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From the Townsend Letter
November 2013

Fatigue as a Symptom: A Systemic Approach to Diagnosing Adrenal Fatigue
by Amy Terlisner, NMD
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In the ICD-9 (insurance/traditional medical care) system, fatigue is a diagnosis. Meaning that the physician has diagnosed you (the patient) with fatigue; this is your disease; and there is no further workup to be done. You have a number (an ICD-9 code) that corresponds with that diagnosis, and he or she will attach that number to your case. Currently, there are codes (diagnoses) for chronic fatigue, fatigue, and fibromyalgia (which has a pain component and other specific symptoms). However, as astute diagnosticians (physicians who seek the cause of disease), the first understanding that we come to is that fatigue is a symptom, not a disease. And for 20 patients that present with fatigue, there will ultimately be 20 different underlying causes.

In an initial intake, I always ask about fatigue, as it is one of the most common symptoms that I see. From there, and with other symptoms and physical exam, I can come to a diagnosis in the future.

What Are Some of the Most Common Lab Tests to Order When a Patient Presents with Fatigue?
The following is a general checklist that should be completed during a workup of fatigue. The second half of this article will discuss treatment of a common cause of fatigue, adrenal fatigue; however, this would represent a general list of tests that I would complete prior to this diagnosis:

  • CBC: which looks at white blood cells, red blood cells, and platelets
  o  Low red blood cell (RBC) counts, low hemoglobin levels, and low MCHC (mean corpuscular hemoglobin concentrations) can indicate anemia – a condition wherein insufficient oxygen is transported through the bloodstream.
    * Causes include: iron deficiency in the diet, malabsorption issues (gastritis, SIBO [small intestine bacterial over­growth], Crohn's, ulcerative colitis, mild GI inflammation), vegan or vegetarian diet, heavy metal toxicity
  o  Low or high white blood cell counts – which can indicate low-grade infections
    * Low-grade infections are a chronic stress to the body and can create mild to severe fatigue.
    * Infectious agents can be viral, bacterial, and/or fungal.
  o  Low or high levels of platelets
    * Low levels of platelets can be due to B vitamin deficiency, heavy metal toxicity, or autoimmune ITP.
    * High levels of platelets can indicate dehydration or overall inflammation.
  • CMP: complete metabolic panel
  o  High levels of AST or ALT can point to etiology in the liver.
  o  High BUN or creatinine can point to etiology in the kidney (however, there are other benign reasons that these can be elevated and other definitive tests may be needed).
  • Thyroid studies: TSH, free T3, free T4, thyroid antibodies, thyroglobulin, and reverse T3
  o  The thyroid gland regulates the speed of many other biochemical reactions in the body. A low-functioning thyroid gland is one of the most common causes of fatigue in the US.

I must stress the importance of working with a physician who can properly interpret your lab values. Traditional medical systems do not focus on optimization of the thyroid gland. They only see gross excesses or deficiencies, which are numbers that fall out of reference ranges; however, many patients have greatly benefited from fine-tuning the thyroid gland even though their lab values have never fallen out of lab-determined reference ranges.

So many patients ask me, why does everyone have a thyroid problem? There are many reasons, but I think that the most common issue relates to excess halogen exposure (halogens are elements on the periodic table with the same number of electrons in their outside shell). Halogens – other than iodine – include chloride, fluoride, and bromide. Minimizing fluoride and bromide exposure is a necessary step in healing the thyroid gland. For a wonderful article on this, check out

  • Hormone studies to include estradiol, free and total testosterone, AM cortisol, DHEA-s, progesterone
  • Neurotransmitter studies: sero­ton­in, GABA, epinephrine, norepinephrine, dopamine at minimum
  • Heavy metal testing
  • Further testing for adrenal function, which can include testing cortisol levels 4 times in one day
  • Sleep studies

Again, these are the most common lab tests to run on a patient with fatigue/chronic fatigue, and are a great starting place. Further or rarer testing could include Lyme disease testing (specialized testing is recommended instead of traditional lab workup), live blood cell analysis, SIBO testing, and/or further viral studies.

Once diagnostic testing comes back, then treatment can begin. I would like to stress that many physicians and patients embark on treatment strategies prior to a sufficient workup (diagnosis). This leads them headed down the incorrect path, with wasted money on ineffective treatments.

The remainder of this article will focus on the most common cause of fatigue that I see clinically: adrenal fatigue. This can easily be diagnosed by the above adrenal function testing, and I typically use salivary testing for this. Do remember that a patient can have 2 or more of the causes of fatigue listed above, all of which contribute to lower energy levels.

Adrenal Fatigue: A Common Western Disease
The adrenal glands sit on top of the kidneys and are pyramidal in shape. They contain two types of tissue: an inner medullary tissue and an outer cortex tissue. The inner medullary tissue, or medulla, produces adrenaline (also called epinephrine) and noradrenaline (also called norepinephrine). The outer cortex tissue produces several classes of molecules, but two that relate to fatigue are cortisol and DHEA. Together, these hormones regulate:

  • blood sugar levels
  • energy levels and sleep rhythms
  • heart rate and blood pressure
  • inflammation levels in the body

When someone is under acute stress, adrenal gland hormone levels rise to help the individual cope with the stressor. Essentially, these hormones prep the body for "flight or fight" responses. However, if the levels remain elevated over time (this can take years or decades, or can occur after a major stressor such as death or loss), they can eventually drop lower and initiate fatigue. In addition, these hormones levels can drop due to lack of exercise, poor diet, and toxins in the environment. Adrenal fatigue may be diagnosed with one or more low cortisol levels.

In evaluating for adrenal fatigue, the patient may have low morning and low evening cortisol levels. The patient may also present with normal a.m. levels, but low p.m. levels. Typically, this patient feels normal in the early hours of the day but exhausted by the afternoon or evening. More disturbing are those with low a.m. but high p.m. levels. These patients are oftentimes exhausted on waking, but by the time night arrives, they are hyperstimulated and cannot fall asleep. Insomnia greatly perpetuates the adrenal fatigue.

Treatment of Adrenal Fatigue
First Steps: Treatment of adrenal fatigue occurs on multiple levels. The more severe the fatigue, the more aggressive the treatment. The first and most basic step in healing is correct diet and hydration. A diet that supports the adrenal glands has several components. First, I recommend adequate hydration with electrolyte support. Typically I recommend patients drink 2 to 3 liters of water daily with added trace minerals and electrolytes. Meeting electrolyte needs takes stress off the adrenal gland, whose many functions include managing electrolytes in the body. Adequate hydration also insures optimal oxygenation to tissues by building blood volume.

The next step in adrenal support is proper diet. First, all gluten-containing products are eliminated. Flours in the US contain bromide, which negatively interacts with the thyroid. The thyroid and adrenal glands work in conjunction to manage energy in the body, so supporting the thyroid gland always supports the adrenal glands indirectly (note: taking thyroid hormone without proper adrenal function can burn out the adrenal gland to an even greater extent, as thyroid hormone increases the degradation of adrenal hormones through detoxification pathway – which may answer why some patients feel even worse on thyroid medication).

Next, I recommend protein at every meal (ideal range is 50–90 grams per day, depending on weight and activity level). Protein consumption stabilizes blood sugar, which is controlled by adrenal hormone level; so by consuming protein, you are taking away a stressor on adrenal glands. In addition, eliminating sugar is also recommended.

Finally, the general naturopathic recommendations to eliminate all processed foods, switch to organic vegetables and grass-fed meats, eliminate microwave use, add in fresh vegetable juicing, and avoid all chemicals and chemical-based sweeteners are also advised.

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