Sleep vs Fatigue: A Functional Medicine Approach

Evan Hirsch, MD

Dr. Wells, thanks so much for having me on.

Audrey Wells, MD

Great to see you. And I want to get started with orienting the audience about these two conditions. So there’s chronic fatigue. There’s actually a formal diagnosis of chronic fatigue syndrome. And then since the pandemic, more and more of us are becoming familiar with the phenomenon that is long COVID. So why don’t we get started with you talking about the definitions of each of those terms?

Evan Hirsch, MD

Absolutely. And so as you mentioned, chronic fatigue syndrome has very specific criteria. You have to have it for at least six months. You have to have different kinds of symptoms associated with sleep and then also pain in the body. But the reality is that you don’t need a diagnosis to be suffering. In fact, oftentimes a diagnosis doesn’t really serve us what really serves this and as we talk more today, we’ll be talking a lot about causes. You know, looking at what are the real root causes of what you have going on. But the reality is, is that if you have a tiredness that’s not resolved with sleep, where basically you can’t just sleep more and get rid of the tiredness that you’re having throughout your day. Maybe you’re crashing. Maybe you’re getting, maybe you have to exist on energy drinks or caffeine. Maybe you have to have a nap like I did when I had my chronic fatigue. All of those things really indicate that there’s a problem and that you have to pay attention to it. It’s not just that you’re getting older.

Audrey Wells, MD

Yeah, this is something that I interfaced with a lot because oftentimes people seek out care from a sleep medicine physician, assuming that there’s that coupling with sleep problems and fatigue when in fact, there’s a little bit of a nuance here between the condition of sleepiness and fatigue. So I often try to differentiate those two because it can affect the search for the cause of the problem.

Evan Hirsch, MD

Absolutely. And in fact, you know, what I’ve found is that there’s a lot of crossover between the number of causes that cause fatigue and the number of causes that cause sleep. There’s a little bit less that caused the sleep issues, from what I’ve seen, versus the fatigue. And oftentimes, sleep can be one of those causes that causes fatigue. But sometimes there can be a combination of over 15 different causes that end up causing a sleep issue.

Audrey Wells, MD

Yeah, I agree. And, you know, in the beginning, it’s sort of a necessary step to eliminate sleep disorder as a contributor to fatigue or sleepiness. But oftentimes, even if a sleep disorder is found and a person receives treatment there are symptoms and suffering left over. So I’m curious to know how you would approach such a patient coming to you with a complaint of chronic fatigue.

Evan Hirsch, MD

So the way that I start and part of my four-step process is to always look at what the causes are that somebody has. So with chronic fatigue, we’re looking at at this point over 38 different causes or we’re looking at 38 over 30 different causes. And those can really be divided up into deficiencies. So things that are not in the body that are supposed to be there and toxicities. These are things that are in the body that aren’t supposed to be there. Now, fortunately, 75% of these causes can be determined by symptoms alone. So whether somebody is going through our step one checklist on our website or whether they’re in a one-on-one call with me, what we’re doing is we’re going to go through that whole process. And by the end of that call, we’re going to know 75 to 95% of all those different causes that somebody has. Because inherently, if somebody is not getting better, it’s either because they haven’t found all their causes or they haven’t found the right treatment for those causes and then navigated those bumps along the way. So the first thing is to figure out all the causes that somebody has.

Audrey Wells, MD

And what are some examples of that, like in my mind, I’m thinking an iron deficiency would be a cause, or a vitamin D deficiency, which is a very common phenomenon, even in areas of the country that seem to get a lot of sunlight, like the southwest, which is where I’m from. So what other sort of deficiencies or toxicities are you finding most in your chronic fatigue patients?

Evan Hirsch, MD

So when we’re looking at those deficiencies, oftentimes we’re looking at deficiencies in hormones. So this is the adrenals which are triangular glands that sit on top of the kidneys and produce cortisol, which is, really our gget-up-and-go hormone. It’s our anti-inflammatory and regulates blood sugars. There’s the thyroid, there’s sex hormones. There can be deficiencies in mitochondrial function, which is found in every cell in the body, except for red blood cells and produces about 70 to 90% of our ATP or our energy. There can be deficiencies in nutrients, kind of like what you talked about, whether it’s vitamin B12 or vitamin D or maybe it’s a deficiency in a mineral like iron or magnesium. And then there’s deficiency season lifestyle habits. So this is not enough water, not enough good food, you know, eating enough, eating too much crap, not enough sleep and not enough movement. So those are kind of the deficiencies that we take a look at and then they go into the toxicities.

Audrey Wells, MD

Yeah, let’s talk about that one toxicity that I see often is the toxicity that comes from life stressors. And I like to point out to people that stress reduction is an active process. How do you look at it?

Evan Hirsch, MD

Yeah, that’s very well said. You know, one of the things that’s a big part of our program is mindset practice. We have a four-step mindset practice that we take people through because we find that people are more successful in our program and they’re more successful in life when they’re practicing good mindset tools, which inherently help with their stress. And so we’re looking at toxins and toxicities that are either mental, emotional, physical, spiritual, or energetic, you know. And so when we look at some of like the mental, emotional things, you know, we’re looking at traumas, you know, whether it’s big trauma, like a really significant trauma that you had or whether it’s little T where it may be, it might be considered more of a mild trauma if it changes the way that we see the world and makes the world appear to be more dangerous and scary, consequently will adapt to it. And then we will, it’ll increase the stress on our bodies. And then in terms of some of the physical ones, we’re looking at things like heavy metals and chemicals and molds and infections like viruses like Epstein-Barr, or whether it’s now COVID or whether we’re looking at other infections like Lyme disease and some of it’s co-infections and then trauma, you know, so well, that’s the mental, emotional component. So those other four are really all together. I call those the toxic five and those are the things that we really have to remove out of our body and out of our lives.

Audrey Wells, MD

You know, I’m glad to have an opportunity to talk about trauma, because I know that this is coming up into more and more conversations regarding health, mental and emotional health. And I agree with you that there’s sort of this unspoken burden that people with unresolved trauma tend to carry around that really leaches out their energy, their vitality from their day-to-day life, and sort of doing the work to uncover that and heal can be really empowering as well as put the pet back in your step, so to speak.

Evan Hirsch, MD

Yeah, I can’t agree more. This was something that I kind of came later too, you know. It was very much, you know, conventional medicine and then integrative medicine and functional medicine and environmental medicine, but still very much physical medicine. And so it’s only been through my own personal development and kind of watching and observing and learning from my patients and clients that I was able to see. And my wife, who’s a trauma informed mindfulness coach and watching the journey that she went on and how she resolved her chronic fatigue before I even had fatigue. She had fatigue that she resolved by really working on her emotional state and on her trauma, really informed me and taught me about how important it is. Now, sometimes reversing your trauma and working on your trauma is 10% of the equation. Sometimes it’s 50% of the equation. But we do find that when people incorporate all those different aspects of healing that they are more successful. And we don’t have a trauma curriculum per se. We have a number of tools, and then oftentimes we’re recommending to people that they need to look at a limbic system retraining program or a somatic trauma retraining program or some of these other ones that are out in the field that are just a really nice compliment for the work we’re doing.

Audrey Wells, MD

You know, I think it’s helpful to even have that vocabulary to pass on to people because it can be difficult to articulate what one’s experience is. And so I really applaud that work in giving people an awareness of what may be contributory. You know, shifting gears a little bit to talk about COVID and long COVID syndrome, this comes up in the sleep medicine world because it seems that there are significant elements of sleepiness that go along with Long-Covid syndrome. And I wonder if you can talk about your experience and some of the cases that you’ve seen.

Evan Hirsch, MD

Absolutely. And so whenever an infection is acquired and in this case with with COVID, what we’re seeing is that, you know, people are getting, you know, persistent symptoms of COVID, which are essentially long COVID, you know, where either you get COVID, either it’s a mild case or a severe case. The symptoms go away and then they reappear maybe a month or two later. And you have all these weird symptoms or you get an acute case of COVID and then the symptoms persist from there. Now we’re finding that COVID can cause or long COVID can cause over 250 different symptoms. And it really depends on where in the body the infection goes. So if it damages the mitochondria, which like I mentioned, will produce 70 to 90% of our energy, then you’re going to have fatigue issues. If it gets into the brain and maybe starts affecting the neurotransmitters, then you’re going to get some mood issues. You can also also have sleep issues as well. If it gets into the muscles, you can have muscle pain and muscle inflammation, you know. But like I said, there are over 250 different symptoms. So really what we’re looking at is any sort of new weird symptom that happened since November 2019 that hasn’t been explained. And oftentimes we can tell, you know, through a number of different questions, but then also through treatment. If they respond well to treatment then we can determine whether or not that’s contributing. But it is this whole picture, you know, where like I talked about with chronic fatigue, there’s oh, there’s these 38 different causes that we’re looking at. And it’s always everybody that we see has a combination of about 20 or more of these different causes. And COVID is just one of those. So sometimes it’s a combination, really, of the big ones being, you know, maybe it’s heavy metals, chemicals, molds,  and COVID, maybe it’s molds and Lyme, you know. So it’s always these combinations that we have to pay attention to. It’s never just one thing. And, you know, as humans, we want things to be simple. We want the magic bullet. We want to say, okay, this is my cause of my chronic fatigue or my long COVID, but it really doesn’t work that way. In fact, you know, with long COVID, I was speaking with colleagues the other day, and most of us were talking about how important it is to treat mold in people with long COVID and that it’s really hard to get them better if you’re not also treating mold.

Audrey Wells, MD

Interesting. You know, that this is a productive discussion because there is precedent for viral illnesses causing protracted symptomatology. You know, you brought up Epstein–Barr virus. In my world, some cases of narcolepsy are thought to originate from the influenza virus. And so we have this precedent of viruses causing a prolonged inflammatory response. So we’re affecting different systems. And, you know, we were talking a little bit before I hit the record button about the utility of the diagnosis versus getting treatment and just having satisfaction from the resolution of symptoms, sort of irregardless of what the diagnosis is. So I’m wondering, you know, if you are taking people with fatigue through your program and looking for causes, do you even find it useful to isolate a particular cause or is it sort of better to just focus on what’s ahead on the horizon?

Evan Hirsch, MD

Well, I think it’s a combination of both. I mean, we definitely have to know what the causes are and then we have to match up the treatment with that particular cause and plan for the future. And, you know, expectations have to be set appropriately. You know, all of our programs are 12 months because that’s the least amount of time that people spend with us. And, you know, yes, you might be 60, 70, 80, 100%. Well, yeah, sometimes 100% better. But for the most part, it really takes a long time to get rid of all of these toxins out of the body. But, you know, when you’re coming back to your question about that diagnosis is I really try to change people’s perspective on it because, you know, the question is, okay, so you have a diagnosis, what’s that going to do for you? You know, people are like, oh, I have Hashimoto’s now. It gives you something to Google which can be helpful, or if you have chronic fatigue syndrome. But if you go see your conventional doctor and they say, okay, now you have this diagnosis and then you say, okay, great, well what are we going to do about it? And I was like, well, we really don’t have any tools to help you, so that’s why I try to retrain people. It’s really about these causes because all these causes that were mentioning today will cause not just one diagnosis, but most of the diagnoses that people have and most of the symptoms that they have as well.

Audrey Wells, MD

Is it possible then to test for COVID affecting the muscles versus the brain versus the other systems that you mentioned in order to isolate that?

Evan Hirsch, MD

There is if you want to do a biopsy, but consequently it’s not you know, nobody wants to do a muscle biopsy or a brain biopsy, obviously. So, yes. So the testing is very poor, unfortunately. And, you know, oftentimes I’ll say that all tests are imperfect. And the reality is that as clinicians, we have to bring all the data in together in order to be able to make a decision. That’s why I talk about so many of these causes can be determined by symptoms alone is really because that it’s the history, it’s the symptoms, it’s the laboratory data that we have. And then even, you know, oftentimes we’re looking at some muscle testing or more intuitive things, which is not something that I ever really thought that I would be examining. But oftentimes it’s like, okay, if we take a look at all this imperfect data that we have, oftentimes we can get more of the picture which can lead us forward.

Audrey Wells, MD

I think that’s a nod to the art of medicine, as it were, and treating a complex human being with a physiology, with an emotional life, a social life, and, you know, someone who’s living in a complex world. So it’s understandable that your program would be a year long. I’m wondering if someone were to enroll, how quickly might they be able to see some results?

Evan Hirsch, MD

Yeah, great question. So the way that we structured it with this four-step process is that after the first step of figuring out the causes that people have, the second step is to start replacing the deficiencies. So the real core, the like, the underlying root causes, the big picture are the toxins, the toxic five, the heavy metals, the chemicals, the molds, the infections, and the trauma. However, everything is better when you have more energy and when you have less inflammation and when you’re able to function better in your daily life. And so the big three in replacing the deficiencies are the adrenals, the mitochondria, and the thyroid. And I find that by optimizing those, it makes everything work better. And so when we replace those, when we work on some of the lifestyle habits or replacing some of the deficiencies that helps people be more resilient, more robust, they’re enjoying their days more because they have more energy. They get that early win. So they start to feel better. So to answer your question, and that usually will take about a month in order to take the supplements that I recommend, depending on the number of causes that they have for step two. And so, you know, if they start month one, you know, generally by month three, they’ll notice a significant uptick in their energy. If their energy was like a four at a ten with ten being ideal, they’ll be out of five or six. So they’re noticing some progress already. Their sleep is usually better at that point because we’ve recreated their circadian rhythm by boosting these things in the morning. In addition to like B12 and some iron, all of those things will help to recreate that circadian rhythms, and then they’re sleeping a bit better and then they’re feeling better, and then it’s easier to do the rest of the program because when we get into step four and we start removing the toxins, it can be more stressful on the human organism to remove these toxins that you’ve been friends with for almost your entire life in some cases. And so that’s why it’s really important to make sure that we support the body better by making sure that we’re supporting the deficiencies in step two.

Audrey Wells, MD

Yeah. You know, to bring the discussion back to sleep, I want to just let the audience know a couple of disturbing statistics that helped me to frame my approach to fatigue. One is that at least a third of Americans are not even meeting the minimum requirement for sleep and adults. So that’s the sleep quantity piece. Also for healthy sleep, you need sufficient quality sleep which can translate into absence of a sleep disorder. And insomnia and sleep apnea are incredibly common. In fact, about 80% of sleep apnea is thought to be undiagnosed so far. So there’s a heavy disease burden out there. And then kind of bouncing off of what you’re talking about, the the timing of sleep is important. So not just quality and quantity sleep, but also keeping that sleep window anchored in the 24 hour period so that the brain has that consistency that it craves and that it does the best. And I’m wondering for the people who come to you, how much sleep problems do you see for quantity, quality, and timing?

Evan Hirsch, MD

Yeah, great question. I would say that it’s probably 80%. Now, there might be some people who, you know, and maybe I would say 40 to 50% actually know that there’s a sleep issue. But, you know, there are some people who are getting seven to nine hours of sleep a night and they’re going to bed between nine and ten and they’re not waking up and they don’t realize that their sleep quality is still compromised. And so when we start to work on things, all of a sudden, you know, if they’ve got an Oura Ring or Whoop or some of these other biometric measurements, they’re starting to see, oh, the readiness is going up, their sleep scores are going up, and they’re finding that their quality is much better.

Audrey Wells, MD

Yeah, that’s really reassuring and I like the metrics that these wearable sleep trackers bring into the conversation. I think any time you’re implementing a treatment or doing an assessment, it’s really useful to define where somebody is on a scale or some sort of measurement device. You mentioned fatigue scale. I’m sure you do lab studies and testing. What other metrics do you use?

Evan Hirsch, MD

You know, I find besides those and besides looking at some of the biometric devices, I do find that the subjective experience is best and just kind of regular tracking. So we’re constantly asking people to fill out forms to tell us, you know, where they are in their progress and whether they’re improving if they’re not. And we want to make sure that we’re making an intervention and supporting them. But in general, you know, when we’re doing regular check-ins, the subjective experience is best though it is, you know, as the human condition is oftentimes, you know when I’m checking in with people and I’m asking, hey, how are these symptoms? How are these symptoms? Do you have these symptoms? They, you know, they may initially say, you know, I don’t, I don’t feel much better. I’ll be like, okay, well, let’s check in on your symptoms. And they’re like, oh, yeah, that’s symptoms gone. That’s symptoms gone. That’s symptoms gone. And so they’re getting better. But they, they may forget, you know, as humans, we were incredibly adaptable, whether it’s for better or for worse. So we do try utilizing some of these other metrics. But, you know, with a lot of the people that we see, they spend a lot of money on laboratory tests sometimes that haven’t been very helpful. And in my experience, you know, I talked about the imperfection of some of these laboratory tests. It’s not always feasible to get ongoing in, you know, testing, especially when some of the tests that we’re looking at, like for heavy metals, chemicals, or molds, it’s going to take six to 12 months to get those toxins out of the body. And consequently, it doesn’t make sense to check them, you know, every three to six months, especially when they’re $500 a pop. So kind of try to take a lot of that into context, but making sure that people are improving along the way. And if there are labs, specific labs that we need to get, we’re getting those and we’re monitoring them regularly.

Audrey Wells, MD

You know, I think that’s a great point about the limited nature of medical tests. No matter what you’re talking about, even if it’s an overnight sleep study in the sleep lab, which is sort of considered the gold standard for measurement of sleep, it’s not 100% accurate. It is just one night in the life of a human being, which is a complex organism. And then when you move to a home sleep apnea test, the accuracy rate goes down even further. So I think some people are surprised to know that and more and more the concept of multi-night testing comes up as a measure to to improve the precision and the accuracy of sleep testing. I also think there’s a lot we don’t know yet about sleep and about other parts of the body, other functions of the body. And for those folks out there who may be new to the term functional medicine, can you compare and contrast that with sort of the typical allopathic model and try to help people understand how functional medicine could be useful to them?

Evan Hirsch, MD

Absolutely. So when you go to see your conventional practitioner, what they’re looking for is they’re trying to make a diagnosis based on a number of symptoms that you have in laboratory tests. And there are, they’re combining all of the information that’s present. And then once they have their diagnosis, then they are matching it up with a particular treatment and so that, you know, oftentimes that treatment might be lifestyle habits and but usually lifestyle habits combined with some sort of prescription. If there is a prescription, that can be helpful. So the difference with functional medicine is that you’re looking at the cause of those particular diagnoses. With functional medicine, you’re usually looking at a combination of these deficiencies and toxins. Most of the functional medicine doctors that I work with, they’re coming to me for additional training in the toxicities, because when we talk about like heavy metals, chemicals, molds, infections, and trauma, these are not necessarily things that I ever learned about in medical school, let alone in my integrative medicine and functional medicine training.

I had to learn more about it in environmental medicine training and beyond. So there are a lot of functional medicine practitioners who don’t necessarily like to deal with some of these things because they are more complex. And just so happens that I had chronic fatigue and my wife had chronic fatigue and my older sister had chronic fatigue and it became a part of my life and it became part of my mission. But just by practicing functional medicine, looking at the causes, replacing some of the deficiencies in hormones and nutrients, etc., fixing lifestyle habits, really fixing people’s food, their sleep habits, their movement, the amount of water that they’re taking in can really help 90% of the population. And then those additional people who still are not better with that approach then you really have to look at those toxicities that are causing such a problem in these people’s lives. But hopefully, that makes sense and I would also say that the functional medicine approach is kind of a combination of natural medicine plus conventional medicine. At this point, you could probably switch out the word functional for integrative medicine. There are some different nuances, but some people prefer to call themselves integrative, which is combining the conventional and the natural medicine. And some people prefer functional medicine, which oftentimes is referred to as like a biochemical look at disease and imbalance. But inherently, they’re both looking at those causes focused mainly on deficiencies.

Audrey Wells, MD

Got it. Yeah. And I think for conditions that can be as complex as chronic fatigue, it makes sense why having sort of a whole-person approach to the condition is so useful not just for drilling down on what the causes are but also to help that person move forward with treatments that are going to be effective at making them feel better. Dr. Hirsch, it’s been a great pleasure to speak with you today. I wonder if you can tell the audience where they might find you if they want to know more about your program.

Evan Hirsch, MD

So I’m at energymdmethod.com. There’s a little button in the right-hand corner of our website and where you can text me directly if you would like. You can click on the learn page to take a number of our quizzes and free ebooks. And I do offer 20-minute free calls with me to see if we’re a good fit to work together.

Audrey Wells, MD

Fantastic. Thank you so much for that information and it’s been a great pleasure to speak to you today.

Evan Hirsch, MD

Thanks so much for having me on.