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Demystifying chronic fatigue and taking a holistic approach address it

Moving beyond chronic fatigue requires interventions that address hormonal health, sleep, nutrition, mental health, and other lifestyle factors

By Dr. Ana Maria Kausel, MD
And Dr. Sarah Musleh, MD

Why am I always tired? 

Countless patients have asked us this question, and as life’s pace and stresses increase, we expect countless others to ask it too. For these people with chronic fatigue, no amount of sleep is enough to feel energized and refreshed.

According to a survey by the CDC, about 15% of women and 10% of men reported feeling tired or exhausted within the past 3 months. And women between the ages of 18 and 44 are more than twice as likely as men to report low energy levels.1QuickStats: Percentage of Adults Who Often Felt Very Tired or Exhausted in the Past 3 Months, by Sex and Age Group – National Health Interview Survey, United States, 2010-2011. Centers for Disease Control and Prevention. April 12, 2013.

In addition to feeling exhausted, many people with chronic fatigue contend with frustration. They bounce from doctor to doctor, trying to determine the cause of their fatigue and receive few answers and even fewer coping strategies. 

Fortunately, there is a better way to move past chronic fatigue—one that treats the whole person, not just their symptoms.

What is chronic fatigue?

Fatigue is the familiar feeling of tiredness. But chronic fatigue is different. Generally, a disease or condition is chronic if it persists for at least 3 months. Chronic conditions may also worsen over time. And, a chronic disease or condition limits quality of life and harms health.2Chronic disease. National Cancer Institute. Accessed December 27, 2022.

Chronic fatigue is not the same as Chronic Fatigue Syndrome (CFS), also known as myalgic encephalomyelitis (ME).3IOM 2015 diagnostic criteria. Centers for Disease Control and Prevention. Updated April 27, 2021. Accessed December 15, 2022. The CDC estimates that anywhere from 836,000 to 2.5 million Americans have CFS.4Epidemiology. Myalgic encephalomyelitis/chronic fatigue syndrome. Centers for Disease Control and Prevention. Updated April 21, 2021. Accessed December 14, 2022. In addition to feeling tired, CFS includes worsening symptoms after exertion, nonrestorative sleep, and some cardiovascular symptoms, among others.5IOM 2015 diagnostic criteria. Centers for Disease Control and Prevention. Updated April 27, 2021. Accessed December 15, 2022.

While no one wants to have a disease or syndrome, people with CFS have some solace in knowing what they have and how they can address it. Unfortunately for people with non-CFS chronic fatigue, answers and relief are often elusive. 

This is because the causes of chronic fatigue can be myriad. And managing chronic fatigue often involves implementing an array of lifestyle interventions. 

But first, we can’t manage what we don’t thoroughly understand, underscoring the need for thorough, holistic clinical evaluation for anyone experiencing chronic fatigue.

Assessing chronic fatigue: The big picture

At Anzara Health, when a patient comes to us with chronic fatigue, we begin our assessment by first looking at the bigger picture of a person’s health. This is because fatigue can be the byproduct of lifestyle factors such as stress, diet, exercise, or sleep, as well as metabolic or hormonal disease or dysfunction. Addressing any (or all) of these elements requires a comprehensive analysis and a comprehensive approach to treatment. 

First, we look at BMI, age range, and sex. In the cases of age range and sex, data indicate that women are more likely to report feeling tired than men. There also appears to be a correlation among certain age cohorts. Women between the ages of 18 and 44, and between the ages of 45-64, tend to report feeling fatigued the most.6QuickStats: Percentage of Adults Who Often Felt Very Tired or Exhausted in the Past 3 Months, by Sex and Age Group – National Health Interview Survey, United States, 2010-2011. Centers for Disease Control and Prevention. April 12, 2013.

BMI is also a critical part of any workup for chronic fatigue because high BMI is associated with feeling tired. A high BMI can cause fatigue for many reasons, including sleep apnea and conditions stemming from insulin resistance. But, even in the absence of sleep apnea, patients with obesity tend to feel more fatigued than people without obesity.7Vgontzas AN, Bixler EO, Chrousos GP. Obesity-related sleepiness and fatigue: The role of the stress system and cytokines. Annals of the New York Academy of Sciences. 2006;1083(1):329-344.

Finally, sex is critical for fatigue evaluation because of hormonal implications. For women, perimenopause and menopause—and their associated hormonal changes—can all affect energy levels.8Taylor-Swanson L, Wong AE, Pincus D, et al. The dynamics of stress and fatigue across menopause: attractors, coupling, and resilience. Menopause. 2018;25(4):380-390. For example, in perimenopause, fatigue can be related to progesterone deficiency.9Prior JC. Progesterone for Symptomatic Perimenopause Treatment – Progesterone politics, physiology and potential for perimenopause. Facts Views Vis Obgyn. 2011;3(2):109-120. And during menopause, fatigue can be associated with estrogen deficiency.10Sarrel PM. Androgen deficiency: Menopause and estrogen-related factors. Fertility and Sterility. 2002;77:63-67. Here we have two different hormonal deficiencies causing the same symptom, underscoring the need for careful assessment.

There are also critical hormonal implications for men. Male hypogonadism (low testosterone) can also be associated with feelings of fatigue and can also affect metabolism, the function of the brain, and composition of bone and muscle tissues.11Kumar P, Kumar N, Thakur D, Patidar A. Male hypogonadism: Symptoms and treatment. J Adv Pharm Tech Res. 2010;1(3):297.

From here, we can begin to assess more granular aspects of health and how they might be contributing to chronic fatigue.

Assessing chronic fatigue: The granular approach

There are many factors that could contribute to chronic fatigue. Equipped with what we learn about a patient by assessing their bigger picture of health, we then delve into the hormonal and metabolic details.

On the hormonal front, we check the function of critical glands, systems, and hormones, such as the thyroid, adrenals, pituitary, ovaries, testosterone, vitamin D, vitamin B12, and levels of folate. For example, some people with chronic fatigue also have low levels of T3,12Ruiz-Núñez B, Tarasse R, Vogelaar EF, Janneke Dijck-Brouwer DA, Muskiet FAJ. Higher prevalence of “low t3 syndrome” in patients with chronic fatigue syndrome: A case-control study. Front Endocrinol. 2018;9:97. an important thyroid hormone. Low levels of T3 are indicative of hypothyroidism,13Triiodothyronine (T3) tests. MedlinePlus. National Library of Medicine. Last updated September 13, 2021. Accessed December 27, 2022. of which fatigue is a common symptom.14Hypothyroidism. MedlinePlus. National Library of Medicine. Last updated June 16, 2021. Accessed December 27, 2022.

Fatigue is also often associated with metabolic conditions, such as diabetes15Diabetes symptoms. Centers for Disease Control and Prevention. Accessed December 27, 2022. and fatty liver disease.16Fatty liver disease. MedlinePlus. Updated April 26, 2017. Accessed December 27, 2022. To rule out either of these diseases, and to assess overall metabolic health, we test liver function, liver enzymes, and triglyceride levels, in addition to screening for leptin resistance. 

Leptin is a hormone that’s integral to metabolism and weight regulation.17Dornbush S, Aeddula N. Physiology, leptin. StatPearls. Updated April 14, 2022. Accessed December 21, 2022. Some people can develop leptin resistance. Fat cells, known as adipocytes, produce leptin. And the more fat cells a person has, the higher their levels of leptin can climb.18Considine RV, Sinha MK, Heiman ML, et al. Serum immunoreactive-leptin concentrations in normal-weight and obese humans. N Engl J Med. 1996;334(5):292-295. Over time, high or rising leptin levels can disrupt leptin signaling, which the body misinterprets as starvation. These starvation signals prompt the body to conserve energy by gaining weight, or to slow down in response to feelings of fatigue.19Gruzdeva O, Borodkina D, Uchasova E, Dyleva Y, Barbarash O. Leptin resistance: underlying mechanisms and diagnosis. Diabetes Metab Syndr Obes. 2019;12:191-198.

While it’s true that many physicians are capable of running these labs, many are simply checking to see that results are within normal ranges. However, many of these ranges are vast and are skewed by the preponderance of metabolic dysregulation and disease in the US. Lab results must be put into the greater context of a person’s health in order to address CFS. 

Finally, a sleep study is often warranted for patients with chronic fatigue, especially if they have obesity. Certain lifestyle factors, such as alcohol and tobacco use, may also contribute to sleep apnea and consequently, chronic fatigue.20Sleep apnea. Causes and risk factors. National heart, Lung, and Blood Institute. Updated March 24, 2022. Accessed December 27, 2022.

Once we’ve identified and/or ruled out any underlying hormonal or metabolic issues contributing to chronic fatigue, as well as determined whether sleep disordered breathing is a contributing factor, we can begin to take action against chronic fatigue.

Moving past chronic fatigue

Based on our clinical experience, in addition to treating the underlying hormonal dysregulation and dysfunction that accompanies chronic fatigue, there are certain habits and behaviors that can alleviate some of the symptoms. They include:

Eliminating toxic habits: Drugs and alcohol disturb sleep and lead to fatigue. Paradoxically, some people may turn to these substances to fall asleep, but their normal sleep cycles will be disrupted.21Vokow N. Connections between sleep and substance use disorders. National Institute on Drug Abuse. March 9, 2020.

Improving gut health: For many people, improving gut health begins with consuming enough fiber. Fiber fuels the microbiota in the gut, and the gut microbiome is responsible for creating neurotransmitters such as dopamine and serotonin,22Chen Y, Xu J, Chen Y. Regulation of neurotransmitters by the gut microbiota and effects on cognition in neurological disorders. Nutrients. 2021;13(6):2099. both of which can be associated with feeling tired or energized, as well as overall feelings of wellbeing and vitality.23Dobryakova E, Genova HM, DeLuca J, Wylie GR. The dopamine imbalance hypothesis of fatigue in multiple sclerosis and other neurological disorders. Front Neurol. 2015;6., 24Meeusen R, Watson P, Hasegawa H, Roelands B, Piacentini MF. Central fatigue: The serotonin hypothesis and beyond. Sports Medicine. 2006;36(10):881-909.

Improving diet: Eating a diet comprised of whole, unprocessed foods may also help alleviate chronic fatigue, especially a diet that’s rich in vitamin B12 and folic acid.25Regland B, Forsmark S, Halaouate L, et al. Response to vitamin b12 and folic acid in myalgic encephalomyelitis and fibromyalgia. Sengupta S, ed. PLoS ONE. 2015;10(4):e0124648. Also, eating a diet rich in fiber will support gut microflora that are critical for neurotransmitter production while improving satiety.26Hervik AK, Svihus B. The role of fiber in energy balance. Journal of Nutrition and Metabolism. 2019;2019:1-11. Finally, try to consume less sugar. For additional guidance on improving diet, read this article, which describes the 30-30, 3-3 rule.

Improving lifestyle: Healthy habits can also help improve chronic fatigue symptoms. Listening to music,27Gangrade A. The effect of music on the production of neurotransmitters, hormones, cytokines, and peptides: A review. Music and Medicine. 2012;4(1):40-43. getting safe sun exposure,28Sansone RA, Sansone LA. Sunshine, serotonin, and skin: A partial explanation for seasonal patterns in psychopathology? Innov Clin Neurosci. 2013;10(7-8):20-24. having sex,29Magon N, Kalra S. The orgasmic history of oxytocin: Love, lust, and labor. Indian J Endocr Metab. 2011;15(7):156. or cultivating a mindfulness practice30Harte JL, Eifert GH, Smith R. The effects of running and meditation on beta-endorphin, corticotropin-releasing hormone and cortisol in plasma, and on mood. Biological Psychology. 1995;40(3):251-265. can all affect neurotransmitters and endorphins that modulate energy levels and feelings of wellbeing.  

Coping with chronic fatigue can be physically and emotionally draining. At Anzara Health, we follow a simple mantra: We know, we listen, we care. While most doctors know, they may not have the time to listen or go as deep on the emotional caring as they’d like. 

As a concierge medical practice, we have the time, skills, and emotional capacity to determine what’s causing your chronic fatigue, to work to address it, and to support you along the way. Also, our in-house dietician and health coach complete the holistic approach to treatment that chronic fatigue requires.

Answers to your chronic fatigue questions—and plan to conquer chronic fatigue—are within reach. It just takes working with healthcare providers who know where to look, have the time to listen to your concerns, and care enough to guide you through.

Struggling with chronic fatigue symptoms? Schedule your consultation with Anzara Health’s chronic fatigue experts today.



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