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Why am I so tired? The Chronicles of Fatigue Part 1: Deficiencies.

Feeling tired (fatigue) is probably the #1 symptom I hear about in my office. Whether it is new, a long-term issue, or just a certain time of day, it all effects our quality of life. This is another example of what I consider common, but NOT normal. Of course there is some normalcy to it, we all feel tired at times, but feeling tired day after day is something to listen to and take action. The first step is figuring out the root cause.

This 5-part series of articles will highlight the top 5 reasons for fatigue, what puts you at risk for one more than the other, and what labs may be helpful. Let's get started!!


Part 1: Deficiencies:

This is a big category, so let’s start with the most common nutrients, but not forget insufficient hormones, hydration, and movement

Iron: iron is essential to our blood cells so that it can carry oxygen throughout our body. With low iron, we get fewer and smaller blood cells that cannot do their job

  • Symptoms: fatigue, shortness of breath, weak feeling/fatigued muscles (especially after going up stairs), dizziness, heart palpitations, looking pale, sleep issues (especially in kids)

  • At risk: Diet that excludes red meat, heavy periods, other source of blood loss (GI issues, postpartum), increase demand of iron such as in pregnancy and vigorous exercise.

  • How to know: Blood test for an iron panel with ferritin. I ALWAYS run a full panel that includes ferritin because that is your iron storage, and symptoms can begin way before you become clinically anemic (when your hemoglobin/hematocrit get low). Goal of ferritin is above 30-50.

B-vitamins (B12): Many B-vitamins are associated with low energy, but I want to highlight B12. B12 is needed for thousands of functions in our body, and it also is closely related to iron and blood cell production. It supports the nervous system, DNA production, and immune system support.

  • Symptoms: All of the above low iron symptoms, getting sick often, numbness and tingling of fingers and toes, mouth/corner of lips ulcers, low mood, foggy brain and cognitive ability,

  • At risk: Low animal diet, not supplementing if vegetarian, GI disturbance (our microflora make B12, and we can also have absorption issues- so if you also have GI issues this could be important information)

  • How to know: Testing. Urine MMA is the best marker, but serum B12 can also be used at a more affordable price point. Goal is for it to be above 500.

Vitamin D: Ah the sunshine vitamin, actually a hormone, has a clear link to fatigue when found to be low, and this is surprising VERY common.

  • Symptoms: Fatigue, mood changes especially depression, bone and muscle pain (only if severe), getting sick often, sleep changes, lower exercise endurance, hair loss,

  • At risk: Vegetarians, those who have limited sun exposure. (This includes living above the 37 deg in latitude (That is anywhere North of San Francisco, Denver, St Louis, and Richmond) and those who wear protective clothing and sunscreen), people with darker skin, Children under 4, Obese (BMI >30), and any digestive disorder that could affect absorption, Celiac disease being one example. Pregnancy.

  • How to know: A simple serum blood test can tell you. Test 25 (OH) D and the goal is for it to be above 40.

Hormones: As we age we naturally start to have declining hormones. Males specifically will see testosterone lower, and women will have fluctuations in estrogen, progesterone, and testosterone as well. DHEA is also important to note here for energy and as a precursor to testosterone.

  • Symptoms: low energy, muscle fatigue, lowered exercise recovery, low libido, irregular cycles, brain fog, sleep disturbance, dry vaginal tissue,

  • At risk: Age >40, low muscle mass, chronic stress, imbalanced nutrition, underlying medical conditions (PCOS, fertility issues)

  • Testing: Hormone panels can be done in a multitude of ways, from blood, to salivary and urine. Timing of the month is key, as well as keeping in mind you should not test if on any birth control.

Poor nutrition and blood sugar imbalances in general can also lead to fatigue because you may not be getting an overall balance of nutrients needed for energy production and a clear mind, as well as containing harder to digest fast foods that tax the system. The goal should be 3 meals a day, spaced evenly, that contain veggies, fruit, good quality protein, low sugar and a healthy fat source.

Hydration is also important for energy! Aiming for ½ your body weight in ounces/day has been shown to increase energy levels.

Exercise: I can’t talk about fatigue (or any health condition for that matter) and not mention the importance of movement!! In more than 90% of studies that look at the energy-exercise connection, we see an improvement in fatigue. That’s a pretty big deal and one that goes overlooked often.


As you can see, so many symptoms overlap, and even with a detailed history and exam, we need to rely on testing in order to appropriately treat. In my practice I like to run a comprehensive blood panel that covers most of the nutrients above, as well as hormone testing if it makes sense for the person sitting in front of me. We also will review nutrition and lifestyle factors in detail to see where could use some support.

Stay Tuned next week for the second chronicle of fatigue: Sleep!

Please reach out if you have any questions or would like to schedule a free 15min consult to see how this may relate to YOU. It’s all about individualized, holistic medicine in my book.



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