Today we discuss what the most common causes and treatments are for fatigue with Dr. Carri Drzyzga. We also take an interesting turn into brain health and brain autoimmunity’s role in fatigue.
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Addressing the Root Cause of Fatigue with Dr. Carri Drzyzga
Dr. Michael Ruscio: Hey guys, before we start the official podcast today, I just wanted to share something that bothered me, unfortunately that came into my line of sight this morning. This was for our website, people can submit questions. Patients can submit patient-related questions. And I don’t typically see these. They’re filtered by my office staff. But I stumbled across one today. And I wanted to share it because I think it illustrates an important point.
Dr. Ruscio Shares: A Real-Life Reminder of How Important Cost-Effective Functional Medicine Can Be
So I’m just going to read this. “Hi, I’m a 21-year old who has been sick with SIBO, severe malabsorption, parasites. I have severe constipation, belching, bloating, fatigue, very low weight, extremely low weight, depressed, sad, anxious to get my health back. And I have no energy. I’m very weak.”
Typically, the grammar’s not great on these things, so I’m not missing words. This is exactly as it’s written.
“I can’t tolerate 80% of all foods. And I just feel I want to die. SIBO overgrowth has ruined my life. Can you help me heal and get back my health without SIBO returning? I don’t have much money, as I’m still in college. In fact, I can’t even go to college anymore. I can’t concentrate, can’t think, can’t even walk. I get tired very easily. I am very weak. I don’t know how I can heal. I’m working with a naturopath already. But there’s still constipation and bloating. I really don’t feel much better. Please, can you help? I was also contemplating on consulting a doctor”—and this is where it gets real interesting—“who tests everything, which in total the whole program would be like $6,000 or even more. So I don’t know what to do with no money, no job. My family can’t even afford a new car. I feel doomed by this illness. I used to be very healthy. But now, my health is a plain disaster.”
So the main thing there that I want to tune in on is the fact that this person is overwhelmed by the $6,000 option. And I get at least one to two of these correspondences a month, either it be a patient saying something to me directly or I stumble upon one of these questions that’s submitted through our website. And it bothers me. And it’s not that I’m trying to be critical of the cost ineffective nature of functional medicine just because, it’s because I see things like this. And I hear stories like this. And it really bothers me.
A college student suffering with their health, they see one doctor. They aren’t getting any results. And then, the next option they’re hit with is $6,000. And this person is probably willing to do anything at this point. If you read her email, you can clearly tell that she is distraught and she is not feeling well, and rightfully so. It’s not easy to not feel well. I’ve been there myself. And if I were in her position, and I was desperate like that, which I was, I probably would’ve taken out a credit card or something like that to pay one of these large fees. Fortunately for me, I found a doctor that was reasonable and just focused on one issue at a time. And so I didn’t have to spend a ton of money. I maybe spent a couple thousand dollars over a few months, which I think is pretty reasonable, rather than $6,000 or more just to get started.
So the reason why I bring this up is because this is a legitimate reality that limits the functional medicine field. It’s probably hurting the field right now, because new people are finding their way to functional medicine. And those who start with an experience like this are probably never coming back, and not only from the perspective of the field, this is bad for the person. This poor gal; hopefully she will not end up working with this doctor who’s going to require $6,000 worth of testing.
And I would hope, giving this doctor the benefit of the doubt, that if she brings up this financial concern, he would be able to come up with a more focused plan, because if this doctor focused on 15% to 20% of all the things he or she could focus on, we could bring the bill from $6,000ish dollars down to probably $800 to $1,200, which is a much better starting point.
And this is the line of thinking that I think’s important for us as clinicians to come back to. It’s not about what are all the things I could test, evaluate, and treat right out of the gate, but what if I was limited in what I could do and I had to focus on what I thought was the most important thing, and then reevaluate. If I was forced to do that, what would I do? And then do that.
That’s what I’ve been doing progressively more and more every day in the clinic. And it really makes things much more efficient and cost effective. Like I’ve said, it’s way better for the patient because it doesn’t burden them financially. And again, clinically, it really is better because you can see much more when you’re looking through a focused lens, rather than trying to interpret what 8, 9, 10 different labs mean, treat these different things maybe at the same time, and try to gauge how these different treatments are being effective or not being effective.
So again, to wrap this up, I just wanted to share this because this is a legitimate concern that a lot of patients are faced with. And it’s extremely damaging to the patient. And it’s extremely damaging to our field. And while I try to give everyone the benefit of the doubt, meaning the clinician in this case, I do have my doubts as to whether or not this clinician, if the patient were to ask them to decrease the bill or focus the care, if they’d be able to do so. And they may just say no, “Because this is my model,” and what have you.
I also get that the ‘test a lot of stuff’ model works for some clinics. I do get that. And I don’t want to discount that because there are some clinical practices that focus on people who are chronically ill. And they’ve learned that for their model, they need to start off with a little bit more. But I think we should always have the ability to be flexible in our approach to help people that don’t have the financial means to the end of doing that and trying to be forced to say, “You know, what, what can I start with?”
And sometimes I look at this through the lens of, if a family member came to me—and family members are always tough—but if a family member or a close friend came to me, and I couldn’t say no, and I had to help them with the limited resources that they had, and they genuinely cared and they were totally invested, what would I do? And so, maybe for some of us out there who are struggling with this, framing it like that might help.
In any case, an unfortunate example of how this, “Let’s get a bunch of data, but order a lot of testing” model is very damaging for some patients because it creates a lot of financial fear. And it creates a lot of limits to what this patient needs help with. And I’m guessing she’s probably also seeing a gastroenterologist, but didn’t mention that, didn’t get the results she was looking for there, saw a naturopath, wasn’t able to get the results there. And now, she’s being smacked with this huge, potential bill.
So anyway, just wanted to share that. And we will now shift gears into the podcast.
Hey, everyone, welcome to Dr. Ruscio Radio. This is Dr. Ruscio. And I am here with Dr. Carri Drzyzga. And today, we are going to be talking all about fatigue.
Hey, Carri, welcome to the show!
Dr. Carri Drzyzga: Ah, thank you so much for having me on. It’s such a pleasure to talk with you again today, Michael!
DrMR: Yeah, it’s always nice chatting with you. I’ve been on Dr. Carri’s podcast a couple of times. And we always have good conversation. So we decided to have on come on and talk about fatigue. And there’s, of course, a lot to say on this topic. But before we jump into that. Carrie, can you tell us a little bit about your background and how you got into focusing on fatigue?
DrCD: Oh, sure, sure. So I am trained as a chiropractor and a naturopathic doctor. And I would say my story, and is what prompted me to write my book, I was 15 years into my private practice as a chiropractor, and I decided I needed to go back to school and get another medical degree in order to really focus on practicing functional medicine to the full scope that I wanted to. So, that meant that I had to move from Canada back to Chicago for a couple of years.
And I was in class like 30 hours a week—morning classes, afternoon classes, evening classes. And that, plus, as you know, being in medical school, all of the studying and the exams and the writing papers. Plus, I was flying back and forth to Canada to still try to maintain my private practice. And thinking about it, I think, “How did I do that? Right? But when you have a lofty goal, sometimes you just do what it takes.
And it was about six months into that craziness that I personally started feeling the fatigue. And, of course, I knew it was because of all of the stress that I was putting my body under. And I just thought, well, I just have to, you know, suck it up and get through it. And that once I graduated and I passed my board exams that I just needed a rest, and that everything would fall right back into place. You know, my energy would come back. My brain function would improve again. And I was very, very naïve about that, Michael, very naïve.
So I was at a point where I was sleeping like 10 hours a night and taking a two-hour nap every day. And after this went by for a few months, I was like, “This, this is not good.” And my brain, my brain just did not respond either. I was having a really difficult time with my short-term memory. And this is a bit embarrassing to say. But I’d have patients coming in, and I would forget their names. I would forget, “Why are they seeing me?” Like, my short-term memory was shot. And thank goodness, we have to keep really great records and files.
DrMR: I was just going to say that probably made you much better at record taking, though.
DrCD: Yeah. But I think this is a common story with a lot of people. Like, they start having brain fog, poor concentration, poor memory, and that’s all layered on top of the fatigue. And it becomes a real mess. And so I broke the rules. And I started treating myself, which we doctors are never really supposed to do that. But I decided to do that because I’m like, “Okay, I need, I have to get better because I went back to school to get this second medical degree. And I want to stay in practice. I want to help as many people as I can. But I first, need to get healthy.”
So that’s what prompted me to share my story in a book. And that’s a little bit about my background.
DrMR: Okay. Okay. And so fatigue is something that’s, of course, near and dear to your heart. And, of course, a lot of patients also suffer with fatigue. And I like the term fatigue much better than the term adrenal fatigue because in my mind the adrenals are never really the cause of the issue, unless it’s a rare exception like Addison’s or Cushing’s, which are extremely rare. And no one on this call probably has that. And they probably don’t even know anyone who has that.
So the adrenals, I think are just a secondary symptom of a deeper, underlying problem. So I like fatigue better than adrenal fatigue because it doesn’t just pin the whole problem on some organ, and take the focus away from what the underlying cause is.
Vitamin R: Rest, Recreation, Relaxation
So let’s talk a little bit more about what some of the common causes of fatigue are. And I was looking through your book before the call, and there’s a lot of different potential causes and corresponding treatments. I organized things for us into a list that starts as basic and escalates us from there. Let’s start with what you call vitamin R, which I love, which I think was rest, relaxation, recuperation. So tell us a little bit more about vitamin R and some ways people can tell they’re deficient and things people can do to obtain more vitamin R.
DrCD: Yeah, so vitamin R is one that I really love to talk about. And one that I find not a lot of doctors really address. And so as you were saying, vitamin R is rest, recreation, and relaxation. And so just for you, the listener out there, thinking about how much do you get that in your life—of rest, of relaxation, of recreation? And that sometimes, Michael, I have to tell patients, “Like, it’s okay to have fun.” It’s okay to schedule downtime so that you just go out and you just have fun and goof off, or you just relax. If that’s to you just taking a long walk in nature and to just be in the present moment. If that’s doing something more formal like getting a pedicure or getting a massage, you know.
DrMR: I love that. Yeah.
DrCD: And if you can couple recreation with exercise, and that you don’t find exercise as a chore, but as something fun to do, that’s even better. So I wrote this in the book; I got to the point where, like a lot of people, I do not enjoy exercising. I will admit it. But I was always interested in learning how to box, which I know a lot of people are quite, they’re like, “Really, you, Dr. Carri?” “Yeah, me.” I was always interested in learning how to box. I don’t know why.
And so I had one of my patients contact me at one point and said, “You know, I can’t come in tonight. I’m going to my boxing trainer.” And I was like, that perked my ears. I’m like, “Your boxing trainer, tell me more about that. Like, I don’t care why you’re not coming in tonight, but tell me about the boxing thing.” So she was seeing this trainer and taking this weekly course, just boxing. And it’s basically hitting the heavy bag and just learning proper technique. So I was like, “Oh, you know I really—, that really sounds interesting. I’m going to go try that.”
And from our first meeting, I was just hooked. I was just hooked on boxing. So we started with three-minute rounds of just jumping rope, which anybody could do at any point. You could do that at home. And that really got me, you know, in tune with—cardiovascularly, I was not doing well. I could not even do a one minute of jumping rope.
And then, we got into hitting the heavy bag. And I realized it took a lot of mental focus and concentration. So for me, a lot of times, I have patients on my mind. I don’t know if you’re like that, Michael.
DrMR: Yeah, I’m always thinking about something.
DrCD: But I have patients on my mind.
DrMR: Yeah, no, I will. Yeah.
DrCD: And so for the listeners out there who are very intellectual and always have something going on in their head, I found boxing to be great because I was able to shut my brain off, because I had to just focus on this one thing, hitting this bag, using proper technique. And if I messed it up, I could potentially hurt my hand, hurt my wrist, which as a chiropractor that’s never good. As a doctor, that’s never good.
And so right there, I felt like, “Okay.” Part of that was just shutting my brain off. And then there was this whole just feeling empowered, especially I think for the female listeners out there, just feeling embowered that there is an inner strength that you really have. And then just beating on the heavy bag. Just beating out the frustrations that I had about different things that we have in life.
And so I got done with my first initial boxing round. And that was, I think 45 minutes. And I was like, “What, this is over? Well, well, I could keep going with this. Like, this is so much fun. When can I come back, you know?” And so then I really realized that, “Boy, if…For those of you out there that can link your exercise with your recreation, it’s just effortless then.” And that’s how you can get more vitamin R.
DrMR: I like it. I think Mark Sisson calls that movement as play, which I think is brilliant. Yeah, because we don’t want to make activity something that feels like another chore because then you’re not going to do it, so totally, totally agreed. So yeah, I’d say to the listener, try to find that thing that you enjoy to do so that it doesn’t feel like exercise, like this drudgerous task, but something that you really enjoy doing, and get energized by it. Totally.
What about blood sugar? Because this is one that is foundationally important, but I think sometimes we overlook it because it’s not necessarily something new and novel and sexy and what have you. But blood sugar is definitely an important one in my mind. I have a few thoughts on it. But why don’t you kick us off with your thoughts about blood sugar, Carri.
DrCD: So you’re right, blood sugar is not anything that’s new or novel or sexy. But I think for a lot of people that might be the missing component to their fatigue. It can sometimes be so basic. And even as a doctor, sometimes I’m trying to look for all of the different causes of taking a functional medicine approach, trying to the find the causes, fix them, and looking into all these sexy tests—the stool test, the breath test, the urine testing—and forget about just the basics.
So blood sugar, and specifically, we’re talking about the need to keep your blood sugar steady through the day. And some people have, they tend to have low blood sugar or hypoglycemia. And some of the symptoms of hypoglycemia would be very commonly people will skip breakfast or they’ll just wait too long to eat. And then, they’ll start feeling tired. They might start feeling irritable. What they call “hangry” now. I don’t think that’s a medical term yet, hangry—hungry and angry. I’ll just like to say bitchy, and because that’s what happens to me. And my husband’s like, “Okay, let’s get you some food right now, Carri.” And shaking, and then they eat. And they feel better.
And then another common symptom of hypoglycemia is waking up during the middle of the night. You’ll be sleeping fine. And then at two in the morning or three in the morning or four in the morning, you just wake up for “no apparent reason.” But it could be just that your blood sugar’s dropping. And as your blood sugar drops, your body spits out adrenaline or epinephrine to try and manage that blood sugar, to get it up real fast. And that’s part of what wakes you up.
And then, the other would be if your blood sugar is running too high. And symptoms of blood sugar that’s running too high is you eat your meal. And you just feel like, okay, you ate your meal. But you could use that little something sweet after you eat—dessert. Even if it’s “a healthy dessert,” like a piece of fruit, the fact that you are craving something sweet after your meal, usually indicates that your blood sugar is too high.
And then, the other one is feeling tired after your meal. Like, you could just crawl up and have a nap. And then, the last thing with having blood sugar that’s running too high is that oftentimes these patients have a hard time falling asleep because their blood sugar is just running too high. And there’s not enough glucose actually getting into the brain at that point.
And so you, the listeners out there think about, “Do I have symptoms of low blood sugar, symptoms of high blood sugar?” And the reality is a lot of people, it’s a mixed bag. And I tell my patients just when you eat your meal, after you eat your meal, just take a moment and check in with yourself, just be present. Just check in with yourself and just see how do you feel.”
So if you ate your meal, and then you feel like, “Oh, I feel a little bit more energized. My brain feels a little bit more clear.” That usually means that your blood sugar was too low to begin with and most likely because you just waited too long to eat. And you just make that adjustment. So if that was like, “Oh, that was a four-hour gap since I ate last, next time maybe I should switch that to three hours.”
And then, the other scenario is you eat your meal, and then you just take that moment and you check in and you see, “How am I feeling?” And if you’re craving something sweet or if you’re feeling a little bit more tired, those are again the very typical symptoms of your blood sugar’s running too high. And that’s often because you, either you ate too many carbs at that meal or just not enough protein or not enough healthy fat. And it’s just a matter of making these adjustments, as you go along. And that really when you eat, you should just feel satisfied. That’s really the goal and the aim is to just feel satisfied.
And oftentimes I find, too, Michael, that well, like you, I run a lot of blood work on patients because I want to know, “Okay, what are the symptoms telling me? But then, what are the blood markers telling me?” And oftentimes, patients, their blood sugar markers will be normal. Although, they’re still having these symptoms going on.
DrMR: And so in that case, you find it’s just better for someone to listen to these signs and adjust accordingly, rather than be steered by the blood work?
DrCD: Yeah, if the blood work is normal, then we want to still pay attention to what their body is telling us, and smooth out that blood sugar. And, of course, if the blood work is really bad, that’s even more of an impetus to the importance of smoothing out that blood sugar.
DrMR: Sure. Yeah, I totally agree. And there are some that have put forth more elaborate blood testing, looking at triglycerides and cholesterol and hemoglobin A1C and fasting insulin. And we look at all these things. But clinically, I find that it’s best just to get someone to do some reflection on their own to tune into these things. And sometimes I look at this really broadly. Even though, you can create exceptions to this rule, for sure. But there are two things that I’m concerned about. And that really is people not eating too low carb and people not eating too high carb.
And the too high-carb thing is not something I see very often because most of the people that come into my office have at least done some initial tinkering with their diet. And usually, the first thing that you do with tinkering with your diet is you pull out some of the sources of too much carbohydrate. So I don’t tend to see a lot of that. But certainly, that’s going to look like things like high blood sugar, high cholesterol, high insulin, people being overweight, people eating more of like a standard American-type diet.
The other end is what I tend to see more, which is people who may not be eating enough carbs because they’ve been low carb for a while. And it worked well for a while for them. But they may have been too low carb for too long. And they need a little bit of a bump upwards. And sometimes, these are people that have been under a lot of stress for a long period of time. And they just don’t have the ability to go into that pseudo-fasting state you get into when you’re really low carb and you need a little bit more carb in their diet.
So it’s, you can definitely poke holes in that. But those are just me trying to provide the listener with a couple of broad strokes to classify some of these things.
DrCD: Yeah. And if I can add one more thing to that?
DrMR: Yeah, sure. Please.
DrCD: Because you’re right, it is about just the individual patient trying to figure out what works best for them, instead of these generic diets out there. But the other thing is, I found a lot of times, patients will do better low carb through the day, but more carb with their dinner.
DrMR: Me, too. Yeah.
DrCD: Yeah, probably you already know this. But for the listeners out there that eating carbs helps to stimulate serotonin production in your body and your brain. And that oftentimes patients who are not sleeping well at night, if we just try and figure out the carb load for them for their dinner, sometimes they need a little bit more carb, sometimes they need a little bit less, that could be blood sugar related. But it could be the impact of serotonin, also.
DrMR: Mmmhmm, mmmhmm. Yeah, that’s typically what I do. And Robb Wolf and I compare notes on our own personal diets every once in a while. And I think Robb’s been pretty big into doing that. And there’s been books and such written about it. Sometimes it’s called carb back-loading or what have you. But yeah, it’s just eating lower carb during the day and then getting a little bit more carb at night. And I think that does work well for a lot of people.
Now, what about food allergies? That’s another thing that can—so the challenge here is that if you’re eating a food you’re allergic to, it can be hard to tell if the energy problem is because of your blood sugar or if it’s because of the food you’re allergic to. And I’ll just quickly share, I don’t have many food allergies. But one I definitely do have is nuts. And all I really get is fatigue. I get some skin reaction the next day. But it’s pretty mild.
And I determined this when I was in school, because in school, you have a very set schedule. And so things are very constant. So there’s not a lot of change in terms of your day to day. “You know, every day at this time, I have lunch after this class, before the next class, and what have you.”
And I was having an apple with a bunch of almond butter, as like my meal/snack, whatever. And I just tanked after that. And I tried the same thing the next week. And I tanked again. And after a few different times, I realized if I have too much nuts, my energy just tanks.
So I have an allergy that it doesn’t manifest as like an acute allergy, but it just definitely makes me feel a little bit tired, a little bit groggy. And there was no other reason for it. It wasn’t like I had a huge meal. And it wasn’t like I didn’t really eat anything at all. I didn’t have a very short night of sleep. There wasn’t a lot of stress. It’s just this, “Ugh, like why am I tired right now? Why am I feeling a little bit down and groggy? And that oftentimes can be one of the manifestations of a food allergy.
But let’s talk a little bit more about food allergies and how people can sort that piece out.
DrCD: So food reactions can be really tricky to figure out because there’s many different sources of food reaction. So there’s the true food allergy, which is an IgE response from an immunologic perspective. There is a food sensitivity, which is usually, either an IgA or an IgG response of the immune system. So that means those foods are triggering your immune system to activate.
And then, as you know, there are food intolerances also, so classic food intolerance being lactose intolerance. I think a lot of listeners can wrap their mind around that, that as we age, for a lot of people, they stop making certain enzymes. In the realm of lactose intolerance that would be we stop making the enzyme lactase to digest lactose.
And then, there’s also food reactions to that I think just depending on the state of health of the gut, too. So, for example, like histamine intolerance, if you’re eating foods high in histamine, but your body doesn’t metabolize histamine well, you’re going to have a reaction. Foods that are high in sulfur, constant reactions like, “There is…This really is difficult.” I can’t imagine for the average Joe out there who’s trying to figure out their food reactions on their own. And then, just for us doctors, too, there’s a lot of moving components to try and figure out food reactions.
Oh, so I was going to say there’s the case for doing blood testing to see if you can figure out an immune response to foods. And, of course, there’s a case also for doing like an elimination diet, where you’d eat a very clean diet for a period of time. And then, as you did, Michael, you just add foods back in. And you just see, “How do I respond to that food?” And you keep that in a journal to try and track to see if you can see any trends. But yeah, it can be really, really tricky.
DrMR: It can be. Yeah, because there’s multiple pieces to this. And that’s why I think it’s good for people to have a big picture guiding process to work through. This was probably one of the hardest chapters for me to write of the book because it’s trying to strike that balance between making sure we hit all the important aspects of diet, but not making it overwhelmingly meticulous. But there are a number of things, yes, that need to be addressed.
So for the listener, yeah, it’s hard. So you probably need either a coach, a doctor, or a good book that can walk you through some of these things. But they certainly can detract from your energy. So this is another thing to certainly keep in mind if your energy’s not where you’d like it to be, which is food allergies.
DrCD: Yeah, and again that food, too, is your—food can be your biggest medicine or your biggest poison. And it’s an important part is to figure out the food component, even though, it’s not the most fun. And it’s hard. And it takes time. But I think in the end, it can be one of the most rewarding when it comes to cause/benefit ratio for patients. It can be one of the most rewarding aspects of how to get them better if it’s their fatigue, if it’s their thyroid, if it’s their gut, if it’s their whatever.
DrMR: Absolutely. I couldn’t agree more that these pillars of blood sugar, food allergies, sleep, exercise, those are going to give you the best return on investment, clearly.
Now, there’s something else I wanted to transition us to, which is sometimes people have done all this stuff. And they’re still not seeing the response they’re looking for. And these are I think, Carri, are people that end their way up in our clinics, which are, “You know, I’ve done this diet, that diet. I’m sleeping enough. I’ve done all these other things. And I still don’t feel well.” So sometimes there’s something present that’s thwarting the ability of their body to respond to a healthy diet.
One of the more common ones that I see, of course, are different types of gut infections or gut imbalances. So I think everyone’s heard my thoughts on that. So why don’t you tell us a little bit about your experience with either gut infections or non-gut infections?
DrCD: Okay. Sure. Certainly. So, like you, I do see a lot of complicated cases that come in to my practice. And a lot of patients that come in, they are quite savvy. They’ve done research on the Internet. They’ve probably looked at your website. They’ve probably looked at my website. And they’ve really already implemented a lot of things. But they’re like, “Why, why am I not feeling better? I thought just cutting out gluten would, you know, save my life.”
Well, no, it’s not just one thing. Usually, it’s a lot of things going on. But if the patient has not had any formal gut testing done, that’s one thing that will come up on my differential diagnosis list. Even if they do not have any digestive symptoms, I’ll still put that on the list, and so asking the patient about if they’ve ever had a stool test done. So stool testing, more or less, gives us a picture of what’s going on in the large intestine, and if there’s any infections there like parasite, yeast overgrowth, bacterial overgrowth, or just a simple probiotic deficiency.
And then, there’s the SIBO testing, too, which I know, Michael, you’re quite adept at SIBO testing. And I know you’ve talked a lot about SIBO on your podcast. But a lot of people still don’t know what SIBO is. A lot of doctors out there still don’t know what SIBO is.
DrMR: Yeah, scary.
DrCD: And that anybody that has chronic fatigue should be screened for SIBO. And I believe they said that at the 2016 SIBO Symposium.
DrMR: Mmmhmm, I believe they did it also. I didn’t catch every piece of it. But I would not be surprised at all if that came up.
DrCD: Mmmhmm. And then, so we started—well, we’re working from the bottom up, so colon and then small intestine. And then, the other thing that I think about is just the stomach, the health of the stomach. Is the patient making adequate hydrochloric acid? Is there an underlying H. pylori infection in the stomach that might be creating a whole trickle-down effect or a domino effect downstream?
DrMR: Yep. So all things that are not incredibly hard to diagnose and not very hard to treat. But definitely, if you’ve gone through the other items, and you’re still not feeling well, that’s something else that’s a consideration.
And that’s actually a nice transition to the next point because problems in the gut can cause certain nutrient deficiencies. And those deficiencies can sometimes manifest as anemias. And just for people who might be new to this, anemia is—there’s generally two different types. There’s B vitamin anemia and iron anemia.
And put simply, they can affect the manufacturing of, or function of red blood cells in your body, which can, of course, cause fatigue for a variety of reasons, because red blood cells carry nutrients and oxygen around your body to all the tissues of your body. So if you don’t have adequate oxygen and nutrient transportation, then your cells are going to be hungry. And that can manifest, as you feeling tired and a litany of other things. But let’s talk a bit more about deficiencies and anemia, Carri.
DrCD: I think that’s great because—I’m glad you bring that point up because anemia, I would say for any listener out there, at the top of the list, of all of these things that we’re talking about today, if you have fatigue, for sure you have to be tested to see if you have anemia or not. Because if you do have anemia, and you’re trying all of these different things, you won’t get better until your anemia is found and treated. And so I’d say that the top two things would be looking to see if you have anemia. And that’s a simple blood test. And then looking to see if you have a thyroid problem, which is, again, simple blood testing.
And for now, so we’ll talk about anemia, that you’re right there is…Actually, there’s basically three types of anemia. There’s the iron deficiency anemia and there’s the B12 deficiency anemia. And then, the other one is just anemia because of inflammation. From a technical standpoint, that’s a normocytic, normochromic anemia. But what I find, Michael, is that when patients come in and they tell me that they have a history of anemia—and for our purposes here, we’ll just settle on iron deficiency—when I have patients that come in with a history of iron deficiency anemia, the next question I ask is, “Why? Why are you deficient in iron?”
And I find a lot of times, their doctors have never gone down that path of trying to figure out the why. They often just will say, “Well, you have iron deficiency anemia, take some iron, and your anemia will go away.” You know, “Like, it’s not that…” Well, it could be that simple. But that’s just a band aid really. The real question is, “Why do you have anemia in the first place?”
So I outline this in my book. So it could be—and this would apply also if it’s B12, but we’ll focus on iron. So one, the first question I’ll think about in my head—this is all the stuff that goes on in my head—is one, is this patient just not getting enough iron in their diet? Of course, that could cause anemia.
Two, is the patient getting enough iron, but it’s not getting absorbed. So that goes back to the, “Is there enough hydrochloric acid being generated in the stomach? Is there an H. pylori infection in the stomach? Or is there actually celiac disease or even silent celiac disease?” Because the reality is, iron deficiency, from a lab perspective, is usually the first sign of celiac disease.
So we have is there—are you not eating enough iron in your diet? It’s not getting absorbed. Is it getting used up really fast? Or is something stealing iron from you? And in that perspective, I think of infections like SIBO. Bacterial overgrowth, they’ll feast on your iron. Yeast infection parasites will feast on your iron.
And then, the fourth is are you bleeding from somewhere? And that could be a low-grade bleed that you would not see when you look in the toilet after you have a bowel movement. And oftentimes, with bleeding, too, we think about things like in our gastrointestinal tract or the digestive tract, is there a polyp that might be bleeding? Is there an ulcer that might be bleeding very low grade? And so those things can be ruled out with a fecal occult blood test, which is a very simple, simple test to do to see if there’s microscopic amounts of blood in the stool.
And then, the other big one that I think a lot of doctors just automatically focus on for female patients is, “Well, they must be just, like, having heavy periods. And that’s why.” But that’s not always the case either.
So first of, if you’re feeling fatigued, you should definitely be tested to see if you have an anemia. And if you do have an anemia, it’s a matter of then doing the investigation to find out why? Because the why is the most important thing.
DrMR: Yep, completely agreed. And as I think everyone can see from Carri’s description there, a lot of that comes back to the gut. And so this is why I think so many of us focus so much on the gut because it can be the cause of so many of these other things.
DrCD: Absolutely. Absolutely.
Thyroid and Brain-Based Fatigue
DrMR: So you also mentioned thyroid, Carri. So let’s talk a little bit more about thyroid. Of course, if someone has overt hypothyroidism, it’s very easy to find in the lab work. It’s fairly easy to treat with a prescription. There’s some nuance to the prescription. Someone may do well on a standard T4 supplement like levothyroxine or Synthroid. Someone may feel better when transitioning to a T4 or T3 combination like Armour or Nature-Throid. But there are also some people who actually feel worse on that. But those are a few thoughts to kick us off. But Carri, why don’t you tell us more about what you see and what you do with thyroid, as it pertains to fatigue, or just thyroid, in general.
DrCD: Oh, sure. So I know you’ve spoken and you’ve had guests on your show speak about the different—just trying to evaluate the thyroid. So there’s the TSH test, which is a very general screening test, but then also testing for free T3, free T4, reverse T3, and then the antibodies, too, TPO antibodies and thyroglobulin antibodies. Like, at a minimum, we want to see the whole picture. And that, as you know, they estimate that 90% of patients with hypothyroidism actually have Hashimoto’s as the real cause of their hypothyroidism, and that Hashimoto’s is your immune system is attacking your own thyroid and slowly destroying it.
But what a lot of patients don’t know and a lot of doctors also don’t know is that when patients have Hashimoto’s, the most commonly they have the TPO antibodies or the thyroid peroxidase antibodies, and those antibodies not only cause problems with your thyroid, but they also cause problems with your brain. And those antibodies cross react with certain tissues in the cerebellum part of the brain. And that whenever you have an immune response, and that immune response is going to attack the thyroid, it would also potentially attack those brain cells. And that can also be part of where people start feeling the fatigue.
The fatigue can be like metabolically mediated in the body. Or it can be a brain-based fatigue. Or it can actually be both going on. And so I think that this is one part of the puzzle that I don’t really hear people talking about is that when patients have Hashimoto’s that there often is a brain component going on. And that, up until recently, medicine, including functional medicine and naturopathic medicine, it’s been like from the neck down. And we’ve forgotten that there’s a whole brain involved also. So I think that’s something new and different that I could share with your listeners.
DrMR: So I’m curious. What would be some things people could do to help with the brain aspect of that? Are there some specific treatments or guidelines for addressing that?
DrCD: So why don’t we first talk about signs and symptoms?
DrCD: And so here is some of the common signs and symptoms for the listeners out there to think about, as a potential red flag that, “Oh, you might also have a brain component to your thyroid,” is that you’re having balance issues. Like your balance is getting slowly worse. Or if you have a history of car sickness or sea sickness, and that’s getting worse. Like, that’s very typical of cerebellum.
Nausea when looking at things in motion. Like, I’ll ask patients, “When was the last time you went to the movies? And how did you feel when you sat through the trailers, the movie trailers, especially those action movies? Were like things are moving across the screen super-fast? You got all these lights flashing.” And a lot of patients will be like, “Oh, I just closed my eyes. Or you know what? It makes me kind of nauseous. If I keep my eyes open, I know I’m going to get nauseous.” That’s very typical of the cerebellum.
And then, the other is if you’re becoming a “cheap drunk,” that if you just have one glass of alcohol, but it really hits you more than it used to, that can be signs that your cerebellum is slowly getting weaker and weaker. And then, from an examination standpoint—and this is something that your listeners could do right now if they’re in a safe space. You can’t do this when you’re driving your car.
But there’s a test called the Romberg’s Test. And this is a neurological test. You just stand with your feet together and your hands to your side and with your eyes open. And just see how well do you maintain your balance. And if you have a hard time with that, that can be a sign that there is probably something going on in your brain for sure. And then, stand with your feet together, hands at your side, but now, close your eyes and see how well do you maintain your balance because now that’s even more putting stress on your brain and cerebellum.
And then to even take that one step further is instead of having your feet side by side, you put them one in front of the other, as if you’re standing on a balance board, heel to toe, eyes open, but then close your eyes and see can you maintain your balance. And if you cannot maintain your balance, that, in particular, points towards weakness of the cerebellum. So those are some things that you could try at home to see, “Okay, do you have any problems there?
And then, when it comes to treatment, so depending on what’s causing—so again, it’s the why? Why is that happening? What’s going on? There’s many different factors that impact brain health. And some of them we’ve already spoken about, especially blood sugar, and then having proper thyroid hormone support.
And then, when it comes to treatment, from a neurological perspective, it could be just focusing and doing exercises that challenge your balance so that you get better at it. So I’ll have patients stand on a BOSU ball. Or I’ll ask them if they like doing yoga. I’ll say, “Just what are the yoga postures that are the hardest for you to do when it comes to your balance? Those are the ones that you should be really working on. Try them with your eyes open. Try them with your eyes closed.” And the more you work on them, the more that’ll create plasticity in the brain, which plasticity is, or neuroplasticity is, making new communications between nerve cells.
So that’s some of the information on the brain. There’s a lot we could talk about with that. But that just gives you some brush strokes.
DrMR: Okay. I certainly like the angle of getting exercise to help keep one’s brain healthy. Are there any novel treatments for the brain autoimmunity? And I ask this from an admittedly, certainly jaded perspective. And so if there’s different information, I’m certainly open to it. But I’ve seen some patients come in, in this feared state thinking that they have brain antibodies, as if that means there’s an incredibly different way that we would treat them outside of a normal Hashimoto’s patient, which would essentially be going through everything that we’ve just talked about, which would be healthy diet, regulate blood sugar, get some exercise, manage your stress, get adequate sleep, remove any gut infections, potentially try some anti-inflammatory compounds like selenium or CoQ10.
And that’s really the brunt of it. And unfortunately, some patients have come in really afraid that there was something else they had to do to protect their brain, as if they were going to die in like two years if they didn’t do anything. And my commentary back to them is, “We just continue to focus on the same core principles that we’re doing. And we’re going to mitigate your autoimmune risk by doing so.” But I’m wondering is there stuff out there that’s highly different than a typical Hashimoto’s treatment from an autoimmunity perspective that’s specific to the brain? And I don’t mean to maintain brain health like you just went through; those recommendations seem great. But is there anything different from an autoimmune perspective for the brain specifically?
DrCD: No, not really, it’s just a matter of, if the patient does have antibodies to different brain tissues, it still—when you boil it all down it still—there’s an autoimmune response going on. It’s just hitting different target tissues. It might be your thyroid. It might be your joints. It might be your gut. It might be your brain. But the basic autoimmune process is treated the same.
Just as you said, Michael, it’s going back to the basics—diet, looking at food reactions and pulling those from your diet, treating the leaky gut, looking for infections, getting rid of those. I think the only component, if there is neuro autoimmunity, is that, I think from a patient perspective, I think for a lot of people, they get much more serious about their diet and about treating their health, much more committed because that puts it at a whole different level. And that–
DrMR: Well, just to interject for one second to play a little bit of a devil’s advocate. First of all, thank you so much for saying that because I think that’s going to help a lot of people listening to this call rest a little easier knowing that there’s not this other esoteric treatment that they have to go through, and if they don’t, they’re risking their brain health.
But something else, I just want to chime in really quick—and I apologize for cutting you off—just to play the devil’s advocate here and provide the other side of this coin. And I don’t think either position is right or wrong. It’s just having multiple perspectives so people can make a decision that is most in alignment with their thoughts and beliefs.
There was recently a study published that showed that the risk of progressing to hypothyroid was exquisitely low if one’s TPO antibodies were under 500. And this is after a 12-year—I believe this is a 12-year follow up. And this correlates with something that I’ve said a number of times before, which I estimated that TPO antibodies anywhere between 100 to 300 appeared to be a clinical win.
And if people have them between 700 and 1,400, they seem to be at higher risk just because there were other negative symptoms, and they didn’t seem to be feeling well and what have you. And so it was nice to see this study reaffirm that the antibodies, as long as they’re lower, even though, they’re positive for the TPO antibodies, everyone, usually it’s about 30 or 35 over that level—if you’re above 30 or 35, you’re considered positive.
However, we’re starting to realize that there is some shades of gray to this, where if you’re under 500, your risk is very, very, very low. I mention that because, again trying to prevent people from thinking because a panel shows some autoimmunity doesn’t necessarily mean that you’re going to have a neurological condition. And that’s a potential. We don’t know this. I’m not saying what we found with the thyroid translates to the brain.
But I’d be inclined to think that it does. That it’s not an issue of having the antibodies necessarily on or off, but just making sure that you do a good job with your diet and lifestyle to keep those antibodies low. They may never go to normal, and from a thyroid perspective, we know that that’s actually okay, because the people that have them below 500, even though, they’re still positive, have a very good prognosis for their future.
So I just put that out there, anticipating and reflecting on some of the patients that have come in with some of these brain antibody panels. And they’re really, really scared. And I’m not sure if they need to be that scared. Yes, let’s definitely do a good job clinically. But let’s just not go to an overly fearful place. So sorry to cut you off, Carri, but I just wanted to throw that in there.
DrCD: Oh, I agree, we don’t want to be fearful with patients in that. There’s actually a lot of things that can be done. And patients should have a lot of hope. And it’s nothing that’s really different. As we said, it’s about getting back to those core principles of diet, lifestyle, eradicating infections. And then, if we’re talking about brain, adding in specific brain exercises. But yeah, it’s all very treatable. There’s no doomsday scenario.
DrMR: Okay. And I didn’t think you were going there. But I just know some people inadvertently, like that’s where they go when they hear about this. And I just, I’m a big advocate of not scaring people more than they need to be scared because I think we end up doing more harm than we do good for them.
DrCD: Oh, no, I agree.
DrMR: So now, that I’ve thoroughly cut you off with like a few minutes’ diatribe, do you remember where you were before I cut you off? And you want to pick up from there?
Exercise and Brain Health
DrCD: I think I was just talking about exercise. And that we just know, in general, that one of the best treatments for brain health, whether it’s just for preventative—just how do we maintain good brain health? How do we improve our brain health?—is just plain old exercise and to think about the more complex the exercise can be.
So some of the research that they’ve done recently for dementia patients is using tai chi as an exercise. And tai chi, just the fluidity of the movements, is very activating to the nervous system. And then having that focused attention and focused intention on your movements is very helpful and healing to the frontal lobe. So it could be something like that that’s very low impact on your joints.
And then, you could go to the other extreme of doing sports, like basketball, tennis, squash, volleyball. Something that’s very aerobic, but also requires a lot of different body movements. And stop and go, that’s also very good from a neurological standpoint. Really, really any exercise, just do any exercise.
DrMR: Mmmhmm, and I’m really glad you made that point just because it reminds me—and just to reiterate this for people—when you exercise, you release something, I believe it’s called brain-derived neurotrophic factor, which is like a repair factor for your brain.
So yes, you may have a little bit of autoimmunity going on. Let’s do our best with your diet and your lifestyle. And one of those big components is exercise. And you could almost think about it like the exercise is going to be stimulating this reparative compound that helps clean out inflammation and damage and repair and heal and rejuvenate your brain. So definitely, Carri, you make a great point with exercise. I think that the importance of that can’t be overstated.
DrCD: And you’re right, it is BDNF. And that’s what’s been proven to help create neuroplasticity or new connections within the brain.
DrMR: Awesome. Awesome. So is there anything else that you think’s really important to mention regarding fatigue? Or did we hit all the key aspects? I think we hit them all, hopefully.
DrCD: We hit a lot of them.
DrMR: Okay. Good.
DrCD: It’s a big subject. It’s a huge subject. And one that’s, well as you know, one that from the current medical model, the current medical model is failing fatigued patients in that oftentimes patients come in. And they have fatigue and they’re not getting any answers. And they know it’s not in their head. It’s not depression. They don’t need to be going on antidepressants. They just want answers that fatigue…There are a lot of different components to fatigue to think of from a clinical standpoint. And it’s not always easy to figure out these cases either. I should just rephrase that. It’s never easy.
Like, when patients come to see me, at this point, they’re very complex. It’s never easy to figure it out. It’s never just one thing like, “Oh, you just go on a gluten-free diet. And it’s going to be rainbows and glitter.” No, it’s not that easy. But at the same time, they have hope because it’s just a matter of time in figuring it out. It’s a puzzle that it will come together.
Episode Wrap Up
DrMR: Yeah, I think that’s very well said. And, Carri, tell people where they can track you down, website or book or read more from you, or connect with you.
DrCD: Okay. So I guess probably the best place to find me online would be at DrCarri.com. And that’s spelled DrCarri.com. And that’s my home base. And that’s where you can find my podcast, The Functional Medicine Radio Show—which, of course, Michael, you’ve been on a couple of times already—and my blog. And that’s where you can get a copy of my book. And it’s available on Amazon, too. And it’s called Reclaim Your Energy and Feel Normal Again! Fixing the Root Cause of Your Fatigue with Natural Treatments.
DrMR: Love it! Love it! Well, Carri, this was a great conversation, as I knew that it would be, and definitely keep me abreast of all the stuff that you’re working on. And thank you again for just taking the time to chat with us.
DrCD: Oh, absolutely, this has been a lot of fun. And I’ll say that to you, too, you keep me abreast of everything that you’re doing, too.
DrMR: My pleasure. Well, thank you again, Carri!
DrCD: You’re welcome!
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