McXtra Care Newsletter | June 2020

Section A

 Recognizing and Understanding Chronic Fatigue


We all experience days of immense fatigue, where the body and mind can’t push themselves any longer. Sometimes we may feel like this for a day or two, and maybe even days, but with adequate rest and sleep, along with some relaxing or pleasurable activities, we spring back to our work schedules and daily routines.

But what is seen increasingly today is a feeling of long-term tiredness and drop in energy levels which lasts for many months. This is Chronic Fatigue and is seen commonly in the 40-50 years age group, and slightly more common in women.


Chronic Fatigue Syndrome (CFS) refers to a profound and severe feeling of exhaustion or tiredness lasting for 6 months or more, and presents with the symptoms below:

  1. Fatigue worsened by exertion (called PEM- Post Exertional Malaise) or exercise (physical or mental), not relieved by rest, and lasting > 24 hours after the exertion/exercise
  2. Feeling unrefreshed and fatigued even after a night’s sleep
  3. Reduction in cognitive functions like memory or concentration
  4. Feeling low and irritable more often than not
  5. Generalized body aches or muscle pains
  6. Joint pains (without any redness, swelling or restriction in movement)
  7. Recurrent headaches
  8. Symptoms of palpitation, dizziness, weakness, anxiety, sweating along with fatigue which come on or worsen while standing and reduce by lying down/reclining (Orthostatic intolerance).
  9. Sore throat episodes, or enlarged nodes in neck/armpits

Other symptoms may include nausea, lack of appetite, recurrent colds, allergies or sinus problems, and reaction/intolerance to alcohol or medicines. Depression can develop in patients with CFS or be the underlying cause of the manifestation of CFS symptoms. The most important factor for establishing Chronic Fatigue Syndrome is the absence of any underlying medical condition.


Chronic fatigue commonly sets in after an episode of illness especially viral infections with flu-like symptoms (fever, body ache, and weakness). Other triggers may include injury (physical trauma), a psychologically disturbing event, or having undergone a hospitalization or surgery. Sometimes no trigger may be identifiable and chronic fatigue may develop gradually over many months or years due to possible chronic physical or mental stress.

The theories so far put forward for developing Chronic fatigue include abnormalities of the immune system and/or the nervous system, decreased energy metabolism in body cells, and hormonal imbalance, but none substantiated convincingly, and no specific diagnostic tests developed yet.


Often an underlying medical conditions can be the cause, and this needs to be meticulously investigated and treated. First thing, a general physical examination by a physician including a Blood pressure check and calculation of Body Mass Index (BMI) is recommended.

Lab investigations should include a Complete Blood Count, Blood Sugar, Tests for Thyroid, Liver and Kidney function, Lipid profile, Vitamin D, and Vitamin B12. Additionally, an ECG with a Stress test (TMT- Treadmill test) is also advisable.

In some cases, testing for sleep disorders would be helpful as it may reveal abnormal sleep rhythms or sleep apnea which may be making sleep less refreshing and contributing to chronic fatigue. The history of snoring is a valuable clue.

psychological evaluation and counselling are also important as the symptoms may be a manifestation of an underlying mental health issues (like depression, bipolar disorder, schizophrenia, delusional disorders, eating disorders like anorexia nervosa and bulimia, drug/alcohol abuse or dementia).

Chronic fatigue is not considered to be a Psychological/Psychiatric illness even though such patients can develop depression over time.

In women, Chronic fatigue can be part of menopause symptoms or Pre Menstrual Syndrome (PMS).


Section B

How to increase energy levels and work capacity


Tests help to rule out conditions like Anemia, Hypothyroidism, Diabetes or other medical conditions present which can be appropriately treated. However, if these are ruled out and no underlying health disorder is found, the diagnosis of Chronic Fatigue Syndrome is usually made.

Lifestyle modification is the cornerstone of managing Chronic fatigue along with periodic support with medicines and supplements.

  1. Slowing down and prioritizing activities along with a reduction in hectic work schedules and multitasking is the first and important step.
  2. Physical activity, exertion and exercise should be gradually graded up. A physical therapist should be consulted to design and monitor a plan of aerobic exercises. Yoga should focus more on stretching, de-stressing, and breathing and then graded up to more complex postures.
  3. Incorporating a daily relaxation time with pleasurable hobbies which may be as a structured class or a self-allotted time (music, craft, reading, games, entertainment, etc) is helpful.
  4. Diet followed should be well-structured. A diet rich in whole grains, fruits and vegetables not only helps improve energy levels but also decreases BMI and cuts the risk of other chronic diseases. Obesity or being overweight has been linked to a greater risk of developing chronic fatigue.
  5. Sleep should be adequate in both duration and quality.
  6. Psychological counseling can help in managing stress as well as the impact on mental health or the presence of depression. Counselling can also help in cognitive training and improvement.
  7. Medicines: Antidepressants are often prescribed to improve low moods, body pains, and lack of sleep in chronic fatigue, but have a supportive role only. Similarly, pain-relieving medicines may be given for short periods for addressing body pain, headache, muscle, and joint pains.

Vitamins and Minerals have been studied to play a role in improving symptoms and energy levels in chronic fatigue, however, there may be considerable variability in individual treatment responses.

Vitamin B12 plays an important role in our body along with Folic acid (Vitamin B9) in producing energy from cellular metabolism, production of Red blood cells that carry oxygen, and for effective nerve functioning. B12 therapy can be tried in chronic fatigue, especially if there is lab evidence of B12 deficiency and can be given in large oral doses or as injections. For effective and surer results, (as oral absorption of Vitamin B12 is dependent on many factors and individual variations), injectable B12 is more commonly used. It is available in dosing regimens ranging from 1mg daily to 3mg alternate day or 5 mg thrice weekly. Though improvement may be felt after the first few doses itself, at least a 6-8 week period with the gradual reduction in injection frequency is required for maintaining a satisfactory level of improvement. Folic acid is combined with Vitamin B12 treatment in an oral dose ranging from 1-5 mg/day, and there are combination injections of B12/folic acid available.

B3 (Niacinamide) and B6 (Pyridoxine) are 2 other B group vitamins available in combination with Vitamin B12, which are known to participate in energy production and improve fatigue symptoms and cognitive functions.

Vitamin C is also often co-prescribed orally, or as a combined pack injection in a separate ampoule to be given in the same sitting as Vitamin B12 injection. Apart from improving immunity and iron utilization in our body, Vitamin C helps to synthesize a substance called L-carnitine in our body which helps in energy production in our cells. L-carnitine itself is also available as injections and oral supplements and may be prescribed for chronic fatigue.

Vitamin D is still being studied further for its role in chronic fatigue. If there is documented Vitamin D deficiency from Lab tests in patients suffering from Chronic fatigue, Vitamin D supplementation, and normalizing its blood levels, can help in improving symptoms. The dose prescribed depends on the amount of deficiency, and can be as single injections (1 to 3 lakh IU), or as oral weekly sachets/liquid shots of 60,000 IU (usually for 8-12 weeks) or as daily oral doses of 1000-2000IU over 3-6 months.

There is still a need for more robust clinical evidence on treatments for Chronic fatigue, and there is a likelihood of variation in the benefit and response not only in different patients but also in the same patient over the years.

Lifestyle modification is the cornerstone of managing Chronic fatigue along with periodic support with medicines and supplements.

Chronic Fatigue is different from Fibromyalgia which is a disorder of altered processing and amplification of pain sensations and signals. It is characterized by widespread and severe pain of muscles and joints along with fatigue, sleep disturbance, and effects on memory and mood. Though some of the symptoms and treatment aspects are common, the symptomatology and management of fibromyalgia are centered around pain relief.

Section C

10 points for effective stress management

Stress is the state of the body when it is made to cope with more strain (physical, mental or emotional) than it can handle or is used to.

Long term or Chronic stress can lead to a number of physical manifestations including frequent headaches, rise in BP, increased load on the heart, palpitations, fatigue and low energy, body pain and muscle tension, digestive complaints, reduction in immunity, decreased sleep, rise in blood sugar, and weight gain. Stress can have an impact on mental and emotional health causing mood swings, anxiety, and depression. Stress can also affect the menstrual cycle in females and sexual drive in both genders.

If your body is giving you signals that it is under stress, try to implement and follow the 10-point approach below. It may sound easier said than done! But use this 10-pointer as a weekly checklist. See how many points you achieved or were able to incorporate. For the ones you could not achieve, it helps to write down the reasons why, and try to follow them the next week.

  1. Regularize working hours– Define your working hours as much as possible in accordance with what suits your personality, efficiency, and capacity, and do not think of work outside those hours. There may be days when this is not possible, but it is important to aim for and manage this on most working days in a week. It is important to note that the duration of work does not correlate with the quality of output, which depends on work comfort, good health, low stress, and holistic living.
  2. Take breaks– On every working day, after 2-3 hours of continuous work, take minibreaks of 10-15 minutes for walking around, and performing simple stretch and breathing routines. Every week at least one full day should be reserved for rest, spending with loved ones and rejuvenation.
  3. Use gadgets and technology appropriately– Gadgets like mobile phones, laptops, and social media have become the pivot of our existence. It is important to use them to increase our efficiency, comfort, and connectivity, but also prevent them from becoming a significant contributor to stress. Maintaining correct postures, limiting hours of use with appropriate breaks, incorporating some recommended health precautions and exercises, and modifying techniques of using mobile phones and laptops can help to reduce the associated stress.
  4. Include Physical Exercise – 30-45 minutes of physical exercise like brisk walking, cycling, yoga, jogging or swimming, should be part of at least 4-5 days in a week. Include 5-10 minutes of breathing (Pranayama) and meditation in your daily routine.
  5. Get adequate Sleep –Lack of sleep can worsen stress and vice versa, turning the mutual impact of stress on sleep into a vicious cycle. Make sure you get 8 hours of undisturbed sleep on most nights in a week. If sleep is disrupted on any one night due to any reason, avoid this consecutively on two nights.
  6. Keep a daily relaxation or leisure time– This should be a technology and work-free hour allotted daily or at least 5 times/week, and apart from your exercise time. This time should include spending time with family and loved ones, engaging in a leisurely or relaxing activity, following a hobby or sport, or socializing.
  7. Seek help and support– Do not hesitate in discussing your stress, problems, and challenges with family, friends, support groups or a professional counselor, and keep an open mind. This can help put many things in perspective and untie knots, give reassurance and comfort, and also help find solutions to many problems.
  8. Inculcate positive attitudes – This may sound tough to follow but a daily auto-suggestion of detachment, forgiveness, and empathy helps reduce pent up anger, misgivings, frustration, and anxiousness all of which amount to significant stress. It is good to sometimes list down the stressors, or make a priority ‘to-do list’ to smoothen out overwhelming feelings and situations.
  9. Eat a Healthy Diet– A healthy and nutritious diet is rich in vegetables, fruits, nuts, whole grains, proteins, yogurt, and plenty of water.  Cut down on high sugar items, processed and packaged foods, deep-fried items, too much caffeine, alcohol, and smoking/chewing tobacco. Timely, unrushed meals (lunch break of at least 30 minutes) with adequate chewing and savoring are important to reduce stress.
  10. Take Medical Care: Often an underlying medical condition may cause or compound stress, or vice versa. It is important to seek a medical consult in case of persistent symptoms. It is also important to get a medical check-up done annually if one is over 45 years of age. Some common investigations advised for stress are Blood Pressure check, ECG, Complete Blood Counts (CBC), Blood sugar, Vitamin B12, Vitamin D, Thyroid function, kidney, and liver function tests. The sheer normalcy of a medical check-up is often a stress-relieving thing in itself while timely detection of any abnormality can help apt treatment and better stress management. The physician will also advise on the need for a course of medicines or supplements to manage the health condition contributing to stress.



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