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Fatigue In The College Student

This article discusses the prevalence of fatigue among college students, the warning signs for serious illness, risk factors for iron deficiency, common infectious causes of fatigue, and screening, diagnostic, and treatment options for depression. It also explores case studies of college students experiencing fatigue and provides insights into fatigue in athletes.

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Fatigue In The College Student

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  1. Fatigue In The College Student • Bruce Helming, MD, FAAFP • University of Arizona • Campus Health Service • bhelming@email.arizona.edu To test, or not to test?

  2. Conflict of interest statement: I have NO actual or potential conflict of interest in relation to this educational activity or presentation.

  3. Objectives • Describe clinical fatigue • Identify warning signs for serious illness • Identify risk factors for iron deficiency • Identify common infectious causes of fatigue • Describe screening, diagnostic and general treatment options for depression

  4. Fatigue Facts • 6 - 7 % prevalence • $136 billion in lost productivity • 7 million office visits • In primary care: • 21 to 33 % report “Significant fatigue” • 1/3 of adolescents report it

  5. Definition – Clinical Fatigue • Inability to initiate activity • perception of generalized weakness, in the absence of objective findings • Reduced capacity to maintain activity • easy fatiguability with exertion • Difficulty with concentration, memory, and emotional stability • mental fatigue

  6. Case 1 • 25 year old male graduate student with about 4 weeks of fatigue with exercise, mild shortness of breath and cough

  7. Case 2 • 22 year old female student with about 2 months of fatigue with exercise, and non-specific leg pain

  8. Case 3 • 24 year old male graduate student with about 8 weeks of generalized fatigue, worse with exercise, as well as some motivation and concentration problems that he attributes to grad school

  9. Case 4 • 19 year old female student-athlete with about 2 weeks of fatigue with exercise, diminished performance in her sport

  10. Case 5 • 22 year old male student-athlete with about 8 weeks of fatigue with exercise, mild shortness of breath with exercise, some generalized daytime fatigue

  11. Fatigue in Athletes • Real or perceived: • Decrease in performance (exercise capacity) • Plateau in performance • Lack of improvement with training • Intolerance to increased training intensity • “Run down” without specific complaint • Patient-driven or from peers, coaches, family

  12. Basic Assumptions • Healthy population • New onset • Reliable historians • No secondary gain

  13. Red Flags • Fever/Chills • Night sweats • Weight loss • Bleeding disorders • Trouble with daily activities • Amenorrhea • Stress fracture • Low BMI

  14. Trouble • Diabetes • Leukemia / cancer • Heart disease • Congenital • Myocarditis • Hypercalcemia • Acute infection • HIV, Hepatitis • Pulmonary embolism

  15. Concussion • Remember to ask about recent head injury • “Follow up accident (MVA)” visits • Many patients are not educated about concussion • Leave ER with lots of normal xrays • Lingering effects on mood, energy, sleep and concentration are common • CDC Concussion information is excellent: • http://www.cdc.gov/concussion/HeadsUp/physicians_tool_kit.html

  16. Functional Exercise Grief Neuropsych Concussion Stress Depression Pregnancy Allergies Asthma Sleep Nutrition Adjustment Disorder Celiac Substance abuse Domestic violence Vitamin D Iron HIV Mono Diabetes Thyroid Cocci Anemia Chronic Infection Metabolic Infectious Fatigue

  17. History • Onset - abrupt or gradual, related to event or illness • Course - stable, improving or worsening • Duration and daily pattern • Factors that alleviate or exacerbate symptoms • Impact on daily life - ability to work, socialize, participate in family activities • Accommodations patient has made to adjust

  18. History, part deux • Depression/anxiety • Current life stress, relationships, school, work • Past trauma or abuse • Change in activity or diet • Medications, substance use • History of anemia, iron deficiency, mood or eating disorders • Menstrual patterns • Family history

  19. More History... • Sleep habits, quality • Nutrition: meal schedule/size, restrictions, caloric intake • Digestive: diarrhea, bloating, discomfort • Exercise: frequency, intensity, duration, effect on symptoms • Social history: interest in school, social activities/support system, hours in work/school

  20. Physical Exam • General • Alertness, appearance, mood/affect • Neck • Lymphadenopathy, goiter, thyroid nodules • Chest • Murmurs, crackles, wheezing • Neurologic • Tone, bulk, reflexes • Extremities • Edema

  21. Lab Workup • Unknown etiology • CBC with differential • Chemistry profile • TSH, with reflex freeT4 • Ferritin, ESR • Consider • Urinalysis • EBV/Mono, Cocci • Pregnancy, Vitamin D • Creatine Kinase, HIV • PPD/IGRA (Interferon gamma release assay for tuberculosis)

  22. US Olympic Blood Workup • RBC, Hgb, Hct, WBC, Differential • Chemistry, Creatine Kinase (CK), LDH • Ferritin, Iron, TIBC, Transferrin Saturation • Cortisol • Lipids, Urine specific gravity

  23. Clinical Indicators for Lab Tests • Hemoglobin/Ferritin • Pallor, tachycardia, dyspnea, symptoms of anemia • Dietary, personal or family history of anemia risk: • Heavy exercise, meat restriction/vegetarian • White blood cell count • Fever, evidence of infection • Weight loss, lymphadenopathy • Erythrocyte sedimentation rate (ESR) • Arthralgia, arthritis, concern for malignancy

  24. Clinical Indicators for Lab Test • Electrolytes • Medications: Diuretics, steroids • Renal function • Elevated blood pressure, edema, pruritis • Medication affecting renal function • Glucose • Polydipsia, polyuria, polyphagia, family history • Thyroid Stimulating Hormone (TSH) • Dry hair/skin, change in bowel habits, menses

  25. Lab Utility • Primary care • 5% hit rate • Higher in students? • Useful in students • Positive • Iron, anemia, mono, thyroid • Negative • Depression, stress, sleep, nutrition, overtraining

  26. Psychiatric • Depression / Anxiety • Adjustment disorder, somatization • Stress, expectations • Family/relationship • Domestic violence • Disordered eating • Anorexia, Bulimia • Substance abuse • Grief

  27. Feeling bad on Facebook • 200 Facebook profiles were evaluated • 25% displayed depressive symptoms • 2.5% met criteria for Major Depressive Episode • References to depression were more common when a response to prior disclosure occurred • Moreno, MA, Feeling bad on facebook: Depression disclosures by college students on a social networking site, Depression and Anxiety, 2011, 0:1-9

  28. Depression • Seen in 2-10 % of college population • Overlap with • Adjustment disorder • Grief • Stress & Anxiety • Sleep disturbances • Responsive to: • Counseling • Medication • Self-management

  29. Depression • loss of interest in pleasure • loss of motivation • loss of sense of control • functional impairment may not relate with severity of depression • denial is frequent • Ask about mood, stressors, and suicide

  30. Depression Screening & Treatment • We’re implementing screening with PHQ-2, followed by PHQ-9 • Sharing of notes and care manager between counseling and medical sides • Screening is a gateway to conversation about mood, sleep, suicidal thoughts • Objective measure of mood for tracking • Tools for providers to assess, diagnose, treat and track are available in EMR (medical record)

  31. Infectious • Acute, subacute, chronic • Mono, CMV, HIV • Cocci (Valley Fever) • cough, fevers, rash • erythema nodosum • College lifestyle can cause: • Inadequate recovery • Impaired healing • Weakened immunity

  32. 50 Fatigued Aussie Athletes }50%

  33. Mononucleosis • Epstein-Barr Virus • Upper respiratory infection followed by fatigue/malaise • Posterior cervical nodes • Splenic rupture • Risk estimates ~ 1:500 • Spontaneous, Valsalva or traumatic • Rest from sports, strenuous activity for 4 weeks

  34. Mononucleosis • 4-6 week incubation • no quarantine • EBV serology to confirm • simultaneous Strep common • rupture most likely in 3 weeks • as late as 7 weeks • if feeling well, light exercise at 3 weeks, progress slowly • rare prolonged fatigue syndrome • typical recovery by 6-8 weeks

  35. Natural History of Mono • 150 patients aged 16 and up, followed for 6 months

  36. Rea, TD, Prospective study of the natural history of infectious mononucleosis caused by Epstein-Barr Virus, JABFP, 2001; 14(4): 234-42. 150 patients aged 16 and up, followed for 6 months

  37. Coccidioidomycosis (Valley Fever) • AKA: Valley Fever, Cocci, Desert Rheumatism, San Joaquin Valley Fever • AZ, CA, NV, UT, NM, TX, Mexico, Guatemala, Honduras, Equador, Paraguay, Argentina • Caused by inhaling spore found in soil: fungal infection • Severity: mild (60%), moderate (30%), severe (10%) • NOT contagious, incubation period of 7-21 days • Majority have mild symptoms, and do not seek care

  38. Cocci Valley Fever Center for Excellence www.vfce.arizona.edu520-626-6517 web search: "CDC Valley Fever"

  39. Cocci • Symptoms: Fatigue, night sweats, cough, chest pain, dyspnea, hemoptysis, headache, arthralgias (diffuse/migratory) • Signs: Fever, weight loss, erythema nodosum/multiforme, eosinophilia, elevated ESR • Xray: infiltrates (unilateral), hilar adenopathy, effusions • 30% of Community Acquired Pneumonia cases in Tucson • 80% had at least one course of antibiotics •    31% received multiple courses • Averaged 5 months and 3 clinic visits to reach correct diagnosis (in adult population)

  40. Cocci • Serologies •     Positive: suggestive, especially in light of clinical history •     Negative: NEVER excludes the diagnosis • Risk factors: Immunosupression, Diabetes, Pregnancy • Treatment: reserved for serious infections, antifungals, fluconazole, itraconazole • Complications: Bone infection, cavitary lung lesions, systemic • Prognosis: Good, but very slow (weeks to months)

  41. Endocrine/Hematologic • Iron deficiency • Anemia • Hypothyroid • Diabetes • Polydipsia, Polyphagia • Polyuria, Weight loss • Vitamin D deficiency

  42. Iron deficiency • History • Meat restriction • Insidious • Females • Increased activity • Screening • CBC, Ferritin, iron studies • Treatment • Oral iron, nutrition

  43. Iron deficiency • ferritin < 35 ng/ml • precedes anemia • declining MCV • absorbed in proximal small bowel • give with vitamin C or OJ • plan 3-4 months of iron • recheck at 4-6 weeks • female vegans have 40% risk

  44. Decline in iron during boot camp • Basic Combat Training, female recruits • 7% at start were iron deficient • 18% at end • iron status correlated with running performance • 1 to 1.5 hours of exercise • 4-6 days/week, for 9 weeks • 16,000 steps/day vs 8,000 for civilians • ~1 lb weight gain over 9 weeks • McClung, JP, Longitudinal decrements in iron status during military training in female soldiers. Br J Nutr, 2009; 102: 605-9

  45. Added iron in female soldiers • 219 female Army soldiers • 8 week basic combat training • 20% had iron deficiency anemia • 100 mg of ferrous sulfate daily vs placebo • Iron improved Vigor scores • on Profile of Mood States (POMS) • Limited iron loss associated with BCT • Did NOT eliminate it at this dose • Improved running performance only if anemic • McClung, JP, Randomized, double-blind, placebo-controlled trial of iron supplementation in female soldiers during military training: effects on iron status, physical performance, and mood. Am J Clin Nutr 2009;90:124-31

  46. Iron status in young athletes • Elite athletes from 11-25 years old • Most females failed to meet iron RDA • 63% vs 19% for males • Low ferritin <35 more common • 57% vs 31% for males • Low levels associated with: • diet in females • higher expenditures in males • Koehler, K, Iron status in elite young athletes: gender-dependent influences of diet and exercise, Eur J Appl Physiology, 2011, DOI 10.1007/s00421-011-2002-4

  47. Iron and the body • Iron deficiency affects: • physical endurance • immune response • temperature regulation • energy metabolism • cognitive performance • behavior disturbances • Murray-Kolb, LE, Iron treatment normalises cognitive functioning in young women, Am J Clin Nutr, 2007; 85:778-87

  48. Iron Supplementation Improves: • Performance (ferritin below 20) • Increased speed on 15 km bike ergometer • Increased VO2Max, and oxygen consumption • “Maximal voluntary contraction strength” in knee extension (response to training effect) • Labs: Increase in ferritin, may see Hgb rise • Subjective (ferritin below 35) • Decreased sensation of “Fatigue” • in adult females (non-athletes)

  49. Iron and cognition • Blinded, placebo controlled study comparing: • Normal vs Iron deficient (ID) vs Iron deficiency anemia (IDA) • (Hb >= 10.5 and < 12) • IDA < ID < Normal on baseline cognitive testing • Increased Ferritin responders • Attention and Learning scores increased significantly • Memory score increased as well (p<0.07) • Increased Hemoglobin responders • Attention and memory scores increased • Learning task speed improved • Murray-Kolb, LE, Iron treatment normalizes cognitive functioning in young women, Am J Clin Nutr, 2007; 85:778-87

  50. Types of iron supplements • Ferrous sulfate • Ferrous gluconate • Iron/Vit C - FerroGels Forte • ascorbic acid, folic acid, cyanocobalamin, and ferrous fumarate • Iron/Colace - Ferro-Sequel • Ferrous fumarate, sodium docusate • Vegetarian/Kosher • Solgar Gentle Iron

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