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  • Writer's pictureGavin Guard, Medical Director

5 Unexpected Reasons You Have Fatigue

Updated: Jan 22, 2022

Key Takeaways

  • Here are 5 reasons you might be experiencing fatigue and excessive tiredness:

  • Poor gut health

  • Sleep disordered breathing

  • Hormone imbalances

  • Inadequate nutrition

  • Anemia

  • It’s important to both take a comprehensive approach to diagnosing and treating these issues in order to get the best long-term results


Do you wake up feeling “groggy”? Experience brain fog (fuzzy thinking, hard time remembering words)? Rely on coffee especially during your post-lunch dip in energy? Are you a busy mom sitting on the couch just wishing you had just one hour by yourself, maybe even take a nap? Do you wish you had more energy to give to others?

This perhaps has lead to:

  • Little energy to play with your kids

  • Poor productivity at work

  • No time to invest into your own health

  • Feel like you’re living at 50%

If this sounds like you then you are among the millions of Americans suffering from chronic fatigue. Just like a good mechanic, the first part of fixing something is identifying and diagnosing the problem.

But the nebulous condition of chronic fatigue is often not well-addressed in a conventional 15-minute doctor visit. You might be told that “all your labs look fine” and not given an ounce of clarity of why you’re not feeling your best.

In this article, I will discuss 5 of the most common issues I see for causing fatigue (some might be a little unexpected).

Reason #1: Poor gut health

Functional digestive disorders affect 4 out of 10 people, and irritable bowel syndrome (abdominal discomfort, diarrhea, constipation) affects 10-15% of the population. It’s common and often overlooked.

How might you know that you have poor gut health? Here are some common symptoms we see from research and from my clinical experience:

  • Digestive symptoms (diarrhea, reflux, discomfort, constipation)

  • Insomnia

  • Joint pain and inflammation

  • Anxiety/depression, brain fog

  • Skin issues like acne or rosacea

  • Low energy

We can also employ testing to discern more insidious causes of poor gut health. Stool tests can assess imbalances in the microbiome (collection of bugs in your gut), possible presence of “bad bugs” such as parasites, overgrowth of bacteria, and fungus, as well as levels of inflammation and digestive sufficiency.

However, I often don’t perform stool tests until a patient fails foundational gut therapies. Why? Because it often does not change much of my treatment recommendations and leads to squandering of the patient’s financial resources. With that said, stool tests can at times be useful to identify silent digestive imbalances that don’t present as obvious digestive symptoms (e.g. fatigue caused by problems in the gut).

It’s obvious from the research that there exists a gut-energy connection. In other words, problems in the gut can lead to low energy and symptoms such as fatigue. For example, fatigue often accompanies IBS. In fact, in a review of 24 studies, 54% of IBS patients had fatigue.

But does treating the gut improve energy? The good news is that it in fact does! And we have lots of research to support this.

For example, a foundational therapy for better gut health such as probiotics has led to improved quality of life when used in those with IBS. To date, 3 collections of studies (encompassing many individual studies) have supported the use of probiotics in improving fatigue, quality of life, and energy levels.

Another digestive therapy called elemental dieting also improves IBS symptoms and quality of life (including energy levels). Finally, an antimicrobial approach to IBS led to better cognition in another study.

In summary, poor gut health is associated with fatigue and improving one’s gut health is associated with improved energy levels, cognition, and quality of life.

Reason #2: Sleep disordered breathing

Sleep disordered breathing includes conditions such as sleep apnea that characterize the restriction of air into the lungs during sleep. It is an often overlooked cause of fatigue and excessive daytime sleepiness (e.g. feel like you have to fall asleep at a business meeting).

It affects 15-30% of males and 10-15% of females. Being overweight or obese increases the odds that you might have sleep disordered breathing. For example, a 10% increase in weight is associated with a 6x increased risk of sleep apnea. Sleep disordered breathing is also found at higher rates in those with atrial fibrillation (up to 60%), hypothyroid, family history of sleep apnea, and smokers.

Symptoms of sleep disordered breathing include:

  • Daytime sleepiness/ fatigue

  • Snoring

  • Apnea (choking)

  • Morning Headache (found in 10-30%)

  • Dry mouth

  • Drool on pillow

Validated questionnaires (here and here) can also be helpful to identify this condition. More rigorous ways to evaluate sleep disordered breathing include sleep tests. This includes tracking your sleep study inside a sleep center. However, this can be especially difficult for those in remote areas like the San Juan Islands. The good news is that a home sleep test shows good accuracy when compared to in-clinic sleep tests for diagnosing sleep disordered breathing (but may miss other sleeping issues). These home sleep tests are cheap, portable, and the best news is that you can sleep in your own bed.

The gold standard for addressing sleep apnea and sleep disordered breathing is a CPAP machine which some of my patients have referred to as “wearing an octopus on your face while you try to sleep”. This refers to the uncomfortability associated with this intervention.

Fortunately, there are other options to sleep disordered breathing, especially for mild-to-moderate cases. This includes the following:

  • Weight loss can be a powerful strategy to help sleep apnea. One study found that even a reduced calorie diet can improve sleep apnea independent of weight loss.

  • Improving your gut health can improve sleep issues through the gut-sleep connection. For example, those with IBS report worse sleep and higher rates of insomnia. One study found that probiotics can improve insomnia.

  • Another therapy is called myofunctional therapy and is practically like physical therapy for your mouth. This is where you strengthen the muscles around your oral cavity to prevent the collapse of your airway when you sleep. It is supported by a few studies.

  • A “smart pillow” has also shown to be effective in two studies. This smart pillow senses when you are snoring (a sign of sleep disordered breathing) and adjusts your airway to prevent the collapse of your airway.

  • Finally, oral devices (AKA mandibular advancement devices) are similar at improving symptoms when compared to CPAP therapy. In addition, more patients prefer them over CPAP therapy.

Don’t let sleep disordered breathing go unaddressed. There are many therapies and options at your disposal to help you solve this issue.

Reason #3: Hormone imbalances

The most common hormone imbalances include female hormone imbalances and low thyroid.

Female hormone imbalances

80% of women will have some form of hormonal imbalances at some point in their lives.

Do you experience anxiety, fatigue around your period, irritability, mood imbalances, irregular periods? If so, you might be part of the 50% of women that experience PMS symptoms.

And if you are over 50 years old, then you are likely to experience irregular periods, brain fog, hot flashes, and skin changes associated with menopause.

One possibility is that your female hormone imbalances are actually being driven by problems in your gut. Quite a few studies have supported the gut-female hormone connection. And most importantly, improving your gut can improve these imbalances.

For example, probiotics can improve conditions such as polycystic ovarian syndrome (PCOS) as supported by a review of 13 studies including 855 participants. Probiotics also were associated with improved diarrhea and abdominal pain associated with periods. You can check out a case study from our clinic in which a patient improved her years of awful periods with a gut-specific approach (listen to Claire’s testimonial here below).

Another option outside prescription medications include herbal female hormone support such as vitex which is supported in a few studies to improve PMS symptoms.

And if you are in the menopausal category, then I encourage you to check out my article on hormone replacement therapy and discuss the risks and benefits with a knowledgeable provider.

Thyroid imbalances

Many other people are affected by low thyroid levels, which is called hypothyroidism. Symptoms include tiredness (81%), dry skin (63%), shortness of breath (51%), hair loss (30%), and constipation. Despite these hallmark symptoms, getting labs are key to accurately assess your thyroid status.

So what should you do about your thyroid?

Just like how we can address your gut health to resolve female hormone imbalances, you can also do the same to help your thyroid.

Why? Well, one reason is that symptoms associated with low thyroid can actually be stemming from the gut. Another reason is that improving your gut can help reduce inflammation and dampen down the immune system that might be driving thyroid issues.

For example, one study showed that eradicating a parasite led to the resolution of hypothyroidism. Another study showed that a patient’s thyroid levels improved by treating her gut with antimicrobials and switching to a different form of thyroid medication that is better absorbed in the digestive tract.

To get a more in-depth review of the gut-thyroid connection, check out my other article here.

If you are suffering from thyroid issues (or have symptoms of such), then I encourage you to get a comprehensive assessment of your thyroid status and work through improving your gut health. You may also inquire about different thyroid doses or forms from your doctor to reach optimal thyroid levels.

Reason #4: Dietary Mismatch

Dietary mismatch includes getting too many/too little calories, not enough nutrients, and the wrong type of foods that we need to fuel our body, brains, and minds.

You probably won’t find it far-fetched to suggest that our nutrition affects ALL systems of your body- nothing is spared from its effect. Therefore, we need the right type and amount of foods for our bodies to thrive.

Here are the most common examples from my clinical experience:

Too much food

Too many calories and food can contribute to weight gain, poor blood sugar, inflammation, and hormone imbalances. All of which can contribute to fatigue.

Unfortunately, 90% of the population is characterized as overweight. Too many of us are eating too many calories but not enough nutrients to match our energy demands.

Nonetheless, saying “just eat less” is not only unhelpful, but potentially dangerous. It’s important to get a coach to help you work through single practices at a time without overly restrictive diets. That is exactly how I help patients through nutrition coaching.

Too little food

On the other end of the spectrum are those who are not getting enough food. This is less common than overeating but it still happens especially in those who are overly concerned about their food choices.

I see this trend more commonly in more active adults (e.g. construction workers who also workout 5x/week) and in younger women who are trying to get fit by overly-restricting their diets.

Eating too little food also poses a risk of getting an insufficient amount of vital nutrients such as magnesium, zinc, B12, omega-3 fatty acids, calcium, and iron.

For most individuals, you probably want to get a balance of protein, carbs, healthy fats, and plenty of veggies/fruits that work well for your digestive system. Not enough of these can certainly lead to symptoms such as low energy levels and fatigue.

Fiber intolerance

Many health gurus claim that since fiber feeds your “gut bugs”, then more fiber is better. However, seemingly healthy high-fiber foods (e.g. broccoli, avocados) can be problematic for some folks, especially for those with digestive issues.

Why is this?

Fiber intolerance → poor gut health→ inflammation and immune system dysfunction→ fatigue and low energy

A dietary template that addresses fiber intolerance is called the low FODMAP diet. This includes moderating high-fiber foods such as onions, garlic, dairy, and some

other vegetables and fruit. A low FODMAP diet has been shown in many studies to improve IBS, inflammatory bowel disease, pain, fibromyalgia, and overall quality of life.

Histamine intolerance

Another type of dietary mismatch that can contribute to fatigue includes too much histamine ingestion. This is another example of how seemingly healthy foods can be problematic. High-histamine foods include spinach, sauerkraut, fermented foods, aged cheeses, and alcohol.

Histamine intolerance affects about 1% of the population and up to ½ of those with digestive issues.

Symptoms of histamine intolerance include:

  • Anxiety

  • Insomnia

  • Joint pain

  • Fatigue

  • Rashes/skin issues

  • Digestive symptoms

Addressing histamine intolerance can lead to improvement of energy and symptoms such as brain fog as found in one study.

There’s less research on histamine intolerance as compared to other studies so I usually wait to use this for patients unless they have a clear need for it.

How to address dietary mismatch

With anything else, work through a stepwise approach to your nutrition. Start with the fundamentals and work through more nuanced dietary templates if you don’t get adequate response from the fundamentals.

Most importantly, work through a provider that is proficient in helping you with your nutrition and doesn’t prescribe cookie-cutter recommendations. You can learn more about my approach to nutrition by scheduling a free appointment here.

Reason #5: Anemia

Addressing anemia can be an absolute game changer to improving fatigue! Why? Because it’s common and usually easy to fix.

Anemia encompasses impaired oxygen carrying capacity. It usually is due to iron deficiency but can also be due to other micronutrient deficiencies such as folate (B9), B12, and copper. Often, these deficiencies are attributed to poor gut health and poor absorption of these nutrients.

Here are some signs that you might be affected by anemia:

  • Inadequate intake: especially for those who are vegan or vegetarian.

  • Poor absorption: due to digestive issues. One common condition is called gastritis which leads to impaired absorption of B12 that can lead to anemia. Symptoms include burning stomach, you get full easily, older age, and have an autoimmune diseases (e.g. Hashimoto’s thyroiditis).

  • Excessive elimination of iron: commonly seen in those with heavy or long periods.

Getting a comprehensive lab assessment can be particularly helpful. The labs that I look at for my patients include:

  • Hemoglobin and CBC: to assess for presence and type of anemia

  • Ferritin: to assess iron levels

  • B12 and folate

  • Parietal cell and intrinsic factor antibodies: to assess for autoimmune gastritis

  • Gastrin: to look for low stomach acid that may lead to poor absorption of B12 and iron

  • Celiac disease panel: a cause of poor absorption of nutrients need by red blood cells

If you have anemia, be sure to work with a provider that can help you with the following:

  • Ensure adequate intake: supplement if necessary with iron, B12 lozenges.

  • Ensure good gut health: screen for underlying issues that could reduce absorption and work through improving your gut health in a stepwise fashion.

  • Fix sources of blood loss if necessary: Manage periods and excessive bleeding. A colonoscopy may be necessary (especially if over 45 years old or family history of colon cancer).

The Bottom Line

In this article, I outlined 5 unexpected reasons for fatigue. This includes poor gut health, sleep disordered breathing, hormone imbalances, dietary mismatch, and anemia.

Don’t let these issues go unaddressed and unsolved. Get a comprehensive assessment and personalized medical care plan today. You can schedule a free 15-minute appointment with me today to review your health concerns and create a game plan for you moving forward.

I hope you found this information useful and helpful in your journey back to a healthier and happier life.

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