Fatigue: A Medical Approach to Discovering the Cause

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One of the more common complaints that I hear from patients is the subjective feeling of being “fatigued” or “tired all the time”, often accompanied by the complaint – “I just don’t have much energy anymore”.  This is always a very difficult complaint to assess because there are so many potential causes and directions that can be taken when hunting for the underlying diagnosis.   It is also a condition that frustrates patients to no end (understandably), making them hunger for a quick solution.  Oftentimes the patient already has visited more than one physician looking for a cause, though often such symptoms are minimalized or never fully addressed.

Getting to the root cause of fatigue is a process, a process that begins by taking a good history and performing a thorough physical exam.  I will ask my patients several probing questions, some of which they may think irrelevant, but need to be answered anyway.  I do this in order to get a handle on what the patient might mean when they use that term, for, the concept and use of the term “fatigue” can be open to interpretation.  It is an inherently vague term, where any two people can define the idea entirely differently.

I always want to know when the fatigue began, was its appearance gradual or sudden, and is it more of a sleepy/tired type feeling or more of a lack of motivation or “want” to get up and do things.  Are there any feelings of depression/sadness or anxiety accompanying the fatigue?  I will also want to know if there is any shortness of breath with exertion, this then potentially making them less active and mimicking true fatigue.  If that be the case, then the core issue really isn’t the fatigue but rather the shortness of breath, which opens up an entirely different diagnostic avenue.  As answers are given I can then direct the questioning into a more specific and appropriate direction from there.

So then, you may be wondering, what ARE the most common causes of fatigue?

By far the most common cause of “fatigue” is going to be OBSTRUCTIVE SLEEP APNEA(OSA). I can say this with confidence because the prevalence of sleep apnea is so high in America (around 20% among men in the US, women a little bit less than that, though the elderly can be up closer to 50%)1, most cases of which are presently remaining undiagnosed and unaddressed.   This is of course directly related to the epidemic of obesity that we have going on in this country.   The main symptoms of OSA are daytime sleepiness, morning headaches, and the sense of never feeling rested/always feeling tired and sleepy.  I will often want a sleep study performed if these symptoms are present.  If OSA is proven by sleep study then a CPAP device (which delivers continuous, positive airway pressure keeping the airway open and oxygenated) MUST be worn at night while sleeping (as the patient tries to lose weight as well), for if the OSA is diagnosed but still not treated it will become the “elephant in the room” and the fatigue will persist no matter what else we try.  It must be treated, or the fatigue may never resolve.

A less common but often underdiagnosed cause of fatigue is NARCOLEPSY WITHOUT CATAPLEXY, which means that such patients can feel on the verge of going to sleep all the time and/or especially when just sitting at a desk without any external stimulation, though are still able to keep themselves awake with effort.  Not every narcoleptic patient will go to sleep without warning (cataplexy) – such examples are only the extreme and more memorable versions of this disorder.  A multiple sleep latency test helps get to the diagnosis, which measures how quickly the brain starts progressing into sleep rhythms in a quiet environment during the day.

Another common cause of fatigue is the one that many patients worry about and that I will certainly always check for in this setting – and that is HYPOTHYROIDISM.  This is also a very common condition that usually results from autoimmune antibodies attacking the thyroid tissue and causing it to produce less thyroid hormone, which can lead to feelings of fatigue, sadness, constipation, hair loss, leg swelling, etc.  Blood work will always be performed when working up fatigue, and this will be one of the conditions I am looking for.

Other causes of fatigue that can be picked up in the bloodwork (and will be part of a panel when searching for causes of fatigue) include ANEMIA (blood/iron loss being the most common cause – either via the GI tract or menstrual-related; also B12 anemias are prevalent), other AUTOIMMUNE DISEASES (like lupus, rheumatoid arthritis, mixed connective tissue disease, gluten allergy/enteropathy, Wegener’s granulomatosis and diseases like it where the anemia and systemic inflammation that they cause can be the primary cause of the fatigue, etc), and VITAMIN DEFICIENIES(including Vitamin D deficiency and B12 deficiency, where Vitamin D deficiency is very common in America and has been associated with chronic fatigue2).

Another important factor in chronic fatigue is of course – OVERSEDATION from POLYPHARMACY(too many medications).  This is a very common cause of fatigue, particularly when patients are having to take pain medication (like opiates and/or muscle relaxers) and/or sleeping medication (like benzodiazepines or other sedative/hypnotics like Ambien).  Of course, if more than one of these medications are taken together this can really increase the likelihood of fatigue (and other consequences, including death!).  Because of this I am always trying to encourage patients to back off the dose/quantity of any opiate or sedative/hypnotic medication that they may be taking (the ultimate goal being to discontinue them altogether).  Overuse of alcohol would fit into this category as well, another sedative agent.

A potential cause of fatigue that patients often worry about (because they may have heard about it from a friend or read about it on the internet) but that is very rare and unlikely to be the case – is LYME DISEASE (a tick-born spirochete infectious disease).  I bring it up here only to discourage patients from worrying about this one, namely because of its rarity.  Other general symptoms can be associated with the fatigue (including headaches, arthritis, muscle pain and rashes) and when a patient has more than one of these occurring in tandem they can often jump to the conclusion that they have Lyme Disease.  The work-up for it can be misleading because the antibodies (when checked) can return positive but yet still represent a false positive (there is a high false positive rate using Lyme antibodies), further confusing the picture.  There must be a very specific history with a very specific rash to diagnose Lyme Disease accurately, and without everything in place it is folly to pursue this diagnosis too aggressively.  The rarity of this disease (especially in Texas) makes it an avenue to go down only in the most specific of circumstances.

Certainly, other INFECTIOUS DISEASEScan be considered, although a good/thorough history and exam taken from and performed on the patient will help determine whether this path of diagnosis needs to be pursued and, if so, in which direction.   This would apply to work-ups for potential MALIGNANCY (CANCER)as well, which certainly can cause fatigue.  There will be signs in the bloodwork (including anemia) that might indicate the need to go down this path as well.

So, in the end, in order to do a really good job of getting to the root cause of fatigue (where of course correcting that root cause is the only way to resolve the fatigue), the physician must spend enough time with the patient to take a thorough history and perform a complete exam, so that any testing he does can be focused in on what matters.  The problem is that many primary care doctors live in a rushed, fast-paced world, where taking the time that is really needed to get to the bottom of any problem in an efficient and cost-effective process is virtually impossible.  As such, often a shotgun approach is taken where several things are checked for at once but without any individualized reasoning or intentionality; and/or the patient’s fatigue is marginalized and the physician thinks to himself “I’ll deal with that next time because this time I need to focus on the more important issues at hand”.

Fortunately, the concierge setting in which I operate allows for ample time to take a thorough history and formulate a plan that takes into account everything going on with that specific patient so that an individualized diagnostic approach can be taken.  This helps arrive at the diagnosis in a more effective and efficient manner, so that a solution can be rendered more quickly (where many times the solution takes some time to be implemented and render full effect, meaning that getting the problem diagnosed quickly is paramount).  Also, in the end, less money is spent on diagnostics when a very specific and intentional course of action is taken that is fully based upon an accurate and thorough medical history and exam, tailored to a specific patient’s very specific problem(s).

As such, if you are ever facing a symptom or symptoms that leave you perplexed and/or that no one has yet to be able to ascertain the cause of, I would encourage you to give me a call (972-993-5003).  I can devote as much time as is needed to assess your symptoms, take a thorough history, perform a comprehensive exam, and formulate an intentional diagnostic and eventual therapeutic plan.   When it comes to a complaint of “fatigue” such an approach MUST be taken for, because so many things can cause it (both benign and easy to fix as well as insidious and ultimately deadly), the symptom must be taken seriously and dealt with immediately, in a very thorough and well-thought-out manner.

 

 

References

  1. https://www.ncbi.nlm.nih.gov/pubmed/27568340
  2. https://bmjopen.bmj.com/content/7/11/e015296

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Inflammation and Weight Gain

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Over the years several studies have shown a link between an inflammatory marker called C-reactive protein (CRP) and weight gain1.  CRP is made by the liver and increases any time your body is trying to fight against something (be it bacteria, virus, autoimmune disease, and even cancer), clinically used now as a general marker for inflammation.  The CRP molecule itself really isn’t the issue, but rather the entire inflammatory process that is associated with it, the CRP simply serving as a scientific and clinical marker of inflammation, in general. 

Any number of inflammatory processes can cause the liver to produce it but, if the CRP is checked and is high in an otherwise healthy individual who is not carrying any kind of known diagnosis nor having any overt symptoms of inflammation, the underlying issue is probably very subtle but still insidiously dangerous.  In such a person a hidden cancer could be to blame, though this is still going to be unlikely.  The most likely causes in such an asymptomatic individual will be either actively forming plaque in the walls of arteries that can eventually lead to things like heart disease and stroke (for, the formation of plaque is a highly inflammatory process as the immune system is trying to unsuccessfully clean out the plaque – see my previous blog from June 12th, 2018), or poor dietary and lifestyle choices (including lack of sleep, increased stress) that promote ongoing subtle yet prolonged inflammatory processes in the body. Given our generally horrible American diets (chock-full of processed and fast foods, high in saturated and trans-fats) and high-stress lifestyles, a combination of plaque formation and poor lifestyle choices are going to be the most likely causes of this inflammation/elevated CRP.

The Cleveland Clinic has defined risk groups for heart disease, with respect to CRP level, as follows:

Low risk: less than 1.0 mg/L

Average risk: 1.0 to 3.0 mg/L

High risk: above 3.0mg/L

Given the fact that elevated CRP is associated with these poor lifestyle choices and heart disease, it isn’t surprising that studies have also shown an association between elevated CRP levels and obesity.

It also isn’t surprising that weight loss has been shown to lower the CRP levels2.  With weight gain comes more and more inflammation – for, people become more sedentary when obese, begin to develop heart disease and plaque (highly inflammatory processes), begin to develop metabolic syndrome (elevated blood sugar with elevated triglycerides) which can ultimately lead to diabetes, begin to develop sleep apnea, all of this which then promotes more weight gain and more inflammation, and thus the CRP level continues to rise – a vicious cycle.

These factors are all inter-related and all feed off each other.  It isn’t that the CRP elevation is the causative agent of all this, rather, the elevation in the CRP is the result of it all and is therefore a very good marker for the ongoing risk of developing end-organ disease (example: heart disease) because of it all.  Unfortunately, there isn’t going to be a “medicine” that can get this inflammation down and therefore cause weight loss.  Rather, it is the other way around.  Weight loss and more healthy lifestyle choices will then reduce the inflammation and drop the CRP, which then begins to reverse this vicious cycle.

There are dietary choices that are less inflammatory (and therefore healthier, inherently promoting weight loss), which include cutting way back on sugar and refined carbohydrates and increasing the intake of fruits, vegetables, lean meats and nuts. A Mediterranean-style diet conforms nicely to these parameters and is promoted by the American Heart Association for that reason.  Other anti-inflammatory foods include olive oil (the enemy of which is vegetable oil, i.e., avoid vegetable oil), avocados, garlic and onions.  Garlic and onions, in particular, have been widely recognized as being very favorable toward heart health (probably by helping to reduce plaque inflammation).  Fatty fish (omega-3 fats), berries, red wine and even dark chocolate are also all anti-inflammatory in nature.  Diets high in fiber have also been shown to be associated with lower CRP levels, proving the anti-inflammatory effect of fiber4.

Curcumin (an extract of turmeric) has been shown to have potent anti-inflammatory effects, thereby potentially favorably affecting the outcomes of a wide variety of diseases5.  Taking this as a supplement is probably a very good idea.

De-stressing and sleeping better have also been shown to link with each other and thereby help reduce the pro-inflammatory effects of cardiovascular disease6.

Vitamin D7, Magnesium8, Vitamin C9and fish oil supplementation10have also been shown to have anti-inflammatory effects.  For specifics regarding the best dosing of those for your specific situation is best discussed with your primary care physician. Of course, I would be happy to assume that role for you if you would like (call 972-993-5003 to schedule a meet-greet appointment).

Of course, it should go without saying (though still needs to be said) that exercise certainly promotes the reduction of inflammation while smoking does quite the opposite by promoting plaque formation (and therefore arterial inflammation), COPD lung disease (promoting pulmonary inflammation), disk disease of the spine (promoting arthritic inflammation), etc.

So, if longevity is your goal, making some of these changes for the long haul is highly recommended. There are certainly many specifics here that should be discussed with your personal physician, though asking for a CRP level check if that has not been performed would certainly be a good idea, for it serves as a marker for such inflammation and a strong motivator for lifestyle modification if found to be elevated.

If you do not have a personal physician, feel free to call my office (972-993-5003) and set up a visit to meet me so we can begin discussing all of this and check some basic labwork, which should certainly include a C-reactive protein level.  We even have a complimentary dietician in the office (we do not bill for her services) who can provide specific details regarding the anti-inflammatory Mediterranean Diet that anyone with an elevated CRP should initiate.

Author:  Christopher Hughes MD

North Texas Preferred Health Partners

3417 Gaston Ave, Suite 700

Dallas, TX 75246

972-993-5003

  1. https://www.ncbi.nlm.nih.gov/pubmed/14993913
  2. http://circ.ahajournals.org/content/105/5/564
  3. https://www.ncbi.nlm.nih.gov/pubmed/15234425
  4. https://www.ncbi.nlm.nih.gov/pubmed/15113967
  5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2637808/
  6. https://www.ncbi.nlm.nih.gov/pubmed/21682656
  7. https://www.ncbi.nlm.nih.gov/pubmed/22677566
  8. https://www.nature.com/articles/ejcn20147
  9. https://www.ncbi.nlm.nih.gov/pubmed/18952164
  10. https://www.ncbi.nlm.nih.gov/pubmed/19461006

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Why “Concierge Medicine” Should Replace the Annual/Executive Physical Exam

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For decades physicians have been recommending that all patients see their doctor at least once a year for their annual physical exam.   But, now with the help of evidence-based medicine, the data is very clear that this practice does not change patient outcomes.  This means that there is no scientific evidence to suggest that undergoing a yearly physical exam will cause patients to ultimately feel better or live longer1.  In fact, the problems that patients worry the most about – heart attacks, strokes and cancer – were not affected one way or the other by a yearly physical exam. Asymptomatic patients who undergo yearly physical exams were as likely to have a heart attack or die from cancer as asymptomatic patients that did not undergo a yearly physical exam.

 

Why is this?

 

Let’s look at what actually kills people in America.  The top 3 killers of Americans are2:

 

  • Heart Disease (Heart attacks, heart failure)
  • Cancer (Lung Cancer, Breast Cancer, Prostate Cancer, Colon Cancer, etc)
  • Chronic lower respiratory diseases (COPD from smoking, Asthma)

 

Let’s focus on the number one killer – Heart Disease.

 

Heart disease develops silently by causing plaque build-up in the arteries that supply the heart muscle with blood.  Plaque begins with cholesterol deposition in the walls of the arteries, the leading cause of this phenomenon being the over-consumption of saturated fats (found in red meat, dairy products, etc) in our diet.  Once the cholesterol begins to build up in the arterial wall, the inside lining of the artery tries to wall it off by thickening and growing up around it. Immune cells also come in and try to eat up the cholesterol (though are unable to effectively to do so), causing inflammation in the wall of the artery.  This then causes platelets to form a clot around all of this, leading to a growing mass of cholesterol, arterial wall thickening, inflammation and clot called an “atherosclerotic plaque”.

 

As this plaque grows it can become unstable once it reaches a point where it is blocking up 30-40% of the arterial lumen.  At this point a patient will not be symptomatic (i.e., no chest pain) because enough blood is still getting around the plaque to perfuse the heart muscle and not cause any damage.  And, even if such a patient were to undergo a stress test, the stress test would not pick up this blockage because, again, enough blood will be getting around the plaque to keep the heart muscle perfused and happy.  Thus, the EKG even under stress (running on a treadmill) will appear normal.  Even the echocardiogram pictures of the heart (stress echo) and nuclear imaging of the heart (nuclear thallium stress testing) will appear normal.

 

But, unfortunately, it is at this 30-40% blockage stage that a plaque can suddenly rupture (especially in smokers and diabetics).  The break in the plaque left by the rupture will quickly clot over (called a “thrombus”), causing 100% blockage of the arterial lumen very quickly.  Blood will not be able to get to the heart muscle downstream from the blockage and the downstream heart muscle will therefore begin to die from oxygen deprivation.  This is what is colloquially called a “heart attack”.

 

Such 100% blockage can be fixed with a stent, placed by a cardiologist on an emergency basis.  But, at 30-40% blockage before anything has happened yet, stents do not help – i.e., there is nothing procedurally that can be done. So, even if we knew about the presence of such a plaque, no procedural intervention would be beneficial.  Rather, this is when a patient really needs to start a statin drug (like Lipitor or Crestor), which have been shown to stabilize (thereby reducing the likelihood of rupture) and shrink the size of plaque, greatly reducing the chance of ever progressing to a heart attack.

 

Now, take the asymptomatic patient who walks into his doctor’s office for an executive physical with plaque blocking up 30-40% of a coronary artery.  He is walking in with the number one killer of Americans hiding deep inside, waiting to strike.  He doesn’t know this plaque exists, nor does his doctor.  The physical exam will not reveal its presence.  An EKG will not reveal its presence either, and it is for this reason that routine EKGs are NOT recommended for asymptomatic patients.3  If this patient was then subjected to an exercise treadmill stress test, it is unlikely that the presence of this lesion would be picked up either.4

 

Thus, in the case of screening for the #1 killer of Americans – a physical exam, EKG and routine stress testing of the asymptomatic patient will not pick up the presence of relatively advanced disease that is waiting to strike and cause a heart attack. Unfortunately, this means that much of what happens in an “executive” or even routine yearly physical exam for an asymptomatic patient doesn’t accomplish anything of actual value for the patient.  Most of what goes on in that setting has no evidence-based scientific data to support it and, in fact, the scientific data generally contradicts these practices.

 

So, what is the alternative?

 

Clearly, we need to get away from the idea that one exam, once a year for the asymptomatic patient is sufficient for the detection of disease and, in particular, risk for deadly disease.  I have utilized heart disease as the primary example today, but, most illnesses that people fear and think that a yearly physical will detect if present fall into the same category as heart disease.  The disease can be hiding and yet still remain undetected.

 

Rather, the asymptomatic patient needs – first and foremost – to have an established relationship with a primary care physician that he trusts and that he consults with on a regular basis.  Whether the symptoms are sudden or subtle, any appearance of symptoms needs to be addressed as early as possible with a primary care physician, before they progress to the point that an ER visit is required.  This then allows for a regular and routine review of symptoms and risk factors (which can change over time), with quick and easy access to the physician in the event that any concerning symptoms appear.  The key is early detection at the first sign of symptoms, for, the presence of symptoms then narrows the testing and isolates the problem much easier, avoiding extra and expensive testing that is ultimately of no value.  This is especially true of ER visits, where the main job of the ER is to get the patient out of the ER – either via admission to the hospital or, referral back to the primary care physician to ultimately figure out what is going on.

 

Thus, ERs are generally to be avoided in favor of a rapid-responding primary care provider.

 

The problem this creates is that rapid primary care responses are hard to come by nowadays when primary care doctors are often inundated with 20-30 patients a day and are unable to respond to individual patient needs as quickly as they would like.  It can often take 2-3 days for a patient to hear back from their physician after placing a call with the office, where getting in to be seen can sometimes then take a day or two more.  By that time patients have often visited an ER or urgent care clinic to have their issue addressed, though usually in a suboptimal and less satisfying manner.

 

A “concierge” type practice is an alternative way to meet these patient needs, where access to a physician is much more rapid given that such physicians allow patients to access them via cell and email and only see 6-8 patients a day on average, rather than 20-30 patients a day in a traditional practice.  In a perfect world, this style of practice would eventually replace the yearly physical, and patient outcomes would be greatly improved. There are already studies beginning to demonstrate this, where patients that are part of more personalized practices like this have far fewer ER visits and far fewer hospitalizations.5   Diabetic patients were shown to have better blood pressure control, better cholesterol control (i.e., improved risk factor modification for heart disease) and better eye exam compliance rates, when compared to national health plan rates.6

 

In conclusion, both patients and businesses should strongly consider changing their thinking on this, moving away from the yearly executive physical which has been proven to be essentially useless, and moving toward something like “concierge” or personalized medicine which can put the patient in contact with his/her physician 24/7 so that ER visits and further complications can be avoided and disease can be caught early and managed in a more effective manner before the patient experiences serious consequences. Furthermore, executive physicals can often cost between $3000-$5000 dollars for one day of testing, while most personalized medicine plans that offer 24/7 physician access year-round will cost around $2000 annually.

 

There is a better way to do things and personalized patient care for an affordable fee is proving to become the preferred way to do it.

 

 

 

Author:  Christopher Hughes MD

 

North Texas Preferred Health Partners

 

3417 Gaston Ave, Dallas TX, 75256

 

972-993-5003

 

 

 

Ref

 

  1. BMJ2012;345:e7191 (Conclusion:  General health checks did not reduce morbidity or mortality, neither overall nor for cardiovascular or cancer causes)
  2. https://www.medicalnewstoday.com/articles/282929.php
  3. https://www.aafp.org/patient-care/clinical-recommendations/all/cw-ekg.html
  4. https://www.mdedge.com/ccjm/article/96089/cardiology/cardiac-stress-testing-appropriate-asymptomatic-adults-low-risk
  5. http://www.ajmc.com/journals/issue/2012/2012-12-vol18-n12/personalized-preventive-care-leads-to-significant-reductions-in-hospital-utilization
  6. http://www.ijpcm.org/index.php/IJPCM/article/view/305

 

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