Ep. 36 Fighting Fatigue: Conservative Management and Nutrition
Episode Summary:
In this episode of It's Not in Your Head, Dan Bates and Justine Feitelson discuss the intricacies of chronic fatigue syndrome and treating excessive fatigue. Learn about the illness behavior network and conservative management strategies for aspects of fatigue including sleep, pain, cognitive issues and mood, with a deeper dive in the role of nutrition and how to make convenient, sustainable changes with such limited capacity. This comprehensive episode offers actionable tips and strategies for improving energy for those struggling with this debilitating condition.
Episode Overview
Hosts Dr. Dan Bates and pain coach Justine Feitelson (Dan and Juz) explore fatigue in chronic pain, distinguishing everyday excessive fatigue from chronic fatigue syndrome, and review conservative management strategies appropriate for either.
Understanding Fatigue vs Chronic Fatigue Syndrome
The episode opens by distinguishing excessive fatigue from chronic fatigue syndrome (CFS), clarifying that CFS is a disease process—likely autoimmune, involving nervous system and receptor dysfunction—that overlaps with syndromes like fibromyalgia and POTS (postural orthostatic tachycardia syndrome).
The behavioral response to illness, termed the Illness Behavior Network, involves fatigue, lowered mood, reduced activity, and cognitive dysfunction, triggered by factors such as inflammatory cytokines (e.g., IL-6).
Canadian diagnostic criteria for CFS: persistent mental or physical fatigue, post-exertional malaise, unrefreshing sleep, pain, cognitive dysfunction, autonomic disturbances, neuroendocrine symptoms, immune symptoms, duration over six months, and exclusion of other causes.
Conservative Management Strategies
Sleep Hygiene
Emphasis on anchoring sleep/wake times, maintaining consistent routines, managing exposure to light, and employing relaxation, breathing, and distraction techniques to support sleep onset and quality. See sleep episodes for more.
The hosts discourage the use of medications before mastering conservative approaches; when needed, medications are selected based on primary symptoms (e.g., amitriptyline for pain and sleep, clonidine for sympathetic outflow).
Pain Management
Identifying pain types (body-part, nerve, nervous system dysfunction) and using targeted approaches, referencing prior podcast episodes for deeper dives on pain and sensitization.
Outcome measures and inventories like the central sensitization inventory help guide personalized management.
Cognitive Function & Pacing
Pacing is essential not only for physical activity but for managing cognitive energy and preventing overwhelm; batching similar tasks, time-blocking, and organizing personal routines are highlighted. See episode on pacing for more.
The controversy around graded exposure versus pacing is discussed, with advocacy for a combined, personalized approach to avoid harm and maximize functional gains.
Autonomic Dysfunction
Management of dysautonomia and related symptoms (POTS, GI issues) largely involves borrowing conservative protocols from these disease communities and seeking specialist support where necessary.
Sensitivities and Mood
Sensory and chemical sensitivities are common, especially in hypermobility and MCAS (mast cell activation syndrome) populations; targeted elimination and tolerance-building are explored.
Psychological support is encouraged, with therapy focused on building coping strategies, combating catastrophizing, and reclaiming joy and meaning.
Nutrition Deep Dive
No Special “Chronic Fatigue Diet”: The episode repeatedly emphasizes that there is no universal or special diet for chronic fatigue syndrome or excessive fatigue; instead, the basics of good nutrition become even more crucial because people in pain or with fatigue struggle to maintain the routines that previously worked for them.
Simplicity and Convenience Over Perfection: Many listeners find it difficult to prepare meals or maintain their appetite. The hosts suggest making eating as simple and convenient as possible, advocating for shortcuts and semi-prepared foods (like pre-cut fruit, salad kits, or instant oats) without guilt—removing barriers is more important than “perfect” homemade meals.
Core Strategies and Practical Solutions
Meal Quality and Timing: Before worrying about calories and numbers, focus on eating regularly (breakfast, lunch, dinner, and snacks) and improving the quality of meals. Skipping breakfast and relying on one main meal is called out as a major pitfall. List out “green light” foods that are well-tolerated, easy, and enjoyable, and keep them in rotation.
Macronutrient Targets and Protein First: The recommended ballpark intake is roughly 30% protein, 30% fats, 40% carbohydrates, with a note to limit saturated fat. The major advice is to intentionally increase protein at every meal—aiming for at least 20 grams per meal (otherwise, it’s “just a snack,” as Justine puts it). Protein also increases satiety, helps stabilize energy and appetite, and can be sneakily increased via protein bars, powders, or even collagen in tea. Tracking macros can be helpful for awareness, especially for those eating plant-based diets, but should be done cautiously and briefly if a history of food anxiety or eating disorders exists.
Upgrading and Swapping Ingredients: Sometimes the solution is simply upgrading what’s already eaten—swap higher-protein tortillas, whole grains for refined grains, or use alternative plant-based proteins like tofu, legumes, or dairy products if possible. Don’t hesitate to use supplements if it helps.
Making Food Prep and Sourcing Sustainable
Overcoming Cooking Fatigue: The hosts tell stories about buying melons but never cutting them, emphasizing that purchasing pre-cut options isn’t lazy—it’s pragmatic. The principle is to accept personal quirks, automate grocery routines, and use convenience products to build consistency. Even “lesser of two evils” options (frozen meals, cereal, protein bars) may be the most sustainable food choices when energy is limited, and pairing these with easy-to-add proteins (pre-cooked chicken, Greek yogurt, cheese sticks, protein powder) is encouraged.
Smart Grocery Systems: Using recurring lists by food group (protein, carb, fat, veggie), rotating choices for variety, and making shopping as formulaic as possible helps lower barriers to sourcing and eating healthy options. Buy what is realistically usable—even if it is more expensive or perceived as “lazy”—because consuming food is the priority.
Special Topics: Dietary Restrictions and Digestive Challenges
Vegetarian and Vegan Approaches: Extra attention is needed to reach protein targets on plant-based diets; milk products, protein-enriched foods, and supplements are recommended, and intentional tracking (just a few days at a time) helps catch deficits. Hosts share patient anecdotes to illustrate the challenges and solutions—Greek yogurt with protein powder, double legumes or tofu, and leveraging new protein sources like pea or soy protein for snacks are all discussed.
Gastroparesis, Nausea, and Appetite Fluctuations: Chronic illness brings appetite problems, GI symptoms, and neurodivergent food “quirks.” Solutions include small, frequent meals, softer and blended foods, eating during windows when appetite is better, and taking anti-nausea medication preemptively. The hosts stress pivoting meal choices as tolerance changes and normalizing temporary food aversions or monotony—adapt and rotate as needed, then pivot back to old favorites.
Hydration Strategies
Simple Formulas and Electrolytes: Dehydration worsens fatigue and cognitive problems, so sticking to straightforward hydration goals—about half bodyweight in ounces (imperial), or 30 mL/kg (metric)—is encouraged.
Those with POTS may need 2–3 liters plus electrolytes daily. Beverage preferences, coffee’s mild diuretic effects, and electrolytes are all briefly considered, stressing that thirst is not a reliable indicator; proactive systems (water bottles, reminders) work best.