Fatigue—Where it Comes From, What to do About it

Fatigue is one of the most common symptoms people experience. As with many health issues, there are often multiple contributing factors, and people feel much better when we identify and address each of them. Here are some common fatigue contributors with some simple solutions.

Vitamin D deficiency

This is probably the most common vitamin deficiency I encounter in practice and often relates to chronic fatigue, joint and muscle pain. I screen everyone in San Francisco because we have less contact with the sun than in other parts of the country, and we also use sunscreen, which is great for preventing skin cancer, but not so great for Vitamin D levels which is made in our skin by exposure to sun. Vitamin D enhances calcium absorption from the gut, is essential for bone growth, supports immunity and reduces muscle pain and fatigue.

Other reasons for low Vitamin D might include having a dairy allergy or eating a vegan diet, having darker skin (the pigment melanin reduces the skin's ability to make Vitamin D from sunlight), poor digestive tract health which reduces absorption, or kidney disease which reduces conversion of the nutrient to its active form. Being overweight also makes vitamin D less available for use in the body.

Iron deficiency

Iron deficiency is common in menstruating women, vegans and vegetarians, elderly people or those with chronic disease that prevents them from absorbing iron efficiently. Iron is part of the hemoglobin molecule in red blood cells that carries the oxygen molecule to our tissues. Without enough iron, your tissues will be gasping for air. You may experience fatigue, dizziness, shortness of breath, brittle nails and hair, and paradoxically heavier menstrual bleeding.


Fatigue is one of the first signs of dehydration, believe it or not. A recent study showed that mild dehydration (a loss of 1% of body water) was enough to impair thinking. One of my basic recommendations for fatigue is to stay well hydrated, especially if you drink caffeine. In my opinion, caffeinated beverages like coffee, black tea and sodas do not count as fluid intake. Water, herbal tea, broth, smoothies and vegetables are some good sources of fluids for hydration. The last four are great because they have electrolytes, which supports cellular fluid absorption. If you drink a lot of fluids and they go straight through you, consider adding a pinch of sea salt and lemon to your water, or trying some of the liquid suggestions above. I do generally recommend around 64 ounces of water daily, give or take, depending on your activity level. If you sweat heavily working out, you can increase that number by half again or double it.

Stress, caffeine and blood sugar imbalance

Blood sugar imbalance is a key contributor to fatigue. With stress, excessive caffeine intake or a diet high in refined carbohydrates and low in protein and good fats—cortisol, a primary stress hormone is released. Cortisol causes blood sugar levels to rise creating a temporary burst of energy, then fall resulting in fatigue, poor concentration and sugar cravings. Sugar and caffeine may seem to help one stay alert, but they easily become part of the stress-fatigue cycle.


Fatigue and apathy frequently accompany depression. Brain chemicals that create feelings of happiness have overlap with those that provide energy. Dopamine, adrenaline and serotonin are a few you may have heard of. A diet with adequate protein, healthy fats and B vitamins is essential for healthy brain chemistry.

Hormonal imbalance

Thyroid hormone is one of the first that comes to mind first when I think of fatigue, and I always screen people with fatigue for hypothyroidism, but sex hormones can play a role as well. Low progesterone can often cause fatigue in women—one of the interesting things about this is that cortisol and progesterone share precursors. When we are stressed, cortisol production takes priority over progesterone and we can become progesterone deficient, creating symptoms of fatigue, irritability, anxiety, depression, weight gain, sugar cravings, menstrual irregularity or insomnia. Natural ways to support hormonal balance include taking a vacation, meditating, gentle yoga, relaxing with friends and sleeping. Adrenal support from herbs or nutrients helps with stress reduction and supports healthy cortisol levels so your body can recover its progesterone levels again. Rhodiola, holy basil, B and C vitamins are great sources of adrenal support as well as adequate protein, healthy fats and colorful fruits and vegetables and avoiding caffeine and sugar. Vitex agnus-castus is a wonderful herb for supporting progesterone levels naturally in the body. I recommend taking it in the last half of the menstrual cycle—Days 14-28.

Nutrient malabsorption or food sensitivities

Either you aren’t putting the right things in, or they are not being absorbed. Low stomach acid, stress, food sensitivities and gut microbial imbalance are possible reasons for malabsorption. Usually it is a combination of factors, and we work on all levels to balance things out. I do food sensitivity testing and stool testing in my practice to pinpoint the important issues and make corrections with dietary modification, anti-inflammatory nutrients such as turmeric and aloe, and adjustments to gut bacteria with herbs and probiotics. Alcohol use can strongly impact gut health and also contribute to blood sugar instability, sleep problems and poorly functioning metabolic pathways.

Lack of exercise

When we don’t move our bodies, our bodies stop wanting to move as much. It has to do with stimulation of the nervous system, physical fitness, blood and oxygen flow and brain chemistry. Studies have shown that lower intensity exercise such as a 20-minute walk 3 times weekly reduces fatigue even compared to higher-intensity exercise. It is a common misconception that high-intensity exercise is the best kind of exercise. If you feel energized after your high-intensity workout, that’s great, but if you find yourself exhausted afterward or struggling to lose weight even though you are working out regularly, you may want to consider mixing it up with lower intensity workouts such as calm bike rides, Hatha or Anusara yoga, walking or Pilates.

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An obvious reason for fatigue, but not always so easy to deal with. Hormonal balance can play a huge role in sleep issues. High cortisol, low melatonin or low progesterone can also contribute to sleep issues. Sleep hygiene, relaxing 30 minutes before bedtime by turning off all screens—television, computer and smartphones—having a cool, dark, quiet room and getting to bed before 11:00 pm can be very helpful. If low progesterone is the issue, a small dosage of natural USP progesterone cream can also be a great sleep aid. The natural form of progesterone has not been shown to cause the side effects that medroxyprogesterone acetate can (i.e. cardiovascular problems, some cancers).

Chronic viral infection, mold and environmental toxicity

If the basic factors contributing to fatigue have been addressed but someone is still not feeling better, we may look deeper into chronic viral infections, mold and environmental toxicities. Each of these could be a topic on their own and, I won’t go into them here, but keep them in mind if none of the other pieces fit for you.  

Dr. Claire Graser is an expert in these health issues. Please give us a call if you would like to enjoy more energy and vitality and be under her expert naturopathic care.