Why am I Tired All of The Time?

One of the most common complaints in a physician’s office is one of fatigue or malaise, but few clinical complaints are as hard to fully qualify and understand as these.  Inherent in the words are a degree of vagary, a lack of a true description or roadmap by which the clinician can be guided.  When the appointment sheet reads “rash”, or when the patient presents with a “broken finger”, the clinical approach is immediately clear.  “Shortness of breath or severe chest pain” obviously demands immediate attention.  But too often when the doctor is faced with the patient who complains of a lack of energy, there is often a state of confusion or indecision that is encountered; not the razor-sharp “aha” that we would expect from the other examples shown. 

For theses reasons, people who are seen in the traditional model of medicine are often passed by, tossed into a heap of traditional therapies, such as anti-depressants, stimulants, tentative thyroid replacement, or caffeine.  Little attention is paid to the understanding of the biochemical processes that are taking place to contribute to this fatigue.  I believe that a functional approach offers the tools and understanding to identify and reverse the processes that are contributing to the fatigue.

According to the CDC, (http://www.cdc.gov/cfs/causes/risk-groups.html), over one million people suffer with Chronic Fatigue- and I suspect that the number is much higher as there is no formalized test, or mandated reporting to confirm this number.  A review of the same web site recommends a “battery” of testing, but this represents only a fraction of the considerations that would be taken by a functional approach.  The CDC approach basically looks to identify known causes of fatigue, such as autoimmune disorders, thyroid dysfunction, or renal disorders – all reasonable considerations in the evaluation of a fatigued patient.  

I see no mention of screening to look for chronic infectious causes, such as mononucleosis, chronic herpes virus infection, chronic EBV, or Lyme disease.  There is no consideration of looking for signs of inflammation or infection, and no tests recommended for evaluating cellular function.  The CDC recommended tests do little more than evaluate a few organ systems.  There is no suggestion to consider the hormones and metabolic pathways that are responsible for the body’s production and storage of energy, and there is not even the slightest comment on addressing how and where energy is actually made in the cell.  This is all Biochemistry 101 folks, taught on the first day of medical school.

So your thyroid studies are normal, your antibody studies for autoimmune diseases are all negative, your blood count is normal (no anemia), and your kidneys are pumping out the champagne of urine.  Congratulations, that is great news.  But you still feel sick, and your doctor is recommending that you take an “antidepressant with a little kick”.  What is wrong with this picture?  Heck, 30 million Americans are taking antidepressants, why not just one more?

The problem is that the allopathic approach has failed to ask three fundamental questions, ones which we learned in our first weeks of medical school:  What does the body use for energy?  Where is it made?  How is it stored?   Without addressing these simple considerations, conventional medicine is missing an opportunity to identify the root of the problem and to offer a real cure.  It also fails to ask the question of what other processes, other than a cursory look at a bum thyroid, a sick kidney or impaired bone marrow system could be causing the problems.

The new functional paradigm returns to an analysis of each of these three questions, while not failing to consider the low hanging fruit of thyroid disease, kidney disease, or cancer.  I believe that by reminding ourselves of the known biochemical pathways that have been known to medical students for decades, we can make steps to stop the fatigue and return the individual to a state of health.

To fully address the utilization and storage of energy, we need to first look at the question from an organ standpoint.  I like to first look at the organ triad of the pancreas, the adrenal glands, and the thyroid- the three primary organs directly responsible for energy production, storage and release.  

The pancreas makes the hormone insulin, as well as digestive enzymes, and through insulin directly tells cells to take glucose (sugar) from our bloodstream.  The muscles and liver should be storing this sugar in the form of glycogen, providing a healthy storage form held in energetic reserve, an on-demand energy “bank.”  

However due to several lifestyle choices, seen most vividly in obesity and diabetes, the insulin signaling doesn’t translate well.  The sugar isn’t taken into the muscle and liver cells, but is scavenged up by the fat cells.  A vicious circle ensues, with progressive cellular resistance to insulin, increased insulin delivery by the pancreas, and more deposition of fat.  After time the pancreas is tapped out and simply can’t make insulin anymore, and we find ourselves with diabetes, and replacing the insulin with shots.  The cells intended to collect and store our glucose are being starved by an inoperative insulin response, and the sugar-guzzling fat cells are getting, well, fatter.  This is an example of unbridled energy transport and storage; the muscle, liver (and brain!) cells get progressively less healthy, and the fat collects in the body, around the abdominal structures,  and in the liver.

Thyroid hormone is like the accelerator of the cells, and every cell in the body has a receptor for thyroid hormone.  Too much thyroid hormone and the patient looks like the energizer bunny; too little and they feel like a sloth.  The causes of thyroid dysfunction are too broad to discuss in this blog- I’ll be sure to cover it in more detail in another post- but regardless of the cause the thyroid needs to be evaluated correctly.  Most physicians simply check a test known as TSH, Thyroid Stimulating Hormone, and look to see if this brain hormone is in the normal range of about .5- 5.0.   So if your TSH is 4.0, that’s it- your doctor says that your thyroid is normal.  But I beg to differ.

I recommend that all patients with fatigue are sure to ask their physicians to do a thorough thyroid panel, one which looks at TSH for sure, but also measures the actual thyroid hormones, T4 and T3, and not simply the brain’s response to these hormones (TSH).  T4 is the more abundant of the two hormones, and is the entirety of the commonly prescribed medicine levothyroxine, or Synthroid.  However the active form of the hormone is the T3, and this should be measured as well.  For many reasons, not the least of which is the overabundance of the hormone cortisol (to be discussed in the following paragraph), the T4 is frequently not converted to the active T3 due to stress (cortisol), inflammation, insulin dysfunction or trace nutrient deficiency.  

And don’t forget to ask to have your Reverse T3 measured.  It is the doppelganger, the evil, energy-sapping twin of T3.   This thyroid antagonist is often increased by the well intended, but misdirected, administration of only T4 (Synthroid).  So be sure to do an accurate measurement of the thyroid hormones, and get the answers that you need to understand your thyroid’s health.

Finally, there needs to be  a signal that tells the body not to store energy, as with insulin, but to release it NOW to prepare for the physical challenges of a warring neighbor tribe, a charging mountain lion, or a heated board meeting.  This is the hormone cortisol, released from the adrenal glands in response to a signal from the brain.  The adrenaline hormones, epinephrine and norepinephrine, work alongside cortisol, and are familiar to us as the jittery feeling that we get when we look into the rearview mirror and see a cop pulling us over.  

As with so many things in the human body, what we are looking for is a state of balance.  Similar to  thyroid hormone, the subject of cortisol probably merits a three part series to fully cover its biology and importance.  In a nutshell, cortisol is our primary stress hormone.  It is the only hormone without which we will die.  Cortisol has multiple immunological functions, but its primary action is one of energy storage and regulation.  

After a meal, assuming that we have given ourselves the opportunity to do so, the insulin works to store energy while we “rest and digest”.  After eating cortisol should be low, while its adversary, insulin, directs the cells to take in sugar and store it as glycogen.  Cortisol and adrenaline on the other hand are counter-regulatory, which is to say that their action oppose that of insulin.  In the throes of the saber-toothed tiger attack, cortisol actively inhibits the storage functions of insulin and conversely directs the cells to mobilize glucose into the bloodstream so that our brain can function better, and our muscles have more energy fight back and escape.  We breathe harder and faster to increase the amount of oxygen is available to make energy.  Our eyes dilate to let in more light.  Our hearts beat harder and faster.

But it is important to realize that cortisol is only meant to be turned on for short periods of time. Potentially months or years could go by between attacks, when energy management is maintained.  But consider the person who is subjected to chronic stress, who is constantly living within a flight or fight response whether there is a tiger actually living in the brushes or not.  This person has an uncoupled energy system, and the messaging to the cells rests more in the dumping of sugars (cortisol) rather than to its storage (insulin).  As the function of insulin is blocked, the blood sugar rises.  Fat is accumulated (well, the sugar can’t go inside the normal storage cells, so where else can it go?), and inflammation and fatigue ensue.  Cortisol is a significant player in the field of energetics, energy, immunity and overall health.  But did your doctor think to check a cortisol study when you presented with fatigue?  Probably not.

The final consideration is that of energy production.  This takes place in the small intracellular organelles known as mitochondria.  These are the little powerhouses of the cell, converting components from our food into packages of energy known as ATP.  This is a complex course of events that will be examined another time, so stay tuned.  Suffice to say that energy production requires many vitamins, minerals, nutrients and oxygen. But for now know that when a mitochondria is starved from its nutritional and metabolic needs, the organelle’s energy production comes grinding to a halt.  Could it be that our malaise and fatigue could not be from a Prozac deficiency, but a deficiency of vitamins, minerals or oxygen?  As I mentioned, these are all essential parts of the energy making machinery, and must be at least considered when addressing the question of fatigue.

So the moral of this story is to have hope.  Functional Medicine offers a broad palate from which to consider the multiple factors that could be contributing to a feeling of fatigue.  Know that there is a doctor who has learned to change his or her thinking, and who and understands that the key to true health is not simply through the use of medications.  You want a doctor who thinks “outside of the box” that has been drawn by the architects of modern medical practices: Big Pharm, the FDA, and the AMA.   If the patients, and more importantly the doctors in this country, learn to step outside of our comfort zones, we can begin to find a path towards true health, renewed energy, and better lives.