1. Dietary issues in Chronic Fatigue Syndrome Melanie Reid Senior Dietitian Southern Fleurieu Health Service Victor Harbor, South Australia Sept 2007

2. Some diet issues Control of blood glucose /insulin levels Food sensitivity / allergy Gut health Weight management General nutrition - optimum levels of nutrients

3. Control of blood glucose/ insulin Symptoms may get worse when glucose or insulin levels spike & dive Dietary strategies include: –Regular meals or snacks (grazing) –Low GI diet –High protein intake

4. Glucose is important because it is a major fuel (energy source) for the body It is the main fuel for the brain and nervous system It provides about half the fuel for muscles We need a steady supply of glucose all day & night – don’t want drops or surges

5. Glucose is released into the blood when Carbohydrates are digested There are 2 main forms of carbohydrates: Sugars: Glucose Fructose Sucrose Lactose (blood sugar) (fruit sugar) (cane sugar) (milk sugar) Starches:

6. CARBOHYDRATES Confectionary Bread Pasta Yogurt Milk Rice Legumes Corn Potatoes Breakfast cereals Fruit Biscuits Cake Soft drinks Cordial Honey Sugar

7. Steady supply of glucose 1. Space carbohydrate foods evenly through the day, in regular meals & snacks 2. Eat moderate quantities of carbs at any one time (avoid excessive amounts) 3. Include types of carbs that release glucose slowly and steadily into the blood (low GI foods)

8. Steady supply of glucose 1. Spacing: If meals are more than 5-6 hours apart, include a small, nourishing snack in between e.g. raisin toast, fruit, milk drink or yoghurt Supper can be especially important if you have an early evening meal.

9. Steady supply of glucose 2. Moderation: Avoid / limit foods concentrated in sugar Eat only moderate amounts of bread, rice, pasta, potatoes, fruit etc – some people do better with the recent CSIRO-type diet

10. Steady supply of glucose 3. Include slow-release carbohydrates: GI measures how quickly carbohydrates break down & release glucose into blood Low GI foods digest more gradually –More stable blood glucose –Less extreme insulin response Try to include a low GI food in each meal

12. Examples of low GI carbs: Oats (porridge or muesli) or bran cereals Pasta Grainy bread Dried beans and lentils (legumes) Barley Sweet potato and sweet corn Milk, yoghurt and custard Some fruits e.g. apples, pears, oranges, dried apricots

13. High protein intake Many people with CFS seem to do better with higher protein intake Protein may help moderate glucose/ insulin responses Also important building block for muscle tissues and blood proteins May need more due to “hyped up” immune response or low level muscle catabolism

14. High protein intake Good sources of protein: Meat, chicken, fish Eggs Milk, cheese, yoghurt, soy drinks Legumes Moderate sources of protein: Wholegrains, nuts

15. Food sensitivity Seems to be more common in CFS Either classic allergy, food chemical intolerance or mal-absorption problems Symptoms can include headaches, various gut symptoms ( e.g. bloating, pain, diarrhoea, constipation, nausea), skin rashes, cognitive problems (e.g. concentration, memory), mood changes, fatigue

16. Food sensitivity Allergy-type reactions may be caused by a range of high-protein foods e.g.: Wheat (maybe other gluten-containing grains as well) Milk Soy Eggs Fish, Beef or other meats

17. Food sensitivity Food chemicals that can cause intolerance reactions: Salicylates Amines Glutamates Preservatives Artificial anti-oxidants Colours (artificial and some natural)

18. Food sensitivity Food chemical intolerance reactions can be difficult to determine: Multiple chemicals and foods involved Dose-related, so seems inconsistent May be delayed response Reaction threshold can change May need trial elimination diet to clarify, with guidance from experienced dietitian

19. Gut problems Strong overlap between CFS and IBS –Pain, bloating, diarrhoea, constipation –Nausea, fullness, indigestion May be caused by : –food chemical intolerance –changes in bowel bacteria –poor stomach emptying / gut motility –impaired digestion (stomach acidity, digestive enzymes)

20. Gut problems Bowel bacteria –May have overgrowth of unfriendly bacteria, lack of friendly bacteria e.g. lactobacilli, bifido species, and strains of E. coli Probiotic supplements may help e.g. VSL#3, Symbiotic, Mutaflor, Lactobac Prebiotic supplements can also help e.g. Benefiber, FOS, foods rich in galactose (milk, legumes)

21. Gut problems Mal-absorption syndromes Undigested sugars can be fermented in the large bowel e.g.: lactose (milk, yoghurt) fructose and fructans (some fruit & vegetables, honey, wheat) polyols such as sorbitol (some fruits, sugar-free products)

22. Fructose malabsorption Fructose mal-absorption → gas, pain, osmotic diarrhoea (possibly also fatigue and effects on mood) Quite common cause of IBS Can be tested by Breath Hydrogen Test Treated by reduced fructose diet – level of restriction depends on each individual

23. Fructose malabsorption Problem foods include: those with high fructose to glucose ratio (glucose assists absorption of fructose) e.g. apples, pears, melons, mango, honey foods with high total sugar load (overwhelms absorptive capacity e.g. dried fruit, juice, confectionary, sweet drinks foods high in fructans/inulins (long-chain fructose) e.g. wheat, onion, leek, asparagus, artichokes

24. Gut problems “One person’s meat is another’s poison” Fructans & inulin can be useful prebiotics that encourage the growth of friendly bowel bacteria (that’s why inulin is added to some yoghurts) but they can cause problems for others e.g. fructose malabsorbers

25. Gut problems Some people find digestive enzyme supplements helpful e.g. Creon Some people need medication to improve gut motility e.g. Maxalon, Motilium

26. Weight management Some gain weight: Less activity, metabolic changes? Need to reduce non-nutritious, high fat/ high sugar foods Low GI / high protein diet can help control hunger Find alternative strategies to reduce “comfort” or non-hungry eating

27. Weight management Some lose weight: Problems with meal preparation, poor appetite, digestive problems etc. Encourage nutritious snacks and drinks May require nutrition supplement drinks e.g. Ensure, Sustagen, Resource (if tolerating milk) or whey-based, soy or rice-based alternatives

28. “ Balanced diet” 2 or more serves meat or alternative At least 4-5 serves colourful vegetables 2-3 serves low fat dairy or alternative 3 or more serves bread/ cereal group 2-3 serves fruit

29. “ Balanced diet” However, this advice needs to take account of individual sensitivities!! -May need alternative sources of protein & calcium if milk isn’t tolerated -May need alternative sources of protein, iron & zinc if meat isn’t tolerated -May need alternative sources of fibre & carbohydrate if wheat isn’t tolerated

30. Nutrient Supplements People with CFS may have higher requirements for some nutrients, and may need supplementation. For example: Magnesium Protein / amino acids Omega 3 fats (fish oil) Nutrients for energy pathway support e.g. Co Q10, Vitamins B3, B12, acetyl-carnitine Anti-oxidants e.g. ά-lipoic acid, curcumin

31. The “Sunshine” vitamin Many people with CFS are low in Vitamin D Important for bone health, muscle strength, immune function, ↓ risk of cancer etc. etc. Simple blood test to check level Supplement may be required - at least 1,000 IU/day - 5,000 – 6,000 IU/day if deficient Vitamin D

32. Other factors for bone health: Adequate calcium - Low calcium intake is quite common Weight bearing exercise - Often limited in people with CFS

33. Orthostatic Intolerance Neurally-mediated hypotension (NMH) & postural orthostatic tachycardia syndrome (POTS) → dizziness, rapid heart-beat High salt intake may be part of treatment (not if person has high BP) e.g. 3 gm salt per day