Tired and drained despite a healthy diet: Could detoxification be behind it?
You eat clean, you sleep reasonably well, and you still feel like a battery that never charges past 40 percent. Sometimes it is worth looking at a question that is rarely asked: how much energy is your body spending right now just to cope with its load?
Tiredness is rarely a lack of willpower. It is often a balance sheet that does not add up. On one side is what your body has to process every day. On the other, how much strength it has left for that.
You are doing everything right. So why are you still so worn out?
In the morning, getting up feels like wading through wet sand. Coffee buys you an hour of calm, then comes the slump. In the afternoon you read the same paragraph three times.
At your family doctor's, everything was within the normal range. And somewhere between relief and frustration, one question lingers: if everything is normal, why don't I feel normal?
I don't want to fob you off with a quick answer here. Tiredness has many sources. Most of them are well known and very treatable. We take care of those first.
And then there is a second level. It is looked at less often in a standard workup. It is the question of your detoxification capacity and your mitochondrial reserve. In other words: how much work does your liver have, and how much power do your cellular power plants supply for it?
This article connects the two. If you are specifically interested in heavy metals as a cause, there is a separate article on metals and mitochondria. This one is about the bigger picture.
The basics first: what should be checked first in tiredness
Before we talk about glutathione and mitochondria, the groundwork comes first. This is not a box-ticking exercise. It is the foundation without which every further consideration is built on sand.
A team from the University of Marburg analyzed 26 studies from family practices in which people came in because of tiredness. Depression was found in 18.5 percent, anemia in 2.8 percent, a serious physical illness in 4.3 percent and a previously undetected cancer in 0.6 percent.
What this means for you: serious causes are rare. Mood and life load, on the other hand, deserve attention from the very start.
Stadje R et al. The differential diagnosis of tiredness: a systematic review. BMC Fam Pract. 2016. DOI: 10.1186/s12875-016-0545-5A review in the Deutsches Ärzteblatt, based on the guideline of the German College of General Practitioners and Family Physicians (DEGAM), adds: tiredness is the main or secondary reason for 10 to 20 percent of all family doctor visits. Sleep disorders, sleep-related breathing disorders, depression and heavy psychosocial strain are the most common causes of persistent exhaustion.
Blood and iron
Blood count and ferritin. Iron deficiency can cause tiredness even without anemia.
Thyroid
TSH as a starting point. Depending on the result, further values, see the article on the thyroid.
Metabolism
Blood sugar, liver and kidney values, markers of inflammation, vitamin B12 if suspected.
Sleep
Sleep duration, snoring, pauses in breathing. Sleep apnea often goes unnoticed for a long time.
Mood
Loss of joy, rumination, lack of drive. Depression often shows up first as exhaustion.
Medications
Some medications cause tiredness. An honest list belongs in the conversation.
A Swiss and French team studied 198 women with tiredness, normal hemoglobin and ferritin below 50 µg/L. For twelve weeks they received iron or placebo. The fatigue score dropped by 47.7 percent with iron and by 28.8 percent with placebo.
What this means for you: a "normal" blood count does not rule out a relevant iron deficiency. More on this in the article on iron deficiency and tiredness.
Vaucher P et al. Effect of iron supplementation on fatigue in nonanemic menstruating women with low ferritin: a randomized controlled trial. CMAJ. 2012. DOI: 10.1503/cmaj.110950A baseline workup is not a detour. It is the shortcut.
If you jump straight to detox and specialty tests when you are tired, it is easy to miss sleep apnea, a B12 deficiency or depression. The conventional workup is useful and important. What an integrative view can add begins where that workup ends without a clear answer.
And now you know why the next level only comes afterwards. Not because it is unimportant. But because it carries more meaning on a clarified foundation.
Energy and detoxification share the same workshop
Imagine your liver cell as a small factory. In the basement are the generators, the mitochondria. Upstairs, on the assembly line, foreign substances are converted and packaged. Both departments run on the same power grid and draw from the same warehouse.
Detoxification is not a passive process. In Phase 1, enzymes of the cytochrome P450 family attach a reactive site to a fat-soluble substance. In Phase 2, a water-soluble tag is coupled to it, for example glutathione, sulfate, glucuronic acid or a methyl group. Only then can the substance leave via bile or the kidneys. I explain exactly how this works in the article on Phase 1 and Phase 2.
The load comes in
Medications, alcohol, residues from the environment and daily life, but also the body's own hormones and metabolic products.
Phase 1 and 2 need raw materials
NADPH, ATP, glutathione, amino acids such as cysteine and glycine, methyl groups from folate and B12 metabolism.
Mitochondria supply and suffer along
They produce the energy for the conversion. At the same time, energy production creates reactive oxygen species, which themselves use up glutathione.
When the reserve shrinks
If the load stays higher than the capacity over time, energy for everything else could become scarcer. You feel this as tiredness.
A research team at the US National Institutes of Health (NIH) reviewed 25 studies on the link between mitochondrial function and fatigue. They looked at structure, enzymes, oxidative stress, ATP production and genetics. Low levels of coenzyme Q10 were consistently associated with fatigue, and carnitine also stood out in all studies on it.
What this means for you: the connection between cellular power plants and exhaustion is biologically plausible and is being researched seriously. But it is not yet a routine test.
Filler K et al. Association of Mitochondrial Dysfunction and Fatigue: A Review of the Literature. BBA Clin. 2014. DOI: 10.1016/j.bbacli.2014.04.001The question is not only: how many toxins are in me? The question is also: how much capacity do I have to deal with them?
Two people with the same load can feel very different. The difference often lies not in the input, but in the reserve.
And now you know why tiredness and detoxification can appear in the same sentence. Not as "toxins" piling up. But as two departments sharing the same resources.
Glutathione: the fire extinguisher that can run empty
Do you know the feeling of having a little too little strength for everything? A molecule in your cells can be in exactly the same situation.
Glutathione is a small protein made of three amino acids: glutamate, cysteine and glycine. It is the most important antioxidant buffer in your cells and at the same time a tool of Phase 2 detoxification. It puts out sparks in the mitochondria. And it packages reactive intermediates from Phase 1.
The catch: glutathione is not an unlimited supply. It is an ongoing production. Its bottleneck is usually the availability of cysteine.
A team at Baylor College of Medicine in Houston measured glutathione synthesis with labeled amino acids in eight older and eight younger people. In the older group, glutathione, cysteine and glycine in red blood cells were clearly lower, new synthesis was slower and markers of oxidative stress were higher. After two weeks with the precursors cysteine and glycine, glutathione rose by about 95 percent and oxidative stress decreased.
What this means for you: glutathione deficiency can be a question of raw materials. The study was small and had no placebo group; it shows a mechanism, not a treatment protocol.
Sekhar RV et al. Deficient synthesis of glutathione underlies oxidative stress in aging and can be corrected by dietary cysteine and glycine supplementation. Am J Clin Nutr. 2011. DOI: 10.3945/ajcn.110.003483The same research group went one step further. In experiments in mice and a study in older people, low glutathione levels were linked to weaker fat burning in the mitochondria. When glutathione was replenished, this finding improved. This is a bridge between a detoxification molecule and energy production: clear in the animal model, shown in humans so far only in small groups.
Researchers in New York used magnetic resonance spectroscopy to measure glutathione in the cerebral cortex of people with chronic fatigue syndrome, people with depression and healthy controls. In both patient groups, glutathione was lower and lactate in the brain fluid was higher. The lower the glutathione, the greater the physical impairment.
What this means for you: oxidative stress could play a role in persistent exhaustion. But cause and effect cannot be separated from data like these.
Shungu DC et al. Increased ventricular lactate in chronic fatigue syndrome. III. Relationships to cortical glutathione and clinical symptoms implicate oxidative stress in disorder pathophysiology. NMR Biomed. 2012. DOI: 10.1002/nbm.2772Glutathione is not a detox product. It is an account balance.
Every load is a withdrawal: alcohol, infections, lack of sleep, medications, environmental substances, intense stress. Deposits come from protein, sulfur, sleep and recovery. If you live permanently in your overdraft, you may feel it as exhaustion.
And now you know why one and the same glutathione reserve is responsible for both detoxification and energy. More on this in the article on glutathione as the master antioxidant.
Methylation: the quiet pacemaker
Maybe you have heard of MTHFR and wondered whether it plays a role for you. The honest answer: sometimes, but less often than the internet claims.
Methylation is a cycle in which folate, vitamin B12 and B6 pass along small carbon building blocks. Your body needs these methyl groups for Phase 2 reactions, for messenger substances in the brain such as serotonin and dopamine, and for converting homocysteine. Through a side pathway, this cycle is directly linked to glutathione production. A bottleneck in one place can therefore show up somewhere else.
What is well established: a genuine B12 deficiency can cause marked tiredness, concentration problems and abnormal sensations. With matching symptoms, it belongs to the baseline workup.
A Swedish team at the Gottfries Clinic in Gothenburg surveyed 38 people with ME/CFS who had received B12 injections and folic acid for at least six months. 15 were classified as good responders, 23 as mild responders. Good responders had received B12 more often and for longer, a folic acid amount adjusted to their MTHFR genotype, and took strong painkillers less often.
What this means for you: for a subgroup, methylation metabolism could be relevant. But there was no control group; the data are a hint, not a confirmation.
Regland B et al. Response to vitamin B12 and folic acid in myalgic encephalomyelitis and fibromyalgia. PLoS One. 2015. DOI: 10.1371/journal.pone.0124648A gene variant is not a diagnosis. Many people carry MTHFR variants and feel perfectly well. Functional values such as B12, folate and homocysteine, viewed together with your symptoms, are usually more meaningful than the gene test.
And now you know why methylation, detoxification and energy are not separate topics. They depend on the same vitamins.
The liver as an energy hub: when fat builds up
A fatty liver is often discovered incidentally on ultrasound. You haven't felt anything, you are told. But is that so? Perhaps you did feel something and just called it something else: tiredness.
A team from Newcastle studied 156 people with biopsy-confirmed fatty liver. Fatigue averaged 51 points on the fatigue scale, compared with 8 in the control group. That was comparable to a chronic bile duct disease. The tiredness, however, did not depend on the severity of the liver disease, but on less physical activity and more daytime sleepiness.
What this means for you: a fatty liver is more a mirror of a strained metabolism than an engine of tiredness. That puts physical activity and sleep at the center.
Newton JL et al. Fatigue in non-alcoholic fatty liver disease (NAFLD) is significant and associates with inactivity and excessive daytime sleepiness but not with liver disease severity or insulin resistance. Gut. 2008. DOI: 10.1136/gut.2007.139303A fatty liver has to perform its core tasks under more difficult conditions: buffering blood sugar, processing fats and, yes, converting foreign substances. From a KPNI perspective, it is a hub where metabolism, inflammation and detoxification meet. You can read how to put a fatty liver into context in the article on MASLD.
And now you know why a fatty liver deserves to be taken seriously in tiredness. Not as the sole cause, but as a sign of an overall load.
Environmental load: what studies show and what they don't
We live with substances that did not exist a hundred years ago. That is no reason to panic. It is a reason to also ask about your surroundings when tiredness is unexplained.
An Australian research group measured chlorinated hydrocarbons in the blood of 14 people with persistent, unexplained exhaustion and 23 healthy people. The exhausted group had significantly higher levels of DDE, a breakdown product of the old insecticide DDT. Thirteen of the fourteen fell into the group with a high total load.
What this means for you: persistent pollutants are a serious line of research. With such small groups, however, it remains a hypothesis.
Dunstan RH et al. Bioaccumulated chlorinated hydrocarbons and red/white blood cell parameters. Biochem Mol Med. 1996. DOI: 10.1006/bmme.1996.0035An Italian case series describes five people who developed the picture of chronic fatigue syndrome months after ciguatera toxin poisoning from fish or after contact with solvents. Compared with other patient groups, they showed more pronounced changes in the immune system. This is an observation in very few people, but it fits with something that comes up again and again in everyday practice: the onset of symptoms sometimes has a trigger nobody asked about.
The most important test for environmental load is often not a measurement, but a good question.
When did it start? Was there a move, a renovation, water damage, a new job, a new hobby involving paints or solvents? Targeted tests make more sense when there is a concrete suspicion.
And now you know why the exposure history belongs in the workup. For individual sources of load such as metals, you can find more on glutathione and heavy metals here.
ME/CFS: when mitochondria do not ramp up under stress
There is a form of exhaustion that feels different. Even small efforts cost days. Sleep brings no recovery. This is the picture of ME/CFS, a distinct and serious illness. It belongs in experienced hands and should not be equated with ordinary tiredness.
Researchers at Newcastle University measured energy production in blood cells from people with CFS and healthy controls. The clearest difference was in the maximal respiratory capacity of the mitochondria. The cells of the patients were less able to increase their energy production under stress.
What this means for you: idling is not the problem; the missing reserve under load is. This picture fits a body that is under constant strain.
Tomas C et al. Cellular bioenergetics is impaired in patients with chronic fatigue syndrome. PLoS One. 2017. DOI: 10.1371/journal.pone.0186802An Australian team compared 19 studies on mitochondria in ME/CFS. They looked at structure, genetic material, the respiratory chain, metabolites and coenzymes. The conclusion: the results are too inconsistent to determine the role of the mitochondria with certainty.
What this means for you: mitochondria are an important piece of the puzzle. Anyone promising you a ready-made mitochondria test with a clear-cut answer is going beyond the evidence.
Holden S et al. A systematic review of mitochondrial abnormalities in myalgic encephalomyelitis/chronic fatigue syndrome/systemic exertion intolerance disease. J Transl Med. 2020. DOI: 10.1186/s12967-020-02452-3And now you know why mitochondria play such a big role in research on tiredness, and why modesty is appropriate when drawing conclusions. I describe how physical activity can be dosed in exhaustion in the article on exercise in chronic exhaustion.
Through the KPNI lens: liver, mitochondria, nervous system
Clinical psychoneuroimmunology does not look at a single organ, but at connections. In tiredness, this is especially worthwhile.
Metabolism
The liver and mitochondria share ATP, NADPH and glutathione. If a lot is used for conversion and defense, less could remain for performance.
Immune system
Activated immune cells are energy guzzlers. Inflammatory messengers can trigger a sense of illness in the brain that feels like tiredness.
Nervous system
A permanently activated stress system shifts energy toward alertness. Sleep becomes shallower, recovery incomplete.
Hormonal system
The thyroid, cortisol rhythm and sex hormones help regulate the energy balance. Many hormones are themselves metabolized in the liver.
Energy is not a luxury. Energy is freedom. The freedom to still feel like seeing people in the evening. The freedom not to wake up already exhausted, negotiating what has to be dropped today.
At ViveCura, the workup therefore begins with the conventional basics and then goes further: how high is the overall load from metabolism, inflammation, environment and stress? And how well stocked are the building blocks for detoxification and energy? The result is not a standard scheme, but an individual picture. You can read how the stress system feeds into exhaustion in the article on burnout and the stress system.
Well established: sleep disorders, depression, psychosocial strain, iron deficiency, thyroid disorders and B12 deficiency are common and treatable causes of tiredness.
Mechanistically plausible, human studies still thin: an interplay of detoxification load, glutathione consumption and a limited mitochondrial reserve as a contributor to persistent exhaustion.
Clinically observed, without a strong study base: that in some people, the onset of exhaustion coincides with a new load. I describe this as an observation, not as proof.
What you can do now
You don't have to change everything at once. Three levers are enough to start. They are deliberately not a cure, but directions.
Three levers for the coming weeks
- Get the basics checked. Blood count, ferritin, TSH, blood sugar, liver and kidney values, B12 if suspected. Also take an honest look at sleep, snoring and mood.
- Fill up the raw materials. Enough protein spread across the day, cruciferous vegetables such as broccoli, Brussels sprouts or cress on a regular basis, enough fluids and regular bowel movements. This can support the building blocks for Phase 2 and glutathione.
- Take an honest stock of the load. Alcohol, lack of sleep, chronic stress, solvents, mold, unnecessary medications. Write down when the tiredness began and what changed at that time.
If you are looking for a calm, everyday way to start, the article on gentle everyday detox has more ideas without the feel of a cure.
Frequently asked questions
Can an overloaded detoxification system make you constantly tired?
It is possible, but it is rarely the first explanation. Detoxification in the liver costs energy and uses up building blocks such as glutathione, amino acids and methyl groups. Your cells' energy metabolism needs the same resources. If the load stays higher than the capacity over a longer period, this may contribute to oxidative stress and a lower mitochondrial reserve. Studies show associations, for example between low glutathione in the brain and physical impairment in chronic fatigue. They do not prove cause and effect. That is why this question belongs after a thorough baseline workup.
What should be checked first in chronic tiredness?
First the common and the dangerous causes. This includes a detailed conversation, a physical examination and simple lab values such as a blood count, ferritin, blood sugar, the thyroid value TSH, liver and kidney values and markers of inflammation. Sleep, sleep apnea, mood and psychosocial strain are just as important. A German review based on the DEGAM guideline names sleep disorders, depression and heavy strain as the most common causes of persistent tiredness. Only once this level has been clarified does it make sense to look at detoxification capacity and mitochondria.
Can iron deficiency without anemia make you tired?
Yes, this has been studied well. In a randomized study from France with 198 women who reported tiredness and had normal hemoglobin but a ferritin below 50 µg/L, the fatigue score dropped by 47.7 percent with iron and by 28.8 percent with placebo. Iron also matters for the respiratory chain in the mitochondria. That is why ferritin always belongs to the baseline in tiredness, before more complex connections are considered.
What does glutathione have to do with energy?
Glutathione is the body's most important own antioxidant and at the same time a central building block of Phase 2 detoxification. In the mitochondria it captures reactive oxygen species that form during energy production. Studies in older people suggest that low glutathione levels may go along with more oxidative stress and weaker fat burning in the mitochondria. If a lot of glutathione is used for detoxification, less is available to protect the cellular power plants. This is a plausible, but not yet conclusively proven, pathway to tiredness.
Does methylation play a role in tiredness?
Methylation is a metabolic pathway that works with folate, vitamin B12 and B6. It supplies methyl groups for Phase 2 reactions and for messenger substances in the brain, and it is linked to glutathione production via homocysteine. A clear B12 deficiency can cause marked tiredness and belongs to the baseline workup. Beyond that, there are observational data from Sweden in ME/CFS in which some patients reported improvement with B12 and folic acid. Controlled studies on this are still lacking.
Can a fatty liver make you tired?
Tiredness is common in fatty liver. In a British cohort study of 156 people with confirmed fatty liver, fatigue was clearly higher than in the control group and similar to that in a chronic bile duct disease. Interestingly, the tiredness did not depend on the severity of the liver disease, but on less physical activity and daytime sleepiness. A fatty liver is therefore more a signal of a strained metabolism than the sole cause.
Can environmental pollutants trigger chronic tiredness?
The data are thin. Small studies from the 1990s and early 2000s describe higher blood levels of certain chlorinated pesticide residues in people with persistent exhaustion, or symptoms that began after contact with solvents. These are hints from small groups, not evidence of a cause. A targeted exposure history is useful: work, home, hobbies, water, mold. Measurements make sense mainly when there is a concrete suspicion.
Are the mitochondria impaired in ME/CFS?
There are hints, but no consistent finding. A study from Newcastle found a lower maximal respiratory capacity of the mitochondria in immune cells of people with CFS. Under stress, the cells were less able to ramp up their energy production. A systematic review of 19 studies, however, concluded that the results are inconsistent and the role of the mitochondria cannot yet be determined with certainty. Mitochondria are therefore an important line of research, but not a finished biomarker.
Can a detox cure help with tiredness?
For classic detox cures, teas or patches there are no robust studies showing an improvement in chronic tiredness. Detoxification is not a process you trigger once with a product, but an ongoing task of the liver, gut and kidneys. This task depends on sleep, protein intake, micronutrients, physical activity and the overall load. A calm approach that fits into everyday life may be more useful than a radical cure that puts additional stress on the body.
How does ViveCura look at chronic tiredness?
First with a thorough conventional medical workup: baseline labs, sleep, mood, medications, known conditions. Then through the lens of clinical psychoneuroimmunology, KPNI for short. The question is how the liver, mitochondria, immune system, hormonal system and nervous system interact. Which loads are coming in, and what capacity is there to meet them? The answer is individual and develops in conversation and examination, not from a standard scheme.
If you want to go deeper
This article is part of the Detox Guide and touches on several other topics. The following texts look at individual building blocks in more detail.
Phase 1 and Phase 2 of liver detoxification
Why the conversion happens in two steps and what an imbalance means.
Detox GuideGlutathione: the master antioxidant
Production, consumption and its role in detoxification.
Detox GuideAlways tired: metals and mitochondria
The special case of heavy metals as a brake on energy production.
Heavy metalsIron deficiency, tiredness and exhaustion
Why ferritin always belongs to the baseline in tiredness.
IronThyroid: normal values, symptoms anyway
When the TSH looks fine and the tiredness stays anyway.
ThyroidMicronutrients in energy metabolism
From calorie to ATP: the cofactors of the cellular power plants.
EnergySleep, hormones and regeneration
The quietest lever against exhaustion.
SleepHormonal disorders and environmental factors
Why it is worth asking about your surroundings, too.
EnvironmentSources
All studies were checked via PubMed for title, authors, year and DOI. The figures cited in the text come from the respective abstracts.
- Stadje R, Dornieden K, Baum E et al. The differential diagnosis of tiredness: a systematic review. BMC Fam Pract. 2016;17(1):147. DOI: 10.1186/s12875-016-0545-5 [Systematic review, meta-analysis, k=26]
- Maisel P, Baum E, Donner-Banzhoff N. Fatigue as the Chief Complaint: Epidemiology, Causes, Diagnosis, and Treatment. Dtsch Arztebl Int. 2021;118(33-34):566-576. DOI: 10.3238/arztebl.m2021.0192 [Review, based on the DEGAM guideline]
- Vaucher P, Druais PL, Waldvogel S, Favrat B. Effect of iron supplementation on fatigue in nonanemic menstruating women with low ferritin: a randomized controlled trial. CMAJ. 2012;184(11):1247-54. DOI: 10.1503/cmaj.110950 [RCT, n=198, 12 weeks]
- Filler K, Lyon D, Bennett J et al. Association of Mitochondrial Dysfunction and Fatigue: A Review of the Literature. BBA Clin. 2014;1:12-23. DOI: 10.1016/j.bbacli.2014.04.001 [Systematic review, k=25]
- Lu SC. Glutathione synthesis. Biochim Biophys Acta. 2013;1830(5):3143-53. DOI: 10.1016/j.bbagen.2012.09.008 [Mechanistic review]
- Sekhar RV, Patel SG, Guthikonda AP et al. Deficient synthesis of glutathione underlies oxidative stress in aging and can be corrected by dietary cysteine and glycine supplementation. Am J Clin Nutr. 2011;94(3):847-53. DOI: 10.3945/ajcn.110.003483 [Real-world, intervention study without placebo group, n=16]
- Nguyen D, Samson SL, Reddy VT, Gonzalez EV, Sekhar RV. Impaired mitochondrial fatty acid oxidation and insulin resistance in aging: novel protective role of glutathione. Aging Cell. 2013;12(3):415-25. DOI: 10.1111/acel.12073 [In vivo, mouse, supplemented by a small human study]
- Shungu DC, Weiduschat N, Murrough JW et al. Increased ventricular lactate in chronic fatigue syndrome. III. Relationships to cortical glutathione and clinical symptoms implicate oxidative stress in disorder pathophysiology. NMR Biomed. 2012;25(9):1073-87. DOI: 10.1002/nbm.2772 [Real-world, cross-sectional with imaging, n=43]
- Regland B, Forsmark S, Halaouate L et al. Response to vitamin B12 and folic acid in myalgic encephalomyelitis and fibromyalgia. PLoS One. 2015;10(4):e0124648. DOI: 10.1371/journal.pone.0124648 [Real-world, cross-sectional without control group, n=38]
- Newton JL, Jones DE, Henderson E et al. Fatigue in non-alcoholic fatty liver disease (NAFLD) is significant and associates with inactivity and excessive daytime sleepiness but not with liver disease severity or insulin resistance. Gut. 2008;57(6):807-13. DOI: 10.1136/gut.2007.139303 [Real-world, cohort study, n=156]
- Dunstan RH, Roberts TK, Donohoe M et al. Bioaccumulated chlorinated hydrocarbons and red/white blood cell parameters. Biochem Mol Med. 1996;58(1):77-84. DOI: 10.1006/bmme.1996.0035 [Case-control, n=37]
- Racciatti D, Vecchiet J, Ceccomancini A, Ricci F, Pizzigallo E. Chronic fatigue syndrome following a toxic exposure. Sci Total Environ. 2001;270(1-3):27-31. DOI: 10.1016/s0048-9697(00)00777-4 [Case series, n=5, with comparison groups]
- Tomas C, Brown A, Strassheim V, Elson JL, Newton J, Manning P. Cellular bioenergetics is impaired in patients with chronic fatigue syndrome. PLoS One. 2017;12(10):e0186802. DOI: 10.1371/journal.pone.0186802 [In vitro, human blood cells, case-control design]
- Holden S, Maksoud R, Eaton-Fitch N et al. A systematic review of mitochondrial abnormalities in myalgic encephalomyelitis/chronic fatigue syndrome/systemic exertion intolerance disease. J Transl Med. 2020;18(1):290. DOI: 10.1186/s12967-020-02452-3 [Systematic review, k=19]