Tired when you go to bed, tired when you wake up. Tired at work, tired when you get home. It’s a familiar story, and even if you are not a habitual victim of chronic fatigue you probably know someone who is. Indeed this is one of the most common complaints for which we now consult our doctors, and more women suffer than men.
There are, of course, different types of fatigue. Most of us have experienced fatigue after a period of hard and fruitful work, and then hopefully, noticed a return in our energy after a good night’s sleep or a relaxing holiday. Some of us, however, suffer from fatigue day in, day out, despite the amount of sleep or rest we have. The causes of this problem vary from the physical to the psychological, and both aspects need to be considered in the majority of those suffering with significant fatigue. This chapter deals with severe fatigue that is troublesome enough to cause the individual to change her lifestyle in some way.
During the last ten years there has been a great deal of research and publicity about severe fatigue, particularly ME (myalgic encephalomyelitis). This term is now replaced by Chronic Fatigue Syndrome which also replaces other similar terms such as post-infective or post-viral FATIGUE AND CHRONIC FATIGUE SYNDROME 195 fatigue. Chronic Fatigue Syndrome (CFS) often, but by no means always, follows an acute infectious illness, such as a sore throat, glandular fever or gastro-enteritis.
The interest of doctors in these chronic fatigue syndromes is a landmark in medical thinking, with research being focused on a symptom, for which there are many possible causes, and not a single disease state. There are serious and not so serious causes of fatigue, so it is important to determine into which category an individual falls. Research has shown that up to ten per cent of those with severe fatigue can be found to have some underlying health problem.
Some sufferers may have a physical illness which may not yet be fully developed, some may have recently experienced acute infection, and others may be mainly depressed. The first step must be to eliminate the possibility of any serious underlying cause before progressing to self-help measures.
As a rule of thumb, fatigue which is persistent or prevents you from working and requires you to make drastic changes to your home life and social calendar, should be regarded as possibly being due to a serious cause. This also goes for fatigue that is associated with weight loss, fever, significant pain or any other troublesome symptoms. This should always prompt you to check with your doctor as your first course of action.
Causes of fatigue (not so serious):
• lack of sleep
• stress or overwork
• lack of physical fitness
• poor quality diet.
Causes of fatigue (serious):
• physical illness, e.g. heart, liver or kidney disease
• after viral or other infection, e.g. glandular fever or ’flu • depression
• rarely, a continuing infection, e.g. tropical.
Wide-ranging surveys have revealed a pattern connecting common nonserious health problems with mild to moderate fatigue which includes muscular aches and pains, bowel problems, headaches, premenstrual syndrome and sleeping difficulties including snoring, and allergies. Addressing these problems can often result in a reduction in the associated fatigue.
When a doctor has to assess a new patient with significant fatigue it is probably best to consider the following four broad groups:
1. It can accompany any acute infectious illness, such as ’flu or a cold. Occasionally, an infection is hidden and this can be the case in some tropical illnesses or parasitic infections. If anyone with fatigue has a fever usually measured at more than 37.5 degrees centigrade, then they should be carefully checked for a possible hidden infection.
2. Fatigue can also follow an infection. After the acute episode has resolved, the individual can be left with fatigue, which instead of resolving in a week or so, drags on for months and even years. This condition is sometimes called ‘ME’ (myalgic encephalomyelitis). That mouthful simply means inflammation of the muscles and nervous tissue, and there is now evidence that patients with ME can, at times, have evidence of damage or alteration to either the muscles, the nervous system or immune system (the part of our body that fights infection). It seems in some ways that the infection, after causing an acute illness, goes into a slow or hidden phase which can sometimes reappear. This is particularly true for the glandular fever virus, but may also be true of other virus infections. The term ME is now commonly replaced with Chronic Fatigue Syndrome (CFS). This is used to describe significant fatigue present for at least three months which typically, but not necessarily, has followed one or more infections. Several of the following features should also be present:
• the fatigue is worse after exercise
• headaches
• forgetfulness or poor concentration
• muscle aches and pains
• recurrent sore throats
• painful enlarged glands in the neck or elsewhere.
Doctors still disagree about this definition. In practice, if this picture is present, and continuing infection, other underlying illness, drug or alcohol abuse, or severe depression are excluded, then this allows at least a working diagnosis of CFS (or ME).
3. Fatigue can also be caused by a wide variety of physical illnesses, including heart conditions, thyroid disease, arthritis, conditions affecting the immune system or nervous system, kidney problems and so on. These conditions should be suspected in older patients, those who experience weight loss or have other unusual symptoms. They will usually be detected by blood and urine tests, together with x-rays. In order to eliminate the possibility of any underlying sinister problem, it is important that all those suffering with severe fatigue do see their medical practitioner for a check up.
4. Fatigue of varying degree is often caused by nutritional factors. This can either be due to a lack of vitamins or minerals, or sometimes other dietary problems. Though we are often told that the average diet in countries like the United Kingdom, Australia and New Zealand should provide all the vitamins and minerals we need, careful scrutiny of the evidence from both governmental and other sources, doesn’t always support this claim. In fact mild nutritional deficiencies are not uncommon, especially among women of childbearing age, the elderly and the ill, and these can affect muscle and brain metabolism and result in loss of energy. This is easily underestimated by the medical profession through lack of knowledge, and may consequently be overlooked.
A relatively recent survey in the UK revealed that up to 20 per cent of adults have a dietary intake below the new minimum recommended by the government’s advisers. This applies particularly to the minerals iron, magnesium and potassium, as well as some of the B vitamins. Deficiency of any of these nutrients can cause fatigue. Most are essential to the function of muscles, nerves and the immune system.
There is good evidence that deficiency is particularly common in certain groups. Iron deficiency, for example, causes anaemia in four per cent of adult women of child-bearing age in the UK. This is mainly because of heavy or prolonged periods with a further ten per cent of women of child-bearing age having evidence of low iron stores, and this may explain why fatigue is more common amongst women. Mild fatigue in such women has long been shown to respond to iron supplements, and is a good example of how a mild or severe nutritional deficiency can be a cause of chronic fatigue.
Iron deficiency is most likely in women who are having periods, particularly if they are heavy, and in vegetarians or people who don’t consume much meat.
Mild deficiency of the B group of vitamins is also quite common, particularly in those who complain of anxiety, depression or mood changes. This may often accompany fatigue. Again, a poor diet, smoking, and drinking too much alcohol, are all significant risk factors for lack of vitamin B.
The mineral magnesium has attracted considerable interest in recent years. This mineral is essential for nerve and muscle function. Intakes in the UK are acknowledged to be borderline or deficient in some 10 per cent or more of adults. In our own surveys of women with PMS we have repeatedly found that over 50 per cent of women with PMS have low magnesium stores.
Go to your doctor if you suffer serious fatigue and . . .
• you have a fever (a temperature of 37.5°C or 99.5°F).
• you are losing weight.
• you have enlarged glands in the neck, armpits or groin.
• you have pains which disturb your sleep or daily activities.
• your facial appearance or colour has changed.
• you have travelled abroad, especially to Asia, the Far East, the Mediterranean, or South, Central or North America.
• you have had contact with animals other than known pets.
• you are troubled by any joint swellings and pains.
• you have bowel problems such as diarrhoea, a change in the colour of your stool or severe abdominal pains.
• you are aged over 50 years.
Establish whether there is a serious underlying cause to your symptoms by:
• Taking a history of your symptoms and giving you a thorough physical examination, with routine blood screening, including a full blood count – to look for anaemia or evidence of infection; serum ferritin – to check your iron stores (particularly useful for menstruating women); thyroid function – to assess the status of your thyroid; biochemistry tests to assess kidney and liver function; measurement of blood calcium, sodium and potassium – to assess mineral imbalances.
• Enlightened doctors may care to measure your red cell magnesium level. This is a simple test that can be performed at district hospital level. Reduced red cell magnesium is associated with fatigue, PMS, muscle cramps or fibromyalgia. FATIGUE AND CHRONIC FATIGUE SYNDROME 199
• Make some assessment of your nutritional state, and look for evidence of vitamin B deficiency in particular. Lack of vitamin B12 and vitamin B1 can be serious, and fatigue may be one of the earliest symptoms. Moderate deficiencies of several of the B vitamins including vitamin B6 have recently been found in a small group of chronic fatigue syndrome patients. Specialist supplements of vitamin B3 (nicotinamide) are sometimes used.
• Consider referring you to a specialist for further assessment. This is most likely if the fatigue is severe and prolonged, has been accompanied by weight loss, fever or significant foreign travel, or has caused you to make major lifestyle changes as previously discussed.
• Treat depression if this is a major component of your illness, but this should not stop doctors from looking for underlying physical or nutritional causes. • Refer you to a specialist unit, or a behavioural psychologist, as simple coping techniques have been shown to help speed up the recovery process.
Maureen was a 47-year-old nurse who lectured in further education. She suffered chronic fatigue and, as a result, her moods were so wildly out of control. She was in the process of disciplinary action at work and finding life generally difficult when she approached the WNAS.
‘I had experienced symptoms for nearly 25 years, but they had become markedly worse in the last three years. My doctor had prescribed numerous forms of hormone treatment which seemed to make the symptoms worse. My total exhaustion, irritability, anger and aggression had almost totally alienated me from the world. I was struggling along on the contraceptive pill continuously as my doctor felt my symptoms may improve if we could suppress ovulation. I had so much time off in the last three years because of exhaustion and my wild moods. I had reached the point where I was afraid to go out of the house. I was so tired that I could not get out of bed in the morning without a friend phoning to command me through the procedure, limb by limb. My doctor had sent me for counselling and had even referred me to a psychiatrist, but I walked out half way through the appointment as I was so angry with his suggestion that I should pull myself together. I often felt like ending my life. I had upset so many people and had lost most of my friends. At work I was regarded as unreliable, and regarded as an oddity. 200 THE NATURAL HEALTH BIBLE Then one day I read about the book, No More PMS! in Woman and Home magazine and decided to read it. To my utter amazement my complete fatigue and mood changes were described almost exactly by other case histories. I made some changes to my diet myself by following the instructions in the book whilst I was waiting for an appointment with the WNAS. After an in-depth consultation I was asked to make considerable changes to my diet. I cut out certain grains, caffeine, and biscuits, which I used to eat day and night. I also took supplements of Optivite and went back to exercising, which I had let slip from my routine. At my follow-up appointment, six weeks later, I was able to report that I had been on an even keel with no wild mood swings, and was feeling so energetic that I had taken to early morning walks. I could hardly believe it and nor could my friends and colleagues especially those who had previously had to resuscitate me in the mornings. I came off the pill too, and my headaches also disappeared. Within three months I had lost half a stone in weight, I was wonderfully stable each day and had regained my energy and enthusiasm for life. I had renewed my friendships, and was promoted to co-ordinator at work within six months. It has now been two years since my treatment with the WNAS. I feel alive again and can’t sing their praises enough. I remain healthy and happy, am keeping to the wheat-free, caffeine-free diet and have taken an additional part-time job as a night nursing sister. I am enjoying it immensely.’
Many treatments or cures have been put forward, some showing some very high success rates, and there are many self-help measures that can be implemented to help overcome symptoms of fatigue.
• Follow the recommendations for The Very Nutritious Diet on page 437 and the suggested menus for fatigue on page 472.
• Tidy up your diet by concentrating on good sources of magnesium – green leafy vegetables and most wholesome foods – and avoid sugar, sweets, and soft drinks which contain hardly any magnesium at all. Women with PMS often have low levels of magnesium, and it seems that the same is often true of people suffering with fatigue.
• Many other nutrients, if deficient, are known to affect the function of the immune system. These include vitamins A, C, E and the trace element, zinc. A healthy diet and a strong multi-vitamin supplement with 20 to 30 milligrams of zinc should be adequate. Specialised fats FATIGUE AND CHRONIC FATIGUE SYNDROME 201 and oils, as found in evening primrose oil and fish oils, have been used to help those with chronic fatigue. In one placebo-controlled trial a supplement of Efamol Marine at 8 capsules daily helped a high proportion of those whose fatigue was post-infective in type. Again this should be combined with eating healthily and possibly a multivitamin preparation.
• In addition to deficiency of certain nutrients, sometimes other dietary problems can cause fatigue. There is evidence in those who have certain types of allergy, that fatigue may be one of the associated symptoms. Intolerance to certain foods seems to be a factor, and this can be suspected if there are symptoms of allergy, including eczema, asthma, nettle rash, migraine headaches and bowel problems including irritable bowel syndrome. In one study, allergy to wheat protein was linked with increased complaints of fatigue, headaches and bowel problems. It is not known how commonly this is a cause of chronic fatigue, but it does seem to be worth considering.
• Symptoms such as anxiety and depression, often accompany fatigue. In fact many physical problems can also cause mental symptoms. Stress, in any form, may also aggravate mental symptoms, and even reduce the ability of the immune system to fight infection. So if you are feeling stressed it is important to find a workable way of overcoming the stressful factors and to spend a little time every day relaxing, see page 29.
• Exercising regularly to the point of breathlessness and losing weight, if you are overweight, can also help mood and stimulate the immune system. You should only exercise regularly if your fatigue is mild and you have no underlying illness.
• Complementary therapies including homeopathy, herbal medicine and acupuncture may be worth considering. One report from Doctors Sheila and Robin Gibson from the Glasgow Homeopathic Hospital concluded that dietary change, nutritional supplements, homeopathy and psychotherapy helped in 70 per cent of participants.
“Within three months I had lost half a stone in weight, I was wonderfully stable each day and had regained my energy and enthusiasm for life.”
Maureen