We’ve been hearing quite a lot about The Science these days. So, what is science? How does science guide medical practice and naturopathic medicine?
The science council defines science as, “the pursuit and application of knowledge and understanding of the natural and social world following a systematic methodology based on evidence.” The answer is, science is a methodology.
It is applied in medicine through Evidence Based Medicine (EBM) which starts with the individual patient and incorporates: clinical expertise, scientific evidence (that best that exists according to a hierarchy), and patient values and preferences.
“Evidence medicine is the conscientious, explicit, judicious and reasonable use of modern, best evidence in making decisions about the care of individual patients. EBM integrates clinical experience and patient values with the best available research information.”
The Evidence-Based Pyramid
In EBM, evidence exists in a hierarchy, represented by the Evidence Based Pyramid (shown above). Animal studies are at the bottom, case reports (clinical anecdotes) somewhere in the middle and randomized control trials and meta-analyses (the Gold Standard of evidence) at the top.
Dave Sackett (the Father of EBM) et al. write in the British Medical Journal (1996),
“Good doctors use both individual clinical expertise and the best available external evidence and neither alone is enough.”
In addiction to scientific evidence, EBM must incorporate:
Patient values
A bottom-up approach (it is patient-centred, not guideline-centred)
The needs of the individual (EBM is not a one-size-fits-all formula)
Clinical expertise
The best available evidence: this does not mean using only randomized control trials. Sometimes the best evidence we have are case reports, historical and traditional use of an herb or animal studies. We still owe our patients the opportunity to see if a treatment works for them, especially if the risk of a given treatment is low.
As clinicians, we use our knowledge in different ways. We start with an assessment of the individual in front of us. This assessment takes into account the factors that influence this patient’s life, their lifestyle, their health condition and their overall health goals.
We then turn to clinical experience, research, our scientific knowledge and guidelines.
We share this information with our patient. Our job is to educate and convey the options so that the individual can provide informed consent. How does this knowledge fit into the patient’s life? How does it inform their choice?
Science is not a set of values. It is not a religion. We do not follow it.
Science provides us with a methodology for seeking the answers to questions we might ask about how the principles of nature, including the human body, are organized.
Science encourages us to ask questions and testing hypotheses in order to find answers.
It is never settled.
Most of all, science doesn’t tell us how to use scientific knowledge.
Our choices are governed by our goals, preferences and values.
So, “follow the sicence?”
No. Follow your goals, preferences, values and dreams.
And use science to help guide your way.
Reference:
Sackett, D. L., Rosenberg, W. C., Gray, J. M., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medicine: What it is and what it isn’t. BMJ, 312(7023), 71–72.
In September of 2019, Jakobsen, Gluud and Kirsch published a review in the British Medical Journal: Evidence-Based Medicine entitled “Should antidepressants be used for major depressive disorder?” (1)
Their conclusion was this:
“Antidepressants should not be used for adults with major depressive disorder before valid evidence has shown that the potential beneficial effects outweigh the harmful effects.”
Now, before we move on with what drove them to make this seemingly radical conclusion, I want to be clear:
I am not stigmatizing medication.
All of those who take medication for depression have asked for help.
Asking for help is important.
Asking for help is brave.
And, whatever help works for you is the right kind of help.
But imagine this; imagine you are a pretty decent swimmer.
You’ve practiced swimming all your life. You’ve gotten lots of experience swimming in pools, lakes, and oceans. You know how to swim, just like you know how to cope with turmoil. But, despite your strength, one day you find yourself drowning.
“No, I’m not drowning,” you might say at first. “I can’t be drowning. I know how to swim! If I’m drowning, it means I’m a failure…
“What will everyone think?”
And so you continue to splash around a bit, until it becomes undeniable. You gasp some water-filled air. Your head submerges and you think, indeed, “I’m drowning.”
When you get your head above water you call for help.
This takes a lot.
It’s not easy to admit that you need help.
It’s not easy to overcome that little voice that tells you that asking for help is troubling other people, admitting defeat, showing weakness—and whatever else that darned little voice thinks it means.
“HELP!” You exclaim, louder this time—little voice be damned.
“HEEELP!”
And someone on shore sees you. They have a life-preserver in their hands and they throw it your way.
Your shame is peppered with relief—and gratitude: there’s an answer to all this suffering. You thrust your hand towards the life preserver, grasping it with a firm bravery.
Only, it starts to sink. It’s full of holes.
“What’s the matter?” The person waiting on the shore exclaims, as you continue to struggle, “Don’t you want help?”
The shame returns. Hopelessness joins it.
I advocate for mental health awareness. I advocate for perpetuating the message that it’s ok to talk about mental illness. It ok to admit you need help.
I believe the following:
Depression is not a a sign of weakness.
It’s not a sign that you are defective.
It’s not a sign that you haven’t learned proper coping skills, or that your coping skills are defective, or that you’re fragile.
It’s also not fixed by simple solutions like eating salad, running or putting “mind over matter”.
Depression happens to a lot of us.
It affects 300 million people globally. It is the leading cause of disability world-wide, with a lifetime prevalence of 10 to 20%. This means that 1 in 5 people will experience depression in their lifetimes.
We all know someone who suffers. Maybe you suffer.
And a lot of people ask for help. The National Health and Nutrition Examine Survey (NHANES) in 2017 found that 1 in 8 people over the age of 12 are taking an anti-depressant, a 65% increase over the last 15 years.
This means that 65% more of us are asking for help.
That’s a lot of life preservers.
So, just how effective is this help?
First, we need to understand how the efficacy of anti-depressants are measured.
The symptoms of depression are subjective. This means they are not observable. There is no imaging that shows if someone is depressed. There are no blood tests for depression. There are no physical exams.
Therefore, to assess the presence and severity of depression, clinicians use questionnaires. The most commonly used depression questionnaire is The Hamilton Depression and Rating Scale (HDRS), a 52-point checklist that assesses various symptoms of depression and rates them on a scale of no-depression to severe.
When patients with depression first see a family doctor or psychiatrist they are often issued the HDRS and given a score.
Let’s use Janet’s story as an example. Janet first came to see her psychiatrist two years ago. She wasn’t sleeping and yet felt sleepy all the time. She’d gained weight but had no appetite. Her entire body was sore, as if she had the flu. She’d lost interest in all of the activities that used to fire her up. She’d lost interest in everything.
After a few weeks of feeling progressively worse, Janet began to be plagued by thoughts of suicide. This scared her. She went to her family doctor, who referred her to a psychiatrist.
Janet’s HDRS score was 25. This meant she was moderately to severely depressed.
Janet was given an anti-depressant, a Selective Serotonin Re-uptake Inhibitor (SSRI). She was told it would correct her “brain imbalance”, and treat the cause of her symptoms. Janet was relieved that there was a solution.
If an anti-depressant can decrease the HDRS by 3 points, then the medication “works”. Or at least the results are statistically significant.
However, if Janet’s symptoms improve by 3 points, from a score of 25 to, say, a score of 22, how does she feel?
Not much different, it turns out.
To experience “minimal improvement”, a decrease in symptoms that someone with depression would notice, say an increase in energy, an improvement in sleep, or a change in mood, a patient’s HDRS score would need to decrease by at least 7 points.
This means the Janet would need to bring her HDRS down to 18 or lower before she starts to feel noticeably better.
Studies show that anti-depressants, on average, don’t do this.
Some randomized control trials do show that anti-depressants decrease the HDRS score by at least 3 points, which is still registered by patients as having no perceptible effect, but the results are mixed.
A large 2017 systematic review showed that anti-depressants only decreased patients’ HDRS by about 1.94 points (2) and another large study published in the Lancet (3) also failed to show that anti-depressants produce a statistically significant effect, let alone a clinically significant one.
In addition to the minimal changes in symptoms, anti-depressant research is also polluted with for-profit bias. Most studies are conducted or funded by the drug companies.
This makes a difference: an analysis showed a study was 22 times less likely to make negative statements about a drug if the scientists worked for the company that manufactured it (4).
Studies at high-risk of for-profit bias were also more likely to show positive effects of a drug (5).
Another limitation of anti-depressant trials is the lack of active placebo control. In Randomized Control Trials, participants are sorted into two groups: an active group, in which they receive the medication, and a placebo group, in which they receive an inert pill.
The goal of this process is to control for something called the “meaning response”, or “placebo effect” where our expectations and beliefs about a therapy have the potential to affect our response to it.
Remember that depression, as I mentioned before, is a condition made up of subjective symptoms.
If I asked you to rate your energy on a scale of 1 to 10, how would you rate it? What if I asked you tomorrow? What if I asked you after giving you a drink of something that tastes suspiciously like coffee?
Because of its subjective nature, and the subjective questionnaires, like the HDRS, that measure it, depression is very susceptible to the placebo response.
Therefore, it’s important to control for the placebo response in every trial assessing anti-depressants.
But it might not be enough to just take a sugar pill that looks like an anti-depressant.
SSRI medication produces obvious side effects: gastrointestinal issues, headaches, changes in energy, and sleep disturbances, to name a few.
When a patient taking a pill (either placebo or active treatment) starts to feel these side effects, they immediately know which group they have been randomized to, and they are no longer blinded.
This can be solved by giving an “active placebo”: a placebo that produces similar side effects to the active medication. Unfortunately anti-depressant trials that use active placebo are lacking.
But what about the people who DO benefit from anti-depressants?
Janet knew a few. She had a cousin who also suffered from depression. He took medication to manage his symptoms. He’d told her many times that he just wasn’t the same without it.
Perhaps you, reading this article have found benefit from an anti-depressant medication. Perhaps you know someone who has: a family member, or a friend. Maybe it was their lifeline. Maybe it’s yours.
According to Jakobson et al., there are indeed some people who benefit from anti-depressants. Anecdotally we know this to be true. However, the results of large studies show minimal to no benefit from medication, on average.
This means that some people might benefit; we know that some do. It also means that an equal number of people are harmed.
In order for the net effect of anti-depressant medication to be close to zero, an equal number of people experience negative effects that outweigh the positive effects seen in others.
So, while some may have already tried medication and benefited from it, those considering medication won’t know if they’ll be in the group who benefits, or the group who is harmed.
The side effects of anti-depressant medication are often underrepresented. In the Lancet study, adverse effects were neither recorded nor assessed (3).
The most common side effects include gastrointestinal problems, sleep disturbances, and sexual dysfunction. More serious side effects, like increased risk of suicide, are also possible. Some of these effects may persist even after the medication is stopped.
Anti-depressant trials are short-term. Most trials assess patients for 4 to 8 weeks, while most people take anti-depressants for 2 years or longer.
Anti-depressants also put people at risk of physiological dependence and withdrawal.
Withdrawal symptoms can occur a few days, or even weeks, after tapering anti-depressant medication. They sometimes last months.
Withdrawal symptoms are often mistaken for depressive relapse. This can make it difficult, or even impossible, for patients to come off medication. This is worrisome considering the lack of research on long-term medication use.
It is sometimes argued that anti-depressants are more effective, or even essential, for severe depression, however the evidence for this is lacking (4).
In their paper, Jakobson, Gluud and Kirsch conclude that, based on the evidence, anti-depressants show a high risk of harm with minimal benefit.
Before prescribing them, Jakobson et al recommend more non-biased, long-term studies that use active placebo, and honestly assess the negative effects of the medications.
They recommend that studies use improved quality of life and clinically meaningful symptom reduction, not just statistical significance, as standards for treatment success.
Despite these conclusions, SSRIs remain a first-line treatment for major depressive disorder. They are also prescribed for conditions like severe PMS, IBS, anxiety, grief, and fibromyalgia, or other pain conditions. 1 in 8 adults in North America are taking them.
As a clinician who focuses in mental health, I am not against medication.
I have seen patients benefit from SSRI or SNRI medications. Sometimes finding relief with medication when nothing else worked.
My clinical practice keeps me humble.
If a patient comes into my practice on medication, or considering medication, I listen. I ask how I can support them. I answer questions to the best of my ability. I trust my patients.
Patient experience trumps clinical papers.
However, for every patient who benefits from medication, just as many experience negative side effects, or no effect. I trust their experiences too.
I also trust the experiences of the patients who have been trying for months, or years, to wean off medications.
Let me repeat it again: depression is real. Asking for help is hard. And it’s important.
Depression is a multi-factorial condition.
This means that it stems from hundreds of complex causes. This is why it’s so difficult to treat. This is why so many people suffer.
Let me also repeat: depression is not easily fixed.
There is no one solution, and there are certainly no ONE-SIZE-FITS-ALL solutions.
So, if you or someone you care about is suffering from depression, what can you do?
First, get help. This is not something you can get through alone.
Second, seek lots of help: gather together a team of professionals, family and friends. You can start with one person: your family doctor or a naturopathic doctor, and then assemble your support network.
Choose people you trust: people who listen, provide you with options, and seek your full informed consent.
It is important to work with a healthcare team who take into account the factors that may be contributing to your symptoms: brain health, gut health, life stressors, nutrition, inflammation levels, presence of other health conditions, sleep hygiene, family history, contributing life circumstances, such as grief, trauma, or poverty, and who lay out various treatment options while filling you in on the risks, benefits and alternate therapies of each.
Medication may be part of this comprehensive treatment plan, or it may not.
It is brave to ask for help.
And I believe that bravery should be rewarded with the best standard of care—with the best help.
References:
Jakobsen JC, Gluud C, Kirsch IShould antidepressants be used for major depressive disorder?BMJ Evidence-Based Medicine Published Online First: 25 September 2019. doi: 10.1136/bmjebm-2019-111238
Jakobsen JC, Katakam KK, Schou A, et al. Selective serotonin reuptake inhibitors versus placebo in patients with major depressive disorder. A systematic review with meta-analysis and trial sequential analysis. BMC Psychiatr2017;17:58
Cipriani A, Furukawa TA, Salanti G, et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. The Lancet2018;391:1357–66
Kirsch I, Deacon BJ, Huedo-Medina TB, et al. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the food and drug administration. PLoS Med2008;5:e45.doi:10.1371/journal.pmed.0050045
Ebrahim S, Bance S, Athale A, et al. Meta-Analyses with industry involvement are massively published and report no caveats for antidepressants. J Clin Epidemiol2016;70:155–63.doi:10.1016/j.jclinepi.2015.08.021
Like many people I see, Sandra was experiencing debilitating exhaustion.
Completing her PhD, she was working all day and collapsing on the couch at 8 pm.
She stopped going out in the evening. She ceased spending time with friends, engaging in activities outside of her studies, exercising, and having sex.
Her motivation and zest for life were at all-time lows.
Her marriage, and her life, were being sidelined in the service of her fatigue.
Her family doctor met her complaints with a defeated shrug. “You’re just getting older,” he offered by way of explanation.
Sandra was 27.
My patient is not alone. At least 20% of patients approach their family doctors complaining of fatigue.
Lack of energy is a problem that can arise from any body system. Fatigue can be an early warning sign that something has been thrown off balance.
I frequently see fatigue in patients suffering from hormone imbalances, including suboptimal thyroid function, insulin resistance, and low estrogen, progesterone, or testosterone. But also in chronic stress, depression, and anxiety.
Fatigue is often connected to mental health conditions, digestive issues, lifestyle imbalances, chronic inflammation, chronic stress, and lack of restful sleep. It’s no wonder, then, that most of the people I work with experience some level of low energy.
Conversely, I see improvement in energy as one of the first signs that someone is moving towards more robust health. Some of the first signs of healing are a clear mind, bright mood, and vibrant, buoyant energy.
There are a few steps you and your naturopathic doctor can take to identify and remove the cause of fatigue, while optimizing your health and energy levels.
Differentiate between sleepiness and fatigue.
It is important to determine if low energy is fatigue or sleepiness.
Sleepiness is characterized by the tendency to fall asleep when engaging in non-stimulating activities like reading, watching TV, sitting in a meeting, commuting, or lying down.
Sleepiness:
Is often improved by exercise, at least in the short-term
Is improved with rest
Fatigue is characterized by a lack of energy, both physical and mental. Fatigue is often worsened by exertion.
Those who are fatigued:
Suffer from mental exhaustion
Experience muscle weakness
Have poor endurance
Typically feel worse after physical exercise and take longer to recover
Don’t feel restored after sleeping or napping
Might experience ease in initiating activities but progressively experience more weakness as they continue them (e.g.: engaging in social activities, movement, working, etc.)
To determine between sleepiness and fatigue, your naturopathic doctor will ask you a series of questions about the nature of your low energy.
2. Assess sleep.
Assessing and optimizing sleep is essential for beginning to treat all low energy and, in particular, sleepiness.
Assessing sleep involves looking at a variety of factors such as:
Bedtime and waking time
Sleep onset: how long it takes
Sleep routine and sleep hygiene habits
Sleep duration: how many times you wake up, how quickly you can fall back asleep after waking
Causes of interrupted sleep such as sleep apnea, chronic pain, frequent urination, children/pets/partners, etc.
Nap frequency and length
Ability to wake up in the morning
Perceived sleep quality: do you wake feeling rested?
The use of sleep aids
Exercise routines, how close to bedtime you eat or exercise.
And so on.
Using a sleep app or undergoing a sleep study are two additional tools for assessing the quality and duration of your sleep cycles that may be useful.
3. Address sleep issues.
Whether the cause of fatigue is sleepiness or not, restful sleep is essential to restoring our energy levels. Optimizing sleep is an important foundational treatment for all health conditions.
Restorative sleep regulates hormones and balances the stress response, called the hypothalamic-pituitary-adrenal axis (HPA axis). It improves cell repair, digestion, memory, and detoxification.
Mental and emotional stress, artificial light, blood sugar dysregulation, inflammation, and hormone imbalances can interfere with sleep.
To address issues with sleep, it is important to:
Maintain a strict sleep schedule. This means keeping bedtime and waking time consistent, even on weekends.
Practice good sleep hygiene by avoiding electronics at least an hour before bedtime, using blue light-blocking glasses if necessary, and keeping the bedroom as dark as possible.
Avoid stimulating activities like exercise in the hours before bed.
Keep the bedroom cool and dark.
Reserve the bed and bedroom for sleep and sex only.
Balance circadian rhythms by exposing your eyes to sunlight immediately upon waking and eating protein in the morning.
In addition to sleep hygiene and balancing circadian rhythms, sleep aids can be helpful. I start my patients with melatonin, a non-addictive antioxidant, to reset the sleep cycle and help with obtaining deeper, more restorative sleep.
It is important to take melatonin in a prolonged-release form a few hours before bedtime and to use it in addition to a dedicated sleep routine.
Determine whether the fatigue is secondary to an underlying medical condition.
Secondary fatigue is defined as low energy, lasting from 1 to 6 months, that is caused by an underlying health condition or medication.
With your medical or naturopathic doctor, be sure to rule out any issues with your immune system, kidneys, nervous system, liver, and heart, and to assess the side effects of any medications you’re taking.
Ruling out chronic infections, pregnancy, anemia, and cancer may be necessary, depending on other signs and symptoms that are present, your individual risk factors, and family history.
While the vast majority of fatigue is not caused by a serious health condition, ruling out more serious causes is an essential part of the diagnostic process.
Remember that this is not a job for Dr. Google! Because fatigue is a sign that something in the body is not functioning optimally, it can be implicated in virtually every health condition, alarmingly serious ones, but also more benign conditions as well.
Taking into account your entire health history, risk factors and particular symptoms, as well as assessing blood work is a complex job that a regulated health professional can assist you with.
Get blood work done.
Assessing blood work is necessary for ruling out common causes of fatigue.
Blood tests are used to rule out anemia, infections, suboptimal iron, B12, and folate levels, under-functioning thyroid, inflammation, insulin resistance, and hormonal imbalances.
To evaluate the cause of fatigue, your doctor will look at:
A complete blood count (CBC) that looks at your red and white blood cells.
inflammatory markers like ESR and hs-CRP
TSH, to assess thyroid function, and occasionally free thyroid hormones and thyroid antibodies, if further investigation is indicated
B12, iron and folate
Other tests such as fasting insulin, fasting blood glucose, liver enzymes, and hormones like estradiol, testosterone, estrone, LH, FSH, and progesterone, depending on the health history and the constellation of symptoms.
Your doctor may take further measures to assess your heart and lungs, or to rule out chronic infections.
6. Identify physiologic fatigue, or burnout.
Once sleepiness and any underlying health conditions have been ruled out, your doctor may determine whether you have physiologic fatigue.
Physiologic fatigue, also commonly called “burnout” or “adrenal fatigue”, is the result of an imbalance in sleep, exercise, nutrition intake, and rest.
It is by far the most common category of prolonged fatigue that I see in my practice. Two thirds of those experiencing fatigue for two weeks or longer are experiencing this type of fatigue.
Feeling a lack of motivation, low mood, and increased feelings of boredom and lethargy are characteristics of this kind of fatigue.
Physiologic fatigue can be confused with depression, leading to a diagnosis and subsequent antidepressant prescription, which may fail to uncover and address contributing lifestyle factors.
To tell if you might be experiencing physiologic fatigue, or burnout, see if you answer yes to any of the following questions, adopted from the Maslach Burnout Inventory:
I feel emotionally drained at the end of the day.
I feel frustrated with my job.
I feel I’m working too hard.
I feel fatigued when I have to face another day.
I have a hard time getting up in the morning on weekdays.
I feel less sympathetic and more impatient towards others.
I am more irritable and short-tempered with colleagues, my family, my kids.
I feel overwhelmed.
I have more work than I can reasonably do.
I feel rundown.
I have no one to talk to.
Fortunately, there are many solutions to improving low energy and mood caused by burnout.
Balance the HPA Axis
Balancing the stress response, otherwise known as the Hypothalamus-Pituitary-Adrenal (or HPA) axis, is an important component of treating physiologic fatigue.
Our HPA axis becomes activated in the morning when the hormone cortisol is released from the adrenal glands. Cortisol suppresses inflammation and gives us the motivated, focussed energy to go about our day.
Towards the end of the day, cortisol levels naturally fall. In the evening, cortisol is at its lowest, and melatonin, our sleep hormone, rises.
Those with HPA dysfunction have an imbalance in this healthy cortisol curve.
They commonly experience sluggishness in the mornings, a crash in the afternoon (around 2 to 4 pm), and restless sleep, often waking up at 2 to 4 am as a result of nighttime cortisol spikes and an impairment in melatonin release.
These individuals often experience cravings for salt and sugar. They may have low blood pressure and feelings of weakness.
It is common for those experiencing burnout to get sick when they finally take a break or experience prolonged healing time from common infections, likes colds and flu.
They may suffer from inflammatory conditions like chronic migraines, muscular tension, and report feeling depressed or anxious.
In this case, balancing the HPA axis is a treatment priority.
Treatment involves:
HPA axis balancing through adaptogenic herbs
Optimizing adrenal nutrient levels
Regulating blood sugar
Improving circadian rhythms
Reducing workload and perceived stress through addressing perfectionism, practicing setting boundaries, and developing mindfulness, among other skills.
Improving sleep
Engaging in regular, scheduled exercise
Reducing inflammation, improving digestion, or regulating hormones
Being proactive about mental health and emotional wellness
Improving self-care and stress resilience
Cognitive Behaviour Therapy can be used to teach healthy coping skills while balancing sleep and stress. Studies show it can be more effective than medication for the depression and anxiety related to physiologic fatigue.
Of course, from a holistic perspective, the above strategies are the foundations for improving general health and wellness for all fatigue-related conditions, regardless of whether the fatigue is due to sleepiness, secondary fatigue, physiologic fatigue, or chronic fatigue syndrome.
Talk to your naturopathic doctor about adaptogenic herbs.
Adaptogenic herbs are an important natural tool for improving mood and energy.
Adaptogens help the body “adapt” to stress. They up-regulate genes involved in boosting the body’s natural stress resilience.
Because of this, adaptogens not only improve energy and mental and physical endurance, they also improve attention and concentration, immune system function, and mental work capacity.
They can treat depression and anxiety, and regulate circadian rhythms.
Common adaptogens are withania (or ashwaghanda), rhodiola, holy basil, the ginsengs, like Siberian gingseng (or eleuthrococcus), schizandra, liquorice, and maca, among others.
My two favourite adaptogens are ashwaghanda and rhodiola, however your naturopathic doctor can work with you to pick the best herbal combination for your individualized needs.
9. Rule out Chronic Fatigue Syndrome.
Chronic fatigue syndrome (CFS) is characterized by fatigue that lasts 6 months or longer, is not improved by exercise and rest, is not related to an imbalance in lifestyle, and is not caused by a primary health condition.
Those with CFS often have signs of an activated immune system such as enlarged lymph nodes, a low-grade fever, or a sore, inflamed throat. Sufferers may experience generalized weakness and pain.
CFS can be an extremely debilitating condition that results in a 50% reduction of daily functioning.
The cause of CFS is not known, however balancing HPA axis function, improving nutrient status, reducing inflammation, healing the gut, reducing toxic burden, boosting mitochondrial functioning, and promoting self-care are all useful treatment strategies.
Our gut is the seat of the immune system, sampling foreign substances from the external environment and activating an immune response, if it finds any of those substances pose a threat to the health of the body.
If our immune system comes into contact with something doesn’t like, even if that something is a benign food substance, an inflammatory reaction can be triggered. Chronic inflammation can exacerbate fatigue.
To test for food sensitivities, your naturopathic doctor will either order a blood test, or recommend an elimination diet where suspicious food is removed from the diet, the gut is healed, and foods are later reintroduced.
Common foods to eliminate are gluten, dairy, sugar, eggs and soy. Stricter Autoimmune Paleo diets involve the removal of all dairy, eggs, grains, legumes, and nuts.
Mind your mitochondria.
Our mitochondria are the “powerhouses” of the cell, responsible for making ATP, our body’s energy currency, out of the carbs, protein, and fats from our food.
Research has shown a link between mitochondrial dysfunction and chronic fatigue.
The mitochondria need a variety of different nutrients to function optimally. These nutrients include B vitamins, magnesium, Coenzyme Q10, and certain amino acids.
When the mitochondria are unable to produce sufficient ATP, fatigue may result. Similarly, a problem with antioxidant production can result in the buildup of reactive oxygen and nitrogen species, otherwise termed “free radicals”, in the mitochondria.
Free radicals can trigger inflammation and immune system activation in the entire body, causing us to feel ill and fatigued.
B vitamins are also important for a process called “methylation” which is essential for energy and hormone production, immune function, detoxification, mitochondrial function, and DNA repair.
Balance your blood sugar.
Insulin resistance, hypoglycaemia, type II diabetes, and metabolic syndrome are all common conditions that reflect the body’s inability to regulate blood sugar.
All of these conditions can cause frequent energy crashes, fatigue after eating, brain fog, and lethargy.
Even those free of the above conditions may still struggle with blood sugar imbalances. Signs of blood sugar dysregulation are craving sweets, feeling hungry less than 3 hours after a meal, getting “hangry”, feeling weak and dizzy if missing meals, waking at night, and snacking at night.
Balancing blood sugar by eating enough fibre, fat and protein at every meal is essential to maintaining the endurance to get through the day.
Your naturopathic doctor can help you come up with a diet plan that keeps your blood sugar balanced and your energy levels stable throughout the day.
Support your immune function and eradicate chronic infections.
Chronic infections can result in prolonged activation of the immune system, resulting in chronic fatigue.
Viral infections, like mononucleosis and Epstein Barr, and gut bacteria imbalances, such as SIBO, C. Difficile, and candida overgrowth can be implicated in chronic fatigue.
Supporting the immune system with herbs, balancing the HPA axis, and using natural remedies to eradicate the infection are all courses of action you may take with your naturopathic doctor to eradicate infectious causes of fatigue.
Uncover and treat hormone imbalances.
Our hormones, the messengers of the body, regulate how our cells talk to each other.
Hormones are responsible for blood sugar control, the stress response, ovulation and fertility, sex drive, metabolism, and, of course, energy production and utilization.
It is possible that those who suffer from low energy have an imbalance in the hormones cortisol, insulin, estrogen, progesterone, DHEA, testosterone, or thyroid hormones. Directly addressing hormones is then the main treatment goal for improving energy.
Uncovering other signs of hormonal imbalance, such as the presence of PCOS, endometriosis, or symptoms of hypothyroidism, as well as ordering blood tests, can help reveal if an imbalance in hormones is the main cause of your fatigue.
Encourage detoxification.
Our body has the powerful ability to process and eliminate the 500 chemicals and toxic substances we come into contact with daily, as well as the hormone metabolites and immune complexes produced as a result of normal metabolic functioning.
Our livers, kidneys, colon, and skin regularly filter hundreds of harmful substances from our bodies. This process happens naturally without the aid of outside support.
However, it is possible that an increased toxic burden on the body paired with a sluggish liver and digestive system, can increase the body’s overall toxic load.
Toxic overload can contribute to fatigue by increasing inflammation and immune system activation, as well as impairing energy production pathways, and disrupting hormonal function.
Reducing contact with harmful toxins, while supporting kidney, liver and colon function can help restore optimal energy and health.
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Treating fatigue first involves developing a relationship with your healthcare provider: finding someone who takes your concerns seriously.
Conducting a thorough assessment of blood, lifestyle factors, sleep, hormones, and digestion, and as many other factors as possible, is essential to uncovering the cause of fatigue.
Treatment involves removing obstacles to healing, supporting energy production, balancing lifestyle, and using herbs to boost energy and stress resilience.
When we consider fatigue as an important sign that something in our body is functioning sub-optimally, we can use our energy levels are important indicators for health.
Sigh… I just finished reading a rather annoying article in the Globe and Mail (don’t even bother to click and add more Google street-cred, seriously) that doesn’t really warrant a response but… here we go. It’s my day off.
The article was written by one Carly Weeks, who doesn’t seem to have a very positive view of naturopathic doctors. I don’t know Carly and have no idea about her health history, but I’m going to take a shot in the dark and imagine she hasn’t suffered from chronic eczema.
Let me know how that steroid cream works out for ya, Carly!
But, ad hominem aside, her issue with naturopathic doctors this week(s)—pun intended, aren’t I hilarious—is, what else: we’re a bunch of quacks who use nothing but false therapies and smooth-talking to coax our patients into thinking they feel better. Well, if that worked, I wonder why more healthcare practitioners don’t try copying those moves too. It might save the government some money, which is what, coincidently, naturopathic medicine is already doing and it’s not by false therapies and smooth-talking. (But we do make time for a lot of talking).
The Globe piece begins with a story about how physicians (not naturopaths, for the record) prescribed radioactive water in the 1920’s. It’s a cute and tragic story about limited safety profiles. And other than its juxtaposition in an article about NDs, I’m not sure what the writer’s point was. We don’t use radioactive water to treat anyone. If you want radiation, which is a therapy, a cancer treatment, then you must see an oncologist. Talk about throwing out babies and bathwater.
The article is largely about how naturopathic doctors are moving under a new regulatory board, under the Regulated Health Practitioners Act. This limits our scope compared to that of provinces like BC or certain US states, where naturopathic doctors have been prescribing drugs and even performing minor surgeries safely where it’s warranted.
Here are some facts:
Naturopathic medicine is incredibly safe. We are trained in conventional diagnosis, anatomy, physiology, physical exams, including gynaecological exams, breast exams and digital rectal exams. We have the ability to perform acupuncture in Ontario and give intramuscular injections. With additional training we can provide IV treatments. We are trained to order and interpret labs and to take blood. I will not deny that conventional medicine and pharmaceuticals have saved millions of lives. However, we know that 10,000 yearly deaths in Canada (and 100,000 in the US) are due to pharmaceuticals alone. A year ago I wrote a post talking about the off-label birth control pill Diane-35. Let’s not start comparing safety profiles here.
Naturopathic doctors are highly trained and educated: We have completed a 4-year very rigorous program that includes a 12-month internship where we treat patients in an out-patient facility. In our training we performed over 100 practical and written examinations. After our second and fourth year we complete two licensing exams, which span a course of 5 full days of examinations combined. Ask anyone I know if what I did was easy. Trick question: they wouldn’t know because they didn’t hear from me for the past 5 years–I was studying the WHOLE time. It’s ok, though, because now I know a lot.
Naturopathic medicine is a regulated profession: In order to practice in Ontario naturopathic medical graduates who have passed both licensing exams, must pass a series of board examinations that are both written and practical. We then must enter into a month-long application process, which includes a police background check and character reference check. If I try to delay treatment of an emergent condition or treat an emergent condition with something like homeopathy or acupuncture (effective treatments for other conditions, but not emergent, life-threatening ones), which is something we are often accused of potentially doing, my licence will be removed. It’s not something we do—it’s that simple. We are held accountable and have a lot of responsibility to deliver safe care.
Naturopathic doctors are health experts: In order to complete the naturopathic medical program we complete 1200 hours of clinical training and 3000 hours of classroom training. This does not include study time for our board exams and pursuit of side interests or continuing education credits that are required to maintain licensure. We are trained in nutrition, which many medical professional, including medical doctors, are not. Naturopathic doctors often see patients that have been failed by the conventional medical system, which means we deal with complex cases on a regular basis. This demands that we keep our skills sharp and our knowledge current.
Naturopathic medicine provides the public with an amazing service that patients are willing to pay for: We spent up to two hours at time with our patients, educating them on any topic of their health picture: the medications they’re on that their doctors don’t have time to discuss with them, their health conditions, their prognosis and what else they can do about it. I spent half an hour talking about an STI a patient of mine had been diagnosed with. She’d seen two doctors and a specialist. None of them had talked to her about it. Patients have told me their doctors no longer perform physicals. Well, we do. And, it turns out, people pay for excellent care. Naturopathic medicine provides the much-needed service of patient education, human-centred care and prevention of disease. It’s an excellent complement to an effective whole-person healthcare strategy.
Naturopathic medicine works: I could say more on this but let’s keep it brief: if it didn’t work, people wouldn’t pay for it. The Globe and Mail, more than anyone should know to “let The Market speak.” (Amiright?) I lied, I will say more. If you don’t think naturopathic medicine works, then call my patients who no longer have chronic pain or allergies or chronic constipation. Ask my patient who couldn’t conceive how her daughter is doing. Blah blah, we help people.
Naturopathic doctors prefer to work in collaboration with other healthcare professionals: Ideally each patient should be managed by a healthcare team. When I start seeing a new patient I immediately establish a relationship with his or her medical doctor. I refer out for labs and to specialists if necessary. Medicine should be integrative, not alternative. Patients shouldn’t be forced to choose.
In addition to accusing us of being a bunch of unsafe quacks, the author writes, “Ontario should have created a regulatory system based on the principle of evidence first.” So, there you have it. Only medicine that is based in evidence should be regulated by the province.
Wow, what a ridiculous statement made by someone who I imagine knows little to nothing about how medicine and so-called “evidence” works.
Firstly, there is more than one type of evidence. In fact, evidence is a hierarchy. At the bottom we have things like clinical case reports or expert opinion, what my friends the skeptics love to call “anecdotal evidence.” Sigh. If you’ve seen something work, you keep doing it. It’s not the best evidence we have, but it’s still evidence. The better forms of evidence, randomized control trials, are being done on naturopathic therapies and naturopathic therapies have been found to hold steady. Actually, many of the therapies we prescribe are done precisely because there is evidence to support it: fish oil for depression and bipolar disorder? Inositol for fertility in patients with PCOS? Evidence, evidence, evidence.
Secondly, only 10% of medical guidelines are based on the type of “evidence” that our friend Carly Weeks is likely referring to: the Randomized Control Trial, which involves comparing two groups: a treatment group to an inactive group that gets something like a placebo. Well, it turns out, we just don’t have that much “evidence” of this sort to dictate what happens in medicine. A tourniquet for a bleeding wound? Using general anesthetic rather than nothing? These things haven’t been compared against placebo. What is the other 90% of medicine based on? Expert opinion: a nice mixture of clinical expertise, intuition, common-sense, “what the heck, might as well try it it couldn’t hurts” and research. I don’t see Carly questioning the use of SSRI for mild and moderate depression or beta-blockers to prevent cardiac events as a result of high blood pressure, both of which have “no evidence” to support their use. Nope, just crickets when it comes to those topics.
Thirdly, the father of EBM, or Evidence Based Medicine, himself, Dave Sackett, said, “Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. Without clinical expertise, practice risks becoming tyrannized by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient.” (Emphasis mine). Individual clinical expertise from both modern and traditional medicine, the best available external evidence and tailoring treatments to individuals patients needs and preferences? Sound like naturopathic medicine to me.
Naturopathic medicine is safe and effective. We have a patient-centred approach and offer wonderful service for the cost, which is often covered by insurance benefits. Naturopathic doctors take the time to listen to your story and educate you on what is happening in your own body. We treat the root cause of your condition, rather than masking symptoms. We are highly-trained healthcare professionals and we are regulated. Soon we will be moving to different regulation. However, the government will be removing some of the rights we’ve had, which include ordering certain lab tests that we’ve safely ordered for years. If you use or support naturopathic medicine, please click the link to sign the petition to maintain the current naturopathic scope of practice in Ontario and support safe and effective natural healthcare for all Ontarians.
When I was very small, the tree at my parent’s house became sick and was cut down. I don’t exactly remember the great pine tree, but I remember it’s large, rotting stump, which was left as evidence of its towering existence on the lawn of our front yard. As a replacement, the city planted another tree in its place: a ginkgo tree.
What was once a disappointingly small, skinny sapling now towers over the two-story house, its trunk the diameter of my outstretched arms, an alarming reminder of the passage of time. I have always been fond of our ginkgo tree, with its delicate, fan-shaped leaves and its aire of exoticism, but I am developing an entirely new relationship with the plant as I begin to discover its array of clinical uses as well.
I found this thought-provoking blog post from a 4th year North American medical student on the computerization of med school. As naturopathic medical students we like to think that we’re the only healthcare professionals that actually “care” about people. However, this is simply not true. I believe that most people get into medicine – any kind of medicine – for the right reasons, one of those reasons being a love for humanity. It’s only whether those reasons are still with us at the end of the 4 years that truly makes the difference.
It seems that, for every person who embraces the idea of holistic medicine with open arms and an open mind, there is at least one skeptic who refuses to acknowledge that alternative medical practices not only exist, but are growing in popularity, helping thousands of people and, most likely, are here to stay.
