Geoff’s Narrations
The Blog
Are people with ME/CFS, fibromyalgia and long COVID at risk for major metabolic problems?
The GIST
- We hear a lot about metabolic problems in chronic fatigue syndrome (ME/CFS) but surprisingly little about the kinds of metabolic problems (metabolic syndrome, liver disease, and type II diabetes) that have become increasingly commonplace in our society.
- Warning bells began chiming for me as I was reading Peter Attia’s “Outlive: the Science and Art of Longevity“. Peter Attia, who got his MD at Stanford, then spent five years as a general surgery resident at Johns Hopkins, opened a practice focused on longevity in 2014.
- Metabolism has played a major role in Attia’s approach to longevity. It turns out that if you can get your metabolism under control, your risk of having many serious conditions that typically occur later in life (cancer, cardiovascular disease, Alzheimer’s) goes down dramatically.
- Attia believes, though, that our medical system is delinquent in not ferreting out metabolic problems as soon as they appear and before they become serious.
- Metabolic syndrome is a good example. It’s often the first time a patient learns they may be in trouble. By then, though, they are at increased risk of a bunch of nasty conditions: atherosclerosis, high blood pressure, non-alcoholic fatty liver disease (NAFLD), chronic kidney disease, sleep apnea, low-grade inflammation, increased risk of breast, liver and colorectal cancer, blood clotting disorders, type II diabetes, and – not surprisingly – reduced life expectancy.
- The sedentariness, inability to exercise much, and problems sleeping are red flags suggesting that people with ME/CFS, FM, and/or long COVID may be at increased risk for metabolic syndrome, diabetes, and other metabolic disorders, and indeed the limited studies that have been done suggest that ME/CFS and FM patients are at substantially higher risk of having metabolic syndrome.
- The way each of our bodies store fat is important. Fat accumulations under the skin are harmless metabolically speaking but visceral fat – fat that is packed into our muscles and organs is inflammatory and may begin the process of insulin resistance.
- Attia believes insulin resistance or hyperinsulinemia is the canary in the coal mine regarding metabolic problems. Attia has described elevated insulin as “the foundation upon which the major three chronic diseases sit”. When insulin resistance occurs the cells become less able to store glucose in them – causing glucose levels in the blood to rise.
- Attia uses a Dexan body scan and fasting glucose/Insulin and oral glycemic load tests to assess the amount of visceral body fat, and insulin resistance, and glucose present.
- He tests uric acid levels because uric acid can worsen insulin resistance, promote inflammation, promote the progression of metabolic disorders, impair fat metabolism, promote visceral fat accumulations, is associated with triglyceride levels, and contribute to fatty liver disease.
- Homocysteine is assessed because it generates oxidative stress, can disrupt insulin signaling, is associated with elevated triglyceride levels, and promotes visceral fat accumulation.
- ALT (alanine aminotransferase) Liver Enzyme – ALT is assessed because the liver regulates both blood glucose levels and fat (lipid) metabolism and the liver can start pouring out bad fats, such as triglycerides, that compound the problem.
- Triglyceride/HDL Ratio – Attia believes that triglyceride levels which are more than twice the HDL cholesterol levels constitute a “very big red flag”.A high TG/HDL ratio is strongly associated with metabolic disorders such as metabolic syndrome and insulin resistance.
- High Triglyceride Levels – Attia believes that the currently accepted threshold for “normal” (150 mg/dL) triglycerides is too high, and that “elevated triglycerides are an under-appreciated warning of poor metabolic health. He proposes that triglyceride levels above 100 mg/dL should be considered abnormal. Triglycerides impair glucose transport into the cell.
- Very-Low-Density Lipoproteins (VLDL) – VLDLs transport triglycerides, cholesterol, and other fats (lipids) in the bloodstream. Increased VLDL levels are strongly associated with metabolic syndrome.
- Continuous Glucose Monitors (CGM) – Attia has his patients use CGMs to determine which foods are causing glucose spikes. Note that which foods spike glucose is very individual.
- See Treatment Takeaways at the bottom of the blog.
Warning bells started chiming as I read Attia’s book on longevity.
Warning bells began chiming for me as I was reading Peter Attia’s “Outlive: the Science and Art of Longevity“. Peter Attia, who got his MD at Stanford, then spent five years as a general surgery resident at Johns Hopkins, opened a practice focused on longevity in 2014.
Metabolism has played a major role in Attia’s approach to longevity. It turns out that if you can get your metabolism under control, your risk of having many serious conditions that typically occur later in life (cancer, cardiovascular disease, Alzheimer’s) goes down dramatically.
One of the reasons Attia opened his longevity practice is his – disgust is not too strong of a word – at the way in what he calls “Medicine 2.0” modern medicine sweeps warning signs of a looming metabolic breakdown under the rug. Stating that it “boggles” his mind, and is “beyond backwards”, Attia is clearly tweaked that doctors aren’t watching things like hyperinsulinemia (insulin resistance) as carefully as they do, say thyroid or cortisol levels.
Only when the patient reaches the stage where they have type II diabetes does anything significant often occur. By then, a lot of avoidable damage has already occurred.
Metabolic Syndrome
Metabolic syndrome can impact many areas of the body.
Metabolic syndrome is a good example of what Attia believes constitutes a massive failure of our medical system. If you meet three or more of the below criteria, you can join as many as 120 million other Americans who have metabolic syndrome:
- High blood pressure (>130/85)
- High triglycerides (>150 mg/dl)
- Low HDL cholesterol (<40 mg/dl in men or <50 mg/dl in women)
- Central adiposity (waist circumference >40 inches in men; >35″ in women)
- Elevated fasting glucose (>110 mg/dl).
Once you have metabolic syndrome, you’re at increased risk of a bunch of nasty conditions: atherosclerosis, high blood pressure, non-alcoholic fatty liver disease (NAFLD), chronic kidney disease, sleep apnea, low-grade inflammation, increased risk of breast, liver and colorectal cancer, blood clotting disorders, type II diabetes, and – not surprisingly – reduced life expectancy.
Should you progress to type II diabetes – as 40% of the people with metabolic syndrome who don’t intervene do – you’re in a world of hurt. Again, you won’t be alone – about one in 9 people in the U.S. have type II diabetes – but your risk of heart attack, stroke, nerve damage, digestive, kidney, and vision problems, cancer, osteoporosis, and erectile dysfunction, etc., go up dramatically. It’s not a happy place to be.
Yet, Attia believes that simple interventions done early could prevent all that. If only the patients knew about them – which brings us to diseases like chronic fatigue syndrome (ME/CFS), fibromyalgia, and long COVID.
About 25% of people with ME/CFS or fibromyalgia met the criteria for metabolic syndrome in several studies.
Metabolic Risk Factors in ME/CFS, Fibromyalgia, and Long COVID
The sedentariness, inability to exercise much, and problems sleeping are red flags suggesting that people with ME/CFS, FM, and/or long COVID may be at increased risk for metabolic syndrome, diabetes and other metabolic disorders. The relationship between being sedentary and these metabolic disorders is well known – as is how effective exercise is at battling them – but the sleep issue is less well known.
Several studies have found that reduced sleep results in increased fasting insulin levels the next day, but there are some qualifiers. The sleep restriction lasted one night, and was generally pretty intense (4 – 4.25 hrs), and studies exploring less sleep restriction (4-5.55 hours) found lower fasting insulin levels. Plus, one longer-term study which found no reductions in insulin sensitivity suggested that the body may be able to adapt.
Chronic Fatigue Syndrome (ME/CFS)
A large CDC study, “Chronic fatigue syndrome is associated with metabolic syndrome: results from a case-control study in Georgia“, (ME/CFS – 111; fatigued but not ME/CFS – 259; healthy controls – 123), found that people with ME/CFS were twice as likely as the healthy controls to meet the criteria for metabolic syndrome (MetS). Plus the more MetS criteria a person with ME/CFS met, the more fatigued they tended to be.
It was striking to see a recent UK Biobank preprint highlight, out of all its finding, evidence of “chronic inflammation, insulin resistance and liver disease”. Earlier in a hypothesis paper, Wirth and Scheibenbogen proposed that insulin resistance found in the muscles in people with ME/CFS “may only represent a broader disturbance of cellular metabolism”. If I have it right, they suggest that the mitochondrial problems in ME/CFS may be one driver of insulin resistance.
Increased levels of triglycerides – a key component of insulin resistance – have been found several times in ME/CFS.
Fibromyalgia
Several fibromyalgia studies have found an increased incidence of metabolic syndrome (MetS). A large 2020 fibromyalgia study, “Coexistence of fibromyalgia and metabolic syndrome in females: The effects on fatigue, clinical features, pain sensitivity, urinary cortisol, and norepinephrine levels: A cross-sectional study“, found that people with FM had a 4 times higher risk for metabolic syndrome than healthy controls. (Twenty-four percent of FM patients and 8% of healthy controls met the criteria for metabolic syndrome.) High triglyceride levels, in particular, were signaled out, and pain levels appeared to be associated with MetS patients as the FM patients with MetS had the highest pain ratings as well.
The authors attributed the increase in metabolic syndrome to pain-associated disability, sleep disturbances, inactivity and increased weight. Other studies have found increased rates of insulin resistance, diabetes mellitus, higher triglycerides and total cholesterol. Even though body mass indexes were similar between FM patients and the healthy controls, the FM patients had a higher waist/hip ratio and a higher insulin resistance rate – indicating they were probably more predisposed to metabolic problems.
Uncontrolled hypertension was common – and related to quality of life measures – and many patients were not getting high blood pressure medication. The authors warned that the combination of MetS and fibromyalgia produced “an important risk factor for cardiovascular diseases and mortality“.
Likewise, a large Danish study, “Lipid metabolism and functional somatic disorders in the general population. The DanFunD study“, which examined people with ME/CFS, chronic widespread pain (CWP), irritable bowel (IBS), and bodily distress syndrome (BDS), found a positive association between these syndromes and elevated glucose, HbA1c, insulin levels, and insulin resistance. Obesity was not a major factor.
Tracking Your Metabolism with Medicine 3.0
Instead of waiting for metabolic syndrome or type II diabetes to show up, Attia proposes a “Medicine 3.0” approach that attempts to nip metabolic problems in the bud. This part of the blog will explain more about the metabolic issues in question and will highlight the metabolic tests Attia uses. While many of us may not be able to get all these tests done, most of us can probably get some of them done.
People with enough resources to pay for these tests themselves should be able to order most of them without a doctor’s prescription.
The Fat Storage Problem
Fat under the skin is fine; visceral fat in the muscles and organs is not.
When we eat carbohydrates, insulin shuttles the glucose produced either into the muscles – if you are exercising – or into the fat cells lying under our skin – if you’re not exercising. At this point, even if you accumulate a lot of fat under the skin, it’s essentially harmless.
Things change when the body starts housing the fat elsewhere in your abdomen, liver, heart, pancreas, muscle tissues, and the blood – where it will start showing up as high triglycerides (one of the metabolic criteria). Now you have pathologic fat – fat which secretes pro-inflammatory cytokines (TNF-a, IL-6).
Healthy fat storage rates range dramatically from person to person. One person may be able to store a lot of fat safely under their skin while another can store very little. This variability in the ability to store fat safely or not goes a long way to explain while some obese people can be healthy metabolically while some skinny people are not. Everyone who is obese, though, will have some form of insulin resistance.
It’s why – diverging from standard medical practice – Attia requires his patients to undergo a DEXA body scan every year to determine how much visceral (bad) fat they’re carrying. Attia believes that storing fat in the muscle cells (instead of under the skin) is the trigger for the development of insulin resistance.
Shulman has found that the best predictor for insulin resistance in muscle was the presence of fat in the muscles. (Fat under the skin is fine; fat buildup in the muscle cells, liver cells, etc., is not.)
The fact that insulin resistance starts in the muscle and then moves to the liver is not great news for exercise-intolerant or inhibited ME/CFS, FM, and long-COVID patients.
Attia Metabolic Test #1 – DEXA Body Scan
Attia requires his patients to undergo a DEXA body scan in order to determine how much visceral fat they’re carrying. If they’re carrying a lot, the goal will be to get those fat levels down. The scan appears to be surprisingly affordable ($100-$300).
The Canary in the Coal Mine – Hyperinsulinemia, or Insulin Resistance
“Hyperinsulinemia is the canary in the coal mine.” —Peter Attia
Attia calls insulin resistance the “canary in the coal mine” for many serious diseases.
Insulin resistance occurs when the muscle, fat, and liver cells increasingly “become dead” to insulin; i.e. they no longer respond to insulin’s signal to store glucose in them. With that, as glucose starts building up in the bloodstream, the pancreas, desperate to get glucose levels in the blood down, secretes even more insulin. That works at first – glucose is kept under control – but it’s a sign that the cells are starting to buckle metabolically.
Chronically elevated insulin usually results in weight gain, and increases the risk of atherosclerosis – and puts one “well down the track toward type 2 diabetes”.
Attia has described elevated insulin as “the foundation upon which the major three chronic diseases sit”. He believes charting insulin resistance is as important, if not more important, than charting glucose levels.
If the insulin resistance continues, the pancreas can become exhausted and stop producing as much insulin, causing blood glucose levels to rise and stay risen. Now you’re looking at some serious stuff: non-alcoholic fatty liver disease, non-alcoholic steatohepatitis (NASH), dyslipidemia (high triglyceride levels), and eventually type 2 diabetes.”
Plus, insulin resistance also disrupts the functioning of AMPK (adenosine monophosphate-activated protein kinase), a master regulator of cellular energy levels within the cells, which has been found impaired in both ME/CFS and FM.
Gerald Shulman, Professor of Medicine, Cellular & Molecular Physiology, and the Director of the Diabetes Research Center at Yale, reports that metabolic-associated fatty liver disease is the leading cause of NASH (non-alcoholic steatohepatitis), liver fibrosis, cirrhosis, end stage liver disease and will soon be shown to be the most common cause of liver cancer.
In fact, Shulman believes that insulin resistance is driving the huge increase in cancers associated with obesity (breast, colon, pancreatic, and liver cancers) and agrees that insulin resistance is a foundational problem for many serious diseases.
“… lf we can understand insulin resistance, then that’s going to be the best way to fix diabetes, type 2 diabetes, heart disease, we’re going to make a big impact there, fatty liver disease and slow down cancers.” —Gerald Shulman
Attia is so taken with the opportunity that catching hyperinsulemia in its early stages presents that he proposes that it “might have a greater impact on human health and longevity than any other target”.
Attia Metabolic Test #2 and #3 – Fasting Glucose/Insulin and Oral Glycemic Load Tests
Fasting glucose/insulin tests are fairly commonly done, but Attia wants to push the envelope further and do oral glucose tolerance or glycemic load test (OGTT) which provides a big hit of glucose (via a drink), then assesses insulin and glucose levels in 30 minute intervals over two hours.
Attia is looking for a bigger-than-normal jump in glucose and insulin levels followed by sustained elevated levels over the two-hour test period. Those elevations indicate that the muscles have been unable to absorb the glucose provided; i.e. insulin resistance is present.
Uric acid crystals.
Attia Metabolic Test #4 – Uric Acid
High uric acid levels can worsen insulin resistance, promote inflammation, promote the progression of metabolic disorders, impair fat metabolism, promote visceral fat accumulations, are associated with triglyceride levels, and contribute to fatty liver disease
Attia Metabolic Tests #5-9 – Homocysteine, ALT Liver Enzymes, Triglycerides/HDL Cholesterol, VLDL
- Homocysteine – generates oxidative stress, can disrupt insulin signaling, and is associated with elevated triglyceride levels, damages the blood vessels, impairs blood flows to the brain, and promotes neuroinflammation and visceral fat accumulations.
- ALT (alanine aminotransferase) Liver Enzyme – the liver regulates both blood glucose levels and fat (lipid) metabolism. In metabolic syndrome, the liver may start pouring out bad fats, such as triglycerides, that compound the problem. The liver readily gains fat as metabolic problems proceed, leading potentially to, first, non-alcoholic fatty liver disease (NAFLD), then non-alcoholic steatohepatitis (NASH, liver fibrosis, and eventually cirrhosis. Increased alanine aminotransferase (ALT) levels are commonly found in non-alcoholic fatty liver disease (NAFLD). Several recent studies suggest the liver may be involved in ME/CFS.
- Triglyceride/HDL Ratio – Attia believes that triglyceride levels which are more than twice the HDL cholesterol levels constitute a “very big red flag”.A high TG/HDL ratio is strongly associated with metabolic disorders such as metabolic syndrome and insulin resistance. It is “widely recognized as a surrogate marker for insulin resistance” and is associated with increased risk of atherosclerosis, heart attack, and stroke, and promotes (once again) visceral fat accumulations.
- High Triglyceride Levels – Attia believes that the currently accepted threshold for “normal” (150 mg/dL) triglycerides is too high, and that “elevated triglycerides are an under-appreciated warning of poor metabolic health. He proposes that triglyceride levels above 100 mg/dL should be considered abnormal. Triglycerides impair glucose transport into the cell.
- Very-Low-Density Lipoproteins (VLDL) – VLDLs transport triglycerides, cholesterol, and other fats (lipids) in the bloodstream. Increased VLDL levels are strongly associated with metabolic syndrome.
The only tests I have taken in the last five years are triglycerides (below 100) and glucose (low).
Using a Continuous Glucose Monitor (CGM)
CGMs are available only through prescription and they are not inexpensive ($10/day), but Attia states that using them for a month or two is all that’s needed. Attia has his clients use them to determine which foods – at which times – send glucose levels soaring. Every five minutes, it takes a reading. Attia believes CGMs are far more effective than hemoglobin A1c measurements. The goal is to use the CGM to lower glucose levels and to minimize the variability (spikes) in your glucose levels.
Attia stated that three monitors (Medtronic, Abbott, Dexcom) produce “clinical grade” results and he likes Dexcom best because it can be calibrated.
Treatment
Diet
Many people with ME/CFS/FM and/or long COVID may be ahead of the game because they already have a good diet. Attia thoroughly explored keto diets, and has come to believe that outside of broad outlines (reduced carbohydrates, plentiful vegetables, and fruits, few processed foods, high fiber, sufficient protein, etc.), diets are individual; i.e., different diets work for different people.
Note that if you’re overweight, losing even small amounts of weight (5-10%) can help reduce triglyceride levels.
A Focus on Fructose
An evolutionary adaptation long ago caused fruit sugar to be directly stored as fat.
Fructose deserves mention all on its own. Fructose metabolizes into uric acid which is associated with fat gain, inflammation, insulin resistance, etc.
It turns out that fructose is metabolized differently than glucose. When confronted with high levels of fructose, the ATP levels inside a cell drop rapidly, causing us to feel hungry. Plus, high levels of fructose can overwhelm the gut – sending fructose to the liver where it can end up as fat, and impair glucose regulation, etc.
(The fructose/uric acid/fat gain scenario is believed to result from an evolutionary adaptation that occurred when the fruit-loving apes needed to find a way to store fat as the climate cooled. From then on, eating fructose translated into fat storage).
While fructose is the kind of sugar found in fruits, eating fruits is not generally a problem because the fructose enters the bloodstream slowly. (Drinking apple juice, or fruit smoothies, is another matter.)
Note, though, that pure table sugar isn’t much better than fructose; it contains about the same amount of fructose as high-fructose corn syrup. Agave syrup is very high in fructose while blackstrap molasses and maple syrup are very low.
| Sweetener | Fructose Content (% by weight) | Notes |
| Table Sugar (Sucrose) | ~50% | Table sugar is sucrose, which is a 1:1 combination of glucose and fructose. |
| Molasses | ~29-40% | Varies by type (light – 29-35%, dark – 20-30%, blackstrap – 10-20%); contains other nutrients like iron and calcium. |
| Honey | ~38-41% | Fructose content is slightly higher than glucose, contributing to its sweetness. |
| High-Fructose Corn Syrup (HFCS 55) | ~55% | Commonly used in sodas; contains 55% fructose and 45% glucose. |
| Agave Syrup | ~56-90% | Known for its high fructose content; varies depending on processing methods. |
| Maple Syrup | ~1-4% | Primarily sucrose; contains only small amounts of free fructose and glucose. |
| Coconut Sugar | ~3-9% |
Improving One’s Metabolic Health
Ways to reduce insulin resistance – increase fiber intake, eat carbs with protein/fats, eat low glycemic index (GI) foods, take in healthy fats (monounsaturated and polyunsaturated fats – olive oil, avocados, etc.), stay hydrated, lose weight if overweight, get as good sleep as possible, manage stress (meditation, yoga, deep breathing exercises), try intermittent fasting, try drugs (metformin, thiazolidinediones (e.g., pioglitazone)).
Ways to lower high blood glucose levels – eat frequent small meals, increase fiber intake, eat carbs with protein/fats, low glycemic index (GI) foods, drugs (Metformin, Sulfonylureas, SGLT2 inhibitors, GLP-1 agonists), supplements (cinnamon, berberine (works similar to metformin), magnesium, chromium)
Ways to reduce triglyceride levels – Statins, fibrates (fenofibrate and gemfibrozil). niacin (Vitamin B3), high dose Omega-3 Fatty Acid Supplements – can all reduce triglyceride levels. Note that prolonged, high-dose niacin (particularly sustained release) can damage the liver, and niacin can impair insulin sensitivity and increase uric acids levels in the blood.
Metformin
Besides maintaining glycemic levels, Metformin might help with pain, mitochondrial functioning, and the gut.
Metformin has got to be one of the most interesting drugs around. Not only can it improve glycemic control and insulin sensitivity but it has immune-enhancing capabilities that suggest it may be helpful in chronic pain.
A recent review paper, “Metformin: A Prospective Alternative for the Treatment of Chronic Pain“, stated: “Data strongly suggest that metformin could open a new avenue for the treatment of pathological pain. The authors believe that metformin’s ability to inhibit mTOR expression may be helping it regulate the activity of out-of-control sensory neurons that are causing so much pain in FM and other diseases. (High glucose levels can damage the nerves across the body.)
Plus, metformin has been found to have many positive effects on the gut, including increasing the levels of butyrate and short-chain fatty acids, and bulking up the integrity of the gut wall – three areas of concern in these diseases. A recent article proposed repurposing metformin to reduce inflammation and oxidative stress, and enhance gut barrier integrity and the gut microbiome in inflammatory bowel disease.
At least five studies/papers on metformin and fibromyalgia/chronic pain have been published. The fact that metformin reduced chronic pain and fatigue in a large UK study suggests insulin resistance may indeed play a role. One study even asked, “Is insulin resistance the cause of fibromyalgia? A preliminary report.“
Exercise
Treatment Takeaways
- Exercise plays a major role in Attia’s prescription for regaining metabolic health. Indeed, a brisk walk for an hour or two can do wonders for insulin resistance and glycemic problems. That’s beyond most people with these diseases but strength training – which can be done more or less anaerobically – provides another way to improve metabolic health. See the blog for more.
- Diet – many people with ME/CFS/FM and/or long COVID may be ahead of the game because they already have a good diet. Attia thoroughly explored keto diets, and has come to believe that outside of broad outlines (reduced carbohydrates, plentiful vegetables, and fruits, few processed foods, high fiber, sufficient protein, etc.), diets are individual; i.e., different diets work for different people.
- Ways to reduce insulin resistance – increase fiber intake, eat carbs with protein/fats, eat low glycemic index (GI) foods, take in healthy fats (monounsaturated and polyunsaturated fats – olive oil, avocados, etc.), stay hydrated, lose weight if overweight, get as good sleep as possible, manage stress (meditation, yoga, deep breathing exercises), try intermittent fasting, try drugs (metformin, thiazolidinediones (e.g., pioglitazone)).
- Ways to lower high blood glucose levels – eat frequent small meals, increase fiber intake, eat carbs with protein/fats, low glycemic index (GI) foods, drugs (Metformin, Sulfonylureas, SGLT2 inhibitors, GLP-1 agonists), supplements (cinnamon, berberine (works similar to metformin), magnesium, chromium)
- Ways to reduce triglyceride levels – Statins, fibrates (fenofibrate and gemfibrozil). niacin (Vitamin B3), high dose Omega-3 Fatty Acid Supplements – can all reduce triglyceride levels. Note that prolonged, high-dose niacin (particularly sustained release) can damage the liver, and niacin can impair insulin sensitivity and increase uric acid levels in the blood.
- Metformin may be a special case. Not only can it improve glycemic control and insulin sensitivity but it has immune-enhancing capabilities that suggest it may be helpful in chronic pain, plus, metformin has been found to have many positive effects on the gut, Fibromyalgia studies suggest it may be helpful in a number of ways.
- Not everyone will agree with Attia’s aggressive approach but for those who do Attia provides guidelines on what to look for. Ultimately we need to solve these diseases to eliminate the risk of metabolic breakdown and thankfully research is focusing more and more on the metabolism. Until then we have what we have. While Attia’s favorite remedy for metabolic issues – exercise – is beyond the reach of people with these diseases, other options – small amounts of strength training, better diets, supplements, and drugs may help.
All is not lost, however. Endurance training is, of course, a key part of complete exercise programs – and an hour or two of brisk walking does wonders for insulin resistance and glucose problems. Some people with fibromyalgia may be able to manage that, but that’s clearly out for most people with ME/CFS.
Endurance training is likely out, but some people may be able to do some strength training – which can help with glycemic control.
Strength training that mostly taxes the anaerobic energy production system, on the other hand, may be achievable for many more people. Simply building muscle mass and, even more importantly, muscle strength can have surprising physiological benefits.
For years I thought strength training was impossible – perhaps because I pushed too hard or because I had not started my stretching routine or maybe I was just not ready for it. Now I know, that at least for me, strength training is not only possible but helpful. While I doubt that any one of us can do the kind of strength training that Attia advises, many of us may be able to do something.
I’ve found that using exercise bands and doing simple exercises like bent knee pushups and core exercises can be done – if approached slowly – and will quickly increase my strength and even build a surprising amount of muscle pretty quickly. For me, the benefits of doing quite limited exercise a couple of times a week include increased well-being, resilience, ability to concentrate, etc. Sometimes when I’m lagging, I find that doing a mini workout with an exercise band or a few bent knee pushups can perk me up. All from engaging in what is essentially an anaerobic form of exercise.
The type 2 muscle fibers that strength training improves atrophy quickly when we are inactive and as we get older. Endurance training – even if you could do it – won’t do anything for these muscle fibers – only strength training will get them back.
Strength training takes on an extra emphasis as we age because bone density, particularly for women, diminishes on a parallel path to muscle mass and strength training stimulates the growth of bone. Studies report that osteoporosis is increased in fibromyalgia (and therefore probably is in ME/CFS as well). It doesn’t take much strength training to improve bone density.
First note that any exercise should be done following a meal in order to get the glucose from the meal into the muscle tissues.
Attia focuses strength training around increasing one’s grip strength, lifting and putting down weights slowly and with control, doing exercises that require pulling, and doing things like step-ups, hip thrusters, and deadlifts that strengthen the legs and lower back.
Attia also focuses on “eccentric exercises” which focus on slowly doing the “down” phase of, say, a bicep curl or weight lift. Slow and sure – the opposite of an aerobic workout. Attia also finds that breathing is important (a blog on breathing is coming up), talks about doing “toe yoga” to improve stability and balance and much more in his comprehensive coverage of exercise.
Conclusion
Some things can be done to reduce the risk of metabolic breakdown.
Given the difficulty exercising, the sedentariness, and the sleep problems diseases like ME/CFS/FM and long COVID impose it was no surprise to see studies suggesting high rates of metabolic syndrome may be present. Indeed, it would have been surprising not to see them.
Pete Attia MD puts metabolic problems at the very crux of many of the chronic diseases that damage our health and shorten our lifespans. He believes our medical system should be actively searching out and identifying and treating metabolic problems well before they reach the metabolic syndrome stage.
Not everyone will agree with Attia’s aggressive approach but for those who do Attia provides guidelines on what to look for. Ultimately we need to solve these diseases to eliminate the risk of metabolic breakdown and thankfully research is focusing more and more on the metabolism. Until then we have what we have. While Attia’s favorite remedy for metabolic issues – exercise – is beyond the reach of people with these diseases, other options – small amounts of strength training, better diets, supplements, and drugs may help.
Health Rising’s Donation Drive Update
These metabolic problems are rarely researched and discussed yet they may impact each of us over time. That’s why we dug into the weeds to learn more about them.
Thanks to everyone who has donated over $43,000 during Health Rising’s End of the Year donation drive.
This blog says a lot about what Health Rising does. Virtually no one talks about the looming metabolic problems that people with ME/CFS, FM, and long COVID may face. Perhaps because this type of metabolic problem isn’t considered a possible cause of these illnesses, studies are rare.
The cost to unsuspecting patients, however, is potentially huge and that’s why we took so much time to get into the weeds about this unusual issue. If that works for you please support us!
Another interesting article. Thanks, Cort.
If you have what appears to be normal hypertension (i.e. not provoked by orthostasis) but are a bit young and don’t have the usual risk factors, as well as having orthostatic intolerance symptoms with normal heart rate and blood pressure during a NASA Lean Test, you might have hypertensive-type OCHOS.
https://pubmed.ncbi.nlm.nih.gov/26909037/
https://pubmed.ncbi.nlm.nih.gov/27525257/
Before you appear to promote a drug like metformin in your blog, do some background research. Here is the black box warning on metformin.
“IMPORTANT WARNING:
Metformin may rarely cause a serious, life-threatening condition called lactic acidosis. Tell your doctor if you have kidney disease. Your doctor will probably tell you not to take metformin. Also, tell your doctor if you are over 65 years old and if you have ever had a heart attack; stroke; diabetic ketoacidosis (blood sugar that is high enough to cause severe symptoms and requires emergency medical treatment); a coma; or heart or liver disease. Taking certain other medications with metformin may increase the risk of lactic acidosis. Tell your doctor if you are taking acetazolamide (Diamox), dichlorphenamide (Keveyis), methazolamide, topiramate (Topamax, in Qsymia), or zonisamide (Zonegran).
Tell your doctor if you have recently had any of the following conditions, or if you develop them during treatment: serious infection; severe diarrhea, vomiting, or fever; or if you drink much less fluid than usual for any reason. You may have to stop taking metformin until you recover.
If you are having surgery, including dental surgery, or any major medical procedure, tell the doctor that you are taking metformin. Also, tell your doctor if you plan to have any x-ray procedure in which dye is injected, especially if you drink or have ever drunk large amounts of alcohol or have or have had liver disease or heart failure. You may need to stop taking metformin before the procedure and wait at least 48 hours to restart treatment. Your doctor will tell you exactly when you should stop taking metformin and when you should start taking it again.
If you experience any of the following symptoms, stop taking metformin and call your doctor immediately: extreme tiredness, weakness, or discomfort; nausea; vomiting; stomach pain; decreased appetite; deep and rapid breathing or shortness of breath; dizziness; lightheadedness; fast or slow heartbeat; muscle pain; or feeling cold, especially in your hands or feet.
Tell your doctor if you regularly drink alcohol or sometimes drink large amounts of alcohol in a short time (binge drinking). Drinking alcohol increases your risk of developing lactic acidosis or may cause a decrease in blood sugar. Ask your doctor how much alcohol is safe to drink while you are taking metformin.
Keep all appointments with your doctor and the laboratory. Your doctor will order certain tests before and during treatment to check how well your kidneys are working and your body’s response to metformin. Talk to your doctor about the risk(s) of taking metformin.”
Since there is no proof that metaformin is a cure for either ME/CFS, Long Covid or fibromyalgia, you have to ask yourself, is it worth any risk?
I can speak from personal experience. When I got COVID in March of 2023 my ME doctor put me on metformin. I’m not diabetic, though my levels were close. After 7 weeks I improved back to my baseline. After 3 months my functionality had improved by 15%. Metformin had the most positive impact on my FM ME CFS symptoms. I have not experienced any of the warnings you posted above. My point is we are all different and I don’t want to discourage people from considering metformin. It’s not a cure, there will not be a cure in my lifetime, but my quality of life is better because of it.
My latest research and personal experience leads me to make the following observations. Infections, stress and our toxic environment in combination leads to increased oxidative stress. This then leads to a change in our metabolic pathways and mitochondrial damage. The body starts to favour glycolysis instead of oxidative fosforilation to try and reduce the free radicals. This produces more lactic acid and reduced ATP. The sells become starved of energy and unable to function as they should. The body tries to shan’t the glucose through the PPP to provide NADPH for the production of glutathione and nucleotides for defence and repair. The people that have genetic weaknesses in these pathways and difficulty dealing and repairing from oxidative stress develop ,ME/CFS. Depending on their enzyme deficiencies they end up with different severity. I have MTHFR, MTRR, G6PD, DBH, GBA, COMT and MAOA mutations and who knows what other mutations, leading to enzyme deficiencies. I.e I have trouble dealing with oxidative stress, detoxifying harmful chemicals, producing certain neurotransmitters and catabolizing catecholamines. So in other words I have trouble dealing with toxic environments, stress and inflammation. Inflation is at the core of all chronic conditions and when the body tries to compensate by using alternative methods of producing energy this leads to insulin resistance and the effects from it – cardiovascular problems, cancer, chronic infections etc. It is a systemic problem and depends on our individual make up. It starts with an event that overwhelms our defences against oxidative stress and have a downstream effect causing compensatory mechanisms and alternatives ways of producing energy avoiding the production of free radical. All this has a cost. This of course is my hypothesis but logically it makes sense and could explain all my symptoms and the development of metabolic syndrome. I am a member of a number of Facebook insulin resistance groups and can confirm that Metformin has helped noone. This the N:1 drug prescribed by endocrinologist in Bulgaria and yet no one has managed to get their Insulin resistance under control long term. It has alot of side effects and is poorly tolerated by many. I personally think this is another gimmick by the pharmaceutical industry trying to promote a drug that is required to be taken for life. The same as the new GLP-1 ones. They do nothing to address the origin of the problem.
Who said it would cure ME/CFS, FM or long COVID – I didn’t and several studies suggest it could help. Metformin is one of the most commonly used drugs in the U.S. 90 million prescriptions were given in 2021 and doctors are well aware of its risks and should communicate them to their patient. Note that the warning says “rarely cause a serious, life-threatening condition called lactic acidosis.” I know of several ME/CFS doctors who are prescribing it.
I dug further as you asked and asked how many people who take Metformin get lactic acidosis
“Metformin use carries the risk of fatal lactic acidosis, particularly in patients with liver and kidney impairment, with an incidence of 1 in 30,000 patients3. The crude incidence of lactic acidosis or elevated lactate concentrations in current metformin users was 7.4 per 100,000 person-years2. In a review of 11,800 patients treated with metformin, only two patients developed lactic acidosis1.
It’s alarming to know that exercise, the thing we all struggle with to some degree and often severely, is so critical to metabolic health, quality of life and lifespan. I’ve had some success in avoiding starchy foods for more than twenty years of illness, eating less (to match reduced activity) to keep my weight down, and so far my bloods look alright compared to Attia’s criteria. With so much inactivity (my steps are below 1000 a day) I thought I’d have issues. I also had a cardiac CT done recently to check my coronary arteries and was surprised to have a zero calcium score. We often can’t exercise easily or much at all but we can hang onto other things we can do especially with diet.
My fat didn’t come from diet.
I was put on 1 1/2 years of tetracycline for acne at the age of 14…
And what do the agriculture industry use for fattening up cattle at the feed lot before the cattle hit the market?.. or chickens…..tetracycline
When my me/cfs shit hit the fan in 1993 all of these large lumps,some as big as 2 inches,appeared to be in my lymph system BUT I also had lumps appear to express themselves just under the skin.i know now that these lumps just under my skin are fat that blew through my muscle.this all expressed themselves within one week….along with lymph and fat lumps came age spots….all these came within a week and ive been stuck in this trap ever since. Before this one week event, I never had an age spot anywhere on my body.
I did have an event in 1981 that caused an ulcer while drinking well water for 6 months while attending college…then went for years pleading with drs. That it feels like something was “growing” inside me and continually,slowely getting worse over time.
I recently was told by my nephrologist that the tetracycline I took at the age of 14 did this harm to me. I just turned 65. I do have at times elevated cholesterol but a change in diet corrects this in a short time. …but cholesterol is measured in the blood only….not measured in the muscle
I continue to have a couple of age spots that fluctuate from red to dark brown. Since starting tudca and taurine my age spots have gotten even lighter.
Could it be that the antibiotics (tetracycline) in cattle feed ,chicken feed etc.or self inflicted by putting trust in my doctor at the young age of 14 be the cause of many cases of me/cfs? Did the tetracycline kill off all of our good gut microbes allowing bad bugs to thrive?
Could this be the reason there has been a life long resistance to find causation by the people that should have done all this science but failed us all miserabley?
THE TRUTH ALWAYS COMES OUT
I too took tetracycline for a long time as a teenager for acne. I have ended up with very recently diagnosed diabetes 2 despite carefully eating a keto diet for 7 months to try to stave it off. It actually increased my insulin resistance & speeded up my descent into diabetes.
Metformin was a nightmare for me. I tried 2 brands, both caused severe IBS symptoms. I got frightened to eat anything. So painful. Now on sitagliptin which has been trouble free so I’m hoping that blood sugar levels will respond.
I also developed insomnia,IBS, FM & hypothyroidism years ago. I was badly treated & ignored by the UK NHS as is common. I used to exercise frequently before the FM hit. Having read the article here today I can see the way my body is going to fail further. I’ve done everything possible to stave it off but I didn’t have enough medical help. It might be that early & prolonged use of tetracycline is my root cause. This article seems very relevant to me & explains much though it’s not a pretty picture.
Interesting comments. Im a 65 year old, former 14 year old tetracycline user as well. I have fibromyalgia and Lyme. I believe I would have Chronic fatigue if not for all the supplements I take every day.
I’d be interested to know which supplements you find particularly useful if you can tell. It’s often tricky to identify the effective ones. I’ve ordered the recommended one in this post. I hope it makes a difference.🤞
Wishing you a Happy Christmas
FACT…Many people, after their covid 19 vaccines, developed diabetes, cancer,turbo cancers etc.
It’s starting to look like BIG P***A is developing treatable illnesses.What better way to keep “the system” flowing$$$$$$$
I keep thinking about the hundreds of visits I made to the “system” and got absolutely lied to….but lots of drs. made lots of money from me indirectly as here in CAN CAN land 🇨🇦 it all gets billed to the govt. Directly thanks to Tommy Douglas.
But this direct billing comes with major abuse of the system. Drs were caught in the 70s and 80s by billing the govt for multiple visits that never occured.
I’m just rambling now but we see how self serving the system is by creating disease and later selling drugs to combat the illnesses they initialy created.$win win$
lyme disease and plum island is starting make even more sense if you look at it from a business stand point
WHAT GREAT INDUSTRY BUSINESS MODELS for the tigers on wall street
Yup sitting 🦆
During/after I got plasmapheresis, my hunger (sensation) reduced to nothing. For years, if I ate more than 55 calories, literally, I gained weight. I still have the weight gain problem, but now I also have the issue of not getting energy from food I eat. So I end up eating more to feel “okay” enough. I have automatic weight gain no matter what I do or how hard I try. I weigh all of my food, and myself, each day.
Have you had thorough thyroid function testing? All 3 hormones, TSH, T4 & T3? They need to be optimal not just in range. If you have test results post them on the ThyroidUk forum on Healthunlocked for helpful comments. Many people are misled by doctors saying that thyroid hormones anywhere in range are normal. It’s not true. TSH needs to be about 1. T3 &T4 should be in the top quarter of the range. T4 often doesn’t convert to the active hormone T3. Shortage of vitamins especially D & folate can cause this. It sounds to me as if you may be hypothyroid in which case it’s not fat your building up but moisture, water weight.
Thanks for responding. At one point, I was actually treated for theoretical hypothyroidism by an “alternative” doctor, because all of my thorough numbers were normal; but we didn’t know what else to do. It didn’t help. I’m also on a multivitamin plus a vitamin D supplement, and my folate was just checked and is normal.
I’ve charted lots of things to keep track, and urine, water, stool, etc are all accounted for. The weight is pure weight. It just keeps on adding on if I don’t decrease calories.
The difficulty is that many doctors are not well trained in treating hypothyroidism. They tend to think that any reading tha is “within range” is acceptable. It’s not. Also multivitamin tablets are not helpful as they contain iron & often iodine which blocks the absorption of many vitamins. They’re a waste of money.
I would suggest that you read posts & advice given on the ThyroidUk forum as there’s much to learn. There are many variations of hypothyroidism, some not easy to spot at all. Being told your reading is “normal” isn’t helpful. You need to ask for & research the actual numbers, ie your result & where it falls in the range. In the UK you have a legal right to see all blood tests results done by the NHS, if you have blood test results post them on the forum with the ranges.
You might be surprised at what you learn. I don’t think you can be certain from what you’ve written that you can dismiss thyroid problems.
There is for example, Central Hypothyroidism where all the readings are in range but are all at the bottom of the range, looks ok but it’s not. You could also check yourself against the list of symptoms produced by Thyroid Uk, there are so many & it might give you a clearer picture.
Fortunately Low dose naltrexone opens calcium ion channels that are in the heart, spleen, brain, eyes muscles, allowing proper functioning. Personally it needs to be paired with small amounts of caffiene, which is possible when used unconventionally, the ldn, caffiene helps calcium influx, prevents heart attack and strokes, increases Cerebral Spinal Fluid and improves mood. The two together give a very decent quality of life with cfs.
Metformin Makers Sued For Carcinogenic Diabetes Drug
In April, a class-action lawsuit was filed against manufacturers of popular diabetes drug metformin. A prescription medicine, metformin is used by patients with type 2 diabetes to control their blood sugar levels.
A complaint filed on April 3 on behalf of various health care insurers alleges that metformin contains unsafe quantities of N-nitrosodimethylamine (NDMA), a carcinogenic contaminant, and that the drug makers knowingly concealed this information.
The plaintiffs are seeking compensation to recover nearly $124 million in payments they have had to make to their members because of the defendants’ alleged actions.
Many of the big pharma drug ingredients can be changed without notice.
I recall on this very site a pharmacist telling of how they often change the makeup of drugs constantly
Many of the covid19 clot shots were manufactured by other farmed out sources and countries that I bet don’t Give a rats ass about you or me. PURE EVIL…such a sick world we live in.
Good chance diabetes will melt away on a carnivore diet providing a person is not in too deep and the damage done
We need to delve into why Joe doe can eat anything and everthing under the sun…. but John doe can’t eat hardly much
Hey Cort, Merry Christmas!
Have you heard about the 15 mio euros from the Federal Ministry of Education and Research in Germany for 7 projects for ME and LC?
One of them at my Alma mater is studying Vidofludimus Calcium for LC, it‘s an entirely new pharmaceutical with new mechanism geared towards MS.
It seems to have neuroprotective, anti inflammatory and anti viral properties.
Maybe you know more?
The Pharma Website: https://imux.com/pipeline/imu-838/
Study announcement: https://aktuelles.uni-frankfurt.de/forschung/post-covid-syndrom-bmbf-gefoerderte-medikamentenstudie-startet/ (german)
All the best
Thank you Cort!
Happy New Year one and all!
Thought I’d share this pre-print about patient advised treatments for Long Covid and ME/CFS. It contains a long list of items which are ranked according to their success (or failure). It also divides these communities into 4 subgroups according to symptom profile and most helpful treatments.
https://www.medrxiv.org/content/10.1101/2024.11.27.24317656v1
I will note that I don’t fit nicely into any of the subgroups… and many of the treatments I have found useful are not listed…
Funny how a study just got published finding that the way food affects metabolism is controlled more by our genetics than by what we eat. It’s almost all in the genes.
https://engineering.virginia.edu/news-events/news/its-genes-weight-and-metabolism-determined-genetics-more-diet
I have MECFS. I’m 83. I want to try strength training. Years ago it was very effective with fibromyalgia. Where can I get guidance on a routine?