By Dr. Shawna Darou, ND
Fatigue, or tiredness is the number one complaint that brings people in for naturopathic care. There are many underlying factors to investigate in determining the cause of tiredness. Below is my top 10 list of factors that that can be causing your fatigue. Many of these are missed in a conventional medical work-up, or they are under-diagnosed if you fall at the low end of the reference range. Each year I add to and update this list because fatigue is so, so common.
Start with the basics:
Before we dig deep, it’s important to rule out (or in) the basic causes of fatigue: low iron, low vitamin B12 and low thyroid function. These are all easily tested with bloodwork:
1. Low Iron levels:
Many women experience iron deficiency anemia due to either low dietary intake of iron, or heavy menstrual cycles. If you have heavy periods and are feeling tired, it is very important to first test for iron deficiency and if low find a good iron supplement to improve iron stores. Low iron levels can manifest as: fatigue and sleepiness, feeling cold, dizziness, increased in headaches, paleness, dry skin and hair loss. Another less-known sign of low iron is an increase in anxiety. In most cases testing for ferritin (iron stores) levels is sufficient, although a hemoglobin, serum iron, TIBC (total iron binding capacity) and % saturation.
2. Low vitamin B12 level:
When you are deficient in vitamin B12, it causes another form of anemia which can also result in fatigue. Along with tiredness, very low vitamin B12 stores can cause numbness or tingling in the hands and feet, feeling cold, difficulty concentrating and a very red tongue. Low B12 levels are most often associated with a vegetarian diet, but are also seen with gluten intolerance and celiac disease. (Low B12 levels in a non-vegetarian, is a big red flag for gluten-intolerance!) Testing is quite simply done with a blood test for vitamin B12 levels.
3. Thyroid function:
Many women experience thyroid disorders, and they often go undetected and untreated especially those considered “subclinical”. Symptoms of thyroid disorder can include: low energy, difficulty maintaining or losing weight, feeling cold, dry skin and hair, low mood or depression, hair loss and constipation. Testing begins with basic blood testing (for TSH, free T4 and free T3), and may also include taking basal temperatures. There is some controversy as to the normal or reference range with thyroid function, so please discuss your results during your appointment if you suspect an undiagnosed or untreated thyroid condition. A mildly-underactive thyroid, called ‘subclinical hypothyroidism’ can cause significant symptoms, and is often overlooked in the conventional medical system.
If the basics have checked out, here is a brief description of other factors to investigate. We determine which ones to investigate or treat based on possible causal factors, and the full constellation of symptoms. For example, causal factors could be: onset of fatigue after a period of high stress, or after a summer of marathon training.
4. HPA Axis Dysfunction (was known as ‘adrenal fatigue’):
In a maxed-out, stressed-out culture where we chronically push ourselves beyond a reasonable capacity and expect our bodies to function well with very little down-time or rest. When we perpetually push too hard, one hormonal system in particular suffers: the adrenal glands. Your adrenal glands produce hormones such as cortisol, DHEA and adrenalin, and they all help our bodies adapt to stress better. Over time with chronic stress, the adrenal system is taxed, and symptoms develop such as: tiredness, sugar and salt cravings, poor tolerance for stress (meaning that stressful situations are harder to handle), poor blood sugar regulation, sleep disturbances and lower body temperature. If you suspect your low energy could be due to stress we start by testing your morning cortisol and DHEA levels (blood test), and may follow up with a salivary adrenal panel to map out the cortisol rhythm through the day.
5. Low free T3 level:
Another lab test that I run frequently is for free T3 levels. I’ll first explain thyroid hormones to understand what free T3 is. T4 also known as thyroxine is made in the thyroid gland, and it is sent peripherally through your body where it is converted to T3 or Triiodothyronine. This conversion is critical, because with low T3 levels, specifically free T3 (unbound T3) you will have symptoms of low thyroid as discussed above. Because T3 is mainly produced outside of the thyroid gland, having a low level does not indicate a problem with your thyroid – rather it indicates a conversion problem.
Causes of low free T3 can include: under-eating, eating too few carbohydrates, over-exercising, extended fasting (including intermittent fasting in some cases). It will also be low after a long illness or bad flu, due to some medications, and after a prolonged period of high stress. Basically the body down-regulates T4 to T3 conversion to slow you down and force you to rest, so symptoms of low free T3 include feeling tired, needing more sleep, gaining weight, feeling cold.
Since low free T3 is not technically a thyroid condition, treatment is to address the underlying cause: take a close look at nutrition, exercise patterns, stress, and allow the body extra time to rest.
6. Blood sugar regulation:
Many people find that when they track their energy patterns, the are either very low just before or just after eating. If your energy is lowest between meals, or before eating this could indicated hypoglycemia or low blood sugar between meals. In this case, eating regularly through the day (every 3 hours), and minimizing sweet and all-carb meals will help. If on the other hand you are very sleepy and bloated after eating, it could indicate high insulin levels or insulin resistance which is associated with poor blood sugar control. In both cases, a blood test for fasting glucose and fasting insulin is an important start.
7. Immune reactions: allergies and intolerances:
Environmental allergies of all types can cause significant fatigue, and usually this is obvious because of congestion, sneezing and itchy eyes. Occasionally this is harder to detect, for example during the late fall with mold allergy where the symptoms are more vague – fatigue, fogginess, irritated eyes, and a heavy sensation in the head.
Food intolerances can also cause significant fatigue, and first I want to differentiate these from food allergies. Intolerances are not life-threatening, and may not cause an immediate reaction. They are associated with many conditions, such as: allergies, eczema, asthma, autoimmune disease, digestive upset, low energy, low mood, and acne for example. In some people, intolerant foods can cause sleepiness, low energy, strong food cravings and fogginess. Elimination of the offending foods will often improve energy levels within one month. We can track these foods down with a food sensitivity test or an elimination diet.
8. Sleep quantity and quality:
One basic area that most of us can improve on is increasing the number of hours of sleep. The body runs optimally on approximately 8 hours per night, but many of us reach only 6 on a regular basis. Look at ways to get to sleep earlier so that you are in bed for closer to 8 hours each night – you will feel a difference after 2 weeks! Sleep quality is another factor in how rested you feel in the morning. Are you tossing and turning in the night? Or waking and having difficulty falling asleep again? Some causes of poor sleep quality include: a bedroom that is too light (which inhibits melatonin release in the brain), high stress hormones in the night (very common during and after periods of stress), night-time hypoglycemia from eating too many carbs / sugars or starches before bedtime, caffeine after noon and chocolate late in the day, hormones and hot flashes can certainly interrupt sleep, and of course being woken by children / spouses and pets which are harder factors to control. If you are having trouble staying asleep or feel that it is not restful, please investigate some of the factors above.
Along the same lines, sleep apnea is always a possibility if you have been told that you snore or if you wake up gasping in the night. We generally associate sleep apnea with men, but it is fairly common in women too, especially post-menopause. With apnea, you are not getting enough oxygen to your brain (and body) at night, which can leave you feeling exhausted all the time.
9. Poor nutrition:
Nourishing your body properly can also have a profound impact on energy levels. Some areas that are commonly missed are getting sufficient protein, having a good amount of iron-rich foods, eating at least 4 servings of vegetables daily to increase micronutrient intake, and also including enough health fats. If your nutrition has slid somewhat and you’re living on convenience foods and takeout, an overhaul to ensure you have plenty of fresh produce, the correct amount and types of proteins for your metabolism, and balanced nutrient-dense meals can greatly help your energy levels. Eating regularly is also a priority – many women skip or delay meals when life is busy, which can certainly cause blood sugar stress and fatigue.
10. Sedentary lifestyle:
Most of us recognize that regular exercise and movement will boost our energy levels, and yet it’s often the first thing to fall away when life gets busy. If you’re sitting 8+ hours per day working, and not getting outside for a walk, the simple solution might be to get your body moving. It’s amazing what a workout will do to boost your energy through the day, especially when life is busy and stressful. If you really can’t find time to squeeze in a workout, then start by increasing your daily activity – walk part of your commute, get outside over lunch, take the stairs and do errands by foot on the weekend. All movement counts, not just what you do at the gym.
11. Mitochondria dysfunction:
This may be something many of you have not heard about, but is also on the list of factors to investigate with fatigue. With mitochondria dysfunction the key is that exerting your muscles will cause profound fatigue. Other symptoms can be brain fog, chronic pain, premature aging and infertility. Mitochondria are organelles inside each of your cells that are the “powerhouse” because they create ATP or usable energy within the cells. You can learn more about mitochondria in this article: https://drshawnadarou.com/2019/08/12/feeling-tired-and-burned-out-it-may-be-time-to-consider-mitochondria-support/
12. Chronic infections:
Another cause of persistent fatigue can be due to chronic infections. The list of infections that can linger in the body causing issues with many systems is growing: for example: Epstein Barr virus (EBV), human herpes virus (HHV-6), cytomegalovirus (CMV), parvovirus (Parvo B19), chronic Lyme disease (Borrelia Burgdorferi) and more. In simple terms, chronic infections cause fatigue due to massive unchecked inflammation. This type of fatigue is usually debilitating, although it may ebb and flow in intensity. There are tests available for these infections to look for past exposure or reactivation. If your fatigue is intense, and no other tests are revealing clues this may be your next step.
13. Low mood or depression:
Finally, we can’t ignore depression as a cause of low energy. Depression is sometimes very clear, but other times not as obvious. Signs of depression include: low motivation, difficulty sleeping or sleeping too much, feeling overwhelmed or emotional, either under or over-eating and not receiving pleasure or enjoyment from things that you used to like. If you think that depression may be the cause of your low energy, please discuss with a health care professional for support and solutions to assist both your emotional and physical state.
If you find yourself frequently saying “I’m tired”, I hope that some of the points above have shown you a potential cause. And, please share this article with anyone in your life who is also too tired. There are many possible causes to investigate!