it is commonly reported in 
 ( 1422% ) of population studies3 , however a 
 recent study found that 25% of employees report fatigue at work4 , 5 .
fatigue is characterized by progressive withdrawal of attention from the environment and 
 demands due to tiredness , dislike of the present activity , and unwillingness to continue , or 
 perform the task at hand6 , 7 .
also , physical resources and the depletion of emotional 
 resources are considered the basic parameters of feelings of being overextended and 
 emotionally exhausted8 .
it has been 
 reported that fatigued persons show decrements in vigilance when performing a particular 
 task via changes in vigilance , alertness , motivation , and subjective states that occur 
 during this transition9 .
previous studies have reported that both the sympathetic nervous system ( sns ) and the 
 hypothalamic - pituitary adrenocortical ( hpa ) axis are the most vital centers linking stressor 
 exposure to disease10 , 11 .
thus , significant increases in these hormones in line 
 with cortisol are associated with stressful situations , such as caregiving and work strain , 
 which may be diagnosed as adrenal fatigue12,13,14 . 

some studies have reported that the improvement of physical and psychological health is 
 related to physical activity which is considered an effective preventive measure and 
 treatment for stress - related diseases15,16,17 .
physically active people show higher resistance to physical stressors and nullifying 
 susceptibility to various influences of life stress18 , 19 , and physical activity has 
 protective effects on non physical stress , such as mental stress20 .
although the findings are not uniform21 , 
 psychological stress protocols show lower responses of the sympathetic nervous system and 
 the hypothalamic - pituitary - adrenal ( hpa ) axis towards physical activity .
a lower cortisol 
 increase was reported in physically active subjects19 , as well as lower cardiovascular reactivity19 , 22 , and more rapid 
 cardiovascular recovery20 to 
 psychological laboratory stressors than less active controls . also , it s more important to 
 notice the variability of stress reactivity which extends to cover all states of physical 
 activity including those who have less distinct differences in activity levels , such as a 
 lower response of heart rate to mental stressors and the faster recovery of elite sportsmen 
 than amateur sportsmen23 .
these 
 inconsistent results may be related to the differential influence of physical activity on 
 stress reactivity .
the relationship between physical activity and stress reactivity may be linked to the 
 personality traits of subjects which may be the most valued stress modulators .
depressed 
 persons are physically inactive in daily life and have lower physical work capacity than 
 healthy persons .
this indicates that a depressive state is associated with physiological 
 well being and may predispose an individual to diseases related to physical inactivity and 
 limited functional capacity24 , 25 .
the rates of mortality and morbidity for the conditions 
 of most diseases may be related to the negative outcome measures of occupation , income , and 
 education which are characterized collectively as socioeconomic status ( ses)26,27,28,29,30,31 . 

these measures are prevalent in countries with state - sponsored health care , suggesting that 
 access to care is not the underlying causal mechanism .
it was proposed that persons with lower ses are exposed to conditions with higher levels of 
 psychosocial disruption that increase the risk of disease through continuous provocation of 
 stress eliciting dysregulation of key behavioral and biological systems32 , 33 . in order to 
 develop or maintain goals towards adequate behavior and performance ,
it is necessary to 
 increase or minimize both personal competence and willingness34 , 35 .
this strategy was used 
 in this present study , even though the assessment of fatigue has no definite 
 methodology .
it was suggested that fatigue can be measured using objective and subjective outcome 
 measures which are significantly different .
objective fatigue measures deal with 
 physiological processes , or performance such as reaction time or number of errors36 , whereas subjective ways include diary 
 studies , interviews , and questionnaires37 , 38 . until about 10  years ago
, fatigue questionnaires for particular studies were mainly 
 developed on an ad hoc basis , and they were used in large scale studies because of their 
 shortness and self - report format .
recently , it was shown that fatigue questionnaires should 
 be developed for specific patient groups , such as patients with cancer39,40,41,42 , or ill persons 
 in general43,44,45,46 .
although there are many benefit outcome measures for both patient 
 and healthy populations , little is known about the suitability of these questionnaires for 
 healthy populations , and only a few questionnaires such as the fatigue scale ( fs ) have been 
 developed to measure fatigue outcomes among hospital and community populations47 , 48 . before the start of the 1990s
they have studied the effect of five components , general fatigue , physical fatigue , 
 reduction in activity , reduction in motivation , and mental ( cognitive ) fatigue on depression 
 and fatigue status48,49,50 .
also , other reviews have 
 documented that multidimensional fatigue scales are seen as more comprehensive and hence as 
 more adequate for providing a complete description of an individual s fatigue 
 experience39 , 40 .
accordingly , this study was designed to assess the effect of 
 physical activity status and environmental factors on the levels of cortisol and acth , as 
 markers of adrenal fatigue status , in a sample of saudi adult volunteers using a 
 questionnaire and biochemical analysis .
in the present cross - sectional study , the data were collected in 20122013 by supervised 
 experienced data collectors .
the research team collected detailed sociodemographic data of 
 the160 saudi adults aged 1522 years who participated in this study .
the present study received 
 prior approval from the ethics committee of the rehabilitation research chair ( rrc ) , king 
 saud university , riyadh , ksa . based on the physical activity of the participants ,
the sample size was calculated with an 
 estimated difference of 5% between the three groups of mild , moderate , and vigorous exercise 
 for estimating the correlation of cortisol and acth hormones with fatigue and physical 
 activity status .
so , in order to investigate cortisol and acth levels in the mild group a 
 sample size of 45 or more was needed for a power of 90% , for the moderate group , a sample 
 size of 37 or more was needed , and for the severe group , a sample size of 60 subjects was 
 required to have the same power .
after 
 centrifugation , serum samples of all tests were stored at 80  c until assayed .
both 
 cortisol and acth were measured in serum samples using immunoassay techniques following the 
 instructions of the ria - elisa kit ( dpc inc . ,
ca , usa ) , and the sia - elisa kit ( md biosciences 
 inc , mn , usa ) respectively . a self - administered questionnaire was used to assess living conditions , household income 
 level , employment and marital status , education level , gender , and age .
participants chose 
 the most suitable answer from categories of employment status ( office worker , independent 
 businessman , professional , public official , student , housewife , part - time worker , not 
 employed ) , marital status ( married , unmarried ) , living conditions ( number of people 
 cohabitating with , living alone ) , and education level ( university , two - year university , 
 vocational college , high school , junior high school , graduate school ) . the short - term international physical activity questionnaire ( ipaq )
was used to evaluate 
 the level of physical activity of the participants51 , 
 52 .
the average number of minutes per 
 day and days per week of physical activity were self - calculated by the participants with 
 reference to the past month .
the frequency and duration of walking for all purposes such as 
 work , transport , or recreation , moderate physical activity , vigorous physical activity , and 
 sedentary activity for a usual week were assessed via a self - administered questionnaire .
finally , the total numbers of minutes of walking , moderate , and vigorous physical activity 
 per week were computed according to the ipaq scoring manual53 , 54 .
the level of adrenal fatigue status was estimated using the adrenal fatigue test 
 questionnaire55 . the adrenal fatigue 
 test assesses adrenal fatigue using a score : a score of  40 suggests no adrenal stress ; 
 4487 suggests mild adrenal stress ; 88130 suggests moderate adrenal fatigue ; and 130 
 suggest significant adrenal fatigue problems .
a seven - day test - retest reliability was conducted ( test - retest ) , with an interval of 7 days 
 between the two assessments ( time 1 and 2 ) .
internal consistency was calculated using 
 cronbach s alpha (  ) for seven general adrenal fatigue test items ( predisposing factors , key 
 signs and symptoms , energy patterns , frequently observed events , food patterns , aggravating 
 factors , relieving factors ) .
the 7-day test - retest reliability was estimated using pearson s 
 r and spearman s rho statistics .
it has been proposed that test - retest reliability 
 coefficients of 0.80 or higher for these statistics are indicative of acceptable test - retest 
 reliability56 .
the severity index was calculated by simply dividing the total number of points by the 
 total number of questions answered by each participant in the affirmative .
it gives an 
 indication of how severely the signs and symptoms are experienced , with 1.0 being normal , 
 1.11.6 being mild , 1.72.3 being moderate , and  2.4 being severe55 .
all statistical analyses were performed using the spss statistical package v. 12.0 for 
 windows ( spss software , inc . , chicago , il , usa ) .
repeated measures anova followed by the 
 bonferroni correction for multiple comparisons was applied for normally distributed 
 parameters , and the wilcoxon test , for nonparametric parameters .
exploratory factor analysis of the items of adrenal fatigue and severity scores were 
 conducted to investigate what common components of the scale more effectively respond to 
 physical exercise treatment .
data are presented as mean  sd . the null hypothesis was 
 rejected at values of p < 0.05 , the level of significance .
table 1table 1.demographic characteristics of the study sample ( n = 160)variablesn , ( m  sd)%sample size 160100gendermale12075female4025age ( yrs)20.22  2.89-height ( cm)167.95  13.0-weight ( kg)67.32  12.25-bmi ( kg / m)23.43  3.76-marital statusunmarried10062.5married6037.5living conditionliving with others11571.9living alone4528.1educational level4-years university or greater65412-years university5031high school or junior high4528employment statusemployed8553not employed7547walking , min / week 91 ( 260.1  462.3)-moderate - intensity activity , min / week59 ( 120.6  390.7)-vigorous - intensity activity , min / week10 ( 75.4  260.6)- shows the characteristics of the participants . the mean age ( standard 
 deviation ; sd ) of the participants was 20.22 ( 2.89 ) years .
the percentage of those who were married was 
 37.5% , that of those living with another person was 71.9% , and that of those who were 
 employed was 53.0% .
the mean number of minutes of walking per week ( sd ) was 260.1 ( 462.3 ) , 
 for moderate intensity activity excluding walking it was 120.6 ( 390.7 ) , and for 
 vigorous - intensity activity it was 75.4 ( 260.6 ) .
table 2table 2.test re - test reliability for adrenal fatigue -q measures for participants with an 
 interval of 7 days between the two assessments ( times 1 and 2)adrenal fatigue -q measuresitemfull sample ( n=160)time 1time 2pearson rspearman s rhocronbach s alphapearson rspearman s rhocronbach s alphapredisposing factors130.810.820.80 ( 0.640.87)0.890.810.85 ( 0.600.87)key signs & symptoms310.90.800.81 ( 0.630.96)0.880.930.88 ( 0.660 .90)energy patterns 130.860.910.87 ( 0.660.97)0.920.850.95 ( 0.650.95)frequently observed events220.890.850.82 ( 0.660.86)0.910.890.88 ( 0.680.97)food patterns90.870.920.86 ( 0.550.95)0.850.800.91 ( 0.820.92)aggravating factors100.960.890.91 ( 0.660.97)0.980.960.96 ( 0.860.98)relieving factors50.810.820.81 ( 0.640.87)0.890.810.89 ( 0.600.97)overall1030.900.800.85 ( 0.630.96)0.960.930.96 ( 0.660.98 ) shows cronbach s  internal consistency for all adrenal fatigue measures .
overall , internal consistency was 
 lower at time 1 than at time 2 which remained acceptable at both time points for all 
 participants .
internal consistency was consistently higher (  = 0.96 for time 2 vs  = 0.85 
 for time 1 ) .
also , reliability was excellent for all adrenal fatigue measures ( pearson r = 90 ; 
 spearman s rho = 0.80 at time 1 and pearson r = 96 ; spearman s rho = 0.93 at time 2 ) .
the 
 results show the questionnaire had good reliability with better results for the 
 investigation of adrenal fatigue stress among the studied participants .
table 3table 3.changes in the level of adrenal hormones , social , and environmental factors 
 according to the adrenal fatigue scores of the participants ( n = 160)variablesadrenal fatigue scorenormal (  40)mild ( 44 - 87)moderate ( 88 - 130)severe (  130)adrenal hormonescortisol ( g / ml)6.2  0.75**10.5 1.9**16.9  3.6**28.5  3.9**acth ( pg / ml)16.9  11.727.9  7.336.3
 14.242.7  9.5marital status : unmarried19.6  6.3**45.9  12.1**92.9  18.3**142.3  10.4**married10.2  2.758.2  7.498.8  5.7152.2  6.8educational level:4-years university or greater9.1  3.4 * 51.3  1.2 * 100.1  3.1 * 165.3  2.4 * 2-years university 12.1 
2.954.5  4.896.7  7.2175.3  7.2high school or junior high15.3 4348.6 59122.8  9.2181.8  11.6employment status : employed6.1  3.6**49.3  2.3**102.3  2.3**170.3  4.5**not employed9.7 
1.351.7  3.695.4  3.6190.3  5.7living condition : living with others5.8  2.7 * 49.3  1.5 * 110.5  3.7 * 165.8  5.6*living alone13.9  5.158.7  6.4108.3  4.3175.5  7.4except where indicated otherwise , values are expressed as the mean . * * p < 0.001 
 significant for unmarried versus married status and employed versus not - employed ; * p 
 < 0.05 significant for university degree versus 2  year university degree or high 
 school degree and living with others versus living alone for all adrenal fatigue 
 scores .
environmental factors and social influences were seen to directly affect the score 
 of adrenal fatigue status in all states , normal , mild , moderate , and severe , of adrenal 
 fatigue .
participants who were unmarried ( p=0.001 ) , had low educational levels ( p=0.05 ) , 
 were not employed ( p=0.001 ) , or were living alone ( p=0.05 ) had significantly higher adrenal 
 fatigue scores .
these parameters of environmental and social factors had the greatest effect 
 on the status of adrenal fatigue .
levels of adrenal hormones such as cortisol and acth were 
 also investigated in this study .
there were significant increases in the levels of cortisol 
 ( p=0.001 ) and acth ( p=0.001 ) , markers of adrenal fatigue , in participants with moderate to 
 severe adrenal fatigue scores compared to those with normal and mild scores ( table 3 ) .
the changes in adrenal hormones 
 significantly correlated with the severity of adrenal fatigue . except where indicated otherwise
, values are expressed as the mean . * * p < 0.001 
 significant for unmarried versus married status and employed versus not - employed ; * p 
 < 0.05 significant for university degree versus 2  year university degree or high 
 school degree and living with others versus living alone for all adrenal fatigue 
 scores . based on physical activity , the participants were classified into three groups : mild 
 ( n=50 ) , moderate ( n=40 ) , and vigorous ( n=70 ) .
table 4table 4.interaction effect between frequency of adrenal fatigue and physical activity of 
 the participants ( n = 160)adrenal fatigue score(m
 sd)physical activity ( ipaq score ) ( n=160 ) 
 mild ( n= 50)moderate ( n= 40)vigorous ( n= 70)normal(score ,  40 ) ; n ( % ) 38.761  3.6 ; 3(6 ) 22.161  1.9 ; 30 ( 75)*12.8  4.8 ; 41(6)**mild(score , 4487 ) ; n ( % ) 55.7  5.9 ; 5(10)48.7  2.6 ; 5(11)*44.9  3.8 ; 11(16)**moderate(score , 88130 ) ; n ( % ) 98.75  4.6 ; 13 ( 26)91.4  3.7 ; 3 ( 8)*88.9  3.8 ; 9(13)**severe(score , 130 ) ; n ( % ) 148  8.2 ; 29 ( 58)135.7  2.9 ; 2(5)*131.5  1.5 ; 9(13)**except where indicated otherwise , values are expressed as the mean sd .
improvement 
 in adrenal fatigue status noticed in participants with moderate ( * p < 0.01 ) and 
 vigorous activities ( * * p < 0.001 ) compared to the mild group shows the influence of mild , moderate , and vigorous physical activities on 
 adrenal fatigue severity .
participants reporting moderate and vigorous exercise intensities showed 
 significant ( p = 0.01 and p = 0.001 ) decreases in adrenal fatigue severity compared to those 
 reporting mild activities .
however , there was significant increase in the ratio ( 75% ) of 
 subjects with a normal fatigue score in the moderate intensity exercise group compared to 
 the vigorous intensity exercise group .
the findings of this study suggest that physical 
 activity especially that of moderate intensity may be effective for improving depressive 
 adrenal fatigue .
the participants in the moderate and vigorous exercise groups showed 
 significant decreases ( p=0.01 and p=0.001 ) in the severity index score of adrenal fatigue 
 compared to those of mild exercise group ( table 
 5table 5.interaction effect between adrenal fatigue severity index and physical activity 
 status of the participants ( n = 160)fatigue severity indexscore(m  sd)physical activity ( ipaq score ) ( n=160 ) 
 mild ( n= 50)moderate ( n= 40)vigorous ( n= 70)normal ( score ,  1.0 ) ; n ( % ) 1.0  0.6 ; 6 ( 12 ) 0.86  0.6 ; 25 ( 62.5)*0.65 0.5 ; 46(66)**mild(score , 1.1 - 1.6 ) ; n ( % ) 1.5  0.75 ; 6(12)1.4  0.6 ; 6(15)*1.32  0.8 ; 12(17)**moderate(score , 1.7 - 2.3 ) ;
n ( % ) 2.28 0.92 ; 8 ( 16)2.2  0.75 ; 5 ( 12.5)*1.9  0.71 ; 9(13)**severe ( score , 2.4 ) ; n ( % ) 5.7 3.2 ; 30(60)3.9  2.9 ; 4(10)*131.5  1.5 ; 3 ( 4)**except where indicated otherwise , values are expressed as the mean sd .
significant 
 decrease in adrenal fatigue severity noticed in participants with moderate ( * p < 
 0.01 ) and vigorous activities ( * * p < 0.001 ) compared to the mild group ) . except where indicated otherwise , values are expressed as the mean sd .
improvement 
 in adrenal fatigue status noticed in participants with moderate ( * p < 0.01 ) and 
 vigorous activities ( * * p < 0.001 ) compared to the mild group except where indicated otherwise , values are expressed as the mean sd .
significant 
 decrease in adrenal fatigue severity noticed in participants with moderate ( * p < 
 0.01 ) and vigorous activities ( * * p < 0.001 ) compared to the mild group also , based on biochemical analysis , there were significant correlations between the levels 
 of adrenal hormones and physical activity .
significant decreases in the levels of cortisol 
 ( p=0.001 ) and acth ( p=0.001 ) were found in the participants with moderate to high physical 
 activity compared to those with mild or sedentary activity .
the decrement in adrenal 
 hormonal levels positively correlated ( p=0.01 , r= 0.976 ) with improvements in the adrenal 
 fatigue status and severity index , especially in the physically active participants ( table 6table 6.correlation between the level of cortisol and atch adrenal hormones and physical 
 activity status of the participants ( n = 160).adrenal hormones(m  sd)physical activity ( ipaq score ) ( n=160 ) 
 mild ( n= 50)moderate ( n= 40)vigorous ( n=70)cortisol ( g / ml)28.6  4.8 12.7  3.2 * 17.3  2.8 * * acth ( pg / ml)34.8  6.8 15.9  6.4 * 22.7  3.8 * * except where indicated otherwise , values are expressed as the mean sd .
a significant 
 decrease was found in the levels of cortisol and atch as markers of adrenal fatigue 
 status in participants with moderate ( * p < 0.01 ) and vigorous activities ( * * p < 
 0.001 ) compared to the mild group .
the decrement positively correlated with the 
 improvement in adrenal fatigue status and severity index in physically active 
 participants ( p=0.01 ; r= 0.976 ) ) . except where indicated otherwise , values are expressed as the mean sd . a significant 
 decrease was found in the levels of cortisol and atch as markers of adrenal fatigue 
 status in participants with moderate ( * p < 0.01 ) and vigorous activities ( * * p < 
 0.001 ) compared to the mild group .
the decrement positively correlated with the 
 improvement in adrenal fatigue status and severity index in physically active 
 participants ( p=0.01 ; r= 0.976 )
in recent years , depression has become increasingly more prevalent among adolescent females 
 on a worldwide scale57 , 58 , and it is considered to be a disease which has a greater 
 worldwide burden than ischaemic heart disease , cerebrovascular disease or tuberculosis59 . in this study , the potential influences of environmental and social factors as well as 
 different levels of physical activity on adrenal fatigue stress and reactivity were 
 investigated .
this study evaluated the reliability of the adrenal fatigue questionnaire used to 
 investigate the importance of fatigue stress in physical activity using the test - retest 
 reliability method .
the results show the questionnaire had good reliability with better 
 results for the investigation of fatigue stress among the studied participants .
the present study investigated the environmental and social factors that affect adrenal 
 fatigue stress in males and females aged from 15 to 22  years .
environmental and social 
 factors were the most influential factors that directly affected adrenal fatigue , and 
 moderate to severe adrenal fatigue stress was significantly associated with unmarried 
 status , low level education , not in employment , and living alone .
this was consistent with a 
 study that reported depression , anxiety , and stress are three common mental health problems 
 worldwide60 , and other studies that 
 investigated the psychometric properties of these questionnaires61 , 62 .
it has also 
 been reported that subclinical depression in adolescence is related to depressive episodes , 
 substance abuse , higher levels of neuroticism , academic underachievement , unemployment , and 
 early parenthood63 .
the ecological 
 perspective suggests that physical activity is influenced by an interaction of demographic , 
 psychological , social , and environmental factors64 . in the present study ,
the relation between physical activity and 
 the status of adrenal fatigue was investigated , and the results show that , pattern of stress 
 responses was related to the level of physical activity .
a significant improvement in the 
 stress fatigue status was also shown by participants with moderate physical activity 
 compared to mild and vigorous physical intensity .
our findings indicate that higher levels 
 of physical activity are associated with lower stress reactivity suggesting that higher 
 levels of physical activity might be protective against the development of stress related 
 diseases .
these results are supported by our measurements of cortisol and acth as markers of 
 adrenal fatigue status .
there was significant change in serum adrenal hormones among 
 participants with physical inactivity and higher fatigue scores .
there were significant 
 increases in serum cortisol and acth levels among participants with lower physical activity 
 and higher adrenal fatigue scores .
however , in participants with moderate to high physical 
 activity , the decrease in the level of cortisol and acth positively correlated with 
 improvement in the severity index and adrenal fatigue score .
the results are in agreement with 
 previous studies which focused on the effect of physical activity on depression via the 
 control of adrenal hormones secretion65,66,67,68 .
another study proposed physical exercise 
 interventions to protect against changes in the adrenal system with ageing69 . increased susceptibility to immunosuppression and infection has been linked with extreme 
 levels of exercise70 .
thus , it may be that physical activity of an intermediate level is the most effective level 
 for stress protection .
furthermore , in general , depressive persons are physically sedentary 
 in their daily life and have lower physical work capacity than healthy individuals71 .
similarly , in the present study , the 
 severity index of fatigue status showed that physical activity plays a pivotal role in 
 reducing the severity of adrenal fatigue status .
psychosocial stress increases the risk of 
 developing cardiovascular and mental diseases , such as hypertension or depression72 , 73 .
physical activity is commonly regarded as beneficial for both 
 physical and psychological health , and is seen as an effective preventive measure and 
 treatment for stress - related diseases74 . 

physically active people show reduced reactivity to physical stressors as well as reduced 
 susceptibility to the adverse influences of life stress19 .
recently , it was reported that the environment has long - term 
 effects on population - based health behavior , and there was a direct relationship between 
 environmental characteristics and physical activity as previously reported in the 
 literature74 , 75 . interestingly
, there are distinct variations in stress reactivity 
 not only between extreme groups of physically active and inactive controls , but also between 
 groups with less distinct differences in activity levels19 .
finally , the findings of the present study imply that intervention 
 strategies to promote more engagement in physical activity for population based health 
 promotion may be necessary . in conclusion , our data suggest that the level of physical activity and environmental and 
 social factors differentially influence the adrenal fatigue status via changes in adrenal 
 hormone levels .
interestingly , the reactivity of adrenal fatigue status was revealed to be 
 sensitive to higher levels of physical activity , unfavorable environmental and social 
 factors .
future studies should evaluate whether the level of physical activity might induce 
 an optimal stress protective effect against stress - related diseases .
 [ purpose ] this research work was performed to examine whether different levels of 
 physical activity and environmental and social factors are associated with changes in 
 adrenal hormones as markers of adrenal fatigue in saudi adult volunteers . 
 [ subjects and 
 methods ] a total of 160 saudi adults aged 1522 years were included in this study . the 
 adrenal fatigue score , sociodemographic attributes , and the level of physical activity 
 were evaluated via pre - validated internet - based questionnaire surveys . 
 adrenal hormones 
 such as acth and cortisol were measured using immunoassay techniques . 
 [ results ] 
 significant increases in the levels of acth and cortisol biomarkers were found in the 
 participants with moderate to severe fatigue scores , poor environmental factors , and low 
 physical activity . 
 however , in physically active participants , significant decreases in 
 acth and cortisol levels were found with remarkable improvement in adrenal fatigue status . 
 
 the decrement in adrenal hormonal levels positively correlated ( r= 0.976 ) with the 
 improvement in adrenal fatigue status in the physically active participants . 
 [ conclusion ] 
 our results suggest that the level of physical activity and environmental and social 
 factors differentially influence the adrenal fatigue status via changes in the levels of 
 adrenal hormones 
 . also , acth and cortisol biomarkers may be useful as markers measuring 
 the severity of adrenal fatigue . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION