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Jan 21, 2018

Guidelines For Ordering Functional Medicine Test Kits

by Dr. Dan Kalish


The Functional Adrenal Stress Profile requires a series of four-time specific saliva collections (morning, noon, afternoon and nighttime) during a typical day on which cortisol is measured to establish its circadian rhythm. Additionally, the sulfated form of DHEA (DHEAGS) is measured on the noon and afternoon samples and the average of those results is reported. Assessing the cortisol rhythm and DHEAGS average is a critical first step in new patient evaluation as well as a fundamental component in follow-up studies.

Physiology Cortisol, which is best known for stimulating gluconeogenesis, is essential for normal glycogenolysis. Cortisol affects the heart, vasculature, blood pressure, water excretion, and electrolyte balance. It mobilizes protein stores in all tissues except the liver; it mobilizes fatty acids from adipose; it is the precursor of cortisone and acts as an anti-inflammatory; and it is the primary hormone directing immune function. Cortisol can stimulate or inhibit gene transcription, promote apoptosis, and affect bone metabolism and calcium dynamics. It affects behavior, mood, neural activity, and a variety of central nervous system biochemical processes. Cortisol affects the eyes, gastrointestinal tract, reproductive function, and the production and clearance of other classes of hormones. It is a major marker of the complex control loops regulating the sex hormones. The general effect of excess cortisol is usually stimulatory and catabolic; a deficiency of cortisol usually results in a slowing of physiology.

The salivary free fraction of the adrenal cortisol output is reported because of its high clinical correlation to accurately assess adrenal function. To determine the cortisol circadian rhythm, four individual cortisol levels is taken at specified intervals throughout the day: in the morning between 6 and 8 a.m., between 12 and 1 p.m., in the late afternoon around 4 or 5 p.m., and at nighttime between 10 p.m. and 12 a.m.

In the presence of stressors, the body almost immediately attempts to increase cortisol levels. This increase is associated with both endocrine and autonomic responses in preparing the body to defend itself normally. However, elevated cortisol levels for extended periods negatively affect virtually every aspect of physiology. For example, it becomes more difficult to maintain proper blood sugar levels; to slow down for rest, recovery, and repair; to get good quality sleep; to balance other hormones; to maintain mucosal immune integrity; to maintain bone mass, to produce effective general immune function; to effectively regulate inflammatory processes; or to detoxify the body. Without proper intervention, continued high adrenal stimulation can lead to adrenal exhaustion and lowered cortisol levels. Eventually adrenal or cardiac failure can occur. 6 DHEA is the major precursor of testosterone and the estrogens. It becomes active at puberty. In this profile, the more stable, sulfated form of DHEA, DHEAGS is measured, providing a more reliable measure of DHEA levels than measuring DHEA directly.  DHEA is an important modulator of many physiological processes. It promotes the growth and repair of protein tissue (especially muscle), and acts as a counter-regulatory agent to cortisol, negating many of the harmful effects of continued excess cortisol. When increased demand for cortisol is prolonged, DHEA levels decline. DHEA then is no longer able to balance the negative effects of excess cortisol. Depressed DHEA levels serve as an early warning of potential adrenal exhaustion. In fact, adrenal exhaustion is evidenced by an elevated ratio of the sum of the four cortisol measurements to the DHEAGS average. (The ideal level of the aforementioned ratio is 5 or 6:1)

A chronic imbalance between adrenal stimulation and cortisol and/or DHEA output is associated with a multitude of both clinical and subclinical systemic disorders.  Chronically depressed DHEA output results in an imbalance in sex hormones.  Abnormal cortisol and/or DHEA values (either elevated or depressed) result in a decrease in the activity of the immunocytes that produce secretory IgA (sIgA). SIgA provides a mucosal firstGline immune defense against virtually every pathogen, including parasites, protozoa, yeasts, fungi, bacteria, and viruses. SIgA also provides a normal immune response to regularly encountered food proteins. Dysfunctional mucosal immunity is associated with an increased risk of infections and of adverse food reactions.

Clinical Use the degree and timing of cortisol imbalances provide the healthcare professional with valuable insights into the nature of causative stressors, and allow the practitioner to formulate remedial protocols. Readily identifiable inducers of increased adrenal stimulation include stressors such as tissue damage, inflammation, pain, and mental or emotional stress. Other significant physiological stressors can be subclinical, and include intolerance to the gliadin fraction of gluten protein, lactose or sucrose intolerance, glycemic dysregulation, delayed food sensitivity, and infection with viruses, bacteria parasites and/or other pathogens. Additional testing may be necessary to rule out the possibility of these and other factors interfering with digestion and absorption and creating inflammation and stress on adrenal glands.  These types of problems could impede absorption and assimilation of essential nutrients, and the maintenance of normal blood sugar. Chronic dysfunction of any of these processes is a sufficient cause of adrenal exhaustion. Physiological pathways, organs, or systems identified as being the major cause of some other disorder may concurrently serve as causative agents in adrenal exhaustion. In most cases, regardless of the priority given to another pathway, organ, or system as being 7 dysfunctional-and virtually regardless of the condition identified-Gadrenal exhaustion resulting from excessive stress must be addressed and rectified in order to restore normal physiology or function.

Conditions Assessed Conditions that may be assessed include adrenal exhaustion, often misdiagnosed as hypothyroid, but may include a hypothyroid condition as well; systemic hyper or hypo excitability, whether of suspected neural or hormonal origin, including suspected thyroid, pancreatic, and sex hormone disorders; states of immunodeficiency; and states of abnormal physiological response to any of a variety of stimuli including foods in the normal diet.

Logical Sequence of Testing The logical sequence of using this test as an initial or as a follow up test is determined by a variety of individual considerations, including the patient's chief complaint, the array of signs and symptoms, the chronicity of the condition, the tests previously taken, and the judgment of the practitioner. Technical assistance is available from BioHealth Diagnostics' support staff.

Functional Adrenal Stress Profile plus V, #205
  • Turnaround: 3 G 4 days
  • 4 Cortisol, 2 averaged DHEAGS, 1 Estradiol, 1 Estriol, 1 Testosterone (AM), 1 Melatonin (bedtime), 1 Progesterone (bedtime)
Also available with ESTRONE added (ask for BHD #205E)

This profile is clinically indicated to evaluate an individual's ability to adapt to environmental, mental, emotional, and physiological stressors; to determine the efficacy of DHEA therapy; to assess rest and recovery relative to morning and bedtime cortisol; and bedtime levels of melatonin and progesterone.  The Functional Adrenal Stress Profile plus V provides an adrenal rhythm and a DHEAGS Gto-Cortisol ratio. Abnormal adrenal rhythm can negatively influence energy production; immune system health; skin regeneration; muscle and joint function; bone health; sleep quality; and liver, pancreas and thyroid function.

Adrenal dysfunction may be associated with the following symptoms: excessive  fatigue; chronic stress and related health problems; dizziness upon standing;  weakness; hypoglycemia; nervousness; irritability; depression; inability to concentrate;  confusion; poor memory; low blood pressure; insomnia; premenstrual tension; sweet 8 cravings; headaches; alcohol intolerance; excessive hunger; alternating diarrhea and  constipation; sternocleidomastoid/trapezius pain and spasms; epigastric discomfort;  poor resistance to infection; food and/or inhalant allergies; dyspepsia; tenderness in  adrenal area; migraine headaches; low body temperature; and diminished sex drive.

Estrogens and Testosterone are included in this profile to further evaluate the efficacy of DHEA therapy. Since DHEA can convert to Estrogens and/or Testosterone, the use of DHEA may be contraindicated if Estrogens and/or Testosterone levels are elevated.  Conversely, if Estrogens and/or Testosterone levels are depressed, DHEA and/or other therapeutic measures may be indicated. Bedtime Cortisol, Melatonin, and Progesterone levels are indicators for rest and recovery and are indicated for anyone with sleep disorders.

SUMMARY: Evaluating the Cortisol circadian (24Ghour) rhythm along with DHEAGS provides an accurate assessment of adrenal function and can reveal maladaptation to stressors. Salivary (free fraction) hormone testing determines the bioactive values at the cellular level, thereby providing a functional assessment of the effects of environmental and physiological stressors.

Dr. Dan Kalish

Dr. Dan Kalish

Founder of the Kalish Institute
Dan Kalish, DC, IFMCP, is founder of the Kalish Institute, an online practice implementation training program dedicated to building Integrative and Functional Medicine practices through clinical and business courses.