Unraveling the Binding Web of Fatigue
Explore diagnosis and treatment options for this pervasive problem with Anne Walch.

Whether a woman is in her thirties or in her seventies, whether she is a mother or she is childless, partnered or single, working inside the home or out, one of the most frequent concerns a woman will bring up with her health care practitioner is that she is lacking in energy. For some women, their fatigue is a debilitating central feature of their life, whereas for the majority of women, fatigue is more a fact of life they have learned to contend with.

Just as there can be widely varying degrees of fatigue, so there are widely varying causes for it. Fatigue can be a complex, multi-factorial, overlapping web of causes and effects. Physical, emotional, psychological, social, economic, and cultural aspects all have to be considered. Where does one even start to unravel the web that binds one in low energy?

As an integrative medical practitioner, I give attention to all of the potential non-physical aspects that feed fatigue, but I primarily focus on the physical factors. Often, by addressing and alleviating the physical causes of fatigue, a woman will have more mental and physical energy to address the emotional and social factors that have also been draining her.

Important clues as to which paths to follow in treating a woman for fatigue will come from carefully listening to her story, asking pertinent questions, performing a thorough physical exam, and taking into consideration the results of lab evaluations. The basic principle of effective treatment is to restore the body's healthy balance by attempting to address the deepest roots of the problem, in as safe, natural, and cost-effective manner as possible.

The underlying physical causes for a woman's fatigue have to be sought from a long list of possible factors. Fatigue can be a symptom of a chronic illness such as fibromyalgia, hypothyroidism, diabetes, heart disease, cancer, multiple sclerosis, lupus, or rheumatoid arthritis. Certain prescription medications can contribute to fatigue. Anemia or other nutritional deficiencies can create fatigue. Depression, sleep disturbances, hormonal imbalances, food sensitivities, infections, and toxicities all need to be considered when evaluating a woman with fatigue. Let's look at a few of the most rewarding fatigue-busting treatment strategies.

Regardless of the ultimate diagnosis and treatment, the most fundamental and ongoing intervention for fatigue is that of diet and nutrition. There is always going to be room for improvement in a woman's energy level if she has been using sweets, alcohol, caffeine, and eating the typical high-carbohydrate American diet. According to USDA surveys, Americans consume, on average, 64 pounds of sugar and sweeteners a year(1) This sugar is consumed in the obviously sweet form of candies, cakes, sodas, and fruit juices. However, significant portion of sugar creeps into our diets via the refined carbohydrates found in bagels, bread, cereals, pasta, chips, crackers, and grains.

If you think of food as fuel, eating a preponderance of refined carbohydrates at each meal is like trying to warm your house with burning newspaper. Sure, there is a quick flash of energy, but there is no sustaining energy. If you want the glowing, sustaining embers of energy like a long-burning oak log, choose to eat healthy fats and adequate protein at each meal, and as snacks. Good sources for protein include eggs, cheese, nuts and seeds, fish, lean meat, and soy products. Women need a minimum of 50gm protein /day (1oz. meat/fish=7gm, 1 egg=6gm.) Healthy fats include extra virgin olive oil, butter, and coconut oil. The best carbohydrates to eat are those from the garden, not the ones from the bakery.

Alcohol is a very concentrated form of sugar and should be used at a minimum if you are troubled by low energy. Caffeine is similar to sugar in that it appears to be a quick source of energy, but in the long run, its regular use will only run you down more. Taper off slowly if you have more than a two cup per day habit. Nicotine gives a quick hit of energy, but it is another artificial energy source that will end up robbing you of energy, if not your natural lifespan. Even if you eat fairly well, there is still a good chance that you are nutritionally deficient in some areas. Many American's diets don't provide the recommended daily amounts (RDA) of all the vitamins and minerals.(2) Supplementation with vitamins, minerals, and amino acids can be very helpful. A basic high-potency multi-vitamin/mineral formula is recommended as a basic supplement for women with fatigue. Magnesium is a mineral that has been shown to be beneficial to patients with fatigue.(3) Individualized amino acid therapy has also been shown to help fatigue.(4) Specific deficiencies of amino acids, essential fatty acids, vitamins and minerals can be assessed with specialized lab tests.

Anemia is a very common cause of fatigue. Iron deficiency is the most common anemia with 5% of US women having it.(5) Simple blood tests can determine if a women is iron deficient. Fortunately, iron deficiency can be easily treated with iron supplements and/or dietary additions.

Vitamin B12 deficiency is another form of anemia that should be considered, particularly in fatigued vegans, vegetarians, elderly, and women with digestive problems. It is often worth giving a trial of vitamin B12 by injection for some fatigued women. I could not find research to directly support a trial of this sort, but many clinicians continue to offer it based on the good results it has provided many of their patients--and it is safe and inexpensive.

Another area in which fatigue can be related to diet is that of unsuspected food allergies or sensitivites.(6) The foods most likely to cause problems are wheat, dairy, corn, eggs, citrus and food additives. There are various means to test for food sensitivities, with the most straightforward and least expensive being an elimination diet. Food sensitivities are a controversial topic but worth exploring, especially when other treatment approaches have not yielded results.

After addressing diet and nutritional issues, another key area for investigation that can yield relatively rapid turnarounds in energy levels is that of hormonal balance, specifically thyroid, adrenal, and female hormones.

Low thyroid function, i.e. hypothyroidism, is a very common problem in women. In addition to fatigue, hypothyroid women may also have constipation, weight gain, dry skin, hair loss, menstrual irregularities, feel cold and have low body temperatures. It is estimated that one in eight women between the ages of 18 and 65 are affected, and after the age of 65 about 20% of women can be affected. Unfortunately, millions of women who are hypothyroid are undiagnosed or under-treated. (9)

Thyroid function is best assessed on the basis of symptoms, physical exam, sub-normal daytime body temperatures as well as lab tests. Integrative medical practitioners will give hypothyroid women thyroid supplements, but usually get better results using a T4 and T3 thyroid replacement rather than the T4-only products such as Synthroid.(10)
Low adrenal function will be a problem in some women with fatigue. This is suspected in women who also have low blood pressures, salt cravings, hypoglycemia, poor stamina, poor stress tolerance, recurring infections, and/or numerous allergies. Saliva and blood tests are available to confirm the condition. A diet low in refined-carbohydrate and with adequate protein, vitamins, herbs, and even bio-identical adrenal hormones can be quite helpful in improving the condition. Stress management modalities are particularly important in women with low adrenal function.

Women that have imbalances of their female hormones, estrogen and progesterone, will complain of menstrual irregularities, moodiness, irritability, bloating, along with low energy. Blood, saliva and urine tests are available to aid in assessing the particular imbalance. Often, herbal treatments can help rebalance female hormones. When herbs aren't enough, then bio-identical female hormones may be prescribed. The improvements in energy can be quite dramatic in peri- and post-menopausal women who finally get good quality sleep after even a few days of the right hormone prescription.

Attending to a woman's diet, nutritional status and hormonal balance will go a long way in improving her energy, and in a surprisingly short time frame. These strategies, because they operate at such a fundamental level, will help even if there are additional causes for her low energy. By addressing such key areas as nutrition and hormonal balance, a foundation has been established to further explore other causes of fatigue.

Anne Walch, MHS, PAC, graduated from Duke University's physician assistant program in 1985 and works at Asheville Integrative Medicine. Her email is awalch9@yahoo.com.

Recommended resources: Teitelbaum, Jacob. From Fatigued to Fantastic. Avery Publishing, New York, 1996. www.thyroid-info.com.
References:
1. CW Enns and others. Trends in Food and Nutrient Intakes by Adults: NFCS 1977-78, CSFII 1989-91, and CFSII 1994-95. Fam Econom Nutr Rev, 1997, 10:4:2-15
2. Mertey W, ed. "Beltsville 1 year dietary intake survey. Am J Clin Nutr. 40, suppl(Dec 1984):1323-1403.
3. Cox IM, et al. Red blood cell magnesium and chronic fatigue syndrome. Lancet.1991; 337:757-760.
4. Bralley JA, Lord RS. Treatment of chronic fatigue syndrome with specific amino acid supplementation. J Appl Nutr.1994;46(3):74-78.
5. Looke, AC et al. Prevalence of iron deficiency in the U.S. JAMA.1997;277:973-976.
6. Brostoff, Jonathan and Gamlin, Linda. Food Allergies and Food Intolerances: The Complete Guide to their Identification and Treatment. Inner Traditions Intl, May 2000.
8. Canaris GJ et al. The Colorado thyroid disease prevalence study. Arch Intern Med. 2000; 160:526-534.
19. Bunevicius R et al. Effects of thyroxine as compared with thyroxine plus triiodothyronine in patients with hypothyroidism. N Eng J Med. 1999 Feb 11:340(6)424-429.

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