Nutritional Considerations in Chronic Fatigue Syndrome
by John W. Cartmell, LMP
As a massage therapy specialist, I've had a number of clients diagnosed with Chronic Fatigue Syndrome (CFS). Chronic Fatigue Syndrome is associated with long-term problems of fatigue or exhaustion inconsistent with the amount of physical exertion, which persist for 6 months or more. It generally does not respond to rest and often results in extreme debilitation. Symptoms may include problems with concentration, reading or comprehension, blurred vision or pain in the eyes, and increased sensitivity to temperatures, odors, foods, or allergies. Symptoms of chest pain, irregular heart beat, digestive problems, muscle twitching or cramps are also common.
The causes of CFS are not well understood nor is the disease well defined; it's sometimes referred to as Chronic Fatigue and Immune Dysfunction Syndrome (CFIDS). Like many diseases, CFS may have more than one cause. Fatigue problems can be caused by toxicity from industrial chemicals or prescribed medications, or result from chronic infection, trauma injury or excessive stress. An imbalance in thyroid, pituitary or adrenal hormones can cause chronic fatigue, as can a dietary insufficiency or imbalance.
Virtually any disease can be caused or made worse if the diet is inadequate to support health. When I developed symptoms of CFS in 1994, I began to explore the possible link between CFS and sub-optimal nutrition. I eventually discovered a basic dietary imbalance that, when corrected, solved my 5-year problems of chronic fatigue.
Sodium is an essential nutrient for fluid balance. The actual amount of sodium required per day is unknown, but the recommended amount for adults varies from a minimum of 200 milligrams to an upper limit of 3,000 milligrams; approximately the amount of sodium in 1¼ teaspoon (7.6 grams) of salt .1,3 The mean daily intake of salt for Americans is around 10 grams per day; approximately 3 grams occurring naturally in foods, another 3 grams from processed foods and 4 grams added during meals.1, 2 Using one-fourth to one-half teaspoon of added salt per day is generally regarded as reasonable and safe. The highest sources of sodium in the diet are salt, animal protein, processed foods and chemically softened water. A diet chronically high in water and potassium, and low in animal protein, processed foods or added salt can potentially lead to sodium depletion. 1, 4
Symptoms of low blood sodium (hyponatremia) include extreme debilitating fatigue, aching skeletal muscles, abnormally high blood pH, chronic low blood pressure, orthostatic tachycardia, cardiac arrythmias and profuse sweating upon minimal exertion.1, 4 Hyponatremia in competitive sports is a growing concern, and in noncompetitive sports such as desert hiking, cases have skyrocketed in the last decade.6 Mild to moderate hyponatremia can often be corrected by simply increasing dietary sodium.6 More severe cases may require a restriction of water, and/or the administration of corticosteroids to support adrenal function. 4
The volume and composition of body fluids are controlled by water ingestion and excretion, acid-base reactions and electrolytes (salts). These mechanisms are closely interrelated and imbalances are typically multiple disturbances.4 Electrolytes such as sodium play essential roles in maintaining proper fluid pH, ionic balance (osmolarity), and fluid pressure. If you disrupt the electrolytic balance, then the body's physiology in general can become disturbed.
Adrenal hormones, "aldosterone" and "cortisone", regulate fluid balance and nutrient levels. Aldosterone controls blood sodium and potassium levels. If potassium levels become too high, aldosterone is secreted causing the kidneys to excrete more potassium and retain more sodium. Low sodium can also stimulate the secretion of aldosterone.1, 2, 3, 4 A diet chronically high in potassium or low in sodium can stress the adrenals.1 Excess potassium is also a natural diuretic and causes some loss of sodium. Foods highest in potassium include whole fruits and vegetables and their juices.1
Cortisol stimulates the breakdown of proteins and fats, and provides for the conversion of some amino acids into glucose as needed (gluconeogenesis). If the diet is deficient in protein, or if digestion of protein is inadequate, extra cortisol must be produced to break down muscle tissue for needed amino acids. This extra demand on the adrenals could conceivably lead to adrenal fatigue and cortisol deficiency with impaired gluconeogenesis, decreased glycogen production, hypoglycemia and a decrease in metabolism.2, 3, 4 Neuromuscular functions might also decrease, as well as resistance to infections, inflammations and/or stress.3, 4 The decreased resistance to stress and disease could increase susceptibility to infections of Epstein Barr or other viruses. In this respect, Epstein Barr, common in people with CFS, may be more an opportunistic infection and a symptom of immune system weakness rather than a direct cause of CFS. Insufficient dietary protein or impaired protein digestion, coupled with an excess of cortisol production and breakdown of muscle tissue, could be a factor in the cause of Fibromyalgia, a soft tissue condition often seen in people with CFS.
When the adrenals become fatigued and unable to release adequate amounts of aldosterone or cortisol, potassium levels rise, sodium and blood sugar levels fall, body fluid volume decreases and hypotension and dehydration can result.3, 4 Aerobic exercise or caffeine consumption can add more stress to the adrenals. Massive water ingestion can also aggravate the condition and lead to a high-water/low-sodium state called "dilutional hyponatremia". 3, 4
If adrenal function is impaired, the physiological balance can become disrupted. High blood potassium (hyperkalemia), low blood sodium, and hypotension, together, suggest adrenal insufficiency.4 Indeed, these are classic symptoms of Addison's disease, a chronic and progressive adrenal disease associated with adrenocortical hypo-function, including insufficient production of cortisol and aldosterone.2 The early signs of Addison's disease include weakness, fatigue and orthostatic hypotension.4 Many who have Addison's disease appear healthy, but they experience acute adrenocortical insufficiency when under stress.4 This is also true in people with CFS. Could CFS be related to Addison's disease?
If the physiological balance is disrupted, normal adrenal function can become impaired. The classic symptoms of Addison's disease, high blood potassium, low blood sodium, and hypotension, can be induced by improper diet or lifestyle and potentially result in adrenal insufficiency. In such cases, diet and lifestyle patterns should be considered in order to promote normal adrenal health and function.
My work as a massage therapist is very physical and used to leave me drenched in sweat and short of breath. My blood pressure was low and my heart beat irregular. I was usually too exhausted in the evenings to even watch TV. I would get up in the morning fatigued and would have to lie down for an hour in the afternoon. If I were busy, I would skip lunch and just get by with an espresso. I didn't avoid salt specifically, but I'd gotten in the habit of not using it. My skeletal muscles ached and were abnormally hardened, and a muscle injury at the elbow would not heal after 6 months. Muscle cramps were a common occurrence. I ate very few processed foods, had 4-8 servings of juice, fresh fruit or vegetables each day and drank water when thirsty, generally about 64 ounces a day.
Working with the balance of sodium and potassium seemed to benefit me greatly. A teaspoon of salt before doing massage decreased my sweating and significantly improved my energy. However, keeping sodium and potassium in a proper balance seemed difficult. If I took a little too much potassium, I would fall back into exhaustion and excessive sweating. Too much salt seemed to drive out potassium and I would have problems with muscle cramps. I felt I was on the right track, but I still lacked a real answer to my problems of chronic fatigue.
In the fall of 1999, I was reading the book Natural Alternatives to Over the Counter and Prescription Drugs, by Michael T. Murray, N.D. Dr. Murray discussed the different common forms of calcium supplements, and how calcium carbonate tends to neutralize stomach acid more than calcium citrate. He advised supplementing with calcium citrate and using hydrochloric acid tablets (Betaine HCl) if necessary to better insure complete digestion. Hydrochloric acid is secreted by the stomach and aids in the first stage of protein digestion.
I had been taking calcium carbonate with meals for years and, although my diet had ample amounts of protein, I wondered if the calcium carbonate might be inhibiting protein digestion and whether that could be a factor in my fatigue. I began taking the calcium carbonate between meals and noticed a definite improvement in energy. When I started taking Betaine HCl with meals, the results were truly remarkable. Within a day, there was a significant increase in energy and stamina. Within weeks, the muscle injury of six months healed. My muscle discomfort substantially improved and areas that were hardened became much more normal. The excess sweating during work ceased and the problems of chronic fatigue vanished.
Socioeconomic changes may be related to the modern day advent of Chronic Fatigue Syndrome. In the mid 1970s, national food standards for processed foods were revised in order to limit the amount of salt added by food processors to soups, snacks and other foods. People became wary of salt and got in the habit of consciously avoiding it. Processed food manufacturers followed the market by giving the public what they wanted--salt free foods. The general avoidance of dietary salt continues to this day. Twenty-five years ago, Americans were thought to be eating too much salt. Now, some may be getting too little salt and as a result, may be experiencing problems of adrenal exhaustion and chronic fatigue.
The early and mid 1970s saw the beginning of the modern day "health and nutrition" movement. People became interested in natural foods and nutrition, and aware of the importance of taking dietary supplements. By the early to mid 1980s, people were taking more dietary supplements, using less salt and sometimes experiencing problems of chronic fatigue. "Chronic Fatigue Syndrome" became an officially recognized disease. I wonder if a general avoidance of salt, or consumption of calcium supplements with meals could sometimes cause CFS.
An active lifestyle focused on health and fitness is especially popular with young, upwardly mobile professionals (YUPPIES). In the mid 1980s, Chronic Fatigue Syndrome was sometimes referred to as "YUPPY FLU", which often manifested after a metabolic stress from trauma or an infection like the flu. The inability to fully recover from such trauma or illness is consistent with problems of adrenal exhaustion and a common symptom in people with CFS.
From the late 1980s to the present, there has been an increased interest in health and fitness with a focus on physical exercise, high consumption of water, juices, fruits and vegetables, and an avoidance of salt and processed foods. In spite of this interest in health and fitness, CFS has persisted as a common ailment of unknown origin. More than 75% of my clients diagnosed with CFS work out regularly, avoid salt and are preoccupied with drinking lots of water or juice. They usually have hypotension as well. Could a lifestyle of health club workouts, increased ingestion of water, juices, fruits and vegetables and avoidance of salt be causing adrenal exhaustion and contributing to the prevalence of CFS? The cause of Addison's disease is unknown in 70% of cases.4 I wonder if the classic "symptoms" of Addison's disease -- high blood potassium, low blood sodium and hypotension -- could also be the "cause" of CFS, and whether these two diseases could be related in cause and effect.
An imbalance or insufficiency of virtually any nutrient can potentially cause problems of chronic fatigue. These two models of adrenal insufficiency--one caused by an imbalance of sodium, potassium and water osmolarity, the other by an inadequate intake or insufficient digestion of proteins--suggest specific dietary concerns which may be common in the etiology of Chronic Fatigue Syndrome. In cases of CFS where nutritional imbalance or insufficiency may be a factor, dietary assessment and revision may offer the best approach to treatment and cure.
1. Mahan, L. Kathleen, Escott-Stump, Sylvia, Krause's Food, Nutrition, & Diet Therapy, 9th Edition, W.B. Saunders Company, Division of Harcourt Brace & Co., Philadelphia, PA, 1996
2. Hole, John W. Jr, Human Anatomy and Physiology, 2nd Edition, Wm. C. Brown Company, Dubuque, Iowa, 1981
3. Guyton, Arthur C., Hall, John E., Textbook of Medical Physiology, 9th Edition, W.B. Saunders Company, Division of Harcourt Brace & Co., Philadelphia, PA, 1996
4. Berkow, Robert, Beers, Mark H, Editors, The Merck Manual of Diagnosis and Therapy, 17th Edition, Merck Research Laboratories, Division of Merck & Co., Inc., Whitehouse Station, N.J., 1999
5. Murray, Michael T, Natural Alternatives to Over-the-Counter and Prescription Drugs, William Morrow and Co. Inc., New York, 1994
6. Kauder, Carol, Mr. Salty to the Rescue, Outside Magazine, Apr. 2000, Mariah Publications Corp., Santa Fe, NM
© 2002 John W. Cartmell, LMP
John W. Cartmell, LMP has been a Licensed Massage Practitioner in Washington State since 1985, and has published articles on massage, health and nutrition in numerous professional journals. He specialized in the treatment of people with chronic and acute pain, fibromyalgia, chronic fatigue, migraines, hip and shoulder problems, arthritis and trauma injuries. He is currently completing work on a Master's degree in nutritional research. This article was originally published in 'Frontier Perspectives', Spring 2000, Vol. 9 Number 1, by The Center for Frontier Sciences at Temple University; reprinted in Townsend Letter for Doctors and Patients, Nov. 2001. Visit the author's web site at http://www.dietadvisor.com.