Chronic Fatigue Syndrome

Also indexed as: CFIDS, CFS

What you need to know

You can defeat chronic fatigue syndrome. With no single known cause, this syndrome largely remains a mystery. According to research or other evidence, the following self-care steps may be helpful:

Gradually increase exercise
Even if you must begin with only a few minutes at a time, exercise can help you feel better

Check out L-carnitine
Take 1 gram three times a day to provide a nutrient important for energy production

Try NADH
10 mg per day of the active coenzyme form of vitamin B3 (nicotinamide adenine dinucleotide) may help your body produce more energy

Consider vitamin B12 injections
Consult a doctor for a trial of 2,500 to 5,000 mcg every two or three days for a few weeks to make up possible deficiency

Consult an expert
Find an experienced professional to help manage the symptoms of this challenging disease

Get stress-reduction counselling
For coping strategies, find a qualified counsellor experienced in helping people with chronic fatigue syndrome

These recommendations are not comprehensive and are not intended to replace the advice of your doctor or chemist. Continue reading the full chronic fatigue syndrome article for more in-depth, fully-referenced information on medicines, vitamins, herbs, and dietary and lifestyle changes that may be helpful.

About chronic fatigue syndrome

Chronic fatigue syndrome (CFS) is disabling fatigue lasting more than six months that reduces activity by more than half. CFS is a poorly understood disease involving many body systems. No single cause of CFS has been identified, therefore, it is diagnosed by symptoms and by ruling out other known causes of fatigue by a doctor.

Suggested causes include chronic viral infections, food allergy, adrenal gland dysfunction, and many others. None of these have been convincingly documented in more than a minority of sufferers. In some people there is also difficulty sleeping, swollen lymph nodes, and/or mild fever. When there is muscle soreness, fibromyalgia may be the actual problem. Although CFS is considered a modern diagnosis, it may have existed for centuries under other names, such as “the vapours,” neurasthenia, “effort syndrome” (diagnosed in World War I veterans), hypoglycaemia, and chronic mononucleosis.

Product ratings for chronic fatigue syndrome

Rating	Nutritional Supplements	Herbs
	L-carnitine NADH Potassium-magnesium aspartate Vitamin B12
	DHEA Fish oil (EPA/DHA) Magnesium	Asian ginseng Eleuthero Liquorice
Reliable and relatively consistent scientific data showing a substantial health benefit. Contradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit. For an herb, supported by traditional use but minimal or no scientific evidence. For a supplement, little scientific support and/or minimal health benefit.

What are the symptoms?

In addition to fatigue, there may also be muscle pain, joint pain not associated with redness or swelling, short-term memory loss, and an inability to concentrate. Some people with chronic fatigue syndrome also experience difficulty sleeping, swollen lymph nodes, and/or mild fever.

Dietary changes that may be helpful

Some doctors believe that people with CFS who have low blood pressure should not restrict their salt intake. Among CFS sufferers who have a form of low blood pressure triggered by changes in position (orthostatic hypotension), some have been reported in a preliminary study to be helped by additional salt intake.¹ People with CFS considering increasing salt intake should consult a doctor before making such a change. (See the Herb information, below, for more information on blood pressure and CFS.)

Lifestyle changes that may be helpful

Exercise is important to prevent the worsening of fatigue. Many people report feeling better after undertaking a moderate exercise plan.² ³ However, most people with CFS are sensitive to overexertion, and excessive exercise may lead to consistently worsening fatigue and mental functioning.⁴ ⁵ ⁶ Exercise should be attempted gradually, starting with very small efforts. One small study found that intermittent exercise, in which patients walked for three minutes followed by three minutes of rest for a total of 30 minutes, did not exacerbate their CFS symptoms.⁷

Other therapies

Some healthcare providers recommend a combination of lifestyle changes (aerobic exercise, healthy diet, and stress reduction), light therapy, and psychological counselling.

Vitamins that may be helpful

The combination of potassium aspartate and magnesium aspartate has shown benefits for chronically fatigued people in double-blind trials.⁸ ⁹ ¹⁰ ¹¹ However, these trials were performed before the criteria for diagnosing CFS was established, so whether these people were suffering from CFS is unclear. Usually 1 gram of aspartates is taken twice per day, and results have been reported within one to two weeks.

Vitamin B12 deficiency may cause fatigue. However, some reports,¹² even double-blind ones,¹³ have shown that people who are not deficient in B12 have increased energy following a series of vitamin B12 injections. Some sources in conventional medicine have discouraged such people from taking B12 shots despite this evidence.¹⁴ Nonetheless, some doctors have continued to take the limited scientific support for B12 seriously.¹⁵ In one preliminary trial, 2,500 to 5,000 mcg of vitamin B12 given by injection every two to three days led to improvement in 50 to 80% of a group of people with CFS; most improvement appeared after a few weeks of B12 shots.¹⁶ While the research in this area remains preliminary, people with CFS considering a trial of vitamin B12 injections should consult a doctor. Oral or sublingual B12 supplements are unlikely to obtain the same results as injectable B12, because the body’s ability to absorb large amounts is relatively poor.

A preliminary trial has shown that people with CFS have reduced functional B-vitamin status when compared to people without the condition.¹⁷ The functional vitamin deficiency seen in this study was most pronounced for vitamin B6. Double-blind trials are needed to establish whether B-vitamin supplementation is effective in people with chronic fatigue syndrome.

L-carnitine is required for energy production in the powerhouses of cells (the mitochondria). There may be a problem in the mitochondria in people with CFS. Deficiency of carnitine has been seen in some CFS sufferers.¹⁸ One gram of carnitine taken three times daily for eight weeks led to improvement in CFS symptoms in one preliminary trial.¹⁹ Supplementation with 6 grams of L-carnitine per day for four weeks also improved fatigue in a preliminary study of patients with advanced cancer.²⁰ Similar improvements were seen in another study of patients with advanced cancer given up to 3 grams of L-carnitine per day for one week.²¹

NADH (nicotinamide adenine dinucleotide) helps make ATP, the energy source the body runs on. In a double-blind trial, people with CFS received 10 mg of NADH or a placebo each day for four weeks.²² Of those receiving NADH, 31% reported improvements in fatigue, decreases in other symptoms, and improved overall quality of life, compared with only 8% of those in the placebo group. Further double-blind research is needed to confirm these findings.

Magnesium levels have been reported to be low in CFS sufferers. In a double-blind trial, injections with magnesium improved symptoms for most people.²³ Oral magnesium supplementation has improved symptoms in those people with CFS who previously had low magnesium levels, according to a preliminary report, although magnesium injections were sometimes necessary.²⁴ These researchers report that magnesium deficiency appears to be very common in people with CFS. Nonetheless, a few other researchers report no evidence of magnesium deficiency in people with CFS.²⁵ ²⁶ ²⁷ The reason for this discrepancy remains unclear. If people with CFS do consider magnesium supplementation, they should have their magnesium status checked by a doctor before undertaking supplementation. It appears that only people with magnesium deficiency benefit from this therapy.

DHEA (dehydroepiandrosterone) is a hormone now available as a supplement. In one report, DHEA levels were found to be low in people with CFS.²⁸ Another research group reported that, while DHEA levels were normal in a group of CFS patients, the ability of these people to increase their DHEA level in response to hormonal stimulation was impaired.²⁹ Whether supplementation with DHEA might help CFS patients remains unknown due to the lack of controlled research. DHEA should not be used without the supervision of a healthcare professional.

In a preliminary study, four patients with chronic fatigue syndrome reported an improvement in their symptoms after taking an essential fatty acid supplement daily for at least 12 weeks.³⁰ The amount used was 10 to 18 capsules per day, and each capsule contained 93 mg of eicosapentaenoic acid (EPA), 29 mg of docosahexaenoic acid (DHA), and 10 mg of gamma-linolenic acid. Because there was no placebo group in this study and, because fatigue often improves after treatment with a placebo, additional research is needed to confirm this report.

Are there any side effects or interactions?
Refer to the individual supplement for information about any side effects or interactions.

Herbs that may be helpful

Some research suggests that CFS may be partially due to low adrenal function resulting from different stressors (e.g., mental stress, physical stress, and even viral illness) and impacting the normal communication between the hypothalamus, pituitary gland, and the adrenal glands.³¹ Liquorice root is known to stimulate the adrenal glands and to block the breakdown of active cortisol in the body.³² One case report described a man with CFS whose symptoms improved after taking 2.5 grams of liquorice root daily.³³ While there have been no controlled trials to test liquorice in patients with CFS, it may be worth a trial of six to eight weeks using 2 to 3 grams of liquorice root daily.

Adaptogenic herbs such as Asian ginseng and eleuthero may also be useful for CFS patients—the herbs not only have an immunomodulating effect but also help support the normal function of the hypothalamic-pituitary-adrenal axis, the hormonal stress system of the body.³⁴ These herbs are useful follow-ups to the six to eight weeks of taking liquorice root and may be used for long-term support of adrenal function in people with CFS. However, no controlled research has investigated the effect of adaptogenic herbs on CFS.

Are there any side effects or interactions?
Refer to the individual herb for information about any side effects or interactions.

Integrated approaches that may be helpful

Highly stressful situations should be avoided by people with CFS. Coping mechanisms for dealing with stress can sometimes be maximized by behavioural therapy, which has been shown helpful for people with CFS in a few controlled studies.³⁵

References

1. De Lorenzo F, Hargreaves J, Kakkar VV. Pathogenesis and management of delayed orthostatic hypotension in patients with chronic fatigue syndrome. Clin Auton Res 1997;7:185–90.

2. Fulcher KY, White PD. Randomised controlled trial of graded exercise in patients with the chronic fatigue syndrome. Br Med J 1997;314:1647–52.

3. McCully KK, Sisto SA, Natelson BH. Use of exercise for treatment of chronic fatigue syndrome. Sports Med 1996;21:35–48 [review].

4. Blackwood SK, MacHale SM, Power MJ, et al. Effects of exercise on cognitive and motor function in chronic fatigue syndrome and depression. J Neurol Neurosurg Psychiatry 1998;65:541–6.

5. LaManca JJ, Sisto SA, DeLuca J, et al. Influence of exhaustive treadmill exercise on cognitive functioning in chronic fatigue syndrome. Am J Med 1998;105:59S–65S.

6. Paul L, Wood L, Behan WM, et al. Demonstration of delayed recovery from fatiguing exercise in chronic fatigue syndrome. Eur J Neurol 1999;6:63–9.

7. Clapp LL, Richardson MT, Smith JF, et al. Acute effects of thirty minutes of light-intensity, intermittent exercise on patients with chronic fatigue syndrome. Phys Ther 1999;79:749–56.

8. Shaw DL, Chesney MA, Tullis IF, Agersborg HPK. Management of fatigue: a physiologic approach. Am J Med Sci 1962;243:758–69.

9. Crescente FJ. Treatment of fatigue in a surgical practice. J Abdom Surg 1962;4:73.

10. Hicks J. Treatment of fatigue in general practice: a double-blind study. Clin Med 1964;Jan:85–90.

11. Formica PE. The housewife syndrome: treatment with the potassium and magnesium salts of aspartic acid. Curr Ther Res 1962;Mar:98–106.

12. Kaufman W. The use of vitamin therapy to reverse certain concomitants of aging. J Am Geriatr Soc 1955;3:927–36.

13. Ellis FR, Nasser S. A pilot study of vitamin B12 in the treatment of tiredness. Br J Nutr 1973;30:277–83.

14. Lawhorne L, Rindgahl D. Cyanocobalamin injections for patients without documented deficiency. JAMA 1989;261:1920–3.

15. Gaby AR. Literature Review & Commentary. Townsend Letter for Doctors & Patients 1997;Feb/Mar:27 [review].

16. Lapp CW, Cheney PR. The rationale for using high-dose cobalamin (vitamin B12). CFIDS Chronicle Physicians’ Forum 1993;Fall:19–20.

17. Heap LC, Peters TJ, Wessely S. Vitamin B status in patients with chronic fatigue syndrome. J R Soc Med 1999;92:183–5.

18. Kuratsune H, Yamaguti K, Takahashi M, et al. Acylcarnitine deficiency in chronic fatigue syndrome. Clin Infect Dis 1994;18(1 suppl):S62–7.

19. Plioplys AV, Plioplys S. Amantadine and L-carnitine treatment of chronic fatigue syndrome. Neuropsychobiology 1997;35:16–23.

20. Gramignano G, Lusso MR, Madeddu C, et al. Efficacy of L-carnitine administration on fatigue, nutritional status, oxidative stress, and related quality of life in 12 advanced cancer patients undergoing anticancer therapy. Nutrition 2006;22:136–45.

21. Cruciani RA, Dvorkin E, Homel P, et al. Safety, tolerability and symptom outcomes associated with L-carnitine supplementation in patients with cancer, fatigue, and carnitine deficiency: a phase I/II study. J Pain Symptom Manage 2006;32:551–9.

22. Forsyth LM, Preuss HG, MacDowell AL, et al. Therapeutic effects of oral NADH on the symptoms of patients with chronic fatigue syndrome. Ann Allergy Asthma Immunol 1999;82:185–91.

23. Cox IM, Campbell MJ, Dowson D. Red blood cell magnesium and chronic fatigue syndrome. Lancet 1991;337:757–60.

24. Howard JM, Davies S, Hunnisett A. Magnesium and chronic fatigue syndrome. Lancet 1992;340:426.

25. Clague JE, Edwards RH, Jackson MJ. Intravenous magnesium loading in chronic fatigue syndrome. Lancet 1992;340:124–5.

26. Gantz NM. Magnesium and chronic fatigue. Lancet 1991;338:66 [letter].

27. Hinds G, Bell NP, McMaster D, McCluskey DR. Normal red cell magnesium concentrations and magnesium loading tests in patients with chronic fatigue syndrome. Ann Clin Biochem 1994;31(Pt. 5):459–61.

28. Kuratsune H, Yamaguti K, Sawada M, et al. Dehydroepiandrosterone sulfate deficiency in chronic fatigue syndrome. Int J Mol Med 1998;1:143–6.

29. De Becker P, De Meirleir K, Joos E, et al. Dehydroepiandorsterone (DHEA) response to i.v. ACTH in patients with chronic fatigue syndrome. Horm Metab Res 1999;31:18–21.

30. Puri BK. The use of eicosapentaenoic acid in the treatment of chronic fatigue syndrome. Prostaglandins Leukot Essent Fatty Acids 2004;70:399–401.

31. Bou-Holaigah I, Rowe PC, Kan J, Calkins H. The relationship between neurally mediated hypotension and the chronic fatigue syndrome. JAMA 1995;274:961–7.

32. Whorwood CB, Shepard MC, Stewart PM. Licorice inhibits 11ß-hydroxysteroid dehydrogenase messenger ribonucleic acid levels and potentiates glucocorticoid hormone action. Endocrinology 1993;132:2287–92.

33. Baschetti R. Chronic fatigue syndrome and liquorice. New Z Med J 1995;108:156–7 [letter].

34. Brown D. Licorice root—potential early intervention for chronic fatigue syndrome. Quart Rev Natural Med 1996;Summer:95–7.

35. Price JR, Couper J. Cognitive behaviour therapy for adults with chronic fatigue syndrome. Cochrane Database Syst Rev 2000;(2):CD001027 [review].

Learn more about Healthnotes, the company.

Learn more about the authors of Healthnotes.

The information presented in Healthnotes is for informational purposes only. It is based on scientific studies (human, animal, or in vitro), clinical experience, or traditional usage as cited in each article. The results reported may not necessarily occur in all individuals. For many of the conditions discussed, treatment with prescription or over the counter medication is also available. Consult your doctor, practitioner, and/or chemist for any health problem and before using any supplements or before making any changes in prescribed medications. Information expires September 2008.

2007-09-01