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How To Deal With Fatigue

Fatigue is a common presenting symptom and unfortunately, its treatment is wrapped in woo! This article presents evidence-backed interventions to help you recover from fatigue

Evidence-based strategies for countering fatigue and over-stress

Fatigue is one of the most common concerns that we face in clinical nutrition and complementary health practice. While the estimates of the prevalence of generalised fatigue in patients seeking primary care (i.e. mostly from medical doctors) range widely from ~8% to over 40%, (1, 2) those of us providing secondary care can see this as a primary or associated complaint in many of our clients. Basically, a lot of people we see are tired and they are damn tired of being tired all the time!

Diagnosable disorders like fibromyalgia in the general population affect around 2% of people, and fewer still exhibit chronic fatigue syndrome (CFS). (3) But much of the fatigue seen is a comorbidity of other physical and mental illnesses (depression, in particular, has a very high association with fatigue) (4) but a significant proportion of fatigue is idiopathic or without any apparent cause. (2)

What is fatigue?

What it’s not

It has been stated that around 80% of people in the western world will suffer from ‘Adrenal Fatigue’(5) however, this contention lacks supporting evidence. Adrenal fatigue is usually diagnosed by a ‘catch-all’ questionnaire that makes the diagnosis likely in almost all cases casting immediate doubt on its validity. A functional basis for the questionnaire and the diagnosis of adrenal fatigue because it is thought that ‘hyperadrenia’ (overproduction or excretion of cortisol and other stress hormones) related to acute and chronic stress may eventually lead to hypoadrenia (low cortisol level), matching the exhaustion/fatigue phase of the general adaptation syndrome. (6) However, the vast majority of people presenting symptoms of ‘adrenal fatigue’ show normal or high cortisol levels. (7)

So, what is it?

Fatigue is known, yet hard to define!

It’s related to a range of lifestyle and environmental factors like lack of sleep, reduced clearance of metabolic waste from the brain via the glymphatic system, over-activity of neurons, poor fuelling of neurons and other cells (often related to relative energy deficiency, metabolic disorder, brain injury, or neurodegeneration), oxidative and glycative damage to neurons and other cells, transient (acute) neurotransmitter depletion, transient low cortisol (not ‘adrenal fatigue’) and micronutrient deficiencies.

How do we deal with fatigue? – Evidence-based holistic health practice

There is little published data on treating general fatigue but there is a fairly large body of research on both chronic fatigue and on over-reaching and overtraining in athletes which exhibit very similar effects and causes (over-stress in particular, whether that is training, nutrition, or lifestyle-induced). Often the first step in research begins at both ‘ends of the spectrum’ i.e. performance ßà pathology (disease) because that’s where the money is!

Eat Move and Live Better!

Eat a Natural, Unrefined Diet

Along with the proven benefits of having greater amounts of unrefined (and consequently lesser amounts of ultra-refined foods) in the diet, a diet based on nutrient-dense whole foods will help to reduce the risk of obesity and metabolic disorder, reduce allergens or irritants associated with symptoms of autoimmune conditions, improve gut health through the provision of essential micronutrients and fibres and resistant starches, reduce the burned of oxidation, glycation, and inflammation in the body, and provide for enhanced ‘autoregulation’ of energy intake.

Destress, Meditate and be Mindful

There are a plethora of studies showing the efficacy of meditation for reducing fatigue. Meta-analyses of these studies show a strong effect of mindfulness exercises on stress and fatigue, (8, 9) and have been shown to reduce fatigue in those still suffering from it after already using cognitive behavioural therapy techniques.  (10) Interestingly, as few as four sessions have been shown to reduce fatigue, an effect that wasn’t seen in a control group listening to a relaxing audio recording. (11)

Move!

Exercise is known to reduce stress, anxiety, depression, and pain. At least 20 min is typically required for anxiety-reducing effects. (8, 9) Exercise is also anti-inflammatory, (12) but over-exercise or over-stress from any cause is pro-inflammatory and over half of all sports injuries are also secondary to overuse. (13) Markers of antioxidant status such as glutathione concentration and inflammatory markers such as interleukin 10 are affected by long periods of intense training. (14) So, exercise helps to mitigate stress and fatigue and helps us to modulate inflammatory and antioxidant pathways, BUT too much (over-reaching) can be just as detrimental as too little.

Overreaching and over-training syndrome in athletes is depicted as a continuum, this is also likely to be the case for generalised ‘stress’. So, excessive exercise (or any other stressor) can be depicted as stress à fatigue à burnout. It’s important to remember that we can habituate ourselves to increased levels of exercise and if we start at a level at which we are comfortable and not over-reacting with excessive stress responses and then incrementally increase volume and/or intensity of our training, we can increase our work threshold.

Practical considerations:

Eat to move!

Eating encourages activity and activity encourages eating! Physical activity can help people to spur the appetite that helps people to eat more to cover their nutrient bases (especially micronutrients) provides fuel sufficiency to aid recovery from fatigue and preserve hormonal status. However metabolically disordered people can have inverse effects from physical activity, (15) and it’s important that increased in food, where possible, should mostly be from natural, unrefined sources to encourage optimal nutrient-partitioning (in other words, where the fuel is stored – in muscle or fat cells).

Eat yourself lean

In a study of basic training in the French military, 3% of participants became over-trained and these had higher rates of trauma and trauma was also associated with higher body fat levels. (16)

Fuel sufficiency, lipid sufficiency, and carbohydrate sufficiency are all associated with reduced risk of over-stress/over-training. However, this should be in the context of the fuel demands of the individual athlete. In other words, while increasing carbohydrate in athletes is known to improve free testosterone to cortisol ratios (a common marker of over-reaching), excessive carbohydrate can reduce the metabolic efficiency and worsen body composition, especially in those who are more insulin resistant.  

Eat yourself well

One of the key aspects of over-stress (and over-training) and chronic fatigue is an increased susceptibility to infection. This can be mitigated by fuel sufficiency and a nutrient-dense diet supplying all the primary and secondary nutrients conducive to health but a common under-appreciated aspect of immunity in athletes is the role of protein. Higher protein intake can encourage better regulation of immune and inflammatory status affecting fatigue and its symptoms. (17) The amino acid glutamine, in particular, is likely to reduce the incidence of infections, (18-20) and improve immunity in athletes. (21) Athletes suffering from the overtraining syndrome (OTS) appear to maintain low plasma glutamine levels for months or years. (22)

Take it easy when resuming training and increase volume as able

A sure-fire way to derail your efforts to come back from fatigue is to push your training too hard or to resume overly intense training when you begin to feel better. It is best to start with an almost ridiculously easy volume and intensity and then incrementally increase that to build your overall work-tolerance rather than ‘smashing’ yourself at each session. Important considerations for fatigue are that ‘grind’ lifts with a slower velocity may be preferable to explosive or ‘metabolic-style’ workouts during times of recovery from fatigue due to the reduced volume required for neuromuscular adaptations, reduced eccentric loadings and better overall neuromuscular adaptations post-exercise. (23) Longer rest periods > 2 min per set are also preferred for those in the recovery phase from fatigue and these facilitate an improved free-testosterone to cortisol ratio. (24)

Which supplements might help?

Protein powder: Helps to preserve overall protein intake and provides additional glutamine

Fish oil: Provides omega-3 fatty acids linked to improved immune and inflammatory status

A good quality multi-nutrient product: Providing minerals and vitamins that have demonstrated benefits for those with fatigue – especially, iron (caution should be exercised as some people have high iron levels and are at risk of iron-overload) zinc, copper, selenium, and vitamins A, C, E, and B6 (17, 25)

10 take-home tips!

  1. Drink 2 x large glasses of water first thing upon rising
  2. Eat 6+ serves of vegetables, 2+ serves of berries, and fruit according to your carb tolerance daily
  3. Take a multi (make sure it’s a good one!)
  4. Take fish oil
  5. Meditate daily
  6. Move for at least 20 min per day
  7. Do some resistance training – start back with low-volume strength training. I.e. 2-3 exercises for 1-2 sets of 3-6 reps, 2-6 x per week at a load that you can handle easily (but increase this by small increments as often as possible!)
  8. Base your meals on quality protein
  9. Don’t be scared of naturally occurring fats
  10. Eat carbs according to your activity levels, and tolerance BUT not at the expense of vegetable or protein intake

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References

1.            Fuhrer R, Wessely S. The epidemiology of fatigue and depression: a French primary-care study. Psychological Medicine. 2009;25(5):895-905.

2.            Bates DW, Schmitt W, Buchwald D, et al. Prevalence of fatigue and chronic fatigue syndrome in a primary care practice. Archives of Internal Medicine. 1993;153(24):2759-65.

3.            Goldenberg DL. Fibromyalgia, chronic fatigue syndrome, and myofascial pain. Current Opinion In Rheumatology. 1996;8(2):113-23.

4.            Stadje R, Dornieden K, Baum E, Becker A, Biroga T, Bösner S, et al. The differential diagnosis of tiredness: a systematic review. BMC Family Practice. 2016;17(1):147.

5.            Warren B. View | BePure 2016 [Available from: http://www.bepure.co.nz/learn/view/41.

6.            Anderson DC. Assessment and nutraceutical management of stress-induced adrenal dysfunction. Integrative Medicine: A Clinician’s Journal. 2008;7(5):18-25 8p.

7.            Shah R, Greenberger PA. Chapter 29: Unproved and controversial methods and theories in allergy-immunology. Allergy And Asthma Proceedings: The Official Journal Of Regional And State Allergy Societies. 2012;33 Suppl 1:S100-S2.

8.            Grossman P, Niemann L, Schmidt S, Walach H. Mindfulness-based stress reduction and health benefits: A meta-analysis. Journal of Psychosomatic Research. 2004;57(1):35-43.

9.            Petruzzello SJ, Landers DM, Hatfield BD, Kubitz KA, Salazar W. A Meta-Analysis on the Anxiety-Reducing Effects of Acute and Chronic Exercise. Sports Medicine. 1991;11(3):143-82.

10.         Rimes KA, Wingrove J. Mindfulness-Based Cognitive Therapy for People with Chronic Fatigue Syndrome Still Experiencing Excessive Fatigue after Cognitive Behaviour Therapy: A Pilot Randomized Study. Clinical Psychology & Psychotherapy. 2013;20(2):107-17.

11.         Zeidan F, Johnson SK, Diamond BJ, David Z, Goolkasian P. Mindfulness meditation improves cognition: Evidence of brief mental training. Consciousness and Cognition. 2010;19(2):597-605.

12.         Woods JA, Vieira VJ, Keylock KT. Exercise, Inflammation, and Innate Immunity. Immunology and Allergy Clinics of North America. 2009;29(2):381-93.

13.         Wilder RP, Sethi S. Overuse injuries: tendinopathies, stress fractures, compartment syndrome, and shin splints. Clinics in Sports Medicine. 2004;23(1):55-81.

14.         Varamenti EI, Kyparos A, Veskoukis AS, Bakou M, Kalaboka S, Jamurtas AZ, et al. Oxidative stress, inflammation and angiogenesis markers in elite female water polo athletes throughout a season. Food and Chemical Toxicology. 2013;61:3-8.

15.         Melzer K, Kayser B, Saris WHM, Pichard C. Effects of physical activity on food intake. Clinical Nutrition. 2005;24(6):885-95.

16.         Bauvent Y, Malgoyre A, Sanchez H, Thefenne L, Ginon B. Study of tolerance and fatigue during the basic training program in the French army among young recruits. Study of the impact on strength and endurance. Annals of Physical and Rehabilitation Medicine. 2014;57, Supplement 1:e272.

17.         Lesourd BM, Mazari L. Immune responses during recovery from protein-energy malnutrition. Clinical Nutrition. 1997;16, Supplement 1:37-46.

18.         Castell LM, Poortmans JR, Newsholme EA. Does glutamine have a role in reducing infections in athletes? Eur J Appl Physiol Occup Physiol. 1996;73(5):488-90.

19.         Castell LM, Newsholme EA. The effects of oral glutamine supplementation on athletes after prolonged, exhaustive exercise. Nutrition. 1997;13(7-8):738-42.

20.         Castell LM, Newsholme EA. Glutamine and the effects of exhaustive exercise upon the immune response. Canadian journal of physiology and pharmacology. 1998;76(5):524-32.

21.         Castell LM. Can glutamine modify the apparent immunodepression observed after prolonged, exhaustive exercise? Nutrition. 2002;18(5):371-5.

22.         Rowbottom DG, Keast D, Morton AR. The emerging role of glutamine as an indicator of exercise stress and overtraining. Sports medicine (Auckland, NZ). 1996;21(2):80-97.

23.         Lopes CR, Crisp AH, Rodrigues AL, Teixeira AG, da Mota GR, Verlengia R. Fast contraction velocity in resistance exercise induces greater total volume load lifted and muscle strength loss in resistance-trained men. Revista Andaluza de Medicina del Deporte. 2012;5(4):123-6.

24.         Rahimi R, Rohani H, Ebrahimi M. Effects of very short rest periods on testosterone to cortisol ratio during heavy resistance exercise in men. Apunts Medicina de l’Esport. 2011;46(171):145-9.

25.         Keith ME, Jeejeebhoy KN. Immunonutrition. Baillière’s Clinical Endocrinology and Metabolism. 1997;11(4):709-38.

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