A normal response of the body, which can become a problem
Ludovic Brunel starts with a reminder: fatigue is first and foremost a natural, defensive response of the body to physical and mental stress, and it generally improves with rest. It becomes a problem when it stops the person from carrying out certain activities, for lack of energy or endurance.
The phenomenon is common. According to the speaker, around 25% of patients in primary care present fatigue-related problems, and COVID-19 has accentuated the trend: having an infection increases the risk of developing fatigue, then chronic fatigue. Most patients, he stresses, do not know why they are tired.
How it shows
Fatigue covers several sensations: weakness, lack of energy or motivation, mental exhaustion, reduced capacity for physical and intellectual work, reduced muscular endurance, difficulty recovering after exercise, and often sleep disturbances. It is also part of a set of closely linked problems: pain, insomnia, anxiety and depression. A depressed person often sleeps badly and moves less; a person in pain loses restorative sleep. In both cases, fatigue sets in.
Its consequences go beyond discomfort: difficulty carrying out daily activities, thinking analytically, making decisions or regulating emotions, and an increased risk of accidents and microsleeps.
The risk factors to keep in mind
Ludovic Brunel draws on a Dutch study of more than 10,000 people, which highlights several factors associated with fatigue: certain medicines (analgesics, antidepressants, sedatives), female sex and body mass index.
Chronic stress is central to his reasoning. Under acute stress, cortisol production increases to cope with it. When stress persists, this production can become dysregulated, up to a state he describes as adrenal fatigue, in which the body can no longer produce enough cortisol.
Three pictures to distinguish
Physiological fatigue
Common in adolescents, it improves with rest and often reflects a lifestyle imbalance. It is managed through good sleep hygiene, a healthy diet and balanced energy expenditure. The speaker emphasises two dietary points: sufficient calorie intake, especially in older people, and sufficient protein. As for physical activity, both too much and too little are a problem: intense exertion is exhausting in the short term, inactivity keeps fatigue going.
Secondary fatigue
It results from an underlying condition and generally improves when that condition is addressed. According to Ludovic Brunel, this is the case for most fatigue, hence the importance of a thorough case history. The leads to explore first: infections, anaemia, vitamin B12 deficiency (especially in older people), musculoskeletal disorders and psychiatric conditions.
Chronic fatigue syndrome
It combines fatigue triggered by little exertion with other symptoms: headaches, sleep disturbances, cognitive difficulties, muscle pain. The criterion the speaker highlights is post-exertional malaise. Symptoms must be present at least half of the time, with moderate to severe intensity, for at least six months.
He remains clear-eyed about the results of current approaches: according to the figures he presents, around 2% of patients report complete and lasting resolution of their symptoms, and 64% a limited improvement. Patients generally benefit from cognitive behavioural therapy and physical activity adjusted to what they can tolerate, as intense exertion is rarely tolerated. Among nutraceuticals, he mentions acetyl-L-carnitine, which has shown an overall positive effect, as well as promising results for essential fatty acids and magnesium.
Assessing fatigue with simple tools
In consultation, Ludovic Brunel uses a fatigue self-assessment table. The items cover the impact of fatigue on daily life, how easily the person gets tired, lack of energy for daily tasks, physical and mental exhaustion, and difficulty getting started, thinking clearly and concentrating. In his view, a score of 22 or more indicates a fatigue problem that warrants support.
In active people who train a lot, he uses the Hooper-Mackinnon questionnaire: four self-assessed items. As soon as the score rises abnormally, or the total exceeds 20, training should be adapted to limit the risk of injury.
The fundamentals of support
Before any supplement, the speaker sets out pillars: a Mediterranean-style diet, attention to sleep, tolerated physical activity, hydration and mental health. His general dietary recommendations:
- small, frequent meals throughout the day;
- snacks low in sugar and with a low glycaemic index;
- plenty of fresh vegetables;
- alcohol to be reduced or avoided, caffeine to be limited in the afternoon and evening.
Above all, he insists on listening. “These are often patients who have not been able to find solutions to their problems, and who are a little disappointed, or even frustrated, by their experience with health professionals,” he observes. Hence the importance of showing empathy, involving the patient in decisions and targeting the symptoms, which vary from one person to another.
The nutraceuticals presented
Correcting deficiencies
According to Ludovic Brunel, deficiencies are often the simplest to correct, using active forms and complexes combining minerals and cofactor trace elements for better absorption. He mentions three common ones: vitamin D3, levels of which are low in Canada, especially in winter; iron, often deficient in women; vitamin B12, whose absorption becomes an issue in older people.
Magnesium
He links nervous fatigue to magnesium deficiency, which is common with chronic stress or an unbalanced diet. He favours bisglycinate, which is well absorbed and a source of glycine, and also mentions magnesium acetyl-taurate. Asked during the session about magnesium malate, he describes it as a well-studied, well-absorbed form that contributes to cellular energy production, more often used in people with muscle problems, but broadly similar to bisglycinate.
D-ribose
Often used in chronic fatigue and fibromyalgia, ribose contributes, according to the speaker, to exercise tolerance and to maintaining the energy reserves of muscle and heart cells. He cites studies reporting a significant improvement in energy and overall well-being.
Melatonin, for a short period
As sleep is a key symptom of chronic fatigue, Ludovic Brunel uses melatonin moderately, for about two weeks, to help the patient get back to a better sleep cycle.
Multivitamins and mitochondrial support
He recommends a comprehensive multivitamin to most of his patients, reporting that this type of supplementation is associated, in people with chronic fatigue, with improvements in sleep, fatigue and headaches. As mitochondrial dysfunction is common in this picture, he mentions carnitine, alpha-lipoic acid and coenzyme Q10. For CoQ10, he refers to studies showing, in patients with fibromyalgia, a reduction in fatigue of around 47% after about 40 days.
Adaptogens and medicinal mushrooms
- Korean red ginseng (Panax ginseng): contributes to stress resistance and physical endurance, with studies on reducing fatigue and on quality of life.
- Siberian ginseng: supports stress resistance and cognitive tasks.
- Reishi: presented as calming for the nervous system.
- Cordyceps: an adaptogen that, according to the speaker, supports the adrenal and thyroid axis.
- Ashwagandha: helps with stress and anxiety, with effects on certain markers of memory and alertness.
What practitioners can take away on Monday
Fatigue is not a diagnosis, it is a starting point. Distinguishing the picture, ruling out a secondary cause, measuring with a simple questionnaire and consolidating the fundamentals then makes it possible to choose targeted nutraceuticals rather than a generic list. And, as Ludovic Brunel points out, a patient who feels listened to follows what is suggested more closely.
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