It breaks my heart to repeatedly see the number of people who come into my clinic who have been fighting off debilitating fatigue, day in and day out for years on end. Many of whom have struggled for so long they don’t remember what it’s like to not feel exhausted! What is even worse is the fact that when these individuals seek out help for their symptoms they are often told by their medical providers “you are just getting older,” “I think you are depressed,” or “it’s all in your head.” People are usually left frustrated without answers, labeled with an obscure diagnosis, and often sent home with a prescription for an antidepressant in the hopes that their senses are dulled just enough to result in some change. I am here to tell you that this doesn’t have to be your path. Fatigue is a symptom, not a cause. Life is too short to spend your days consumed by lethargy where minuscule tasks leave you feeling drained. In the following article, I will share some of the correctable causes of fatigue I have encountered in my practice that have helped people gain back their vitality and the state of wellness we all deserve!
So what is Chronic Fatigue Syndrome?
Chronic Fatigue Syndrome (CFS) which is also called Myalgic Encephalomyelitis (ME), is a diagnosis that is given to those who meet the following criteria:
- Substantial reduction/impairment in the ability to engage in pre-illness levels of occupational, educational, social, or personal activities that persists for more than 6 months, is accompanied by fatigue that is often profound, is of new or definite onset, is not the result of ongoing excessive exertion, and is not substantially alleviated by rest
- Post-exertional malaise
- Unrefreshing sleep
Plus, at least 1 of the following symptoms:
- Cognitive impairment
- Orthostatic intolerance
- Symptoms must be present at least half of the time and have moderate, substantial, or severe intensity 1
In reading the criteria, you can see a CFS/ME diagnosis is based solely on an accumulation of symptoms. Unfortunately, when the diagnosis is given, this is often where the investigation into why those symptoms are there ends.
Just to put this syndrome into perspective, it is estimated that up to 2.5 million people suffer from CSF/ME, 90% of whom have not been diagnosed. CFS/ME costs the United States economy nearly $24 billion a year in medical bills and lost incomes. Even the Centers for Disease Control and Prevention (CDC) recognizes the fact that our medical system does not fully appreciate the impact of this syndrome and states that most medical schools in the United States do not even have ME/CFS as part of their training 2.
Theories Behind a Cause
Various theories have been proposed regarding the etiology of CFS/ME from both the conventional and alternative medical communities. Viral and bacterial infections (e.g., Epstein-Barr virus, Mycoplasma pneumonia, Lyme Disease), immune system compromise, neuroendocrine, genetic, gastrointestinal, and psychological factors have all been investigated as sources that trigger CSF/ME. Despite the exploration of causative factors, the exact etiology remains unknown 3. It is my personal belief that although most of the theories explored do hold merit, every person with CSF/ME has it for different reasons. This is why it is essential to approach each case on an individual basis to figure out the root-cause of the problem.
One of the hallmark differences that separates Functional Medicine from Conventional Medicine is one simple word, WHY? Investigating and correcting WHY a disease process is present is what separates managing a health condition from resolving it. In Functional Medicine we are are always trying to get to the root-cause of what is missing or imbalanced in the body that is creating dysfunction. Often times it involves addressing multiple factors including physical, emotional, and spiritual well being. With CSF/ME some of the most promising evidence out there to date regarding etiology shows that like many other chronic disease states, inflammation is the driving force 4. This is why I believe we see such great results in CSF/ME when we apply a functional approach. By removing the culprits that are causing inflammation and replacing the factors that are missing, the body will bounce back into a state of balance that makes you look and feel healthy again!
Reaching Outside of the Box
As previously mentioned many things need to be explored when dealing with CFS/ME. It is always a good idea to work with your primary care physician to rule out anything serious first (i.e., autoimmunity, sleep apnea, cardiovascular disease, cancers) and then proceed to look into functional causes. The following paragraphs will identify some of the areas I investigate and address in my practice at GrassRoots Functional Medicine, to help people recover from CFS/ME.
Nutrient Deficiencies & Mitochondrial Dysfunction:
Time and time again, I am amazed to see the power that basic nutritional principles can have on optimizing energy and improving fatigue. Although changing your dietary habits is not guaranteed to be the smoking gun for reversing 100% of your symptoms, it almost always plays a vital role in the recovery and maintenance of optimal health. If you are starting from scratch, I like to recommend a 30-day elimination diet that focuses on paleolithic principles free of processed foods, sugars, grains, legumes, and dairy products. If this is too much, cutting out sugar, gluten and dairy can also yield some pretty miraculous results. Beyond cutting out foods, it is even more important to add in clean (ideally organic) nutrient dense foods with lots of colors. It is crucial to eat all colors of the rainbow shooting for around 12 servings a day (1 serving = ½ cup of fruits and veggies or 1 cup of leafy greens). I am a firm believer that the majority of your diet should be plant-based with the addition of a moderate amount of lean meats (organic, local, grass-fed) and healthy fats (olive oil, coconut oil, nuts and seeds, avocados, ghee, etc.). Of course there is no perfect diet for everyone, in fact, I don’t even like to say the word diet. What you are looking to achieve is sustainable lifestyle modifications that are individualized to your body’s needs.
Mitochondrial dysfunction is extremely common among patients I see in my practice, and it very rarely gets the attention it deserves. Mitochondria are the powerhouses of the cells in your body. These are organelles that act as a digestive system which takes in the nutrients you consume and breaks them down to create energy allowing the cells throughout your body to use. The Mitochondria rely on a whole host of nutrients to function at full capacity. If you are depleted of specific nutrients, mitochondrial dysfunction occurs which leaves the cells in your body robbed of energy they need to thrive. Several nutrient deficiencies have been linked to mitochondrial dysfunction and chronic fatigue and can be evaluated through simple blood or urine tests. Some nutrient deficiencies that have been shown in the literature to play a potential role with chronic fatigue include Vitamin D, B-Vitamins, Magnesium, Zinc, Coenzyme Q10, and various amino acids 5, 6, 7, 8, 9, 10, 11. A great test I frequently use at GrassRoots Functional Medicine to assess nutrient deficiencies and mitochondrial dysfunction is called an organic acid test (OAT). This is a urine test that looks at what is happening at a cellular level as opposed to merely what is floating around in the blood. The OAT is an excellent tool to consider when you're trying to identify if nutrient deficiencies are a root-cause of your chronic fatigue.
Digestive Compromise/Leaky Gut:
Every time you turn around it feels like there is new research released linking the human digestive tract (gut) to chronic disease. The gut is such an amazing design and places such an integral role in almost all aspects of our health yet it seldom gets the respect and treatment it deserves. I cannot tell you the number of times I have seen people become completely revitalized with energy after correcting imbalances in the gut. What is tricky about digestive dysfunction is the fact that there are multiple problems that can arise many of which occur at the same time and present with similar symptoms. One of the best things about gut dysfunction is that the most effective therapy is also the cheapest, addressing the diet! In many situations, a simple elimination diet (removing gluten/grains, dairy, legumes, sugar, processed foods and alcohol) for 28 days can alleviate the vast majority of symptoms. In more advanced cases, where dietary factors have been ruled out, I like to order functional tests that evaluate the gut in more detail. Some of the testing I commonly use at GrassRoots Functional Medicine includes stool testing (evaluating for pathogenic bacteria, yeast, parasites, digestive enzyme deficiencies etc.), breath testing (evaluating for small intestine bacterial overgrowth (SIBO)), or the OAT test which tells us if there is candida (also linked to CFS12) or problematic bacteria like clostridia contributing to intestinal imbalance. Although testing can be more of an initial investment, it helps you identify exactly what you are treating which saves a lot of time and money when compared to the trial and error method that comes from guessing. Another simple therapy that has been shown in the literature to help with mood and energy is simply taking a probiotic 13 . Probiotics are safe and can be an effective way to boost the beneficial bacteria in your digestive tract that keep you feeling great!
Lyme Disease and Chronic Infections:
Another common cause of fatigue that is often seen by the conventional medical community with great skepticism is chronic infections. There are several microbes that have been proposed as triggers of chronic fatigue including the Epstein Barr Virus, human herpesvirus 6, mycoplasma, chlamydia pneumonia, and various Staphylococcus species 14, 15, 16. Lyme disease and associated co-infections (Babesia, Bartonella, Ehrlichia, Anaplasma, etc.) are other sources of fatigue I have become extremely passionate about since moving back to Vermont (aka Tick Country). With that being said, I have plenty of Lyme disease patients in Texas as well. It is an unfortunate truth that these infections are running rampant throughout the United States and are impacting people in almost all areas in the country. Other hallmark symptoms of Lyme beyond fatigue include: musculoskeletal pain, migratory joint pain (joint pain that moves around your body) and neurocognitive difficulties 17.
Dr. Richard Horowitz, an international leader in Lyme disease and tick-borne illness recently had his Multiple Systemic Infectious Disease Syndrome (MSIDS) Questionnaire clinically validated as a tool that can help patients and clinicians with the diagnosis or Lyme disease and chronic infections 18 . If you are concerned that Lyme Disease or tick-borne illness may be impacting your health, completing the Horowitz MSIDS Questionnaire and reviewing it with a Lyme literate practitioner can be a great place to start. It is also important to understand that you can get chronic infections under control! There is a lot of doom and gloom out there regarding Lyme Disease and related infections, but people get better all of the time. When tackling these critters, it is essential to work with someone who will do more than blast the bugs with drugs! You need someone who will look at the entire scenario supporting all aspects of the body from a holistic approach. Sometimes stronger therapies are necessary, but if you don’t support the immune system while treating the organism, you will rarely get the results you are searching for.
It is hard to feel energetic when your hormones are out of whack! What is a hormone? Hormones are produced by various groups of cells in the body known as endocrine glands. Hormones are specialized chemical messengers that control most major bodily functions from the most basic needs like hunger to complex systems like reproduction, the emotions, and mood. When people think of hormones, their mind often gravitates to sex hormones like estrogen, testosterone, and progesterone. Although these hormones are essential and can play a significant role in fatigue, there are several other types of hormones that need to be assessed and corrected as well including thyroid hormones, adrenal hormones, and even metabolic hormones like insulin and leptin.
It is not uncommon for women to start having problems with their health after big swings in sex hormones. Puberty, pregnancy, and menopause are popular triggers for health issues among women. In fact, Menstrual abnormalities, endometriosis, pelvic pain, hysterectomy, and early/surgical menopause are all associated with CFS 19. Although hormone replacement is never an initial intervention, I have seen bioidentical hormones play a significant role in optimizing health especially in the perimenopause/menopause time frame of life. Unfortunately, there are a lot of practitioners throwing hormones around loosely placing people on supraphysiologic doses for their age. This can be dangerous and often leads to short-term highs followed by long-term crashes. Hormone therapy can be a good option, but it is essential to go low and slow replacing hormones to appropriate levels for one's age. There is no reason a 60-year-old woman should have the hormones of a 25-year-old. At the same time, there is no reason a 60-year-old woman should have no hormones at all! If you do decide to get on bioidentical hormone replacement therapy (BHRT), make sure your practitioner checks your hormone levels. All too often I see women come to GrassRoots Functional Medicine currently on hormones and their levels are either non-existent or through the roof. Although symptom management is critical, we need to make sure the levels are within a safe and effective range. Another test that is essential to get when you are on hormones is an estrogen metabolite test. This looks at whether or not your body is breaking down the hormones into safe metabolites which is what you want to see or problematic inflammatory metabolites that have been associated with DNA damage, oxidative stress, and even cancers. In addition to testing hormone labs through local laboratories, I use the DUTCH Complete dried urine test for assessing hormone levels, estrogen metabolites, and adrenal hormones. I find the DUTCH test to be one of the best on the market and would highly recommend it for anyone who is on or thinking about hormone replacement. As with everything, there is a right and wrong way to replace hormones and if hormones are balanced appropriately, they can have a tremendous impact on your vitality.
There are so many possibilities to consider when trying to get to the root-cause of chronic fatigue. The chart above lists some additional culprits along with tests I find useful in my practice to help isolate them. Beyond the physical components that cause chronic fatigue, there is also a huge mental, emotional, and spiritual component that needs to be addressed and supported while embarking on this battle. You must stay optimistic, never give up, know you will get better, and believe in a power that is bigger than yourself! This is a journey that you can not complete on your own; rely on your support system and find the right help. If you are looking for someone to partner with your on your journey to optimal health, I am currently accepting new patients at my clinic in West Lebanon, New Hampshire and in San Antonio, Texas. You can call us at (888)-644-7664 or email us at email@example.com to set up an appointment. Life is too short to be tired. Find the root-cause and take back the energy you deserve!
Wishing you good health,
Dr. Seth Osgood DNP, FNP-BC, IFM-CP
About the Author: Dr. Seth Osgood is a Doctor of Nursing Practice, Board Certified Family Nurse Practitioner and Institute of Functional Medicine (IFM) Certified Practitioner. Dr. Osgood received his post-graduate training in Functional Medicine through the IFM and from working with International Functional Medicine expert Dr. Amy Myers. He has helped people from around the world improve their health utilizing a Functional Medicine approach.