Fatigue is one of the most common symptoms that I see in clinic, clients may present with other health problems but when I review their health history and “other” symptoms, the fatigue box is commonly ticked.
There are many different causes of fatigue and identifying the underlying cause is the key to treatment and improving your energy levels.
While there are many causes of fatigue, simply having fatigue can also cause many other symptoms, and unless you treat the underlying causes rather than just treat symptoms you will never fully recover to have abundant energy.
Symptoms of Fatigue
The many symptoms of fatigue can be caused by many different conditions, this is where functional pathology testing can be so important to get to the underlying cause.
I have see people who are chronically tired, even experiencing extreme fatigue, yet the blood tests from the doctor come back “fine”, in this case they are often prescribed anti-depressants. This does not get to the underlying cause, or even resolve the fatigue.
Here are some of the common symptoms of fatigue
There are different lifestyle changes, supplements and medications that can work amazingly well to help with headaches, stress, mood and chronic pain, but we want to find out the cause of fatigue so we can eliminate it all together, and be the best possible version of ourselves.
Causes of Fatigue
The top 10 causes of fatigue to investigate first
There are many different causes of fatigue but it is important to investigate the cause of your fatigue systematically, while chronic viral infections, mould and methylation issues can all be the underlying cause of fatigue I think it is important to look at the most common (and obvious causes first).
1. The quality of your diet
Your diet which is not only what you eat but how much you eat, is one of the first places to start with when addressing any health problem.
If you are eating processed foods, too many refined sugars, a diet high in industrial processed vegetable oils and not enough “real food” then you are simple not going to be getting enough adequate nutrition to fuel your body.
While I don’t think everyone has to follow a perfect diet all of the time, if you are finding that you are constantly fatigued or have extreme fatigue symptoms then experimenting with a 30 day real food diet that eliminates all of the processed foods, the stuff that comes in cardboard boxes and focus on eating more fruit and vegetables, enough quality protein, plus generous amounts of quality fats.
A 30 day real food diet can transform your energy levels
It’s amazing how many people feel so much better eating this way, and once the 30 days is up we can add small amounts of the foods that you cut out back in, this is a good way to see if you have any food intolerances, or maybe you were just eating a nutrient poor diet.
Even if you only improve 30% this is a good start, the other improvements will come from improving some of the other causes of fatigue.
2. The quantity of your diet
While a quality diet is important, it is also vital that you are eating enough, so many times I see health conscious people eating salads and vegetables, small amounts of lean proteins and not many fats, this ends up being a low calorie diet.
Short term low calorie diets can actually help to increase your energy, but if you have a long term calorie deficit it will put your body into a stress response. When this happens thyroid function slows down, metabolism slows down which can leave people scared to add more calories, as they worry that it will lead to weight gain.
I find the opposite is true, as clients increase calories with a nutrient dense quality diet not only do energy levels increase, but if they have weight to lose they can often drop a few kilo’s.
There is no magic formula for the amount of calories that you should eat, this is going to vary for everyone depending on activity, age and occupation.
I don’t recommend that people track there calories all the time, as this can become either obsessive or boring, depending on your personality type, but tracking your calories for a few days can help to understand if you're actually eating enough.
It’s not just total calories that you need to look at but also get an overview of your macronutrients which are protein, fats and carbohydrates. For some people they are not getting enough healthy fats and protein, this can occur on a vegan or raw food diet, but for other people they may not be getting enough carbohydrates like on a ketogenic diet.
This article helps to work out your protein needs
A Ketogenic diet can be a fantastic source of energy, and a great diet for many people, but it does not suit everybody, particularly people who already have a lot of stress or have underlying hormonal problems, this lack of carbohydrates can lead to fatigue.
Action step: Track your calories and macronutrients for a few days using My Fitness Pal or one of the other many tools and apps that are available to do this.
3. Not enough sleep or not enough quality sleep
Along with diet not enough sleep may seem like an obvious cause of fatigue, but it is amazing how many people simple do not sleep enough, or unknowingly have very poor quality sleep.
The amount of sleep that you need is going to vary from person to person, but most people need between 7-9 hours of sleep a night.
With so many things to do in life with work, family and social life a good way to try and fit it all in is to cut out an hour’s sleep a night, while this can work in the short term it is going to lead to fatigue in the long term.
If you need 8 hours of sleep a night but your only getting 7 it may not seem a big deal, but that adds up to missing 7 hours of sleep a week or put another way, you are missing out on an entire night’s sleep a week!
“ I don’t feel tired at night “ or “ if I go to bed early I can’t sleep “ is another reason why people can stay up late, there can be many reasons for this.
High cortisol levels at night will give you the tired but wired feeling, too tired to do anything but you can’t sleep so you end up staying up watching TV or staring at some other type of screen. Watching screens also help to suppress the bodies production of melatonin, which is the sleep hormone, so even when you do go to bed you have a restless night’s sleep.
Sleep apnea is another cause of fatigue, with this it can feel like you are sleeping through the night but wake up feeling exhausted, this is because you are stopping breathing multiple times a night which stops you getting quality sleep.
There are several devices and apps that you can use to track your sleep, while not perfect they can be a good way to see if you are waking up at night, and to track the rhythm of your sleep. This includes the Fitbit, Oura, and apps available on your phone (just make sure your phone is in flight mode at night)
A good way to assess your individual need for sleep is the next time you are on holidays go to bed at the same time every night, ideally not too late, and sleep in a dark room with no alarm to wake you up. It may take 3-4 days for your body to relax and sleep as much as you need but this is a good way to assess your ideal level of sleep.
Here is a good resource on sleep - 37 experts share their sleep tips
Action step: If you can’t take time out for a holiday to assess your sleep then trial not using any devices with screens for an hour before bed, including TV, if you simply must do this then use blue light blocking glasses so that you do not suppress your melatonin. Go to be at least 8 hours before you have to get up in the morning.
Spend some time reading, practicing meditation or listening to music before bed instead of screen time. Put your phone in flight mode (the alarm will still work), turn off all electrical devices in your bedroom, or better still remove them, and make the bedroom as dark as possible.
Some people are chronically dehydrated without even realizing it, they may not even feel thirsty but this can lead to chronic fatigue like symptoms. If you’re someone that drinks less than 6 glasses of water a day then this maybe part of the reason why you feel so tired.
There is no magic number for the amount of water that you need to drink either, and once again this is going to depend on your climate and activity levels, I would suggest increasing your water intake by 2 glasses a day for a couple of weeks and see what difference this makes.
Action step: Use a water bottle for a couple of days so that you can assess how much water you currently drink, if it is less than 1.5 litres a day try slowly increasing the amount of water each day until you are having at least 1.5 litres, if you live in a hot climate or sweat a lot then you will need more than this.
5. Low Iron and Anaemia
This can affect both men and women, but it is more common for women to be low in iron because of the monthly menstrual cycle. You can also have anaemia which is low hemoglobin and red blood cell count, but have normal iron and ferritin levels, or you can have low iron without anaemia. It is important to assess this properly with pathology testing as the treatment is going to be different depending on the results.
Low iron and anaemia can cause fatigue but also many other symptoms like pale skin, muscle weakness, low appetite, trouble sleeping, the symptoms are varied because the body relies on healthy iron and hemoglobin levels to transport oxygen to cells throughout your body.
Action step: Get your hemoglobin levels and an iron studies test which measures iron, transferrin, transferrin saturation and ferritin which is your iron stores. The optimal range is very different to the lab reference range, let me know if you need help assessing the results.
6. Low Vitamin B12
Severe deficiencies in vitamin B12 will lead to anaemia, but even a mild deficiency of B12 can cause fatigue. B12 can be checked in a routine blood test with your doctor, although it is not always included so you may need to ask for it, and don’t take your doctor’s word for it that your levels are fine, as they will only be looking at the reference range and not the optimal range.
The reference range for vitamin B12 is usually around 200 to 700 pg/ml but the optimal range is above 500 pg/ml and levels below 400 will start causing B12 deficiency symptoms like fatigue, tingling, weakness, brain fog and these symptoms can be subtle at first.
Many people can be below optimal for B12 levels and this can be due to genetics, medications like the oral contraceptive pill, Metformin for diabetes, and PPI medications for reflux and digestion problems affecting the absorption of Vitamin B12. Vegetarian and Vegan diets are also at greater risk of a B12 deficiency as the active form of Vitamin B12 is only found in animal products.
Not all Vitamin B12 supplements are created equal, avoid the synthetic cyanocobalamin and go for either methylcobalamin or hydroxocobalamin. I recommend either the Metagenics or Orthoplex White label brands in Australia (contact me for details), or if you are in other parts of the world the Thorne Research or Jarrow formulas are very good and can be purchased from Amazon or Iherb.com
7. Common Medications can cause Fatigue
There are many commonly prescribed medications that can cause fatigue, it is important however to never stop taking any prescribed medication without first talking with your doctor.
Addressing the underlying cause which lead to you needing to take medication is the first step to being able to reduce the dose or stop altogether, and sometimes there is an alternative medication that may not cause fatigue.
Medications that can cause fatigue include:
Action step: Assess your medications and see if you are taking any that can contribute fatigue, the symptoms do not always occur straight away and can creep up slowly so you may not connect your medication with fatigue. A naturopath or functional medicine practitioner can help you address the underlying cause so that eventually you may not need these medications, or talk to your doctor about alternatives.
If your not able to stop a medication sometimes you can add in specific nutrients to help with fatigue, for example statin medication used to treat high cholesterol deplete the body’s ability to produce co-enzyme Q10, by taking a quality Co-enzyme Q10 you can offset the negative effects of the statins.
8. Too much or too little activity
Physical activity improves circulation, increases endorphins and overall helps to improve your energy levels, especially if it is outside or somewhere in nature.
If you are just too exhausted or have extreme fatigue then you may have to look at some of the other causes of fatigue, but if you are feeling flat, not sleeping well or find yourself desk bound for most of the day then increasing your exercise levels can be a great way to stimulate more energy, and improve sleep quality.
On the flip side too much exercise, especially combined with a poor diet or lack of nutrients can exacerbate fatigue. Overtraining can lead to adrenal dysfunction and nutrient deficiencies and it maybe a good idea to back off your training load, switch to less endurance based activities or do some testing to find out the cause.
Action step: If your not exercising or spending time in nature just get out and about, get moving and spend some time in the sun. Set small goals and just get started, team up with a friend to help you be accountable and make it more fun.
If you are doing a lot of exercise, especially endurance exercise and feeling exhausted assess your diet to make sure you are eating enough, assess the common deficiencies and assess your adrenal function.
9. Low blood sugar
Hypoglycaemia otherwise known as low blood sugar can cause fatigue, mood changes and even disrupt sleep. It is quite common, especially for people following a typical Western diet which can be high in refined carbohydrates.
Symptoms are often worse after meals, especially after lunch when a rise in blood sugar is quickly followed by a quick drop leading to afternoon fatigue, sleepiness and cravings for sugar and caffeine.
Low blood sugar at night can also cause a rise in your stress hormones, this can lead to you waking up at 2 or 3am wide awake and not being able to get back to sleep.
Action step: Tracking your blood sugar levels before eating and one and two hours after eating can identify low blood sugar as the cause of your fatigue. Alternatively if you focus on cutting out refined carbohydrates and eating small meals that contain protein and healthy fats every 3 hours you will notice an improvement in your energy levels and mood.
Supplements that can help with sugar cravings and stabilize blood sugar levels include Jarrow Formula’s Glucose Optimizer.
10. Food allergies or intolerances
Reactions to foods, whether that is a true food allergy like celiac disease or a nut allergy, or an intolerance to dairy, gluten or other foods can lead to fatigue There are several companies out there providing food allergy / intolerance testing and while they maybe useful I find that they are quite expensive and I only use them as a last resort.
A better way to assess food allergies and food intolerances is to follow an elimination diet for at least two weeks and preferably four weeks. This diet cuts out all of the most common allergens, as well as foods high in salicylates, preservatives and other chemical “numbers” that are often added to processed foods.
This type of program is better suited to people that have more symptoms than just fatigue, if you have skin problems, headaches, allergies, sinus, digestion problems or other unexplained symptoms then you may benefit from an elimination diet.
Symptoms may actually get worse in the first week or two as your body goes through a withdrawal process, I recommend doing a diet like this with your Naturopath or Nutritionist, and at Planet Naturopath we can help you with an elimination diet.
Action step: Follow a 30 day elimination diet and record your symptoms throughout this time.
Looking Beyond the Basic Causes of Fatigue
The first 10 causes of fatigue can be assessed through dietary changes, improving your lifestyle and simple blood tests, for many people they have addressed these causes yet are still fatigued, if this feels like you we may have to dive a bit deeper into some more detailed testing.
11. Low Thyroid Function
Hypothyroidism can cause a wide range of symptoms and one of the big ones is fatigue. It is estimated that 12% of people either have low thyroid or sub optimal thyroid function yet 60% of these cases go undiagnosed.
The reason that low thyroid function is often not detected is because doctors usually only check Thyroid Stimulating Hormone (TSH) when they are assessing thyroid function, this is the messenger hormone from the brain telling the thyroid to produce more hormones. But the reference range for TSH is quite broad and it is possible to have normal TSH but low T4 and low T3 which is the metabolically active form of thyroid hormone.
I have written extensively about thyroid testing in the past and this article explains why you need to do a complete thyroid test to assess thyroid function.
Action step: If you have a family history of thyroid problems, or have not been fully assessed with a complete thyroid test that measures TSH, T4, T3, reverse T3 and the thyroid antibodies I would order the complete thyroid test here.
12. Adrenal dysfunction or “Adrenal Fatigue”
Adrenal dysfunction, otherwise known as adrenal fatigue can cause many different symptoms, especially fatigue. With adrenal dysfunction levels of fatigue can change throughout the day but the most common times to experience fatigue are in the morning and afternoon, and often you can have that “tired but wired” feeling at night, this is when you are exhausted from the day but when you lie down you cannot sleep.
Sometimes doctors test cortisol levels with a blood test, cortisol is the main adrenal hormone and the number one stress hormone, but a blood test is not a good way to assess adrenal function.
Your cortisol levels naturally change throughout the day, and the best way to assess the changes in cortisol is the DUTCH hormone test which measures your free cortisol levels and your total cortisol production. This is better than a saliva cortisol test which only measures free cortisol.
I have written detailed articles about adrenal dysfunction which you can read, or check out the video below where I explain how the DUTCH hormone test works.
13. Bacterial Infections
Chronic bacterial infections can be a cause of fatigue, especially chronic fatigue like symptoms, or fatigue that seems to change from day to day. Often you will have symptoms of a bacterial infection like sinusitis or a urinary tract infection, but you can also have bacterial infections in the digestive tract or gum disease and not even realize.
A good place to start with any chronic health problem is optimizing digestive function, even if you do not have obvious digestion symptoms I recommend doing a G.I Map test. A G.I Map test can identify hidden bacterial, parasitic of fungal infections that can cause inflammation, poor absorption of nutrients leading to many different health issues, including fatigue.
You can read more about testing digestion function in this article here.
Also getting assessed for urinary tract infections by your doctor, and getting a thorough oral examination from your dentist can help to identify other hidden causes of fatigue.
14. Viral infections
Viral infections such as Epstein bar virus, cytomegalovirus and Ross river virus can all lead to fatigue, at the onset of a viral infection you may experience sudden extreme fatigue. These types of infections are often not routinely tested for so sometimes you have to ask your doctor to test for the common viral infections that are in your region.
Chronic viral infections can also lead to mitochondrial dysfunction, so even after you are over the viral infection your fatigue can continue, sometimes lasting for years. Viral infections are one of the main triggers for chronic fatigue syndrome.
There are no medications to treat these types of viral infections, but there are herbs, nutrients and even medicinal mushrooms that can boost your immune system and speed up your recovery. Some of my favourite immune boosting products contain herbs such as Astraglus, Reishi and other medicinal mushrooms
15. Chronic Fatigue Syndrome
Chronic fatigue syndrome (CFS) as the name suggests is fatigue that has been persisting for 6 months or more and can be quite debilitating. Symptoms are usually worse after activity and because so many other causes of fatigue need to be ruled out first it can be difficult to diagnose, there is no blood test for CFS and it is a diagnosis of exclusion.
The Organic Acids test is my favourite test to determine the cause of fatigue when all the pathology and other tests come back normal. This can identify blocks in energy production and metabolism, nutrient deficiencies and the metabolites of neurotransmitters, these can be all involved in the cause of CFS.
Action steps: If you have ruled out other causes of fatigue and you have CFS then diet and nutrition is of utmost importance. Supplements that can be beneficial include B vitamins, Co-enzyme Q10, carnitine and adaptogenic herbs.
Depression can cause fatigue, low motivation as well as the low mood symptoms. Depression can have many different symptoms which can range in severity from mild to severe, sometimes people may not view themselves as being depressed as they may not think that they have the “typical” depression symptoms.
Depression does not mean that you need to take anti-depressant medication, like fatigue, depression can have many causes so starting with improving diet, regular exercise and mindfulness meditation can be a great place to start.
If you have ruled out the other causes of fatigue and you are experiencing low mood, sadness and depression it is a good idea to talk to a psychologist who can help guide you on the best approach for you.
There are nutritional and herbal supplements that can help with mild to moderate depression, talk to a naturopath or functional medicine practitioner on the best options for you.
17. Heart Disease
Arteriosclerosis which is a partial blockage of your arteries can lead to fatigue, shortness of breath and in more severe cases fatigue. This can occur in any age but the risk increases as you get older, other risk factors include diet, lifestyle choices and genetics.
If you are experiencing symptoms of fatigue combined with shortness of breath you should see your doctor, they can organise scans and a stress test to help determine if atherosclerosis is the cause.
Action steps: For fatigue combined with breathlessness see your doctor.
Diabetes can cause fluctuations in energy levels, this can range from mild tiredness to extreme fatigue as your blood sugar levels fluctuate. The number one prescribed medication for diabetes is Metformin which can also cause fatigue by depleting vitamin B12.
Stabilizing blood sugar levels with a lower carbohydrate diet (especially eliminating all refined sugars) with adequate amounts of protein and plenty of healthy fats is the best way to address the fatigue caused by diabetes.
Many people have diabetes and do not even know as they have not had glucose, HbA1C and insulin levels checked, its hard to diagnose diabetes from just a basic glucose test so it is important to be more thorough with testing. A glucose tolerance test may also be indicated if you have inconclusive results with the other tests.
Most cases of type 2 diabetes can be managed with diet and lifestyle, the research shows that a low carbohydrate diet can reverse the insulin resistance and the symptoms of diabetes.
Action steps: Get assessed for diabetes or insulin resistance with a glucose, HbA1C and insulin test.
Methylation and genes like MTHFR which are involved in methylation, are currently a hot topic in the health world, and for good reason. If you have never heard of methylation that is not surprising as most of the research into methylation has only occurred in the last 10-20 years, and a lot of this has only been published recently.
The biochemical process of methylation is involved in a almost all body functions, and problems occurring with methylation have been linked to cardiovascular disease, dementia, cancer and other chronic health conditions.
Methylation is involved in many key processes including
Genetic testing through companies such as 23andme can help to determine if you have mutations in the genes involved in the methylation cycle, there is more to it than just looking at MTHFR.
While blood tests can be used to assess folate and B12 levels, a better way to assess how your cells are using these key nutrients in the methylation cycle is with an Organic Acids test.
Action steps: While knowing your genetics is helpful, doing a Organic Acids test is a better option for finding out how energy production is working and if you are lacking the key nutrients for methylation.
If you need help assessing your genetic information you can schedule a consultation and we can help you understand your genetics and how it relates to methylation and other aspects of health, including diet and nutrition.
20. Mitochondrial dysfunction
Your mitochondria are like your cells batteries, they produce ATP which is what your body uses for energy. Mitochondrial disease is quite rare but mitochondrial dysfunction where your bodies ability to produce energy can affect a lot more people.
How the mitochondria works and how it can have a reduced function is still not fully understood, but it is one of the main causes of Chronic Fatigue Syndrome. The symptoms can be wide and varied and include poor recovery from exercise, muscle weakness, neurological problems and sleep issues.
There is no perfect test to measure mitochondria function, an Organic Acids test measures key nutrient deficiencies like the B vitamins and Coenzyme Q10 which are important for mitochondrial function, an Organic Acids test also measures the citric acid cycle which is how your body makes ATP.
A good quality nutrient dense low inflammatory diet is important to support mitochondrial function, essential nutrients include the B vitamins, lipoic acid and Co-enzyme Q10.
21. Chronic Inflammatory Response Syndrome
Chronic Inflammatory Response Syndrome (CIRS) otherwise known as Sick Building Syndrome can be caused by mold exposure or from tick bites with conditions like Lyme disease.
According to Dr. Shoemaker, the proper diagnosis of CIRS involves:
To warrant a diagnosis of CIRS, the following criteria should be met:
1. History, signs, and symptoms consistent with biotoxin exposure. In cases of mold toxicity, history should include exposure to toxin-producing molds as documented bythe EPA-approved ERMI test. In other cases (microcystin, ciguatera, etc.), history should include likely exposure or laboratory evidence of exposure.
2. A genetic predisposition to biotoxin-related illness based on identification of an HLA susceptible haplotype.
3. Abnormalities documented by Visual Contrast Sensitivity (VCS) testing.
4. Biomarkers consistent with the neuroimmune, vascular, and endocrine abnormalities that characterize CIRS. If you have a history consistent with biotoxin exposure, a susceptible genotype, and an abnormal VCS test, you are very likely to show the laboratory abnormalities seen in CIRS. Major and minor criteria are a work in progress.
This can happen in old water damaged buildings, as well as state of the art new buildings, and some people are more susceptible than others for developing this syndrome.
The first step is to assess places you frequent the most which is usually your home and work place for water damage, sometimes this is not obvious as the water damage maybe behind walls or a leaking dishwasher or other appliance.
If you suspect that you may have mould toxicity or CIRS there are tests that you can do to assess your immune response and inflammation levels
Action steps: Assess your home workplace for possible water damage, Dr.Shoemaker is the authority on CIRS and has developed testing to assess whether this is affecting you, at Planet Naturopath we can organize these tests to assess for CIRS.
The Next Step
There are a lot of different causes of fatigue, if you are struggling with fatigue and need help to get back on track identifying and understanding the cause can seem overwhelming. At Planet Naturopath we can help identify the underlying cause of your fatigue, and work with you on a treatment plan to help optimize your diet and nutrition, to help you get your energy back.