Chronic Fatigue Syndrome

Posted on February 22, 2013

Chronic fatigue syndrome (CF) also known as chronic fatigue immunodeficiency syndrome (CFIDS) and fibromyalgia (FM), also called Fibromyalgia Syndrome (FMS), are complex, multifactorial, functional disorders that affect estimated 12 million Americans. The symptoms include, but not limited to severe fatigue and exhaustion, “brain fog”, insomnia, and depression in CF, and in FM in addition, wide spread pain. The current medical model(s) has difficulty understanding and treating these disorders, thus resulting in unnecessary suffering to the patient.

Some of the underlying factors for CF and FM include dysfunctions in the immune, neurological and hormonal, and digestive systems In FMS and CF, neurological, endocrine, gastrointestinal, hepatic, immune pathologies must be considered. All of these systems are intricately interconnected and interdepended. Moreover, when these systems are imbalanced, corresponding metabolic problems, systemic inflammation, nutritional deficiencies, sleep dysfunction and psychiatric components may occur. Other diseases such as migraines, interstitial cystitis and irritable bowel syndrome can often be associated with FMS and CF.

In order for the FMS and CF to be treated effectively and efficiently, all of the underlying factors must be addressed, in many cases reversing the condition, or at least helping the patients to improve significantly.


CF is different from normal fatigue or exhaustion, in that it does not pass easily, and often accompanied with other feelings of general malaise, flu-like-symptoms, psychological and digestive symptoms. It can come on suddenly, often after an insulting agent (condition or trauma), like an accident, illness or infection, and unlike normal fatigue and exhaustion CF is not relieved by rest and reduction in the level of activity.

According to Center for the Disease Control and Prevention (CDC), in general, in order to receive a diagnosis of chronic fatigue syndrome, a patient must satisfy two criteria:

1. Have severe chronic fatigue of six months or longer duration with other known medical conditions excluded by clinical diagnosis, and

2. Concurrently have four or more of the following symptoms: substantial impairment in short-term memory or concentration, sore throat, tender lymph nodes, muscle pain, multi-joint pain without swelling or redness, headaches of a new type, pattern or severity, disturbed sleep, and post-exertional malaise lasting more than 24 hours.

The symptoms must have persisted or recurred during six or more consecutive months of illness and must not have predated the fatigue.

In addition to the official symptoms of CF, some other signs and symptoms include: constipation/diarrhea, abdominal bloating, burning or pain, nausea, acid reflux, palpitations, chest pain, irregular heart beat, shortness of breath, dizziness, vertigo, weight gain, night sweating, depression, anxiety, panic attacks. There are more possible signs and symptoms that are associated with CF and FM, but as far the conventional diagnosis is concerned, the above signs and symptoms are the criteria for diagnosing with CF.

I. Immune dysfunction and how it relates to CF and FM.

Immune system is our body’s defense system. It protects us from viruses, bacteria, parasites, allergens, cancer cells, and other insulting agents, collectively called antigens. When they invade, the immune system mounts an immune response that involves many different kind of cells. Among them are lymphocytes, neutrophils, monocytes, eosinophils, basophils, macrophages, natural killer cells (NK), and immunoglobulins, collectively called white blood cells, which produce different types of immune response, depending on the nature of the pathogen involved. Our bodies have two types of immune system, the cell-mediated and humoral immunities. Generally, when the invading agents attack, the body’s initial cell-mediated response is to mobilize the macrophages and NK cells, in order to keep the invaders at bay. Even though they are very effective when they come “face to face” with the pathogen, they are not specific in their response. They are free to roam around and when find a pathogen act spontaneously to destroy it by the process called phagocytosis. On the other hand, the humoral immune system is very specific in its ability to destroy the invading pathogens. It uses the antigen/antibody to seek, recognize, and act to destroy the invading pathogen. They include lymphocytes, which further include B and T-cells, and Killer cells. Each type of lymphocytes is responsible for different type of response. T-cells are the master immune cells. They mature in thymus and help to destroy the infected cells, and coordinate the overall immune response. They recognize the invading agent or cell, called antigen only after a specific antibody has attached itself to that antigen, and act to destroy that entire complex. B-cells, also called the “memory cells”, control the antigen-antibody response that is specific to the offending pathogen. In other words, antibodies are like a laser that “paint” the target; target being an antigen. After the target has been “painted”, a missile (T-cell) is send to destroy it.

Often, in CF and FM, this complex immune system does not function properly. It may under or overrespond when it encounters an antigen. When the immune system has an insufficient response, then it can completely miss and not recognize the invading pathogens, and when it over responses it can become overzealous, and confused and mistaken usually harmless substances, like pollen, dust or even our own tissue as being an invader, mounting an immune reaction. These reactions can be allergic (hypersensitive), or autoimmune.

In an allergic response, the body is producing an inappropriate number of antibodies, for example, on initial or heavy exposure to pollen, the “memory cell” produce antibodies, so on the consequent exposure(s), the body may experience the heightened inflammatory and allergic symptoms, like sneezing, runny nose and wheezing.

In an autoimmune response, the body is making the antibodies on its own tissue; it “laser paints” the wrong target, thus producing the “friendly fire”. Therefore, when the different tissue is affected, different symptoms are produced. When the body attacks its myelin sheet the disease is called Multiple Sclerosis. When the thyroid tissue is affected – an Autoimmune Thyroid, pancreas – Diabetes, joint tissue – Rheumatoid Arthritis, if the antibodies are against serotonin, dopamine, or other neurotransmitters or their receptors, the result can be mood or other psychiatric disorders. There are over eighty types of autoimmune disease, most of which are difficult to treat, particularly from the point of view of the conventional model of medicine. In any case, all of immunoreactivity factors and imbalances in the immune system must be considered, and underlying causes removed, no matter what medical model is used.

Another major immune response is inflammation. When the immune system is chronically exposed to antigens, it can become up-regulated (overactive) and produce an exaggerated and prolonged inflammatory response. Approximately 60% of our entire immune system is concentrated in the Gastrointestinal (GI) tract, and appropriately called Gut Associated Lymphoid Tissue (GALT). Antigen exposure from food, bacteria, viruses, fungus, chemicals, or substances our bodies naturally produce can cause the GALT immune cells to release inflammatory mediators such as interleukins, cytokines, nitric oxide and others. These inflammatory mediators will cause pain, inflammation, vasoconstriction, and free radical formation, further stressing an already venerable immune system.
There are mechanisms for inflammation other than the ones originating in the GI tract. For example, acute or chronic viral, bacterial, parasitic or fungal infections can drive the inflammatory response, creating a cascade like effect on the rest of the body, affecting the hormonal, neurological, gastrointestinal and liver functions. There is strong evidence that links a multitude of viral infections with the onset of CFIDS. These infections may or may not be easily to identify with the traditional serum tests. The use of specific serum immuno assay would help to indicate the presence of possible infections, autoimmune dysfunction and/or inflammation, even when they are chronic and latent.

II. Hormonal Dysfunction.

Hormonal system is probably the most complex and interconnected system in the human body. In order to talk about it, we would first need to understand how the hormones work, and their relation to human physiology.

Our hormonal system regulates our body’s metabolism, stress response, and reproductive function. There are many different types and classes of hormones.

Hormonal function and endocrine glands are controlled by our Central Nervous System (CNS) mostly via negative feedback mechanism. It is similar to that of a thermostat in the heating system. In the hormonal system, sensors detect a change in the hormone level and adjust the hormone secretion so that the body levels maintained within appropriate range. The regulation of hormones starts in the hypothalamus, which is the coordinating center of the brain for the hormonal as well as behavioral, and autonomic nervous system functions. It is at the level of hypothalamus that emotion, pain, body temperature, and other neural input are communicated to rest the hormonal system. The information from the hypothalamus is then transmitted to the pituitary gland via the hormones that stimulate the pituitary to make its own ones. The pituitary gland has been called the “master gland”, because its hormones control the function of many other glands and cells. Some of those glands are adrenal, thyroid, testes and ovaries.

Based on the scientific studies, and our clinical experience, there is certainly exists a link between the hormonal dysfunction and CF and FM. These include both thyroid and adrenal hypo and hyperactivity, though it is most likely thyroid and adrenal hypoactivity. Problems with other hormones, like stress and reproductive hormones are also common, as well as growth hormone (GH) deficiencies.

Thyroid Gland

Thyroid gland is responsible for the rate of metabolism in all tissues of human body and protein synthesis, thus having a profound effect on many different systems in the human body, i.e. cardiovascular, respiratory, psychological, gastrointestinal, and muscle function. Most common in patients with CF and FM is functional thyroid hypofunction, although hyperfunction is not unlikely. Some of the low thyroid function signs and symptoms include fatigue, increase in weight gain, even with low-calorie diet, constipation, sensitivity to cold, poor circulation, and numbness in hands and feet, depression, dry skin, brittle hair, heavy menstrual cycles, and low body temperature.

Functional thyroid disorders are very common in patients with CF and FM and generally overlooked in today’s healthcare model. Most patients with functional thyroid imbalances do not have primary thyroid imbalances. Thyroid function depends on thyroid hormone synthesis, receptor site binding, peripheral conversion, carrier protein and can be altered by other hormones, immune responses, stress, gastrointestinal and hepatic functions, as well as nutritional deficiencies.

Unfortunately, the prevalence of the undiagnosed thyroid disease in the United States is shockingly high, especially when we can diagnose and treat it so easily. The effects of untreated thyroid can lead to a more serious problem, like cardiovascular, elevated cholesterol, infertility, osteoporosis, and depression. This is why patients with CF and FM should be screened for the thyroid dysfunction.

Adrenal Gland

Adrenal glands are two triangular shaped glands that sit on top of each kidney. Two different parts of adrenals produce three types of hormones, mineralocorticoids, corticosteroids, and gonadocorticoids. They are responsible for controlling mineral balance, blood pressure, stress response, blood sugar, and even though they do produce reproductive hormones, they have minimal effect on the reproductive function, at least not directly. One of the main corticosteroid hormones is cortisol. Cortisol is released in response to stress (chemical, physical and emotional). Most people think of stress as being emotionally upset or “stressed out” at work. In contrast, our body interprets stress in much wider terms. These stressors include: psychological, emotional stress, infections, inflammation, anemia, free radical stress, blood sugar imbalances, food allergies, toxicity, poor diet, lifestyle, and more. When our body is under any of the stressors above, our nervous system shifts into sympathetic or “fight or flight” response. Bronchioles dilate, to help us breath easier, and blood get shunted towards the muscles and the brain. Cortisol helps to mobilize glucose so our muscles and our brain can function better during the stress response. Levels of cortisol vary because of circadian nature of its release during 24-hour period. It should be at its highest in the morning and lowest at midnight. When this circadian release of cortisol is affected, a body’s altered response to stress may occur. It could be one of three stages: hyper response, mal-adaptation, and hypo response. The first stage is a hyper response, it is body’s initial response to stress. During this stage, the cortisol levels are high, to adapt to the demand of stress. The next stage is Mal-adaptation stage, during which cortisol levels can be high or normal, but DHEA (“feel good” hormone) levels drop. DHEA is a precursor for estrogen and testosterone. This stage is characterized by body’s poor response to cortisol, cortisol resistance, and body’s diminished ability to resist stress. The final stage is adrenal hypo response stage. At this point, adrenals are tired and can no longer meet the demand of cortisol production, and inability to resist stress. During this stage, the body is venerable to most if not all stressors, see above. This may be one reason why patients with CF and FM have so many different symptoms going on all at the same time. Generally, as stress continues unresolved, patients go from stage one to stage three, but not always. Some people can remain in second stage their entire life, others can go from stage one to stage three. As the levels of cortisol decrease, the damage from the previously high levels does not disappear. High cortisol levels in humans can cause problems with blood sugar and insulin regulation, problems with thyroid and pituitary functions, imbalances in liver and gastrointestinal function, cardiovascular and immune systems, as well as insomnia, depression, bone loss, and neurodegenerative disease.

To understand what is going on with patient’s adrenals, cortisol as well as DHEA levels must be obtained. However, because cortisol release is cyclical, it is extremely important to measure several cortisol samples, throughout the day. This is one reason why it is better to do salivary cortisol panel over the regular serum test, because of flexibility, convenience, not many labs are open at midnight, and it is less invasive. Another reason we prefer to do salivary over the serum test is because saliva measures the levels of bioactive or free hormones, where as, traditional serum test measures the levels of inactive ones (protein bound).

There are several schools of thought on the topic of hormones and their relationship to CF and FM. Some believe that hormonal deviations in CF and FM are due to the effect of pain and stress on the nervous system. Others believe that hormones alone are responsible for the disease, yet others believe that hormones play little or no role in CF and FM. It should be said that FM and CF are complex, multifactorial, functional disorders, and that exact etiology differs from patient to patient. Hormones are regulated and controlled by our central nervous system (CNS), just like anything else in our body, but it is not to say that the CNS is at the root cause of all of the disorders. Instead, in order to fully understand the etiologies behind CF and FM, a physician needs to create a unique and exquisitely tailored, patient-centered approach, because each person is genetically, metabolically, psychologically, and socially different and all of these factors must be accounted, evaluated, and understood before making a definitive diagnosis.

Growth Hormone
Refer to Growth Hormone Deficiency in Fibromyalgia article by Dr Bennett

Neuro-Endocrine Imbalances and their relation to CF and FM

As discussed previously, there exists a strong connection between the CNS and hormonal system, hence the term Neuro-Endocrine. Most hormones that play an influential role in CF and FM are regulated via hypothalamo-pituitary control mechanisms. Hypothalamo-pituitary-adrenal axis (HPA) is the main pathway of the regulation of cortisol, and other stress hormones. In short, hypothalamus produces corticotropin-releasing factor (CRF), which stimulated pituitary to release adrenocorticotrophic hormone (ACTH), which in turn allows adrenal glands to produce cortisol. Cortisol levels are regulated by the HPA axis via a negative-feedback loop mechanism (when cortisol levels are high they feed into hypothalamus and hypothalamus makes less CRF, so pituitary make less ACTH). To make matters slightly more complicated there is one more part of the brain called hippocampus that has an overall “braking” activity on HPA axis that to otherwise tends to “fire away” full throttle. When a person is under a high level of stress (chemical, physical, and emotional), the body responses by elevating its cortisol levels (via HPA axis). The prolonged production of cortisol has a destructive effect on the hippocampus cells that are very sensitive to cortisol. These cells respond by allowing in stimulatory neurotransmitters, glutamate and aspartame, that cause the influx of calcium ions, which promotes oxidative damage to hippocampal cell, leading to apoptosis (cell death), the process known as excitotoxicity. (Another reason for not having NutraSweet (aspartate), commonly present in diet drinks, as well as monosodium glutamate (MSG), present in most processed foods, because it can lead to excitotoxicity and the consequent death of brain cells. Thus, the hippocampal dysfunction leads to loss of negative feedback inhibition (control) of HPA, leading to even further cortisol production. This vicious cycle is a common feature in FM and CF. Hippocampus has many other functions, one of them is being that it functions as memory center, also hippocampal destruction is the featured sign in a number of neurodegenerative disorders. This is a one explanation for the problem with short-term memory, and unpredictable response to stress, in CF and FM patients.

III. The GI dysfunctions and their relationship to CF and FM.

The GI dysfunctions are the most overlooked and mismanaged disorders in healthcare today. Traditional healthcare providers are lacking the ability to diagnose, and identify functional GI patterns, are nor trained in providing adequate lifestyle and dietary support and cannot link the interconnected web-like patters of systemic disorders to the GI tract. A good example of these is a recent survey from the American Gastroenterological Association, which found that symptoms of GI tract disorders existed with no structural, pathological, radiological, and laboratory findings and comprised forty one percent of membership’s practice. These patients are the one that are told, “your GI symptoms are normal” yet continue to suffer from chronic health dysfunction.

The identification and treatment of the GI disorders is doomed to fail if the treatment involves traditional drugs such as anti-inflammatory, antacids, or enteric nervous system inhibiting agents. These approaches do not address the underlying causes or triggers of the dysfunctions. Instead, these drugs are trying to give immediate and temporary relief to cover the symptoms.

Part of the problem with the complete failure of the allopathic approach to GI dysfunction is based on its emphasis of suppressing versus improving GI function. This approach only leads to chronic dependence on medications that prevent the GI tract from attaining optimum function.

Like mentioned above, the GI disorders must be addressed and treated in the patients with CF and FM. Moreover, if they are not addressed, treatment of CF and FM will become significantly hindered or impossible.
So let’s look at the significance of the GI system in human physiology.

The GI system is connected to every major system in the human body. Over 60% of the human immune system is found in the GI tract. The GI tract is responsible for the production of 99% of the body’s neurotransmitters. In addition, the GI tract serves very important metabolic functions, such as impacting the nutrient absorption, eliminating toxins, metabolizing hormones, energy production, etc.

Let look at what happens when the GI tract is exposed to antigen.
When the GI tract is exposed to antigen, the GALT will trigger the inflammatory response that will create a vicious cycle which includes inflammation, pain and oxidative stress. Antigen exposure will stimulate the GALT to induce an immune response that involves inflammatory mediators such as interleukins, tumor necrotizing factor (TNF), and others. These inflammatory mediators will induce inflammation, pain, and vasoconstriction. They will also cause the GI lining to thin, further predisposing to inflammation. Gastrointestinal dysfunction should always be considered in all patients presenting with chronic pain. In my practice, I have long noticed that in the great majority of all chronic patients have some sort of GI dysfunction. Those who read this article that have chronic pain ask yourself “Do I have digestive problems: acid reflux, indigestion, burning, belching, bloating, pain, constipation, diarrhea, or abdominal gas?” The most likely answer to that question is “Yes”.

We already discussed how GI dysfunction can lead to pain, inflammation, vasoconstriction, and free radical formation further affecting the immune system. The impaired GI system can also rave chaos on various hormonal systems(thyroid, adrenal, and reproductive systems), anemia, weight gain, mood and depression, neurodegeneration, chronic fatigue, cardiovascular function, and liver detoxification.

The lowered gut immunity can lead to increased sensitivity to food as well as to microbial antigens. A person may develop an immune response to gluten (wheat protein) for example. Once the sensitivity is established, exposure to wheat, in the GALT will cause a release of inflammatory mediators that will further stimulate a vicious cycle between the gut and the HPA axis. Same cycle can develop from any other type of antigen, not just food, but also Candida overgrowth, toxin, bacteria or parasitic inoculation. This chronic exposure of the GALT to antigens and generation of the vicious cycle can cause the body to shift from an anabolic (building) to a catabolic (breakdown) metabolism. All chronic generative conditions are catabolic conditions, when the rate of break down of the tissue is higher that the rate of regeneration.

Another vicious cycle that occurs with the adrenal stress involves leptin, a hormone that help to regulate appetite. You may ask what is wrong with the hormone that helps me to control my appetite. Similar to insulin resistance (high levels, but diminished response), which by-the-way is what mainly causes leptin resistance, high levels of leptin quickly cause leptin receptors in the hypothalamus to be down regulated, leading to leptin resistance. Brain decreases its signaling to the body to decrease food intake, leading to obesity.
Obesity, in turn, creates a vicious cycle of insulin resistance, leptin resistance, and increased cortisol levels, once again driving the HPA axis.

When the body is under the adrenal stress, it becomes more vulnerable. Earlier we discussed that high cortisol levels in humans can cause problems with blood sugar and insulin regulation, problems with thyroid and pituitary functions, imbalances in liver and gastrointestinal function, and many other systems. I would like to focus on how imbalances in the Liver detoxification, can contribute to CF and FM.

IV. Liver.

Liver’s main function is to detoxify toxic substances (foreign and native to our body) into less or non-toxic ones in order for our bodies to eliminate them into our sweat, urine, and feces. To do so it uses a complex series of detoxification reactions, like Phase I and Phase II detoxification.

Phase I detoxification consists of a series of enzymatic reactions that transform fat soluble toxins like hormones, neurotransmitters, intestinal bacterial toxins, bacteria, antigen-antibody complexes, drugs, pesticides, other chemicals, into water soluble substances. During Phase I prepares these toxic substances to either be cleared out of the system or makes them ready for Phase II detoxification. For each molecule of toxic substance being detoxified in Phase I, one molecule of free radical is produced. It worth mentioning that after Phase I detoxification the compound that is produced to go to Phase II detoxification, that compound is more active, therefore more toxic.

Phase II is even more complex than Phase I. It involves six pathways: glutathione conjugation, glycine conjugation, methylation, sulfation, acetylation, glucoronidation. We will not go outside the scope of this paper discussing each of those pathways, but collectively they neutralize the toxic substances from Phase I to be cleared into sweat, urine or bile.

A healthy liver depends on proper nutrition/nutritional support and a healthy GI function. When the GI tract is imbalanced, as it could be with food sensitivities, GI infections, inflammation, or high levels of cortisol due to stress (chemical, physical, emotional), all can make liver detoxification impaired.. When this [impaired liver detoxification] happens, toxic substances, that are harmful to our organism are not being cleared efficiently, causing them to re-circulate in the blood steam to the first organ downstream, liver. This increased influx of toxic substances into liver increase the normal load that healthy liver can manage, and over prolonged exposure, and high amounts of toxins, and eventually lead to chronic liver dysfunction.

Studies indicate that the impaired liver detoxification can greatly increase the potential for metabolic disorders. Among them neurological disorders, chemical sensitivities, adverse drug reactions, fatigue, and autoimmune disorders, all of which can be present in CF and FM patients.

Most hormones are also detoxified in liver. When liver function is impaired, hormones can become partially metabolized. When a hormone is partially metabolized, the end result can be a hormonal dysfunction that is difficult to diagnose, particularly by traditional methods, or inability to handle any type of toxic compound or drug. Also, impaired detoxification increases a total oxidative stress to the body and support other vicious cycles discussed earlier.


Sleep disturbance is one of most common features of CF and FM. High percentage of fibromyalgia sufferers has a sleep disorder called alpha EEG anomaly, problem staying asleep. Other types of sleep disturbances include restless leg syndrome (RLS), sleep apnea, and problem falling asleep.

Alpha EEG anomaly affects deep sleep, preventing sufferers from getting a good night’s rest.
Alpha EEG anomaly occurs when sudden bursts of brain activity occur during a time when the brain should be in deep sleep. These periods of intense activity are measured as alpha waves on an EEG monitor. People with alpha EEG anomaly do not have difficulty falling asleep, but once they reach deep sleep, their brains begin to act like they are awake. This leaves sufferers feeling tired and drained. Because GH secretion is linked to stages 3 and 4 of the sleep cycle.

Read: Growth Hormone Deficiency in Fibromyalgia article by Dr Bennett

Studies also suggest that a lack of sleep can lead to weakness in the immune system and it’s ability to handle stress, suppressed thyroid function, decreased metabolic activity, decreased cognitive function, and can induce pain in overall healthy individual. All of these symptoms can be a consequence on GH deficiency that is prevalent in FM patients.

As far as Sleep Alpha EEG anomaly is concerned, we understand, is often related to blood sugar imbalances, i.e. hypoglycemia, (low blood sugar). People who crave sweets and caffeine “to keep them going”, feel irritable, shaky, nervous or unsocial when miss meals, have low energy, especially in the morning and in between meals, that is improved by food, and often are told by others that they “should eat something” are likely hypoglycemic. The result of hypoglycemia, which most have for many years, is chronic stress. This stress is chronic stress is putting undue demand on the adrenal glands, with the consequent decrease in function to maintain normal blood sugar levels, in particular, during the times of fasting, i.e. sleep. When sleep, we use glycogen (stored glucose) from muscles and liver. We can lose as much as two thirds of our glycogen storage in one night. If a person has a blood sugar imbalance like hypoglycemia, they cannot maintain the blood sugar level overnight. As levels of blood sugar drop, brain, that is unable to maintain its own food supply (glucose), sends out signals to the adrenals to produce cortisol in order to increase the glucose levels. A healthy individual will produce just enough cortisol in order to maintain their blood sugar level, but in a person with hypoglycemia, stress response will cause the adrenal glands to produce adrenalin and nor-adrenalin instead, to maintain their blood sugar levels to compensate for a lack of cortisol. The production of these stimulatory hormones is what causes the person to wake up in the middle of the night, with difficulty of going back to sleep and having high alpha brain activity.
For those individuals who have elevated levels of cortisol before the bedtime will have difficulty falling asleep, because cortisol is a stimulatory hormone, and abnormally high levels of it will cause insomnia. This type of insomnia though less common can also effect people with FM and CF.

Balancing out HPA, blood sugar imbalances are therefore imperative in patients with FM and CF.


Anemia is generally characterized by decrease in blood red blood cells (RBC), hemoglobin (Hgb), and hematocrit (Hct), and can be easily evaluated by a simple blood test. Some of the symptoms include: weakness, fatigue, shortness of breath, brittle nails, feeling cold, and pallor appearance. There are too many causes of anemia to list in this article, but the importance of treating anemia in patients with CF and FM cannot be overemphasized.
There are two types of anemia most common in CF and FM. Megablastic and iron deficiency anemia (IDA).
IDA is the most common type of anemia and is usually caused by inadequate dietary iron intake or blood loss (NSAIDS use, heavy menstruation, and trauma). Chronic diseases can also cause IDA, due to increased red blood cell (RBC) destruction, and possibly to decreased iron absorption.

Megablastic anemia is characteristic of folic acid and vitamin B-12 deficiency, most common with poor dietary habits, strict vegan diets, excessive dieting, and problems with absorption.

We need RBC and Hb (a main component of RBC) to carry oxygen from the lungs and into the tissue and carbon dioxide and other metabolic waste byproducts from the tissues to lungs. Oxygen is required in nearly all processes in the human body. Without the oxygen there is no energy production, protein synthesis, there is no life. Decreased oxygen to the tissue and diminished clearance of waste byproducts can produce such a burden on already burdened organism in people with CF and FM that it can compromise any attempts to get these people well.

If anemia is not addressed early on in the treatment, the effects of the treatment are going to be compromised. Because blood not only delivers oxygen and sugar to cells in the body, but also the therapeutic agents, like medication, supplements, and nutrients, as well as ridding of toxic substances. This is why every patient with FM and CF should have a thorough blood work to rule out these deficiencies

Nutritional deficiencies (Also refer to this great summary article on Nutritional Deficiencies in CF & FM)

Some experts believe that nutritional deficiencies are causative factors of CF and FM, while others believe that the syndromes cause them, but most agree that there are nutritional deficiencies in CF and FM. Because nutritional deficiencies are relatively easy to correct they should be addressed early on in treatment.


One of the most common minerals that is deficient in CF and FM is Magnesium. Magnesium is needed for the immune function and metabolism. Deficiency of magnesium can cause depression, anxiety, fatigue, weakness, sleep disorders, all of which are obviously most common symptoms of CF and FM.
A study of supplementing of 300-600 mg of Magnesium and 1200-2400 mg of Malate had also significant improvement in FM pain.


A large percentage of people with FM and CF have neurally mediated hypotension, a condition when a person experiences drop in their blood pressure without any obvious defect in their hearts. A quick survey of these people is likely to find that they are always trying to restrict sodium in their diet. For these group, a natural sodium supplementation like unprocessed see salts will be appropriate and can help dramatically.


Zinc is another mineral often found deficient in FM, CF. Zinc is responsible for healthy functioning of the immune system.


L-tryptophan is dietary precursor to serotonin, a neurotransmitter intimately connected with the mood. A large percentage of FM & CF patients have decreased levels of tryptophan in their blood. Supplementing with 5-hydroxytryptophan, the immediate precursor to serotonin, has show to be beneficial for mood and muscle pain.


L-carnitine is an amino acid that is essential for the energy production at the cellular, mitochondrial level. It does it by helping to funnel fatty acids and acetyl Co-A into the mitochondria for energy production. It is an established fact that the cellular energy production is needed for all metabolic processes such as making of hormones, proteins, enzymes, and many other vital bodily functions. This energy production is also responsible for healthy homeostatic mechanism (natural balancing ability of the body). Because of its important role in energy production, carnitine deficiency may well impair mitochondrial function. If so, it could cause symptoms of generalized fatigue along with myalgia, muscle weakness, and malaise following physical exertion.


Choline is an essential nutrient that is similar in function to B vitamins.


Vitamin B-12 is an important vitamin that is essential for many functions. These include energy and red blood cell production, carbohydrate/sugar metabolism, liver function.

High dozes of Vitamin B-12 have shown to improve energy in patients with CF. In pharmacological dozes Vitamin B-12 also acts as analgesic (pain killer), and can significantly decrease pain in fibromyalgia patients.

V. Psychiatric Component

Those who suffer with FM and CF know how unpredictable their moods and reaction to stress can be. Many of our patients describe their depression as disabilitating, often being one of the biggest hurdles on their way to recovery. Patients with chronic fatigue find that they are much less motivated to exercise, eat right, and make other positive changes in their lifestyle, (fibromyalgia patients usually have pain as their biggest hurdle, depression usually comes close second).

Studies indicate that FM and CF have imbalances in the neurotransmitters that affect these patients on mental and emotional level. Correcting these imbalances nutritionally as described above therefore is paramount.


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