On Fatigue

The Wellness Diaries - Part 5

© photo by Bertie

One reason why I write this blog is to try and live up to the ambitious goal of Family and Community Medicine - as my specialty is called in academia - to treat populations along with individuals. 

So, when I notice the same complaint beginning to trend, that’s a flag, as well as an opportunity to share a little timely medical advice with more people than I could ever see in the office.

Certain complaints are seasonal. And if every season were to have its chief complaint, that of Fall would be fatigue.

Typically, the patient will come to me convinced that they have a thyroid problem. “I googled my symptoms,” they will say, “and I think my thyroid must be low - or high - I forget which….”

I’m happy to oblige by checking a TSH (a pituitary hormone that is high with low thyroid and low with high thyroid - hence the Googler’s confusion). I’ll throw in a hemoglobin and iron level for good measure, vitamins D and B12, and maybe a few other labs to rule out organic disease.

But generally speaking, and with all due respect, it’s not your thyroid. Usually, fatigue is a lifestyle issue. 

Ok, maybe not always, but enough to justify a pragmatic, empiric approach: first, get your lifestyle ducks in a row. Not forever, but for now, as a trial, a little one-person experiment. If that resolves your energy deficit, great; if not, we can always search for the rare condition causing the common symptom as a second step.

The lifestyle ducks I have in mind, which are the three cornerstones of wellness, are diet, exercise, and sleep. Let’s talk about how to optimize them for maximum energy in that order, leaving the most important one for last.

Trigger warning: I’m going old-school here - prescriptive, paternalistic, and without the evidence, data, and studies.

Diet

Eat a whole food, low glycemic, Mediterranean-style diet. Avoid red meat, whole dairy, and concentrated sweets - and when I say avoid, I don’t mean eliminate; life is meant to be enjoyed, and food is a big part of that. I do mean that when it comes to those items, go for the high-end stuff and only on special occasions (happy for this to be a loose definition).

After breakfast, stick to a high protein, 200-300 calorie snack every 3-4 hours to fuel yourself over the course of the working day. Examples would be yogurt, fruit, nuts, or a bar (preferably the less-processed kind).

Drink water or seltzer. If you like to caffeinate, as I do, drink coffee in the morning and tea, which has about half the caffeine load, in the afternoon. With a half-life of up to 5 hours, it pays to watch your afternoon caffeine intake if you want to sleep well at night.

One patient who worked at Facebook was putting on ten pounds a year by grazing on delicious treats that were laid out all day long. That was back when people used to go to the office every day, but the temptation can be even greater at home.

For him, it helped to take a few minutes in the morning or the night before to plan out meals and snacks, prepare them ahead of time, and avoid the food at work entirely.

Exercise

Ideally, exercise should be a daily discipline. We don’t eat or sleep three or four times a week, why should exercising so sporadically be considered sufficient?

Try to incorporate the elements of strength, agility, flexibility, and endurance into your routine. These can be separate or combined. For example, you might want to lift weights twice a week, run twice a week, and do yoga twice a week (that’s my routine if anyone is interested). Or you may want to play a sport that incorporates several of these elements at once, like basketball, soccer, or squash. 

Take at least one day a week to do something different, preferably outdoors, like a game, hike, bike, or swim. When in doubt, do yoga.

It may sound like a lot, but on the plus side less can be more. Better to exercise every day for ten minutes than once a week for two hours. The key is to make it into a habit that you can expand or contract depending on your day, but not omit.

I recently saw a patient who told me she gets together with a group of friends and colleagues on Zoom every day at noon for a collective 7-minute workout.

Sleep

You don’t need to go to medical school to know that you will be tired if you don’t get enough sleep. Your grandmother can tell you that. But how much is enough?

Common wisdom says eight hours, but here let me dip into the data. 

This past April the British journal Nature Aging published a huge study of almost 500,000 subjects looking at the effects of sleep duration on mental health, cognitive function, and a variety of other data including brain imaging and genetic information. 

The study had some limitations, including that it looked for correlation, not causation, was racially uniform with 94% Whites, and only included subjects between the ages of 38 and 73 years. Nevertheless, it’s rare for a study to have such a large n which is enough to make it significant.

So, what’s the magic number of hours to sleep for optimal cognitive function and mental health? 

Seven (isn’t that great? It’s like getting an extra hour in the day).

Remember that sleep requirements vary by age, with children and adolescents definitely needing more. But one misconception that this study dispels is that older people need less sleep. 

They may get less sleep for a variety of reasons, but that’s not because they don’t need it. Here it’s important to dig a little. 

I have one patient who was waking up every few hours to pee. We figured out that because of a dry mouth condition he was inadvertently drinking too much water, and we came up with an alternative solution that made a world of difference.

Naps are hugely beneficial, much more so than stimulants, especially in the early afternoon. If you ever wonder why we get tired after lunch, it’s because we are designed that way. Take a look at this graph of circadian rhythm:

See that dip a little after noon. That’s why the civilized world takes siestas (thank you Spain and Italy, for showing us how to live). 

Here’s what you do: find a place to lie down. Cover your eyes. Don’t try to sleep, but instead watch your breath go in and out of your nostrils. If you fall asleep great; if not, the breathing meditation will reboot your brain (Rachel doesn’t like the breathing thing but says she would be happy to recommend some excellent but soporific podcasts that will work even better).

Set an alarm to somewhere between 10 and 20 minutes - less is not enough to get into the zone; more may put you into a deep stage of sleep and leave you groggy.

Aside from its obvious importance to physical and psychological health- which everyone knows from experience - the main function of sleep seems to be housekeeping, organizing and pruning memories, clearing waste products from the brain, and other neuroprotective chores. 

Along those lines, long sleep is like cleaning your apartment, while a nap is like clearing your desk.

I will usually recommend a two-week trial of these lifestyle modifications. Most of the time the patient improves. And even if they can’t always stick with the program, the next time they are tired at least they will know why.

If nevertheless, the problem persists, it’s time to look for another cause.

Do you get “enough sleep” and yet still wake up tired? Do you snore? If so, you might need a sleep study to rule out obstructive sleep apnea.

Do you feel down a lot of the time, or just meh (shvach in Yiddish)? You could be depressed, which can be both a cause of fatigue as well as its effect.

Do you suffer from other, more subtle, signs or symptoms that may point to a more occult process - like connective tissue disease, infection, or malignancy?

That would require a more extensive workup. The trick is to avoid such a workup unless it’s truly necessary by not putting the medical cart ahead of the lifestyle horse.