Why am I so tired all the time? I am asked that question multiple times EVERY DAY.
Our society is exhausted, and it's only getting worse.
Do you ever wake up refreshed, make it through the day easily, then still have energy in the evening for home activities and family time?
If you do, consider yourself fortunate. Most of us don't. Not by a long shot.
In this article, I will discuss the most common reasons why you may be tired and give you some pointers on how to regain some energy and quality of life.
Let's get started...
What Does It Mean To Be Tired?
What do people mean when they say they are tired?
Sometimes they may be frustrated - "I am so sick and tired of this traffic."
Others may mean they are emotionally spent - "I am so tired of fighting with my husband."
Still others may mean they are physically worn out - "I am so tired from that workout." Or "I am so exhausted. The baby kept me up all night."
For the purpose of this article, when I talk about being tired, I am primarily referring to a lack of energy.
In my online hormone practice, I always start the first appointment with a new patient this way: "Give me 3 goals that you have in meeting with me." 95% of the time, the first 2 things that people list are:
1. Lose weight
2. More Energy
People are simply exhausted, both physically and emotionally.
Let's dive into the most common causes of fatigue that I see in people and discuss some solutions to this national epidemic...
Common Causes of Being Tired
Fatigue may be occassionally due to a single obvious reason, but most of the time it is because of several things, not just one.
Like most health issues, what you eat and your level of activity play a huge role in your energy level.
There may also be some hormonal issues as well as other things going on in your body that you need to consider.
Let's break these down further...
1. Adrenal Issues
As you know, we live in a very high stress society. Most of us are on the move constantly, then we wonder why we feel so tired!
This type of lifestyle plays havoc on our adrenal system.
One of the major functions of our adrenal glands is to produce cortisol, DHEA and epinephrine in response to stress (physical and mental).
These hormones help regulate our immune system, heart rate, and energy storage.
Under normal situations, a stressful event will trigger the adrenals to release a surge of cortisol which then signals the mitochondria in our cells to temporarily increase energy production.
That increase in energy helps us to get through the physical or emotional stress we are experiencing.
When the stress passes, the cortisol levels then drop back to the normal range.
When the body is under CONSTANT physical stress, such as a chronic infection, inflammation from obesity, insulin resistance, an autoimmune condition, etc., the adrenals are under pressure to continuously secrete large amounts of cortisol.
The same is true for constant emotional or mental stress.
High cortisol levels promote hypothyroidism.
It also worsens insulin resistance and leptin resistance.
With all of these conditions, fatigue is a common symptom.
Eventually, the adrenals will no longer able to produce adequate amounts of cortisol, so the levels in the body begin to drop. Adrenal fatigue results.
When this situation occurs, constant fatigue is a hallmark symptom.
Even normal day-to-day activities become exhausting. Exercise may make you feel wiped out for days.
To test for adrenal or cortisol issues, I usually start with an 8am serum cortisol level.
If your levels are <11 or >18, you have adrenal issues that should be addressed.
That may require getting salivary or urine cortisol levels 4 times throughout the day. You should discuss this with your doctor.
What What Can You Do About It?
To learn more in detail about management of adrenal issues, read my article here.
As a quick summary, here are my recommendations that you can do even without a doctor if your serum cortisol levels are abnormal.
If your morning cortisol level is >20, consider these supplements:
- Phosphatidylserine: Phosphatidylserine has been shown to reduce cortisol levels if taken in doses up to 600mg per day. Use 4-6 capsules at night (each capsule is 100mg) and recheck cortisol levels in 2-3 months.
- Ashwagandha: Ashwagandha is an adaptogen that can actually help to lower cortisol levels when they are high and raise them when they are low. It also can boost libido and may help with weight loss. It can also reduce anxiety symptoms caused by chronic stress. Doses vary from 500-2000mg per day depending on tolerance and severity of symptoms.
- Melatonin: Melatonin has been show to reduce cortisol levels and may actually help improve your sleep at night. Even if you are sleeping well, melatonin can still help reduce cortisol levels and should be considered. It can also help with depression symptoms. Doses vary from 1-3mg, but most people tolerate 3mg well.
If your morning serum cortisol is < 11, consider these supplements:
- Adrenal glandulars: These work best for patients with very low cortisol levels. They also tend to provide an immediate boost to energy levels. Using glandulars in combination with other supplements listed below may be necessary. Should be used for 6+ months.
- Adrenal Adaptogens: Adaptogens can actually help to lower cortisol levels when they are high and some can even raise cortisol levels when they are low. There are many types of adaptogens but I find that blends of multiple adaptogens tends to work best. These can be combined with glandulars as well for more benefit. Should be used for at least 3 months.
- CoQ10: This coenzyme is involved in proper mitochondrial energy production and can help increase energy levels, which can be very helpful in adrenal-related issues. Use 2 capsules (240mg) per day for several months.
- Alpha Lipoic Acid: ALA helps increase mitochondrial energy production, acts as a powerful antioxidant, reduces peripheral neuropathy, and lowers inflammation. ALA can also help with weight loss due to its effects on insulin. Start at 600mg daily and increase up to 1800mg daily as tolerated.
- Vitamin B6: Vitamin B6 is used in several pathways in the creation of adrenal hormones and many patients are deficient in it. Taking higher doses of B6 during the acute phase of treatment may be necessary for a short period of time.
If your levels are either extremely high or low, it is critical that you see your doctor for further testing. You could have undiagnosed Addison's Disease or Cushing's Disease.
Besides supplements, learning some stress management techniques is also critical for optimizing your adrenals and improving your fatigue.
These include things such as yoga, daily meditation, prayer, and even just going outside for 15-30 minutes every day.
2. Thyroid Issues
If you are more tired than you think you should be, checking your thyroid should be high on your list.
Since the thyroid is your "metabolism" gland, any conditions affecting it will affect your energy level.
Besides feeling tired, thyroid issues can cause these common symptoms:
- Weight gain or inability to lose weight
- Feeling cold all the time
- Brittle nails
- Thinning hair or hair loss
- Low body temperature
- Mood changes, such as anxiety or depression
- Brain fog
- Hormone imbalances - irregular periods, PMS
If you are having some of these symptoms, you should ask your doctor to run a complete thyroid panel:
Only checking the TSH level could miss up to 80% of patients with a thyroid condition.
Ideal levels for your thyroid tests include:
- TSH - ideal range is 0.5-2.0.
- free T4 - ideal range is in the upper 1/3 of the testing range
- free T3 - ideal range is >3.5
- reverse T3 - should be < 15
- TPO antibody - >35 is diagnostic for Hashimoto's thyroiditis
- Thyroglobulin antibody - >35 is diagnostic for Hashimoto's thyroiditis
So What Can You Do About It?
If any of your labs are out of these optimal ranges, you should talk to a doctor that is knowledgeable about the thyroid. Supplements and prescription medication made be needed to boost your thyroid function.
If your doctor isn't willing to work with you, consider finding a certified functional medicine doctor from the Institute of Functional Medicine.
3. Blood Sugar Imbalance
Blood sugar fluctuations are a common cause of feeling tired. You may be experiencing this especially if you have any "crashes" during the day when you feel weak, tired, and dizzy.
Most people are on a constant roller coaster - they eat a diet high in sugar or processed carbohydrates. This causes their blood sugar to rise rapidly.
The rise in blood sugar triggers their pancreas to release insulin to carry the sugar into the cells to be used as fuel.
The blood sugar then drops, sometimes rapidly, which makes them feel tired, moody, and even dizzy.
It also triggers their hunger, so they eat more sweets or high carb foods and the cycle starts all over again.
This situation is made even worse by:
- Insulin Resistance
Half of Americans already have insulin resistance and most have no clue.
When we constantly eat a diet high in sugar and/or processed carbs, our insulin levels remain high to try to manage the sugar load.
Our body responds to anything that is present in excess by learning to ignore it. That is what happens with insulin when we have insulin resistance.
We respond to the persistently high insulin levels by down-regulating the insulin receptors in our cells. This protects the cells from getting overloaded with glucose.
This causes the insulin and glucose levels to gradually increase. Eventually, pre-diabetes and type 2 diabetes occurs.
I bet you don't know many if any diabetic patients that feel energetic, do you?
- Poor Diet
We eat way too much sugar and processed carbs. Most of us know that intuitively.
In a little over 100 years, the average consumption of sugar has increased from about 40 pounds per person per year to well over 100 pounds per person per year!
We have also increased our consumption of grains (wheat, corn, etc) by almost 50% over the past 40 years.
I was raised in a small town. Growing up, my diet was full of poor food choices. Every breakfast had some form of grain and sugar - cereal, pastry, etc. Every other meal did not seem complete unless it included some form of bread and a sweet dessert.
With the changes that have been made to wheat and the continued increased processing of our food, we are learning that we have to make some conscious changes to our diets in order to improve our long-term health.
So What Can You Do About It?
Try to eat a whole food, nutrient-dense, high quality diet which is high in lean meats and organic vegetables.
If you need more help, a great starting point would be starting the Whole 30 diet or ketogenic diet.
I would also suggest hiring a certified nutritionist that is knowledgable about functional medicine.
4. Sedentary Lifestyle
When someone spends the entire day either sitting or laying down, should they be surprised that they feel tired?
Our bodies were made to move! Lack of movement with cause atrophy of our muscles and a general decline in our fitness level.
One study showed that regular, low-intensity exercise can reduce the feeling of fatigue by 65% and increase energy by 20%. 12 population-based studies showed similar results.
This study showed it specifically in women.
Have you ever been on an exercise program, then because of life events, had to stop for a few days? Isn't it amazing how quickly you lose your level of fitness and feel tired?
Now multiply that times 100 and you can get an idea of what a sedentary lifestyle will do to you and your energy level.
So What Can You Do About It?
Simply put, start moving! Anything that you start doing now will be more than you were doing before.
If you aren't currently exercising, start with a brisk walk at least 3 times per week.
Listen to your body. If it exhausts you, you may need to back off of the intensity. This is especially true if you are having some adrenal issues. Increase the time and intensity as tolerated.
Eventually, you will want to incorporate some simple weight training and high intensity interval training (HIIT).
If you are struggling with knowing exactly what to do and how much, I would strongly recommend hiring a personal trainer who can design a workout schedule just for you.
They will also serve as a form of accountability for you and make sure you are doing everything safely.
I highly recommend realfitness.net. Jessica is a world-class trainer as well as a certified nutritionist. She has helped many of my patients (including myself).
If you have significant health issues - heart problems, uncontrolled blood pressure, etc. - discuss it with your doctor before starting.
5. Poor Sleep
Sleep is our body's way of recharging itself and giving it the energy to function the next day. When we don't sleep enough or the quality of sleep is poor, we are going to feel tired.
If you are chronically tired, you need to take a long hard look at your sleep habits and sleep quality. Your energy will not improve if you are sleeping poorly.
- Poor Sleep Hygiene
Many people have developed horrible sleep habits over time.
This can include drinking caffeine throughout the day (including the evenings), sleeping in uncomfortable beds, sleeping in a bedroom that is too light or too hot, and staring a some sort of electronic screen the entire evening right up until bedtime.
The excessive use of electronic devices has become an epidemic in children and adolescents. In fact, this use has a direct effect on their quality of sleep. It has also been linked to the increase in depression in adolescents.
Normally, around 9pm at night, the pineal gland in our brain begins secreting melatonin. Melatonin helps our body to relax and prepares it for the night of sleep.
Excessive light, especially blue light, has been shown to suppress the secretion of melatonin in our brains.
I also see tons of patients that try to function on as little as 4 hours of sleep per night. That simply isn't enough. You body will eventually start breaking down.
- Obstructive Sleep Apnea
It is estimated that 22 million Americans suffer from obstructive sleep apnea. What's worse, up to 80% of those are undiagnosed!
Ask yourself these questions. Ask your spouse to answer them about you as well:
1. Do people complain that you snore like a freight train?
2. Has anyone ever noticed that you frequently gasp or even stop breathing while you are asleep?
3. Do you wake up exhausted in the morning, even if you have slept for 7-8 hours or more?
4. Do you find yourself dozing off during the day if you sit still for more than a few minutes?
If you answered yes to one or more of these questions, you should make an appointment to talk to your doctor about it.
Obstructive sleep apnea is a condition where the tongue falls back against the soft palate and the soft palate collapses against the back of the throat.
The result is the airway closes. You have to wake up out of deep sleep enough for your body to overcome the obstruction. This can happen multiple times every hour.
Since you don't stay in the restful deep stages of sleep, you don't truly get good rest.
Untreated obstructive sleep apnea has been associated with an increased risk of heart disease, congestive heart failure, and stroke.
Obesity is a risk factor for obstructive sleep apnea, but obstructive sleep apnea also worsens obesity, thus creating a vicious cycle.
It has also been shown to worsen insulin resistance and fatty liver disease.
So What Can You Do About It?
If you have sleep apnea, fortunately, all of these risk factors can be reversed with the use of a continous positive airway pressure (CPAP) device.
Your doctor can order an overnight sleep study which will determine whether you have sleep apnea or not.
Everyone should follow these common sense sleep habits:
- Try to sleep a minimum of 7-8 hours every night
- Reserve the bed for sleep and sexual relations only
- Consider installing blackout curtains in your bedroom
- Reduce your thermostat to keep your bedroom cool at night
- Make sure you have a comfortable, supportive bed and pillow
- Turn off all electronic screens at least 2 hours before bedtime
- At the very least, install a blue light filter on your smart phone, tablet and computer to use after dinner
6. Digestive Issues
Gut issues are often the root cause of many conditions of the body. The gut can also be playing a major role in your fatigue.
Here are some gut issues to consider:
- Leaky Gut
Leaky gut (intestinal permeability) occurs when the inflammation in the intestines causes gaps between the cells. These gaps allow foreign substances such as bacteria and other proteins to be absorbed that wouldn't be normally.
Those foreign substances trigger a strong immune response which further increases inflammation. That inflammation results in symptoms such as fatigue, mood swings, abdominal bloating and pain, achiness, headaches, and others.
The inflammation also prevents the absorption of many nutrients from what we eat, such as iron and vitamin B12. A deficiency of these nutrients worsens feelings of fatigue.
Leaky gut can be caused by a poor diet of processed foods, prescription medication, thyroid disorders and autoimmune disorders.
What Can You Do About It?
Remove processed foods from your diet, especially gluten and sugar.
Replace it with natural, organic whole foods. I also recommend fermented foods that are full of healthy bacteria that our body needs.
Fermented foods include sauerkraut, kumbucha, kefir, kimchi and yogurt.
There are also several gut-healing supplements that can help. These include:
- Probiotics - I recommend that it have at least 10 bacterial strains and at least 50 billion cfu.
- L-glutamine - this amino acid helps repair damage in the GI tract. Take 1000-3000mg daily in divided doses between meals.
- Digestive Enzymes - these enzymes help breakdown the fats and proteins in our meals. Take 1-2 with each meal.
- Quercetin - this product has bioflavanoids which help to balance histamine levels and helps with digestion and allergies. Take 2-4 capsules per day.
- Betaine Hcl with Pepcin - these are vital components of gastric acid secretion. It assists with digestion of food and absorption of nutrients. Take 1 with each meal. You may increase by 1 capsule per meal as needed. If you develop burning in your stomach, reduce the dose by 1 capsule with each meal.
- Food Intolerances
Many people are sensitive to certain foods and may not even know it. Although they may not be truly "allergic," consuming those foods still triggers inflammation and a reaction from the body. Again, a common feature of inflammation is fatigue.
What Can You Do About It?
There is not a good lab test for food sensitivities. The gold standard for determining them is the Elimination diet.
With the elimination diet, you remove the most common foods that cause food sensitivities for 3-4 weeks. If your symptoms improve during that time, you know that you are most likely sensitive to at least one of the foods.
You then re-introduce the foods one at a time and see if you react. If you don't, you are most likely not sensitive. If you do react, then you need to avoid that food as much as possible in the future.
The most common food sensitivities include:
- Processed or refined sugar
Water constitutes up to 75% of the body weight of infants and up to 55% of the body weight of adults.
Most of us are mildly dehydrated on an almost constant basis. That results in symptoms of fatigue, headache, brain fog, and mood swings.
Studies show that even mild dehydration can affect our mood, energy level and mental functioning. Here is another study.
Thirst is one of the last symptoms that you may feel when you are dehydrated. Fatigue and the other symptoms may already be present by the time you feel thirsty.
So What Can You Do About It?
Simply drinking more water may be the simplest yet most effective thing that you can do to increase your energy level.
As a general rule, I tell my patients that they should have to urinate at least every 2 hours. If you are going longer than that, chances are you are dehydrated.
A simple way to determine your daily water needs is to take your weight in pounds and divide that in half. That number will be the approximate amount of water in ounces that you should drink daily.
For example, if you weight 140 pounds, you should be drinking about 70 ounces of water per day.
By the way, that amount is just for your baseline water needs. If you are exercising, you need an additional 8 ounces for every 30 minutes of exercise.
Eating a diet high in moist vegetables such as celery, cucumber and carrots is another way of increasing your water intake.
7. Other Causes to Rule Out
Although feeling tired is a common symptom that all of us have at times, it can also be a sign of something more serious going on in your body.
If your fatigue is more severe and lasts longer than it typically does, it is extremely important that you see a doctor for a complete history, physical exam, and blood work.
Some of the more serious potential causes of your fatigue include:
Anemia is a condition where you have lower levels of red blood cells. Red blood cells carry oxygen in the blood to be used by the cells in the body.
Anemia is actually a symptom and not a diagnosis. Something is causing the anemia. That cause needs to be investigated thoroughly.
As a general rule, if someone is anemic, either the red blood cells are not being produced adequately by the bone marrow, or there is either blood being lost somewhere or the red blood cells are being destroyed somewhere.
Not only does anemia cause fatigue, it can also cause symptoms of weakness, dizziness, shortness of breath, pale skin, and an irregular heart beat.
Some causes of anemia include:
- Heavy menstrual periods
- Iron, vitamin B12 or folic acid deficiency
- GI bleeding - ulcer, gastritis, hemorrhoids, colon polyp, GI malignancy
- Anemia of chronic disease - cancer, autoimmune disease, and other inflammatory conditions can suppression bone marrow production
- Bone marrow suppression - leukemia, multiple myeloma
- Aplastic Anemia - the bone marrow stops making red blood cells. Can be caused by autoimmunity, infections, medications, and toxic exposures
- Hemolytic anemia- a condition where the body destroys the red blood cells faster than they can be made.
- Sickle Cell Anemia - a genetic condition caused by a defective form of hemoglobin
Many of these causes of anemia are life-threatening and should be worked up by a medical professional.
If you are anemic, don't just assume it is from something like heavy periods or a bleeding hemorrhoid. Have it evaluated!
Inflammation in general taxes our bodies and will usually cause us to have significant fatigue.
If your fatigue is persistent or progressive, you should see your doctor. Make sure that you request that your blood work include inflammatory markers, including the following:
- Complete Blood Count (CBC)
- Erythrocyte Sedimentation Rate (ESR)
- C-reactive Protein - (CRP)
If any of these tests are abnormal it indicates an increase in inflammation and further workup is required. Several autoimmune conditions could be the cause including Hashimoto's thyroiditis, rheumatoid arthritis, lupus, and many others.
As stated above, various different malignancies may have fatigue as one of the primary symptoms. This could include cancers of the blood, gastrointestinal system, reproductive system, and lungs.
It is critical that you see a doctor for evaluation if your fatigue is persistent and an obvious source has not been found.
If you are tired, there are probably several reasons that you should consider.
You may have some hormonal issues such as insulin resistance and thyroid dysfunction.
Your diet and activity level are also probably playing a role.
You should also look into your stress, sleep habits, gut function, and level of hydration.
There are also many potentially serious causes that need to be considered. Therefore, it you are excessively fatigued, see your doctor!
Now it's your turn...
Are you tired?
What did you find that caused your fatigue?
Any advice you would have for others?
Leave your questions and comments below.