The Comprehensive Guide to Why You Feel Tired All the Time
There are 2 sets of stories I get when people come to see me about feeling tired.
Scenario 1: I'm so tired and I can't sleep!
"I've placed crystals under my pillow/burned cleansing sage to eliminate bad spirits/placed soap under the sheets/counted all of the sheep/Feng Shui-ed my room/flipped my mattress/bought a new pillow/put up a dream catcher/taken all the sleep aids and nothing has worked!"
Scenario 2: I sleep 8-9 hours a night and I'm still tired, what gives?
"It must be my chakras/my partner tossing and turning/waking up on the right side of the bed/the universe in conspiring against me/alien abduction."
There are also 2 specific requests I get frequently:
Request 1: "Can you check my thyroid?"
Request 2: "Can you prescribe me a sleep aid?"
Many people think their fatigue is related to a medical condition or are convinced the solution is related to a biological lack of endogenous pharmaceutical medication production.
This comprehensive guide to fatigue is for anyone who feels tired, would like more energy, and wants to get the root of the problem!
What is Fatigue?
Fatigue is the medical term used to describe feeling tired and it has a wide range of possible causes including lifestyle, environment, mood, and medical conditions.
Symptoms of fatigue include:
having trouble getting to or staying asleep
feeling tired or sleepy in the day
feeling forgetful or making more mistakes than usual
feeling cranky, anxious, irritable, emotional, or short tempered
having less energy or interest in doing things
have a smaller attention span
worry about lack of energy or sleep
Fatigue can impact all areas of your life including relationships, work, school and recreation.
Fatigue can also be a safety concern impairing your ability to drive or make good decisions.
Getting to the root cause of fatigue and working towards gaining energy can be an intimidating, complex, and lengthy process for someone who already feels exceptionally tired.
But, the outcome for those who see it through is life changing!
If you don't feel well rested and full of energy you can't show up in the world to serve other's in the best way possible!
If you're fatigued you won't be able to take care of yourself, your pets, your partner, your kids, your parents, or your house plants!
Here is a comprehensive guide to help you understand the causes of fatigue and what can be done to improve your energy so you can get back to changing the world!
Issue 1. Not enough sleep
Sleep is one of the only times our brains repair, recover and detoxify.
Most adults need 8-9 hours of uninterrupted sleep to feel well rested.
As a bedside nurse I worked shift-work for several years, so I am familiar with real life challenges that make getting enough sleep difficult. But there are ways to improve quality and quantity of sleep.
Sleep Hygiene recommendations are a standard set of instructions to help fall asleep and stay asleep.
Solution 1: Prioritize bed time
The more hours of sleep you are able to get before midnight the higher quality your sleep will be.
Chose an ideal bed time and wake time and progress toward it. Keep the same bed time whether it is a weekday or week end.
If you're currently heading to bed at 1 or 2am without a good reason, it is time to start moving your bed time earlier.
Start by moving your sleep time 15 to 30 minutes at a time with the aim to get to bed by 9pm or 10pm and wake 8 hours later.
If you find you are not sleepy, do not force yourself to lie in bed. This can be counter productive if you are lying in bed with negative thoughts about how you won't be able to sleep running through your head. Instead do a quiet, relaxing activity for 15 or 20 minutes and when sleepy get back in to bed.
While getting enough sleep is important, so is getting too much. Set a wake time and stick to it. Avoid hitting the snooze button several times as you will not get added benefit from this type of sleeping in and will find your sleep onset may be difficult the following night.
Solution 2: Minimize sleep disruptions
If you get up in the night you are disrupting your sleep and will be less likely to get the benefits of REM sleep.
If possible, turn off our technology so that you will not be getting calls or notifications during the night.
Before cellphones and tablets, the biggest cause of disrupted sleep besides babies was getting up pee.
Getting up to pee at night, or nocturia, involves you waking up, turning on a light, walking to the washroom, doing your business, maybe checking your text messages, getting back to bed, possibly thinking about all the things you need to do tomorrow, and trying to get back to sleep. Possibly repeat 2-3 more times.
To minimize getting up to pee at night I advise all of my patients to avoid fluids 3 hours before bed and to sit on the toilet at night before bed for 10 minutes to stimulate the detrusor muscle.
If you get a dry mouth and are prone to drinking water through the night I advise drinking more water earlier in the day, keeping a humidifier in your room and using mouth moistening products overnight rather than taking sips of water. You can find mouth moistening sprays and mouth washes at your local pharmacy.
If a disruption in your sleep is inevitable such as waking to feed the baby I recommend keeping the lighting as low as possible to keep your body in a restful state.
Solution 3: Melatonin
Melatonin is the body's natural sleep hormone.
Melatonin is ten times higher at night than during the day. They rise with the onset of darkness peaking between 11pm and 3am. And falling sharply at sunrise.
Endogenous Melatonin is the hormone your body produces. Exogenous melatonin comes in the form of a supplement that may be prescribed to take at bedtime.
The pineal gland in the brain is the body's natural Melatonin production center. After you've learned about how Melatonin works, you can scroll down to the medication section to read about supplementing with Melatonin.
The body naturally raises melatonin levels in the evening and decreases it in the morning.
Melatonin rises in relation to cues in your environment like the sun going down.
To help your body's natural rhythms decrease your light exposure before bed time.
This includes dimming the lights not only in your home, but also on your tech devices. Apps such as f.lux change the light quality on your devices automatically through the day to mimicking sunup and sundown.
Some medications affect Melatonin production, so it is important to know whether your medications could be contributing to insomnia.
Issue 2: Unrestful Sleep Environment
How do you feel when you see the colours red or orange?
How about the colours blue and green?
Does the former make you feel energized and the latter make you feel calm?
Our environment influences our energy and emotions.
Solution 1: Bedroom activities
Do you ever notice how when you get into your washroom your body is cued to relieve itself? Your bedroom should be the same way.
When you enter your bedroom your body should anticipate one of two activities:
sleep or sex.
If you want to get a restful sleep avoid using your bedroom as your office, living room, home theatre or dining room.
Solution 2: Lighting
The brain's pineal gland, which is the centre for melatonin production, can be easily affected by light.
This makes lighting in your room very important, but preferences can differ.
While I prefer to cut out all light with black-out blinds as I live in a city with a lot of artificial light streaming through the windows, you may prefer to not use blinds to allow the sun to wake you naturally.
If you chose blackout blinds there are high tech lighting options to simulate sunrise and sunlight in the morning to help you wake up and signal hormonal changes that support the natural sleep-wake cycle.
Solution 3: Noise reduction
Noise pollution is a real issue for those living in cities, with noisy neighbours or with teenagers.
Noise can keep you in an alert state making it difficult to fall asleep and stay asleep.
Solutions include low tech options like sound proofing and ear buds or high tech options like sound machines to drown out background noise.
Issue 3: Tech Obsession
Never in the history of human kind have we had more access to entertainment, friends and family at the tips of our fingers than right now.
Many of us are guilty of checking our phone immediately before bed and immediately on waking and several times an hour.
It's important to consider how this affects our energy and sleep.
Use of technology before bedtime is proven to delay sleep onset.
Solution 1: Filter out blue light
Our brains are simple. They know light means day and dark means night.
Maybe even, the light from the sun means day and fire means night.
Cellphones, tablets and computers emit blue light that is similar to daylight. To minimize the effect there are settings, apps and blue light filtering glasses that exist to solve this dilemma of needing to use technology after dark, but not wanting to affect your sleep hormones so much.
Look up the blue light filtering solution for your device.
Alternatively, invest in blue light filtering glasses and wear them in the evenings.
For shift workers, blue light filtering glasses worn at night are hypothesized to decrease risks related to shift work including heart disease and certain cancers.
Solution 2: Turn off your devices at night
Is scrolling through your Facebook or Instagram feed at 2am really necessary?
Some people leave the television on to help them fall asleep only to wake up a few hours later to turn it off. If this is you, minimize disruptions by setting a sleep timer or choosing a different activity to relax before bed.
The artificial light from television or other screens and overstimulation of social media, online news outlets, text messaging or responding to email lead to disruptions in sleep hormones.
If reading helps you fall asleep, read physical books with a small reading light rather than using a tablet, computer or phone screen.
Solution 3: Take tech breaks
Scrolling endlessly and staring as screens can be fatiguing. Not in the same way a sprint or weight session in the gym are, but fatiguing none the less.
Physically, screens can cause eye strain and make being sedentary for hours on end easy.
Take tech breaks every fifteen minutes by looking away from your screen for two to three minutes. Get up for a brief walk or stretch hourly.
Mental fatigue can come from information overload, running self-criticism that can come from looking at carefully curated social media accounts, and negative or sensational stories in the media. Not to mention sitting and scrolling is another opportunity for endless inactivity that compounds fatigue.
Ditch technology altogether for extended times where possible.
Issue 4: Excessive Stress
Melatonin is the hero and stress hormones are the villains when it comes to sleep.
Solution 1: Minimize Cortisol
If a bear walked into your cave and roared at 2am while you were sleeping, stress hormone Cortisol would be the hero making you alert and ready to protect yourself.
In our modern lives we have multiple stressors including work, school, family, relationships, bills, taxes, illness, time crunches, expectations, fear of missing out and on and on.
To combat stress, create a relaxing routine before bed. Maybe this is a warm bath, reading a chapter of a good book, journalling, prayer or meditation, having a healthy snack high in tryptophan (see Issue 5, Solution 3), brushing your teeth and doing a 10 minute guided meditation for sleep.
Leave your worries at the bed room door. There is no place for worry in the bedroom.
One strategy I frequently recommend is to journal before bed or to leave a journal beside your bed. Creative ideas and recurrent negative thoughts are common once we get into bed and close our eyes to sleep. Write down your to-do list or worry list or brilliant creative idea list before bed. Then, if you wake up in the middle of the night with recurrent thoughts, again write them down. This way you are confident all of your worries or brilliant ideas will be there for you in the morning and you can clear your mind to focus on a restful night's sleep.
Solution 2: Address Your Mental Health
Depression, anxiety, and bereavement are all causes of fatigue.
They are very common and experienced by most people at some point in their lives.
And, no, the associated fatigue is not "all in your head," you have a real physiologic reason to feel exhausted!
But, it doesn't have to last forever.
Depression, anxiety and bereavement are associated with changes in hormones that affect your energy levels.
Once you recognize your mental health can affect your energy levels and are associated with chemical changes in your brain and body it is important to address your mental health by reaching out to a professional.
Do not risk going it alone and suffering longer than necessary.
Evidenced based therapy and/or medication are effective and can change your life.
Solution 3: Cognitive Behavioural Therapy, Meditation and Vagal Stimulation
Evidenced based therapies for insomnia are effective non-pharmacological treatments.
For example, if you have a difficult time getting to sleep one night, your brain may play an automatic message all day about how tired your are and how difficult it is to fall asleep. Sure enough, when it comes time to sleep, sleep will be a difficult thing and your negative thoughts are reinforced. Further, you may have recurring thoughts all night about how tired you will be the next day. A fear of not being able to sleep and of being tired becomes a reality night after night in a cycle of negative thoughts. Eventually you associate the bedroom with sleeplessness rather than restfulness.
Therapy can help to change your inner automatic dialogue and re-train your brain to have more positive thoughts and beliefs around physical or mental fatigue and sleep.
Being able to change your thinking patterns to truly believe you are going to have a restful night of sleep and wake up refreshed can be a powerful tool.
Likewise, progressive muscle relaxation exercises and slow-paced breathing before bed have been shown to be effective in improving sleep onset.
Prayer and positive intention setting are also good strategies.
Download my Stressed to Centred Guide to get started on conquering your stress!
Issue 5: Dietary Choices
What you put into your body will affect your energy.
Luxury vehicles are filled with premium fuel, and you should treat yourself as such because your body is your vehicle for life.
Solution 1: Hydrate
Our bodies are 50% water. Dehydration causes increases in stress hormone cortisol, difficulty in producing energy, and difficulty removing waste. When we're well hydrated, we're like a well oiled machine. When we're dehydrated things move a little more like sludge.
If you do not have any history of heart failure or other organ failure aim to consume half an ounce to an ounce for each pound that you weigh. You'll need more fluid on hot days or when you are very active.
Aim to consume the fluid early in the day so you are not running to the washroom at night.
The type of fluid you consume is also important.
A litre of fizzy sugar water or coffee are not effective for hydration. These will send your blood sugars and cortisol for a loop as well as dehydrate you.
Instead stick to clean filtered water. Add some lemon or lime slices for flavour and to create more alkaline water.
Have your water quality checked and consider a filtration system to eliminate toxins from your water and balance the trace minerals.
Solution 2: Balanced Diet
Either not enough or too much food will leave your energy systems feeling sluggish.
Low fat, low sugar, low salt, highly processed products are often also low nutrient products.
Avoid processed foods and try to get most of your daily calories from fresh wild or organic, pesticide and hormone free fruits, vegetables, legumes, dairy, fish and meats.
Your gut is full of bacteria that are part of your microbiome. When you eat, your gut bacteria also eat. Support gut health and good bacteria with whole foods, high fiber options, and fermented foods like sauerkraut and kefir.
If you struggle with making healthy choices or eating the right amount of food to support your energy needs through the day consult a specialist.
If you struggle with sugar cravings download my 10 Day Sugar Detox Program to get on the path to conquering your cravings.
Solution 3: Meal Timing & Bed Time Snack
Having a small snack with a food that includes tryptophan before bed could help with sleep.
The right snack can balance sugar through the night and tryptophan is a hormone that causes sleepiness.
Examples of bedtime snacks include a half a peanut butter sandwich or an ounce of cheese and apple slices.
Avoid heavy meals or high sugar foods before bed. Heavy meals could lead to acid reflux and cough when lying flat disrupting your ability to get to sleep. High sugar foods can lead to swings in your blood sugar from high to low through the night as your insulin spikes to deal with the extra sugar.
Solution 4: Avoid Caffeine & Nicotine
Kick your after dinner coffee habit. Kick the smoking habit altogether.
Caffeine & Nicotine are stimulants and should be avoided 4 to 6 hours before bedtime.
Hidden sources of caffeine are tea, soft drinks, and chocolate. Some supplements and pain medications also contain caffeine, so it is important to check the labels.
Solution 5: Alcohol
While caffeine is a stimulant, alcohol is a depressant. Most people find it relaxing.
A lot of people have a glass or two of wine with dinner or in the evening to wind down.
Some people use alcohol to self-medicate to initiate sleep.
Alcohol may prevent your from getting in the restorative REM sleep. It may also disrupt your sleep hormones causing you to wake in the middle of the night. Further, alcohol is a diuretic. So when you do wake up, you will also find you need to get up to pee. Lastly, it can cause sleep apnea, a medical condition that leads to not getting enough oxygen while you sleep (this is covered in more detail below).
Issue 6: Activity & Timing
With more desk jobs and less manual labour, more of us are less active during the day than generations past.
Solution 1: Get active
If you don't get your wiggles out in the day, you may find you are compelled to get them out at night! This shows up as difficulty falling asleep, staying asleep and possibly restless legs.
Increasing your activity during the day will level your body feeling truly fatigued at night.
If you work at a desk job take a walk at lunch or request a standing desk. Through the day chose routes that force more activity like taking the stairs instead of elevator.
Try to get 30 minutes of vigorous activity on most days of the week.
Solution 2: Exercise early in the day
Congratulations for getting your exercise in! That is excellent!
For some people, the only time in the day they can find to exercise is just before bed.
While this may not cause sleep disruption for some people, others will have difficulty falling asleep after exercise.
Exercise is an activity that favours energy and alertness.
If your exercise routine is making it difficult for you to fall asleep try moving it to an earlier time in the day such as first thing in the morning or immediately after work.
Issue 7: Mitochondrial Dysfunction
Your mitochondria are the energy powerhouses of your cells.
They produce 90% of the energy needed to power your body.
While there are genetic diseases that cause obvious clinical dysfunction, there is also more subtle dysfunction caused by lifestyle and environmental factors that influence your cells abilities to produce energy.
Solution1: Healthy Habits
While we can't change our genes. We can change our environment.
Healthy habits are key to ensuring healthy mitochondrial function. These include healthy balanced diet, minimizing processed foods, exercise, hydration, supplementation as advised by a care provider.
Solution 2: Supplementation
Testing for end products of mitochondrial function can give clues to how to support an individuals mitochondrial function.
These are typically the focus of functional health practitioners who may advise on supplementation to support the mitochondria.
Issue 8: Medical Conditions
There are several medical considerations for clients coming to see me with complaints of feeling tired.
I've outlined several common medical conditions below, but the list is not all inclusive.
Each of these conditions requires investigation, management and regular follow-up with a qualified care provider which is beyond the scope of this article.
In order fatigue to improve, the underlying condition must also improve. This may require regular follow-up visits for monitoring and treatment plan changes.
Seek a qualified medical provider for more information. I do not recommend self diagnosis and self treatment.
Sleep Apnea
Have you ever been told you snore?
Most people don't know that they snore unless someone else tells them. Many of my patients are convinced they do not snore, but when they go home and ask their spouse they learn the truth. Your partner has probably tuned out your snoring and is too polite to make it an issue. But, snoring can be an indication of a serious health condition that has several possible treatments: Sleep apnea.
There are two causes of sleep apnea: Obstructive or Central.
Obstructive is caused by a collapse of the soft palate that blocks the airways when you are relaxed in your sleep. Central is caused by a disruption in your bodies usual signals that keep you breathing. Both can lead to not getting enough oxygen while you sleep.
If you have sleep apnea, your brain, heart, liver, kidney, gastrointestinal tract and all other body tissues are not getting enough oxygen during the night. This leads to fatigue and can contribute to diseases including cognitive impairment and heart failure. The only way to diagnose sleep apnea is with a sleep study. Discuss with your care provider whether a sleep study is right for you.
If you are diagnosed with sleep apnea, diligent use of your prescribed treatment whether that is weight loss, a mouth guard, or CPAP machine will be a key to improving your sleep quality and preventing long term consequences of untreated sleep apnea. You may also consider surgical options for the soft palate.
Thyroid Dysfunction
Thyroid hormones affect your energy production. Too little thyroid hormone and you might feel depressed and tired. Too much thyroid hormone and you might feel anxious and not be able to sleep. If you are fatigued, visit your care provider to have your thyroid hormone levels checked.
Adrenal Dysfunction
Your adrenal glands produce your stress hormones. Unusual cortisol production can lead to changes in energy. Visit your care provider to have your adrenal hormone levels checked.
Blood Sugar Abnormality
Blood sugar levels that are too low or too high can leave you feeling ill and fatigued. Visit your care provider to have your blood sugar levels checked.
Anemia
Anemia is the term for low hemoglobin.
Hemoglobin is the part of the blood that carries oxygen around our bodies.
Low hemoglobin can be caused by bleeding, poor production, chronic disease, malignancy, or low levels of iron, B12 or folate.
Infections
Influenza, Lyme disease, Epstein Barr Virus, tooth infections and urinary tract infections are some examples of infections that can cause fatigue.
Your care provider can ask about your history to determine if further testing and treatment is warranted for infectious causes of fatigue.
Heart Disease
Your heart plays a central role in circulating blood through 60,000 miles or 100,000 kilometers of arteries, capillaries and veins. If your heart beats abnormally fast or slow or doesn't pump enough blood with each heart beat you could feel fatigued. Visit your care provider to discuss heart health to determine if this could be a factor in your fatigue.
Rheumatological Conditions
Fibromyalgia, polymyalgia rheumatica, lupus, and sjorgen's are some of the rheumatological conditions associated with fatigue. Your medical provider or specialist can test for these if they suspect these conditions may be contributing to your fatigue.
Gastrointestinal Conditions
Untreated celiac disease or other chronic gastrointestinal disorders may lead to malabsorption of nutrients and chronic inflammation that contribute to fatigue. If you suffer from bloating, gas, constipation or diarrhea discuss your symptoms with your care provider.
Leg Cramps
Leg cramps at night can be caused by dehydration, tight muscles, exercise close to bed time, and certain medications and medical conditions. Stretching, massage, heat and ice are options for leg cramps. Magnesium supplementation can also help. Speak with your medical provider if you experience leg cramps at night.
Vitamin and Mineral Deficiencies
Everything from beating heart cells, to working muscles, to digestion, to immune function, to brain signals requires a balance of vitamins and minerals.
A healthy diet rich in organic fruits, vegetables, legumes and meats may be enough for individuals with a healthy digestive system and genetically normal metabolism. But many factors in our modern lives may contribute to inadequate levels of vitamins like B12 and D or minerals like magnesium.
Our bodies are very good at keeping blood levels of vitamins and minerals in a safe range.
Not too little, not too much.
For example, vitamin B12 stores in the liver can last 2-5 years if there is no dietary source. So, a deficiency can take a long time to show up in a vegan or vegetarian who is not getting enough B12 from their diet. Once the stores get too low symptoms such as fatigue will emerge.
On the other hand, too much of a vitamin or mineral can cause toxicity. Over-supplementation can be as serious as under-supplementation.
I frequently see clients on upwards of 20 supplements that they have decided to start themselves because of clever advertising or have been advised on by several providers who aren't aware of what the client is already taking. I work with these clients to decrease supplementation to the optimal level.
Visit your care provider to determine what supplementation is right for you.
Pregnancy
Two very important questions I ask my female patients who are seeing me for fatigue are: when was your last menstrual period and is there a chance you could be pregnant?
Fatigue is common in pregnancy and energy levels can change through pregnancy with hormonal changes, nutritional requirement changes and sleep changes.
Substance Use
Nicotine, alcohol, marijuana, cocaine, opioids and other recreational drugs can all contribute to fatigue. Reach out to your care provider for helping with quitting substance use.
Supplement: Medications for Insomnia
Insomnia is a problem falling and/or staying asleep and feeling unrested in the day.
Long-term treatment of insomnia with medication alone is not the best strategy.
Medications serve a purpose and play a role in some cases of insomnia, but they should not be used as a band aid solution to the root cause.
For example, the evidence suggests 6-8 weeks of Cognitive Behavioural Therapy for Insomnia (CBT-I) is often sufficient alone without medication therapy.
That being said, there are many medication options for treatment of insomnia including benzodiazipines, non-benzodiazipines, melatonin, antidepressants, diphenhydramine, antipsychotics, barbituates, and over-the-counter medications.
A qualified medical professional will make medication recommendations based on your age and medical status.
Do not be put off by the "drug-class" such as antidepressant or antipsychotic. A medical professional who is qualified to assess, diagnose and prescribe will determine based on their expertise which option may be best for you.
Some medications come with side-effects such as daytime drowsiness, dizziness, impaired driving and lightheadedness. A medical professional will review possible side-effects with you.
For those who prefer to use options that most mimic their body's natural hormonal pattern, who travel a lot and need help with jet lag, or who work shift-work Melatonin supplementation is a good option. You can help reset your body clock by taking a Melatonin supplement 30 minutes before your intended bedtime. Check with your care provider before initiating supplementation.
Magnesium is a mineral commonly used to help relax the body and has been used as a sleep aid. If you are already taking magnesium, you may want to move the timing to before bed. Again, discuss with a professional whether magnesium supplementation may be right for you.
Again, medications should not be used alone, rather should supplement sleep hygiene advice and complementary therapies like cognitive behavioural therapy.
Bonus: Sleep Hygiene Checklist
To get you started on the road to better sleep and better energy download my free Sleep Hygiene Checklist by entering your e-mail address below or on the homepage!
*Medical Disclaimer: This article is not a substitute for professional advice and is only for informational purposes only.
