LISTEN & SUBSCRIBE: Spotify | Apple Podcasts | YouTube | Amazon Music
Cortisol has made headlines in the past couple of years. If your feed has you questioning whether cortisol is behind everything from “moon face” to belly fat, this episode is here to help. We break down what cortisol actually does, what a normal daily cortisol curve looks like and why true cortisol disorders are rare. We also dig into what’s more likely behind carrying more weight around the midsection and whether it’s worth measuring cortisol at all. Plus, why the basics (sleep, managing stress and healthy routines) tend to matter more than any alleged cortisol quick-fix — including “cortisol cocktails.”
Expert: Dr. Nadir Mulla, primary care physician
Notable topics:
Why cortisol is the body’s energy mobilization hormone
The cortisol curve: how the body naturally controls cortisol levels
How rare are cortisol disorders?
The simple morning habit that could optimize your cortisol curve
Uncovering what's more likely to be behind "cortisol face" and "cortisol belly"
What heart rate variability can tell you about your stress levels
Why managing stress, your sleep schedule and diet are more important than any cortisol quick-fix tips
"Cortisol cocktails" may work — just not for the reason you might think
Learn when to see your doctor about fatigue and any symptoms
Like what you hear?
View all episodes and SUBSCRIBE wherever you get your podcasts, including on:
Spotify | Apple Podcasts | YouTube | Amazon Music | Pocket Casts | iHeartRadio | Podcast Index | Podcast Addict | Podchaser | Deezer
Stay up-to-date
Please Enter Email
Please Enter Valid Email
ZACH MOORE: Welcome to On Health with Houston Methodist. I'm Zach Moore, I'm a photographer and editor here, and I'm also a longtime podcaster.
KIM RIVERA HUSTON-WEBER: I'm Kim Rivera Huston-Weber, and I'm a copywriter here at Houston Methodist.
ZACH: And Kim, cortisol. Seems to be the villain of the month, at least on social media.
KIM: Yeah. I mean, there's a lot of content creators out there that are talking about high cortisol levels and that being the cause of cortisol face, cortisol belly. So the thinking is that if you have higher levels of cortisol, that's why your face might appear puffy or you might carry a little bit more love around the waist. But it's one of my favorite things that we get to do on the podcast is explore these topics and kind of see what's true from fiction.
ZACH: Right, right. And, you know, cortisol is really only a term I've heard people talk about the last couple of years, I think people started talking about.
KIM: Yeah, you know, and it's the body's stress hormone. And I don't think we really think about it unless, you know, somebody startles you or something like that. But, you know, how much do we really think about our body's hormones on the day-to-day? I mean, I certainly don't.
ZACH: Right.
KIM: It plays a big part in a lot of our body's functions so we do need it to survive. And you know, I'm excited that we got to talk about it with our expert because it was very illuminating for me.
ZACH: Yeah, a necessary quote, unquote, "evil?" We'll find out. Who did we talk to about this today, Kim?
KIM: Yes, We spoke to Dr. Nadir Mulla. He's a Primary Care Physician here at Houston Methodist.
[Sound effect plays to signal beginning of interview]
KIM: Thank you so much for being with us today, Dr. Mulla.
DR. NADIR MULLA: Happy to be here. Thanks for having me.
KIM: Of course. So, one of my favorite things that we get to do on the podcast is we get to talk about these trends that are happening on social media. And one of the biggest for the past couple of years has been cortisol. So, to start, what is cortisol and what role does it play in how our body functions?
DR. MULLA: These are great questions. I love that the public is getting more and more knowledgeable about different topics, and I like to see that eagerness to learn. I'll tell you that cortisol is a pretty complicated topic in medical school. Spent a lot of nights trying to figure it out. And even in preparing for this, I feel like my cortisol rose a little bit. [Laughing] But yeah, so cortisol it's commonly known as the stress hormone. I think that's a little bit of a misnomer. I would say it's more of an energy mobilization hormone. So yes, it is a hormone which is basically a chemical messenger in your body. It's derived from cholesterol, so cholesterol turns into many different hormones in our body. It's primarily made out of fat. And cortisol is actually the downstream product of a lot of things that actually go on in our brain. So there's a big series of messengers, series of events that happen from light entering your eye all the way 'till your kidneys where on top of your kidneys sit the adrenal gland, which actually produces your cortisol, and that has its whole host of effects. But yeah, so it is commonly considered the stress hormone. And, you know, let's say that you are walking down the street and a car is about to come in and hit you. It swerves out of the way. Immediately you are stressed, activated, your senses are hyper aware, without you even having conscious thought about it. That is a very acute form of stress and it's actually not cortisol, it's your catecholamine, so adrenaline, norepinephrine. That is gonna be your immediate activation of your stress system. In that time, though, you're gonna be unsettled, your heart rate's gonna be elevated, your breathing is gonna be faster, your eyes are actually wider and dilated. And that's all from epinephrine or adrenaline. After that process it takes about 10 minutes for the cortisol to actually raise or rise in your system, and that has its own stream of effects a little bit later down the line.
KIM: It's so interesting, you know, and a lot of the conversation online is really focused on these extremes. And so, like, either very high cortisol or very low cortisol. But, kind of before we get into that, I'd like to understand what's normal with our cortisol. So, can you explain how our body naturally controls or manages cortisol?
DR. MULLA: Excellent question, and I think there's one key point to take out of this if you're gonna take anything at all. It's not as simple as high cortisol or low cortisol. If it was that easy, it'd be a lot more simpler but there's actually a lot more nuance to it. The general trend that you need to understand, though, is that cortisol is gonna be highest in the morning and lowest, almost undetectable, when you're about to go to sleep. And with that, that is why I said in the beginning it's really controlled a lot by the light that enters your eyes. We have certain receptors in our eyes that send messages to the, very complicated term, suprachiasmatic nucleus. It's a little area of the brain that that sits on the top of the roof of your mouth. And that's actually -- in more simpler terms we call it the SCN, but it's actually your master clock, okay? So when we talk about circadian rhythm and whatnot, that is primarily controlled by that master clock the SCN, okay? The SCN, or that master clock, sends signals to other parts of the brain where it'll continue to send signals. And the way that it sends signals for cortisol to be created is in pulses, okay? These pulses happen in the morning every 60-90 minutes, in the evening 90-120 minutes. And each pulse will vary in terms of how much it tells the adrenal glands to produce cortisol. So in the morning it tends to be much bigger and in the evening it tends to be much smaller. Now, I think we're getting a little ahead but in the extreme cases where you have really high cortisol or really low cortisol, these things are completely out of whack. I think for most people they do suffer from an inappropriate amount of cortisol being released but not in any kind of measurable way, it's just that their rhythm is off. As far as people having actual issues with their cortisol and their cortisol systems, the too high one it's only about two to three cases per million people.
KIM: Oh wow.
DR. MULLA: But too low, about 100, 150 per million people. So the true issues with hormones is actually quite rare. A lot of times our cortisol will fluctuate more with chronic stress, poor sleep habits, in my world of sports medicine a lot of times overtraining and decreased sleep, so not enough recovery. So, if you think about the high in the morning and the low in the evening, a lot of people that are, like, burnt out, chronic fatigue sometimes -- and again it's a lot of factors that come into chronic fatigue and stress and whatnot, but oftentimes you'll find that their curve rather than being high in the morning and low in the evening tends to be medium in the morning and still not completely low in the evening. And it makes sense if you think about what cortisol does. Like I said earlier, cortisol is kind of a energy mobilizer.
KIM: Mm-hmm.
DR. MULLA: It does a lot of different things. When you're sick your body needs to mobilize energy so cortisol will rise. When you do exercise, cortisol will rise. When you're psychologically stressed, cortisol will rise. So, if it's chronically activated, if you're not sleeping well, if you're not getting proper nutrition, if you use too much caffeine, and that's a whole separate topic, or nicotine, or alcohol, all this can kind of affect your cortisol level. Now, is that saying that your cortisol is the issue or is that more of your lifestyle being an issue? And like I said, true cortisol issues are actually very rare, it's much more a lifestyle or behavioral thing that can fix that flattened curve to more a one that peaks in the morning and decreases in the evening.
KIM: So it kind of sounds like cortisol, when it's functioning normally, it is kind of helping us regulate that circadian rhythm, maybe helping us get -- wake up in the morning.
DR. MULLA: Exactly.
KIM: And then maybe, like, settle in at night. Because, you know, there's less light at night and maybe that's, like, helping to lower things. So, we know sleep is involved. Are there other functions, like, is it tied to our metabolism? Because, I know later we're gonna talk about cortisol belly. But, you know, are there other functions to cortisol with our body?
DR. MULLA: Great question. I do wanna mention one thing. So, when we wake up in the morning, we kind of do so naturally. And that is a phenomena called the cortisol awakening response. Like we talked about, when cortisol is elevated it releases energy or mobilizes energy in the body. And if you're thinking in terms of metabolism, it goes into your fat and says, "Fat, hey, release your energy." It goes to the liver says, "Hey, make some sugars." Goes to your protein in your muscle and it kind of breaks down the muscle too. And it increases your blood sugar and gives you energy. So cortisol in the right context, you can feel more mentally alert, you can feel energized. And when we think about the natural progression of cortisol, especially in the night, so at night it's really low. But then when it starts to get closer to the morning, your brain will send signals like, "Hey, raise the cortisol." And what actually wakes you up is that increased energy that results from the cortisol rising, or ideally spiking in the beginning of the day. And when you think about people that are chronically stressed and if you think about in the evening, late night ruminations they're tired but they can't sleep, their cortisol might be a little bit higher than it should be because you're sending the signal to your brain, "Hey, I'm psychologically stressed." It does its pathway in the brain, raises your cortisol so you'll be tired but can't sleep in the evening. And then because in the evening your cortisol is a little bit higher, you're not getting the appropriate peak when it comes to the morning. So when you do wake up in the morning, you're still tired because you don't have the proper energy in the morning and the proper amount of cortisol in the morning, that peak in the morning. So different things can affect that. Again, getting your eight hours of sleep is really essential. I think we always understate how important sleep is. Hydration. Hydration can lead to an appropriate rise and fall. And then, it's very interesting, but in the morning what you can do especially within the first hour of waking up is you have this special opportunity that doesn't exist in other parts of the day where if light enters your eyes, ideally sunlight, it doesn't have to be directly looking into the sun, but just going outside in the morning and getting some light. Or if light is not available, then a 10,000 lumen bulb, that can actually stimulate receptors in your retina which then sends signals to your brain which then can send signals to actually raise your cortisol even a little bit more. And that's ideal on getting that nice peak. And then over time, then your body will get wired and wired down to have that same signal. So the best thing that you can do for cortisol regulation is gonna be sleeping and waking up at the same time, ideally especially waking up at the same time every day, getting that light in at the beginning of the day that can really set your day off great. And then towards the evening, making sure that the light is lower, making sure that you're not ruminating too much over your stressors, avoiding caffeine, avoiding alcohol, and then you can have that nice decline in your cortisol which allows you to sleep rather peacefully.
KIM: That's so interesting, you know, because maybe we should be having a little bit of sun before we have our first cup of coffee.
DR. MULLA: Yes. You know, there's -- okay, great -- I'm gonna go on a little be of a tangent here. [Laughing] So, a lot of people all suffer from, like, a mid-afternoon crash.
KIM: Mm-hmm.
DR. MULLA: And, you know, sometimes it's all that maybe your cortisol is actually, you know, coming down a little too quickly amongst whole other things, lots of different other things but one aspect. So some people will take their caffeine early, first thing when they wake up, but sometimes even just delaying your caffeine by 30 minutes or 60 minutes can help prevent at least a component of that mid-afternoon crash. So there are definitely people that have benefited from moving their caffeine from first thing in the morning to 30, to 60 minutes after their wakeful period.
KIM: You know that -- I think that probably does make sense because I've definitely been the person that has had that mid-afternoon crash and I've also been the person who will ruminate before falling asleep. So is that why it's often recommended that, you know, if you can't fall asleep to do something like box breathing or trying to do some kind, something to help, like, kind of calm the mind or, you know, maybe make your body feel a little bit more comfortable?
DR. MULLA: 100%. Breathing is very tied into our stress response and our relaxation response, so if you think about the two different ways that our nervous system operates, we have the sympathetic and parasympathetic systems. In more plain terms, sympathetic is that fight or flight and parasympathetic is that rest and relax, okay? So when you're having these stressors in our life, back in the day it was lions, tigers, lack of food, things like that. Real physical stressors.
KIM: Now it's emails.
DR. MULLA: Now it's emails, exactly. And our brain doesn't really differentiate these, so psychological stressors or physical stressors still activate the same kind of systems. So that can increase you're sympathetic tone or your fight or flight system, increase your cortisol and whatnot and prevent you from having that appropriate curve. And so, as far as the parasympathetic, or that rest and relaxation, yes, breathing and deep breathing can stimulate the vagal nerve, which is one of the bigger buttons that we can actively control and press to bring down our elevated state. So even, you know, box breathing or usually I'll say to people to do an inhalation, a deep inhalation, and then a sudden sharp one at the end followed by exhalation through the mouth. I could demonstrate the real quick. So it's... [Deep breath] I feel a little bit calmer already, I don't know if it's reflected in my voice but –
KIM: I think I feel a little bit calmer.
DR. MULLA: Great, great, great. Yes, that'll active your rest and relaxation system and that can be really beneficial. So, I wanted to go into a couple different directions here. So, as far as cortisol and whether or not it's worth measuring for the layperson, especially since we talked about how rare the extremes are of super high and super low. And if you're worried about fatigue, burn out, all that kind of stuff I wanna be very clear that those are very real symptoms and we have a lot of different diagnoses for that that are not necessarily tied to cortisol. Cortisol, like we talked about, it's very pulsatile in nature, the way it's secreted, and there's troughs and there's peaks and if we get a sample at any one moment in time, it has to be put into a lot of context and you need a lot of repeated samples for us to actually gain any meaningful information. So unless you're having serious symptoms like unexplained weight loss, weight gain, purple striae, muscle weakness, hyper or hypotension, most people are not suffering from a true cortisol issue, most people are really suffering from lifestyle issues. Chronic stress, things like that. So, I would say if somebody was interested in improving these aspects -- I love biomarkers, I think biomarkers are great, but they need to be in the appropriate context with the health care professional whether, and preferably especially in the context of cortisol, an Endocrinologist. But I would say for the layperson that suffers from chronic fatigue or things like that, feeling wired, but tired at night, or not feeling like they're particularly restful in the morning. There's a lot of different things that can go into it, sleep apnea, anxiety and depression, poor sleep hygiene, all of -- insomnia, shift workers, all of these things can affect that. If I were gonna point somebody in a direction that's more reasonable, not as invasive, not without as much noise, I would ask them to look, maybe, into heart rate variability.
KIM: Mm-hmm.
DR. MULLA: Heart rate variability is a -- it actually has little to do with, or what I gain, what I interpret, has little to do with actually your heart but more to do with the balance between your sympathetic and parasympathetic nervous system. So, going back a little bit what is heart rate variability? So, your heart beats are not on a metronome, okay? There are little variations in the timings of the beats, and that timing, moment to moment, can be affected by breathing, by acute stress. And the higher the variability, meaning the more the differentiation between different beats, the more off the metronome it is, the more it tells you that you're parasympathetic, or your rest and relax is activated.
KIM: Mm-hmm.
DR. MULLA: If you are very stressed or your sympathetic nervous system is very -- or your fight or flight is very activated, it's gonna act more like a metronome and your heart rate variability will be lower. Okay? And so it's actionable. You can -- And the thing is I don't want you to look moment to moment for the different heart rate variability, I want you to look more so in terms of trends. So how does it trend at night? How does it trend over the week? For athletes it's really great because it can give them an objective marker on whether or not they're overtraining.
KIM: Mm-hmm.
DR. MULLA: Or under-recovering or under-nutritioned well before some of the other major signs that your body is screaming that these things are happening. So I would say, I would encourage people if they're concerned about their cortisol -- And heart rate variability is a little bit tied to cortisol but it's not one- to-one causality, but I would say that's a much better thing to look at in terms of how is that trending. It's a lot cheaper, easier, modifiable without all the noise that happens with the pulses and the troughs and what not. And you can monitor trends over time much easier, you know. And a normal heart rate variability is anywhere between like 30 to 110. And the thing is you don't wanna compare with other people.
KIM: Mm-hmm.
DR. MULLA: What's baseline for you is gonna be very different from a baseline from somebody else.
KIM: Yeah, I'm sure my heart rate's a lot different than say, like, Lebron James.
DR. MULLA: Exactly, exactly, yeah. I'd be curious to see what his heart rate variability is and whether or not that's something that they actually track for him.
KIM: Yeah, no. I mean, 'cause I'm sure with elite athletes they have all sorts of resources to check what's going on with their bodies because their bodies are their career.
DR. MULLA: Yeah, yeah, especially in the triathlon world where people are doing a lot of endurance training, or marathon runners or whatever. I think they're really into these kinds of biomarkers and whatnot to check how their training is going.
KIM: Yeah. You know, 'cause you kind of mentioned some of the symptoms that might be associated with high and low cortisol. So -- and online that's the conversation that's happening right, it's about the extremes. So, what are some of the symptoms that are associated with low cortisol and what are some symptoms that are associated with high levels of cortisol. And you had mentioned that, you know, we kind of go through these peaks and valleys throughout our days. So is this sustained high and sustained low cholesterol where these symptoms emerge?
DR. MULLA: That's a great question, and I think that's where a lot of the issues come up. And I just want people to know that the conversation is not as simple as high versus low. There is an appropriate high in the morning, an appropriate low in the evening. So, we'll do different tests if we're concerned for sustained too high or sustained too low, which, again, too high 2-3 cases out of a million, too low 100-150 out of a million. And a lot of times people think they're suffering from high. So, to -- I'm glad that the epidemiology of that shows that it's even rarer in the high versus the low. As far as high, I've written a couple of things down so. Moon facies, muscle weakness, easy bruising, purple stretch marks, getting skinnier in the legs and the arms, getting more of a round at the midsection, and then on the flip side, Addison's disease, which is low cortisol. Fatigue, weakness, low blood pressure, skin darkening. And again, I wanna emphasize how rare these are. And if you are feeling like maybe your face is a little bit rounder, maybe your jaw's losing definition, maybe you're having some weight at the midsection, you know. Part of that is just the natural fluctuation of how people grow over time, you know, we are not as muscularly robust as we used to be. You hit your peak musculature around 25, 26, and then after that you lose about 1% a year and then you're more likely to hold on to fat, things like that. So, I think it is -- It would be easy to say, "Hey, your cortisol is either too high or too low. Take this supplement, do this." And there's a lot of people making a lot of money off of preying on people's desires to feel better, to not have this. And I think that's just the way that things have always been. People will always try to sell you something. But, the conversation is not as easy as "take this supplement." I wish we could put exercise into a pill.
KIM: Yeah.
DR. MULLA: I wish we could put proper sleep into a pill. I wish we could put stress regulation into a pill. But I don't think that's happened yet.
KIM: Yeah.
DR. MULLA: I think we're far away from that even happening, if that's even possible. So think it, you know, an honest discussion with yourself, an honest discussion with your health care provider, and you know, we don't need to medicalize anxiety, stress, poor sleep, and whatnot. We can try to work on these things in our lifestyle and I think that your cortisol is just a messenger. It's doing things right. If you're chronically stressed it's acting appropriately, it's not acting inappropriately. So fixing those lifestyle factors, which by the way if you want a timeline of how long it takes for these things to get better it takes several weeks, sometimes a couple months to have a routine established and then your cortisol will respond appropriately in several weeks' time. It's not something that will change moment to moment or day to day, you know. Your suprachiasmatic nucleus which is that master clock takes a lot of things into consideration or doesn't change so easily so quickly. It takes sustained waking up at the same time, sustained sleeping at the same time for you to optimize the performance of your overall, you know, cortisol system amongst other systems in your body.
KIM: So, one of the biggest things online is the cortisol face and the cortisol belly. And we all know that our weight management is very multifactorial, that there's just a lot that goes into our weight. And, you know, I'd love to know, what -- are there other reasons why our face might be a little rounder, why we might be carrying a little bit more love in our midsection? You had mentioned that, you know, we start losing muscle as young as our mid-twenties. So, are there other factors that could go into what these content creators are calling the cortisol face and the cortisol belly?
DR. MULLA: I think people are most conscious when fat enters the face or the belly and that's the place where it's most displeasing to the person. So I think, again, that's just preying on the fears and insecurities of that person. Different people have different areas, just genetically, where they will have fat be increased. South Asian populations definitely get a lot more around the belly. Sometimes people look at it viscerally and it all just depends, person to person. It's not necessarily related to cortisol in most people. In those cases where people do get fat on the face or the belly, or the back of the neck, that can be medically driven but again, that's something that's super rare.
KIM: Yeah. So, you had kind of touched on this but, you know, many content creators are offering solutions to quote, unquote "cortisol woes." So, they're saying we should cut out caffeine, they're saying we should maybe consider dong cold plunges or sauna, and I think, of course, some are recommending supplements, and I think there is even now a beverage on the market that is saying that it can help you lower your cortisol levels. Does any of this work?
DR. MULLA: This is a great question that I think deserves a lot of nuance. And I think, like most of the other things that we talked about, the answer is a little bit more complicated and not at first intuitive as it can be. And I think there's a lot of room for misinterpretation, so I'm gonna start off with that. Okay so, as far as caffeine or exercise, or different stressors. So, they have done studies on this and there are people that drink caffeine chronically and there are people that drink it once in a while. Your body's really good at recognizing stress and especially new stress. So if you're to imagine two people, one person who drinks caffeine every day.
KIM: That would be me.
DR. MULLA: All right, exactly. And one person who never really drinks caffeine, or less than twice week. Just telling me -- Just tell me what you think in terms of if they drink caffeine, who do you think will get more of a spike?
KIM: Probably the person who doesn't.
DR. MULLA: Exactly.
KIM: Drink caffeine regularly.
DR. MULLA: Yeah. So, again, the conversation is very complex and nuanced. And in terms of caffeine and caffeine consumption it really does depend. If you drink caffeine four or five times a week, your cortisol response is gonna be much more blunted compared to somebody that doesn't, okay? And when it comes to exercise, you can take even trained people, let's say you have a trained runner, they do their runs, they get a little bit of a cortisol bump in their wave that eventually goes from up to down. But they'll get a little bump around that time when they do their runs. If you told them instead of running that day go lift some weights, they're gonna have a much bigger bump than they typically do. So, new stressors, something new. For example me, yesterday, getting ready for this, my cortisol increased and that's just my body's way of saying, "Hey, you're a little bit stressed, here's some extra energy for you to be able to handle this.
KIM: Yeah.
DR. MULLA: So, there's that to add. Now, there's different things that will affect the cortisol. So, there are, for example, ashwagandha, okay? Some people really tout that as something that can decrease cortisol. Now, is that true? Objectively it can be a little bit true.
KIM: Mm-hmm.
DR. MULLA: And it's a -- again a complicated discussion. So we talked about factors that affect the cortisol which includes stress. So, does ashwagandha affect your cortisol directly? No. What it can do is it can bring you a calming effect. So your prefrontal cortex, which is where we do a lot of our processing, interacting with the world will be a little bit more calmed down. So it's not sending the signal to the amygdala, which is not sending a signal to the hypothalamus and pituitary and so on, so forth to have such a big stress response. But does it necessarily affect the cortisol? No. Grapefruit juice, grapefruits, does that directly affect cortisol? It affects some of the enzymes that break down cortisol and some people will say that that will decrease your cortisol sometimes by 10, 11%. And I think that sometimes when people get focused on these specific measures, sometimes you miss the forest for the trees. This cortisol system has been designed and evolution, and gone through its model for many, many, many generations before us and it's pretty fine-tuned. And I think the big thing is taking in the forest, sleep, stress, and you know, just the major things, hydration and whatnot. So, I think if you can focus on those I think you're gonna get much more bang for your buck, much more benefit. And then in the end, if you feel like after all of those measures you still need something in terms of giving yourself a little boost or kind of cutting it towards the end of the day then you can consider, you know, some of these other supplements and things like that.
KIM: Yeah. So, you had mentioned the grapefruit juice, that's another very popular thing online. There're people are calling it the "cortisol cocktail" or the "adrenal cocktail." And I've seen people make it different ways but usually it's a combination of coconut water, orange juice, maybe grapefruit juice, salt, and a -- Some folks include different ingredients like magnesium. If someone were to drink a beverage like this, is it really going to do anything to our cortisol levels, realistically?
DR. MULLA: I think there can be a decrease but let's say that you're still ruminating about different things that night, let's say you're still sending heavy light signals into your eye, especially with blue light, or short wavelength light into your eye, that's gonna activate your body to respond in kind. So if the only interventions that you're doing is this cocktail, I don't think that's really gonna be doing that much because the other systems would be overriding and still causing you to have an increased cortisol in the night time which is not gonna make you feel that much better. Sometimes, you know, a placebo can be a hell of a drug.
KIM: Yeah.
DR. MULLA: And if you're doing something and you think it's gonna work and you're telling yourself it's gonna work, so then your stress is reduced, then you're gonna feel like, "Hey, this is really working for me." But in terms of the actual physiology and what's going on, that's a different question, you know.
KIM: Yeah. Well, and it makes total sense, right? Because if I like to drink decaf tea at night and so may -- It's not the tea itself that calms me down, it's the ritual, right? So it's making the making the tea, it's sitting down and reading and having -- and drinking the warm beverage, that's what's helping my parasympathetic system work a little bit more. It's not the actual beverage itself a lot of times.
DR. MULLA: I think you brought up something very interesting and really great and actually helps tie into this conversation quite a bit. So we talked about that master clock, the suprachiasmatic nucleus, the SCN. Having these cues at night, these rituals, an evening routine and whatnot where you wind down and calm down is actually really helpful and really beneficial. I'm glad that you're not scrolling on your phone and getting that light and getting that sensation. But yes, over time our SCN will adapt to some of these things.
KIM: We've talked a lot about everything to do with cortisol, pretty much, and I'd love to understand, you know, if someone is really concerned, they're seeing this content online, what should they do if they fear that their cortisol levels are too high or maybe too low and maybe having symptoms?
DR. MULLA: I think it's very reasonable to have the fear especially given the contents of everything, and I just want people to know that their symptoms are very real. You know, the fatigue is very real, not having energy in the morning is very real, being unable to sleep yet tried at night is very real. Feeling like you don't have energy enough to do the day is very real. And I think that a lot of times there's a lot more other explanations that better can explain what's going on in terms of why you're feeling that way, and very rarely is it that something is particularly wrong with your body's cortisol. I think cortisol is the messenger, it's a symptom, sometimes, of other problems like we talked about: sleep, or stress, or anxiety, depression, insomnia, shift work, jetlag. So, I think, you know, if people are feeling, you know, that they're concerned, writing a journal with the times of what they're feeling and when they're feeling it and bringing that to their health care professional so you guys can work together in terms of figuring out what's gonna be best for you. Rarely will it require, specifically, cortisol testing. I think uncovering the rocks that are far more common are gonna yield an explanation way more often, probability-wise, as opposed to cortisol being the issue. And cortisol is not the -- is just a messenger for the system. Rather than having a peak in the morning and a trough in the evening, it can be medium in the morning and medium in the evening, and that's not a sign that your cortisol system and your body system is messed up or that we need to give you medications to fix it. It's a sign that other areas in your life could be optimized so that your body can restore its natural rhythm.
KIM: We don't need to fix the cortisol, we need to fix everything else. [Laughing]
DR. MULLA: Yeah, yeah. And again, if sleep, exercise, and getting good sun could be put into a pill, I think that would do great.
KIM: Yeah, I think we'd all take that pill.
DR. MULLA: Yeah.
[Sound effect plays to signal end of the interview]
ZACH: So, Kim, what was your biggest take away from your conversation with Dr. Mulla?
KIM: You know, I think I was about the fact that our body is on a cycle with our cortisol levels, so they peak really high in the morning and then they're lower at night to help us get ready for bed. It just plays a big role in our sleep, wake cycle that I just had no idea about.
ZACH: Yeah. And I think, you know, as a society, not to overly generalize, but we're always looking for an excuse, a scapegoat, something to point to that's like, "Hey, not my fault," right? And although cortisol imbalances they do happen, they are extremely rare. So, I guess my point is go down all the usual suspects first before you decide or self-diagnose you might have cortisol imbalance.
KIM: Yeah. You know, Dr. Mulla is very clear that these imbalances are very much real, they're conditions. You can work with your physician. If you're truly concerned about your levels, you know, you should speak with your doctor, but these conditions are quite rare. So, you know, if you're having issues I think getting back to the basics. Are you going to sleep at a good time? Are you getting -- actually I think getting up at the same time every day...
ZACH: Yeah.
KIM: Is probably better for a good sleep routine. But if you're, like, really hyped and can't get to sleep at night, like, what are you doing leading up to going to sleep? Are you, like, playing a very intense video game? Are you doom scrolling, like, what are you doing before you're going to sleep?
ZACH: Is it Christmas Eve, right? [Laughing]
KIM: Yeah are you up –
ZACH: Cortisol levels are through the roof!
KIM: Yeah are you up having a good time? There's a lot of things that kind of go into whether or not we might be gaining weight or potentially, you know, having quote, unquote "cortisol face." There's a lot that could be going on that you should talk to your doctor about but also reflect. It's good for us all to reflect sometimes, right?
ZACH: Right. And I know we might sound redundant here on the podcast because we talk about the same things so often, like, get enough sleep, have a good diet, exercise, those sorts of things. But there's a reason we're always recommending and reinforcing them because if you do those things they're gonna put you in the best place you can be with your health.
KIM: Yeah, and you know, I hear it a lot in my workouts, it's all about process, not perfection.
ZACH: Yeah.
KIM: So, I think making sure that you're doing all of those thing more often than you're not, it's not about -- You don't have to be doing it completely perfectly all the time, but if you're doing it more often than not, you know, that's going to benefit your health more over time.
ZACH: Yeah. So bottom line, cortisol, we need it, it's here, don't run from it, embrace it. [Laughing] Is it a necessary evil? That's still a harsh term but it's here and for right now it's the villain of the month on social media.
KIM: Yeah.
ZACH: But tune some of that noise out and just get down to the science of it, right?
KIM: Yeah, exactly. And it's important for our body and, you know, get back to those basics.
ZACH: That's right, back to the basics. All right, that's gonna do it for us this time on, On Health with Houston Methodist. Be sure to share, like, and subscribe wherever you get your podcasts. We drop episodes Tuesday mornings so until next time stay tuned and stay healthy.
KIM RIVERA HUSTON-WEBER: I'm Kim Rivera Huston-Weber, and I'm a copywriter here at Houston Methodist.
ZACH: And Kim, cortisol. Seems to be the villain of the month, at least on social media.
KIM: Yeah. I mean, there's a lot of content creators out there that are talking about high cortisol levels and that being the cause of cortisol face, cortisol belly. So the thinking is that if you have higher levels of cortisol, that's why your face might appear puffy or you might carry a little bit more love around the waist. But it's one of my favorite things that we get to do on the podcast is explore these topics and kind of see what's true from fiction.
ZACH: Right, right. And, you know, cortisol is really only a term I've heard people talk about the last couple of years, I think people started talking about.
KIM: Yeah, you know, and it's the body's stress hormone. And I don't think we really think about it unless, you know, somebody startles you or something like that. But, you know, how much do we really think about our body's hormones on the day-to-day? I mean, I certainly don't.
ZACH: Right.
KIM: It plays a big part in a lot of our body's functions so we do need it to survive. And you know, I'm excited that we got to talk about it with our expert because it was very illuminating for me.
ZACH: Yeah, a necessary quote, unquote, "evil?" We'll find out. Who did we talk to about this today, Kim?
KIM: Yes, We spoke to Dr. Nadir Mulla. He's a Primary Care Physician here at Houston Methodist.
[Sound effect plays to signal beginning of interview]
KIM: Thank you so much for being with us today, Dr. Mulla.
DR. NADIR MULLA: Happy to be here. Thanks for having me.
KIM: Of course. So, one of my favorite things that we get to do on the podcast is we get to talk about these trends that are happening on social media. And one of the biggest for the past couple of years has been cortisol. So, to start, what is cortisol and what role does it play in how our body functions?
DR. MULLA: These are great questions. I love that the public is getting more and more knowledgeable about different topics, and I like to see that eagerness to learn. I'll tell you that cortisol is a pretty complicated topic in medical school. Spent a lot of nights trying to figure it out. And even in preparing for this, I feel like my cortisol rose a little bit. [Laughing] But yeah, so cortisol it's commonly known as the stress hormone. I think that's a little bit of a misnomer. I would say it's more of an energy mobilization hormone. So yes, it is a hormone which is basically a chemical messenger in your body. It's derived from cholesterol, so cholesterol turns into many different hormones in our body. It's primarily made out of fat. And cortisol is actually the downstream product of a lot of things that actually go on in our brain. So there's a big series of messengers, series of events that happen from light entering your eye all the way 'till your kidneys where on top of your kidneys sit the adrenal gland, which actually produces your cortisol, and that has its whole host of effects. But yeah, so it is commonly considered the stress hormone. And, you know, let's say that you are walking down the street and a car is about to come in and hit you. It swerves out of the way. Immediately you are stressed, activated, your senses are hyper aware, without you even having conscious thought about it. That is a very acute form of stress and it's actually not cortisol, it's your catecholamine, so adrenaline, norepinephrine. That is gonna be your immediate activation of your stress system. In that time, though, you're gonna be unsettled, your heart rate's gonna be elevated, your breathing is gonna be faster, your eyes are actually wider and dilated. And that's all from epinephrine or adrenaline. After that process it takes about 10 minutes for the cortisol to actually raise or rise in your system, and that has its own stream of effects a little bit later down the line.
KIM: It's so interesting, you know, and a lot of the conversation online is really focused on these extremes. And so, like, either very high cortisol or very low cortisol. But, kind of before we get into that, I'd like to understand what's normal with our cortisol. So, can you explain how our body naturally controls or manages cortisol?
DR. MULLA: Excellent question, and I think there's one key point to take out of this if you're gonna take anything at all. It's not as simple as high cortisol or low cortisol. If it was that easy, it'd be a lot more simpler but there's actually a lot more nuance to it. The general trend that you need to understand, though, is that cortisol is gonna be highest in the morning and lowest, almost undetectable, when you're about to go to sleep. And with that, that is why I said in the beginning it's really controlled a lot by the light that enters your eyes. We have certain receptors in our eyes that send messages to the, very complicated term, suprachiasmatic nucleus. It's a little area of the brain that that sits on the top of the roof of your mouth. And that's actually -- in more simpler terms we call it the SCN, but it's actually your master clock, okay? So when we talk about circadian rhythm and whatnot, that is primarily controlled by that master clock the SCN, okay? The SCN, or that master clock, sends signals to other parts of the brain where it'll continue to send signals. And the way that it sends signals for cortisol to be created is in pulses, okay? These pulses happen in the morning every 60-90 minutes, in the evening 90-120 minutes. And each pulse will vary in terms of how much it tells the adrenal glands to produce cortisol. So in the morning it tends to be much bigger and in the evening it tends to be much smaller. Now, I think we're getting a little ahead but in the extreme cases where you have really high cortisol or really low cortisol, these things are completely out of whack. I think for most people they do suffer from an inappropriate amount of cortisol being released but not in any kind of measurable way, it's just that their rhythm is off. As far as people having actual issues with their cortisol and their cortisol systems, the too high one it's only about two to three cases per million people.
KIM: Oh wow.
DR. MULLA: But too low, about 100, 150 per million people. So the true issues with hormones is actually quite rare. A lot of times our cortisol will fluctuate more with chronic stress, poor sleep habits, in my world of sports medicine a lot of times overtraining and decreased sleep, so not enough recovery. So, if you think about the high in the morning and the low in the evening, a lot of people that are, like, burnt out, chronic fatigue sometimes -- and again it's a lot of factors that come into chronic fatigue and stress and whatnot, but oftentimes you'll find that their curve rather than being high in the morning and low in the evening tends to be medium in the morning and still not completely low in the evening. And it makes sense if you think about what cortisol does. Like I said earlier, cortisol is kind of a energy mobilizer.
KIM: Mm-hmm.
DR. MULLA: It does a lot of different things. When you're sick your body needs to mobilize energy so cortisol will rise. When you do exercise, cortisol will rise. When you're psychologically stressed, cortisol will rise. So, if it's chronically activated, if you're not sleeping well, if you're not getting proper nutrition, if you use too much caffeine, and that's a whole separate topic, or nicotine, or alcohol, all this can kind of affect your cortisol level. Now, is that saying that your cortisol is the issue or is that more of your lifestyle being an issue? And like I said, true cortisol issues are actually very rare, it's much more a lifestyle or behavioral thing that can fix that flattened curve to more a one that peaks in the morning and decreases in the evening.
KIM: So it kind of sounds like cortisol, when it's functioning normally, it is kind of helping us regulate that circadian rhythm, maybe helping us get -- wake up in the morning.
DR. MULLA: Exactly.
KIM: And then maybe, like, settle in at night. Because, you know, there's less light at night and maybe that's, like, helping to lower things. So, we know sleep is involved. Are there other functions, like, is it tied to our metabolism? Because, I know later we're gonna talk about cortisol belly. But, you know, are there other functions to cortisol with our body?
DR. MULLA: Great question. I do wanna mention one thing. So, when we wake up in the morning, we kind of do so naturally. And that is a phenomena called the cortisol awakening response. Like we talked about, when cortisol is elevated it releases energy or mobilizes energy in the body. And if you're thinking in terms of metabolism, it goes into your fat and says, "Fat, hey, release your energy." It goes to the liver says, "Hey, make some sugars." Goes to your protein in your muscle and it kind of breaks down the muscle too. And it increases your blood sugar and gives you energy. So cortisol in the right context, you can feel more mentally alert, you can feel energized. And when we think about the natural progression of cortisol, especially in the night, so at night it's really low. But then when it starts to get closer to the morning, your brain will send signals like, "Hey, raise the cortisol." And what actually wakes you up is that increased energy that results from the cortisol rising, or ideally spiking in the beginning of the day. And when you think about people that are chronically stressed and if you think about in the evening, late night ruminations they're tired but they can't sleep, their cortisol might be a little bit higher than it should be because you're sending the signal to your brain, "Hey, I'm psychologically stressed." It does its pathway in the brain, raises your cortisol so you'll be tired but can't sleep in the evening. And then because in the evening your cortisol is a little bit higher, you're not getting the appropriate peak when it comes to the morning. So when you do wake up in the morning, you're still tired because you don't have the proper energy in the morning and the proper amount of cortisol in the morning, that peak in the morning. So different things can affect that. Again, getting your eight hours of sleep is really essential. I think we always understate how important sleep is. Hydration. Hydration can lead to an appropriate rise and fall. And then, it's very interesting, but in the morning what you can do especially within the first hour of waking up is you have this special opportunity that doesn't exist in other parts of the day where if light enters your eyes, ideally sunlight, it doesn't have to be directly looking into the sun, but just going outside in the morning and getting some light. Or if light is not available, then a 10,000 lumen bulb, that can actually stimulate receptors in your retina which then sends signals to your brain which then can send signals to actually raise your cortisol even a little bit more. And that's ideal on getting that nice peak. And then over time, then your body will get wired and wired down to have that same signal. So the best thing that you can do for cortisol regulation is gonna be sleeping and waking up at the same time, ideally especially waking up at the same time every day, getting that light in at the beginning of the day that can really set your day off great. And then towards the evening, making sure that the light is lower, making sure that you're not ruminating too much over your stressors, avoiding caffeine, avoiding alcohol, and then you can have that nice decline in your cortisol which allows you to sleep rather peacefully.
KIM: That's so interesting, you know, because maybe we should be having a little bit of sun before we have our first cup of coffee.
DR. MULLA: Yes. You know, there's -- okay, great -- I'm gonna go on a little be of a tangent here. [Laughing] So, a lot of people all suffer from, like, a mid-afternoon crash.
KIM: Mm-hmm.
DR. MULLA: And, you know, sometimes it's all that maybe your cortisol is actually, you know, coming down a little too quickly amongst whole other things, lots of different other things but one aspect. So some people will take their caffeine early, first thing when they wake up, but sometimes even just delaying your caffeine by 30 minutes or 60 minutes can help prevent at least a component of that mid-afternoon crash. So there are definitely people that have benefited from moving their caffeine from first thing in the morning to 30, to 60 minutes after their wakeful period.
KIM: You know that -- I think that probably does make sense because I've definitely been the person that has had that mid-afternoon crash and I've also been the person who will ruminate before falling asleep. So is that why it's often recommended that, you know, if you can't fall asleep to do something like box breathing or trying to do some kind, something to help, like, kind of calm the mind or, you know, maybe make your body feel a little bit more comfortable?
DR. MULLA: 100%. Breathing is very tied into our stress response and our relaxation response, so if you think about the two different ways that our nervous system operates, we have the sympathetic and parasympathetic systems. In more plain terms, sympathetic is that fight or flight and parasympathetic is that rest and relax, okay? So when you're having these stressors in our life, back in the day it was lions, tigers, lack of food, things like that. Real physical stressors.
KIM: Now it's emails.
DR. MULLA: Now it's emails, exactly. And our brain doesn't really differentiate these, so psychological stressors or physical stressors still activate the same kind of systems. So that can increase you're sympathetic tone or your fight or flight system, increase your cortisol and whatnot and prevent you from having that appropriate curve. And so, as far as the parasympathetic, or that rest and relaxation, yes, breathing and deep breathing can stimulate the vagal nerve, which is one of the bigger buttons that we can actively control and press to bring down our elevated state. So even, you know, box breathing or usually I'll say to people to do an inhalation, a deep inhalation, and then a sudden sharp one at the end followed by exhalation through the mouth. I could demonstrate the real quick. So it's... [Deep breath] I feel a little bit calmer already, I don't know if it's reflected in my voice but –
KIM: I think I feel a little bit calmer.
DR. MULLA: Great, great, great. Yes, that'll active your rest and relaxation system and that can be really beneficial. So, I wanted to go into a couple different directions here. So, as far as cortisol and whether or not it's worth measuring for the layperson, especially since we talked about how rare the extremes are of super high and super low. And if you're worried about fatigue, burn out, all that kind of stuff I wanna be very clear that those are very real symptoms and we have a lot of different diagnoses for that that are not necessarily tied to cortisol. Cortisol, like we talked about, it's very pulsatile in nature, the way it's secreted, and there's troughs and there's peaks and if we get a sample at any one moment in time, it has to be put into a lot of context and you need a lot of repeated samples for us to actually gain any meaningful information. So unless you're having serious symptoms like unexplained weight loss, weight gain, purple striae, muscle weakness, hyper or hypotension, most people are not suffering from a true cortisol issue, most people are really suffering from lifestyle issues. Chronic stress, things like that. So, I would say if somebody was interested in improving these aspects -- I love biomarkers, I think biomarkers are great, but they need to be in the appropriate context with the health care professional whether, and preferably especially in the context of cortisol, an Endocrinologist. But I would say for the layperson that suffers from chronic fatigue or things like that, feeling wired, but tired at night, or not feeling like they're particularly restful in the morning. There's a lot of different things that can go into it, sleep apnea, anxiety and depression, poor sleep hygiene, all of -- insomnia, shift workers, all of these things can affect that. If I were gonna point somebody in a direction that's more reasonable, not as invasive, not without as much noise, I would ask them to look, maybe, into heart rate variability.
KIM: Mm-hmm.
DR. MULLA: Heart rate variability is a -- it actually has little to do with, or what I gain, what I interpret, has little to do with actually your heart but more to do with the balance between your sympathetic and parasympathetic nervous system. So, going back a little bit what is heart rate variability? So, your heart beats are not on a metronome, okay? There are little variations in the timings of the beats, and that timing, moment to moment, can be affected by breathing, by acute stress. And the higher the variability, meaning the more the differentiation between different beats, the more off the metronome it is, the more it tells you that you're parasympathetic, or your rest and relax is activated.
KIM: Mm-hmm.
DR. MULLA: If you are very stressed or your sympathetic nervous system is very -- or your fight or flight is very activated, it's gonna act more like a metronome and your heart rate variability will be lower. Okay? And so it's actionable. You can -- And the thing is I don't want you to look moment to moment for the different heart rate variability, I want you to look more so in terms of trends. So how does it trend at night? How does it trend over the week? For athletes it's really great because it can give them an objective marker on whether or not they're overtraining.
KIM: Mm-hmm.
DR. MULLA: Or under-recovering or under-nutritioned well before some of the other major signs that your body is screaming that these things are happening. So I would say, I would encourage people if they're concerned about their cortisol -- And heart rate variability is a little bit tied to cortisol but it's not one- to-one causality, but I would say that's a much better thing to look at in terms of how is that trending. It's a lot cheaper, easier, modifiable without all the noise that happens with the pulses and the troughs and what not. And you can monitor trends over time much easier, you know. And a normal heart rate variability is anywhere between like 30 to 110. And the thing is you don't wanna compare with other people.
KIM: Mm-hmm.
DR. MULLA: What's baseline for you is gonna be very different from a baseline from somebody else.
KIM: Yeah, I'm sure my heart rate's a lot different than say, like, Lebron James.
DR. MULLA: Exactly, exactly, yeah. I'd be curious to see what his heart rate variability is and whether or not that's something that they actually track for him.
KIM: Yeah, no. I mean, 'cause I'm sure with elite athletes they have all sorts of resources to check what's going on with their bodies because their bodies are their career.
DR. MULLA: Yeah, yeah, especially in the triathlon world where people are doing a lot of endurance training, or marathon runners or whatever. I think they're really into these kinds of biomarkers and whatnot to check how their training is going.
KIM: Yeah. You know, 'cause you kind of mentioned some of the symptoms that might be associated with high and low cortisol. So -- and online that's the conversation that's happening right, it's about the extremes. So, what are some of the symptoms that are associated with low cortisol and what are some symptoms that are associated with high levels of cortisol. And you had mentioned that, you know, we kind of go through these peaks and valleys throughout our days. So is this sustained high and sustained low cholesterol where these symptoms emerge?
DR. MULLA: That's a great question, and I think that's where a lot of the issues come up. And I just want people to know that the conversation is not as simple as high versus low. There is an appropriate high in the morning, an appropriate low in the evening. So, we'll do different tests if we're concerned for sustained too high or sustained too low, which, again, too high 2-3 cases out of a million, too low 100-150 out of a million. And a lot of times people think they're suffering from high. So, to -- I'm glad that the epidemiology of that shows that it's even rarer in the high versus the low. As far as high, I've written a couple of things down so. Moon facies, muscle weakness, easy bruising, purple stretch marks, getting skinnier in the legs and the arms, getting more of a round at the midsection, and then on the flip side, Addison's disease, which is low cortisol. Fatigue, weakness, low blood pressure, skin darkening. And again, I wanna emphasize how rare these are. And if you are feeling like maybe your face is a little bit rounder, maybe your jaw's losing definition, maybe you're having some weight at the midsection, you know. Part of that is just the natural fluctuation of how people grow over time, you know, we are not as muscularly robust as we used to be. You hit your peak musculature around 25, 26, and then after that you lose about 1% a year and then you're more likely to hold on to fat, things like that. So, I think it is -- It would be easy to say, "Hey, your cortisol is either too high or too low. Take this supplement, do this." And there's a lot of people making a lot of money off of preying on people's desires to feel better, to not have this. And I think that's just the way that things have always been. People will always try to sell you something. But, the conversation is not as easy as "take this supplement." I wish we could put exercise into a pill.
KIM: Yeah.
DR. MULLA: I wish we could put proper sleep into a pill. I wish we could put stress regulation into a pill. But I don't think that's happened yet.
KIM: Yeah.
DR. MULLA: I think we're far away from that even happening, if that's even possible. So think it, you know, an honest discussion with yourself, an honest discussion with your health care provider, and you know, we don't need to medicalize anxiety, stress, poor sleep, and whatnot. We can try to work on these things in our lifestyle and I think that your cortisol is just a messenger. It's doing things right. If you're chronically stressed it's acting appropriately, it's not acting inappropriately. So fixing those lifestyle factors, which by the way if you want a timeline of how long it takes for these things to get better it takes several weeks, sometimes a couple months to have a routine established and then your cortisol will respond appropriately in several weeks' time. It's not something that will change moment to moment or day to day, you know. Your suprachiasmatic nucleus which is that master clock takes a lot of things into consideration or doesn't change so easily so quickly. It takes sustained waking up at the same time, sustained sleeping at the same time for you to optimize the performance of your overall, you know, cortisol system amongst other systems in your body.
KIM: So, one of the biggest things online is the cortisol face and the cortisol belly. And we all know that our weight management is very multifactorial, that there's just a lot that goes into our weight. And, you know, I'd love to know, what -- are there other reasons why our face might be a little rounder, why we might be carrying a little bit more love in our midsection? You had mentioned that, you know, we start losing muscle as young as our mid-twenties. So, are there other factors that could go into what these content creators are calling the cortisol face and the cortisol belly?
DR. MULLA: I think people are most conscious when fat enters the face or the belly and that's the place where it's most displeasing to the person. So I think, again, that's just preying on the fears and insecurities of that person. Different people have different areas, just genetically, where they will have fat be increased. South Asian populations definitely get a lot more around the belly. Sometimes people look at it viscerally and it all just depends, person to person. It's not necessarily related to cortisol in most people. In those cases where people do get fat on the face or the belly, or the back of the neck, that can be medically driven but again, that's something that's super rare.
KIM: Yeah. So, you had kind of touched on this but, you know, many content creators are offering solutions to quote, unquote "cortisol woes." So, they're saying we should cut out caffeine, they're saying we should maybe consider dong cold plunges or sauna, and I think, of course, some are recommending supplements, and I think there is even now a beverage on the market that is saying that it can help you lower your cortisol levels. Does any of this work?
DR. MULLA: This is a great question that I think deserves a lot of nuance. And I think, like most of the other things that we talked about, the answer is a little bit more complicated and not at first intuitive as it can be. And I think there's a lot of room for misinterpretation, so I'm gonna start off with that. Okay so, as far as caffeine or exercise, or different stressors. So, they have done studies on this and there are people that drink caffeine chronically and there are people that drink it once in a while. Your body's really good at recognizing stress and especially new stress. So if you're to imagine two people, one person who drinks caffeine every day.
KIM: That would be me.
DR. MULLA: All right, exactly. And one person who never really drinks caffeine, or less than twice week. Just telling me -- Just tell me what you think in terms of if they drink caffeine, who do you think will get more of a spike?
KIM: Probably the person who doesn't.
DR. MULLA: Exactly.
KIM: Drink caffeine regularly.
DR. MULLA: Yeah. So, again, the conversation is very complex and nuanced. And in terms of caffeine and caffeine consumption it really does depend. If you drink caffeine four or five times a week, your cortisol response is gonna be much more blunted compared to somebody that doesn't, okay? And when it comes to exercise, you can take even trained people, let's say you have a trained runner, they do their runs, they get a little bit of a cortisol bump in their wave that eventually goes from up to down. But they'll get a little bump around that time when they do their runs. If you told them instead of running that day go lift some weights, they're gonna have a much bigger bump than they typically do. So, new stressors, something new. For example me, yesterday, getting ready for this, my cortisol increased and that's just my body's way of saying, "Hey, you're a little bit stressed, here's some extra energy for you to be able to handle this.
KIM: Yeah.
DR. MULLA: So, there's that to add. Now, there's different things that will affect the cortisol. So, there are, for example, ashwagandha, okay? Some people really tout that as something that can decrease cortisol. Now, is that true? Objectively it can be a little bit true.
KIM: Mm-hmm.
DR. MULLA: And it's a -- again a complicated discussion. So we talked about factors that affect the cortisol which includes stress. So, does ashwagandha affect your cortisol directly? No. What it can do is it can bring you a calming effect. So your prefrontal cortex, which is where we do a lot of our processing, interacting with the world will be a little bit more calmed down. So it's not sending the signal to the amygdala, which is not sending a signal to the hypothalamus and pituitary and so on, so forth to have such a big stress response. But does it necessarily affect the cortisol? No. Grapefruit juice, grapefruits, does that directly affect cortisol? It affects some of the enzymes that break down cortisol and some people will say that that will decrease your cortisol sometimes by 10, 11%. And I think that sometimes when people get focused on these specific measures, sometimes you miss the forest for the trees. This cortisol system has been designed and evolution, and gone through its model for many, many, many generations before us and it's pretty fine-tuned. And I think the big thing is taking in the forest, sleep, stress, and you know, just the major things, hydration and whatnot. So, I think if you can focus on those I think you're gonna get much more bang for your buck, much more benefit. And then in the end, if you feel like after all of those measures you still need something in terms of giving yourself a little boost or kind of cutting it towards the end of the day then you can consider, you know, some of these other supplements and things like that.
KIM: Yeah. So, you had mentioned the grapefruit juice, that's another very popular thing online. There're people are calling it the "cortisol cocktail" or the "adrenal cocktail." And I've seen people make it different ways but usually it's a combination of coconut water, orange juice, maybe grapefruit juice, salt, and a -- Some folks include different ingredients like magnesium. If someone were to drink a beverage like this, is it really going to do anything to our cortisol levels, realistically?
DR. MULLA: I think there can be a decrease but let's say that you're still ruminating about different things that night, let's say you're still sending heavy light signals into your eye, especially with blue light, or short wavelength light into your eye, that's gonna activate your body to respond in kind. So if the only interventions that you're doing is this cocktail, I don't think that's really gonna be doing that much because the other systems would be overriding and still causing you to have an increased cortisol in the night time which is not gonna make you feel that much better. Sometimes, you know, a placebo can be a hell of a drug.
KIM: Yeah.
DR. MULLA: And if you're doing something and you think it's gonna work and you're telling yourself it's gonna work, so then your stress is reduced, then you're gonna feel like, "Hey, this is really working for me." But in terms of the actual physiology and what's going on, that's a different question, you know.
KIM: Yeah. Well, and it makes total sense, right? Because if I like to drink decaf tea at night and so may -- It's not the tea itself that calms me down, it's the ritual, right? So it's making the making the tea, it's sitting down and reading and having -- and drinking the warm beverage, that's what's helping my parasympathetic system work a little bit more. It's not the actual beverage itself a lot of times.
DR. MULLA: I think you brought up something very interesting and really great and actually helps tie into this conversation quite a bit. So we talked about that master clock, the suprachiasmatic nucleus, the SCN. Having these cues at night, these rituals, an evening routine and whatnot where you wind down and calm down is actually really helpful and really beneficial. I'm glad that you're not scrolling on your phone and getting that light and getting that sensation. But yes, over time our SCN will adapt to some of these things.
KIM: We've talked a lot about everything to do with cortisol, pretty much, and I'd love to understand, you know, if someone is really concerned, they're seeing this content online, what should they do if they fear that their cortisol levels are too high or maybe too low and maybe having symptoms?
DR. MULLA: I think it's very reasonable to have the fear especially given the contents of everything, and I just want people to know that their symptoms are very real. You know, the fatigue is very real, not having energy in the morning is very real, being unable to sleep yet tried at night is very real. Feeling like you don't have energy enough to do the day is very real. And I think that a lot of times there's a lot more other explanations that better can explain what's going on in terms of why you're feeling that way, and very rarely is it that something is particularly wrong with your body's cortisol. I think cortisol is the messenger, it's a symptom, sometimes, of other problems like we talked about: sleep, or stress, or anxiety, depression, insomnia, shift work, jetlag. So, I think, you know, if people are feeling, you know, that they're concerned, writing a journal with the times of what they're feeling and when they're feeling it and bringing that to their health care professional so you guys can work together in terms of figuring out what's gonna be best for you. Rarely will it require, specifically, cortisol testing. I think uncovering the rocks that are far more common are gonna yield an explanation way more often, probability-wise, as opposed to cortisol being the issue. And cortisol is not the -- is just a messenger for the system. Rather than having a peak in the morning and a trough in the evening, it can be medium in the morning and medium in the evening, and that's not a sign that your cortisol system and your body system is messed up or that we need to give you medications to fix it. It's a sign that other areas in your life could be optimized so that your body can restore its natural rhythm.
KIM: We don't need to fix the cortisol, we need to fix everything else. [Laughing]
DR. MULLA: Yeah, yeah. And again, if sleep, exercise, and getting good sun could be put into a pill, I think that would do great.
KIM: Yeah, I think we'd all take that pill.
DR. MULLA: Yeah.
[Sound effect plays to signal end of the interview]
ZACH: So, Kim, what was your biggest take away from your conversation with Dr. Mulla?
KIM: You know, I think I was about the fact that our body is on a cycle with our cortisol levels, so they peak really high in the morning and then they're lower at night to help us get ready for bed. It just plays a big role in our sleep, wake cycle that I just had no idea about.
ZACH: Yeah. And I think, you know, as a society, not to overly generalize, but we're always looking for an excuse, a scapegoat, something to point to that's like, "Hey, not my fault," right? And although cortisol imbalances they do happen, they are extremely rare. So, I guess my point is go down all the usual suspects first before you decide or self-diagnose you might have cortisol imbalance.
KIM: Yeah. You know, Dr. Mulla is very clear that these imbalances are very much real, they're conditions. You can work with your physician. If you're truly concerned about your levels, you know, you should speak with your doctor, but these conditions are quite rare. So, you know, if you're having issues I think getting back to the basics. Are you going to sleep at a good time? Are you getting -- actually I think getting up at the same time every day...
ZACH: Yeah.
KIM: Is probably better for a good sleep routine. But if you're, like, really hyped and can't get to sleep at night, like, what are you doing leading up to going to sleep? Are you, like, playing a very intense video game? Are you doom scrolling, like, what are you doing before you're going to sleep?
ZACH: Is it Christmas Eve, right? [Laughing]
KIM: Yeah are you up –
ZACH: Cortisol levels are through the roof!
KIM: Yeah are you up having a good time? There's a lot of things that kind of go into whether or not we might be gaining weight or potentially, you know, having quote, unquote "cortisol face." There's a lot that could be going on that you should talk to your doctor about but also reflect. It's good for us all to reflect sometimes, right?
ZACH: Right. And I know we might sound redundant here on the podcast because we talk about the same things so often, like, get enough sleep, have a good diet, exercise, those sorts of things. But there's a reason we're always recommending and reinforcing them because if you do those things they're gonna put you in the best place you can be with your health.
KIM: Yeah, and you know, I hear it a lot in my workouts, it's all about process, not perfection.
ZACH: Yeah.
KIM: So, I think making sure that you're doing all of those thing more often than you're not, it's not about -- You don't have to be doing it completely perfectly all the time, but if you're doing it more often than not, you know, that's going to benefit your health more over time.
ZACH: Yeah. So bottom line, cortisol, we need it, it's here, don't run from it, embrace it. [Laughing] Is it a necessary evil? That's still a harsh term but it's here and for right now it's the villain of the month on social media.
KIM: Yeah.
ZACH: But tune some of that noise out and just get down to the science of it, right?
KIM: Yeah, exactly. And it's important for our body and, you know, get back to those basics.
ZACH: That's right, back to the basics. All right, that's gonna do it for us this time on, On Health with Houston Methodist. Be sure to share, like, and subscribe wherever you get your podcasts. We drop episodes Tuesday mornings so until next time stay tuned and stay healthy.
Categories: When Should I Worry About...
Did you find this article helpful?
Thank you for your feedback.
