Adrenal Fatigue, Low Cortisol, and Blood Sugar

Adrenal Fatigue, Low Cortisol, and Blood Sugar
Scott Resnick MD 2023

Low cortisol, adrenal fatigue, and blood sugar are all intimately related. I’ve been following some threads recently, and I’ve noticed some common themes. It seems like so many people have a component of anxiety with their fatigue symptoms. The classic “tired and wired”. Is this you? The reason may lie in the way that your body is managing glucose.

This will all make sense soon, so read on.

Does Adrenal Fatigue Really Exist?

The common theme of this group is adrenal dysregulation, often seen with either elevated cortisol (hypercortisolism) or low cortisol (hypocortisolism), right? (It’s commonly called “adrenal fatigue” which is truly a misnomer). And like so many of us (me included), there seems to be an ongoing challenge to manage cortisol. But today I want to specifically address the low cortisol state, which is an end product of extended stress.

And let me just emphasize here, the adrenal glands don’t “fatigue”. They are instructed to lower cortisol output by the brain. I can inject a person who has measurably low cortisol with the central signaling hormone ACTH and guess what? Their adrenals pump out cortisol like nothing happened.

If you open any biochemistry book, the first sentence for the chapter on cortisol is that its primary job is to raise our body’s blood sugar. It is a ‘counterregulatory’ hormone and opposes the effects of insulin. Insulin lowers blood sugar and directs glucose into storage as glycogen and fat.

Cortisol: The Energy Management Hormone

Cortisol takes these storage forms of energy and liberalizes them when the energy is needed. Insulin and cortisol counter-regulate one another. They are Yin and yang, the two sides of a teeter-totter.

Our brains and hearts require glucose to work well. (Brains can run on ketones, but that’s a different post). So, we have cortisol, a dedicated hormone to ensure that we always have enough glucose in our bloodstream. Cortisol is a steroid hormone, which means that it works on our DNA.

Cortisol’s primary job is to raise blood sugar, but it does it at a fairly relaxed pace. Think of how a salivary cortisol curve looks. The curve rises and falls over the course of hours. Cortisol (and subsequently glucose) rises up gradually with order and patience.

Adrenaline: The “Twin Troublemakers”

But there are two other players in the cortisol and insulin, yin/yang story. They are epinephrine and norepinephrine, the twin troublemakers, known collectively as ‘adrenaline’. These guys are scrappy, the proverbial bulls in the glucose china shop. Yes, they can effectively raise our glucose, but they do it in a hurry, recklessly, and with the known side effects: anxiety, racing heart, jitters, nervousness, queasiness, and nausea.

Our body accepts these incident risks. I mean if you are going to be eaten by a tiger, and getting away requires a double shot of adrenaline, our body is content to let us feel like crap after the escape. The important thing is… we made the escape. We can lick our wounds another day.

Now consider what happens when a person has suppressed cortisol (hypocortisolism). They lose the ability to raise the glucose in the morning with their CAR (cortisol awakening response). They are also unable to respond using cortisol to the inevitable stressors (babies? bosses? husbands? traffic?). What happens then?

Epinephrine and norepinephrine jump in, it’s just what they are intended to do. It’s their job. We accept a state of anxiousness and nervousness to raise our blood sugar. Survival first. Make the escape. Stop and ask questions later.

Adrenal Dysfunction: A Case Study

Imagine Susan, who has a flattening cortisol curve from earlier stressors. Maybe it’s from her cross-training class, her calorie restriction diet, and her critical husband. She gets up, rushes the kids to school (alright, imagine pre-Covid), and passes on breakfast. Or she just grabs an energy bar. She already has lowered cortisol, and a flattened CAR, and is likely trending towards hypoglycemia when she wakes. OK. Her flattened curve means that there’s no cortisol to normally raise the blood sugar.

What happens? First, she starts to crave carbs. Maybe you know how this feels.

And then there’s traffic. And baby Jillian starts crying in the back seat while spilling her juice. The phone rings, and it’s the boss’s ringtone, Susan bobbles the phone while driving, and it slips behind the seat. Is there any wonder why her body turns to adrenaline to raise her blood sugar? Is it any wonder when Susan leans on the horn, curses at the crossing guard, gets sweaty and anxious, and feels her headache building again?

It’s just “normal” physiology. It’s our body using its resources, epinephrine, and norepinephrine, to keep us alive by raising our blood sugar–in a hurry.

Adrenal Fatigue Treatments? Start Here

The resolution? Of course, take steps to normalize cortisol levels, lower stress, nutrients, supplements, etc. But in the meantime, consider maintaining blood glucose via dietary means. I recommend that my patients ingest a diet higher in fats, fiber, and proteins, as these are broken down and absorbed more slowly. Yogurt, nuts, eggs, beef jerky, avocado, edamame, cheese, tofu, whatever… can be eaten more frequently and in smaller meals throughout the day.

Ideally, we can regulate our blood sugar with food– but be sure to stay away from excessive simple carbs like donuts. These just spike insulin and cause the blood sugar to crash again. Which causes adrenaline to be released, which causes… and the cycle repeats.

I’ve learned to change my perspectives on medicine, by Thinking Different about what is driving our health. When we look at things from a state of systems, in this case, the “energetics” triad of insulin, cortisol, and thyroid, we begin to see how symptoms like anxiety, evolve.

Manage energy well, store the adrenaline for when you really need it, and you’ll begin to feel better. There are plenty of tigers out there, but most are not really tigers. As blood sugar stays in the normal range, and we learn to breathe, they all become paper tigers.

Hope this helps! 🐯🐯😃


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Reader Interactions


  1. Dominik says

    Thank you so much for this article, it gave an epiphany! For the first time I understood how crucial it is to lower your carb intake when your cortisol is low (my case). What do you think about keto diet? Would it be a good idea for someone with “adrenal fatigue”/low cortisol? Or you find it too stressing for already stressed body?

    • Scott Resnick, MD says

      No! I strongly recommend against the keto diet for somebody whose adrenals aren’t working well. I truly believe that most people need more, not fewer, carbs. When I open my biochemistry book, the very first sentence under ‘cortisol’ is that it’s primary job is to raise blood sugar! So if the adrenals are already under a stress, why ask them to work harder? And here’s the kicker. Our backup plan for low carbs when cortisol isn’t available is adrenaline. This is why so many people are “tired and wired”. Hope this helps!

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