Stress is defined as the physiological or psychological response to internal and external stressors. Stress evokes changes in nearly every system of the body, influencing how people feel and behave. At the most basic level, the stress response acts to enhance survival. So, while we understand that acute (short-lived) stress can result in beneficial outcomes, such as improved mental or physical performance, the opposite holds true for sustained, chronic stress. Therefore, identifying stressors and implementing healthy stress-reduction techniques are foundational for achieving optimal health and preventing disease. (13) 

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Understanding Stress and Its Impact

The stress response is a complex physiological reaction that occurs in the body when an individual perceives a real or imagined threat. This response is crucial for survival, as it prepares the body to confront or flee the danger. The stress response involves the activation of several interconnected systems in the body, including the sympathetic ("fight or flight") division of the autonomic nervous system and the hypothalamic-pituitary-adrenal (HPA) axis. 

When a person encounters a stressor, the hypothalamus, a region of the brain, releases a hormone called corticotropin-releasing hormone (CRH). CRH signals the pituitary gland to release adrenocorticotropic hormone (ACTH), which, in turn, stimulates the adrenal glands located on top of the kidneys. The adrenal glands respond to ACTH by releasing stress hormones, primarily cortisol. Cortisol plays a central role in the stress response by mobilizing energy reserves, increasing heart rate, and sharpening the senses, preparing the body to respond effectively to the perceived threat. (16) 

Physiologically, several changes occur in the body during the stress response. Heart rate and blood pressure increase, enhancing the delivery of oxygen and nutrients to vital organs and muscles. Breathing becomes faster and deeper, ensuring an adequate oxygen supply to the lungs. Blood flow is redirected away from less critical functions, such as digestion and the immune system, and is prioritized towards the brain and muscles. Additionally, the body releases glucose and fatty acids into the bloodstream, providing immediate energy sources for the muscles. Pupils dilate to improve vision, and the senses become more acute. These physiological changes collectively prepare the body to respond rapidly to the stressor. (38, 40) 

However, prolonged or chronic stress leads to adrenal and nervous system dysregulation and places high demands on vital organs, including the heart, blood vessels, and immune system. Diseases strongly linked to stress and adrenal dysregulation include autoimmune disease, cancer, cardiovascular disease, irritable bowel syndrome (IBS), irregular and painful menstrual cycles, and mood disorders.

Identifying Stressors

Identifying stressors is crucial for healthy stress management and reduction as it allows individuals to pinpoint the root causes of their stress. By recognizing specific stress triggers, individuals can develop targeted coping strategies, make necessary lifestyle changes, and seek appropriate support. 

Diet and Stress

Chronic stress can negatively affect eating habits and the body's use of calories and nutrients. Stress places a greater demand on the body for oxygen, energy, and micronutrients. However, stress leads many people towards emotional eating, favoring nutrient-poor "comfort foods" over those that meet nutrient requirements. Conversely, others may lack the time and motivation to prepare nutritious meals or experience reduced appetite, leading to skipped meals. Either scenario can result in blood sugar swings and nutritional deficiencies that reduce the body's ability to adapt to stressors and perpetuate unhealthy eating patterns. (36) 

Caffeine acts as a nervous system stimulant and activates the HPA axis. Caffeine consumption is associated with elevated cortisol and adrenaline levels and higher blood pressure. Excessive intake of caffeinated beverages is associated with an increased perception of stress and stress-associated symptoms, such as anxiety, nervousness,  restlessness, insomnia, and disorganized thoughts. 

Exercise and Stress

Excessive sedentary time is related to poor mental health, as is supported by this 2018 study showing reductions in sedentary time (i.e., increased physical activity) are associated with improved mood, stress, and sleep. The benefits of exercise on stress and mental health can be attributed to the natural production of endorphins. Regular physical activity reduces fatigue, improves cognitive function, improves sleep, and stabilizes mood. (30) 

While exercise is generally considered a positive and healthy activity, it can be a stressor under certain circumstances. A 2021 study found significantly elevated cortisol levels up to two hours after high-intensity interval training (HIIT). Intense or prolonged physical activity, especially when the body is not adequately prepared or given enough time to recover, can put significant stress on the musculoskeletal, cardiovascular, and endocrine systems. Therefore, individuals must balance their exercise routines with adequate rest, hydration, and nutrition. 

Sleep and Stress

There is strong evidence to support the interconnected relationship between sleep and stress. Anxiety and depression can interfere with the ability to fall asleep and stay asleep soundly. Conversely, sleep deprivation causes cortisol hypersecretion and hyperarousal of the nervous system, leading to higher levels of stress and anxiety. (8)

Assessing Hormonal Balance

We have established that during periods of chronic stress, the adrenals are continuously stimulated, leading to an overproduction of cortisol. Over time, adrenal dysfunction will develop, characterized by abnormal cortisol secretion patterns in which irregular peaks and troughs occur throughout the day.  

Abnormal cortisol levels will disrupt the delicate balance of the body's other hormonal systems. Chronic stress exerts a profound negative impact on thyroid health and function. Prolonged stress dysregulates the hypothalamus-pituitary-thyroid (HPT) axis, leading to abnormal secretion of thyroid-stimulating hormone (TSH) and hindering the conversion of thyroxine (T4) to the active form triiodothyronine (T3). HPT axis dysfunction is associated with hypothyroid and hyperthyroid states. Additionally, stress can trigger autoimmune responses, contributing to autoimmune thyroid conditions (Hashimoto's thyroiditis and Graves' disease). (9) 

Psychosocial stress also suppresses the hypothalamic-pituitary-gonadal axes in women and men, negatively impacting ovarian and testicular function and reducing the production of sex hormones estrogen, progesterone, and testosterone. Imbalances in reproductive hormones are associated with a vast array of symptoms, including depression, irregular menstrual patterns, and infertility in women; and erectile dysfunction, muscle wasting, and enlargement of breast tissue in men. (17, 31)

Gut-Brain Connection

The gut-brain axis, a complex bidirectional communication network between the gut and the brain, plays a pivotal role in regulating various physiological processes, including stress responses. Emerging research has highlighted the intricate connection between the gut and the brain, suggesting that the gut microbiota, a diverse community of microorganisms residing in the gastrointestinal tract, profoundly influences brain function and behavior. This interaction is dynamic, with signals traveling along the vagus nerve and through the bloodstream, enabling constant communication between the gut and the central nervous system. (5) 

Chronic stress can disrupt the composition and diversity of the gut microbiota, leading to dysbiosis, a condition characterized by an imbalance in gut bacteria. Dysbiosis has been linked to various stress-related disorders, including anxiety, depression, and IBS. Stress-induced changes in the gut microbiota composition can affect the production of neurotransmitters, such as serotonin and GABA, which play crucial roles in regulating mood and stress responses. Additionally, stress can compromise the integrity of the intestinal barrier, allowing harmful substances to enter the bloodstream, triggering inflammation, and potentially exacerbating stress-related conditions. (37) 

Functional Medicine Labs to Evaluate the Stress Response

It can be difficult for patients under a great deal of stress to attribute their symptoms to psychological stress and to identify precisely what is causing them to feel stress. Therefore, the physician's role is to bring awareness to internal and external stressors and their implications on health. Functional medicine tests can be an important tool in this process by providing patients with solid data points that indicate health status. 

Hormones

A popular assessment of the impact of stress is based on salivary cortisol measurements. Normally, cortisol levels should peak upon waking in the morning and gradually decline throughout the day. Chronic stress can blunt the morning's cortisol awakening response (CAR) and disrupt the typical diurnal cortisol secretion pattern.

Depending on the patient's history and reported symptoms, other hormonal tests may be beneficial in understanding the full extent of the stress response's impact on endocrinological systems. A complete thyroid and sex hormone panel can assess thyroid, ovarian, and testicular function. Additionally, melatonin can be measured to evaluate for imbalances leading to poor sleep. 

Comprehensive Stool Test

A comprehensive stool test measures markers of digestion, absorption, inflammation, immune activation, intestinal permeability, and the intestinal microbiome to thoroughly assess gut health and function as it relates to the gut-brain axis. 

Micronutrients

Psychological and physical stress influences the concentrations of micronutrients by increasing their utilization and excretion, leading to an increased risk of deficiency if precautions are not taken to ensure optimal nutrient status. A micronutrient panel measures the levels of essential nutrients to screen for deficiencies and insufficiencies. 

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A Functional Medicine Approach to Stress Management

Stress management can be substantially improved by focusing on developing positive coping habits to use in place of unhealthy ones. Techniques to calm the mind and promote a parasympathetic state, a healthy diet and exercise routine, and natural supplements designed to support the adrenal glands are all ways to address stress healthfully. 

Nutritional Recommendations 

An unfortunate fact is that most Americans eat the Standard American diet (SAD), characterized by nutrient-devoid foods high in calories, sugar, unhealthy fats, and alcohol. The SAD lacks the high-quality and nutrient-dense foods the body requires to function and predisposes the body to dysglycemia, which is linked to increased perceived stress. Shifting dietary habits to follow whole-food and anti-inflammatory principles helps ensure that the body meets nutritional requirements to support the health of every body system. 

Supplements & Herbs

Micronutrients that are especially important for supporting adrenal function are B vitamins, vitamin C, magnesium, and zinc (32). As discussed above, these vitamins and minerals decrease substantially during stress (22). Supplementing these nutrients individually or with a complex (like a multivitamin) will help to prevent deficiencies.

Ashwagandha is an adaptogenic herb that supports adrenal function and mitigates stress symptoms by lowering elevated cortisol levels. Evidence-based positive clinical outcomes associated with ashwagandha supplementation include reduced anxiety, improved energy, prevention of stress-induced ulcers, and treatment of insomnia. (35) 

Certain mushrooms, like Reishi, Cordyceps, and Lion's Mane, are also adaptogens that promote resilience to stressors by balancing the HPA axis. Improvements in anxiety, depression, fatigue, and sleep have been reported with their use.

Complementary and Integrative Medicine

Mind-body therapies encompass a range of techniques that focus on the connection between mental and physical well-being. These approaches recognize the profound influence of thoughts, emotions, and behaviors on overall health. Mind-body therapies offer holistic strategies that alleviate stress symptoms, promote relaxation, enhance coping mechanisms, and improve overall quality of life. Examples of mind-body therapies include meditation, yoga, deep breathing, and biofeedback. (24)

Cognitive behavioral therapy (CBT) was developed in the 1960s and has since been extensively researched and is now considered a first-line therapeutic modality for treating psychiatric and mental health disorders. By identifying and challenging negative thought patterns and learning healthier coping strategies, CBT also helps individuals effectively manage stress-related conditions.

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Summary

In embracing a functional medicine approach to stress management, individuals are empowered to address the root causes of their stress rather than merely masking symptoms. By considering the intricate interplay of lifestyle, environment, and emotional well-being, functional medicine provides a comprehensive framework for understanding how stress impacts the body uniquely for each person. Through personalized interventions, such as targeted nutritional support, mind-body therapies, and lifestyle modifications, individuals can manage stress effectively and enhance their overall health and resilience.