is occurring, will only be affected by diet up to a certain point. 

Let's go through what is most likely occurring to you and what can be done to mitigate it before it becomes worse. 

"Hyperinsulinemia" is only relevant in the context of metabolic syndrome. It is pretty meaningless on its own as insulin levels are pretty dynamic and easily manipulated through a variety of ways. Serum insulin levels do not always correlate with insulin resistance. You can have resistance at normal to low insulin serum levels. But since you measured your insulin while fasting and we already established a context of metabolic syndrome, we can safely assume your hyperinsulinemia is correlated with resistance and overexpression.  

Being hyperinsulinemic, as you described, for many years, is metabolic dysfunction, which causes metabolic stress. Metabolic stress is the type of stress that disrupts the HPA axis through improper metabolic function. The reason your insulin levels were so high was in response to chronic, erratic, ups and downs in blood glucose with large disparities between the two. This sets a high blood glucose, insulin and body fat set point as metabolism adapts to protect itself from hypoglycemia, which it interprets as "starvation". Once these markers are set to a high point, they pretty much feed off each other like a vicious circle affecting the HPA axis's homeostasis. 

We often talk about "insulin resistance" and "leptin resistance" as these two hormones are central to overweight/obesity and metabolic dysfunction but one hormone that is often ignored is cortisol. But cortisol is a central hormone when it comes to the adaptive metabolic pathologies involved in the development of diabetes. 

For the diabetic, cortisol breaks the body down into glucose, at an exponential rate. The diabetic does not have to do a single "unhealthy" thing for this process to continue unabated. Worse, there isn't much a diabetic can do to stop it. When cortisol becomes overexpressed and chronic in the blood stream its receptors become damaged and you develop a type of "cortisol resistance". 

The term "resistance", when applied to any of these hormones, is basically a simple way of describing that they lose their normal function to varying degrees and at different rates in various tissues and organs. I am refraining from saying "they no longer work" because that's not correct. Instead, it simply takes larger concentrations of these hormones to do their job effectively and this in itself contributes further to the "resistance". These larger concentrations can not be produced by the body itself so they must be dosed exogenously through prescribed medications. 

On another side note, I am referring to hormone "resistance" in this post in the context of high serum levels because you measured your cortisol and found it to be abnormally high. But I don't want readers to get too caught up in this because, like I mentioned above, "resistance" is very complex and does not always correlate with serum levels. Once serum levels are high, it's usually at end stage resistance but these hormones begin to lose their proper function and effectiveness long before serum levels become abnormal. "Overexpression" does not imply high concentrations. Expression is the operative word. You can have overexpression at low to normal concentrations. 

The metabolic stress caused by poor blood glucose control raises many hormones chronically to abnormal levels, interfering in their proper pulsatile function. This pulsatile function is what prevents "resistance". If cortisol remains overexpressed, it loses its normal function with time and contributes further to metabolic dysfunction as it continuously dumps glucose into the bloodstream at the expense of lean muscle mass. This does not allow for proper blood glucose regulation. 

But things only get worse from there as overweight/obesity/metabolic dysfunction contributes to other comorbid pathologies that raise cortisol demand even further. Here are a few common ones, but certainly not the only ones: 

• Autoimmune - If you are overweight/obese you are at risk for developing inflammatory conditions like autoimmune, arthritis, cardio vascular disease (CVD) and asthma. You are also more prone to injuries or needing invasive procedures and surgeries which contribute further to cortisol overexpression/demand. 
• Sleep Apnea - This condition is a known cortisol trigger as it interrupts sleeping patterns and causes a frequent state of hypoxia (low oxygen). 
• Mental Illness/Health - When you are in bad physical health, it causes bad mental health and conditions like chronic clinical depression and anxiety dysregulate cortisol. 
• Hormonal Changes (Menopause) - Women who are overweight/obese have a higher risk of irregular and abnormal menstruation which contributes to stress and the release of more cortisol. This abnormal menstruation also contributes to a lengthy and abnormal perimenopausal/premenopausal period which further causes a stress response. Not to mention that these women often also have conditions like polycystic ovary syndrome (PCOS) and anemia which are further stressors. 
• Exercise - People who are overweight/obese cannot keep an exercise regimen as all of the ailments described above, and then some, effect their mobility, stamina and endurance. This causes an avoidance of exercise which further deteriorates cortisol's pulsatile function. These people can either not exercise enough or as frequently so they never profoundly effect cortisol to prevent its further deterioration. 
• Diet - Overweight/obese people cannot seem to keep a consistent diet unless it's the Standard American Diet (SAD). As far as healthy protocols are concerned, they can't seem to stick to one, much less to any. They always go to fad, unsustainable, ineffective protocols for "quick weight loss" or for "curing their diabetes" which in turn causes them to end up continuously changing strategies, disrupting nutrient availability and furthering the increase of the stress response. The constant shifting between starvation style diets and ridiculous fasting regimens exacerbate stress and causes more cortisol dysfunction. 
• Insulin - Poor insulin function effects the metabolizing of amino acids, some of which are directly responsible for regulating cortisol. 
• Leptin - Under expression of leptin raises cortisol levels as the body cannot regulate its energy flux properly. 
• Finally, all of the above end in prescription medications of which many affect... guess what? Cortisol, once again. This is especially the case of glucocorticoids. 

As you can see, one stress leads to another and they compound together to create a very complex pathology that further deteriorates the stress response and doesn't respond to any one treatment. This is not the fault of "insulin" or "blood glucose", though people with metabolic syndrome/diabetes are usually never truly able to fully normalize either through diet alone, but it occurred through the overexpression of cortisol which they either did nothing about or exacerbated with fad protocols. 

This unregulated and exaggerated stress response is part of the end stage of metabolic dysfunction known as diabetes. The diabetic is mostly making their excess blood glucose from within, not without. This is why, once again, your doctor doesn't give a 💩about your diet at this point. What you need is a new HPA axis and since no one will donate theirs to you, you are basically up 💩creek. 

Your question was what can you do about it. Well, that's the million dollar question as no one has been able to do a thing for this except dose more insulin and dish out more glucose lowering medications. Once again, this is why diabetes is chronic and progressive. This is why prevention is so important because being overweight/obese, even for a short period of time, can have long reaching consequences in the future. This is why we emphasize diet, exercise and stress mitigation as the three lifestyle areas you need to target for remission. 

So my suggestion for you to mitigate stress is: 

• Continue your diet and make sure you eat enough to reduce metabolic stress, which is what initially caused this problem to begin with. It wasn't emotional, financial or any other type of "stress" that did this to you. It was metabolic stress from poor glucose control. 
• Keep predictable and consistent meals and sleep/wake times in order to stabilize circadian rhythms. Stabilizing circadian rhythms reduces stress. 
• Do not fast for long periods of time so that your blood glucose remains stable and doesn't drop too low for too long. People with metabolic issues have under expression of glucagon during fasting so they do not produce the glucose necessary to keep healthy serum levels. This causes stress. Poor functioning insulin also does not regulate ketones very well and ketones cause stress. 
• Exercise correctly and frequently enough without overdoing it. You have to have a steady state exercise regimen in place. Steady state is what ensures you aren't overdoing it. Stay away from high intensity protocols, hot yoga, strenuous Zumba and too much weight lifting. You also have to make sure you are doing enough steady state exercise to make a difference so walking around while shopping isn't going to cut it. 
• Take control of any condition like sleep apnea, autoimmune, etc. If you have any of these conditions, make sure you keep them under control by addressing them with the proper treatment. Keep tabs on your treatment to ensure it's actually being effective. 
• Drop any caffeine immediately. You don't need stimulants. These are detrimental for cortisol overexpression and people who insist on having caffeine cannot take full control of their blood glucose. If you can't control your blood glucose, you will continue triggering an inappropriate stress response. 
• Check for any nutritional deficiencies like electrolytes and B6 vitamin status. These effect the HPA axis. 

Addressing all of the above will help make the body more resilient in dealing with stressors in general. Every little bit of stress reduction helps. 

Aside from all of the above, you can also take ashwagandha. Ashwagandha is a root which also goes by the names 'Indian ginseng' or 'winter cherry'. 

I usually do not recommend this type of stuff, but it just so happens that ashwagandha has been researched extensively in placebo controlled, double blind, human studies. This is an example of such a study and it links to others which can be found at the bottom. You can also Google more studies and other information on ashwagandha. Just make sure the sources are legitimate. In other words, don't go to the ashwagandha sales center for your info. 

Ashwagandha is considered an adaptogen. Adaptogens work at a molecular level by regulating a stable balance in the HPA axis. Ashwagandha mitigates the connection between the HPA axis and serotonin. Serotonin is a regulator of this axis. 

Ashwagandha has been shown to decrease cortisol up to 32%. My husband was able to lower his cortisol from 17 to 8 in about three months by taking ashwagandha. He took between 125 mg and 250 mg daily. I recommend Sensoril Ashwagandha or KSM-66 Ashwagandha. Sensoril Ashwagandha is for daytime use and KSM-66 Ashwagandha is for night time use. These can be found on Amazon. Ashwagandha can also be found over the counter at any health food/vitamin shop and you can discuss its use with your doctor. 

We have established that ashwagandha has an effect on cortisol but what does this mean for long term use? I don't think anyone knows. Though ashwagandha is "natural" it still works like any pharmaceutical would. It's basically raising serotonin in order to drop cortisol. Like I have said before, hormones are suppose to work in a pulsatile manner. They should never be chronically high or low. Ashwagandha keeps cortisol low through its effect on serotonin. This means lower blood glucose and less loss of muscle mass. 

When my husband stopped taking ashwagandha, his cortisol levels remained low. Of course, we don't know if this was the result of the ashwagandha or not, but at least it gives some hope that you won't have to take it forever. Just keep checking your cortisol levels. 

The long term effects of high cortisol is diabetes. The long term effects of keeping it low is less diabetes, plus maybe something else we don't know about. So you might as well go with the lesser of two evils. It's not like there are other choices except for pharmaceuticals which all do the same thing - lower the blood glucose that's already been produced. At least lowering cortisol allows you to simply not produce so much glucose to begin with.