One of the most common reasons people come to my office for the first time is tiredness. Initially in this article I was going to explore the main reasons why people are tired. The article got lengthy in a hurry! In this issue of the newsletter I will deal with the main nutritional reasons for fatigue and in future posts I will deal with some other reasons for tiredness.
There are several nutritional deficiencies that can cause anemia. Anemia is when a person has low numbers of red blood cells, low hemoglobin and low hematocrit, all these values are checked in a simple blood test called a CBC. To be diagnosed with anemia, all 3 values must be low. Red blood cells contain hemoglobin which is what makes them red. The hemoglobin binds oxygen and delivers it to all the cells in the body. If a person has low amounts of hemoglobin or low numbers of red blood cells, this means it is more difficult for the tissues to receive oxygen which leads to tiredness. Other symptoms of anemia can be palpitations, shortness of breath, restless legs, paleness and weakness.
The process of making red blood cells involves iron to help make the hemoglobin and B12 and folic acid to help the red blood cells mature to function properly. If any of these raw materials are low, people can become tired before they technically meet the requirements for being diagnosed as anemic. I look at these people as not being anemia YET.
Iron deficiency can happen at any stage of life but is seen most often in women in their reproductive years. Iron deficiency can happen for 3 big reasons, losing blood (which leads to iron loss), inadequate intake and decreased absorption.
In many cases when a woman is iron deficient the cause is heavy periods causing blood loss. Heavy periods are a frequent problem through all years of menstruation but often are of particular concern in teenage girls and in women as they get into their late 30s or 40s when perimenopausal hormone changes are starting. Iron deficiency can also be an issue during pregnancy as iron requirements are higher. It can also be an issue after childbirth, especially if there was quite a bit of blood loss with delivery or heavy bleeding in the weeks after the birth. If iron levels are low with adequate intake and no obvious source of blood loss then doctors will often investigate as this can be a sign of bleeding in the bowels which can be an early sign for colon cancer. Doctors routinely will screen for colon cancer at age 50 using stool samples which are analyzed to look for trace amounts of blood that is not visible to the naked eye.
Iron is found in many foods including red meat, dark meat in poultry, kidney beans, tofu, molasses, lentils, green leafy veggies, liver, seeds and nuts, raisins and other dried fruits. People following vegetarian diets or avoiding red meat often will have lower iron intake in their diets and can become iron deficient due to low intake. Young children are sometimes at risk for low iron levels especially if they are picky eaters.
The last major cause of low iron is inadequate absorption. This is seen frequently in patients with inflammatory bowel disease (Crohns and colitis) or celiac disease. In these cases, if the bowels are repaired and the person is able to more adequately absorb iron then their iron levels will go up, until this happens they may need to supplement.
I recommend that most women during their reproductive years take a good quality multivitamin with iron in it to prevent iron deficiency, especially if they have heavy periods. I also think a multivitamin should especially also be taken by women who are pregnant, nursing or planning to become pregnant. I also think vegetarians or athletes need to give iron levels some extra consideration. In some cases, extra iron supplements can be a very good idea though they should never be given to men or post-menopausal women unless there is evidence that they need it. Women who are having periods lose blood every month which in most cases will keep iron from building up to dangerous amounts, men and post-menopausal women aren’t losing blood or iron monthly and can develop toxicity with high levels.
B12 deficiency is a frequently under diagnosed cause of tiredness. Symptoms of B12 deficiency include exhaustion or tiredness, neurological symptoms (nerve pain, numbness, tingling, impairment of sensations of touch and vibration), insomnia, impaired memory, and changes in blood work indicating anemia. The neurological symptoms of B12 deficiency can be very serious and permanent even once blood work normalizes.
As with iron, reasons for major reasons for deficiency are low intake and absorption. B12 is found in all animal foods so typically if someone eats meat but is deficient, they are deficient because of poor absorption. The absorption of B12 is complicated and involves the stomach and the lower ileum (last part of the small intestine), both have to be healthy enough to absorb the B12. Often B12 deficiency will occur in patients where their stomach or intestinal health is compromised. Autoimmune destruction of the cells of the parietal cells in the stomach can also cause B12 deficiency, in this case it is called pernicious anemia. Absorption of B12 gets more difficult with age, many elderly people can benefit from B12 supplementation which can help with memory, depression and low energy that often goes undertreated in elderly patients. Vitamin B12 levels can also decline with certain types of medication including medications that block stomach acid, the birth control pill and some diabetic medications.
Vegans don’t receive vitamin B12 in their diets because they don’t eat animal products that contain B12. I recommend all vegans absolutely include a vitamin B12 supplement and even vegetarians who do consume dairy and eggs can benefit from B12 supplementation to prevent problems down the road.
Serum B12 numbers aren’t perfect, while they can be an indicator that B12 levels are low, having B12 in the range (especially the low end of the range) may be too low for that particular individual. It is recommended that if B12 levels are suspected to be low that a trial of B12 may be indicated. In our office, a typical trial of B12 would be doing B12 injections, once per week for a month. If there is no improvement then we discontinue. If patients notice an improvement than we continue B12 injections as dictated by how they feel. Some patients feel best to continue weekly for a while, others will do a monthly shot for maintenance and still others do a course of B12 and feel good for several years and at that point will sometimes do another course of B12 shots. B12 can also be supplemented with drops or tablets that dissolve under the tongue which avoids relying on the digestive tract for absorption.
Anemia can also be caused by folic acid deficiency and vitamin B6 deficiency. Vitamin B6 deficiency will also present often with PMS, carpal tunnel syndrome, tiredness and sleep issues. Folic acid deficiency in pregnancy can lead to neural tube defects in the babies. Both of these deficiencies can be preventing by taking either a good quality multivitamin or a B complex vitamin. This is one of the many reasons that taking B vitamins (or a multi with higher levels of B) can help with tiredness. In times of stress requirements for B vitamins go up, when someone is stressed I like them do have at least 50 mg of most of the Bs in their supplements.
Vitamin D deficiency can also cause tiredness. I would suspect this most in someone who is tired starting with the short days of fall and gradually worsening through the spring but always has dramatically increased energy by late summer. In these people, generally you will also see a dramatic improvement in their energy from a vacation in the sun (more than you would expect just from getting away for a vacation). I usually will see seasonal affective disorder in these same patients. Often there is also a history of bone loss and musculoskeletal aches and pains. I think most people should take a minimum of 1000-2000 IU/day, for many people this isn’t enough. I will regularly use larger doses when I think they are indicated but do prefer to monitor blood levels periodically in patients who use very large doses. Current research seems to suggest that toxicity is much more difficult to achieve than was once thought, dosage recommendations have increased quite a bit in the last couple of years, especially in northern locations.
Stay tuned for more reasons for tiredness in future articles. In later posts, I’m going to attempt to deal with sleep issues, hormonal imbalances and blood sugar imbalances as causes for low energy.