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Fatigue - an increasing epidemic

Fatigue is one of the most common reasons for patients in New Zealand to seek medical help.  This is because almost any chronic medical condition can cause fatigue as one of its symptoms.  Possible causes that must be ruled out include but not limited:

  • Hypothyroidism.  The thyroid is a gland responsible for producing hormones associated with the body’s metabolic rate.  Hypothyroidism  typically presents with a collection of symptoms such as weight gain, constipation, sluggishness, hair loss or dry skin, hair, and eyes.  This can be ruled out with several blood tests including TSH (Thyroid Stimulating Hormone, which comes from the brain), free T3 and free T4.  Free in this case means unbound and therefore available for use in the body.  T4 is produced by the thyroid itself, and has 4 molecules of iodine, and it is converted to the active T3hormone in the peripheral tissues 11.

  • Anemia is another possible cause of fatigue.  The word anemia refers to a low red blood cell count.  Red blood cells are responsible for carrying oxygen to peripheral tissues.  Without sufficient oxygen, patients will feel sluggish and exhausted.  There are several types of anemia with different causes, iron deficiency anemia, and macrocytic anemia, which is usually caused by low Vitamin B12 and/or folate (mentioned later), vitamin B6, C and E deficiencies anaemia. Anaemia can also be caused by hemolysis (red blood cells that burst open), chronic diseases, malabsoption, nutrients restriction, medication and certain autoimmune conditions 12.

  • Depressive disorder  presents with a collection of symptoms including not just feelings of sadness, but also loss of interest in normal activities, changes in appetite and sleeping patterns, restlessness, slowed thinking, low libido, difficult concentration, and fatigue or loss of energy 13.  Many other psychiatric disorders may also be considered as a source of fatigue, including bipolar affective disorder, schizophrenia, delusional disorders, and dementia 23.

  • Insomnia usually presents with difficulty falling asleep or waking up repeatedly in the middle of the night, combined with a sense of feeling unrefreshed upon waking or a sense of exhaustion throughout the day.  Note that depressive disorder also presents with insomnia as one of its symptoms 14.

  • Mononucleosis may present with nothing more than fatigue, drowsiness, headache, sore throat, and malaise, which means a general sense of illness.  Usually mono also involves swollen lymph nodes as well as a swollen spleen and occasionally an enlarged liver 15.

  • Diabetes Mellitus is usually fairly easy to recognize because in addition to drowsiness and fatigue, it presents with excessive thirst, hunger, and urination.  These patients may also experience nausea and decreased exercise tolerance 16.

  • Malnutrition or malabsorption syndromes can be caused by a number of underlying conditions, including medications, diseases that damage intestinal lining directly such as Celiac’s, Crohn’s, or Whipple’s Disease, parasites, food intolerance, pernicious anemia (an autoimmune disease that inhibits absorption of Vitamin B12, mentioned below), cancer, or patients who have had surgical bowel resection.  Symptoms of these illnesses include gas and bloating, chronic diarrhea sometimes mixed with fat, wasting and weight loss 17.  Eating disorders can also cause fatigue due to low caloric intake and nutrient deficiency, for the same reasons.

  • Congestive heart failure occurs when the body cannot pump blood well enough to supply the needs of the body.  In addition to fatigue, symptoms include shortness of breath (sometimes worse upon lying down), swollen lower legs, and an urge to urinate at night.  CHF is typically a chronic process but in some cases it can present acutely 18.

  • Chronic disease (such as renal or liver failure) in general may present with fatigue as well as malaise, loss of appetite and weight loss.  These two diseases in particular also may present with itching and dry skin, nausea, drowsiness and confusion, difficulty thinking and concentrating, and sleep problems 19, 20.  Chronic Liver Disease may additionally present with a buildup of fluid in the abdominal cavity in advanced cases, breast enlargement in men, and small spider-like veins in the skin 20.

  • Malignancy or leukemia present with symptoms similar to those of chronic diseases generally, including appetite and weight loss, fatigue and malaise.  Additionally, solid tumors usually present with persistent, unrelenting pain which is typically worse at night.  Due to blood clotting alterations associated with cancer, often patients in more advanced stages may present with seemingly inexplicable bleeding symptoms, and metastases (spreading of cancer from its original location to a peripheral location) may cause a patient’s voice to change or lead to a cough unresponsive to symptomatic treatment 21.

  • Many rheumatologic illnesses may also present with fatigue.  The clinical pictures for these illnesses are many and varied, but the diagnoses to be considered include Sjogren’s Syndrome, Polymyalgia rheumatica, Giant cell arteritis, Polymyositis, and Dermatomyositis 23.

  • Lyme Disease is a multifaceted illness caused by a bite from a tick infected with the bacterial organism Borrelia burgdorferi, but often patients who are positive for this organism also suffer from several coinfections as well.  Symptoms may wax and wane, but they are often very general, including fatigue, malaise, chills, fever, headache, lightheadedness or fainting, muscle pain, various neurological symptoms, and severe itching.  Some of these patients initially present with a rash shaped like a bull’s eye, and patients may or may not recall a tick bite.  Typically Lyme Disease is associated with the outdoor east coast of the United States, but it has spread significantly to other parts of the country and the world 25.

  • Vitamin B12 Deficiency may be caused by the autoimmune condition Pernicious anemia, in which the compound necessary for absorption of the vitamin fails to be produced, or it may be caused by malabsorption due to gastritis, surgical removal of certain key parts of the stomach or small intestine necessary for absorption, a vegetarian diet (as the primary sources of Vitamin B12 in the diet are animal products), or acid blocking pharmaceuticals.  Symptoms are very similar to those of anemia, including weakness, lightheadedness, rapid heart rate and breathing, pale complexion, diarrhea and constipation 26.

  • Fibromyalgia is a condition that is closely linked with Chronic Fatigue Syndrome, and they frequently occur together in the same patients.  Both conditions have diagnostic criteria but no obvious causes or definitive lab values.  Symptoms include widespread musculoskeletal pain, called tender points, which present with a deep ache and occasionally a shooting, burning pain.  The pain tends to worsen with movement, weather changes, and stress 27.

If all of these ailments are ruled out, however, your doctor may diagnose adrenal fatigue or Chronic Fatigue Syndrome, which are the focus of the rest of this article.

Your adrenals are two pyramid-shaped glands that sit on top of your kidneys.  They perform a variety of functions, but adrenal fatigue specifically refers to their ability to help the body cope with stress.  Although the diagnosis is controversial, according to naturopathic physicians, prolonged stress can lead to adrenal burnout 10.

Alternatively, Chronic Fatigue Syndrome must have lasted for at least 6 months in order to be considered chronic, and also must include four of the following symptoms:

  • Weakness or exhaustion for more than 24 hours following mental or physical activity

  • Unrefreshing sleep

  • Substantial impairment of short term memory and/or concentration

  • Muscle pain

  • Pain in joints without redness or swelling

  • Tender enlarged lymph nodes around the neck and armpits

  • Recurrent sore throat 2.

Chronic Fatigue and Adrenal Fatigue are both conditions which can be successfully treated by Naturopathic Doctors.

How do you get Chronic Fatigue Syndrome or Adrenal Fatigue?

Adrenal fatigue is a term that was coined by Dr James Wilson in 1998 10.  It is considered to be a less severe version of adrenal insufficiency, which is also known as Addison’s Disease.  Because adrenal fatigue is subclinical, it remains an unrecognized diagnosis in the conventional medical community, however 22.

Proponents of adrenal fatigue maintain that it is generally caused by prolonged stress.  The core of the adrenal glands produces an acute stress neurotransmitter called epinephrine, also known as adrenaline (hence the name, adrenal glands). One of three outer layers of the adrenal glands produces another hormone meant to offset the effects of adrenaline and “buffer” the body against the effects of acute stress.  This hormone is called cortisol 22.

Epinephrine performs a very important function: it gives us the strength we need to get over an acutely stressful situation.  Our ancestors needed the function of epinephrine in order to stay alive in a hostile environment.  However, today’s society is one in which everyday events have been elevated to the level of life-and-death encounters.  Today, adrenaline is released in our bodies when we are stuck in traffic, when we are late for meetings, when we are confronted by an angry boss, when deadlines approach, and when family tensions reach a fevered pitch, to name just a few.  Modern life has become very fast-paced and stressful, and in order to cope, our adrenals are forced to secrete ever-increasing amounts of cortisol.  Eventually, they just get tired – or at least, that is the theory10.

No single primary cause of Chronic Fatigue Syndrome has been established, although many theories exist.  These theories include genetic abnormalities, neurotransmitter imbalances including elevated serotonin and decreased dopamine, low levels of cortisol (as in adrenal fatigue), abnormalities in the sleep-wake cycle, allergies, autoimmune abnormalities, and infectious agents, including viruses, certain bacteria and fungi. In up to 80% of cases, CFS starts with a flu-like condition or an acutely stressful event 9.

Some theories have been proposed that mercury toxicity may be responsible in part for Chronic Fatigue Syndrome 28.  But regardless of the initial cause, it has been fairly well established that once begun, Chronic Fatigue Syndrome affects the part of the brain known as the hypothalamus 9.  The hypothalamus acts as a command center for many processes, including hormone regulation, adrenal function, blood volume, sleep, thirst reflex and eating behavior.  Hormones affected include Thyroid Hormone (TSH), Anti-Diuretic Hormone (ADH), Growth Hormone, adrenal hormones (cortisol and DHEA), and sex hormones (estrogen, progesterone, and testosterone).  Each of these explains one of the major symptoms of CFS, and the sleep deficiency especially predisposes these patients to Fibromyalgia as well 1.

Signs and Symptoms

Adrenal fatigue presents with different symptoms depending on the stage of the illness.  The first stage occurs when you have been under a lot of stress for a long time, but not quite so long that your adrenals are unable to adapt.  During this stage, cortisol output is chronically higher than it should be, but still not high enough to compensate entirely for the adrenaline output.   In this stage you may experience:

  • Weight gain

  • High blood pressure

  • Disturbed sleep

  • PMS

  • Irritability

During the second stage, when your adrenals can no longer produce sufficient cortisol to compensate for your stress, you may experience:

  • Depression

  • PMS

  • Insomnia

  • Sugar cravings and hypoglycemia

  • Low blood pressure upon standing (orthostatic hypotension)

  • Recurrent infections and difficulty shaking off infections 10.

Chronic Fatigue patients may present with a wide variety of symptoms in addition to fatigue.  Most of these symptoms are due to dysfunction of the hypothalamus, which again is the part of the brain that is in control of many of the body’s hormones.  These symptoms include:

  • Poor memory

  • Achiness in muscles and joints

  • Worsening fatigue with exercise

  • Anxiety with palpitations and sweating

  • Decreased libido

  • Increased thirst

  • Chronic prostatitis

  • Nutrient deficiencies

  • Poor liver detoxification

  • Sinusitis and chronic nasal congestion

  • Spastic colon

  • Anemia 2.

Other conditions with similar symptoms:

Chronic Fatigue Syndrome and adrenal fatigue both have many similar symptoms to the list of general causes of fatigue at the beginning of this article.  The physician must rule out these other chronic and potentially serious illnesses before these diagnoses can be made.  Naturopathic Doctors would add a few other conditions to the list, including environmental toxicity with heavy metals 23.

How can I find out if I have Adrenal Fatigue or Chronic Fatigue Syndrome?

A diagnosis of adrenal fatigue can be made clinically by your Naturopathic Doctor, but the workup may be similar to an evaluation for adrenal insufficiency, or Addison’s Disease.  This would include electrolytes (with expected low sodium and high potassium, due to decreased production of another adrenal hormone called aldosterone), DHEA (another hormone produced by the adrenal glands), serum cortisol (usually drawn in the morning), and occasionally serum ACTH, which is a hormone produced in your brain in order to stimulate your adrenal glands 24.  As an alternative to serum cortisol, your doctor may order a salivary cortisol test, in which saliva samples are collected at four different times throughout the day.  The salivary cortisol response correlates better with the ACTH output than does serum cortisol, suggesting that it may be a better parameter to test for adrenal function29.

Chronic Fatigue Syndrome is both a clinical diagnosis and a diagnosis of exclusion.  Because of this, the workup for the diagnosis is fairly exhaustive, including:

  • History and physical examination consistent with the clinical criteria for the diagnosis (mentioned in the introduction of this article)

  • Laboratory studies including a Complete Blood Count (CBC) to rule out anemia and infections, Erythrocyte Sedimentation Rate (ESR) to check for inflammatory conditions and possibly autoimmune diseases, BUN and creatinine to rule out Chronic Renal Insufficiency, glucose to rule out Diabetes, liver enzymes (ALT and AST) to rule out Chronic Liver Disease, TSH to rule out hypo or hyperthyroidism, ANA to evaluate for rheumatic illnesses, and a variety of serologies (blood tests) to rule out Lyme Disease, Epstein Barr Virus (EBV, responsible for mononucleosis), Hepatitis B and C, and HIV (all of which fall under the category of chronic infections generally) 23.

How are Adrenal Fatigue and Chronic Fatigue Syndrome treated conventionally?

The conventional world recognizes only the two ends of the adrenal spectrum: dangerously high cortisol levels (called Cushing’s Syndrome), or dangerously low cortisol levels (called Addison’s Disease).  Adrenal Fatigue is considered subclinical and therefore usually goes untreated in the conventional medical model 22.

Because Chronic Fatigue Syndrome does not present with clear physiologic markers, it is often treated as a psychiatric disorder.  Antidepressants may be prescribed, as well as muscle relaxants for patients who also have a concurrent diagnosis of Fibromyalgia.  Pain killers may also be necessary for these patients, as well as hypnotics to assist with sleep.  Treatment may also include lifestyle management, including stress reduction techniques and exercise programs 23.

How does a Naturopathic Doctor treat Adrenal Fatigue or Chronic Fatigue Syndrome?

Adrenal fatigue is treated differently depending on the stage of exhaustion.  Early adrenal fatigue (when the adrenals are putting out a high level of cortisol which is still insufficient) should be treated with calming nutrients and neurotransmitters or neurotransmitter precursors, and by removing stimulants from the diet.  Later adrenal fatigue should be treated with nutritional building blocks for cortisol production as well as adaptogenic botanicals, which are intended to support and nourish the adrenals without overtaxing them.  Your Naturopathic Doctor may also recommend dietary changes to offset symptoms of hypoglycemia.  Very severe cases of adrenal fatigue may be treated with low levels of hydrocortisone given several times throughout the day to mimic the normal output of the adrenal glands.  This should not be necessary forever, but it may be very helpful in certain cases while building up the body’s nutrient stores and removing obstacles to cure 1.

Patients with Chronic Fatigue Syndrome tend to respond best when their various issues which flow from hypothalamic dysfunction are addressed in turn.  In order to feel better quickly, it may also be necessary to deal with the pain directly at first if patients also have Fibromyalgia (a frequent concurrent diagnosis for Chronic Fatigue patients).  However, after a few weeks to a few months on a protocol that addresses the root cause of the illness, analgesics may no longer be necessary 1.

Most importantly, adequate sleep must be restored before the body will have a chance to heal.  Next, hormonal imbalances need to be assessed (both clinically and perhaps via lab work) and addressed.  Often CFS patients may have positive titers for certain viruses, in which case the patient should be treated with natural or possibly prescription antiviral medications.  Some patients may also have developed secondary fungal or bacterial infections which perpetuate their symptoms, in which case these organisms should also be eliminated.  Additionally, in naturopathic medical philosophy, your body will heal itself if we remove the obstacles to cure (inadequate sleep, infectious organisms, and hormonal imbalances) and give the body what it needs to perform its work of repair.  To that end, your naturopathic doctor will correct any dietary or nutritional deficiencies that may exist 1.


Fatigue has become an epidemic.  Fortunately, even when all diagnostic tests are considered to be within normal limits, there is still hope.  Functional problems without a structural component are very well treated by Naturopathic Physicians.

For more information about how you might have gotten adrenal fatigue and what to do about it, check out this excellent and comprehensive post, Tired all the time? It’s likely Adrenal Fatigue.

References1 Teitelbaum, Jacob.  (2007).  From Fatigued to Fantastic.  Penguin Group, USA.2 Mayo Clinic (2011).  Mayo Clinic.  Chronic Fatigue Syndrome.  Retrieved November 7, 2011 from Prins JB, van der Meer JW, Bleijenberg G. Chronic fatigue syndrome. Lancet. 2006;367:346-554 Devanur LD, Kerr JR. Chronic fatigue syndrome. J Clin Virol. 2006;37:139-505 Cornuz J, Guessous I, Favrat B. Fatigue: a practical approach to diagnosis in primary care. CMAJ. 2006;174:765-76 Henningsen P, Zipfel S, Herzog W. Management of functional somatic syndromes. Lancet. 2007;369:946-557 Viner R, Christie D. Fatigue and somatic symptoms. BMJ. 2005;330:1012-158 Papadopoulos AS, Cleare AJ.  Hypothalamic-pituitary-adrenal axis dysfunction in chronic fatigue Syndrome.  Nat Rev Endocrinol. 2011: 10: 153.9 University of Maryland Medical Center.  (2009).  University of Maryland Medical CenterChronic Fatigue Syndrome – Causes.  Retrieved November 5, 2011, from\10 Wilson, James.  (2001).  Adrenal Fatigue: The 21st Century Stress Syndrome,  [Smart Publications, Canada]11 PubMed Health.  (2010).  A.D.A.M Medical Encyclopedia.  Hypothyroidism.  Retrieved November 5, 2011 from PubMed Health (2011).  A.D.A.M Medical Encyclopedia.  Anemia.  Retrieved November 5, 2011 from Mayo Clinic (Feb 11, 2010).  Mayo Clinic.  Depression (major depression).  Retrieved November 7, 2011 from PubMed Health (2011).  A.D.A.M Medical Encyclopedia.  Insomnia.  Retrieved November 7, 2011 from PubMed Health (2011).  A.D.A.M. Medical Encyclopedia.  Mononucleosis.  Retrieved November 7, 2011 from Merck Manual (2008).  Merck Manual.  Diabetes Mellitus.  Retrieved November 7, 2011 from PubMed Health (2010).  A.D.A.M. Medical Encyclopedia.  Malabsorption.  Retrieved November 7, 2011 from PubMed Health (2011).  A.D.A.M. Medical Encyclopedia.  Heart Failure.  Retrieved November 7, 2011 from PubMed Health (2009).  A.D.A.M. Medical Encyclopedia.  Chronic Kidney Disease.  Retrieved November 7, 2011 from University of Maryland Medical Center (2008).  University of Maryland Medical Center.  Liver Disease.  Retrieved November 7, 2011 from Davis, Charles Patrick (2009). Cancer.  Retrieved November 7, 2011 from Nippoldt, Todd B (2011).  Mayo Clinic.  Addison’s Disease Expert Answers.  Retrieved November 7, 2011 from Craig, Timothy (2002).  Chronic Fatigue Syndrome: Evaluation and Treatment.  American Family Physician.  2002 Mar 15;65(6):1083-109124 Merck Manual (2007).  Merck Manual.  Addison’s Disease: Primary or Chronic Adrenocortical Insufficiency.  Retrieved November 7, 2011 from PubMed Health (2011).  A.D.A.M Medical Encyclopedia.  Lyme Disease.  Retrieved November 7, 2011 from Oh, Robert C  (2003).  Vitamin B12 Deficiency.  American Family Physician.  2003 Mar 1;67(5):979-986.27 PubMed Health (2011).  A.D.A.M. Medical Encyclopedia.  Fibromyalgia.  Retrieved November 7. 201128 Sterzl I.  Reactions to metals in patients with chronic fatigue and autoimmune endocrinopathy.  Vnitr Lek.  1999 Sep; 45(9):527-31.29 Aardal-Eriksson, E.  Salivary cortisol – an alternative to serum cortisol determinations in dynamic function tests.  Clin Chem Lab Med. 1998 Apr; 36(4):215-22.

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