00:00:00:03 - 00:00:25:09 

Noah Reed 

Welcome back to the DUTCH podcast, where integrative medicine providers can expand their understanding of functional endocrinology and testing. And everyone, no matter who you are, can learn more about their body’s most complex communication system. I'm Noah Reed, vice president of sales and marketing for the DUTCH Test. Coming up on this week's episode, we're back in our Endocrine Essentials series with the basics of cortisol. 

 

00:00:25:19 - 00:00:48:08 

Noah Reed 

Cortisol is the stress hormone and can tell you a lot about how someone manages stress by looking at the first hour and a half of their day. The cortisol a week in response or CAR acts as a mini stress test to show how your body uses cortisol to wake up and feel alert. Our guest, Dr. Christina O'Brien, will be covering the CAR, metabolize cortisol and more on this week's episode. 

 

00:00:48:14 - 00:01:19:18 

Noah Reed 

So, stay with us. Dr. Christina O'Brien is a chiropractor institute for Functional Medicine certified practitioner and is board certified in functional neurology. She is also a registered nutritionist, dietician and is certified in acupuncture. Dr. O'Brien uses a whole person approach. This approach is a combination of detecting underlying interferences, which may inhibit the body's natural ability to heal itself, along with the inspiration and knowledge and support for people to achieve better health through better living. 

 

00:01:20:04 - 00:01:36:12 

Noah Reed 

Dr. O'Brien is dedicated to helping people reduce their risk of lifestyle related, preventable chronic conditions, including chronic pain. As well as encouraging them to become more responsible for promoting optimal health and well-being. And now on to the show. 

 

00:01:37:11 - 00:01:41:21 

Mark Newman 

1. Dr. Christina O'Brien, so glad that you could join us today.

 

00:01:42:12 - 00:01:45:06 

Christina O'Brien 

Thank you. I'm really happy to be here. Thank you for inviting me. 

 

00:01:45:18 - 00:02:10:07 

Mark Newman 

Absolutely. I wanted to have a nerdy cortisol person on so we could talk about the axis and all of that. So, we're always talking about comprehensiveness. And, you know, we want to characterize, well, a person as it relates to whatever family of hormones we're talking about, in this case, cortisol. So, tell us like what testing tells you about the person's HPA axis and stress response. 

 

00:02:10:07 - 00:02:16:07 

Mark Newman 

Just talk generally a little bit big picture and then we'll narrow in on some of the finer details of that. So, start playing. 

 

00:02:17:06 - 00:03:00:06 

Christina O'Brien 

Share. So, we know that prolonged stress either causes or intensifies a whole host of illnesses like ulcers and colitis and depression and anxiety. And when we experience stress, a body turns on the same physiological response that we would see in nature in an animal. But in humans, what we often see is that rather than the fight, flight and freeze that an animal experiences and then moves on from really quickly, humans tend to not be able to respond quite as quickly. 

 

00:03:00:23 - 00:03:43:22 

Christina O'Brien 

And over time, this chronic activation of the stress response over and over and over again reduces our metabolic threshold and literally can make us sick and make us sick or sick or more than we were to begin with. And when we see a patient who's experiencing stress and experiencing isolation and depression and anxiety and those types of things, chronic illness or acute illness, we want to know how their body is able to respond in the moment to a stressor.

00:03:43:22 - 00:04:02:08 

Christina O'Brien 

And some people respond better than others. But a way to measure that is really important for a clinician so that we know where to meet the patient in a how to best help them to get better. And there's not really there's no better way clinically to measure that than using the cortisol awakening response. 

 

00:04:03:14 - 00:04:23:10 

Mark Newman 

Well, and, you know, it's our that our fault that we have consciousness. So, the zebra, you know, gets chased by the lion but isn't also going through a divorce and COVID lockdowns and all of that. So, for us, lots of issues we have to deal with in terms of just that stress response and whether we can actually turn it off and return to normal. 

 

00:04:23:13 - 00:04:43:23 

Mark Newman 

And so, yeah, we're trying to look at the consequences of that in the laboratory testing. So, what are the big picture like categories of information that you're trying to get from the testing? What are those big questions you're trying to ask as you look at a DUTCH complete or a DUTCH plus for your patients that you think might have an issue with their HIPAA access? 

 

00:04:44:13 - 00:05:17:07 

Christina O'Brien 

Sure. And you know, the reality is, I don't know that we have any patients anymore without some type of impact to their HIPAA access. And everybody's experiencing stress. We live in a really stressful world at a really stressful time, and we really want to see how each individual person is responding to that. And we used to think of adrenal output and measuring the HIPAA access and describe it in terms of adrenal fatigue. 

 

00:05:17:07 - 00:05:47:10 

Christina O'Brien 

And there was a three-stage model that we used that was really simple to understand, but really was oversimplified and not very accurate scientifically. So now we know and we're, I think, getting better and better describing really the way it works is we have so we can describe it in three stages that we have one being an ongoing acute stressor, like having a stressful job or taking CAR e of a sick family member. 

 

00:05:47:10 - 00:06:24:15 

Christina O'Brien 

And we'll typically see cortisol elevated in those situations. And then stage two and we have often normal lab values for cortisol, which can confuse some providers because they expect, oh, they're under stress brain high cortisol, but we don't always see that we have a way of protecting ourselves and we down regulate the HIPAA access and look like we're producing normal amounts of cortisol when in reality we're experiencing a lot of stress, stress more chronic than acute. 

 

00:06:24:23 - 00:07:09:01 

Christina O'Brien 

And we'll often see, and this is why looking at other factors are also important data as below normal and he friends who are experiencing chronic stress. And then the stage three is we see long term stress which will often most of the time show up as a depression cortisol and DHEA as output and that we can refer to as burnout and and because that's the way that we measure adrenal function is a measurement of adrenal hormone output People incorrectly for years assumed that this represented a function within the adrenal gland itself. 

 

00:07:10:02 - 00:07:48:10 

Christina O'Brien 

But we know now this is more related to the response of the adrenals to a stressor and is really more a way of measuring HPI access activity and we use the adrenal hormone as surrogate markers so we can more appropriately talk about things like HPI access dysfunction or hypo cortisol ism or hyper cortisol, soma and or other things that are really more related to the function of the day access rather than true functioning of the adrenal glands. 

00:07:48:10 - 00:08:18:01 

Christina O'Brien 

When we talk about adrenal gland function truly being high or low, that's a very serious and potentially life-threatening situation. We're talking about things like Addison's or not enough HGH being secreted from the pituitary gland or a brain dysfunction, a hypothalamic dysfunction because of long term glucocorticoid use. So, there are there are lots of ways now that we really know that we can define this. 

 

00:08:18:01 - 00:09:03:08 

Christina O'Brien 

And those are things that we want to look for in patients when we're talking about the HPI access and some of the biggest things I see and practice things that we can do something about that we can modify that are just regulating somebodies access permanently. Are things like a blood sugar dysregulation or inflammation or a sleep disturbance or even perceived stress, which is a fascinating area of research to me and in my own practice, and really understanding that people, even if they're worrying about something, if it's not an actual thing, it's almost like wishing it to come true because they're focusing on it and thinking about it and perceived stress really to the brain is 

 

00:09:03:08 - 00:09:25:19 

Christina O'Brien 

the same as an actual stress. And using cortisol awakening response to quantify that with concrete data points is the absolute best way for providers to help patients to understand where they're coming from and to meet them where they are and to help them to get better. 

 

00:09:25:23 - 00:09:52:16 

Mark Newman 

Which is interesting for you as a person on staff with us and a person who who came on to work for us being someone who didn't actually use the Cortisol Awakening response because when we started it was DUTCH complete, right? Which gives you the up and down pattern of free cortisol, which is one important metric, right? Which you can get from urine with the DUTCH complete, you can get it from saliva with any saliva test looking at that up and down pattern. 

 

00:09:52:21 - 00:10:16:06 

Mark Newman 

And then the cortisol awaking response adds extra value to that and an extra marker so what was it that was compelling to you to sort of shift in your mind of thinking that the primary most important thing that we could look at with that up and down pattern is the cortisol awakening response itself. So, explain what that is and why it convinced you of its importance. 

00:10:16:19 - 00:11:04:17 

Christina O'Brien 

Absolutely. So, the cortisol awakening response we also called the CAR is a predictable increase in cortisol that happens in the morning. Right after you wake up. So the cortisol awakening response is an increase in cortisol measured then between when you wake up, which is considered time zero and the peak in cortisol output for the day, which it should be not always, but should be, which is approximately 30 and at the very outside, about 45 minutes after waking and and really not just the absolute amount measured at that 30 to 45 minutes post awakening but at that moment 30 to 45 minutes post awakening. 

 

00:11:04:17 - 00:11:35:19 

Christina O'Brien 

And it's a result of two different things so first it's the momentum of rising cortisol levels that starts actually several hours before you wake up because of normal circadian rhythm which hopefully we have some fragment of normal circadian rhythm left when we're doing this testing, although not always, especially for nightshift workers, it changes really everything. And so HGH levels are rising and we're waking up and the second is more transient spike. 

 

00:11:36:01 - 00:12:22:13 

Christina O'Brien 

32 at the most 45 minute in cortisol. It's about a 50% increase and we measure it up percentage increase. To help us better understand what's happening. And this is in response to light, the brain responds to light. There's a part of the brain called the super guy cosmetic nucleus that sees light and responds to red. And we see this waking superimposed almost on the circadian dynamic of the age where access is all controlled by light, which is why when we wake up in the afternoon, if we're taking a nap, there's no cortisol awakening response there so when you look at the literature and you really see what's happening, we know that the cortisol awakening response 

 

00:12:22:13 - 00:12:36:06 

Christina O'Brien 

is really the most not only reported measure of cortisol used in clinical research, but the most accurate way to test the HPI access for clinical abnormality so. 

 

00:12:36:06 - 00:12:48:06 

Mark Newman 

You're you're saying there's a circadian rhythm and the cortisol, a waking response is superimposed on that. So, when is the bottom when do people bottom out in terms of cortisol production? Not right before waking, but is it earlier than that? 

 

00:12:50:01 - 00:13:34:21 

Christina O'Brien 

So, you know, it's often depends on the patient. So, we see a rise in melatonin that is seen with the lowest levels of cortisol. So, in theory, the lowest levels of cortisol should be at nighttime when we're sleeping, when melatonin is highest for those terms are not always inverse. And that's where when we're measuring the cortisol, the wakening response, we can see not only is the how is somebody responding to their body's ability to wake up and for their day, but we're also measuring in most cases the stressors of the day before. 

00:13:35:07 - 00:14:16:13 

Christina O'Brien 

And when I first started using DUTCH testing, I was doing that urinary cortisol diurnal curve, and I used it in clinical practice for years and years and didn't even know embarrassingly much about the power or why it was really important. And when I started working with providers, I'm talking to providers all day long about their test results, I started to recognize patterns in the Cortisol Awakening response where I could see what I felt like were neurological dysfunctions in people based on their cortisol, a waiting response. 

 

00:14:16:13 - 00:14:41:09 

Christina O'Brien 

And it started as you know, I prepare every day to get ready for providers, and I look at the test results and I look at what the patient has written on their form, and often that doesn't tell the full story of what's happening with the patient. So, when I would see, say, a blunted cortisol awakening response or an elevated cortisol awakening response, I would assume something about the patient. 

 

00:14:41:09 - 00:15:02:11 

Christina O'Brien 

And then when I got on the provider with the provider, I would often ask them, did they recently have a concussion or are they dealing with depression or anxiety or and different aspects of what we can measure using the CAR ? And the vast majority of the time, the provider would say, well, how did you know that we didn't even talk about that? 

 

00:15:02:11 - 00:15:31:15 

Christina O'Brien 

Or They didn't put that on the form? Or, you know, that's something I didn't know about the patient. So, it's a way waking really acts like a mini stress test for the HPI access, which is influenced by the plasticity of the brain, really. So how adaptable are you? And animals like we talked about really adaptable. They can have a stressor and then go right back, but the longer we're under stress, the less adaptable our brain becomes. 

 

00:15:32:05 - 00:16:01:06 

Christina O'Brien 

And it really directly influences our stress response directly influences our energy levels and how stressed out we feel, how alert we are during the day. It addresses our blood sugar management and or lack thereof. It addresses how anxious we all are, depressed we are, how much we're worrying about things. It tells us about someone's autoimmune process. Are they developing an autoimmune process, or do they have an autoimmune progression? 

 

00:16:01:14 - 00:16:16:16 

Christina O'Brien 

Are they able to control their inflammation or do they have neuroinflammation that we can see, and have they had a recent infection? How is their memory? And then even cancer outcomes? And in the literature, we could see based on someone's cortisol awakening response. 

 

00:16:17:11 - 00:16:39:05 

Mark Newman 

So, the cortisol, a response is related to many of the factors that go on with dysfunction. So, let's narrow it down and start on the low side. So, when you're talking about a cortisol, a waking response that's flat, so you wake up and it's at one place and you're expecting it to jump up by, say, 50% over that half hour and it just doesn't it's sluggish. 

 

00:16:39:05 - 00:16:48:08 

Mark Newman 

So, what are the things that you find clinically that most often are correlating to a low or sluggish cortisol weakening response? 

 

00:16:49:02 - 00:17:16:17 

Christina O'Brien 

Yeah. So with that, with a low CAR b and we see different variations of that to based on what's happening with the person, and that's part of the really fun part about it and where you can really with those concrete data points, really target therapies for people and to me that's so exciting and where we can say, OK, they have a blunted CAR  at this point or at this point and we know that we can shift our CAR e based on that. 

00:17:16:17 - 00:18:14:00 

Christina O'Brien 

But with a low CAR , we can see most often the result of an underactive HPI access. Someone with excessive psychological burnout, someone with seasonal affective disorder. I'm in Dallas right now, so talking to people in the north and we we relate to those, you know, in the winter when they're experiencing those things, we'll see a low causality awakening response when it's actually seasonally relevant and people who have poor sleep or have sleep apnea and people with PTSD and people with chronic fatigue and also chronic pain and people with systemic hypertension and functional GI disorders and people with postpartum depression, people with autoimmunity, usually an autoimmune process that is progressing or is advancing and people who've 

 

00:18:14:00 - 00:18:25:00 

Christina O'Brien 

had a recent concussion. I probably the most common things that I see when I have somebody was when I'm looking at someone's results with a blunted cortisol awakening response. 

 

00:18:25:03 - 00:18:53:08 

Mark Newman 

And you're able to I want to maybe split hairs a little bit here. It gives you more information about whether that HPA axis is indeed let's just use the word sluggish or not. So, if you go back in time to more of our old school options of a saliva report that doesn't have that that baseline. So, it's the diurnal pattern, but not the CAR which is similar to the DUTCH complete where we get that nice up and down pattern, but you don't specifically get a CAR . 

 

00:18:53:12 - 00:19:22:22 

Mark Newman 

So are most of those things that you just listed also consistent with a generally low cortisol profile when you don't have the CAR and then the CAR allows you to tease out a little bit more exactly how dysfunctional it is on the low side, or are some or most or all of those things you listed specific to to when the CAR itself is low, does it apply to both of those situations, a low overall cortisol pattern and a low CAR or is it one or the other? 

 

00:19:22:22 - 00:19:23:13 

Mark Newman 

Does that make sense? 

 

00:19:24:07 - 00:19:56:02 

Christina O'Brien 

Yes. So, there is a correlation, a clear correlation between post waking cortisol results and, for example, major depressive disorder, which would be a more elevated part. We can clearly see and I'm just looking at the cortisol. We can see how people are responding to waking. But the magic really is in that percentage change between the first sample and the second sample and the second sample and the third sample. 

 

00:19:56:02 - 00:20:25:17 

Christina O'Brien 

And that's where those things that we just talked about are truly illuminated. We can assume and in looking at a normal diurnal curve is not an accurate way to look at somebody who's spastic at this activity. But we absolutely cannot duplicate that mini stress test for the day without looking at that cortisol awakening response that percent change is what illuminates everything for us. 

 

00:20:26:03 - 00:20:42:02 

Mark Newman 

So, we talked about the low side of things. When the axis is sluggish or depressed, so what are the clinical core letters that you see when a CAR  is exaggerated so it's bigger than you expect to see? It's a big bounce in the morning. What do you see with that? 

 

00:20:42:20 - 00:21:29:11 

Christina O'Brien 

So, I typically see when we have an elevated cortisol, a weakening response and an overactive HPI access or somebody who has ongoing job-related stress, where are anticipatory stress for the day is elevated because this truly is a mini stress test for the day. How is the patient's body responding to the day that they're facing and sometimes when the alarm goes off and people are startled by it and can slightly elevate the cortisol awakening response and the CAR  can be a little bit higher, and then we would expect to see if someone completely wakes up early or is just naturally a morning person. 

00:21:29:22 - 00:22:04:20 

Christina O'Brien 

And we can see generalized depression disorder in an elevated CAR , not as much the seasonal affective disorder, which typically will show a low path, but generalized depression will elevate the whole awakening response. And somebody who wakes up with an active infection or inflammation will show a higher, higher than expected, and we will see a higher CAR  around ovulation and and we'll see a higher CAR  in somebody who has a blood sugar dysregulation. 

 

00:22:05:06 - 00:22:30:14 

Mark Newman 

So, it seems like you're discussing two somewhat separate situations which are interesting to tease out and important to put into context for the interpretation. So, you mentioned like anticipatory stress, right? So, if you wake up on the day of an exam or you have an exam every day in terms of like lots of stress, then you could have an exaggerated CAR and that would be a normal response to the life you're living and maybe point to some lifestyle changes that are needed. 

 

00:22:30:14 - 00:22:32:21 

Mark Newman 

Would that sound like a correct interpretation? 

 

00:22:33:19 - 00:22:57:10 

Christina O'Brien 

That's absolutely right. And when we look at the research, we could see that the cortisol awakening response for people who have ongoing job-related stress is different on a weekday than a weekend day. So, it is reflective of your current life experience and that's what's beautiful about measuring the cortisol awakening response is that we can quantify how your body is responding to your life currently. 

 

00:22:57:14 - 00:23:23:15 

Mark Newman 

And then so a different interpretation of that. If I if I drop into someone's life on a day when they don't have a particularly high amount of stress and yet their cortisol, a waking response is high. So, my interpretation of that would be that your stress response is actually overactive, meaning you can have too much stress and you get a result, or you can have a stress response that is exaggerated. 

 

00:23:24:10 - 00:23:30:07 

Mark Newman 

Both are problematic, but the solution may be different. Is, is that a correction perpetration of or something. 

 

00:23:30:07 - 00:23:30:12 

Christina O'Brien 

Like. 

 

00:23:30:23 - 00:23:31:03 

Mark Newman 

That? 

 

00:23:31:07 - 00:23:32:06 

Christina O'Brien 

That's exactly right. 

 

00:23:32:17 - 00:23:42:02 

Mark Newman 

OK, so so then different solutions depending on what's actually driving that CAR , which is where then your job of asking good questions of your of your patient is really important. 

 

00:23:42:22 - 00:23:43:19 

Christina O'Brien 

That's exactly right. 

 

00:23:44:07 - 00:24:02:05 

Mark Newman 

One of the things we sometimes discuss as it relates to the CAR is, of course, if you collect it incorrectly, you're going to get results that don't make sense. What sort of pattern would you see where you would want to lean into that with your patient and ask some follow up questions about like, wait a minute, let's make sure that you got this right? 

 

00:24:02:05 - 00:24:04:10 

Mark Newman 

In terms of timing, what would that look like for you? 

 

00:24:05:17 - 00:24:31:07 

Christina O'Brien 

Right. So, if we have, you know, especially after talking to a provider or if I have my own people that I'm working with and I see a hugely blunted cortisol awakening response or really way over amplified cortisol awakening response, and it's not something that we would expect to see. We want to ask about collection and timing and using salivary cortisol. 

 

00:24:31:07 - 00:25:09:12 

Christina O'Brien 

It seems like it's pretty straightforward, but it's important to make sure that compliance is is on point. And emphasizing to the patients the importance of following the instructions CAR efully can now be overemphasized emphasized when we see a huge blunting, I think would be probably the most often most common thing that I hear when someone collects incorrectly where they really don't collect enough hours, 5 minutes of waking up, but they wait a little bit and they you know, get up and move around. 

 

00:25:09:21 - 00:25:37:17 

Christina O'Brien 

And we always want to recommend that they keep out the collecting device at their bedside so that they truly do do out within the first 5 minutes. And then exactly at 30 minutes, we have them set a timer and we talk through these things with patients. Clinicians talk through the most important that they do, setting a timer for that 30-minute mark and add 60-minute mark so we can get as absolutely close to the cortisol, the true cortisol, the wakening response for that person that we can. 

 

00:25:38:00 - 00:25:51:18 

Mark Newman 

So, it sounds like the baseline sample of making sure it is actually a baseline sample within the first 5 minutes of waking is a really key point to where that data is going to actually speak accurately about their stress response. 

 

00:25:52:06 - 00:25:59:09 

Christina O'Brien 

That's exactly right. That first 5 minutes is key to making the data from the cortisol awakening response relevant to that patient. 

 

00:25:59:11 - 00:26:17:03 

Mark Newman 

Which gives me this really pretty up and down pattern. And I get a pretty up and down pattern when I look at the DUTCH complete like it's up and it's down and I collect on waking, but I'm collecting a urine sample. So why do we not call that what you see in urine up? Why is that not a cortisol awakening response? 

00:26:17:14 - 00:26:48:16 

Christina O'Brien 

That's a terrific question, and I hear that often from providers. And when we wake up, we're measuring everything that was in the bladder overnight right and that's what we typically see on the urine test. It still tells us what's happening with someone's what is all first thing in the morning, no question, but a saliva sample and particularly using a small cotton collection device rather than spitting into a tube directly gives us that in the moment. 

 

00:26:48:18 - 00:27:13:19 

Christina O'Brien 

Cortisol response. That is where all of that most valuable data lies in the cortisol. The way getting response. And if we can grab the tiniest window possible and really get that true within the first 5 minutes, but even the first minute or two of wakening of awakening, we're able to really get that true CAR and truly measure that patient stress test for the day. 

 

00:27:14:06 - 00:27:39:02 

Mark Newman 

So, it matters what it represents. So, what you're saying, I hear you saying is the waking urine sample is interesting, but it represents it's basically an overnight urine. And if you do a waking sample in saliva, but you use more of a traditional collection than the sample requirement in terms of volume is going to take you long enough such that it's not really a true waking sample. 

 

00:27:39:02 - 00:27:49:02 

Mark Newman 

It's Waking Plus, which doesn't give you as accurate of a measurement of the CAR , which is why we chose the little cotton swabs instead of, hey, fill this tube up with spit. 

 

00:27:49:19 - 00:28:13:13 

Christina O'Brien 

Right. And it seems like. Well, in a way. Well, OK, so what these 5 minutes versus one minute, it does make a huge difference and it makes it more efficient and it allows us to truly measure that CAR . And again, not to say that a urine sample is inaccurate, right? Because I in clinical practice use just urine for years and years and years and got terrific results. 

 

00:28:13:13 - 00:28:26:13 

Christina O'Brien 

But adding of course, all awakening response is adding, and superimposing is such a valuable layer on truly assessing that patient stress response in the moment. 

 

00:28:26:18 - 00:28:57:07 

Mark Newman 

OK, so it's key. It's one of the things we love. So, I want you to add to it and just explain to people the cortisol a waking response is a picture and it's, it's a single variable that's important. So how would you describe the rest of what we would call the DUTCH? Plus, I'm looking at the cortisol awakening response and I'm also looking at measurements of like, what are the what are the things as you work through that information that you're the sort of hierarchy of information that you're looking at as it relates to what's going on with the axis? 

 

00:28:58:13 - 00:29:24:11 

Christina O'Brien 

So, when we look at the not only the cortisol awakening response collected in saliva, but when we're talking about using urine for collecting that two hour post waking sample, we're again, collecting all of the cortisol that's in the bladder from waking to 2 hours later. But when we use that cortisol a weakening response, we're collecting those more time points. 

 

00:29:24:11 - 00:30:03:01 

Christina O'Brien 

Those three time points are thing in the morning, but then we're able to collapse the dinner time and bedtime and overnight sample using those same cotton swabs in those collection teams to collect. And in the moment, cortisol for each collection point for the rest of the day, which again gives us a more immediate result or immediate data point for how best to help that patient not just in the morning but throughout the day in current time rather than in whatever was in the bladder or for X number of minutes in the moment. 

 

00:30:03:04 - 00:30:14:00 

Christina O'Brien 

Much more accurate in a minute, usually not even 5 minutes with what's happening with that cortisol, and we can truly better help the patient that way. 

 

00:30:14:03 - 00:30:33:20 

Mark Newman 

So, if I'm categorizing that information in terms of what I'm getting, having those samples later in the day tells me what's going on there and that's helpful. Maybe it's low, maybe it's high. That's helpful. That's one variable at dinner at that at those time points. Those are interesting. Those are useful. Then there's also the diagonal pattern itself, right? 

 

00:30:33:20 - 00:30:52:11 

Mark Newman 

How is that overall up and down pattern throughout the day, which is an important variable. So, I've got the cortisol, the waking response. That's a variable I've got the diurnal pattern, that's a variable. I've got those individual points of how is my life and my stress and my cortisol levels in the afternoon, in the evening at bedtime. At those points. 

 

00:30:52:22 - 00:31:09:03 

Mark Newman 

What else do you see? And I and I'm probably leaning a little bit into like the metabolites and some of the other things we look at for the DUTCH plus diurnal pattern cortisol awakening response, individual time points. What else are you able to get out of that because of the comprehensiveness of what we're measuring? 

 

00:31:09:23 - 00:31:48:07 

Christina O'Brien 

So, when we have so when we just have the cortisol awakening response, that's our mini stress stress test for the day, we can see how the person is waking up, how they're responding to that day. In general. But the diurnal pattern of cortisol, whether in urine or saliva, when the CAR is the least invasive and absolute best single biomarker for snapshot assessment of the HPI access in routine clinical practice, because we can see not only their cortisol awakening response but their entire diurnal pathways. 

 

00:31:48:18 - 00:32:36:23 

Christina O'Brien 

And when we start to see dysregulated and in that diurnal curve, not just the CAR but the die on occurs, we start to see things showing up in different areas of their life. Clinically, we can start to see more illness develop. We can see dysregulation of blood sugar and certainly of sleep. So when we combine then that CAR superimpose that on a diurnal curve, urine or saliva curves, we can make a patient's protocol more robust and because we then have a bigger picture and we're learning the bigger story about what's happening as far as the activity of the patients access and then when you add things like metabolized cortisol to that picture total and free 

 

00:32:36:23 - 00:33:09:05 

Christina O'Brien 

cortisol and cortisone with a DHEA then you're now expanding the window of the protocol that you can provide that patient in an order to be able to just help them adapt to their daily life. And we can even use things like heart rate variability where we can add another layer to that, where we're talking about an you know, measuring their cortisol for stress, but also measuring HB access dysfunction on a whole different level. 

 

00:33:10:03 - 00:33:28:22 

Mark Newman 

So, then what do you say to the doctor colleague that says, listen, if I talk to my patient, this is my crude translation, and I just guess, like, I'm pretty darn good at it, so I don't need to test? I've heard that from a number of people. Like the testing is not that helpful. I listen to my patient I know what's going on. 

 

00:33:28:22 - 00:33:42:00 

Mark Newman 

I treat them like having practiced and then also now working for us, staring at hundreds and thousands of these things. How would you encourage someone like that? That's that's working without the testing. 

 

00:33:44:17 - 00:34:23:12 

Christina O'Brien 

So, I mean, there are there are things you can certainly do. You know, roughly to help people in general when they're not testing. And but I've always had an in my clinical experience has been that being more data driven and actually looking at the numbers will always give you a clearer picture of what's happening with the patient. I can't tell you how many times I've had providers on the phone where we're looking at the patient's requisition form and the provider says, wait a minute, a patient never told me that. 

 

00:34:23:17 - 00:34:58:03 

Christina O'Brien 

I didn't know that about the patient. So even even a slightly different assessment allows the patient's current status on our requisition form isn't like a name for some providers. So clinically, I don't ever pretend to know well enough on my own without the data. And there's no better example, I think, than having results talking to a provider, letting the provider come up with a really robust protocol based on the testing that we see. 

 

00:34:58:12 - 00:35:20:15 

Christina O'Brien 

And then three months four months or six months later, getting to see the guest of getting to see the result of the robust protocol that the provider put them on by having them retest again and looking at their CAR again and looking at their diurnal curve again and getting to see the actual data, they feel better. Yes, you know, they're there, right? 

 

00:35:20:15 - 00:35:44:06 

Christina O'Brien 

Feels different. They're responding better to things. Their subjective results are clearly better, but there's nothing like being able to see the objective results we can see even on retest with a patient where we work together and the providers come up with this great protocol and, you know, totally we're going to make this huge difference and they implement that and the patient is receptive and they actually make those changes. 

 

00:35:44:06 - 00:35:58:13 

Christina O'Brien 

Then we see a retest and it's like, OK, everybody's literally doing a happy dance because that person is truly better, and we can see it in the data and there is no better way than knowing when we're actually making a change. Then looking at that data. 

 

00:35:59:13 - 00:36:31:09 

Mark Newman 

Well, in our, our, our mission as a company is to profoundly change as many lives as we can, which loosely translated is to create as many happy dances as we can for both providers and patients. So, this is a topic that needs illuminating. I know it can be confusing. And so, thank you so much for joining us and clearing up the value of some of the different pieces of the axis testing that we have and making that more manageable for our providers to understand. 

 

00:36:31:09 - 00:36:32:11 

Mark Newman 

So, thank you for joining us. 

 

00:36:32:23 - 00:36:35:00 

Christina O'Brien 

Absolutely. Thank you so much for having me. 

00:36:35:18 - 00:36:55:13 

Noah Reed 

Dr. O'Brien. Thank you so much for joining us today. And to all of our listeners, thank you. If you found any of these episodes helpful, we'd really appreciate it. If you take the time to rate and comment on your favorite streaming app. We're still a new podcast and we love your support, so please like subscribe and share this podcast with your friends on next week's episode. 

 

00:36:55:13 - 00:37:13:18 

Noah Reed 

We're continuing the cortisol theme in our Endocrine Essentials series. Now that we all have a baseline understanding of cortisol and what it is now, we to learn about what to do with the different patterns in cortisol. Testing. So, stay tuned for the resident DUTCH expert, Dr. Kelly Ruef, to walk us through some patterns and case studies. I'm Noah Reed. 

 

00:37:14:11 - 00:37:16:06 

Noah Reed 

Thanks for joining us. Until next time.