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Chronic Fatigue Syndrome/ME
By Dr. Sarah Myhill, MD* •
November 17, 2010
Dr. Myhill is a widely recognized UK-based nutritionist and GP in private practice who specializes in preventive health, fatigue issues, and patient education. The following is excerpted with kind permission* from her informative website, www.drmyhill.co.uk
It is critically important for the body to maintain blood sugar levels within a narrow range.
If the blood sugar level falls too low, energy supply to all tissues, particularly the brain, is impaired. However, if blood sugar levels rise too high, then this is very damaging to arteries and the long term effect of arterial disease is heart disease and strokes. This is caused by sugar sticking to proteins and fats to make Advanced Glycation End-products (AGEs) which accelerate the ageing process.
Normally, the liver controls blood sugar levels.
It can create the sugar from glycogen stores inside the liver and releases sugar into the blood stream minute by minute in a carefully regulated way to cope with body demands which may fluctuate from minute to minute.
Excess sugar flooding into the system after a meal can be mopped up by muscles, but only so long as there is space there to act as a sponge.
This occurs when we exercise. See “Exercise - the right sort.” This system of control works perfectly well until we upset it by eating the wrong thing or not exercising.
Eating excessive sugar at one meal, or excessive refined carbohydrate, which is rapidly digested into sugar, can suddenly overwhelm the muscle and the liver’s normal control of blood sugar levels.
• We evolved over millions of years eating a diet that was very low in sugar and had no refined carbohydrate. Control of blood sugar therefore largely occurred as a result of eating this Stone Age diet and the fact that we were exercising vigorously, so any excessive sugar in the blood was quickly burned off.
• Nowadays the situation is different: We eat large amounts of sugar and refined carbohydrate and do not exercise enough in order to burn off this excessive sugar. The body therefore has to cope with this excessive sugar load by other mechanisms.
When food is digested, the sugars and other digestive products go straight from the gut in the portal veins to the liver, where they should all be mopped up by the liver and processed accordingly.
• If excessive sugar or refined carbohydrate overwhelms the liver, the sugar spills over into the systemic circulation.
• If it is not absorbed by muscle glycogen stores, high blood sugar results, which is extremely damaging to arteries.
If one were exercising hard, this would be quickly burned off. However, if one is not, then other mechanisms of control are brought into play.
The key player here is insulin, a hormone excreted by the pancreas. This is very good at bringing blood sugar levels down and it does so by shunting the sugar into fat. Indeed, this includes the "bad" cholesterol LDL.
There is then a rebound effect and blood sugars may well go too low.
Low blood sugar is also dangerous to the body because the energy supplied to all tissues is impaired.
When the blood sugar is low, this is called "hypoglycemia." Subconsciously, people quickly work out that eating more sugar alleviates these symptoms, but of course they invariably overdo things; the blood sugar level then goes high and one ends up on a rollercoaster ride of blood sugar level going up and down throughout the day.
Ultimately, this leads to metabolic syndrome or syndrome X - a major cause of disability and death in Western societies, since it is the forerunner of diabetes, obesity, cardiovascular disease, degenerative conditions and cancer.
One problem is that sugar and fast carbs are addictive.
The problem is that people feel boosted by a high level of blood sugar. This is because they have a good energy supply to their muscles and brain - albeit short-term.
The problem arises when blood-sugar levels dive as a result of insulin being released and energy supply to the brain and the body is suddenly impaired. This results in a whole host of symptoms:
• The brain-symptoms include difficulty thinking clearly, feeling spaced out and dizzy, poor word finding ability, foggy brain and sometimes even blurred vision or tinnitus.
• The body-symptoms include suddenly feeling very weak and lethargic, feeling faint and slightly shaky, rumbling tummy and a craving for sweet things. Sufferers may look as if they are about to faint (and indeed often do) and have to sit down and rest.
The symptoms can be quickly alleviated by eating something sweet; if nothing is done, then the sufferer gradually recovers. These symptoms of hypoglycemia can be brought on by:
• Missing a meal (or missing one’s usual sweet snack top-up such as a sweet drink),
• By vigorous exercise,
• Or by alcohol.
• Diabetics may become hypoglycemic if they use too much medication.
So the brain likes sugar. Running a high blood-sugar allows the brain to function efficiently and also releases the happy neurotransmitters such as GABA and serotonin which have a calming effect. See “Edge effect,” on the actions & effects of key neurotransmitters. We all recognize this because comfort-eating foods are carbohydrates.
The second problem is that we have a “thermostat” for blood sugar.
This is a measure against which blood-sugar levels are compared and controlled, which I suspect gets set upwards if blood sugars run consistently high. I believe this because I’ve seen several people with diabetes who run consistently high blood-sugar levels but feel hypo if their blood sugars drop below 7 or 8.
So, whatever interventions one makes to control high blood sugars must be done slowly so that this “thermostat” can be gradually reset.
The fermenting gut as a cause of hypoglycemia.
This is a major cause of hypoglycemia because sugars (or carbohydrates that are digested to sugars) are fermented to produce various alcohols. These destabilize blood sugar levels. [See “Fermentation in the gut and CFS”]
Energy supply to the brain.
The brain's preferred fuel supply is fat. See “Brain fog - poor memory, difficulty thinking clearly, etc.”
Eating a low fat diet and relying on sugar to nourish the brain is a little like running your car on reserve petrol tank rather than a full tank. The brain goes into panic mode at the prospect of the fuel supply running short and produces adrenaline which results in all the symptoms of hypoglycaemia. This ensures a petrol station is just round the corner as one rushes for a carbohydrate snack!
Also see “Phospholipid exchange” for the right fats to consume.
We have a “sugar addiction gene.”
This makes perfect evolutionary sense. We evolved eating a “Stone Age Diet” [emphasis on meat/seafood, eggs, root veggies, fruits, nuts and seeds].
But every so often there would be a carbohydrate bonanza - perhaps the banana tree would ripen. The only way primitive man could take advantage of this would be by eating the lot! Bananas do not store well and one is at risk of someone else eating them. Once he started eating, the carbohydrate addiction gene would switch on and he would go on eating until there was none left.
He would gain weight, which would give him energy for other tasks such as building the house, fighting the neighbors, getting the wife pregnant or whatever!
The "carbohydrate gene" is switched on when just 3% of the diet contains sugar.
The trouble with Western diets is they are high in sugar and refined carbohydrate, and so the sugar addiction gene is permanently switched on. See Wikipedia on ”Sugar addiction.”
When you can get your sugar intake low, the gene is switched off and you stop craving.
Disturbed sleep is a common symptom of hypoglycemia.
When blood glucose levels fall for any reason, glycogen stores in the liver may be mobilized to prop them up. Another rapid and very effective way in which the body replenishes the low glucose is by conversion of short chain fatty acids to glucose.
In a healthy person on a good balanced diet, the only time this is of importance is during the night because of the long break between food intake. Short chain fatty acids are used to prop up circulating glucose and prevent a fall below whatever that person’s usual fasting glucose level is. Short chain fatty acids are made in the gut by bacteria fermenting fiber (and such starch as escapes small intestinal digestion). Production is maximized from about 3 hours after food intake.
That is to say, short chain fatty acids are highly protective against the dips we see in blood sugar. Therefore, a key symptom of a hypoglycemic tendency is disturbed sleep. This occurs typically at 2 to 3 am, when blood sugar levels fall and there are insufficient short chain fatty acids to maintain a blood sugar.
Low blood sugar is potentially serious to the brain, which can only survive on sugar - and therefore, there is an adrenalin reaction to bring the blood sugar back, but this wakes the sleeper up at the same time.
The commonest symptom of alcohol causing hypoglycemia is sleeplessness. Initially, alcohol helps one to go to sleep, but then it wakes one up in the small hours with rebound hypoglycemia.
Insulin is [also] a stress hormone.
There is a final twist to the hypoglycemic tale which complicates the situation further.
When one becomes stressed for whatever reason, one releases stress hormones in order to allow one to cope with that stress. Insulin is such a stress hormone - and has the effect of shunting sugar in the blood stream into cells. This produces a drop in blood sugar levels and also causes hypoglycemia.
Therefore, hypoglycemia can be both a cause of stress and the result of stress; indeed, another one of those vicious cycles that are so often seen in disease states.
Manifestations/symptoms of hypoglycemia.
Hypoglycemic symptoms and manifestations can be divided into: 1) those produced by the “counterregulatory hormones” which oppose the action of insulin by raising glucose in the blood (epinephrine/adrenaline and glucagon) when triggered by the falling glucose; and 2) the “neuroglycopenic” effects on brain function and behavior produced by the reduced brain sugar.
• Adrenergic manifestations. Shakiness, anxiety, nervousness; Palpitations, tachycardia; Sweating, feeling of warmth; Pallor, coldness, clamminess; Dilated pupils (mydriasis); Feeling of numbness "pins and needles" (parasthesia).
• Glucagon manifestations. Hunger, borborygmus; Nausea, vomiting, abdominal discomfort; Headache.
• Neuroglycopenic manifestations. Abnormal mentation, impaired judgment; Nonspecific dysphoria, anxiety, moodiness, depression, crying; Negativism, irritability, belligerence, combativeness, rage; Personality change, emotional lability; Fatigue, weakness, apathy, lethargy, daydreaming, sleep; Confusion, amnesia, dizziness, delirium; Staring, "glassy" look, blurred vision, double vision; Automatic behavior, also known as automatism; Difficulty speaking, slurred speech; Ataxia, incoordination, sometimes mistaken for "drunkenness"; Focal or general motor deficit, paralysis, hemiparesis; Paresthesia, headache; Stupor, coma, abnormal breathing; Generalized or focal seizures.
TREATMENT OF HYPOGLYCEMIA
Low Glycemic Index Diet
Treatment is to avoid all foods containing sugar and refined carbohydrate.One needs to switch to a diet which concentrates on eating proteins, fats and complex (and therefore slowly digested) carbohydrates. Initially I suggest doing a high protein high fat diet, but include all vegetables (care with potato), nuts, seeds, etc. Fruit is permitted but rationed, since excessive amount of fruit juices or dried fruits contain too much fruit sugar for the liver to be able to deal with. I suggest one piece of fruit at mealtimes. See “Stone Age Diet” and “Low Glycemic Index Diet.”
See “Nutritional Supplements - what everybody should be taking all the time even if nothing is wrong.” [Note: for those outside the UK, these include a good multivitamin/mineral, vitamin C, fish oil, sunshine and/or vitamin D3, and sea salt].
Exercise. See Exercise “the right sort.”
The Brain’s Preferred Fuel
The brain's preferred fuel are ketones, which the liver synthesizes from medium chain fatty acids. The best source of these is coconut oil.
This fuel source is much more constant than glucose and highly protective against hypoglycemia. Coconut oil 10-20ml twice daily is often very helpful! See “Brain fog - poor memory, difficulty thinking clearly etc.” The brain loves fat!
If the brain runs short of fats and ketones, it can swap to short chain fatty acids (which come from the large bowel fermenting soluble, or ‘prebiotic’, fiber such as that in peas & beans and certain fruits & veggies, which can provide up to 500k cals a day) - or worst, sugar.
The trouble with sugar, again, is it is a short term fuel, like running on reserve tank. The brain is constantly assessing the fullness of the tank and if the tank starts to run low, the brain stimulates the release of adrenaline - this will bring blood sugar up for the brain, but one then suffers from the adrenaline effects. (See the adrenergic manifestations of hypoglycemia, listed above.)
I consider taking high dose probiotics [“helpful” bacteria that play a role in healthy digestion] an essential part of controlling low blood sugar. This is because probiotics ferment carbohydrates to short chain fatty acids – these have no effect on blood sugar and are the preferred fuel of the mitochondria in each cell, which convert these fuels to ATP, the currency of energy in the body.
There are two ways we can go about supplying probiotics. We can eat probiotics very regularly. But the best and cheapest way to get probiotics is to brew your own [specifically, Kefir] – see “Probiotics - we should all be taking these all the time and double the dose following antibiotics and gastroenteritis.” Probiotics also displace yeast, which worsens the hypoglycemia problem.
With a normal supply of stomach acid, the stomach, duodenum and small intestine should be free from acid-sensitive bugs - bacteria, yeast, and parasites – leaving the large bowel to ferment foods that can’t be digested upstream. But when the acid-sensitive bugs exist in the upper gut, fermentation takes place there, and unwanted products are produced. See “Fermentation in the Gut and CFS.”
A fermenting gut produces alcohol, which further destabilizes blood sugar levels.
Niacinamide (vitamin B-3) and chromium are particularly helpful. I recommend taking a high dose for two months. Both these supplements have a profound effect on blood sugar levels to stabilize them but sometimes have to be given in high doses initially to kick start the necessary mechanisms. By this I mean niacinamide 500mgs, 3 daily at mealtimes and possibly double this dose.
Rarely, niacinamide in these doses can upset liver enzymes, but this is accompanied by nausea – so if you feel this symptom, reduce the dose to 500mgs daily. Niacinamide is a really interesting vitamin – it shares the same action as diazepam (Valium) to produce a calming effect which is not addictive. I suspect it works because so much anxiety is caused by low blood sugar, and niacinamide helps prevent this.
Identify Other Factors that May Play a Role in Hypoglycemia
These other factors to consider include:
• Allergies to foods. These can certainly cause hypoglycemia – the top three allergens are grains, dairy products and yeast. But one can be allergic to any food! Again, see “Stone Age Diet.”
• Hypothyroidism. See “Hypothyroidism.”
• Adrenal problems and cortisol. The job of the adrenal gland is to produce the stress hormones to allow us to move up a gear when the stress comes on.
Cortisol raises blood sugar levels. It is largely excreted during mornings, and declines as the day progresses - this is why we should feel at our best early in the day, and blood sugar problems get worse as the day progresses.
Often people compensate for this by eating more as the day goes on, and this explains why many hypoglycemics do not need or eat breakfast, with supper being the largest meal of the day.
Changing all of the above will help. But it may be appropriate to do an adrenal stress profile and actually measure output of the stress hormones cortisol and DHEA since a small supplement may be very helpful. See “Adrenal Gland - the gear box of the car (DHEA and cortisol)– underactive.”
• Sex hormones, The Pill and HRT. These hormones all have the effect of raising blood sugar levels. Indeed this is the mechanism which is responsible for gestational (pregnancy) diabetes.
The problem is that stopping these hormones then causes hypoglycemia and one gets withdrawal symptoms. I suspect it is part of the mechanism that makes these hormones so addictive.
• Toxins and pollutants. There was a fascinating paper in the Lancet that showed that the biggest risk factor for diabetes (and this is the end product of years of hypoglycemia as insulin resistance results) is the level of pollutants in the body (pesticides, volatile organic compounds and heavy metals).
The paper showed that chemical pollutants were a greater risk factor than being overweight! It was suggested that the overweight problem reflected a larger chemical burden as the body tried to “dump” chemicals where they would be out of the way.
When people who have the highest levels of POPs in the blood were compared to the people with the lowest levels of POPs in the blood, they were found to be 38 times more likely to be diabetic.
The chemicals literally get in the way of many biochemical processes and prevent the body functioning normally. So for some people, doing detox regimes is very helpful – i.e., far infra red sweating/saunaing and improving liver detox with vitamins and minerals. We can easily test for pollutants in fat by doing a fat biopsy – this is a simple test, easier than a blood test! See “Detoxification - an overview.”
• Nickel toxicity. Nickel toxicity is a very common problem, and nickel, from stainless steel, catalytic converter emissions, or cigarette smoke, for example, is a substance often found stuck onto DNA. See “DNA adducts.” Nickel biochemically looks very much like zinc, and so enzymes which normally incorporate zinc into them, in the presence of zinc deficiency, will take up nickel instead.
This prevents the enzyme or the hormone from functioning normally. Clinically, nickel toxicity often presents with hypoglycemia. See “Nickel - a nasty toxic metal.”
• Fructose intolerance. Fructose is fruit sugar generally perceived to be a healthy alternative to glucose. No problem if one is tolerant of fructose or if it is taken in small amounts, but intolerance of fructose or excessive intake can result in hypoglycemia.
This is because the control mechanisms that apply to glucose are bypassed if the system is awash with fructose. In fructose intolerance (aldolase type B deficiency), fructose-1-phosphate builds up because it inhibits glycogen phosphorylase which is essential for the provision of glucose from glycogen and it also inhibits fructose-16-biphosphatase which is essential for provision of glucose from protein and fat.
This combination can result in severe hypoglycemia because it means effectively the body cannot mobilize glucose from stores in the liver for when blood sugar levels fall. This combination can lead to severe hypoglycemia.
Even if the enzyme works perfectly well, excessive fructose intake will stress the same pathways. Sugar stores in the liver cannot be mobilized. Because liver uses up short chain fatty acids for the production of glucose to try to avoid this hypoglycemia, this tendency can be measured by looking at short chain fatty acids in the blood and also measuring levels of fructose-6-phosphate which gets induced in this situation.
These three metabolic problems - i.e., levels of short chain fatty acids, levels of fructose-6-phosphate and LDH isoenzyme (indicative of liver damage), can help diagnose this problem.
I recommend people avoid tropical fruit (high fructose), and go for berries which are low fructose but rich in goodies!
* * * *
Failure to tackle hypoglycemia will result in “Diabetes.” Indeed diabetes is an inevitable consequence of Western diets and lifestyles. On current figures 50% of the UK population will be diabetic by the year 2030.
INITIAL CONSIDERATIONS DURING ADAPTATION
The problem for the established hypoglycemic is that it may take many weeks or indeed months for the liver to regain full control of blood sugar, and therefore the symptoms of hypoglycemia may persist for some time whilst the sufferer continues to avoid sugar and refined carbohydrate.
This means that when you change your diet you will get withdrawal symptoms and it may take many weeks of a correct diet before these symptoms resolve. This type of addiction is very much like that which the smoker or the heavy drinker suffers from.
With time, the regimen can be relaxed, but a return to excessive sugar and refined carbohydrate means the problem starts again.
Finally, many sufferers of hypoglycemia may need something sweet to eat immediately before and during exercise, until the body learns to fully adapt.
TEST FOR HYPOGLYCEMIA
Measuring blood sugar levels is not a terribly useful test for hypoglycemia, partly because the levels fluctuate so much and partly because by the time one gets the symptoms of hypoglycemia, the blood sugar levels have started to correct. A much better test would be to measure short chain fatty acids in blood collected in the morning before breakfast. The test should be done as follows: It is important to continue your usual diet – indeed, there are no special dietary instructions for the test, but the blood sample must be taken between 9 and 12 hours after a meal – e.g., first thing in the morning before breakfast. In the UK, for example, the short chain fatty acids blood test is conducted by Acumen lab.
* Excerpted with kind permission from Dr. Sarah Myhill’s patient education website (www.DrMyhill.co.uk) ® Sarah Myhill Limited, Registered in England and Wales. Registration No. 4545198. Registered Office: Upper Weston, Llangunllo, Knighton, Powys, Wales LD7 1SL, UK. Tel 01547 550331 | Fax 01547 550339.
Note: This information has not been evaluated by the FDA. It is generic and is not meant to take the place of one’s physician and is not meant to prevent, diagnose, treat or cure any condition, illness, or disease. It is very important that you make no change in your healthcare plan or health support regimen without researching and discussing it in collaboration with your professional healthcare team.
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