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Natural Strategies for Stopping a Common Energy Drain in ME/CFS and Fibromyalgia

  [ 80 votes ]   [ 2 Comments ]
By Jacob Teitelbaum, MD • • October 12, 2011

Dr. Teitelbaum, a well-known fatigue and pain specialist who contracted CFS as a medical student, has researched ME/CFS/FM patients’ nutritional and therapeutic needs for more than 20 years. This article is reproduced with kind permission* from his educational web site at


Treating Low Blood Volume & Decreased Heart Function in CFS & FM

In this important article we will discuss a critical but usually overlooked part of treating Chronic Fatigue Syndrome and fibromyalgia effectively. It can be relatively easy to treat, but is not very glamorous, and is therefore often forgotten.

We will focus on research by Dr. Barry Hurwitz and a team of University of Miami researchers, including Dr. Nancy Klimas, who is wonderful and one of my favorite people in the CFS community... Their [2009] study shows that patients with CFS have:

1. A lower blood volume (basically are dehydrated).

2. Fewer red blood cells to carry oxygen and nutrients (basically anemia, despite normal blood tests).

The study also discusses that although the heart may be smaller in CFS and beats less efficiently, this is likely caused by the dehydration and low blood volume, as opposed to primarily being a heart problem. (More on the details later.)

The good news is that all of these issues can be effectively treated and optimized naturally - which can leave you feeling much better!


There are several key things that you can do to treat the low blood volume and low blood cell levels that will leave you feeling better:

1. Treat the Dehydration.

Despite your increased thirst and drinking a lot ("like a fish"), most of you are still dehydrated because you're urinating even more. This occurs for several reasons, including underactive adrenal function and a decrease in antidiuretic hormone ("anti-peeing hormone"), both of which are routinely present in CFS because of the hypothalamic dysfunction ("blowing a fuse") that we often discuss….

Quick Fixes:

a. Drink more water! Instead of counting glasses of water (an annoying way to spend the rest of your life), check your mouth and lips to see if they are dry. If they are, drink!

b. Eat more salt. Unless you have high blood pressure or heart failure, you need more salt than most people. In fact, many studies have shown that the more salt people eat the longer they live [see sidebar at end of article, “High Salt Intake is Associated with BETTER Health”], and for most people the need to avoid salt has been a problematic medical myth (see six dangerous "Medical Myths"). Use an iodized salt or better yet sea salts... Enjoy salty foods as well.

c. Improve adrenal function. This is discussed at more length in "The Adrenal Gland, and Symptoms of Adrenal Insufficiency," but a simple way to do this is with an excellent product called Adrenal Stress End.

d. Saline IVs. Clinical experience has also shown that salt water (saline) IVs can be very helpful. The effects are transient though, unless other nutrients are added  - e.g., the Myers’ Cocktails [which are IV vitamin and mineral therapies first conceived in the 1970s by the late John Myers, MD, at Johns Hopkins] administered at holistic physicians' offices [such as] the Fibromyalgia and Fatigue Centers.

2. Increase Your Body's Production of Red Blood Cells.

Although treating the infections and hormonal problems we discuss overall in the SHINE Protocol will do this (addressing possible problems with Sleep, Hormones, Infection, Nutrition, and Exercise), below are key things that will help.

a. Treat for low iron - even if your blood tests are normal but modestly low. The best blood test is called a "ferritin" level. Your doctor will say it is normal if it is over 12, but research has shown(2) that in people with chronic fatigue, iron supplementation increased energy dramatically in people with a ferritin under 50 (see Iron Helps Fatigue - Even with Normal Iron Levels and No Anemia) who were not anemic. If the ferritin blood test is under 50, or the iron percent saturation blood test is under 25%, take 1-2 tablets of iron (29 mg with vitamin C) each afternoon or evening on an empty stomach for 4-6 months.

b. Treat for low testosterone and low thyroid levels - despite the normal blood tests. Both of these, especially the testosterone (use only the safe and natural bioidentical forms), increase red blood cell production.

3. Improve Your Heart Function

Though the study discussed in this article notes that the low blood volume and anemia are key, other studies and clinical experience show that nutrients that improve heart function also improve energy in CFS patients. These include:

a. Ribose (Corvalen) 5 gm (1 scoop) 3x day for 3 weeks, then twice a day.

b. Acetyl L-carnitine 500 mg 2x day. [See for example "Long-chain acylcarnitine deficiency in patients with Chronic Fatigue Syndrome," Journal of Internal Medicine, Jul 2011].

c. The Energy Revitalization System vitamin powder (contains 50 nutrients including B vitamins and magnesium).

d. Coenzyme Q10 at 200 mg daily.

Give the above treatments 6-12 weeks to see the effect. But by one month, most of you will be feeling a lot better with these treatments. In addition, if you have not already done so, do the free Symptom Analysis Program to tailor an overall treatment protocol to your case. Although you do not need to have your blood tests results, if they are available the program will also analyze the more important tests.


The study(1) looked at 146 people with chronic fatigue syndrome, 30 of whom were very severely affected. It compared them to healthy controls and then factored in how active or sedentary the people were.

People with CFS showed 25% lower heart contractility, so they pumped much less blood.

They then did specialized testing which showed what the person's total blood volume was and also whether they had enough red blood cells, both of which have been shown to be low in the majority of those with severe CFS.

As all of the above problems have been shown to be common in CFS, the study explored whether there was predominantly a heart problem or whether all of these findings could be explained by dehydration and having too few red blood cells. I would note that, normally, having too few red blood cells would be called being anemic.

Unfortunately, the standard blood tests for anemia compare the amount of blood cells relative to the blood volume. As both are low, the blood count tests come back as normal despite CFS patients in reality being functionally very anemic.

As the study authors note, "The elevated prevalence of low red blood cell volume suggests that the CFS subjects may have an anemia type that goes undetected by standard hematologic evaluations."

In other words, people with CFS are likely to be anemic despite normal testing (being 6% to 13% lower than optimal, depending on the severity of their CFS).

The role of decreased heart function in CFS has been a major focus of work by Dr. Paul Cheney, MD, PhD, a chronic fatigue syndrome expert who is intimately familiar with the effects of heart problems, as he needed a heart transplant himself. He theorizes (and I am markedly oversimplifying his theory) that heart function decreases as an adaptation to not being able to properly handle the oxygen needed to make energy in CFS.

Chronic disease in general can trigger dehydration and low red blood cell volume, so there are many possible reasons for these occurring in CFS. Deconditioning can also then decrease heart function.

This study was associated with another study looking at whether injections of a prescription blood cell stimulating hormone called
"erythropoietin" would be helpful in CFS, which would naturally lead to some focus towards interpreting the results as being associated with a deficiency of blood cells as opposed to a heart problem. The benefits of erythropoietin treatment were modest relative to the cost and hassle, though, and I think the researchers’ bias is fairly modest.

The authors conclude, "Given these findings, it may be prudent in the clinical setting to perform a direct examination of blood volume status in CFS patients and consider treatment for those with abnormal levels. A blood volume deficit may:

• Impact adversely oxygen delivery and nutrient supply,

• Impair hemodynamic regulation (e.g., blood pressure and heart function),

• And contribute to the exacerbation of fatigue and other CFS symptomatology."

As their earlier study showed minimal benefit from only increasing the amount of red blood cells using erythropoietin, it again shows the need to use an overall treatment approach to treat all the problems present in CFS.

These include raising red blood cell mass and treating the dehydration, but also treating the underlying infections, adrenal under activity, and other problems that are at the root of these problems.

As we know that most people with CFS will have the dehydration and "anemia despite normal blood testing," I do not think it is worth the cost of doing these expensive nuclear scans, but instead recommend the simple treatments discussed in the summary above, which we know are helpful in CFS. (Again, these are part of the SHINE Protocol.)

* * * *

SIDEBAR: High Salt Intake is Associated with BETTER Health
Re: “Sodium Intake & Mortality Follow-Up in the Third National Health and Nutrition Examination Survey - NHANES III.”

This study is a fascinating one. It is based on the NHANES data base, which is one of the most respected (if not the most respected) nutritional data bases in the country. What the study showed is the opposite of what we have been led to believe medically.

It showed that the lower the salt intake, the HIGHER the risk of death. Put differently, our advice to people to avoid salt is more likely to be harmful than helpful!

On the other hand, though there was no significant evidence that salt was harmful, the evidence for a low salt diet being harmful was modest, so if people want to avoid salt it probably won't hurt them too much.

The possibility of a low salt diet being harmful was also likely affected by more people in the low salt diet group having high blood pressure, so it may have been the underlying high blood pressure which caused their higher death risk (i.e., people with high blood pressure were told by their doctors to be on low salt diets, and this could be a “confounding variable” that makes people misinterpret the data. The low salt didn’t kill them, but rather it was their earlier high blood pressure).

Bottom line – Enjoy yourself! Eat the amount of salt that your body wants and don’t worry about it (if you don’t have high blood pressure or heart failure).

The Abstract:
“Sodium Intake and Mortality Follow-Up in the Third National Health and Nutrition Examination Survey - NHANES III.” (The full text article is here - )

Background: Sodium restriction is commonly recommended as a measure to lower blood pressure and thus reduce cardiovascular disease (CVD) and all cause mortality. However, some studies have observed higher mortality associated with lower sodium intake.

Objective: To test the hypothesis that lower sodium is associated with subsequent higher cardiovascular disease (CVD) and all cause mortality in the Third National Health and Nutrition Examination Survey (NHANES III).

Design: Observational cohort study of mortality subsequent to a baseline survey.

Participants: Representative sample (n=8,699) of non-institutionalized US adults age 30 and older, without history of CVD events, recruited between 1988-1994.

Measurements and Main Results: Dietary sodium and calorie intakes estimated from a single baseline 24-h dietary recall. Vital status and cause of death were obtained from the National Death Index through the year 2000.

Hazard ratio (HR) for CVD mortality of lowest to highest quartile of sodium, adjusted for calories and other CVD risk factors, in a Cox model, was 1.80 (95% CI 1.05, 3.08, p=0.03). [Note: an HR of 1.0 would represent no difference; so a ratio of 1.80 would indicate that individuals in the lowest sodium intake quartile were 80% more likely on average to die of a cardiovascular event than those in the highest sodium intake group.]

Non-significant trends of an inverse association of continuous sodium (per 1,000 mg) intake with CVD and all-cause mortality were observed with a 99% CI of 0.73, 1.06 (p=0.07) and 0.86, 1.04 (p=0.11), respectively, while trends for a direct association were not observed.

Conclusion: Observed associations of lower sodium with higher mortality [all causes] were modest and mostly not statistically significant. However, these findings also suggest that for the general US adult population, higher sodium is unlikely to be independently associated with higher CVD or all-cause mortality.


1. Low Blood Volume and Red Blood Cell Mass Study, Abstract: "Chronic fatigue syndrome: Illness severity, sedentary lifestyle, blood volume and evidence of diminished cardiac function," Barry E. Hurwitz, Nancy G. Klimas, et al. Behavioral Medicine Research Center, University of Miami, Florida. Clinical Science (Lond), Oct 19, 2009. See full text at

2. Reference for Iron Study: "Iron supplementation for unexplained fatigue in non-anaemic women: Double blind randomised placebo controlled trial,"  F Verdon, et al. BMJ, May 2003.

* Copyright © 2011 by The Annapolis Chronic Fatigue and Fibromyalgia Research Center for Effective CFS/FMS Therapies. All rights reserved.

Disclaimer: These statements have not been evaluated by the FDA. This information and the supplements discussed are not intended to diagnose, prevent, treat or cure any illness, condition 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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Article Comments Post a Comment

ME/CFS & fibro & red blood cells
Posted by: lochner
Oct 12, 2011
I have a couple of blood conditions that should have made their way into this article. Re red blood cells...I have plenty, but they are malformed, and this makes it hard for them to pass through the capillaries. Consequently, low oxygen & nutrition delivery. Further, I have a very high fibrin count which seems to be common with people with ME/CFS. My fibrin count was 1200 when the high normal is around 300. Some people have speculated that fibrin is a cause for ME?CFS. I say just the opposite. I have dealt with my high fibrin via monthly phlebotomies and natural blood thinners and I still have the disease. My belief is that the disease creates the excess fibrin & malformed red blood cells. I do want to comment that the phlebotomies & blood thinners have helped me to breathe easier, and my blood pressure is down. Still on BP meds, tho. lochner
Reply Reply

Low Blood Volume
Posted by: Susanna1
Oct 12, 2011
Thank you for that article, Dr Teitelbaum. I have had an echocardiograph showing another angle to this which I never see mentioned. My report said 'The IVC diameter is small, consistent with central hypovolaemia.' I have not been able to find out about this, and which comes first, the narrowed IVC diameter or the hypovolaemia. I've never seen any reference to this in relation to CFS. I have tried a saline IV and felt worse after, feeling very heavy. Can you provide a possible explanation for my finding and any suggestions for treatment please? Thank you, Susanna
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