ME :: Myalgic Encephalomyelitis

CFS :: Chronic Fatigue Syndrome

FM :: Fibromylagia

CHRONIC FATIGUE SYNDROME
The Environmental Connection

This Abridged version by Neil Reynolds.
Original article by Roger French, Natural Health Society of Australia.

A long established World Health Organisation definition of health is "a state of complete physical, mental and social wellbeing, and not merely the absence of disease." Chronic fatigue syndrome appears, on the surface, to occur in the absence of disease, yet, on the other hand, it can manifest as the opposite of complete physical, mental and social wellbeing. In the past, it was variously named as post viral syndrome, neurasthenia, yuppy flu, myalgic encephalomyelitis (ME) and now chronic fatigue syndrome (CFS).

There is no doubt that CFS is an all-too-real and sometimes devastating illness. Yet people with the disease have sometimes had to suffer the anguish of doctors believing that they are malingering or imagining the symptoms.

This was backed up by the environmental medicine practitioner, Dr Mark Donohoe, who wrote, "Women wait for nearly five years for their doctors to make the correct diagnosis ..., and most have been sent to psychiatrists, given drugs which worsen the problems or have simply be abandoned by a doctor who feels powerless to help." (1)

The number of people suffering CFS is substantial and is growing. According to the UK body, Action for ME, the incidence in the population as a whole lies between one in 500 and one in 250, the commonest age of onset being early 20's to mid-40's. In children, the commonest age of onset is 13 to 15, but cases can occur in children as young as 5.(2) CFS is about twice as common in women as in men, and affects all social classes and ethic groups similarly.

The basis of the negative attitude to sufferers in the past, which is fortunately now improving, is the orthodox view that the cause of CFS remains unknown, and that no management approach has been found to be universally beneficial and none can be considered a cure. However, as Action for ME has stated, most people with CFS can expect some degree of improvement with time ..., so a positive attitude towards recovery needs always to be encouraged.

It is the view of this writer, based on a review of research and professional opinion, that the causes can be explained with a high degree of confidence, that sufferers do have a measure of control over their illness and that there are steps that can be taken to greatly increase the prospect for a return to health.

WHAT CHRONIC FATIGUE SYNDROME IS

Amid confusion surrounding the illness, it was originally known as myalgic encephalomyelitis until 1988 when it was formally defined as chronic fatigue syndrome, an illness involving severe and disabling fatigue, of uncertain cause and associated with a variable number of physical and/or psychological symptoms. Research has demonstrated that the disease can affect the immune system, the endocrine (hormone) system, the musculoskeletal system and the nerves, (2)

Patients show evidence that their immune systems have been activated as there are increasing numbers of immune cells (T-lymphocytes) in the blood and yet the overall function of the immune system is poor. The immune dysfunction can be periodic and associated with various factors including latent pathogenic microorganisms in the body.(3)

A number of predisposing factors for CFS are listed by the group, Action for ME.(2) They are being female, family history, disorders such as the closely related fibromyalgia and irritable bowel syndrome (which could simply be other manifestations of the same underlying causes) and previous mood disorder.

The characteristic feature of CFS is overwhelming fatigue which is typically exacerbated after physical or mental exertion. The fatigue is commonly described as like no other in type and severity, and is also accompanied by a wide range of other symptoms.

Diagnosis by a practitioner is based on fatigue and other symptoms.(1) The fatigue must be unexplained, persistent or relapsing and persist for six months or more. Plus: it is of new or definite onset; it is not the result of ongoing exertion; it is not substantially alleviated by rest; and it results in a substantial reduction in occupational, educational, social or personal activities.

With regard to the other symptoms, four or more of the following must be concurrent, persistent for six months or more, and not have occurred before the fatigue set in: impaired short-term memory or concentration; sore throat; tender cervical or axillary lymph nodes; muscle pain (myalgia); multi-joint pains without arthritis; headaches of a new type, pattern or severity; unrefreshing sleep; and post-exertional malaise lasting more than 24 hours.

Besides these formal symptoms, sufferers of CFS often experience digestive upsets and intolerances to foods and chemicals.

A characteristic feature of the fatigue is that after exertion that is beyond what the patient can tolerate, the impact is delayed and the fatigue may be felt later the same day, the next day or even later. This can be followed by a recovery period of days or even weeks. In some instances, the activity can be carried on for some time but has a cumulative impact with a a setback occurring after several weeks or more.

Cognitive (mind function) fatigue is experienced by many people with CFS. The most prominent features are slow processing speed, impaired memory and poor learning, although there is no specific pattern of these symptoms.(4)

The severity of CFS ranges from mild to very severe. In mild cases, the individuals can care for themselves and do light domestic tasks, although with difficulty. In most cases they would be able to continue in employment. They may spend much of their free time resting. At the other extreme, a person with very severe CFS is in bed for most of the time, often cannot tolerate any noise and is generally extremely sensitive to light.

To be free of these symptoms and restore energy and quality of life, the sufferer needs to deal with the causes of CFS. Although in orthodox medicine these are unknown, to those of us who focus on prevention through lifestyle, they are reasonably clear.

THE CAUSES ARE CLEAR ENOUGH

We all know that a fatal dose of arsenic or cyanide could cause death in a matter of hours, but what if the person consumes, for example, one-thousandth of the safe doses of hundreds of different chemical every day? After many years or decades, it is reasonable to hypothesise that the chemicals could accumulate in most of the cells of the body, in particular in the energy-producing units, the mitochondria, so that each cell is now partially poisoned and energy production is partially suppressed. Every system would be affected - fatigue would be pervasive, the immune system would be impaired, digestion would be weakened and every other function restricted.

To find out whether this theory has substance - and therefore to have the motivation to act on it - we need to work through the evidence provided by a large number of research studies into CFS.

Firstly, could CFS be all in the mind? The answer is provided once and for all by Action for ME which states(2) that a Working Group "finally and totally dismisses the notion that CFS/ME is all in the mind. No longer should patients have to tolerate their illness being trivialised by those responsible for their welfare."

Is CFS caused by infection? The answer is provided by the Centers for Disease Control and Prevention, Atlanta, Georgia:(5) "So far, no infectious agent has been associated with the illness."

A number of factors have been observed to `trigger off' CFS and other factors to help maintain it, but these are not necessarily causes, some may be and some may not be.

Triggering Factors and Maintaining Factors

Action for ME summarises a list of triggering factors as follows:

Certain infections are common triggers for CFS. About 10% of cases of glandular fever, viral meningitis and viral hepatitis are followed by CFS. Other viral infections that sometimes trigger ME include herpes viruses, enteroviruses and hepatitis viruses. Other conditions which may trigger CFS are Q fever, salmonellosis, toxoplasmosis, brucellosis, influenza and influenza-like infections

Immunizations. There are reports of CFS developing after immunization.

Life Event. There is only weak evidence that stress may be a trigger. However, it has been observed that stress is common at the time of onset of symptoms.

Environmental Toxins. Exposure to pesticides and other environmental toxins may be a trigger, although this is not common.

Maintaining factors are listed as follows:

Sleep disturbance. The majority of suffers experience sleep difficulties which will tend to exacerbate fatigue and other symptoms.

Mood Disorders. Disorders of mood, especially depression and anxiety, occur in a large majority of CFS sufferers. They can exacerbate symptoms and affect recovery. Inactivity. The decrease in activity that results from CFS may become a problem in its own right, with loss of physical fitness, problems with balance and temperature control, loss of confidence and sleep disturbance.

Overactivity. Activity beyond the level that an individual can tolerate often prompts a worsening of symptoms.

Ongoing Stressors. Emotional and physical stressors, including infections, vaccinations and surgical operations, can cause setbacks.

Iatrogenic Illness. Inappropriate medical advice or prescribing can sometimes contribute to the maintenance of the disease.

Illness Beliefs. While CFS is certainly not all in the mind, particular beliefs about the illness, especially about its cause, may perpetuate the condition in some sufferers. For example, a belief that the illness is caused by a persistent virus could act as an obstacle to recovery.

Toxic, Man-Made Chemicals

When we delve into the findings about the effects of environmental chemicals, we discover that here there is enormous potential for damage to health and wellbeing, damage that could easily affect every system in the body and which could interfere with energy production leading to persistent fatigue and a variable array of other symptoms.

According to the Greater Boston Physicians for Social Responsibility(6), vast quantities of chemicals that are nerve poisons (technically `neurotoxic') are released into the environment each year. Of the top 20 chemicals, nearly three-quarters are known or suspected neurotoxicants of which around half a billion kilograms are released by large industrial facilities annually. They include methanol, ammonia, manganese compounds, toluene, phosphoric acid, xylene, chlorine, carbon disulphide, dichloromethane, styrene, lead and glycol ethers.

In addition to these industrial chemicals, just over half a billion kilograms of registered pesticides are released each year in the United States alone.

Neurotoxic chemicals that have been identified as the causative agents in nerve disorders include chlorinated hydrocarbons which are the DDT family including lindane (used as indoor wood preservative) and dieldrin; organophosphates particularly sarin; formaldehyde; toluene; certain dental materials; pyrethroids; and other biocides. (7)(8).

In one study of nerve disorders, out of 184 cases, 61% were suffering CFS (7).

Recognising that medical drugs are also a form of environmental chemical, a number of these can similarly affect the nerve system. Agents shown to initiate nerve sensitisation include ethanol, Carbachol, Physostigmine, morphine, amphetamine, cocaine, antidepressants, diazepam, inverse benzodiazepine agonist and Chlondine (8).

The predominant pesticide groups, chlorinated hydrocarbons (or organochlorines) and organophosphates (OPs) have been found to have substantial effects. A 1995 study to determine whether blood levels of chlorinated hydrocarbons are elevated in patients with CFS found that DDE (a breakdown product of DDT) was detected in all serum samples, while hexachlorobenzine (HCB) was found in 45% of the CFS sufferers compared to less than half (21%) in the control group of non-sufferers. The total organochlorine level was much higher in the sufferers at 15.9 parts per billion compared to only 6.3 ppb in the control group. Of the total organochlorines found, DDT and HCB comprised more than 90%. The researchers concluded - in what was probably an understatement - that "recalcitrant organochlorines may have an aetological role in CFS".(9)

Another study looking at DDE and HCB in CFS sufferers found that 13 of the 14 patients with fatigue had high total organochlorine content in their blood serum, and their red and white blood cells were significantly different from the control subjects not suffering CFS. In those with high HCB, the number of red blood cells and the haemoglobin content were both reduced, which, as in the case of anaemia, would be expected to produce fatigue. In the patients with unexplained fatigue, the levels of DDE were significantly higher.(10)

A third study, conducted in 1999, found a novel explanation for the effects of organochlorine pesticides. Like DDE and HCB, DDT is also at high levels in CFS patients and there is evidence that sub-lethal levels of DDT and HCB decrease the destruction of Staphylococcus aureus (Golden Staph) by the immune system, so that these potentially dangerous bacteria can build up in the body. Consistent with this finding, research found that 89% of patients with chronic muscle pain were found to have significant levels of Staphylococci bacteria which produce a membrane-damaging toxin. The researchers concluded, "This may well be an important component in the development of CFS." (11)

The organophosphate pesticides appear to have similar toxic effects to the organochlorines. A 1996 study found that some farmers have developed symptoms identical to those of CFS after chronic exposure to organophosphates such as malathion. Most significantly, the clinical symptoms did not arise until some time after the OP exposure and were initiated by an influenza-like illness, which was then followed by incapacitating fatigue plus other classic CFS-like symptoms. The researchers suggest that OP exposure prepares the person in some way for the later onset of CFS, adding that this is comparable to patients who develop CFS after aseptic meningitis or poliomyelitis in their youth. With evidence that OP exposure causes significant impairment of the immune system, the person would thus be more vulnerable to persistent viral infections including Epstein-Barr and human herpes, in which the immune system abnormalities are similar to those of CFS. (12)

The foregoing evidence, which is but a sample of the evidence of damage by pesticides, indicates that at least the organochlorine and organophosphate pesticides can be significant causes of CFS.

Heavy Metals

Heavy metals, particularly mercury, are known to affect nerve tissue. A 1999 study by Czech researchers investigated whether there was hypersensitivity (high sensitivity) to dental and environmental metals in people with CFS and also other clinical disorders. They found that fatigue, regardless of the underlying disease, is primarily associated with hypersensitivity to inorganic mercury and nickel, whereas with other heavy metals, the effects were similar in both CFS sufferers and healthy people. When the dental amalgam was replaced with non-metal `fillings', after 6 months the sufferers reported that fatigue was considerably relieved and many symptoms had disappeared. The researchers suggest that inflammation caused by these metals may affect certain hormone systems and indirectly trigger CFS.(13)

As we will see shortly, the mercury compound, thimerosal, is thought to account for hypersensitivity to the vaccine for hepatitis B. Also, any level of mercury exposure may be harmful.

Significantly, the Greater Boston Physicians for Social Responsibility state that the official `toxic threshold' for mercury has fallen relentlessly, and   `Safe' Levels of Chemicals Not Safe

Over recent years, scientists have discovered that lower and lower doses of chemicals are harmful. In an assessment of `safe thresholds', the Greater Boston Physicians for Social Responsibility point out that safe thresholds for known neurotoxicants "have been continuously revised downward as scientific knowledge advanced." For example, the `safe' blood level for lead was set in 1960 at 60 micrograms per decilitre, but in 1990 this was revised down to 10 mcg/dl. More recent studies suggest that there may be no safe level for lead. With mercury, the Physicians say that the toxic threshold has "fallen relentlessly" and, like lead, any level of exposure may be harmful.(6)

One of the major problems with chemicals is that most are not tested for their toxicity to humans or animals, let alone to the developing brain of a young child. Further, when chemicals are tested, the risks are estimated for one chemical at a time, and no allowance is made for multiple chemical exposures which often interact to magnify the damaging effects or cause new types of harm - synergism.

For example, brain cells that control movement and memory died when animals were exposed via the skin to DEET, used in insect repellents, and permethrin, a commonly used insecticide.(14)

Chemical Intolerance

Chemical intolerance relates to all people with multiple chemical sensitivity (MCS) and also to 20 to 47% of individuals with CFS, in contrast to approximately 4 - 6% of the general population.(8) The levels of chemicals that trigger CI would normally be considered non-toxic or sub-toxic, but individual susceptibility is seen as the reason why some people are susceptible to nervous/hormonal sensitisation. The simplest type of environmental chemical intolerance, according to 1998 research at the University of Arizona, could result from prior exposure to a chemical at toxic or sub-toxic levels. Later, exposure to low levels of other chemicals, such as newsprint, chlorinated tap water or perfume, produces symptoms because of cross-sensitisation. (8)

In more complex types of CI, sensitisation in CFS could be induced by widely divergent events, ranging from infections to surgery, to chemicals, to physical or emotional stress, or to exercise.

Even early-life stresses can have accentuated effects in MCS patients and other people with CI, which would include some CFS sufferers. Early-life stresses, such as physical or psychological child abuse, or family history of substance abuse, can induce lasting changes in certain components of body chemistry.

The researchers conclude that chemical intolerance affects a substantial number of CFS patients and that nervous/hormonal sensitisation could explain the ability of low-dose chemicals or other stimuli to elicit large responses. (8)

Breaking Down the Blood-Brain Barrier

A theory which would fit perfectly well with the problem of chemicals and chemical intolerance is to do with weakening of the blood-brain barrier. Researchers at the Health Sciences Centre, Toronto, Canada, proposed that this may contribute to the causes of CFS. They list the factors that can increase permeability of the blood/brain barrier which has the function of preventing harmful and unwanted substances from entering the brain. These factors include viruses, stress, deficiency of essential fatty acids, the free radicals peroxynitrite and nitric oxide, depletion of the free-radical-destroying enzyme glutathione, cytokines, five-hydroxytryptamine and methyl-aspartate overactivity. (15)

A professor of pharmacology at Duke University Medical Centre reported that stress is another factor that can cause "minor breakdown of the blood/brain barrier" allowing chemicals to permeate the brain more easily.(14)

The Toronto researchers proposed that breakdown of the barrier could lead to dysfunction of the brain and dysfunction of nerve transmissions as appears to occur in CFS.(15)

Vaccination Can Precipitate CFS

Charles Shepherd, MD, of the United Kingdom ME Association, proposes that because the primary purpose of any vaccine is to mimic the effects of infection on the immune system, it is conceivable that vaccines could act in a similar manner to infections and precipitate CFS. Dr Shepherd's own practice has records of more than 200 patients who developed CFS or experienced relapse following vaccination. In addition, he has more than 150 reports of CFS or ME sufferers who have experienced similar links with vaccination.(16)

The most commonly implicated vaccines in CFS, says Dr Shepherd, are tetanus, typhoid, influenza and hepatitis B. He also has reports of a few cases involving hepatitis A, polio and rubella vaccine. About one-third of the doctor's cases of vaccine-induced CFS involve the hepatitis B vaccine, and may be a reaction to a component of the vaccine such as thimerosal.

Dr Shepherd also says that approximately 60% of CFS patients experience an increase in symptoms following influenza vaccination.

Regarding tetanus vaccination, since it can produce side-effects in healthy people, it may well cause relapse in CFS sufferers.

Rubella may be more significant than indicated above. In chronic fatigue patients, A D Allen found abnormally high levels of antibody to the rubella virus, and the sicker the patients were, the more rubella acitivity there was. The patients also showed evidence that being reinfected with the rubella virus produced CFS, and he postulated that the source of reinfection was a US herd immunisation program. Allen reports that within three years of the introduction of a new, more potent live rubella vaccine back in 1979, reports of chronic fatigue began appearing in the medical literature.(17)

Nutritional Allergies

Allergy is a common feature of CFS. A 1998 study involving 16 CFS sufferers found that 81% of them showed adverse reactions to foods - food sensitivity or allergy - especially to dairy products and meat. The only significant nutritional deficiency was that 44 % of sufferers had low zinc intake. Dietary supplements were used by all subjects on a regular basis.(18)

Adverse Ratios of Essential Fatty Acids

Abnormalities in the mix of essential fatty acids are found in chronic diseases, and this applies to CFS.

In a placebo-controlled study of essential fatty acid therapy, CFS sufferers of from 1 to 3 years were given a preparation containing the key essential fatty acids, linoleic, gamma-linolenic eicosapentaenoic and docosahexaenoic acids at a dose of 4 grams per day for three months. At one month, 74% of the patients receiving the fatty acids and 23% of those on the placebo assessed themselves as improved, with the improvement being much greater in the former. At three months the corresponding figures were 85% and 17%, with those receiving the supplement showing continued improvement. There were no adverse effects and analyses showed that the ratios of essential fatty acids in the sufferers were corrected by the treatment.(19)

Another study showed that abnormalities in essential fatty acids can cause both overactivity and underactivity in immune function and also abnormal responsiveness in the sympathetic nervous system. By using dietary manipulation to correct the ratios of EFAs, 90% of CFS patients improved within 3 months and more than two-thirds became fit for full-time duties.(20)

An Australian study in year 2000 showed significantly different lipid profiles between CFS sufferers and healthy individuals. The CFS group had high level of the trans fatty acid, elaidic acid.(21) This trans fatty acid, consumed mainly in margarine, has been associated with a significantly increased risk of heart disease.

Nutritional Deficiencies

Back in 1991 it was found that people with CFS who were given magnesium had improved energy levels, better emotional states and less pain. Twelve out of fifteen treated patients reported benefit compared to only three out of seventeen given a placebo.(22)

In a year 2000 study, subjects with CFS or fibromyalgia were given pharmaceutical and alternative therapies. The nutrients commonly prescribed were multivitamins, magnesium glycamate/malic acid, vitamin B12 and iron. Of the 38 sufferers treated, 29 reported feeling better of much better while only 1 subject reported feeling worse. (23)

By the year 2001 a greater number of nutrients had been found to be relevant. A detailed review of the literature by M R Werbach of the UCLA School of Medicine in California, found that marginal nutritional deficiencies that may have causative relevance include deficiencies of the B vitamins thiamine, riboflavin, folic acid and B12, vitamin C, magnesium, sodium, zinc, L-tryptophan, L-carnitine, Co-enzyme Q10 and essential fatty acids. Any of these nutrients could be marginally deficient in CFS patients, says Werbach, a finding that appears to be primarily due to the illness process rather than inadequate diet.(24)

A number of these deficiencies will cause some of the symptoms of CFS. Magnesium deficiency is capable of causing muscle pain; folic acid deficiency is associated with fatigue; vitamin C deficiency causes depression of immunity; while low levels of L-tryptophan are associated with depression.

Although the above researchers tended not to find substantial nutritional deficiencies in CFS sufferers, this may be due to lack of awareness that Recommended Daily Allowances have sometimes been found to be well below optimal levels. It is quite possible that dietary deficiencies do contribute to the underlying cause of CFS.

Free Radical Oxidative Damage

Free radical damage is coming to be recognised as the underlying cause of cancer, heart disease, stroke, Parkinson's disease, Alzheimer's disease, multiple sclerosis and other conditions. It would come as no surprise if CFS is to be added to this list.

A role for oxidative damage in CFS was proposed by two eminent bodies in year 2001 - the CFS/FM Integrative Care Centre, Toronto, and the School of Molecular Biosciences, Washington State University. The Toronto researchers reported that a number of recent studies has shown that oxidative stress may be involved in the development of CFS,(25) while the latter researcher proposed a mechanism by which this occurs.

Expressed in technical language, the mechanism is as follows. When nitric oxide, which is normally beneficial to cells, increases in quantity, it can combine with a free radical called superoxide, to form an extremely powerful free radical, peroxynitrite. This can damage a wide range of tissues, which could explain the variation in symptoms found in CFS (as well as in the similar conditions, fibromyalgia, MCS and post-traumatic stress disorder, and also to a degree, Gulf War syndrome). There is substantial evidence for the role of these free radicals.(26)

Here lies an interesting comparison with the cause of multiple sclerosis which was proposed in the journal, Medical Hypothesis, September 2000.(27) Because magnesium is required for the release of nitric oxide from cells, a magnesium deficiency would allow nitric oxide to build up in cells where it could react with superoxide to form peroxynitrite. The peroxynitrite.then damages the nerve sheaths leading to the symptoms of multiple sclerosis. The fact that magnesium has been found to ease the symptoms of CFS, as described above,(22) suggests that a magnesium deficiency does exist, and it triggers off the above chain of events leading to free radical damage, presumably to the energy-producing processes in the cells.

Reduced Blood Flow

It has been found that in CFS patients various areas of the body receive less blood than normal. This is not necessarily a cause of CFS; it could be an effect or it could an intermediate factor.

In 1999 it was found that oxygen delivery to muscle was reduced, and it was proposed that the impaired oxygen delivery may cause reduced energy production in muscle cells, leading to muscle fatigue. This is consistent with findings from other studies of abnormalities in the part of the nervous system that controls blood flow.(28)

In 2002 South Australian researchers found that an area of the brain that controls the stomach received substantially less blood flow in some sufferers of CFS. The part of the brain concerned governs the smooth muscle in the stomach and intestines, which would explain why stomach and bowel symptoms are common in CFS. The researchers also found a 20% reduction in blood flow to an area in the left side of the brain which controls access to words, which would in turn explain why some sufferers experience difficulty in expressing themselves.(29)

It could be hypothesised that if oxidative damage to the part of the brain that regulates the heart is compromising heart function, blood flow in general could be reduced, setting off a chain of events involving impairment of virtually every system in the body, which could account for the variety of symptoms in CFS.

Stress

Whereas some researchers say the link between stress and CFS is weak, Dr M R Werbach of the UCLA School of Medicine, California, reports that the levels of stress in the five years prior to the onset of CFS has been found to be highly significant in its development.(24)

As mentioned earlier, researchers, writing in the American Journal of Medicine in 1998, said that early-life stress, such as child abuse, can induce chemical sensitivity which could account for the symptoms of CFS. The researchers have also proposed mechanisms by which physical or emotional stress in general could lead to abnormal sensitivity to toxic chemicals.(8)

Putting the Causes All Together

An explanation for the causes of CFS, which would fit most of the studies referred to above, was proposed by the Sydney biochemist, Dr Robert Buist, back in 1988, the year that the name 'chronic fatigue syndrome' was adopted. The proposed explanation was published as an editorial in International Clinical Nutrition Review under the heading, `Chronic Fatigue Syndrome and Chemical Overload'.(30)

A  precis is a follows.

Blood supplies oxygen and nutrients to all cells in the body via arteries, arterioles and capillaries. By the time the capillaries reach the cells, they are extremely fine, about 3 microns (3 millionths of a metre) in diameter, which is even finer than the 8 micron diameter of the red blood cells which are the component of the blood that carried oxygen.

Under normal circumstances, the red cells can squeeze along the capillaries because they have a biconcave shape (like a hollow disc) and are elastic. Thus every cell in the body is able to receive the oxygen it needs to function and to survive.

If, however, the red cells lose their elasticity, they cannot fit into the capillaries so the cells supplied by those capillaries are then starved of oxygen. Without oxygen, the cells are unable to break down sugar to its basic building blocks, carbon dioxide and water, and can only `burn' the sugar as far as the intermediate stage of lactic acid. This is the acid that forms during anaerobic (without oxygen) exercise and its irritation is the reason that muscles are sore the day after unaccustomed exercise. If this lactic acidosis occurs in the brain and nerves there will be nervous system disorders. If it affects muscles, we get muscle fatigue or pain or both. Because the lactic acidosis can occur in many areas of the body, this would explain the plethora of symptoms in CFS.

These postulations are supported by findings at Oxford University which showed that CFS patients exhibit lactic acidosis abnormally early after moderate exercise.

The key question is, what might cause the red blood cells to become rigid and unable to fit into the finest capillaries?

Dr Buist's explanation is that because cell walls, including those of red blood cells, contain fat and cholesterol, they could accumulate fat-soluble pesticides and other chemicals which could damage the cell walls through free radical attack, causing the rigidity. The group of pesticides mentioned in particular is the organochlorines.

This theory is consistent with the problems associated with organochlorines, organophosphates and free radical attack, as mentioned earlier in this article.

"It is quite possible", concludes Dr Buist, "that with CFS we are seeing yet another health-related consequence of the massive proliferation of chemicals upon our planet. As yet only a small section of our community ... are affected. Each year, however, the toll is becoming greater as the environmental chemical load increases." This, continues Dr Buist, may reflect an inability of the liver and kidneys to produce enough detoxifying enzymes in the face of an inadequate level of antioxidant nutrients in the body.

Further, he explains, that with all animals in Antarctica now contaminated with DDT, as well as birds in South Pacific islands, there is no way we can eliminate toxic chemicals from our industrialised environment.

This means that every single one of us is contaminated to a greater or lesser degree. Dr Buist states that CFS sufferers need to reduce their total chemical load as much as possible.

The first investigation in Australia - other than for pest control workers - into the build-up of synthetic chemicals in the body, was conducted by Mark Donohoe, MD, and other practitioners and published in 1989 (31) These investigators found that Australians on average had higher levels of chemicals in their bodies than Americans and that a small proportion of the Australian population - something of the order of 1 in 10 - are unable to shift man-made chemicals out of their bodies and have accumulated high levels in their fat. They observed that because the chemicals cause immune suppression, these people are unable to take even the slightest stress and are likely to be chronically ill with fatigue, allergies, hypoglycaemia, Candidiasis or even cancer or AIDS.

The condition of the liver is critical factor in determining whether toxic chemicals accumulate or are eliminated. Because the liver is the body's chemical laboratory and detoxifying organ, the first step in a chronic condition is often liver overload. In some cases this will already have manifested as hepatitis.

MANAGEMENT AND TREATMENT OF CFS

"No management approach to CFS/ME has been found universally beneficial, and none can be considered a `cure'," states the Action for ME Guide (2) - as mentioned earlier. However, some degree of improvement can be expected with time and treatment.

So goes the orthodox view which focuses mainly on dealing with the symptoms. When natural therapies that deal with the underlying cause are employed, the potential for improvement is much greater. But, first, here is an outline of the orthodox view.

Orthodox Management of CFS

Three strategies are involved in managing the illness - graded exercise, pacing and behavioural therapy.(2)

Both activity and rest can be harmful when overdone, but beneficial when carried out with the appropriate degree of balance. Graded exercise is a structured and supervised program that aims for gradual, progressive increases in aerobic activity such as walking or swimming.

Pacing means achieving an appropriate balance between rest and activity. The aim is to prevent patients entering a vicious cycle of activity and setbacks, the `push-crash' phenomenon, characterised by over-exertion during periods of better health, followed by a relapse of symptoms due to the excessive activity. The practitioner assists the patient to set realistic guides for increasing activity when appropriate. A survey of 2000 sufferers showed that 89% found it helpful.

Cognitive behavioural therapy aims to empower patients to identify, understand and modify their belief systems and behaviours to enhance recovery. It involves goal setting and psychological support, along with activity management and a good sleep routine.

Counselling is considered to be an important part of helping patients to cope with a long-term illness like CFS.

The Natural Therapies Approach

To actively bring about recovery from CFS - if this is possible, which it often is - depends on identifying the causes and taking steps to correct or minimise those causes.

The first step will be to obtain adequate amounts of all essential nutrients, without over-consuming fat, protein and carbohydrate, which is a problem built into the typical modern way of eating. Natural Health Dietary Guidelines provide that the intake of fresh, green, yellow and red vegetables and fruits is three-quarters of total food intake by weight (even up to four-fifths) and these water-rich, alkali-forming foods are balanced by relatively small amounts of protein, unrefined carbohydrate and unsaturated fat. These guidelines are detailed, along with sample meal plan and recipes, in the Spring 1999 issue of this magazine.

Occasional periods on a cleansing/detoxifying diet is almost invariably beneficial in hastening recovery. This can be done in a limited way at home, provided the individual has a certain level of understanding of how to undertake a cleansing diet. This is spelled out in an article on self-healing available from the Natural Health Society.

Under professional supervision, cleansing can be taken much further, is more effective and is much easier! Experienced professional supervision is available at the Hopewood Health Retreat at Wallacia NSW, which was established in 1960, is not-for-profit and is closely affiliated with the Natural Health Society.

If blood tests indicate high levels of toxic chemicals, it will be essential to seek organically-grown food and be meticulous about minimising exposure to chemicals. Even if there are no such test results, it will still be highly desirable to minimise exposure to chemicals.

As Dr Robert Buist says,(30) people with CFS should reduce their total chemical load as much as possible, including suspect foods and chemicals, drugs and atmospheric pollutants. But don't avoid these completely because the body will then lose tolerance and when the person is exposed to chemicals occasionally, they will react violently. Individuals who have totally lost tolerance are said to be "allergic to the 20th century".

Also strengthen the body's defences with good diet, and specifically, says Dr Buist, by ensuring that the body has an optimal intake of antioxidants - especially vitamins E and C - which are fundamental to chemical detoxification and tissue protection generally.

Recovery will be enhanced by having adequate rest and sleep (but not too much) and practising stress reduction techniques such as meditation or listening to relaxation tapes.

When these steps are applied thoroughly and if CFS is in its early stages, recovery is possible in a matter of days or weeks. If the body has accumulated a lot of chemicals and the damage is deep-seated, recovery could take many months. However, there is room for optimism. One sufferer with mild CFS commented, "After a mere five days, I couldn't believe how much more energy I had."

Therapies Utilised by Doctors Paul Cheney and Mark Donohoe

These two medical practitioners are among the leaders in the field of CFS. Dr Mark Donohoe has a Sydney practice devoted to environmental medicine, and Dr Paul Cheney is a USA practitioner and leading proponent of the integrated approach to CFS. The following is a combination of the treatments outlined by these practitioners in separate papers.(1) (32)

Mark Donohoe says that the basic themes in treating CFS patients are:
  • Managing the intestines through nutrition and probiotics;
  • Detoxifying of chemicals and minimising further toxic load;
  • Reducing the toxicity of the nervous and muscle/skeletal systems
    • ;
  • Establishing an ongoing dietary and nutritional program.
  • Activity limitation and exercise prescription are also included.

Intestinal management involves resting the intestines which Mark Donohoe achieves with a low-allergenic nutritional agent such as `UltraClear'. He prefers this to fasting. His explanation for the need for probiotics is that just under two-thirds of all CFS patients have been given broad-spectrum antibiotics, lasting over 6 months, during the years prior to the illness. He believes that iatrogenic (doctor-caused) problems are "one of the biggest unrecognised factors in this illness". The taking of friendly gut bacteria is a long-term program which needs to be considered well beyond the point where the sufferer begins to feel better.

Protecting the nervous and muscular systems depends on preventing free-radical damage to the energy-producing parts of the cells, the mitochondria. This protection is provided by antioxidants and magnesium which, in effect, protect the central nervous system against toxic chemicals. Dr Cheney has discovered that brain injury of almost any kind can be amplified by components of the nerves themselves and this amplification can be inhibited by magnesium, which explains why this mineral is so important. Dr Donohoe adds that magnesium should always be used in conjunction with antioxidants and a good nutritional program.

Establish an ongoing dietary and nutritional program. Paul Cheney's modified elimination diet is low-fat, eliminates red meat, refined sugar and aspartame, and also eliminates gluten (in wheat and rye) in the sicker patients, but allows it in the less sick if they can tolerate it. His patients go on/off/on suspect foods in a three-week cycle to see if these foods cause sensitivity or allergy, and then such foods are restricted.

Supplements that may be used by Dr Cheney include:
  • Broad spectrum multivitamins orally;
  • Broad spectrum antioxidants orally;
  • high-dose vitamin B12 ;
  • High dose Coenzyme Q10 (CoQ10)
  • Magnesium, particularly in the form of magnesium glycinate which has excellent availability. This would be the most important mineral for CFS, and can be administered orally or injected;
  • Flax oil for essential fatty acids. It contains mostly omega-3, but also omega-6 and omega-9 and is really important for some sicker patients.

Dr Cheney's rationale for using high-dose B12 is not because the patient is normally deficient in this vitamin, but because they are deficient in an enzyme to which the vitamin is a co-enzyme.

He thinks more attention should be paid to bioflavonoids because these resuscitate antioxidant nutrients and enable them to be recycled in the body and do their good work all over again.

Along with nutrition, activity limitations and exercise prescription are given full attention. Pacing is employed, says Dr Cheney, and the patient must avoid overheating and avoid hot bathing. In the belief that anaerobic systems are still working normally, patients are supervised in lifting light weights. With aerobic exercise, the aim is for the patient to stay within their limit and not exceed it. Aerobic exercises that seem to be well tolerated are walking, swimming and cycling.

Dr Donohoe emphasises the need for persistence, warning that the most tragic mistake is to be winning the battle with a therapeutic program, then stop it too early or have the patient cut it short because they are feeling better. The practitioner, he says, "can often only stand by helplessly as the person's health deteriorates. Trying to beat it the same way again does not work as effectively, and unfortunately sometimes does not work at all." The treatment needs to be continued well beyond the point where the sufferer begins to feel better.

This highly experienced GP summarises his treatment as follows:
  • Rest the intestines with non-allergenic nutritional agents;
  • Restore normal bowel flora with quality, appropriate probiotics;
  • Provide antioxidants through diet and supplements;
  • Supplement with magnesium orotate and aspartate to restore bodily reserves and minimise damage;
  • Expect little improvement for the first six weeks, then slow recovery proportional to the time that the person has been unwell;
  • Persist! Persist! Persist with management and treatment for at least three months beyond the point where the sufferer is feeling significantly improved.
Further Supplement Suggestions

As already stated, the foundation for a high intake of antioxidants and other protective nutrients is an abundance of green, yellow and red vegetables and fruits. This can be perfectly complemented by the juices of these vegetables, particularly silverbeet, celery, parsley, cabbage, carrot, beetroot and a leaf or two of dandelion. In addition - and only in addition to these foods - top up with supplements of multivitamins, the carotene/carotenoid family (from which we make vitamin A), vitamin C, vitamin E, zinc and selenium. Other valuable supplements already mentioned are magnesium, vitamin B12, bioflavonoids, CoQ10, flax oil and probiotics.

Additional supplements that other practitioners would consider include the enzyme glutathione, N-acetylcystine, alpha lipoic acid, OPC's (oligomeric proanthocyanidins), Ginkgo biloba and bilberry (Baccinium myrtillus).(25) MR Werbach suggests in addition taking B vitamins, L-tryptophan, L-carnitine, panax ginseng, the herb licorice, grapeseed and cranberry.(24)

Finally in the list of supplements, the Centers for Disease Control add preparations that have been claimed to benefit CFS - astralagus, borage seed oil, bromelain, comfrey, echinacea, garlic, ginseng, ginkgo biloba, primrose oil, quercetin, St Johns wort and Shiitake mushroom extract.(33) The only one of these that has been evaluated for CFS in a controlled study is primrose oil.

SUCCESSFUL RECOVERIES

The Natural Health approach to chronic fatigue - and most other illnesses - is practised at the Hopewood Health Retreat, Wallacia NSW, which is not-for-profit and closely affiliated with the Natural Health Society, both organisations having been founded by the same people in 1960. Hopewood Naturopath and Osteopath, Doug Evans, advises that numerous guests have come to Hopewood because of CFS, and that there has generally been quite good success. In fact, Doug overcame his own chronic fatigue by these methods many years ago.

He described the case of a woman, Teresa (not her real name), who consulted the retreat in 1994 for progressive fatigue. The onset had been gradual following an episode of infectious mononucleosis (glandular fever), associated with the Epstein-Barr virus. Teresa had a history of mild fatigue with periodic flare-ups to moderately severe fatigue lasting a few days. During these periods, she experienced severe concentration and memory difficulties. She also suffered from a recurring moderately sore throat, accompanied by swellings of the glands in the neck.

Depression was a problem occasionally, which was aggravated by her family's lack of empathy.

In spite of her fatigue, Teresa continued to push herself to exercise, running approximately 10 kilometres and swimming 132 laps on most weeks. At the time of the first consultation, she had been too weak to maintain this level.

She had been taking a number of vitamins, primrose oil, flax oil, MaxEPA (fish oil for essential fatty acids), multiminerals, iodine and vitamin C. She had also tried homeopathic and herbal remedies.

At the first consultation, she weighed 63.1 kgs for a height of 170 cm and blood pressure was 92/60, which is bordering on low.

In a two-week stay at Hopewood, Teresa was provided with total rest, including rest of the digestive system through an advanced cleansing program. As is often the case, her energy level declined further during this time, although she remained alert and maintained positive attitudes.

During the rebuilding period near the end of the two weeks, she gradually regained strength and stamina. At the final consultation, her weight was 55.8 kg and her blood pressure had improved to 110/70. Her inflamed sore throat had recovered completely.

Teresa was given a dietary and lifestyle program to follow at home, which emphasised adequate rest and avoidance of excessive exercise.

Five weeks after leaving the retreat she reported to Doug Evans that she was at least 90% recovered, and delighted with the improvement.

REFERENCES
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  2. Action for ME Guide
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  21. Cox IM, et al, Lancet 1991; 337: 757-60
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  25. Pall ML, Med Hypotheses 2001 Aug; 57(2): 139-45
  26. Med Hypotheses 2000 Sep; 55(3): 239-41
  27. McCully KK, Clin Sci 1999; 97: 603-8
  28. Robotham J, Syd Morn Herald 2002 May 4/5: 9
  29. Buist RA, Inter Clin Nutr Rev, 1988 Oct; 8(4): 173-5
  30. Donohoe M, Natural Health 1989 Feb/Mar: 2-5 & Apr/May: 3-7
  31. Cheney P, Diagnosis and Management of Chronic Fatigue Syndrome
  32. Centers for Disease Control, `CDC Treatment', www.cdc.gov/ncidod/diseases/cfs/treat.htm


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