What you believe and how you act have a profound effect on your physiology, so it’s no accident that many athletes are not the most healthy specimens. Ian Craig views a complex case of a chronically fatigued long-distance triathlete.

Chronic fatigue is not something that you often hear athletes admitting to, but it is a condition with increasing common occurrence; not just in athletes, but in general population too. Think about it - if you spend years physically and mentally pushing your body and mind to their 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, for instance, that heavy exercise training can strongly suppress immune function in an inverted-U pattern, whereby ‘moderate exercise’ is most supportive of immune function (1). But in these cases, athletes generally come bounding back the very next season.

It’s when athletes don’t come bounding back that we need to question what is wrong with them. When we hear the words ‘chronic fatigue syndrome’ (CFS), most of us think of the poor souls who spend several years in bed without hope of recovery. These people do exist, many more than should exist with our current knowledge,. However, the type of clients that I seem to be attracting to my Johannesburg 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.

Of well-known sports people, Olympic canoeist and six-time World champion, Anna Hemmings (2), was such a case - she described her experience like “not fully in the sick world, but not fully in the well world either”. She went from being able to race 2 1/2 hour marathons to not managing a light 20 minute paddle. She was one of the lucky ones, though, because she didn’t wait for the doctors and quickly discovered a therapy that worked for her, meaning that she recovered within a two year period and even regained her World title. She used Reverse Therapy (3), which is an educational programme designed to identify triggers of fatigue and pain, primarily focussing on de-tuning the hypothalamus from over-stimulation of the endocrine and nervous systems.

What is chronic fatigue syndrome?

This is a very good question, because nobody can give a definitive answer. It has been said that it is caused by a disturbed microbiome (4) or by autoimmunity (5) - these of course form part of the picture, but CFS is 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.

CFS, and its related conditions such as ME and fibromyalgia, and often autoimmunity, is generally associated with some combination of the following:

  • - Adrenal fatigue or overtraining - on the web page of Anna Hemmings, she said that she was not suffering from overtraining syndrome (OTS), but the way that she righted herself was by de-tuning her hypothalamus output, meaning that she was actually 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 - this relates to the first point because it’s not really the hypothalamus itself that causes the physiological over-stimulation, but more the mind above which sends messages to the hypothalamus. As you’ll see in my case study, often the hypothalamus-pituitary axis is exhausted, but the mind is still pushing it to use every ounce of resource available to it.
  • - 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 actually infected with this parasite (6), but immune-suppression is necessary for symptomatology to occur, meaning that athletes who are pushing their bodies to the limits are particularly prone. Interestingly, according to South African chronic fatigue specialist Cecile Jadin (7), most of us are infected with the Epstein Barr virus, but glandular fever is actually made of up co-infections, explaining why some of us shrug it off quickly, while 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 CFS 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 CFS 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 Jones’s when it comes to bulldozing their way through modern life.

So understanding yourself or understanding your client is really important when it comes to helping them out of their CFS situation. You can see that CFS may manifest for a number of different reasons, but all of the above is likely to be at play. All good athletes have a strong value system of mind-over-matter, but when they have ignored the feedback messages from their body for long enough, that is when their body becomes depleted and succumbs to endocrine or neural disturbance like Anna Hemmings, or chronic infection like Seb Coe.

Introducing Monique

I live and work 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. But, the athlete cases that find their way to my door, lead me to believe that people here are still chasing gold, and in many ways they are - digital gold. I see people who work 12-hour days, manage family life AND still fit in Ironman training by getting up at 4am to train. It is little wonder that most of them plateaux at a fairly mediocre performance level, while some of them become dramatically unstuck health-wise.

I’ve chosen a case that has given me a great deal of satisfaction because it became one of emotional management more than nutritional complexity. Monique was first referred to me by my chiropractic colleague in February this year. She was a 43 year old mother of three, and had been a triathlete for the past five years, qualifying annually for and competing well at the World long-course triathlon championships. The most pressing two symptoms that she presented with were fatigue and recurrent inflections, 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 was propped up with 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 had her on a high-protein, fairly low-calorie diet for the past five years despite heavy training loads.

In terms of training, it averaged three to four hours 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 focussed 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 two hours a day!), plus I shared an inspirational Jo Pavey interview with her, showing that an older athlete (40+) can succeed internationally if they attain the right life balances.

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

Session 2

Between sessions 1 and 2, I asked Monique to do some genetic tests, so that I could obtain a view of the following: a) preferred macronutrient dietary balance, b) enzyme systems that may need supporting, 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 obviously 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 thankfully already decided to scrap her World championships intensions for 2016. I therefore kicked straight into action and further negotiated a reduction in her training load to 2 x 30min gentle sessions per day, and to work with my yoga teacher to introduce some parasympathetic (yin) influence to her hectic life.

Dietary wise, her genetic results did not support a low-carb approach and 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 history, current information and genetic results, I recommended:

  • - A brain formula with phosphotidylserine and a strong 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 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 (breakdown of oestrogen and adrenaline)
  • - An adrenal adaptogenic blend

The next six months

And that approach, bar a few adjustments here and there, was my strategy for the next six months. Our monthly sessions were focussed on counselling Monique in terms of maintaining healthy and progressive habits, while helping her to keep her competitive goals alive. Coming from this ‘more is better’ culture that we have here, she is completely addicted to her exercise, so to try and break that connection has been really 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 (April), 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 (May), Monique was coping with five training days in a row, she was off her cortisone, her cortisol levels were back in range and she was just taking a little DHEA.

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

In July there was further improvement - her ACTH levels were back to normal, suggestive of 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 haven’t seen Monique now for two months, so I assume that she is running around like a crazy chick again. In reflection, she did slow down, but not nearly as much as I would have liked; however, we still got extremely good results in a short period of time. If she is able to carry our work forward as a life lesson, in effect rejecting her Johannesburg culturing, I believe that she can still compete at the levels of a few years ago prior to when her fatigue and immune challenges setting in.


  1. Nieman (1994). Exercise, infection and immunity. Int J Sports Med. 15:S131-S141.
  2. Hemmings A (2016). Chronic fatigue syndrome. www.annahemmings.com/page28.asp
  3. Eaton J (2010). A radical new approach to recovery. www.reverse-therapy.com.
  4. Navaneetharaja N et al (2016). A role for the intestinal microbiota and virome in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS)? J Clin Med. 5(6):E55.
  5. Autoimmunity Research Foundation (2007). www.autoimmunityresearch.org.
  6. Flegr J et al (2014). Toxoplasmosis – a global threat. Correlation of latent toxoplasmosis with specific disease burden in a set of 88 countries. PLoS ONE. 9(3):e90203.
  7. Jadin C (2002). A Disease Called Fatigue. HPH Publishing.
  8. Wilkins E (2016). M.E, CFS, Fibromyalgia Supported Recovery Programme. www.thechrysaliseffect.com.
  9. Aron E (1999). The Highly Sensitive Person. Thorsons.
  10. Craig I (2014). Hypothalamus-Pituitary Axis. Functional Sports Nutrition. Jan/Feb 2014, pp6-8.