Chronic fatigue, a persistent state of tiredness that doesn't improve with rest, is often dismissed as mere exhaustion from stress or overwork. However, when fatigue becomes prolonged and debilitating, it can have deeper, less obvious causes. Uncovering these hidden factors is key to effective treatment. Below, we explore the underlying reasons for chronic fatigue and discuss science-backed approaches to managing it.
1. Nutrient Deficiencies: The Energy Deficit
Many cases of chronic fatigue can be linked to nutrient deficiencies that impair the body’s ability to produce energy. Iron deficiency, for example, leads to anaemia, which directly impacts oxygen transport to tissues, causing fatigue. Even without anaemia, low iron stores can result in decreased energy (1).
Deficiency in vitamin B12 and folate can also cause fatigue. These nutrients are crucial for DNA production and energy metabolism, and a lack of them can lead to impaired red blood cell production, reducing oxygen delivery to the body's tissues (2).
Treatment: Addressing these deficiencies through dietary changes or supplements has been shown to significantly improve energy levels. For iron, eating iron-rich foods like red meat, spinach, and lentils, or taking iron supplements, can help. For B12 and folate, incorporating foods like fish, dairy, eggs, and leafy greens, or taking supplements, can be beneficial.
2. Thyroid Disorders: The Silent Energy Killer
Hypothyroidism is another hidden cause of chronic fatigue. The thyroid gland regulates the body’s metabolism, and when it underperforms, energy production slows down. Even mild cases, often referred to as subclinical hypothyroidism, can result in unexplained fatigue (3).
Treatment: A blood test for thyroid function is essential. If hypothyroidism is diagnosed, treatment involves thyroid hormone replacement therapy, typically using levothyroxine.
3. Hormonal Imbalances: Energy Dysregulation
Fatigue can also result from hormonal imbalances beyond thyroid dysfunction. Conditions such as adrenal insufficiency (where the body doesn't produce enough cortisol) or sex hormone imbalances (like low oestrogen in women or low testosterone in men) can lead to energy dysregulation. Women, particularly during menopause or perimenopause, often experience fatigue due to shifting hormone levels (4).
Treatment: Hormonal imbalances can be treated with hormone replacement therapy or lifestyle changes aimed at supporting hormonal health. For instance, menopausal women can benefit from oestrogen therapy, while adrenal insufficiency requires corticosteroid replacement.
4. Neurological Imbalances: Fatigue at the Brain Level
Neurological conditions like multiple sclerosis (MS), Parkinson's disease, or even undiagnosed migraines can lead to chronic fatigue. These conditions impact the brain’s ability to regulate energy and muscle function, often leaving sufferers feeling drained even after minor physical activity (5).
Treatment: Treatment depends on the specific neurological condition. Medications that modify the disease progression (e.g., for MS) or manage symptoms (such as dopamine replacements in Parkinson's) can improve energy levels. For other neurological imbalances, cognitive behavioural therapy (CBT) and physical therapy may provide relief from fatigue.
5. Mould Exposure: The Hidden Environmental Culprit
Chronic fatigue may also stem from environmental factors like exposure to mould. Mould produces mycotoxins, which can lead to “mould illness” or chronic inflammatory response syndrome (CIRS), causing symptoms like fatigue, brain fog, and headaches. Homes or workplaces with water damage are often the primary source of mould exposure (6).
Treatment: Reducing mould exposure by improving ventilation or removing mould-infested materials is essential. Treatments may include medications to reduce inflammation and bind mycotoxins, such as cholestyramine, along with dietary modifications to support detoxification.
6. Hidden Food Intolerances: Gut Reactions to Fatigue
Food intolerances and sensitivities can also lead to chronic fatigue. Conditions like coeliac disease, where the body reacts negatively to gluten, are well-known culprits. However, even non-coeliac gluten sensitivity or other intolerances (such as to lactose or FODMAPs) can contribute to persistent fatigue due to chronic inflammation and poor nutrient absorption (7).
Treatment: An elimination diet can help identify offending foods, followed by a tailored diet to avoid them. For example, avoiding gluten in coeliac disease patients can reverse fatigue caused by the condition. Consulting a dietitian for food intolerance testing and management can help alleviate fatigue.
7. Chronic Infections: The Unseen Energy Drain
Infections that persist long after the acute phase can cause chronic fatigue. Conditions like Epstein-Barr virus (EBV), Lyme disease, and even post-viral syndromes, such as those seen with long COVID, can result in prolonged fatigue due to the lingering effects of immune system activation (8).
Treatment: There is no single treatment for chronic infections, but management involves antiviral or antibiotic medications, depending on the infection, along with supportive therapies to improve immune function. For instance, studies show that addressing viral reactivation in conditions like EBV can reduce fatigue levels.
8. Sleep Disorders: The Energy Saboteurs
Chronic fatigue is often the result of undiagnosed sleep disorders, such as sleep apnoea, insomnia, or restless leg syndrome. Sleep apnoea, in particular, is a common condition where the airway becomes partially or completely blocked during sleep, leading to poor sleep quality and daytime fatigue (9).
Treatment: Polysomnography (a sleep study) can diagnose these conditions, and treatment varies depending on the disorder. Continuous positive airway pressure (CPAP) is effective for sleep apnoea, while cognitive-behavioural therapy (CBT) is useful for insomnia.
Chronic fatigue can be caused by a wide variety of underlying factors, often hidden and overlooked. Nutrient deficiencies, thyroid disorders, hormonal and neurological imbalances, mould exposure, food intolerances, chronic infections, and sleep disorders all play a role. By identifying the root cause, treatment can be tailored effectively, improving energy levels and overall well-being. If you're struggling with persistent fatigue, consider seeking medical advice to investigate these possible causes.
References
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2. O'Leary F, Samman S. Vitamin B12 in health and disease. Nutrients. 2010;2(3):299-316.
3. Vanderpump MP. The epidemiology of thyroid disease. Br Med Bull. 2011;99(1):39-51.
4. Charmandari E, Nicolaides NC, Chrousos GP. Adrenal insufficiency. Lancet. 2014;383(9935):2152-2167.
5. Kluger BM, Krupp LB, Enoka RM. Fatigue and fatigability in neurologic illnesses: proposal for a unified taxonomy. Neurology. 2013;80(4):409-416. doi:10.1212/WNL.0b013e31827f07be
6. Shoemaker RC, House DE. Sick building syndrome (SBS) and exposure to water-damaged buildings: time series study, clinical trial and mechanisms. Neurotoxicol Teratol. 2006;28(5):573-588. doi:10.1016/j.ntt.2006.07.
7. Campagnolo N, Johnston S, Collatz A, Staines D, Marshall-Gradisnik S. Dietary and nutrition interventions for the therapeutic treatment of chronic fatigue syndrome/myalgic encephalomyelitis: a systematic review. J Hum Nutr Diet. 2017;30(3):247-259. doi:10.1111/jhn.12435.
8. Rasa S, Nora-Krukle Z, Henning N, et al. Chronic viral infections in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). J Transl Med. 2018;16(1):1-25.
9. Marin JM, Carrizo SJ, Vicente E, et al. Long-term cardiovascular outcomes in men with obstructive sleep apnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005;365(9464):1046-1053.
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