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Chronic fatigue: the link with your gut

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Chronic fatigue, or feeling tired all the time, is evidence that the ‘powerhouses’ of your cells aren’t supplying you with enough energy, says Dr Sarah Myhill. But the problem’s not all in your head, or even your thyroid – it’s usually in your gut

Chronic fatigue syndrome (CFS) is not a diagnosis; it’s a clinical picture of symptoms that may have many causes. Fatigue, in fact, is a protective symptom. It prevents you from damaging your body by doing too much. Since 1982, I estimate that I’ve treated more than 5,000 patients with CFS. I now know there’s only one way to get well, and it entails a package of treatment. That package has to be implemented in the right order, rather like building a house-there’s no point putting in the upstairs windows until the foundations and walls are in place.

Many patients come to me having tried things like thyroxine or B12 injections, but unless the appropriate diet, micronutrients, rest and activity pacing are in place, they may not see any benefit. The treatment I recommend requires a complete change in lifestyle and usually starts with the state of your gut. Patients have to become their own doctors, detectives and psychotherapists to work out their best strategies for recovery.

The cell’s powerhouse

We are made up of lots of different types of cells-including heart, blood, muscle and nerve cells. All these cells are different because they have different jobs of work to do, which require energy.

While every cell type is specialized, the way energy is supplied is the same: by mitochondria. I think of these organelles as little engines that power every cell in the body.

The job of mitochondria is to supply energy in the form of the chemical compound adenosine triphosphate (ATP). This is the universal currency of energy. It can be used for all sorts of biochemical jobs-from muscle contraction to hormone production. When mitochondria fail, the result is a poor supply of ATP; cells then go slow because they lack the energy to function at normal speed. When cells go slow, all bodily functions slow down.

CFS could be a sign of mitochondrial failure affecting every cell in the body.

We all have a pot of energy available to spend over the day. What prevents us from spending too much is feeling fatigue, a symptom that arises when energy demand exceeds energy delivery. That pot of energy must be spent just to stay alive on jobs like maintaining heart, gut, brain, kidney and liver functions.

These ‘housekeeping’ duties consume two-thirds of our energy, leaving one-third to be spent on extracurricular activities like physical actions and higher mental functioning. With CFS, either that pot of energy is small or too much energy is being spent on physical and mental activity.

Do you have CFS?

Check out the list below to see if you’ve got symptoms that signal CFS, then turn the page to find out how to treat it

Symptoms of CFS

Two key symptoms (mental and physical) in CFS patients which I believe reflect mitochondrial dysfunction are:

o very poor stamina-you can do things, but only for a few seconds before tiring
o delayed fatigue-symptoms persist for 24 hours when you overdo things.

Mental fatigue manifests as poor short-term memory, inability to follow a line of argument, difficulty reading or watching TV, poor problem-solving ability and difficulty dealing with more than one thing at a time (so-called ‘foggy brain’). As one patient put it, “Nothing right in my left brain, nothing left in my right brain!”

In addition, other common symptoms include:

o malaise (feeling ill)
o muscle pain, caused by poor antioxidant status, early switch into anaerobic metabolism or magnesium deficiency
o muscle weakness (including eye muscles, causing episodic, variable or blurred vision)
o sleep disturbance (the ‘biological clock’ moves on one to six hours, so CFS sufferers drop off to sleep late and wake up late), making them natural ‘owls’
o tendency to get recurrent infections
o general hypersensitivity to, for example, noise, light, touch, pain, smells
o drug/alcohol intolerance, especially to antidepressants, beta-blockers, statins and blood-pressure medications, reflecting poor detoxification pathways, cytochrome p450 enzyme (needed for drug metabolism) stress and an outpouring of free radicals
o feeling ‘not with it’
o poor temperature control
o gut symptoms
o headache
o mood swings
o joint pain

There may be tender trigger points in muscles and tendons, signs of inflammation like tender, swollen lymph nodes in the neck and/or low-grade fever. Depression may also arise because energy-giving ATP is needed for neurotransmitters like serotonin and acetylcholine to work.

How to treat deep fatigue

Understanding the process of cell respiration and what’s going wrong in CFS sufferers provides the biological basis of treatment. In many, if not most, instances it has to do your diet and the state of your gut, which explains why the following are must-dos that make a positive difference:

o Follow a ‘Stone Age’ or low-glycaemic index (GI) diet, which avoids major allergens and includes probiotics
o Correct mitochondrial function with D-ribose, magnesium injections, NAD 500 mg, acetyl-L-carnitine and coenzyme Q10
o Address poor antioxidant status with B12, coenzyme Q10, SOD (superoxide dismutase) and glutathione peroxidase
o Get plenty of sleep so mitochondria can be repaired. Aim for nine hours between 9.30 pm and 6.30 am
o Try detox regimes, if appropriate, such as far-infrared saunas and chelation therapy (see WDDTY September 2014), to unload heavy metals, pesticides, social poisons (alcohol, tobacco, recreational drugs), volatile organic compounds and prescription drugs
o Optimalize gut function, including having sufficient stomach acid, pancreatic function and fermentation in the large bowel
o Pace your activities to avoid undue mitochondrial stress
o Address secondary damage partly caused by mitochondrial failure, such as immune disturbances, hormone gland (like the thyroid) failure and slow liver detoxification
o Correct secondary hypothyroidism, secondary hypoadrenalism and poor melatonin levels
o Identify chronic allergies/infections, which can arise from fermentation in the gut caused by microbes to which the immune system is reacting inappropriately.

How your body gets energy

Energy in the body is supplied by mitochondria, which first produce NAD (nicotinamide adenosine diphosphate), which is then used to power oxidative phosphorylation to generate ATP (adenosine triphosphate). ATP is the ‘currency’ of energy in the body.

Almost all energy-requiring bodily processes have to be ‘paid for’ by NAD and ATP, but mostly ATP-and reserves of ATP in cells are tiny. At any given moment in heart muscle cells, there’s only enough ATP for around 10 contractions. So mitochondria have to be very good at recycling ATP to keep cells constantly supplied with energy.

If cells are not efficient at recycling ATP, they will run out of energy very quickly, causing physical weakness and poor stamina. The cells have to shut down and wait while more ATP is manufactured.

In producing energy, ATP (three, or ‘tri’, phosphate) is converted into ADP (two, or ‘di’, phosphate), which is recycled back through mitochondria to produce ATP.

But if cells are stressed and no ATP is available, they will use ADP instead, converting it to AMP (one, or ‘mono’, phosphate). The trouble is, AMP cannot be recycled-or only so slowly that it’s of no significant use.

The only way ADP can be regenerated is by the body making brand-new ATP from the sugar ‘D-ribose’, but this sugar is itself only slowly made from glucose, taking anything from one to four days. This delay is one possible biological explanation for the delayed fatigue see
n in CFS.

Natural Ways to fight fatigue

Although some of the following recommendations (particularly those regarding the amount of rest) largely apply to those with extreme fatigue (i.e., CFS), anyone who feels tired all of the time can benefit by adopting many of these suggestions.

Adopt a ‘Stone Age’ diet

Carbohydrates tend to cause fatigue even in ‘normal’ people. The modern tendency is to use carbs as a fuel source when we should be using fat. Long-chain fats from vegetables, nuts, seeds and fish are excellent building blocks for making new cell membranes. (If we laid all the body’s cell membranes flat, they would cover 10 km2!)

However, these long-chain fats don’t make good fuel. The body prefers medium-chain fats from meat, lard, butter (assuming no allergies), coconut oil and chocolate (dark, at least 70 per cent cocoa solids). The normally functioning lower gut ferments vegetable fibre into short-chain fatty acids, another glorious fatty fuel.

Food allergy is a common cause of many symptoms, such as irritable bowel, asthma, mood swings, headache, arthritis, ‘allergic muscles’ (sensitization caused by mechanical muscle damage like tears and bruising) and, of course, fatigue. The most common offenders are grains, dairy, yeast and toxins.

Chemicals in the diet inhibit enzyme systems and slow metabolism down. This applies to drugs as well as food additives, and pesticide, hormone and antibiotic residues. Seafish caught inshore can carry a mercury load.

Avoid food with additives, colourings, flavourings and plastic wrappings (especially if heated), and switch to organic wherever possible.

The Stone Age diet:

o includes low-GI foods (they don’t raise blood sugar levels quickly)
o avoids common food allergens
o avoids mouldy foods and highly fermentable foods
o is as chemical-free as possible.

Foods allowed in the Stone Age diet

The following are allowed both during the day and in the evening.
o All meats: chicken, beef, lamb, pork, turkey, duck, goose and any ‘game’ meats such as venison, pheasant and grouse. Organ meats like liver, kidney and offal are fine too.
o Eggs: an excellent source of lecithin, an essential fat that cells need, particularly those required for neural transmissions.
o All fish: this includes salmon, mackerel, cod, haddock (but take care with smoked fish, as they often contain dyes). Tinned fish in brine or olive oil is fine, as are also tinned shrimps, prawns, mussels and cockles, provided there are no additives.
o All green vegetables.
o Root vegetables (but in moderation as they also contain carbohydrates): carrots, parsnips, turnips, swedes, celeriac.
o All salad ingredients, such as avocado, lettuce, tomato, cucumber, celery, peppers, onion, cress, bamboo shoots.
o French dressing: best to make your own from olive oil, lemon juice, garlic and mustard.
o Low-carbohydrate fruit: berries are excellent examples.
o Seeds: sunflower, poppy, sesame.
o Nuts: peanuts, Brazil nuts, hazelnuts, cashews, pistachios, walnuts; also nut butter spreads like tahini (sesame seed butter).
o Coconut oil: it’s delicious and a great source of medium-chain energy-giving fats.
o Cold-pressed nut and seed oils: use sunflower, olive, sesame, grapeseed, hemp, linseed oils liberally-but never for cooking, as heat damages their beneficial health-giving qualities.
o Fermented soya: I advocate growing the probiotic drink kefir in soy milk (instead of the usual cow’s milk) because the carbohydrate in soya is fermented out. Kefir also teems with friendly microbes to help repair
the gut
o Spices: chilli, cumin, ginger, coriander, pepper, cloves.
o All herbs.
o Salt (ideally SOLO, an all-natural sodium-reduced
sea salt).

Drinks allowed during the day

o Bottled or filtered water
o Herbal teas.

Foods allowed with caution (low potential for allergy, but can be fermented)

o Rice and potatoes: brown rice cakes or puffed rice from healthfood shops
o Specific grains: millet, buckwheat, sago, quinoa
o High-carbohydrate fruit: bananas, grapes, melons
o Dried fruits: sultanas, apricots, prunes, raisins, figs, dates
o Pulses: lentils, butter beans, chickpeas, flageolets
o Mixtures of nuts, seeds, dried fruits
o Arrowroot flour: as a thickener for gravy.

Fix your gut

Gut dysbiosis and poor digestion (where foods are fermented instead of digested) can also cause problems. First, fermentation produces wind and gas with bloating, belching and borborygmi (rumbling noises); second, it produces toxic byproducts like alcohol, D-lactate and hydrogen sulphide, which inhibit mitochondrial function; and third, it allows an overgrowth of microbes in the upper gut that can trigger allergy. Indeed, many cases of arthritis are due to this.

In addition to eating low fermentable foods:

o take hydrochloric acid with pepsin (two capsules with your first bite of food at every meal)
o eat fermented foods like sauer-kraut and kefir.

Take supplements

Once again, this supplement programme is for those with chronic fatigue syndrome, but anyone suffering from fatigue can modify it (i.e., take B12 and magnesium by mouth and not injection) according to needs.


o One multivitamin/mineral capsule daily (be aware this contains B vitamins, which can cause insomnia, so don’t take it in the evening)
o One omega-3 supplement that is particularly high in EPA (eicosapentaenoic acid); I recommend VegEPA (available online). Suggested dosage: 4 capsules/day for 1 month, then a maintenance dose of 2-4 capsules/day. For vegetarians, 1 capsule/day of BioCare MicroCell Essential Fatty Acids (online at Alternatively, 1 dsp (dessertspoon) hemp oil.
o Multimineral supplement (2 tablets, depending on manufacturer)
o Acetyl-L-carnitine, 1 g
o D-Ribose, 2.5 g
o Copper, 1 mg
o L-Glutathione, 250 mg
o VegEPA, 4 capsules
o 1 dsp hemp oil
o Coenzyme Q10, 200-300 mg
o Niacinamide, 500-1,500 mg
o Magnesium, up to 800 mg a day or for severe fatigue, magnesium sulphate, 0.5 mL (cc) by injection
o Vitamin B12 one tablet, or for extreme fatigue, 0.5 mL (cc)
by injection


o D-Ribose, 1/2 tsp in tea or coffee

Midday or lunchtime

Dissolve in 1/2 pint of water:

o D-Ribose, 1/2 tsp
o Multimineral supplement (one tablet, or depending on manufacturer’s instruction)
o Manganese, 5 mg


o D-Ribise, 1/2 tsp in tea or coffee


Dissolve in 1/2 to 1 pint of water:

o Acetyl-L-carnitine, 1 g
o Zinc, 30 mg
o Multimineral supplement (1 tablet, or depending on manufacturer’s instruction)
o D-Ribose, 1/2 tsp (or adjust to complete the daily dose)
o Vitamin C, at least 2 g (depending on gut tolerance) ascorbic acid or 1,000 mg magnesium ascorbate if ascorbic acid causes gut irritation. Take up to 10 g ascorbic acid (5 g magnesium ascorbate). Because a fermenting gut is so common, I suggest taking a single large dose at night. Most vitamin C is not absorbed, but sits in the gut overnight and helps to reduce microbial numbers in the upper gut when the gut is empty.


Here’s how to make the most of your rest periods

Those who suffer from extreme fatigue require complete rest from exercise, visitors, telephone calls, reading, computers, talking, child-minding, noise and TV-all activities that have to be carefully rationed throughout the day.

When resting, lie horizontal to reduce the work of the heart (it’s much harder to push blood around an upright body than one where everything is on the flat).

Take a proper rest, perhaps when you go to bed, regularly during the day, even on days when you feel well. The fatigue in CFS is delayed, so if you push yourself one day, expect to ‘pay’ for it 12-36 hours later. If you do feel well one day, don’t overdo things or
you’ll be worse off the next.

Do things in short bursts. You’ll be more efficient doing things for 10-40 minutes (whatever your window of time is), then resting for the same length of time. I had one patient who could only walk 30 metres, but by walking 15 metres and resting, then going on again, she got up to walking a mile a day.

Vary your activity. This applies to the brain as well as the body. Listening to the radio or music uses a different part of the brain from watching TV, and doing the dishes (ideally, while sitting on a high stool) uses different muscles from walking.


Saunas are a great way to detox

When your cells have problems shunting ATP and ADP to and fro, it suggests blockage by some sort of toxin, either those produced within the body, such as free radicals) or exogenous (from outside the body, such as heavy metals, pesticides, VOCs (volatile organic compounds).

However, these exogenous toxins can all be got rid of by heat/sweating regimes (with the exception of heavy metals). I would recommend a sweating detox at least three times a week, and my preferred technique is with far infrared (FIR) saunas. Hot Epsom salt baths may work as well.

The heat from far infrared radiation, present in sunlight, literally shakes up toxic molecules, so those that aren’t well stuck on are ‘shaken off’ and mobilized out onto the lipid layer on the surface of skin, where they can be washed off. It’s not essential to sweat for these regimes to be effective. The washing off is as important as the heat, or toxins will simply be reabsorbed.

I have carried out several tests on people before and after taking a sauna where tests prior to the sauna have demonstrated the toxic load of pesticides, volatile organic compounds and other toxic chemicals. On retesting after the sauna, in every single case every parameter has been improved.

For heavy metal detox, the best is chelation therapy, where a large molecule such as DMSA, DMPS, or EDTA is used either orally or intravenously to chelate out (gather up and expel) toxic minerals.

People can recover from fatigue first by getting their regimes as tight as possible (in terms of diet, supplements, pacing of activities, sleep and detox). When they start to feel better-and only then-should they start to increase their levels of activity, but if you experience delayed fatigue, reduce your activity levels again until your body has recovered.

Adapted from Dr Sarah Myhill’s book Diagnosing and Treating Chronic Fatigue Syndrome (Hammersmith Books, 2014), available on Amazon. Dr Myhill is a practising GP, an expert on chronic fatigue and a WDDTY panel member

How to find out why you are chronically tired

The following are among my favourite tests for determining why patients are so tired:

Mitochondrial function profile

This batch of tests includes:

o ATP profiles, to assess levels of ATP (basic form of energy at cellular level), how well energy is released from ATP, rate of production of ATP from ADP in cells, and movement of ATP and ADP across mitochondrial membranes
o Plasma cell-free DNA, to measure cell damage and antioxidant status
o Red-cell NAD levels, to measure efficiency of energy production in cells
o Coenzyme Q10 levels, to measure the most important antioxidant in mitochondria
o Acetyl-L-carnitine, which delivers fuel in the form of acetate to mitochondria
o Superoxide dismutase (SOD), to measure the three types of this major antioxidant enzyme as they reflect levels of zinc, copper and manganese
o Glutathione and glutathione peroxidase tests, to assess levels of the trace element selenium
o Red-cell magnesium, which may be part of the ATP profile or done separately.

Thyroid function profile
This batch of tests shows levels of the two thyroid hormones in blood-free T4 and free T3-and of thyroid-stimulating hormone (TSH), which controls their production.

Adrenal stress profile
This package of tests looks at how the adrenal gland functions and the likelihood of adrenal fatigue by measuring salivary levels of the adrenal hormones cortisol and DHEA over 24 hours.

Tests suggested by gut symptoms

o Gut fermentation test, for evidence of fermentation by bacteria or yeast
o Salivary VEGF test, for assessing low stomach acid
o Urine hydrogen sulphide test, to measure this gas, produced by people who ferment food, which can inhibit mitochondrial function
o Comprehensive digestive stool analysis, to determine digestive ability and gut flora status
o Early-morning short-chain fatty acids and/or tests of fructose intolerance, to determine a tendency for low blood sugar (hypoglycaemia).

Tests for chemical sensitivity and toxic stress

All tests are available at Biolab in the UK ( and Genova Diagnostics in the US (

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