Paul A Goldberg MPH, DC, DACBN, DCBCN
"Life is one process of getting tired" Samuel Butler, 1912
We all know what it is to feel fatigued occasionally. It is a normal signal broadcast by the body to obtain sleep. For those in good health, a solid night's sleep will recharge their batteries and return them to feeling top notch. They awake with a gleeful anticipation of the challenges of the day ahead and are driven with an inner strength that seems to say, "bring on the day!"
The above scenario, however, is not true for everyone. For many, waking in the morning brings on a sense of inadequacy and dread as they face challenges they have no strength to face. These growing numbers of people are in a persistent state of unrelenting fatigue. They find themselves altering between being tired, very tired and plain old exhausted. Dragging himself or herself into the physician's office these are the individuals who are being labeled with the medical diagnosis of "Chronic Fatigue Syndrome" (C.F.S.).
Prior to "Chronic Fatigue Syndrome"
At least as far back as the eighteenth century, there are numerous references to the cause of fatigue and its role in disease. George Miller Beard, an American Neurologist, popularized the idea that nervous energy can become exhausted and in a 1869 article coined the term "neurasthenia". Beard hypothesized that the problem was due to increasing technology, which was taking its toll on the individual's homeostasis. The notion of lost nerve energy playing a vital role in disease was taken up with enthusiasm by an American founder of neurology, S. Weir Mitchell, who became an advocate of his "rest cure" required to restore the energy of the nervous system in these patients. Numerous explanations have arisen for chronic fatigue since then.
"Chronic Fatigue Syndrome" as a Diagnosis
The popularity of the term "Chronic Fatigue Syndrome" began in the late 1980's. Modern Medicine has chosen to encapsulate chronic fatigue as a disease entity that is baffling and difficult to define. CFS as a medical diagnosis has grown in popularity as physicians encounter growing legions of patients complaining of fatigue, depression, difficulties in concentration, irritability, muscle and joint pains and a host of other complaints not traceable to a specific diagnosis. Patient's symptoms are often severe to the point of disability and these weary individuals may be found doctor shopping trying desperately to arrive at both a diagnosis and a treatment plan.
Many people with chronic fatigue go through a myriad of tests running from one specialist to another only to be labeled with CFS through a process of elimination. Chronic fatigue is one of the most common complaints that physicians hear from patients. When better defined diagnoses have been eliminated, CFS has become a convenient default diagnosis or "diagnosis of exclusion", a way for the doctor to say, "I don't know what is wrong with you."
Definition of CFS
Much debate has surrounded the issue of how to define CFS. Attempts at a definition have been made and are along the lines of excluding conditions more so than stating what it is and what its causes are. According to guidelines set in 1994 in conjunction with the Centers for Disease Control, in order to receive a diagnosis of chronic fatigue syndrome, a patient must satisfy two criteria:
1. Have severe chronic fatigue of six months or longer duration with other known medical conditions excluded by clinical diagnosis.
2. Concurrently have four or more of the following symptoms: substantial impairment in short-term memory or concentration; sore throat; tender lymph nodes; muscle pain; multi-joint pain without swelling or redness; headaches of a new type, pattern or severity; unrefreshing sleep; and post-exertion malaise lasting more than 24 hours.
It is clear that even when a patient fits this diagnosis that it serves little benefit. They are left clueless (as was the physician giving the diagnosis) as to what is wrong with them. Labeling a patient's symptoms does not explain why they are ill or how to return them to good health. The diagnosis of "Chronic Fatigue Syndrome" (CFS) has nonetheless grown in popularity as increasing numbers of patients complain of fatigue, depression, difficulties in concentration, irritability, muscle and joint pains and a host of other complaints.
Numerous patients come to our office diagnosed with Chronic Fatigue Syndrome or simply suffering with chronic fatigue and not knowing how to return to health even after seeing multiple doctors and trying numerous remedies. They are understandably frustrated at not knowing what is wrong. Most have long stories of how they have been unsuccessfully "treated".
Importantly, the patients we see with "chronic fatigue" are each very different despite many of them being diagnosed with "chronic fatigue syndrome."
I refer to "Chronic Fatigue Syndrome" as a" Garbage Can Diagnosis" as it constitutes part of a medical junk pile that hundreds of thousands of patients are placed into each year. Other garbage can type diagnoses that have become popularized include "fibromyalgia" and "irritable bowel syndrome".
Patients labeled with CFS are typically treated by physicians (after a slew of negative medical diagnostic tests) with anti-depressants, stimulants, and prescriptions for psychological treatments or simply with the advice that "you will have to learn to live with it".
What purpose does it serve the physician to attach the name "Chronic Fatigue Syndrome" to the patient's symptoms? The title does not help the patient recover nor does it lead the patient to a constructive course of action to follow. Thediagnosis serves the physician in two ways:
1. It gives the patient a name to identify their symptoms with therefore doctor has "done their job" since a diagnosis has been given.
2. The doctor can assign an insurance code to the patient's bill and prescribe a nonspecific drug for the patient's symptoms. The patient continues down the road of illness but the "problem" has been "diagnosed' and a "treatment" has been given.
Chronic Fatigue Syndrome is a confusing title used by physicians unable to determine why a patient is chronically ill and perplexed as to what to do about it.
Based on experience with numerous patients labeled with "Chronic Fatigue Syndrome", along with patients I have worked with over the past thirty-five years who came to our office complaining of chronic fatigue prior to receiving a medical diagnosis, there is an over-riding denominator and that is poor health.
As long as the causes of good health are not addressed, patients remain fatigued and ill. Unfortunately, very few physicians take the time and make the effort to identify what the real responsible factors are in each patient.
Patients labeled with "CFS" are not simply tired. They feel poorly all over. Patients are often hesitant initially to say how poorly they feel. In many cases they will simply state their most bothersome symptom, e.g. headaches, poor digestion, low back pain, arthritic pains, etc. With all the specialization in the medical field this is how patients have been trained to respond, i.e. to focus on symptoms in one area of the body. Further probing, however, usually reveals an individual who has not felt well in many years. For some patients the decline in their health have been so gradual that they do not recognize how much their health has deteriorated until a real health program is initiated and full vitality restored. It is astounding how many patients (including many physicians who have consulted with me regarding their own health problems) have learned to accept feeling run down as a way of life until they are simply unable to function any longer.
The patient who on our clinic's questionnaire states that their health is "excellent", often later reveals they have constipation and/or diarrhea, frequent gas, have trouble getting out of bed in the morning, rely on coffee, cigarettes, soft drinks or other stimulants, have skin problems, bad breath, joint stiffness, etc., but that "overall "their health is good'!" After all," the patient continues," doesn't everyone have these kinds of problems?" Sadly, the answer is yes, more and more individuals in our society are experiencing physical degeneration and feeling chronically lousy earlier and earlier in their lives. Chronic fatigue has become part of the norm for many, accompanied by muscle pains and aches, headaches, indigestion, irritability, skin outbreaks, reliance on coffee and other stimulants, sleep disturbances, etc. Gradually and insidiously these problems have been swept into the realm of normalcy. I have witnessed this even in young people in their twenties already experiencing early signs of physical decay. Sadly, many accept their digestive problems, reliance on stimulants, inability to concentrate, chronic fatigue, depression, etc., as being "normal."
Two essential steps should be taken to help insure that the patient's journey to good health (including getting rid of their chronic fatigue) is successful:
I. Address the overall health of the patient by taking appropriate steps to support it, including addressing rest and sleep patterns, sun exposure, adequate activity, adequate pure water, fresh air, appropriate diet, mental poise, absence of toxic habits, etc. These factors are basic to what make us up as human beings yet are generally overlooked or given mere lip service to in most doctors' offices. Because these are basic to health, any other measures that are instituted without addressing these first will certainly fail. Unfortunately, most physicians do not have the inclination, training or experience to go over these most important aspects of health with their patients.
II. Address specific weaknesses in the person's biochemical makeupwhereas each of us is unique in an infinite number of ways. There are a myriad of differences among us in terms of our makeup. Added to this genetic variability are the many environmental variables that interact with our genetic makeup. Knowing what makes each person unique allows an effective, individual approach to be taken. A practitioner with an in-depth knowledge of clinical nutrition, clinical epidemiology and the appropriate use of functional laboratory testing should be utilized to perform this assessment. Factors the practitioner should consider as contributing to the patient's chronic fatigue include the following:
1. Food Allergies
2. Amino Acid Imbalances
3. Mineral depletion, anemia and other nutritional imbalances
5. Hypoglycemia/diabetes/blood sugar dysregulation
6. Toxic Conditions - an accumulation of metabolic by products can result in a significant impairment of the body's ability to produce energy.
7. Impaired Liver function - the liver has numerous functions including blood sugar control and detoxification.
8. Hypoadrenalism - The adrenal glands produce adrenalin and cortisol both of which influence energy production.
10. Autoimmune diseases
11. Depression of psychological origin - depression and fatigue commonly occur together
12. Prescription Drug Medications - fatigue is a common side effect of many drugs
13. Environmental/Occupational Illness - environmental sensitivities/allergies commonly involve a loss of vitality.
14. Chronic Digestive Disturbances/Intestinal Dysbiosis - when digestion and/or intestinal function is altered so is the production of energy.
Fatigue is the most common denominator of all health problems. When the body is unable to produce sufficient energy, for whatever reason, fatigue results. Fatigue represents the body crying out for help...it signals us to make the effort to identify what we are doing that is draining our body's vitality faster than it is being replaced and to correct the problem before damage occurs. The reasons for fatigue are numerous but to a conscientious doctor the answers are generally forthcoming and rarely if ever should include the use of drugs.
The following case studies exemplify some of the patients I have worked with, whom had been given the diagnosis of "Chronic Fatigue Syndrome" by their medical physicians, and how they worked their way back to health.
Case Study Number One
A forty two year old female presented at our office with the medical diagnoses of chronic fatigue syndrome and irritable bowel syndrome. She had an assortment of other complaints including depression and muscle pains. Her medical physicians had prescribed anti-depressants, stool softeners, muscle relaxants and sedatives.
The patient had been in poor health for over a decade. Her fatigue had been increasing and she no longer had any days when she felt energetic. She described her energy levels as varying between "bad and terrible". The fatigue along with the irritable bowel symptoms was interfering with her work as an accountant and she found herself on the brink of divorcing her husband of 16 years of marriage admitting that much of the problem was the short temper she had developed along with her poor health. Her history included drinking three to six cups of coffee per day accompanied by many sweets and pastries which she nibbled throughout the day. She had little appetite other than for sweets. She stayed up till after midnight most evenings and used several cups of coffee in the morning to stimulate herself. Her bowels fluctuated between constipation and diarrhea. There was an extensive history of sore throats and sinus infections for which she had been given numerous courses of antibiotics averaging three to four courses of antibiotics per year. The patient rarely got any fresh air or sunlight and had few social contacts.
The patient was thin, pale and appeared depressed and anxious.
Vital signs were within normal limits. The patient was sensitive to touch over her shoulders, back and arms.
Standard laboratory studies were within normal limits including a complete blood count, blood chemistry and lipid profile. Functional digestive tests were performed including a thorough evaluation of the patient's diet, a Candida titer, stool microbiology and an adrenal stress index to measure the patient's cortisol levels. The dietary was nutrient poor with inadequate amounts of trace minerals, quality proteins, essential fatty acids and fiber. The gut flora were severely disturbed and the titer for Candida was significantly elevated. The cortisol levels measured low throughout the day.
A comprehensive program was outlined for the patient. I explained that her symptoms including the chronic fatigue, muscle pains and bowel problems were largely the result of long time poor health habits combined with ongoing stress. These habits had resulted in impaired digestion, imbalances of her gut flora, and a weakening of her endocrine system. I cautioned her that without changes she was likely to continue to worsen with time and in light of the parental history particularly I urged her to make every effort to get things turned around.
The patient was instructed on the need to eliminate her toxic habits including coffee and junk foods. An early bedtime schedule was given. Her dietary reform began with a two d liquid diet of purified water and vegetable broth only. This was followed by the gradual introduction of a high quality dietary of fresh vegetables, good quality proteins limited quantities of non-glutinous grains, essential fatty acids and other dietary essentials. Specific mineral supplements were employed as a temporary measure to assist her recovery. A schedule of outdoor activity and sunbaths was discussed as were daily walks, which were increased in distance as her, health improved. I encouraged her to try to heal her relationship with her husband as well as go places where she could develop new friendships. We discussed the advisability of her getting a dog as a companion since she liked dogs.
The patient responded positively and rapidly to the program given to her after an initial worsening of her symptoms for the first few days as she got off of the coffee and sweets. She reported feeling more relaxed and found it easier to sleep. In less than three weeks the fatigue began to dissipate accompanied by an improvement in her intestinal functioning and a significant lessening of the muscle pains in her shoulders and arms. She lost her taste for sweets and was soon enjoying natural, healthy foods.
Her relationship with her husband also began to smooth out and she felt more like socializing with others.
The specific causes of this patients fatigue were identified and addressed by employing an individualized program of care based on her history and laboratory testing. Her "chronic fatigue syndrome" became a thing of the past by implementing those steps needed to build health.
Case Study Number Two
A thirty four year old female was referred to our office. The patient's chief complaints were severe chronic fatigue of two years duration, generalized muscular pain, low back pain, depression, poor memory, obesity, irregular periods, constipation and acne. She had been to two medical internists and one psychiatrist, who had diagnosed her with "chronic fatigue syndrome, chronic depression, and fibromyalgia" and placed her on a number of prescription drugs for her symptoms.
Her medical work up had included blood chemistries, CBC, thyroid profile, radiographic studies, sedimentation rate, Epstein Barr Virus study and a screen for hepatitis (all negative). Prescriptions of muscle relaxants, naprosyn, and Prozac had been given. Following over eighteen months of drug prescriptions and medical care the patient had consulted with a Doctor of Chiropractic who worked with the patient for an additional six months without significant improvement.
The patient was discouraged with her ongoing chronic fatigue and other symptoms and expressed little hope for the future. She was puzzled and dismayed by the fact that she was significantly overweight and that exercising had not proven helpful.
1. 2. 3. 4.
Family history of asthma and hay fever Consumed conventional foods. Use of the birth control pill for six years Dissatisfaction with her employment as a hospital dietitian.
1. Drank a large amount of fruit juices daily along with eating copious amounts of pasta. 2. Obtained six to seven hours sleep per night. 3. "Worked out" at a health spa six days per week one to two hours each day. 4. Drank three cups of coffee daily.
5. Received little sunshine and fresh air. 6. Bathroom habits irregular.
The patient was significantly overweight for her height and had low blood pressure. Despite heavy exercise, the muscles were small and flaccid. Skin tone was poor. The tip of the tongue was sore. Spinal palpation revealed multiple reoccurring misalignments and muscle spasms. The patient's hair and eyes were dull. Significant gastric rumblings were heard upon auscultation.
In reviewing the laboratory reports the patient brought, I noted a fasting blood glucose of 98. While this falls into the "normal medical reference range" it was too high for a healthy fasting blood sugar level. Her cholesterol levels were low at
100. I requested a glucose tolerance test (six hours), food allergy testing, amino acid analysis and stool microbiology along with a careful analysis of the patient's dietary.
The glucose tolerance test level dropped to under 35 mgs. of glucose per 100 cc. of blood on the fourth hour, a typical hyperinsulin reaction. A careful review of the patient's diet revealed a large intake of refined carbohydrates accompanied by minimal intakes of B complex vitamins and trace minerals. Plasma amino acid analysis showed the patient to be low in seven of the ten essential amino acids including phenylalanine and tyrosine, important precursors to hormones and neurotransmitters. The stool microbiology showed an almost complete absence of normal bowel flora. The food allergy testing showed a severe immune response to wheat, which was ingested on regularly by the patient.
Course of Action
Following a lengthy discussion with the patient regarding the reasons I felt she was ill, the patient was initially placed on a limited vegetable and protein dietary thereby eliminating the foods which she had tested allergic to and lessening the burden on her digestive and endocrine systems. She was instructed to eat small amounts of food three times per day and to get in bed by 10:00 P.M. each night. Coffee was eliminated. During the first few days the patient experienced headaches, which she worked through without taking drugs. She was instructed to reduce her exercise at the spa to every other day for a maximum of 30 minutes each time and reluctantly she followed these instructions. I also insisted that she spend time out doors to obtain sunlight and fresh air, which she was badly lacking in.
On a temporary basis, she was given extra amounts of the specific amino acids that she had tested low on. Attention was given to chewing well, eating slowly, and establishing regular bathroom habits.
The first few days were rough as the patient got off the allergic foods, coffee and sweets but she was encouraged by positive signs. There was marked improvement in her digestion and elimination followed by significant improvements in her energy level. In the first thirty days she lost ten pounds even though she had greatly reduced the amount she exercised. Her weight loss continued over the next five months resulting in losing over 25 pounds. This was due to her metabolism working much more efficiently. She discontinued her drug medications. The sore tongue abated as her body's deficiencies were corrected by improved diet and digestion and her hair and eyes took on a new glow. Her muscle strength improved, as did her skin tone. The muscle stiffness and low back aching began to dissipate during the first three weeks. The patient learned to enjoy being out of doors and began spending less time inside and more time in the out doors enjoying hiking and gardening.
Improved digestion and assimilation are critical for improved energy, healthy skin, and good mental functioning. With her digestion improved, food could be efficiently transformed into human tissue. Elimination of allergens allowed for inflammatory reactions in the muscles and joints to abate. Bolstering low amino acid levels, and implementing proper eating habits along with a varied diet of whole foods were also critical to recovery and supplied greater amounts of minerals and vitamins to serve as catalysts for energy production. The hours of sleep prior to midnight are important and getting to bed earlier allows healing an opportunity to occur. The weight loss was achieved not by placing the patient on any weight loss program, which we feel is always a mistaken approach, but by improving the patient's health. This we believe is always the most effective way to normalize a patient's weight whether they are over or under weight. The patient took on a way of life that was in line with her biological needs.
Case Study Number Three
A fifty three year old male suffered for over six years with multiple complaints of chronic fatigue, depression, and indigestion. He was most concerned with the chronic fatigue which was severe and made life very difficult for him. His job was in jeopardy due to poor work performance. He consulted an internist, who after running standard laboratory tests (which were negative) diagnosed him with Chronic Fatigue Syndrome and prescribed Prozac. The drug made the fatigue worse. Within a couple months the patient's anxiety returned despite the Prozac. He read an article about allergies being potentially related to chronic fatigue and went to a Medical Allergist where he was skin patch tested. The allergist reported he was allergic to dust, and suggested the patient put plastic sheet covers over his mattress and pillows. This did not alter the patient's condition. The patient was also concerned about his indigestion, which included passing considerable gas throughout the day making for an embarrassing situation at his office. The patient commented that he was very tired of being fatigued and frustrated at trying to find solutions. He liked to be active and participate in outdoor activities but his
fatigue made this difficult to do. He obtained sufficient rest and sleep, had good family relationships and tried to watch his diet carefully. He expressed craving corn in any form and things with tomatoes in them.
The patient's vital signs were normal. He did his best to be pleasant but it was clear that he was tired and depressed. He was bloated and percussion of his abdominal region indicated large amounts of gas being present in his intestines.
A blood chemistry, blood count and functional lab testing were performed. The patient's blood chemistry and blood count were within normal limits. The patient had a number of severe food antibody reactions including corn, tomatoes, wheat, and milk. His salivary cortisol levels were elevated. The stool microbiology revealed a number of abnormal bacteria present and the almost total absence of normal bacteria.
Plan of Action and Outcome
The patient was initially placed on a liquid diet for three days to rest his digestive tract and allow him to desensitize from his food allergies. This was followed by a carefully planned dietary individualized to his needs including the removal of all food allergens and a rotation type diet to help prevent further allergic reactions from occurring. These steps alone brought about a significant improvement in his digestion and reduction in the amount of gas the patient was experiencing for which he was most happy about. The patient was gratified that within the first two weeks he noted significant improvements in his digestion.
I advised him to take up some type of autogenic training and made several suggestions. He began attending Hatha Yoga classes under an experienced teacher and the patient reported feeling more relaxed and less stressed out. He also began going to a synagogue for services, which he reported, helped him feel more peaceful and counseled with his rabbi about some personal issues he was having. Within sixty days the patient reported a dramatic improvement in his energy levels as well as receiving comments from his supervisor about their pleasure at seeing his work performance improving.
A state of dysbiosis i.e. when there is disruption of the normal bacterial flora in the gut can result in changes in the intestinal membrane and produce allergic reactions to ingested materials. It is therefore critical to restore the normal gut environment and the proper bacteria that should reside there and not just remove food allergens alone.
If a patient is chronically anxious and worried this will keep the digestive tract in a disrupted state as well. Being out in the natural world, biofeedback and other forms of autogenic training, taking steps to enhance ones spiritual relationship and enhancing relationships with others including family, friends and pets all help us feel more connected. This in turn enhances our sense of well being and overall health.
The above cases illustrate the need to identify the causes behind why people become chronically fatigued (or otherwise ill) and institute a health program for them based on the identified causal factors. The use of vague terms such as "chronic fatigue syndrome" is irresponsible on the part of the physician, misleading to the patient and leads us away from the correct pathways that can restore many ill people to a higher level of health and greater enjoyment of life.