What is Chronic Fatigue?
Aging, reduced metabolism due to muscle loss, inflammation and stress from countless diseases, and drug treatments can all drain energy levels and increase fatigue. Physical fatigue can lead to mental fatigue (lack of focus or attention, depression, stress, and anxiety) and vice versa, which is why a supplement that has the ability to help with both aspects is ideal. There are many different descriptions for fatigue, but they all revolve around a lack of energy. If you’re spending more of your day in bed or in a chair, it’s time to talk with your doctor about potentially having your fatigue treated.
Chronic fatigue syndrome (CFS) is severe and disabling fatigue, usually with a variety of other potential symptoms, including reduced concentration, sleep problems, musculoskeletal pain, and even headaches.
The cause is unknown and experts have speculated it may be triggered by a variety of things— from a lingering infection to an autoimmune syndrome—but no single reason has been identified and no single supplement has consistently been recommended in clinical guidelines because of lack of research.
But I believe this section could help people with CFS because when ranking supplements, I focused on what has worked for more extreme conditions, like cancer-related fatigue, which, like CFS, can impact physical and mental function.
And I think this section could potentially help with all chronic fatigue situations where the reason cannot be easily identified and corrected with a trip or two to the doctor. (For example, on rare occasions, fatigue can be the result of nutrient deficiencies, such as B12, folic acid, or iron, which can lead to anemia; low thyroid or testosterone can also cause fatigue, and this is easily corrected as well.)
When you’re dealing with fatigue that is more intractable to lifestyle changes, using stimulants to improve energy levels can be problematic. Too little of a stimulant takes a long time to work—if it does at all—while getting too much can be dangerous because it increases the risk of a cardiac event, such as an arrhythmia.
Therefore, the supplements recommended in this section are mild to moderate and have a safe track record overall.
Natural Remedies For Chronic Fatigue
1. (tie) American ginseng (Panax quinquefolius) or Panax ginseng 1,000 to 2,000 milligrams a day in at least two divided doses
In a very well-done Mayo Clinic study— similar to a Phase 3 drug trial—with 364 cancer patients, participants took either 2,000 milligrams of Wisconsin ginseng, a common type of American ginseng, or a placebo. By the end of the first month, both groups were experiencing reduced fatigue. After about 2 months, twice as many ginseng patients reported less fatigue. Side effects were similar to a placebo.
The ginseng used consisted of pure ground root from one production lot (manufactured by Beehive Botanicals) and contained 3 percent ginsenosides, which researchers believe are the active ingredients. Most ginseng products on the market have at least 3 percent; some go as high as 50 percent ginsenosides.
The higher the concentration of ginsenosides is, the lower the dose you should start with (always look for at least 3 to 5 percent ginsenosides). The same research group at the Mayo Clinic saw some benefits for cancer-related fatigue at 1,000 milligrams per day with a 5 percent ginsenoside product in a previous clinical trial. Ginseng derived from water extraction or from pure ground root has shown the best results and safety; alcohol- or methanol-based extraction methods could be less effective and possibly even toxic with long-term use.
Ginseng may reduce the inflammatory process associated with cancer or chronic fatigue, which in turn impacts cortisol, reduces stress, and improves energy. Ginseng (Panax or American) has a long history of improving energy levels in healthy individuals, but the fact that it worked in the extreme case of cancer-related fatigue tells me it can also help with other types of fatigue. (As I was preparing this section, a preliminary clinical trial from MD Anderson Cancer Center found similar benefits in cancer patients with Panax ginseng at similar dosages.)
2. (tie) Guarana (Paullinia cupana) 50 milligrams twice a day (containing no more than 40 milligrams of caffeine per day)
This plant from the Amazon River basin has been used as a stimulant for ages because it contains caffeine, but it also has a high saponin and tannin content, which may also contribute to reducing fatigue and improving focus. Bayer sponsored a study that found 222 milligrams of guarana (containing 40 milligrams of caffeine) worked better than a placebo for reducing mental fatigue and improving focus and attention. Other clinical studies of 75 milligrams of guarana found it improved memory.
Yet, this data on its own isn’t enough to convince me that guarana could be a real winner in the fight against fatigue. I want to see how it does for extreme fatigue, such as what you experience during cancer treatment, which is why I like this next trial: The most famous study with cancer-related fatigue and guarana was done in Brazil. Researchers used a standardized extract with a 6.46 percent caffeine content (not much) and a 1.7 percent tannin content.
Essentially, patients in this study received only around 5 milligrams of caffeine a day from guarana (a standard cup of coffee has 50 to 100 milligrams). More than 70 patients took either a 50-milligram guarana supplement or a placebo for 3 weeks, then took nothing for a week, and then crossed over to the other group (the original placebo subjects took the supplement and vice versa). After 21 days, half of the guarana patients reported significantly reduced fatigue compared to about 10 percent of the placebo group.
Most other trials have also used guarana with a fairly low caffeine content. When I (and others) have tried it, the effects seem to be attributable to more than just the caffeine; the other compounds in this plant help increase energy—not so much that it makes you jittery, though—and allow you to maintain concentration and focus. Instead of a roller-coaster effect—with higher energy and then a crash —it’s more of a consistent merry-go-round feel.
While the participants in these studies did not report anxiety and insomnia (as you might expect with products containing caffeine), I wouldn’t take it in the late afternoon because it could be too stimulating for some people. Pregnant women should not use guarana either; while it may just be a mild stimulant, guarana cannot be considered safe in pregnancy unless it receives more safety research.
Yerba mate is another plant containing caffeine, and it’s beginning to show some benefits for improved energy when used in beverages. It may end up working as well as guarana supplements, but more research regarding safety is needed.
D-ribose has shown good results in a few preliminary studies (not nearly as good as the ginseng studies, though). They suggest 5 grams of this supplement three times a day can help reduce chronic fatigue from unknown causes. But a large, well-done study that proves it can beat a placebo is still needed. Regardless, it seems to have a good safety record, and it’s certainly worth trying for a week or two to see if it works.
4. Work out more
While it didn’t earn a place in my “What Works” section, my prediction is resistance exercise with protein powder supplementation will appear in that section in the next edition of the book. Exercise (both aerobic and resistance training) has been shown in numerous clinical trials to improve energy levels and reduce fatigue. In fact, weight lifting just twice a week (upper and lower body) for 15 to 20 minutes continues to show excellent results. It’s simple: Increase your muscle mass and your metabolism increases, which also increases energy levels. If you’re experiencing extreme fatigue, it’s best to exercise every other day (versus daily) because it takes longer to recover from exercise when you’re that worn down.
Many patients have told me how much better they feel when they cut back on daily exercise. Do aerobic (“cardio”) exercise every other day for approximately 30 minutes (moderate to vigorous intensity), and on the other days perform a light activity, such as a short walk. Now, for those of you without fatigue issues or who are just tired at the end of the day, regular daily (or almost daily) exercise can make you feel better. Regardless, consistent exercise can keep you at your peak both physically and mentally!
In chronic fatigue patients, graded exercise therapy (doing 30 minutes of easy exercise 5 days per week) has shown some of the most compelling evidence yet of how exercise can improve fatigue and help patients get back to normal social and work activity.
5. Dial in your diet
Talk to a nutritionist about calculating an adequate daily calorie and nutrient intake. Eating too much or too little—or not enough nutrients—can create fatigue. On average, you should consume approximately 15 calories for every pound that you weigh, meaning if you are 150 pounds, you should eat about 2,250 calories a day to maintain your weight. This is a very general guideline; everyone’s metabolism is different. A nutritionist or a good personal trainer can perform testing to determine your actual daily metabolic rate (how many calories you’re burning a day).
6. Eat adequate protein
You require adequate amounts of high-quality protein to rebuild and repair body tissues, including muscles, which contributes to good energy. The best sources are from dairy, eggs, fish, meat, and poultry, but if you’re vegetarian, there are also soy, brown rice, and hemp protein powders as well as dietary sources, such as beans, lentils, and quinoa.
The average daily protein requirement is about 0.8 gram of protein per kilogram of body weight (1 kilogram = 2.2 pounds), so a 150-pound (68 kilograms) person needs about 54 grams of protein a day. This might sound like a lot, but one small protein drink and one small serving (mini-can) of tuna fish, for example, gives you about 40 to 50 grams of protein. Two eggs give you 12 to 15 grams; a steak, 40 grams; a chicken breast, 30 grams; 3 ounces of fish, 20 grams; 1 cup of milk, 8 grams; 1 cup of yogurt, 8 grams; and so on.
Protein is everywhere! In the next few years, I think the recommendation will be to consume a maximum of half your body weight in grams of protein per day to maintain muscle mass and energy. So, a 200-pound person would need to eat up to 100 grams of protein per day. This becomes a little harder, which is why I love to recommend taking 25 to 50 grams per day of whey protein isolate (powder that only contains protein, no fat or sugar—or only very small amounts of fat and sugar) to improve energy levels.
One of my favorites is the Jay Robb brand (it comes in strawberry, vanilla, and chocolate flavors), but there are so many options, so look around.
What Supplements Are Useless For Chronic Fatigue?
B vitamins for energy or fatigue are a waste of money unless you have a specific type of really rare anemia caused by a deficiency. And B12 injections for energy? Save your money! The human body needs such small amounts of these vitamins, and then it’s just so cells can carry out their normal functions. There are no credible studies showing B vitamins can improve metabolism or energy or reduce fatigue.
Caffeine pills/concentrated caffeine sources
I think a single energy drink can be helpful, but more than two a day is a lot of concentrated caffeine. Think of it this way: When you drink shots of hard liquor, you get drunk fast, but if you’re downing more diluted sources like light beer, you need larger volumes to feel the buzz. Caffeine is somewhat similar. When you concentrate the amount in a very small volume of liquid, it’s easy to overdose, resulting in anxiety and even skipped heartbeats (bad cardiovascular effects).
That’s why I don’t recommend caffeine pills except in some rare situations where nothing else works. And you can become addicted to higher doses of caffeine and develop a tolerance, where you need even larger doses to get the same effect. Finally, withdrawal from these very high doses of caffeine provided by pills and energy drinks is tough, and it can cause moderate to severe headaches. (Warning: The high acidity of energy drinks can potentially cause serious tooth damage.
Rinsing with water or chewing sugarless gum after drinking them could help— or just don’t drink them.)
This dietary supplement had a lot of researchers excited because it just makes sense that it would help reduce fatigue. L-carnitine has a transport function in the body. It shuttles fatty acids into the cells, which helps produce energy (again, I’m talking energy on a cellular level, not on a run-a-marathon level).
However, clinical trials haven’t supported the fatigue-reduction theory. There have been a few small studies suggesting that getting 1 to 2 grams (1,000 to 2,000 milligrams) per day of L-carnitine may reduce fatigue in some individuals, but a recent large Phase 3–like study of 2,000 milligrams per day of L-carnitine over 4 weeks did not show a benefit in cancer patients compared to a placebo. Some might argue that the study wasn’t long enough, but in my book, 4 weeks was adequate to see a hint of efficacy in cancer-related fatigue.
And if it doesn’t work for cancer-related fatigue, I’m skeptical that it can help for other types of serious fatigue. In my experience working with countless cancer patients, I haven’t seen it do anything.
However, if you have lower levels of L-carnitine, which may be the case in some people with chronic fatigue syndrome, supplementation might make a difference.
In one 2-month study, CFS patients who took L-carnitine reported significant improvements in fatigue. I’m still on the fence, but it might be worth trying a minimum dose of 2,000 milligrams per day (this is not a small dose).
Most of the positive research from L-carnitine has come from a group of researchers in Italy, and I’d like to see other trials from outside the country confirming the results before I jump on the L-carnitine bandwagon.