Adrenal fatigue: A fake disease (updated)

While Scott Gavura is taking a summer hiatus from blogging, here’s an update to an an old post, on a popular topic.

One of the realities of being a pharmacist is that we’re easily accessible. There’s no appointment necessary for consultation and advice at the pharmacy counter. Questions range from “Does this look infected?” (Um, yes) to “What should I do about this chest pain?” to more routine questions about conditions that can easily be self-treated. Pharmacists have an important triage role — advising on conditions that can be safely self-managed, and knowing when medical referrals are necessary or appropriate. Among the most common questions I’ve received in my time working in a retail pharmacy are related to stress and fatigue. Energy levels are down, and patients want advice and solutions. Some want a “quick fix,” believing that the right mix of megadoses of vitamins are all that stand between them and unlimited energy. Others may ask if prescription drugs, herbal supplements, or even caffeine tablets could help. Evaluating vague symptoms is a challenge. Many of us have busy lifestyles, and don’t get the sleep and exercise we need. We may also compromise our diets in the interest of time and convenience. With some simple questions I might make a few basic lifestyle recommendations, talk about the evidence supporting supplements and vitamins, and suggest physician follow-up if symptoms persist. Fatigue and stress may be part of life, but they’re also symptoms of serious medical conditions. But they can be hard to treat because they’re non-specific and may not be easily distinguishable from the fatigue of, well, life.

This same vague collection of symptoms is called something entirely different in the alternative health world. It’s branded “adrenal fatigue,” an invented condition that’s widely embraced as real among alternative health providers. There’s no evidence that adrenal fatigue actually exists. The public education arm of the Endocrine Society, representing 14,000 endocrinologists, recently updated their advice on a common medical question, noting:

“Adrenal fatigue” is not a real medical condition. There are no scientific facts to support the theory that long term mental, emotional, or physical stress drains the adrenal glands and causes many common symptoms.

But if you search the internet, there are hundreds (probably thousands) of posts arguing that your doctor (and the entire medical community) is wrong. But the scientific facts are clear when it comes to adrenal fatigue. It’s a fake disease, and there’s no credible scientific evidence to support it.

Invented by a chiropractor and naturopath

The adrenals are a pair of glands that sit on the kidneys and produce several hormones, including the stress hormones epinephrine and norepiniephrine that are associated with the “fight or flight” response. Can you tire these glands out? In the absence of any scientific evidence, chiropractor and naturopath James Wilson coined the term “adrenal fatigue” in his 1998 book of the same name. Take a look at Wilson’s own extensive questionnaire, at adrenalfatigue.org. Do you ever experience the following? You may have adrenal fatigue.

• Tiredness not usually relieved by sleep?
• Having trouble getting up in the morning?
• Get low energy, moody or foggy if you don’t eat regularly?
• Feel worse if you miss a meal?
• Need salty or sweet snacks or caffeine to keep going?
• Eat lots of fruit?
• Feeling run down and stressed?
• Muscles sometimes feel weaker than they should?
• Struggling to keep up with life’s daily demands?
• Can’t bounce back from stress or illness?
• Decreased sex drive?

Some lifestyles are apparently more vulnerable to adrenal fatigue, including single parents, shift workers, an “unhappily married person”, and the “person who is all work, no play.” There’s no information provided to substantiate the quiz, qualify the vague terminology, or link to any relevant literature. (Of course there is the usual Quack Miranda warning on every page which makes all of this possible: “These statements have not been evaluated by the Food & Drug Administration … etc.”)

Based on this quiz, it’s safe to assume that adrenal fatigue is the most prevalent fake disease in the world. And sure enough, that’s what its proponents think too:

Dr. John Tinterra, a medical doctor who specialized in low adrenal function, said in 1969 that he estimated that approximately 16% of the public could be classified as severe, but that if all indications of low cortisol were included, the percentage would be more like 66%. This was before the extreme stress of 21st century living, 9/11, and the severe economic recession we are experiencing.

What does the evidence actually say?

So let’s look into the medical literature on adrenal fatigue. There’s not much in Pubmed, though there is a systematic review from Cadegiani and Kater entitled “Adrenal fatigue does not exist: A systematic review“, which notes:

Theories on adrenal impairment as the genesis for fatigue are tempting, as they allow for a treatable condition. Despite the widespread use of the term “adrenal fatigue” by the general media and certain health practitioner groups, in this systematic review, only ten citations were found with this exact expression, and they were all only descriptive and did not perform any test regarding the HPA axis and “adrenal fatigue”. Studies that tried to correlate the HPA axis and fatigue states used the term “burnout” instead of “adrenal fatigue” to denote adrenal depletion. Therefore, a distinction between the “general information” and the actual scientific literature regarding this condition is evident.

And also:

No confirmed methods of clinical screening for AF are available. Indeed, the popular questionnaire developed by Dr. Wilson and published in the first book exclusively dedicated to the description of this supposedly disease has not been cited in any indexed databases.

The conclusion is important, so I’ll quote it in its entirety:

To our knowledge, this is the first systematic review made by endocrinologists to examine a possible correlation between the HPA axis and a purported “adrenal fatigue” and other conditions associated with fatigue, exhaustion or burnout. So far, there is no proof or demonstration of the existence of “AF”. While a significant number of the reported studies showed differences between the healthy and fatigued groups, important methodological issues and confounding factors were apparent. Two concluding remarks emerge from this systematic review: (1) the results of previous studies were contradictory using all the methods for assessing fatigue and the HPA axis, and (2) the most appropriate methods to assess the HPA axis were not used to evaluate fatigue. Therefore, “AF” requires further investigation by those who claim for its existence.

Why is adrenal fatigue a “fake disease”

One of the hallmarks of alternative medicine is the “fake disease”. Fake diseases don’t actually exist – they are invented without any objective evidence showing that they are real. Fake diseases tend to emerge from vague symptoms which can’t be attributed to a specific medical diagnosis. This is not to say what patients are experiencing isn’t real – the issue is the diagnosis, and the practitioner making the call. As has been pointed out by other SBM contributors, it’s understandable to want reasons and answers when you have debilitating symptoms. But symptoms need to be studied in rational and objective ways in order to understand the underlying illness – call it the “root cause” if you prefer. The diagnosis guides the treatment plan, so getting a diagnosis right is essential. While a group of vague symptoms might lead a medical doctor to run tests to rule out serious illness, alternative medicine providers seem to jump to the diagnosis and techniques they prefer, even if they’re completely unvalidated, or made up out of thin air. It’s your Chi. Your energy fields. It’s wifi. It’s gluten. In this case, it’s your adrenals. Rather than offer a guide to proper care, a fake disease is a distraction from the truth.

Adrenal fatigue is a prototype fake disease. Defining a cluster of symptoms in general terms is the first mistake. Symptoms need to be collated in a rational way to understand the parameters of the disorder. With adrenal fatigue, there’s no objective operational description, nor is there a validated symptom score, as the systematic review notes. Using a vague list of symptoms to identify patients is the second mistake. While laboratory tests are advertised for identifying adrenal fatigue, there’s no persuasive data to suggest that any testing used by naturopaths is valid in any way.

Adrenal fatigue shouldn’t be confused with adrenal insufficiency, a legitimate medical condition that can be diagnosed with laboratory tests and has a defined symptomatology. Addison’s disease causes primary adrenal insufficiency and usually has an autoimmune cause, with symptoms appearing when most of the adrenal cortex has been destroyed. Secondary adrenal insufficiency is cause by pituitary disorder that gives insufficient hormonal stimulation to the adrenals. Some liken adrenal fatigue to a milder form of adrenal insufficiency — but there’s no underlying pathology that has been associated with adrenal fatigue.

While adrenal fatigue may not exist, the same can’t be said for the treatments. When you’re treating a fake disease, anything goes. Everything from homeopathy to herbal remedies to hydrotherapy, to traditional Chinese medicine and vitamin supplements are advocated for treatment. The endpoints of treatment are as nonspecific as the criteria for diagnosis. Wilson, conveniently, has his own supplement programs, and there’s no shortage of solutions out there.

Conclusion: Symptoms are real, adrenal fatigue is not

While adrenal fatigue may not exist, this doesn’t mean the symptoms people experience aren’t real. These same symptoms could be caused by true medical conditions such as sleep apnea, adrenal insufficiency, or depression. Accepting a fake disease diagnosis from an unqualified practitioner is arguably worse. Patients don’t receive a science-based evaluation of their symptoms, and they may be sold unnecessary treatments that are probably ineffective and potentially harmful. The Endocrine Society’s guidance is entirely appropriate:

Doctors urge you not to waste precious time accepting an unproven diagnosis such as “adrenal fatigue” if you feel tired, weak, or depressed. If you have these symptoms, you may have adrenal insufficiency, depression, obstructive sleep apnea, or other health problems. Getting a real diagnosis is very important to help you feel better and overcome your health problem.

There’s no question that it would be frustrating to be experiencing fatigue symptoms and then to be told by a health professional that there is nothing medically wrong. But that is arguably better than the distraction of treating a fictitious condition.

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Photo from flickr user Kevin Harber used under a CC licence.