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 initials

Age at first clinic visit

Occupation BMI Drugs prescribed

SC 19 None 21 NoneHS 20 None 18 DianetteAV 27 None 20 AmitriptylineKS 34 Administrative assistant 24 Anti-depressantJK 36 Medical representative 24 SteroidsTY 48 Farmer's wife 20 AntibioticAT 63 Retired 22 NoneJH 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

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

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

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

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)

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

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 duration (months)

Months to

'proper' cold

Occupation Estimated recovery

(%)

Patient comments at follow-up visits

SC 7 5 University student

100 Enjoying university away from home and doing well health-wise

HS 31 22 Home study planning University course

85 Learning to drive, Italian at home and exercising in preparation for going to University

AV 34 20 Full-time employment

90 Coping well, moved away from home to live with partner. Job going well

KS 21 20 Adminstrative assistant

90 Much happier, people have remarked how well she looks. Coping well with job and living on her own.

JK 19 11 Medical representative

85 Just coping with high-pressure 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-treat)

Retired 100 Rapid improvement back to 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

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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

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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

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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.

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