Flipped Curve Adrenal Protocol from Carrie Jones, ND, FABNE, MPH

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Patterns of adrenal hormone release can deviate from normal in several different ways, and the adrenal glands do not function in isolation. They participate in the bigger hormonal cascade of the entire hypothalamic-pituitary-adrenal (HPA) axis.

Carrie Jones ND, FABNE, MPH is an expert on HPA-axis function. She is a Naturopathic Physician who is board certified in Naturopathic Endocrinology (FABNE) with a Master’s in Public Health (MPH) and over 17 years in the field of functional and integrative medicine. As a practitioner, medical director and educator, she lectures all over the world on the topic of health and hormones. 

“Most people who think they have adrenal fatigue actually have psychological and physical stress that activates a cascade of events from the brain down,” states Dr. Jones.  “The hypothalamus produces corticotropin-releasing hormone (CRH), which informs the pituitary to produce adrenocorticotropin-releasing hormone (ACTH), which binds receptors on the adrenal cortex to trigger a release of cortisol. If cortisol production is triggered chronically or excessively, precursors are shunted toward cortisol and away from DHEA and other androgens. So, it’s best to evaluate multiple adrenal hormones in the context of the whole HPA axis.”

But cortisol patterns are an important place to start when assessing HPA axis function.  Cortisol release has a  normal diurnal cycle. Cortisol production is normally at its highest around 8:00 am or 30 minutes after waking and then declines steadily during the day, reaching its lowest points between midnight and 3:00 am. 

Acute or chronic stress disrupts HPA-axis function and causes irregularities in the diurnal cortisol curves. There are a variety of patterns that may emerge, depending on the type of stress and its impact on parts of the HPA axis.  One common abnormality results in the “flipped curve” pattern. This is when cortisol levels rise again in the evening, instead of continuing a normal decline. This happens frequently with “night owls” since elevated evening cortisol promotes wakefulness  Signs of higher than normal evening and night cortisol production include:

• Feeling tired but wired
• Food/sugar cravings
• Irritability
• Can’t get to sleep or wake frequently

“The “flipped curve” pattern shows that patients are producing and releasing cortisol in the wrong amounts at the wrong times in their circadian rhythm” states Dr. Jones. “Their cortisol awakening response is often too low in the morning, but the signature in the pattern is that the curve “flips up” in the evening instead of continuing its normal downward trajectory.  This translates into that “second wind”  before bed and difficulty falling asleep and staying asleep. I call this the “new parent” pattern, because we see this in parents with young children who are often up at all times of the night.”

The good news is there are natural compounds that help normalize the pattern, by supporting cortisol production in the morning and blunting or inhibiting cortisol release at night.

Licorice root is a traditional herb that supports cortisol production, which is why it is often recommended for nutritional support in the morning upon waking or with breakfast. Then, there are several natural ingredients that help inhibit cortisol production at night.  Working synergistically, these ingredients help to gradually balance and support a healthy, normal cortisol pattern.

However, the desired outcome also depends on changing some lifestyle habits, and incorporating new ones.

Supporting normal morning cortisol:

• Licorice root upon waking. Stimulating adaptogens like Panax Ginseng and Rhodiola until early afternoon.
• Full spectrum light exposure immediately on waking (either from the sun or full spectrum light bulbs) for a good 10- 20 minutes 
• Gentle exercise: stretching, yoga (no exercise after 4pm)
• Eliminate caffeine after 2 pm, 
• Hydrate throughout the day, herbal teas and water, avoid soft drinks
• Reduce stress and improve coping skills

Supporting Normal cortisol decline in the evening

Begin taking calming ingredients right before or after dinner and before bedtime.  Ingredients such as L-theanine, magnolia/honokial, phosphatidyl-serine and ashwagandha help support melatonin production and inhibit excess cortisol production.

Things that will increase cortisol production at night, include sugar and alcohol intake, as well as use of electronics, which are best avoided after 8pm. Some things that help balance HPA function:

• Avoid electronic screen use after dinner, or use blue-light blocking glasses in the evening.
• Protein snack before bed to prevent drop in blood sugar
• Improve sleep hygiene: establish routine bed/waking time; no TV, laptop or phone in bedroom; dark and cool room
• Reduce stress, improve coping skills, practice relaxation and breathing techniques before sleep

Dr. Jones has some favorite supplements to help patients with “flipped curve” cortisol patterns. Her “Flipped Curve” Adrenal Protocol is designed to help normalize cortisol release timing to improve the cortisol awakening response in the morning, and help cortisol lower appropriately in the evening. Her protocol also includes patient handouts for important lifestyle recommendations as well as a handout about the Cortisol Awakening Response.

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