WHAT HAPPENED THIS TIME?

I was accused of violating another article of the Brazilian Code of Medical Ethics. Article 35: The doctor is prohibited from exaggerating the severity of the diagnosis or prognosis, complicating the therapy or exceeding the number of visits, consultations or any other medical procedures”. The thing was: I wrote an article on fatigue that was published in a popular magazine around here in February 2017. Actually, it was on a Chronic Fatigue Syndrome which everyone was talking about at the time. The title was: Adrenal Fatigue: how to avoid it to live longer and better. I was not referring precisely to “the Chronic Fatigue Syndrome”, a condition which is not easy to be straightforward about, mainly because there are a lot of uncertainties regarding its etiology and because any treatment strategies have been totally effective against it, according to the scientific literature [1]. Strictly speaking, it includes a severe and disabling new onset of fatigue of more than 6-month duration and not relieved by rest [1,2]. Also, it may present itself with post- exertional malaise, impaired memory or inability to concentrate, cognitive difficulties, unrefreshing sleep, orthostatic intolerance, somatic symptoms and pain (sore throat, tender cervical or axillary lymph nodes, muscle pain, multi-joint pain and headache [3]. In the article, I just said that I was getting many patients complaining about some terrible lack of energy. They would say they were ever so tired, always tired, but couldn’t get enough sleep at night, very often with difficulty in falling asleep. Most of them complained of low libido, particularly women, and their testosterone levels tended to be very low, with a good correlation with S-DHEA levels (dehydroepiandrosterone-sulfate, a steroid hormone produced by the adrenal cortex). Forgetfulness was very disturbing. Not surprisingly, anxiety and/or mild depression were also present in most cases, although they were not usually described as criteria for the diagnosis of the “official” Chronic Fatigue Syndrome. In short, it was a condition that greatly affected the patients’ quality of life and still does. It has been considered the 21^st century stress syndrome. The first problem apparently was that I mentioned Adrenal Fatigue. However, I started the article  by saying that Adrenal Fatigue was an expression that should not be used [4] according to a note from the Brazilian Society of Endocrinology and Metabolism (SBEM) [5]. Notwithstanding, it was a "familiar" expression for many people, being fatigue ever so common. Observe that the article was focused on how to prevent it, other than how to diagnose/treat it. But the second problem was that, once I got the accusation, I might have affronted them by saying that, working as a clinical nutrition practitioner, I didn’t think the name given to the syndrome was very important. Chronic Fatigue Syndrome is a very vague name anyway, once fatigue may be the first symptom of many serious diseases [2]. In my practice, I investigate the patients with the subjective feeling of exhaustion as everyone else, considering both their clinical signs/symptoms and their test results, in particular DHEA or S-DHEA, total and free testosterone, serum cortisol levels between 7 and 9 a.m., TSH, magnesium, vitamin B12, hemoglobin, transferrin saturation, and some others parameters possibly related to this symptom. I don’t think I exaggerate the severity of the diagnosis or prognosis at all. On the contrary, my first step is to do this “usual” investigation with “simple” laboratory tests. Nevertheless, my focus is on how to prevent it through a healthy lifestyle, the use of adaptogens (Rhodiola rosea [6-8] Withania somnifera, known as Ashwagandha [9-12], Panax ginseng [7,13-16] balanced diet, regular exercises, good sleep hygiene, anti-stress therapies, and so on. I must say that all active compounds and extracts used in the formulas are authorized prescriptions in the country and I don’t ever prescribe antidepressants [17,18] or corticosteroids [18] that are sometimes indicated to treat the so-called Chronic Fatigue Syndrome.

SO, WHERE DID I REALLY GO WRONG?

One of the two things: a. Exaggerating the severity of the diagnosis or prognosis; b. Complicating the therapy or exceeding the number of visits, consultations or any other medical procedures. After reading the accusation carefully, I identified only that it was assumed I was complicating the therapy and not individualizing the treatment. They referred to a particular case when I mentioned a patient that said “I don’t want to be a slave of capsules”. I believe it was also assumed that this was a final statement, not the beginning of a conversation and it was not considered that the patient could have totally changed his mind after my explanation on the benefits of the recommended supplementation. Well, my arguments are very clear. 1) The supplements are prescribed, if needed, after a thorough investigation of the nutritional, metabolic and hormonal status. I emphasize to the patients that it would be difficult to optimize their results only through  diet alone, especially if they feel very tired, making it hard on them to be pro-active and find solutions to their condition. 2) If, after my explanation, the patients are still reluctant to take capsules, I truly recommend them to try to find another way to improve their health. I say that, whatever we do in life, we’ve got to be coherent with our true feelings and beliefs. They are “messages” which somehow activate our cell receptors in a way that only positive information will modulate our genes towards health. I very much value the patients’ preferences. I do not propose a two-week treatment, but a lifelong therapy, including the use of supplements which, I believe, are necessary to overcome the inherent human evolutionary-derived limitations in tissue homeostasis and cell maintenance, as proposed by Applied Health span Engineering [19,20]. So, the patients’ total adherence to the treatment is essential. 3) I guess the accusation assumed that, if I use the same nutrients and herbs to treat all patients with symptoms of chronic fatigue, the treatment is not individualized. On that matter, it was a wrong judgement, not considering that the doses and combination of nutrients and herbs are always personalized. Also, whenever possible, I attentively analyze their nutrigenomics panel, which makes their prescriptions  ever so individualized. 4) Why not to consider the testimony of patients that have been submitted to the treatment I recommend for chronic fatigue? I have many of them that would be willing to report their well-being before and after the treatment. I included in this article some references of studies with level of evidence A and B to prove that we do have some studies that show effectiveness and safety of supplements either on fatigue itself or on some related symptoms, such as cognitive impairment and mood/sleep disorders. For sure many studies are yet to be done. Nevertheless, remember that I have a holistic view on the use of supplements. A broad-spectrum supplementation (non-specific for fatigue) includes not only adaptogens, but also green tea [21], vitamins (B-complex vitamins [22,23], vitamin C [23]), minerals (iron [2], selenium [21], zinc [23], magnesium [23]), amino acids (L- tryptophan [23], arginine [24] aspartate, L-carnitine [23]), mitochondrial support (pyrroloquinoline quinone/PQQ [24], nicotinamide adenine dinucleotide hydride [24] and coenzyme Q-10/ubiquinol [21-26] lipoic acid [27,28] and many other options to choose from. Also, I can make another point here. There’s a popular saying that states: Experience is better than science. In our context, they probably go together. That is to say that we can never undervalue what we learn from every day clinical practice and I really like the combination of adaptogens, B-complex vitamins, vitamin C, magnesium and other substances used for the treatment of fatigue, regardless of the diagnosis itself and always   following a thorough nutritional, metabolic and hormonal investigation.

A BIRD’S EYE VIEW

Well, I might have written something not totally correct about the official “Chronic Fatigue Syndrome”. I am sorry. But, true, I don’t really see fatigue under a framed pattern. It is a very common complaint indeed, usually following a very stressful period of someone's life. It has been said that adrenal fatigue is a fantasy, but I do see quite a few patients complaining of some prolonged lack of energy with a lot of signs/symptoms and altered laboratory results that do improve with the use of supplements, lifestyle changes, pleasurable and relaxing activities, such as meditation, mindfulness, bathing in the sea, walking on the grass, watching the sunset, listening to some smooth music, reading a good book, dancing, singing, cooking, traveling, and so on. One day, I believe, we will all conclude that no particular name is necessary for this syndrome, but, if so, I would call it “stress-related Chronic Fatigue Syndrome”. In short, we should basically try to bring the patients into balance and recover their health before it aggravates with some chronic illness(es). Very simple, actually, the way I see it!

SO, DOCTORS, WITH ALL DUE RESPECT, WHAT’S WRONG WITH US?

I mean, the whole “family” of medical doctors. Please, let’s consider we are all colleagues that are supposed to be working together to help our patients optimize their health and find their own process of cure at a deeper level to live better and longer. Let’s step back and look, as if from a second helicopter, trying to see what is going on in our profession. It  is contradictory to promote health to others and hurt ourselves with harmful accusations associated to unpredictable consequences. Get inspired by the words of John Lennon: “Remember to let it (light) into your heart, then you can start to make it better”. With love and glory.