Who isn't tired these days? We're constantly on call for work, family and friends, and often forget to take time for ourselves.
Most of us recognise that chronic stress can take its toll on our health and well-being. But what if you're so fatigued that even getting more sleep doesn't seem to help?
Complementary and alternative medicine provide an explanation for stress-induced fatigue that offers hope to the chronically tired.
According to naturopathic doctors, holistic nutritionists and others, adrenal fatigue is a condition where the adrenals, glands that sit above the kidneys, don't produce enough cortisol.
Cortisol is a hormone that plays a role in managing stress and regulating metabolism, sleep, blood sugar and inflammation.
"Fatigue is probably the number one complaint among new patients in my practice," says Leila Kirdani, a family physician specialising in functional medicine.
"Anyone with prolonged fatigue, with difficulty sleeping, who feels 'burned-out' or lack of enjoyment in life, may be suffering from adrenal fatigue."
Basically, the theory goes that too much stress wears out our adrenal glands; they get tired and don't produce enough cortisol for us to feel energised.
So why aren't our family doctors telling us about this?
As a registered dietician in private practice, I often get new clients who have been told by their naturopathic doctors that they have adrenal fatigue and need to follow a special diet and a regimen of supplements and herbs.
Hours of searching the scientific literature has led to very little in terms of evidence-based dietary advice to help these individuals. Which raises the question:
Is adrenal fatigue real?
The very existence of adrenal fatigue is a contentious issue. It isn't recognised by any endocrinology societies or endocrinologists, medical doctors who specialise in hormone-related health problems.
A recent systematic review of the scientific literature found that there was no evidence for the existence of adrenal fatigue as a medical condition.
Theodore C Friedman is an endocrinologist at Charles R Drew University of Medicine and Science who describes himself as being open to complementary medicine.
Like many medical doctors, he says adrenal fatigue doesn't exist: "It's something made up by naturopathic doctors; endocrinologists don't recognise it as a real condition."
Saul Marcus is a naturopathic doctor in Connecticut. "When it comes to adrenal fatigue, conventional medicine insists it doesn't exist. However, adrenal fatigue is essentially a stress reaction, and stress is very well understood as a cause of illness."
So we see the bipolar worlds of conventional medicine and complementary and alternative medicine are firmly divided into two camps: Adrenal fatigue doesn't exist versus adrenal fatigue is an important medical issue.
Somewhere in the middle is the idea that adrenal fatigue is a term that encompasses a wide range of general symptoms rather than a discrete medical problem. Does the label matter?
What's really going on with your adrenal glands?
According to Kirdani: "There is a distinct bias in the medical community when it comes to adrenal fatigue. For some reason, doctors think that either your adrenal glands are perfectly fine, or else they have ceased to function."
"Naturopaths have it wrong," Friedman says. "They describe adrenal fatigue as a stress-induced condition where your adrenal glands don't produce enough cortisol. In fact, when you're stressed out, your adrenal glands make more cortisol."
What endocrinologists and other medical doctors do recognise is adrenal insufficiency, a disorder where the adrenals don't produce enough hormones.
The adrenal glands make two hormones: cortisol and aldosterone. According to Friedman, "Aldosterone is often under-appreciated or unrecognised by naturopaths."
He also says that adrenal insufficiency is on a gradient: "You can have varying levels of cortisol deficiency, aldosterone deficiency or both."
Having low aldosterone causes salt to be lost in the urine, which leads to symptoms such as brain fog, feeling worse after exercise or feeling dizzy when you stand up.
Friedman says that people with low aldosterone can be diagnosed by an endocrinologist and then can be treated with synthetic aldosterone, extra salt or liquorice root.
Because the role of aldosterone is often ignored by alternative medicine, this is one adrenal issue that your naturopath may not test for. (Marcus, the naturopathic doctor, says one reason naturopaths may not test for aldosterone is because it requires a blood test, and in some states they are not licensed to order blood work.)
Where cortisol is concerned, people can have low cortisol as a result of their pituitary gland not producing enough of a hormone that stimulates the release of cortisol from the adrenals.
A smaller portion of people have Addison's disease, where the adrenal glands are attacked by antibodies. As a result, the adrenals won't produce enough cortisol. Friedman says that these patients need to see an endocrinologist and get on cortisol right away.
As Friedman puts it, people with adrenal insufficiency do have fatigue, so it makes sense to examine their adrenal glands. "It's the concept of the adrenals burning out that doesn't make sense."
How do you get tested for adrenal fatigue or adrenal insufficiency?
Marcus says adrenal fatigue can be diagnosed in several ways. Many practitioners test cortisol levels in saliva, but these also can be diagnosed based on symptoms.
"If someone is feeling tired and under some sort of stress, their adrenal function is probably not optimal, and it may be okay to try taking some supplements for the adrenals."
Friedman calls the saliva test used by natural-health practitioners unreliable and says a blood test is a far better way to measure cortisol levels.
The blood test measures levels of electrolytes (including sodium) as well as several hormones. This gives a picture of which hormones are out of the normal range and what could be causing issues.
Taking care of your adrenals
Google "adrenal fatigue diet" and you'll find websites recommending everything from eliminating dairy to following a paleo diet that also vetoes grains and beans. At this point, there isn't any evidence to show that any of this will help you manage stress or feel more energised.
When my clients are dealing with stress and fatigue, I recommend eating whole foods, plenty of vegetables, heart-healthy fats and lean protein, limiting highly processed foods and added sugars, as well as cutting down on caffeine and alcohol, which can negatively affect sleep.
Choosing foods that stabilise your blood sugar and are lower on the glycemic index is also important, as your energy levels and mood are closely related to blood sugar.
Go for slow-burning carbohydrates such as sweet potatoes, barley, quinoa and rolled oats, and always combine them with a protein such as beans or lentils, chicken, fish or lean meat.
Get healthy fats from oily fish, olive oil, avocado, nuts or seeds at each meal and snack, and chances are you'll feel more energised.
Marcus, Kirdani and Friedman all say that whether you're dealing with stress or adrenal fatigue, taking care of your overall health helps.
Friedman feels that the naturopathic approach can be valuable, as talking to someone about stress and ways to cope can help.
He also doesn't have a problem with people taking certain supplements that boost their immune system and energy levels, as long as those don't interact with other medications or supplements.
Marcus and Kirdani recommend supplementing with sea salt, B vitamins and herbs such as rhodiola or lemon balm. (Please see a medical professional before taking supplements or herbs to make sure they're safe for you.)
Patients also may use an adrenal glandular, essentially ground-up adrenal glands (usually from pigs or cows), other tissues or extracts.
Friedman warns: "The naturopathic approach can be dangerous if cortisol or ground-up adrenals are prescribed.
People often feel better on cortisol, but side effects include osteoporosis, weight gain and diabetes. As such, it shouldn't be prescribed lightly."
Does it matter what we call it?
While the worlds of conventional and alternative medicine are divided on adrenal fatigue as a condition, everyone seems to agree that managing stress makes sense.
So does eating well and treating any vitamin or mineral deficiencies, as well as getting regular physical activity and enough sleep. Working on all of these areas will help you boost energy, reduce fatigue and make you healthier.
Whether these positive lifestyle changes are improving stress levels or healing adrenal fatigue is irrelevant.
What does matter is if treating so-called adrenal fatigue ends up preventing the diagnosis of a serious medical problem.
Friedman's take-home message is clear. "If you're experiencing fatigue, you need to see an endocrinologist to make sure you're getting at the real issue and not masking fatigue that's being caused by another health problem," he said.
"If you do have an adrenal issue, it needs to be treated as soon as possible."