In this article, we will be looking at how your digestive system can make your fatigue feel worse and how probiotics can make a difference.
Fatigue is a funny word coming to the end of 2021. There’s the somewhat obvious pandemic fatigue, then end of year fatigue, end of school year fatigue, and the list continues.
What if it’s none of those things, and your fatigue has been going on for much longer?
First, as I do, whenever I meet someone interested in improving their sense of energy, we need to define better what the problem is.
Could the definitions of energy and fatigue be independent of each other and different things?
A group of researchers think so. This proposed difference is one of my favourite yet, unproven hypotheses. It starts with an interesting statistic that up to 45 per cent of Americans[i] and around 10 per cent of Hong Kongers reported having persistent fatigue.[ii]
The intriguing part is there is no agreed way to measure fatigue. Furthermore, a lot of fatigue is treated as a symptom of another underlying illness. Unfortunately, studies have also demonstrated that up to half of the people seeking help for their fatigue do not receive a diagnosis explaining it.[iii]
Generally, the phrases “lack of energy” and fatigue are interchangeable. When low energy could be a “lack of vigour”, and fatigue is better expressed as a perception of reduced physical or mental capacity. I choose to use the term “competency” with my patients. Based on these definitions, it is possible to have both “low vigour” and a sense of underwhelming physical and mental competency.
Studies have looked into this difference more specifically. One study found that passive things like sitting at a desk or watching TV, for example, have a stronger tendency to decrease energy instead of increasing fatigue.[iv] In another study, exercise has a more significant effect on increasing energy than reducing fatigue. A meta-analysis of 16 studies on exercise demonstrated that high-intensity exercise increases energy but does not decrease fatigue.[v]
For this article, let’s talk about fatigue.
Now that we have explored the definitions of energy and fatigue, it’s this type of reduced mental and physical competency that we are looking to solve. But also a symptom we commonly see connected with the dysfunction in the digestive system.
Chronic fatigue syndrome (CFS) is connected to leaky gut, or intestinal permeability and correction of leaky gut improves symptoms within CFS.[vi]
An extension to this is that over 60 per cent of people with Irritable Bowel Syndrome (IBS) reported fatigue in combination with other symptoms. A significant difference in controls.[vii] Fatigue ranks the third most common symptom after frequent bowel movements and abdominal pain in IBS.
This increased fatigue has been explained by the connection between the immune and digestive systems.[viii] First, inflammation occurs within the gut and the immune system. Consequently, the immune system becomes imbalanced and breaks down the intestinal tract’s lining. This imbalance then leads to a broader inflammation across all the body systems, likely to cause severe fatigue in many different conditions.
So, if leaky gut is the end game that can lead to fatigue, then it seems the next logical question is what causes the inflammation that begins the process. The answer to that is something that we’ll be exploring in different ways in this pillar of the site; an imbalanced bacterial diversity within the microbiome, commonly known as gut dysbiosis.
In part of the gut dysbiosis picture, Gram-negative bacteria set up shop in your digestive tract, causing fatigue.
Gut dysbiosis has been implicated in many conditions, including more severe mental health conditions and chronic fatigue.[ix] Before you rush to think that gram-negative bacteria are named that way because they are negative, it’s not the case! Gram-negative bacteria are named this way because they have a thinner cell wall than other bacteria. Common gram-negative bacteria commonly occurring that can cause initial inflammation are Citrobacter, Enterobacter, Klebsiella, Proteus and Akkermansia. All of these are members of the Proteobacteria phylum.[x]
Similar to how bacteria colonise your teeth and around your gum, creating plaque that your dentist cleans, these gram-negative bacteria set up colonies on the lining of your digestive tract. Inflaming the part of the lining that they live on and, causing the leaky gut.
When the gut lining becomes leaky, something called an endotoxin that lives on the outside of the bacteria moves into the bloodstream causing the immune system to flare up, creating a situation called “endotoxemia.” Endotoxemia manifests as a form of fatigue and a loss of motivation, and anhedonia, an inability to feel pleasure in normally pleasurable activities.[xi]
When treating fatigue in the clinic, I often see adjunctive digestive symptoms. This combined picture is especially the case in more chronic fatigue syndrome cases. You can often see the bacteria mentioned above pop up in high amounts in comprehensive stool testing. Another panel we get to see within the stool testing is your probiotic and prebiotic levels. Indications that can offer some gateways to probiotic species and genus can help you.
Probiotics can assist fatigue-based symptoms, but you must be careful with which formula you choose if you have chronic fatigue syndrome.
You may have come across this article because you’ve been feeling a combination of digestive symptoms with fatigue or because you are struggling with more intense chronic fatigue syndrome symptoms. If you are in the latter category, this section will be a little more important to cover as certain species of probiotics may help or hinder depending on which they are.
In the previous section, we’ve touched on gram-negative bacteria and fatigue, but what about gram-positive bacteria? Gram-positive bacteria are another category of bacteria that include many probiotics you might have heard of, such as Lactobacillus.
Ok, so now you’re telling me that probiotics aren’t good for me? No, that’s not what I’m saying. I am saying that mounting research suggests that species of probiotics such as some Lactobacillus species may do more harm than good depending on the context in which they are used.
A pilot study looking into microbiome change in chronic fatigue suggested that poorer mood was associated with higher levels of Lactobacillus for all subjects.[xii] Unfortunately, they didn’t state which species, and this is contradictory to other studies suggesting Lactobacillus species decrease anxiety in chronic fatigue.[xiii]Confused yet? Let me explain.
Some probiotics create a form of lactic acid called D-lactic acid that can have an undesirable change on the balance of the microbiome, making chronic fatigue worse.[xiv]
Now, this is not just Lactobacillus causing the problem. Some of the older research pointing to specifically Lactobacillus has overstated the problem. What has been found is that Lactobacillus can interact with other species of commonly occurring bacteria that produce D-lactic acid as well, such as Enterococcus faecalis and Streptococcus sanguinis.[xv] This imbalance or dysbiosis increases the amount of D-lactic acid beyond a threshold that the human body can handle, creating an excess called D-lactic acidosis. The symptoms of which appear mainly similar to that of chronic fatigue syndrome.[xvi]
This acidosis situation can cause other problems in the brain. For example, elevated levels of D-lactic acid have been shown in small studies to cause an inability to concentrate and weakness,[xvii] two symptoms synonymous with chronic fatigue syndrome but also brain fog.
So what’s the point here? Well, I see many patients who have tried a general broad-spectrum probiotic and have felt worse! Consequently, probiotics and their ability to help in this situation get written off when the whole microbiome’s balance might have been more of a problem than the specific probiotic formula that was bought off the shelf, often heavy with Lactobacillus species.
I wish the answer to the question – does my digestion make my fatigue worse had some more cut-and-dry explanations.
I think the answer to the question is a resounding yes. What do you think? It’s fair to say that we still need to be patient regarding the more straightforward explanation as to why. The studies are coming. I think it will lie within non-specific forms of bacteria causing the problem, something we’ve mapped to some extent with the gram-negatives contribution, but our insights into the environment as a whole. For example, the balance between the different less pathological species we have discussed above.
If you are looking to solve your issue around fatigue and its connection to your digestion, you can investigate it via comprehensive stool testing such as the GI360 or GI-Map.
The microbiome is as unique as your fingerprint.[xviii]
We have a lot to learn. Still, what we know is the proportions of the different species in your digestion can play a huge role in how you’re feeling. Especially in fatigue or your sense of mental and physical competency. The results of the tests can take the guesswork out of your situation, helping you take steps towards releasing yourself from feeling bloated and tired. Helping you find some answers at the same time.
Hope this helps.
References
[i] Loy BD, Cameron MH, O’Connor PJ. Perceived fatigue and energy are independent unipolar states: Supporting evidence. Med Hypotheses. 2018;113:46-51. doi:10.1016/j.mehy.2018.02.014
[ii] Wong WS, Fielding R. Prevalence of chronic fatigue among Chinese adults in Hong Kong: a population-based study. J Affect Disord. 2010;127(1-3):248-256. doi:10.1016/j.jad.2010.04.029
[iii] Nijrolder I, van der Windt D, de Vries H, van der Horst H. Diagnoses during follow-up of patients presenting with fatigue in primary care. CMAJ. 2009;181(10):683-687. doi:10.1503/cmaj.090647
[iv] Bryan D. Loy, Patrick J. O’Connor & Rodney K. Dishman (2013) The effect of a single bout of exercise on energy and fatigue states: a systematic review and meta-analysis, Fatigue: Biomedicine, Health & Behavior,1:4, 223-242, DOI: 10.1080/21641846.2013.843266
[v] Bryan D. Loy, Patrick J. O’Connor & Rodney K. Dishman (2013) The effect of a single bout of exercise on energy and fatigue states: a systematic review and meta-analysis, Fatigue: Biomedicine, Health & Behavior,1:4, 223-242, DOI: 10.1080/21641846.2013.843266
[vi] Maes M, Leunis JC. Normalization of leaky gut in chronic fatigue syndrome (CFS) is accompanied by a clinical improvement: effects of age, duration of illness and the translocation of LPS from gram-negative bacteria. Neuro Endocrinol Lett. 2008;29(6):902-910.
[vii] Piche T, Huet PM, Gelsi E, et al. Fatigue in irritable bowel syndrome: characterization and putative role of leptin. Eur J Gastroenterol Hepatol. 2007;19(3):237-243. doi:10.1097/01.meg.0000252627.50302.b4
[viii] Morris G, Berk M, Carvalho AF, Caso JR, Sanz Y, Maes M. The Role of Microbiota and Intestinal Permeability in the Pathophysiology of Autoimmune and Neuroimmune Processes with an Emphasis on Inflammatory Bowel Disease Type 1 Diabetes and Chronic Fatigue Syndrome. Curr Pharm Des. 2016;22(40):6058-6075. doi:10.2174/1381612822666160914182822
[ix] Safadi, J.M., Quinton, A.M.G., Lennox, B.R. et al. Gut dysbiosis in severe mental illness and chronic fatigue: a novel trans-diagnostic construct? A systematic review and meta-analysis. Mol Psychiatry (2021). https://doi.org/10.1038/s41380-021-01032-1
[x] Salguero MV, Al-Obaide MAI, Singh R, Siepmann T, Vasylyeva TL. Dysbiosis of Gram-negative gut microbiota and the associated serum lipopolysaccharide exacerbates inflammation in type 2 diabetic patients with chronic kidney disease. Exp Ther Med. 2019;18(5):3461-3469. doi:10.3892/etm.2019.7943
[xi] Safadi, J.M., Quinton, A.M.G., Lennox, B.R. et al. Gut dysbiosis in severe mental illness and chronic fatigue: a novel trans-diagnostic construct? A systematic review and meta-analysis. Mol Psychiatry (2021). https://doi.org/10.1038/s41380-021-01032-1
[xii] Jackson ML, Butt H, Ball M, Lewis DP, Bruck D. Sleep quality and the treatment of intestinal microbiota imbalance in Chronic Fatigue Syndrome: A pilot study. Sleep Sci. 2015;8(3):124-133. doi:10.1016/j.slsci.2015.10.001
[xiii] Rao AV, Bested AC, Beaulne TM, et al. A randomized, double-blind, placebo-controlled pilot study of a probiotic in emotional symptoms of chronic fatigue syndrome. Gut Pathog. 2009;1(1):6. Published 2009 Mar 19. doi:10.1186/1757-4749-1-6
[xiv] Sheedy JR, Wettenhall RE, Scanlon D, et al. Increased d-lactic Acid intestinal bacteria in patients with chronic fatigue syndrome. In Vivo. 2009;23(4):621-628.
[xv] Sheedy JR, Wettenhall RE, Scanlon D, et al. Increased d-lactic Acid intestinal bacteria in patients with chronic fatigue syndrome. In Vivo. 2009;23(4):621-628.
[xvi] Wallis A, Ball M, McKechnie S, Butt H, Lewis DP, Bruck D. Examining clinical similarities between myalgic encephalomyelitis/chronic fatigue syndrome and D-lactic acidosis: a systematic review. J Transl Med. 2017;15(1):129. Published 2017 Jun 7. doi:10.1186/s12967-017-1229-1
[xvii] Uribarri J, Oh MS, Carroll HJ. D-lactic acidosis. A review of clinical presentation, biochemical features, and pathophysiologic mechanisms. Medicine (Baltimore). 1998;77(2):73-82. doi:10.1097/00005792-199803000-00001
[xviii] https://www.hsph.harvard.edu/news/press-releases/personal-microbiomes-contain-unique-fingerprints/, viewed 10th December, 2021.
