A chronic fatigue case study – Ian Craig

What we believe and how we act profoundly affects our physiology. It’s no accident that many athletes are not reaching optimal health. Ian Craig views a complex chronic fatigue case of a long-distance triathlete.

Chronic fatigue is not something you often hear athletes admitting to, but it is an increasingly common occurrence and not just in athletes, but in the general population too. If you spend years physically and mentally pushing your body and mind to the absolute limits, there is a good chance that something will eventually crack. Mostly the cracks are ‘just’ injuries and short-term illnesses that curtail a season or a block of training. It has been well documented that heavy exercise training can strongly suppress immune function in a J-shaped pattern, whereby ‘moderate exercise’ is the most supportive for immune function (1). But in these cases, athletes generally come bounding back the next season.

When athletes don’t come bounding back, we need to question what is wrong. When we hear the words ‘chronic fatigue syndrome’, most of us think of the poor souls who spend several years in bed without hope of recovery. These people exist, many more than should exist with our current knowledge. However, the type of clients that I seemed to attract to my practice are not bound to their bed, but they are certainly not vibrating at the same frequency as they once were, meaning that the more intense things in their life, namely sports training, have to take a firm backseat.

Olympic canoeist and 6-time World champion, Anna Hemmings (2), was such a case – she described her experience as “not fully in the sick world, but not fully in the well world either”. She went from being able to race 2h30 marathons, to not managing a light 20-minute paddle. Fortunately, she was one of the lucky ones because she didn’t wait for the doctors and quickly discovered a therapy that worked for her, meaning that she recovered within two years and even regained her world title. She used Reverse Therapy (3), an educational programme designed to identify triggers of fatigue and pain, primarily focusing on de-tuning the hypothalamus from over-stimulation of the endocrine and nervous systems.

What is Chronic Fatigue Syndrome?

Chronic fatigue syndrome is caused by a disturbed microbiome (4), autoinflammation or by autoimmunity (5). However, chronic fatigue syndrome is much more complicated than single causes; a multitude of factors contribute to this devastating condition, and because of the lack of a single treatment option, doctors are mostly not well-resourced to deal with it.

Chronic fatigue syndrome, along with related conditions such as ME and fibromyalgia, and often autoimmunity, are generally associated with a combination of the following:

• • Adrenal fatigue or overtraining – Anna Hemmings said she was not suffering from overtraining syndrome (OTS), but the way that she righted herself was by de-tuning her hypothalamus output. This means she was suffering from an extended form of overtraining, not just adrenal fatigue but most likely whole body endocrine and nervous system fatigue.

• • Mental or emotional over-stimulation – relates to the first point because it’s not the hypothalamus that causes the physiological over-stimulation but more the mind, which sends chemical messages to the hypothalamus. As you’ll see in my case study, the hypothalamus-pituitary axis is often exhausted, but the mind pushes it to use every ounce of available resources.

• • Infectious agents – we’ve all heard of glandular fever in athletes and the associated Epstein-Barr virus. Perhaps most famously, middle-distance runner Sebastian Coe suffered from glandular fever when at his prime in 1982 and soon afterwards was in and out of hospital with toxoplasmosis, a parasitic disease caused by infection with Toxoplasma gondii. It has been estimated that 30 to 50 per cent of the world population is infected with this parasite (6). Still, immune suppression is necessary for symptomatology, meaning athletes pushing their bodies to the limits are particularly prone. Most of us are infected with the Epstein-Barr virus, but glandular fever comprises of co-infections, explaining why some shrug it off quickly. In contrast, others have recurrent problems with it (such as the case with Seb Coe), leading to the term ‘post-viral fatigue syndrome’. According to Jadin, infections that contribute to chronic fatigue syndrome include but are not limited to, Rickettsia, Borrelia, Bilharzia, and Chlamydia.

• • Type-A and highly-sensitive personalities – according to Elaine Wilkins, founder of The Chrysalis Effect Chronic Fatigue Syndrome Recovery Programme (8), being a go-getter is potentially also going to set you up for eventual physiological breakdown because you are not likely to listen to the subtle feedback from your body telling you to slow down. So, too, does being an ‘empath’ or a ‘highly sensitive person’ (9), the highly intuitive, caring, nurturing type of person who is not likely to keep up with the Joneses when it comes to bulldozing their way through modern life.

Understanding yourself or your client is important in helping the chronic fatigue syndrome case. All of the above points are likely to be at play to greater and lesser extents. Good athletes have a strong value system of mind over matter. Still, when they have ignored the feedback messages from their body for long enough, their body becomes depleted and succumbs to endocrine or neural disturbance, like Anna Hemmings or chronic infection, like Seb Coe.

Introducing Monique and her chronic fatigue state

At the time of first writing this article, I lived and worked in what I believe to be one of the most stress-cultured cities in the world. Johannesburg originated as a small village in 1886 which grew rapidly during the gold rush of that time to become the largest city in South Africa. The athlete cases that found their way to my door led me to believe that people there are still chasing gold, and in many ways, they are – digital gold. I saw people who worked 12-hour days, managed family life AND still fit in Ironman training by getting up at 4 am to train. It is little wonder that most plateauxed at a fairly mediocre performance level, while some became dramatically unstuck health-wise.

I’ve chosen a case that has given me great satisfaction because it became one of emotional management more than nutritional complexity. Monique was first referred to me by a chiropractic colleague. She was a 43-year-old mother of three and had been a triathlete for five years, qualifying annually for and competing well in the World Long-Course Triathlon Championships.

The most pressing two symptoms that she presented with were fatigue and recurrent infections, mostly bronchitis, which had previously progressed to pneumonia, so she frequently took antibiotics to avoid this eventuality. She had also suffered from chronic asthma after the premature birth of her third child eight years previously. She took an array of medications, including asthma and sinusitis support, cortisone and testosterone cream, plus a list of dietary supplements as long as your arm. Lab tests from her endocrinologist two days before had revealed extremely low testosterone and DHEA levels. Additionally, her dietician had her on a high-protein, fairly low-calorie diet for the past five years despite heavy training loads.

Her training averaged at 3-4h per day – she more or less tried to do all three disciplines every day, with some gym work thrown in. She was guided by a respected South African coach, but one who very much followed the prevailing very high volume, low-quality culture without due consideration for individual tolerance.

I started my intervention with a very focused educational view of the hypothalamus-pituitary axis and how it influenced adrenal, thyroid and ovarian function (10). Almost surprisingly, she still experienced a menstrual bleed monthly, but interestingly the timing of that was closely linked to her worst asthma symptoms. I negotiated strongly for a lowered training load, which she eventually agreed to (down to 2h per day), plus I shared an inspirational Jo Pavey interview with her, showing that an older athlete (aged 40+) can succeed internationally if they attain the right life and training balance.

Monique’s food diary, guided by her Dietitian, comprised of: 3 protein shakes, a chicken salad, fruit and yoghurt, and a wrap – hardly the substance of a top athlete. Therefore, I started with some basic fresh Mediterranean diet principles, asking her to eat rather than drink her meals and to prepare as much as possible from scratch. She didn’t work, but spent so much time training and driving around after her kids that food and self-care were not priorities for her.

Session 2: Follow-up on Monique’s chronic fatigue state

Between sessions 1 and 2, I asked Monique to do some genetic tests so that I could add some insights to the following: a) preferred macronutrient dietary balance, b) enzyme systems that may need support, and c) power and endurance attributes, so I could comment further on training content. When she saw me, she had some bad news – from an MRI scan, she had been diagnosed as having a pituitary tumour, which explained her low testosterone and DHEA levels. It was small, and her endocrinologist just wanted to keep an eye on it for now rather than to operate. Monique had decided to scrap her World Championships intentions for 2016. I therefore kicked straight into action and further negotiated a reduction in her training load to 2 x 30-minute gentle sessions per day and to work with my yoga teacher to introduce some parasympathetic influence to her life.

Diet wise, her genetic results did not support a low-carb approach. I further educated her on fresh, organic Mediterranean examples, becoming more bespoke to her needs on this occasion. I also pressed the reset button on her supplement regime and, based on her health history, pituitary tumour and genetic results, recommended:

• • A brain formula with phosphatidylserine and a potent antioxidant blend

• • Nucleotides for new cell growth (especially immune)

• • High-dose curcumin for anti-inflammation

• • A sprouted broccoli seed product to support glutathione due to a single nucleotide polymorphism (SNP) in the GSTM1 enzyme

• • Pure, high-dose fish and borage oil for anti-inflammation and membrane support

• • Vitamin D for immune support

• • Magnesium to support a SNP in the COMT enzyme (for breakdown of oestrogen and adrenaline)

• • An adrenal adaptogenic blend

The next six months

That approach, bar a few adjustments here and there, was my strategy for the next six months for tackling her chronic fatigue. Our monthly sessions focused on counselling Monique on maintaining healthy and progressive habits while helping her keep her competitive goals alive. The ‘more is better’ culture that prevails in Johannesburg, encouraged her addiction to her exercise, so to try and break that connection was tough. Continuing with the same training patterns, even when recovered, would just land her in the same heap next year, so I had to try and establish new behavioural patterns.

Two months after the initial intervention, she reported that she had not been sick for three months and that her asthma was well under control – result…! But, she still had problems with her energy, which was extremely inconsistent. My inner thought was “good” because she would just use extra energy to channel into heavy training again.

A month later, Monique was coping with five gentle training days per week; she was off her cortisone, her cortisol levels were back in range, and she was just taking a little DHEA.

A month later, her weight had settled to normal after removing cortisone, she had not been ill for five months (in her words, “unheard of”), and she was planning a recreational cycling trip to the Pyrenees with her husband.

One month later, there was more improvement – her ACTH levels were back to normal, suggesting normal pituitary activity. We therefore agreed that it was time for a repeat MRI test to make sure. Additionally, I referred her to my physiology colleague, who coached in a careful individualistic way.

I then didn’t see or hear from Monique for several months. She returned to my clinic six months later, looking like a different person – she had a greyness to her skin when I first worked with her, but a year later she now had a radiant glow, something I associate with health and beauty. Her amazing news was that there was no sign of the pituitary tumour after a repeat MRI scan! She had not returned yet to competition but was enjoying feeling healthy and pursuing more recreational sporting activities. That’s a win, I’d say, against chronic fatigue. Further, I believed that she could return to competing at the levels she had attained before her chronic fatigue syndrome and immune challenges set in.

To continue learning about Integrative Sports Nutrition, where health feeds performance, click here to access CISN’s library of articles.

Click to listen to Ian Craig’s ‘The Science and Strategy of Personalizing Nutrition‘ interview on the Nutra-preneur podcast here.