Colleen Gill, MS RD CSOcolleen.gill@uch.edu

720-848-0464 Anschutz Cancer Center720-848-1090 Integrative Medicine

9/30/10

What does fatigue look like? How does it impact you?◦ You have to be motivated to make changes

Sources of fatigue Options to safely address potential issues:◦ Depression, stress◦ Sleep◦ Exercise◦ Diet, fluids◦ Supplements

Make informed choices

Polovich et. al., 2005, reprinted with permission

Common complaint to PCPWomen > Men

Acute: Drowsiness/need for sleepChronic: Decreased energy/motivation

Trouble sleeping or sleeping too much “No energy”; tired, weak, exhausted, slow

Decreased tolerance for prior exercise Lack of motivation, “paralyzing” Sadness, irritability, frustration Difficulty concentrating Difficulty making decisions Feelings of loss of control◦ Emotionally, psychologically,

economically and socially

Most fail to ask for help Hoping it will disappear on its own Unaware of possible interventions

Many providers fail to offer advice

To treat effectively, you must identify the underlying cause(and be patient over weeks/months)

◦ Anemia◦ Autoimmune: arthritis, lupus, FM◦ Cardiac, blood pressure changes◦ Hormonal: Diabetes, Adrenal◦ Infection◦ Inflammation◦ Kidney or liver disease◦ Meds: sleep, anxiety, antihistamines, pain◦ Neurological◦ Pain syndromes; unrelieved◦ Pulmonary/ lung disease◦ Thyroid

More likely if person wakes rested, then tires with activity

Emotional (Explains 40 – 80%) Stress, anxiety Depression Grief

Lifestyle Mediators Sleep Exercise; inactivity/debilitation Nutrition Hydration

More likely when person wakes with low energy

Stress Depression, New or aggravated

Depression often presents as: Lack of energy Decreased motivation

Overwhelming fatigue

Women > Men Heredity◦ Family history of self medication, depression

Personality◦ Pessimistic outlook, lower self esteem◦ Difficulty coping with stress

Life events or persistent stress Lower socio-economic status Co-occurring conditions, age Substance abuse (both cause and effect)

Acute, Clinical, Major, Bipolar, Seasonal

Altered circadian rhythm: chemo, shiftwork◦ Affects melatonin and cortisol levels

Anxiety, decreased ability to fall asleep Drugs, alcohol or stimulant use (caffeine) Sleep apnea (10% women/25% men)◦ Snoring, interrupted breathing waking unrested

Pain intensity and duration can limit sleep◦ No brownie points for martyrdom!

Menopause, hot flashesItchy, Bitchy, Sweaty, Sleepy, Bloated, Forgetful, and Psycho

http://www.sleepfoundation.org/site/c.huIXKjM0IxF/b.3934129/k.31D9/Poll_Stats.htm

Increased Needs◦ Fever, infection, metabolic inefficiencies

Limited Intake◦ Problems of nausea, appetite, early satiety, taste

Increased Losses (Diarrhea, Vomiting) ◦ Decreased retention and absorption of nutrients◦ Electrolyte imbalances

Fatigue Pain Nausea Mood

Cells are made primarily of fluid and lose function when turned into “prunes”

Initial choices that seem logical, but actually aggravate fatigue

Napping Sleeping longer Limiting exercise Increasing caffeine/stimulants

Often eliminated when tired, yet inactivity leads to worsening fatigue

Exercise Increases blood flow, releases

hormones that improve mood, sleep Decreases inflammation Improves immune function Improves sense of control, self esteem Limits stiffness

Start slow, but include daily Most are safe if you don’t overdo it!◦ A physical therapy eval may reassure, structure

Mornings are often best◦ Most energy available, less likely to “cancel”

Options◦ Walking, stationary bike; anything you enjoy◦ Water aerobics*, swimming limit stress to joints◦ 3 – 5 minute intervals, rest between◦ Short bouts work

Exercise limits loss of muscleand strength

Medications Prescribed: may also improve other issues St Johns Wort, multiple drug interactionsAlternative: acupunctureSupplements: Omega 3/fish oil, multivitaminBehavioral Therapy; avoid “turtle” behavior; confront Relaxation, distraction, guided imagery,

structured breathing Anxiety Techniques: Thought stopping, humor Social connection, family involvement

Source Treatment

STRESS = NovelUnexpectedThreat to self or egoSense of lack of control

Yoga, exercise Support groups/church Counseling Meditation/breathing Music/Art therapy Diversion Maintain a reasonable

work/personal schedule◦ Keep “White Space”

Consolidates learning/memory Recharges; maintains emotional balance Immune function maximized with restMaximizing Sleep Short naps, if at all: < 30 minutes Watch evening fluids/bathroom trips More daytime activity; less evening excitement Limit caffeine, increase evening carbs Tryptophan (5 HTP, warm milk); Melatonin Medications as needed: control pain, aid sleep

Only humans limit sleep!

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Strict routine/times to sleep Dark, quiet, cool environment◦ White noise, fans

Conscious relaxation, deep breathing Guided imagery/Counting Sheep Biofeedback Meditation Thought stopping◦ Journaling at night

> 2% weight loss dysfunctionHeadache, anorexia, dark/low urine

Mix it up and pace your intake◦ Avoid burn out by adding variety◦ Drink 2 ounces at each commercial break!

Non-caffeinated is better◦ Caffeine = short term boost Excess affects sleep chronic drain◦ Limit caffeine intake to 200 -300 mg/day (2 cups)

Fluids clear toxins

If you are unable to eat normal volumes

And are losing weight Eat more often; schedule it!◦ Treat eating like it’s medication; set timers◦ Develop a list of options for the fridge

Increase the caloric density◦ Packing more calories into the small volumes◦ Include fluids with calories

Low blood sugars = Less energy available for cells

Fatigue

Eat 4+ times/day for a steady blood sugars

Include protein in every meal/snack◦ 1/3 will convert to carbohydrate over two hours,

stabilizing blood sugars and energy levels◦ Sources: meats, dairy, eggs, nuts, beans, soy

The Right Amounts◦ ¼ carbohydrate sources

bread, pasta, potatoes, rice, cereals◦ ¼ protein sources◦ ~ ½ fruit, vegetables, beans

The Right Mix: No Naked Carbs◦ Eat sweets as part of a mixed meal◦ Include fat, protein, fiber to slow stomach emptying

Limit high Glycemic Index carbohydrates ◦ Processed/”white” foods

Red Blood Cell production improves with adequate folate, B12 (and iron if indicated)

Multiple vitamins help if diet is limited Folate sources in the diet◦ Green leafy vegetables, dried beans, grains, oj

B12 sources in the diet◦ Meats, cheese, eggs

Note: Most low Hematocrit levels in cancer treatment are due to effects of chemotherapy on the bone marrow, not a lack of nutrients

Iron in animal based foods (heme iron): 35% absorbed◦ Attached to protein

Non-heme iron in plant based foods 1 - 3 % absorbed(cereals, greens, beans, tofu)◦ Absorption increases with vitamin C:

OJ, broccoli, strawberries, tomatoes, spinach◦ Cooking acidic foods in cast-iron increases iron

content in foods◦ Absorption decreases with tea, antacids

or calcium supplements in same meal

Fluids for renal/kidney clearance Cruciferous family of vegetables◦ Broccoli/sprouts, cabbage, kale, Brussels sprouts,

cauliflower Sulfur containing foods◦ Garlic, legumes, onions, eggs

Fiber for GI clearance◦ Fruits, vegetables, whole grains, legumes

Limit alcohol and caffeine◦ Stresses to the liver detoxification processes

Prioritize Activities◦ Limit the “stupid stuff”

Let others help where able!Avoid Superwoman/man complex◦ Accept “good enough”◦ Delegate, with concrete ideas◦ Save time for the things you enjoy most and that

only you can do best Pace, plan ahead◦ Divide tasks into pieces, with rest between

Crock pots are great◦ Contact AICR (www.aicr.org) for “One Pot Meals”

or “Cooking Solo” Take advantage of convenience foods◦ Frozen, prepackaged, fast foods/restaurants

Check www.thesixoclockscramble.com

Your energy stores are your bankPrioritize, withdraw carefully

& balance with “deposits”

Multivitamin, + D if low Magnesium, frequently low in fatigue◦ 200 mg, three times a day, assess after 10 days Aspartate, succinate, fumerate, malate, citrate; versus oxide MgProPlus *Avoid magnesium with renal failure, diarrhea

Omega 3 fats in fish oils◦ Addresses inflammation issues; cytokine messengers

Levocarnitine/L-carnitine◦ 2 g in elderly improved cognition, strength, fatigue◦ 4 g/day normal levels; resolved fatigue BJCancer 2002◦ 6 g in advanced cancer less fatigue, increased

appetite, muscle, QOL Nutrition 22(2): 136-45, 2006◦ Melatonin◦ Hormone produced in darkness to maintain sleep

Increases blood flow◦ Delivers nutrients

Releases hormones◦ Improving mood, sleep; less depression, stress

Decreases inflammation Improves immune function ◦ Unless excessive

Improves sense of control, self esteem Limits stiffness

Hydration Regular meals and snacks◦ Combine protein and carbs

Adjust expectations, limit stress!◦ Meditation, yoga, biofeedback◦ Distraction; reading, music, humor◦ Talk to a therapist or social worker◦ Stay connected with people, nature

Clears the slate for awhile

Address depression and anxiety◦ Antidepressants, Ritalin, Remeron◦ Acupuncture

Address pain, without sedating Treat anemia, other medical issues Anti-inflammatory therapies◦ Omega 3 fats

www.painfoundation.org www.nimhinfo@nih.gov◦ National Institute of Mental Health

1-800-969-6642◦ National Mental Health Association

American Academy of Sleep Medicine◦ www.aasmnet.org

National Sleep Foundation◦ www.sleepfoundation.org

www.cancer.gov; or www.aicr.org Type fatigue in the search field

Patience is Critical!

Fatigue usually resolves over weeks to months,

not days!