1

Practitioner-prescribed phytotherapy for chronic fatigue syndrome: audit of eight

cases with positive outcome

Ann F Walker PhD MCPP MNIMH

New Vitality Clinic, 366 Wokingham Rd, Earley, Reading RG6 7HT

Correspondence:

Dr Ann Walker at the address above

Telephone: + 44 (0) 118 966 6930

e-mail: annfranceswalker@googlemail.com

Running heading: Successful phytotherapy for CFS

Descriptors: CFS; chronic fatigue syndrome; nutrition; supplements; herbal medicine

Ann Walker Ann retired from her post as Senior Lecturer in Human Nutrition in 2008 after 35
years at the University of Reading. She became interested in the medicinal uses of herbs, when

her husband, Alan, who had chronic fatigue syndrome, successfully responded to treatment with

Chinese Herbal Medicine. While holding down her post at Reading, Ann retrained as a herbal

practitioner at the College of Phytotherapy. She runs a Clinic on two days a week where she

treats patients suffering from a wide variety of conditions with a combination of nutrition and

herbal medicine. At the University of Reading her clinical studies have investigated the effects of

nutrients and plant extracts as single and complex interventions. Her study groups have included

those with PMS, adverse menopausal symptoms, type II diabetes and hypertension. She is the
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author of several books on human nutrition and many scientific papers. Ann is currently Director

of Continuing Professional Development of the CPP and is Co-Director, with her husband, of

“Discovering Herbal Medicine” - a 12 month home-study course – completion of which allows

entry to most BSc degree courses in Herbal Medicine in the UK.

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Abstract

This audit was undertaken with a view to documenting the efficacy of practitioner-
prescribed multi-nutrient intervention, including herbal medicine, for the treatment of
CFS. The audit was carried out on data collated retrospectively from case notes taken in
a clinic of herbal medicine in the three years ending April 2003.

The eight women who met the inclusion criteria for the audit were aged between 19-67
years. All showed substantial improvement in their health during the course of their
treatment. Following consultation with a herbal practitioner, the intervention comprised
of individually-tailored advice on diet modification and nutrient supplementation and
individually-prescribed herbal medicine. The most frequent dietary advice was to
increase intake of fruit and vegetables (7/8) and oily fish (7/8). The most frequently-
prescribed supplements were a high-potency vitamin and mineral formulation (8/8),
vitamin C (6/8), omega-3 fatty acids (6/8), a bone-mineral formula containing calcium
and magnesium (6/8) and magnesium (4/8). The duration of treatment described
averaged 22 months (range 3-41 months).

A total of 85 herbs were prescribed at least once among the group. Those prescribed
most frequently included Hypericum perforatum (8/8), Astragalus membranaceus (7/8),
Vitex agnus-castus, Echinacea purpurea (both 6/8), Glyccyrhiza glabra, Passiflora
incarnata, Schizandra chinensis, Valeriana officinalis, Verbena officinalis, Viburnum
opulus, Zingiber officinale (each 5/8) and Cinnamonum verum, Hydrastis canadensis,
Silybum marianum and Withania somnifera (each 4/8). Ranking order for weight of
individual herbs prescribed, calculated on both an individual monthly mean and a global
total for the group varied from the frequency ranking as would be expected, on account of
the variable quantities of herbs used in prescriptions.

This audit provides preliminary evidence that a multifaceted nutrient intervention,

including herbal medicine, can be effective for the relief of CFS symptoms. A
prospective, longitudinal study of this multi-dimensional approach to treatment of CFS is
now warranted.
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Introduction

Fatigue is condition which is difficult to define because of its multi-dimensional and

heterogeneous nature (1). It can be a symptom of other health problems such as
premenstrual sydrome, depression or diabetes. When fatigue has persisted for more that
six months, in the absence of other obvious pathology, and accompanied by the presence
of specific symptoms, including sore throat, joint pain, muscle pain, impaired memory or
concentration, then the term Chronic Fatigue Syndrome (CFS) may be applied (2). CFS
usually results from a combination of aetiological factors, including, viral infection, poor
nutrition, stress, overwork, lack of (or too much) exercise and lack of sleep.

To date, the only proven natural therapies shown to be helpful for CFS are graded
exercise therapy (3) and cognitive therapy (4). Even so, progress towards recovery is
slow and not all subjects benefit from treatment. As far as nutrition is concerned, only
single nutrient interventions have been studied systematically. Iron-deficiency anaemia is
well known as a cause of fatigue and weakness (5). Magnesium deficiency has been
linked to fatigue, because of its role in cellular respiration (6), including mitochondrial
function (7), and the oxidation of long-chain fatty acids.

Generalised weakness, depression and fatigue are among the common symptoms of
vitamin B12 deficiency (8). Furthermore, low body status of folic acid is common in
patients with fatigue (9). Indeed, the use of folic acid supplements have been shown to
abolish a plethora of symptoms, including low mood, muscular and mental fatigue in
CFS sufferers with low folic acid status (8). CFS sufferers have also been shown to have
low body status of vitamin B6, compared to controls (10).

Omega-3 essential fatty acids, low in modern diets, are required for a wide range of
biological and physiological processes, including some in the immune system. In a
double-blind, 3-month intervention study with 63 CFS subjects, those supplemented daily
with 4 g of oil containing EPA and DHA (eicosapentaenoic and docosahexaenoic acids),
showed, compared with the placebo group, marked impovement in fatigue and symptoms
associated with persistent fatigue: myalgia, dizziness, poor concentration and low mood
(11).

There is increasing evidence that fatigue is associated with abnormalities of the immune
system (12; 13; 14; 15). It is evident from studies such as those of Barringer et al. (16),
that poor immuno-competence can be ameliorated in some groups by supplementing with
multi-nutrients. Indeed, in populations consuming less-than-ideal diets, single-nutrient
intervention studies are unlikely to show optimal effects on the immune system when
multi-nutrient deficit prevails.

The objective of the current audit was to document the health benefits accrued to women
with CFS using a practitioner-prescribed, multi-faceted intervention of nutrition and
phytotherapy.

Methods
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The audit

The purpose of the audit was to identify, from among case history notes of patients
attending a clinic of herbal medicine from May 1 2000 to April 30 2003, women who (a)
met the CDC (Centre for Disease Control, USA) CFS classification criteria (2) at their
first consultation and (b) had made substantial improvement in their health in that time
period. The CDC criteria are persistent or relapsing fatigue of > 6 months, not alleviated
by rest and preventing normal activities, with four or more of the following: (a) loss of
memory or concentration, (b) sore throat, (c) tender lymph nodes, (d) muscle pain, (e)
joint pain, (f) headaches, (g) waking un-refreshed from sleep, or (h) post-exercise
malaise.

Intervention

Individually-prescribed treatment was given to each woman, following the recording of a

detailed medical history at first consultation. The treatment strategy had three
components: (a) diet modification, (b) dietary enhancement through essential-nutrient
supplementation, and (c) herbal medicine. Follow-up consultations were held with each
patient after 2 and 6 weeks and thereafter at 2 to 3 monthly intervals. Few changes were
made to dietary advice and dietary supplementation prescribed throughout treatment.
However, the herbal prescriptions were likely to change in accordance with patient
presentation at each consultation.

Diet:

All patients were advised to eat a healthy diet. In particular and if not already doing so,
to incorporate the following key features into their regular diet: (a) at least five portions
of fruit plus vegetables per day, (b) wholegrains, including cereals, nuts, seeds and
beans, (c) a balance of fatty acids (omega-6 and omega-3), by using olive oil and
products, eating two portions of oily fish a week and reducing intake of seed oils
(sunflower, corn, vegetable), (d) three portions of dairy products per day and (e) plenty
of fluids, including water.

Supplements:

A high potency vitamin and mineral supplement (Multi Max or Multiguard, Lamberts
Healthcare Ltd, Tunbridge Well, UK) was prescribed for all subjects to provide a full
range of vitamins and minerals at daily target amounts or above to ensure nutrient
repletion.

To reduce inflammation, which can be an important factor in CFS, a two-pronged

approach was used: enhanced intake of antioxidants and of omega-3 fatty acids. Hence
supplements of antioxidant vitamins (1000 mg/d vitamin C and 500 iu/d natural-source
vitamin E) and omega-3-enriched fish oils were prescribed as indicated. If diet was
unusually restricted, special provision was made to ensure nutrient repletion through
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supplementation. For example, calcium was supplemented (with magnesium) if dairy

products were not tolerated or intake was low. If dairy intake was adequate (3 portions a
day) then magnesium supplementation alone was used if intake of wholegrains, nuts,
seeds or beans was low and/or symptoms of cramps, muscle twitches, palpitations,
restless legs, PMS, neck tension, tightness across the chest or headache presented at first
consultation.

Herbal medicine:

The weight (as equivalent of dried herb) of each herb prescribed for an individual was
calculated from patient records using an EXCEL (MicroSoft) spreadsheet. The
calculation for tinctures (1:5 aqueous alcoholic extracts) assumed that 1 ml is equivalent
to 0.2 g of dried herb, and appropriate conversion factors were made in a similar fashion
for 1:3, 1:4, 1:8 and 1:10 tinctures. For fluid extracts (1:1 aqueous alcoholic extracts), 1
ml was assumed to be equivalent to 1 g of dried herb. Herbal extract tablets were
calculated as equivalent weight of dried herb using manufacturers' data. Liquid herbal
preparations were mainly obtained from Phyto Products Ltd, (Mansfield Woodhouse,
Nottinghamshire NG10 8EF, UK), Proline Botanicals Ltd (Stamford, Lincolnshire, PE9
4LF, UK) and Natures Laboratory Ltd (Brereton Lodge, Goathland, Whitby, North
Yorkshire YO22 5JR). Herbal extract tablets were obtained as follows: Galega
officinalis, and Gymnema sylvestre from MediHerb (Warwick, Australia) and Hypericum
perforatum from Lichtwer Pharma UK Ltd (Marlow, Bucks, SL7 1FJ) and Lamberts
Healthcare Ltd (Tunbridge Wells, Kent, TN2 3EH, UK). Other tablets used were:
Passiflora incarnata tablets (Potters Herbal Supplies Ltd, Wigan, Lancashire, WN1 2SB,
UK), dried ginger root capsules (Bio Health Ltd, Rochester, Kent, ME2 4HU, UK) and
Sunerven tablets (comprising Passiflora, Valeriana, Verbena and Leonurus cardiaca from
GR Lane Health Products Limited, Gloucester, GL1 3QB, UK).

The intake of herbs was expressed in two ways. Firstly, the total intake of herbs was
calculated for each woman over the entire duration of her treatment as weight of dried
herb equivalent, in grams. This value was then divided by the number of months of
treatment, to give a monthly intake average. The full array of herbs used among all 8
women was placed on a spread sheet, and the group mean of the monthly average intake
for each herb was calculated and ranked.

In the second method of calculation, the total intake of herbs (g) for each individual over
her entire treatment period was entered into a spread sheet with the full array of herbs
used by the 8 women. The total dried weight equivalent of herbs used among the eight
individuals was then calculated to give an overall grand total of weight of each herb used
by the group for the entire duration of treatment.

Results
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Patients:

Eight patients met the criteria and their details are shown in Table 1. Their ages ranged
from 19 to 67 years at first consultation. The prevalence of CDC CFS Classification
symptoms was: loss of memory or concentration (5/8), sore throat (6/8), tender lymph
nodes (4/8), muscle pain (3/8), joint pain (6/8), headaches (5/8), unrefreshing sleep (7/8)
and post-exercise malaise (8/8). In addition, other symptoms not used in the CDC CFS
Classification were noted as shown in Figure 1.

Table 1 Details of eight women qualifying for the CFS audit ranked in order
of age

Patient Age at first Occupation BMI Drugs

initials clinic visit prescribed
SC 19 None 21 None
HS 20 None 18 Dianette
AV 27 None 20 Amitriptyline
KS 34 Administrative assistant 24 Anti-depressant
JK 36 Medical representative 24 Steroids
TY 48 Farmer's wife 20 Antibiotic
AT 63 Retired 22 None
JH 67 Retired 20 HRT
BMI, body mass index.

Two of the women in the audit (KS and JK) had been diagnosed by their doctor or a
specialist as having PCOS (polycystic ovary syndrome) prior to the first consultation.
Three of the younger women were unable to continue with their studies or to engage in
paid employment at first consultation (SC, HS, AV), those in work were struggling to
cope and had no social life at all (KS, JK), while those retired women (AT, JH) were not
enjoying retirement, lacking the energy to engage in any pursuit outside the home or to
enjoy interaction with grandchildren.

Diet:

Figure 2 shows the dietary advice and essential-nutrient supplement regime which was
recommended for the women. The case notes show that it was necessary to advise 7 of
the 8 women to increase their fruit and vegetables and oily fish intake. Only 2 women
were requested to use more olive oil and less omega-6-rich oils and to eat more dairy
products.

Supplements:

All eight women were advised to take a high-potency vitamin and mineral supplement
such as Multiguard or Multi-Max (Lamberts Healthcare Ltd). These formulas are
higher than the RNI (Reference Nutrient Intake, 17) for B vitamins and trace elements.
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Seven of the 8 women were advised to take extra vitamin C (1g), while one was already
doing so before the first consultation. Six of the 8 women were advised to take a omega-3
fatty acid supplement (5 ml of Extra High Strength Cod Liver Oil, Seven Seas Ltd, Hull,
HU9 5NJ, UK) to provide a total intake of DHA (docosahexaenoic acid) + EPA
(eicosapentaenoic acid) of 2 g per day).

Figure 1 Number of women in the audit suffering from symptoms not included
in the CDC CFS classification system

No 'proper' colds

Muscle weakness

Cold hands/feet

Insomnia

Catarrh

Irritable bowel syndome

Nausea

Palpitations
Muscle cramps

Ear ache

Dizziness

Painful periods

PMS

Cystitis

Mood swings

Sore eyes
Gastritis

Noise intolerance

Croaky voice

Night sweats

0 1 2 3 4 5 6 7 8 9

Figure 3 shows that in order to reach the RNI of 700 mg for women, three portions of
dairy products a day are required. Six of the 8 women were not consuming and did not
intend to consume 3 portions of dairy products per day. To ensure that they met the daily
calcium target of 700 mg per day, a calcium + magnesium supplement (Osteoguard,
Lamberts Healthcare Ltd, containing 500 mg of calcium as carbonate and 250 mg of
magnesium as oxide) was prescribed for 6 out of 8 of the women. Magnesium citrate
(MagAbsorb, Lamberts Healthcare) alone (4/8).

Herbal medicine:

Eight-five herbs (Table 2) were used in prescriptions in at least one of the 8 women. The
most commonly used herbs were assessed in three ways: (a) frequency of use among the
group, (b) mean weight of individual intakes of each herb expressed as dried herb
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equivalent per month and (c) total weight of dried herb equivalent (kg) prescribed for the
entire group during the entire period of treatment.

Figure 2 Number of women in the audit given specific dietary advice or

prescribed nutrient supplements

More fruit & veg

More oily fish

More olive oil

Less omega-6 EFA

More diary products

Multi vit/mineral

Vitamin C

Omega-3

Calcium&magnesium

Magnesium

Vitamin E

Chromium

0 1 2 3 4 5 6 7 8 9

As far as frequency of use was concerned, only fifteen herbs were used among 4 or more
of the women. These were Hypericum perforatum (8/8), Astragalus membranaceus
(7/8), Vitex agnus-castus, Echinacea purpurea (both 6/8), Glyccyrhiza glabra, Passiflora
incarnata, Schizandra chinesis, Valeriana officinalis, Verbena officinalis, Viburnum
opulus, Zingiber officinale (each 5/8) and Cinnamonum verum, Hydrastis canadensis,
Silybum marianum and Withania somnifera (each 4/8). Figure 4 shows the twelve herbs
which were most commonly used when expressed as mean weight of dried herb (g) of
individual intakes per month. Figure 5 shows the twelve most commonly used herbs
expressed as total weight of dried herb equivalent (kg) prescribed for the entire group
during their treatment

Outcome:

A summary of the outcome of treatment is shown in Table 3. The average duration of

treatment was 22.3 months, but this varied from 3 to 41 months. Table 2 also shows that
the three younger women were, at the end of the treatment period, either fully employed,
studying or planning further education, while the older women were able to live a more
active life, including taking up tennis again (TY) and singing in a choir some evenings
(JH). At the end of the treatment period, the following practitioner estimates were made:
three had made a full recovery, three a 90% recovery and two a 85% recovery. In the
case of HS, recovery was hampered by a knee injury brought on by unaccustomed
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exercise late in her treatment and JK continued to take on too much work throughout her
treatment.

Table 2 Common and Latin names of the 85 herbs used in prescriptions for
the 8 women in descending order expressed as mean of individual
woman intakes per month* (g dried herb equiv)
Latin name Common name g Latin name Common name g
Hypericum perforatum St John's wort 548.7 Ocimum sanctum Holy basil 5.4
Schizandra sinensis Schizandra 254.0 Stachys officinalis Betony 5.4
Galega officinalis Goat's rue 149.9 Arctium lappa Burdock 5.2
Silybum marianum Milk thistle 147.3 Althaea officinalis Marshmallow root 5.0
Astragalus membranaceus Astragalus 120.7 Aesculus hippocastanum Horse chestnut 4.9
Glycyrrhiza glabra Licorice 99.2 Piper methysticum Kava kava 4.8
Valeriana officinalis Valerian 99.1 Epilobium parviflorum Willowherb 4.1
Zingiber officinale Ginger 74.8 Aloe vera resin Bitter aloes 3.7
Gingko biloba Gingko 63.2 Dioscorea villosa Wild yam 3.7
Withania somnifera Ashwaganda 60.8 Barosma betulina Buchu 3.7
Filipendula ulmaria Meadowsweet 55.9 Plantago lanceolata Ribwort plantain 3.4
Gymnema sylvestre Gymnema 52.6 Angelica sinensis Chinese angelica 3.1
Verbena officinalis Vervain 51.1 Elettaria cardamomum Cardamon 3.1
Leonurus cardiaca Motherwort 31.6 Viburnum prunifolium Black haw 2.9
Taraxacum officinale fol Dandelion leaf 28.5 Gentiana luteum Gentian 2.9
Melissa officinalis Lemon balm 27.8 Smilax spp Sarsaparilla 2.7
Lycopus virginicus Bugleweed 26.6 Allium sativum Garlic 2.6
Passiflora incarnata Passion flower 26.5 Ziziphus jujuba Ziziphus 2.6
Vitex agnus-castus Vitex 26.3 Crataeva nurvala Crataeva 2.4
Scutellaria lateriflora Skullcap 25.5 Uncaria tormentosa Cat's claw 1.9
Echinacea purpurea Echinacea 19.4 Gelsemium sempervirens Yellow jasmine 1.9
Cimicifuga racemosa Black cohosh 18.7 Foeniculum vulgare Fennel 1.8
Taraxacum officinale rad Dandelion root 16.9 Mentha x piperita Peppermint 1.8
Calendula offinalis Marigold 16.0 Equisetum arvense Horsetail 1.7
Scutellaria baicalensis Baical Skullcap 15.9 Paeonia lactiflora Peony 1.6
Piscidia erythrina Jamaica dogwood 15.2 Berberis vulgaris Barberry 1.2
Eschscholzia california Californian poppy 14.2 Hydrastis canadensis Golden Seal 1.0
Eleutherococcus senticosus Siberian ginseng 12.7 Viola odorata Sweet violet 1.0
Lactuca virosa Wild lettuce 11.4 Tabebuia impetiginosa Lapacho 0.9
Baptisia tinctoria Wild indigo 11.0 Hyssopus officinalis Hyssop 0.9
Phytolacca decandra Pokeroot 10.4 Solidago virgaurea Golden rod 0.7
Cinnamomum verum Cinnamon 10.2 Zea mays Corn silk 0.6
Cynara scolymus Artichoke 10.1 Betula pendula Silver Birch 0.5
Euphrasia spp Eyebright 9.8 Oleo europea Olive leaf 0.5
Bupleurum falcatum Hare's ear root 9.0 Verbascum thapsus Mullein 0.5
Agrimonia eupatoria Agrimony 8.8 Anemone pulsatilla Pasque flower 0.5
Salvia officinalis Red sage 8.5 Myrica cerifera Bayberry 0.4
Viburnum opulus Cramp bark 8.5 Ephedra sinensis Ephedra 0.3
Matricaria recutita German Chamomile 8.0 Sambucus nigra Elderflowers 0.3
Lavandula angustifolia Lavender 7.6 Urtica dioica Nettle 0.3
Carum carvi Caraway 6.4 Juglans cineraria Butternut 0.2
Oreganum vulgare Oregano 5.7 Lobelia inflata Lobelia 0.1
Thymus vulgaris Garden thyme 5.5
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Figure 3. Contribution of food servings towards achieving daily calcium intake

target (RNI) for women (mg)

Reference
Nutrient Intake

45 g cheddar
cheese

1 glass of milk
(200 ml)

45 g sardines

60 g tofu

1 125 g pot
yoghurt

100 g cooked
spinach

100 g cooked
brocolli

1 glass soyamilk
(200 ml)
0 100 200 300 400 500 600 700 800

Discussion

Patients and outcome:

None of the women in the audit was overweight. Indeed, 7 of the women had a BMI
(Body Mass Index) within the healthy range of 20-25, except HS, who was underweight.
All women suffered symptoms which complied with the diagnosis of CFS under the CDC
classification system.

Symptoms not featured in the classification system, namely, no 'proper' colds, muscle
weakness, cold hands and/or feet, insomnia and catarrh were each suffered by 6 or more
of the 8 women at first consultation (Figure 1). Some of these symptoms were more
frequent among the group than symptoms used for the CDC classification. Two of these
are worth mentioning in more detail.

No 'proper colds' refers to a lack of head colds with rhinitis. Patients showed a major
step forward in their recovery at around the time that they reported experiencing their
first 'proper cold'. On average this was after six months of treatment, although there was
considerably variability in duration among patients, no doubt reflecting the degree of
severity of their condition at first consultation. Although there is little mention of
differences in response to the common cold virus in connection with fatigue in the
medical literature, our clinical observations point to three categories of response.
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Figure 4 Twelve most commonly used herbs for treating 8 women in audit
expressed as mean of individual intakes per month* (g dried herb
equiv)

Hypericum
Schizandra
Galega
Silybum
Astragalus
Glyccyrrhiza
Valeriana
Zingiber
Gingko
Withania
Filipendula
Gymnema

0 100 200 300 400 500 600

The first is a healthy-body response, typical of a person contracting one or two head colds
a year with rhinitis. A person in this state may say "I rarely get colds". The second
category is the response shown by a person with moderate fatigue (sometimes called
'tired all the time' or TATT). Typically, he or she seems to have poor resistance to the
common cold virus, contracting a head cold with rhinitis as often as every 2 months. A
typical comment from such as person might be "I get every cold going". The third
category includes people with CFS, when the immune response to viruses is abnormal
and the normal symptoms of a head cold fail to manifest. A patient with CFS will often
say "I have not had a cold for years". However, close questioning will reveal that health
relapses follow exposure to the respiratory viruses and that these often coincide with
colds among other family members. These relapses may occur as often as once every
two weeks and largely account for the remitting and relapsing nature of CFS.

Poor peripheral circulation (cold hands and feet) is common among CFS patients
attending our clinic and is often accompanied by low blood pressure. In such cases,
herbs with circulatory stimulant action would be indicated. In the audit Zingiber
officinalis (Ginger, 1 g a day of dried root as capsules) was the herb of choice and
improvement in circulation to extremities was normally reported within 6 weeks of daily
use. For this reason Zingiber was one of the most commonly-used herbs used in the
audit (Table 2 and Figure 4).
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Figure 5 Twelve most commonly used herbs for treating 8 women in audit
expressed as total weight of dried herb equiv (kg) prescribed for the
women during their treatment

Hypericum
Glycyrrhiza
Schizandra
Galega
Silybum
Zingiber
Filipendula
Astragalus
Gingko
Gymnema
Valeriana
Withania

0.0 2.0 4.0 6.0 8.0 10.0 12.0

Diet:

Although patients attending our clinic are always reminded to include wholegrains, nuts,
seeds and beans in their diet for their high contents of magnesium and trace elements,
there was no record of anyone being given this advice in this audit.

Advice to eat at least 5-a-day of fruit and vegetables is pivotal to healthy eating. Only
one woman in the audit appeared to be approaching this intake, since seven were
specifically given this advice according to case history notes. Fruit and vegetables
provide necessary antioxidant protection against free radical toxins, which are now
known to be aetiological factors in all chronic disease. In CFS it is important that this
potent detoxicating food group is adequately supplied for its anti-inflammatory
properties.

Another important factor in reducing the inflammatory response is to achieve an optimal

balance of the essential fatty acid families: the omega-6:omega-3 ratio. Nevertheless,
only two of the eight patients were advised to include more olive oil (high in the 'neutral'
mono-unsaturated fatty acids) and less omega-6-rich oils in their diet, despite the overuse
of omega-6-rich oils, (such as sunflower oil) and products made from them in the British
diet. Nevertheless, 7/8 of the women were advised to eat more oily fish, rich in omega-3
fatty acids. The low prevalence of recorded advice on lowering omega-6 fatty acids in
this audit is likely to be an underestimate of the true picture, due to the retrospective
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nature of the audit and lack of recording of every detail of advice on diet.

Table 2 Outcome of integrated treatment with nutrition and phytotherapy for

chronic fatigue: an audit of 8 case histories

Patient Treatment Months Occupation Estimated Patient comments at follow-up

duration to recovery visits
(months) 'proper' (%)
cold
SC 7 5 University 100 Enjoying university away from
student home and doing well health-wise
HS 31 22 Home study 85 Learning to drive, Italian at home
planning and exercising in preparation for
University going to University
course
AV 34 20 Full-time 90 Coping well, moved away from
employment home to live with partner. Job
going well
KS 21 20 Adminstrative 90 Much happier, people have
assistant remarked how well she looks.
Coping well with job and living
on her own.
JK 19 11 Medical 85 Just coping with high-pressure
representative job with lots of long-distance
driving
TY 22 20 Farmer's wife 100 Much better. Playing tennis and
enjoying life once more.
AT 3 4 (post- Retired 100 Rapid improvement back to
treat) normal life
JH 41 15 Retired 90 Much more robust. Joined a
choir and even manages the odd
late night.

Only two patients were advised to eat more dairy products. However, to achieve the
target (RNI- Reference Nutrient Intake) of calcium for women of 700 mg, it is necessary
to eat about 3 portions of diary products. To emphasis this point, Figure 3 shows the
contribution of portions size amounts of dairy products compared to the RNI (Reference
Nutrient Intake) for women (17). Large numbers of UK citizens and especially women,
fail to meet their daily calcium intake target, according to data taken from weighed
dietary surveys of randomly-selected subjects in the National Diet and Nutrition Surveys
(e.g. 18). Again, this low level of advice on intake of calcium-rich foods in the audit
reflects the retrospective nature of the audit. In contrast to many CAM practitioners, in
our clinic we do not take the view that consumption of dairy products is the prime cause
of inflammatory conditions, including catarrh. Our approach to inflammation is to reduce
the body's tendency to inflammation through an adequate supply of antioxidants and a
proper fatty acid balance. This approach works well in practice for even the most
stubborn cases of catarrh as long as the nutritional changes are adhered to for a sufficient
time (more than 3 months).

The lack of precise records on dietary advice highlighted in the audit is now being
addressed in our clinic through the use of a therapeutic regime proforma given to all
 15

patients after first consultation.

Supplements:

The National Diet and Nutrition Surveys reveal that many people in the UK, of all ages,
do not reach their daily nutrient targets (Recommended Nutrient Intake or RNI) from
diet, with younger people among the worse affected (e.g. 18).. Women, in particular, are
more prone to nutrient imbalances than men, because of their low energy requirements
and, therefore, low intake of food to maintain body weight.

Nutrient supplementation was given to all the patients in this audit to ensure nutrient
repletion. People with CFS are particular at risk of low nutrient status. As well as the
probability of them being among the large groups of individuals in the community who
do not reach daily nutrient targets, they usually only engage in limited exercise. Low
energy intake consequent on a low energy expenditure is a risk factor for nutrient
deficiency. The use of dietary supplements has a long, safe history of use if used sensibly
within Upper Safe Intakes guidelines (19).

A high potency multivitamin and mineral supplement was recommended for all women.
These types of supplements are higher than the RNI for most nutrients. In particular, the
formulas used mostly in this practice, Multiguard or Multi Max are higher in B-
complex vitamins and trace elements than an A-Z multi vitamin and mineral formulation
based on RDA (The EU Recommended Daily Allowance for Labelling Purposes). A
higher nutrient intake is used in our clinic to speed tissue repletion, but, even so, the full
effect may not be evident for up to 3 months of daily supplementation, since tissue
exchange of many nutrients occurs only slowly.

To reduce inflammatory tendency in CFS the dual effects of antioxidants and omega-3
fatty acids were brought to bear. Hence, 6/8 of the women were advised to take a
supplement of vitamin C (1g per day). It is important to ensure adequate antioxidant
intake before giving advice to increase the intake of essential fatty acids, which are
highly unsaturated and hence liable to oxidation. [Indeed, our recently published study
on smokers with a low intake of fruit and vegetables, who were given fish oil (2 g omega
3 per day), showed enhanced LDL cholesterol oxidation after 3 weeks, which was
reversed by the further addition of 5 portions of fruit and vegetables a day (20)].
Omega-3 supplementation was recommended to 6/8 of the women. Between 1-2 g of the
active omega-3 fatty acids DHA + EPA (docosahexaenoic acid and eicosahexaenoic acid)
per day was prescribed, depending on the extent of inflammatory symptoms

Many of the women in the audit were not eating adequate dairy foods, being cautious in
their consumption because of their (in our opinion, mistaken) view that these foods are
'mucus forming'. Hence, the widespread recommendation in this audit to use calcium
supplements. We recommended Osteoguard (either 1 or 2 tablets per day, depending on
calcium intake). Each tablet contains 500 mg of Ca and 250 mg of magnesium, but as
calcium carbonate and magnesium oxide, which are not as absorbable as the organic
 16

forms of these nutrients. For 5/8 women there were indications of low magnesium status
(symptoms included, palpitations, muscle twitches, muscle cramps, restless legs at night,
headaches, tightness across the chest, PMS or stiff neck). For these women, 1 or 2 tablets
of magnesium (150 mg) as citrate was recommended (MagAbsorb), since this form is
more bioavailable than the oxide (21).

Herbal medicine:

Figures 4 and 5 show the 12 most commonly used herbs for treating the 8 women,
expressed on the basis of weight of dried herb equivalent intake, calculated in two ways.
The same herbs are present in both Figure 4 and 5, although the order differs according to
the method of calculation. However, four herbs included in Figure 4 and 5 were not
among the most frequently prescribed herbs according to subject. This is because they
were prescribed for two individuals at relatively high doses to address insulin resistance
for co-existing PCOS (polycystic ovary syndrome) (Galega officinalis and Gymnema
sylvestre extract tablets). Gingko biloba was prescribed for one women as a standardised
extract tablet, based on a 50:1 extract. Filipendula ulmaria was prescribed for one
patient as the fluid extract (1:1). On the other hand, some herbs which were used with
the majority of subjects (high frequency) (Cinnamonum, Echinacea, Hydrastis,
Passiflora, Verbena, Viburnum opulus and Vitex), did not feature in Figure 4 and 5,
because the dosage (as dried herb equivalent), considered necessary for a therapeutic
effect, was relatively small, or these herbs were only used for a short time.

Hypericum was the most commonly used herb of all 85 prescribed for the 8 women
during their treatment. This herb was commonly used on the basis of both frequency of
use and weight of dried herb intake (Table 2 and Figures 4 and 5). Hypericum is well
indicated for treatment of CFS. It has a wide spectrum of actions, with reported benefits
in most organ systems (22). Although best known in modern times for its anti-depressant
activity, which is supported by over 30 double-blind clinical, this herb also has immuno-
modulatory and anti-viral effects. Hypericum can be safely used, even with children and
the elderly, as long as the patient is not concomitantly using certain classes of drugs such
as Digoxin, Cyclosporin or the contraceptive pill, the levels of whose active constituents
in the blood are critical to their efficacy (23). This is because the detoxicating action of
Hypericum in enhancing liver function enhances drug disposal and hence reduces
circulating levels. In the audit, one woman was taking Dianette for acne, not for
contraceptive purposes, but she stopped taking this drug shortly after commencing
treatment, so Hypericum was then prescribed.

Other herbs used most commonly among the 8 women include 4 with immune and nerve
tonic actions to raise vitality. These were Astragalus, Withania, Schizandra and
Glyccyrhiza. The actions of these herbs has been termed adaptogenic (substances that act
in the body according to its prevailing physiological state) and may act in immune and
nervous tissue. The mode of action of adaptogens is hence 'state specific' and is best
illustrated by the mechanism of action of phytoestrogens, since modern science has
identified the cell receptors involved. Phytoestrogens are capable of blinding to the cell's
oestrogen receptors (particularly to the ß-oestrogen receptors located in bone, brain and
 17

arteries). Once bound, phytoestrogens exert a mild oestrogenic effect when circulating
oestrogen levels are low such as in the menopause. However, when circulating oestrogen
levels are too high (as in cyclic mastalgia, endometriosis and other 'oestrogen dominant'
conditions), binding to or occupancy of the oestrogen receptor blocks the effects of
oestrogen by inhibiting its binding and hence reduces its potency. Herbs with marked
phytoestrogenic properties among the 85 herbs used with the 8 women include
Cimicifuga racemosa, Dioscorea villosa, Angelica sinensis, Smilax spp and
Eleutherococcus senticosus. The nature of the receptors targeted be these adaptogenic
herbs which modulate immune and nervous function are as yet unidentified.

Other herbs in a prescription were chosen according to individual presentation. For

example, Vitex was prescribed for some women where there were problems associated
with the menstrual cycle.

Conclusion

In our hands, a multi-dimensional treatment strategy based on dietary modification,

dietary supplementation and herbal medicine, led to a steady amelioration of symptoms
in the 8 patients with CFS in this audit. Advice on diet modification was based on
published data on healthy eating principles. Dietary supplementation was based on
clinical trial evidence and phytotherapy was based on a mixture of traditional use and
scientific knowledge. However, this 3-dimensional approach is by no means a rapid or
magic cure. Indeed, health benefits are only likely to accrue if the patient accepts the
limitations that CFS imposes on them, as well as taking personal responsibility for
compliance to lifestyle changes and a demanding therapeutic regime.

During the course of their treatment, as the health of patients improved, a change was
noted in their response to cold viruses - an observation not previously documented and
which needs further investigation. In particular, the point at which the patients developed
their first head cold with rhinitis coincided with a marked amelioration of symptoms, to
the extent that the classification of their condition as CFS no longer applied. Although
not fully recovered at that phase, the patient appears to be well on the way to recovery
provided that she/he puts sensible limits on exercise and other activities. Nevertheless,
graded exercise, taken on a regular basis, and within the patient's capabilities, is then very
much recommended. Exercise undertaken in this way will, itself, stimulate the immune
system in a positive way. But it should only be undertaken when the body is in a fit state
to benefit from it. Once recovered, ex-CFS sufferers should follow good nutritional
principles indefinitely and adjust other aspects of their lifestyle to accommodate their
vulnerable constitution.

Acknowledgements

Grateful thanks to the patients in the audit for their interest in Herbal Medicine and their
tenacity in carrying out a demanding treatment programme. Thanks also to Leigh
Deller-Smith, Stephen Hicks, Alan Lakin and Freda Miller for their invaluable support in
running New Vitality Clinic.
 18

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