Simplifying nutritional support in CFS/Fibromyalgia – Highly Effective Treatments for Pain and Fatigue by Jacob Teitelbaum – published 2003 In last month's issue we talked about the causes of widespread nutritional deficiencies in Chronic Fatigue Syndrome and Fibromyalgia CFS/FMS). These included poor quality diet and digestion (which can be helped dramatically with plant-based digestive enzymes -- e.g. Similase by PhytoPharmica), bowel infections, and increased nutritional needs secondary to the illnesses. This has resulted in an immense number of recommendations for different nutrients, each of which have been purported to be critical for people getting better. This has caused patients to become very confused and overwhelmed with the vast number of supplements that they're told they need to take. Because of this, we have worked on a simplified approach that makes it easier for most people to get the nutritional support they need -- both easily and effectively. I would like to begin, however, by reviewing the importance of long-term nutritional support with key nutrients in CFS (and for most people). In the next issue, I will review the nutrients that only need to be taken for three to nine months while the body is in its "Repair Phase." Why are vitamins and minerals so important in CFS/Fibromyalgia? Dr. Janet Travell, White House physician for presidents John F. Kennedy and Lyndon B. Johnson and professor emeritus of Internal Medicine at George Washington University, co-wrote Myofascial Pain and Dysfunction: The Trigger Point Manual, which is acknowledged as the authoritative work on muscle problems. In one chapter alone, Dr. Travell and coauthor Dr. David Simons reference 317 studies showing that problems such as hormonal, vitamin, and mineral deficiencies can contribute to pain and muscle disorders. Numerous other studies have also shown that adequate amounts of vitamins and minerals, especially folic acid, zinc, and selenium, are critical for proper immune function. Zinc levels in particular have been found to be quite low in people with CFIDS/FMS (and also in AIDS). Every vitamin and nutritional mineral is very important in some way to health. If the patient is low in any of a number of vitamins and minerals, their fibromyalgia simply will not subside. B vitamins, for example, are the backbone of energy production and it is important that patients with CFS/fibromyalgia get at least 50 mg of most of these, plus 800 micrograms of folic acid and 500 micrograms of vitamin B12. These can have a dramatic effect on your patients' well being. Why such high levels of Vitamin B12? Vitamin B12 is a key nutrient in CFS. Technically, a patient's B12 level is normal if it is over 208 pg/dL. Studies, however, have shown that people can suffer significant nerve and brain dysfunction from B12 deficiency, even if their levels are as high as 300 pg/dL. In addition, a recent study using the respected Framingham database showed that metabolic signs of B12 deficiency occur even with levels over 500 pg/dL.
Why are the "normal" levels set so low? In part, the normal values were initially set according to what prevents anemia. This is problematic, however, because the brain and nervous system's needs for vitamin B12 are often much higher than those of the bone marrow. Also, the medical establishment has greatly enjoyed poking fun at the old-time and holistic doctors who gave vitamin B12 shots for fatigue. The use of B12 shots, despite "normal" levels, is considered almost a symbol of unscientific, archaic medicine. As noted in an editorial in The New England Journal of Medicine, however, current findings suggest that those old-time doctors may have been right. I suspect, though, that our modern medical establishment will be a little slow to eat crow. Recent research shows that despite having low normal B12 levels in the blood, CFS patients often have very deficient (and sometimes absent) B12 levels in their brains! This suggests that, because of the metabolic problems present in CFS/FMS, patients may need a very high B12 level in their blood to get adequate levels past the blood-brain barrier and into the brain, where B12 is needed. In addition, vitamin B12 helps to reduce excessive levels of nitric oxide, a neurotransmitter that can be too high in CFS/FMS and that can easily contribute to symptoms. More and more, research studies are supporting what holistic doctors who effectively treat CFS/FMS using B12 shots have said for years! It is no surprise then, that when their other problems are also treated, many people respond dramatically to B12 injections. If a patient's B12 level is under 540 pg/ml, I treat with a 1-cc (3,000-microgram) injection of hydroxycobalamin (from a compounding pharmacy; e.g. Cape Drug at 410-7573522 or the Apothecary at 800-869-9159 are two excellent ones), one to five times a week, for fifteen injections. These shots are very safe and fairly inexpensive. If a patient feels worse when the injections are stopped, I resume giving the shots, usually every one to five weeks (but as often as three to four times a week in some cases) for an extended period of time. Most people, however, can maintain the benefit after fifteen injections by taking the 500 mcg/day of oral B12 which is present in the Daily Energy Enfusion vitamin powder. Magnesium In addition to high dose, balanced B vitamins, I also urge my CFS/Fibromyalgia patients to take a magnesium supplement. Magnesium is involved in hundreds of different body functions, but is routinely low in the American diet as a result of food processing. The average American diet supplies less than 300 milligrams of magnesium per day, while the average Asian diet supplies over 600 milligrams per day. I generally recommend taking 200 milligrams of magnesium a day. Magnesium absorption is very difficult, which is why I like to use the glycinate forms. Because of the bowel infections in these syndromes, some patients may get diarrhea and cramps initially at this dose (although this is less common with the glycinate form). If this is a problem, they can simply lower the dose initially and then gradually increase it. Adding calcium to the magnesium can lessen the diarrhea, but also decreases the magnesium's absorption. If the patient is magnesium-deficient, their muscles will stay in spasm and the
fibromyalgia will not resolve. This is but one of the reasons why taking magnesium is so critical. In addition, magnesium is important in energy production. Adding 900 milligrams of malic acid can dramatically help energy as well. Most magnesium is intracellular, making blood tests an unreliable measure. Keep in mind that magnesium blood tests do not drop below normal until severe magnesium depletion occurs and everyone with CFS/FMS, fatigne, or muscle achiness should take magnesium. In fact, as epidemiological evidence suggests that low magnesium intake is associated with increased heart attack deaths, I recommend magnesium supplementation for anyone on the standard Western diet. An exception is if kidney failure with a blood creatinine level over 1.6 milligrams per deciliter (mg/dL) is present -- very rare in CFS/FMS. Other vitamins and minerals Many other nutrients are also critical. VitaminAis necessary for proper mucosal immunity. This is very important, as CFS patients often have chronic respiratory infections. Unfortunately, too much vitamin A (over 8000 units a day) can result in birth defects and therefore more is not better. Betacarotene does not cause birth defects, but may not have the same effect as the vitamin A.
Vitamin D deficiency has also been implicated in CFS and is important not just for bone strength but for proper immune function as well. A recent study suggests that vitamin E deficiency is also present in CFS. Minerals are also critical. For example, selenium and iodine are critical for proper thyroid function and evidence suggests that iodine and iodide intake in the American population is not anywhere near optimal. Japanese women often get approximately 7500 mcg of iodine/iodide a day from seaweed in their diet. It is suggested that iodine and iodide deficiency may contribute to an increase in fibrocystic breast disease as well as suboptimal thyroid function. As noted above, zinc is critical for proper immune function as well as wound healing. Chronic infections appear to cause increased utilization of zinc, resulting in marked zinc losses. This has been demonstrated in MDS patients and has been found in fibromyalgia as well. Zinc, however, has a narrow therapeutic optimum range with greater than 22 mg/day worsening HDL cholesterol levels. Copper is important for proper superoxide dismutase function. Excess copper is prooxidative however, and has also been implicated as a possible aggravating factor in CFS. Because of this, it is prudent to not get too much copper in one's supplement. I recommend one-half mg a day. Chromium is needed for proper insulin sensitivity -- 200 mcg/ day can decrease the hypoglycemia that is commonly seen from inadequate adrenal function in CFS. Amino acids
Amino acid deficiencies are common in CFS and treatment with these has been shown to be beneficial. There are many critical roles that these amino acids play. Tryptophan is critical for production of serotonin. Serotonin deficiency has been suggested in CFS and may be one of the reasons that substance P levels (the pain transmitting neurotransmitter) are 300% higher in fibromyalgia patients. Low serotonin may also aggravate the already marked sleep dysfunction and neurally mediated hypotension (NMH) present in these syndromes. Tyrosine is necessary for dopamine and norepinephrine production. Low dopamine may contribute to the high prevalence of restless leg syndrome and both of these deficiencies can contribute to the fatigue and cognitive dysfunction. Other amino acids are also critical. I suspect that one of the key underlying root causes of CFS is glutathione deficiency. Glutathione is a critical antioxidant in fighting chronic infections as it prevents destruction of natural killer cells. Research has shown that the amino acids that make up glutathione (cysteine, lysine, and glutamine) are markedly deficient in post viral fatigue states such as CFS. These deficiencies are therefore likely to be critical. To give a few more examples, serine 500 milligrams/day by itself has been shown to significantly help with CFS symptoms. Lysine can suppress some herpes viruses and also helps in the production of carnitine, which is another critical deficiency in CFS. Carnitine deficiency can then contribute to the average 32-pound weight gain seen in CFS/FMS, while preventing proper mitochondrial function. From this discussion you can see how critical it is to get broad-spectrum nutritional support in these syndromes. To simplify this, I have created a good tasting vitamin powder that allows people to get the 50 key nutrients they need by taking one capsule and one good tasting drink a day. This replaces 25 supplement tablets daily. The End Fatigue "Daily Energy Enfusion Powder" can markedly increase energy and decrease pain. It is available from PhytoPharmica (800-931-1709). As noted before, 100% of my royalty for all products I make goes to charity, and I do not take money from any company whose products I recommend. The effect on how people feel has been likened to the increasing brightness that occurs when you turn up a dimmer switch. Because the product is a powder, it also allows patients to adjust their dose. Although one scoop /day supplies optimum therapeutic nutrition, patients may want to start with half a scoop/day or a quarter scoop twice/day if they are sensitive or have diarrhea. They can then i ncrease to the dose that feels best. Some people like the convenience of taking it once a day and others prefer to divide their nutritional supplements through the day. Either way is okay. Patients take the one capsule of B-complex that comes with the powder in the morning, as the level in the capsule is optimum for most people. Additional B-complex capsules can also be obtained separately (Daily Energy B Complex). This new product was made to supply outstanding, overall, lifetime nutritional support for most people (not only CFS patients), tastes great, helps people feel a lot better, and beats the heck out of patients having to take 25 nutritional supplement tablets a day! I suggest you try it yourself.
Jacob Teitelbaum MD is a board-certified internist and director of the Annapolis (Maryland) Research Center for Effective CFS/Fibromyalgia Therapies. Having suffered with and overcome these illnesses in 1975, he spent the next twenty-seven years creating, researching, and teaching about effective therapies. He is senior author of the recently published landmark study "effective Treatment of CFS and Fibromyalgia -- A Placebo Controlled Study" (which can also be found on his web site). Dr. Teitelbaum lectures internationally and gives two-day practitioner workshops. He is also the author of the best-selling book From Fatigued to Fantastic! His newest book is Three Steps to Happiness: Healing through Joy (Deva Press 2003). For more information visit Dr. Teitelbaum's web site at www.endfatigue.com.