colleen gill, ms rd cso - denver, colorado · colleen gill, ms rd cso ... limit high glycemic index...
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Colleen Gill, MS RD [email protected]
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
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
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 [email protected]◦ 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