Why Am I Always Tired? Causes, Diagnosis & What to Do

Act now: prioritize 7–9 hours of regular sleep and add 20–30 g of proteins to each meal – then get a basic blood panel (CBC, TSH, ferritin, B12, vitamin D) within two weeks. These steps quickly separate lifestyle causes from treatable medical ones, and they give your clinician concrete data when talking about next steps. Note that reducing late-night refined carbs such as white bread and limiting alcohol and caffeine at least six hours before bed improves sleep continuity and helps you wake more refreshed.

Start by checking common medical and lifestyle parts that drain energy. Low hemoglobin (<12 g/dL in women, <13 g/dL in men) and ferritin under 50 ng/mL often produce persistent fatigue; hypothyroid labs (TSH above ~4.0 mIU/L) and vitamin B12 under ~200 pg/mL matter as well. Sleep apnea and fragmented sleep are a major factor when you snore, gasp, or fall asleep during the day – screen with Epworth Sleepiness Score or a sleep study if symptoms are fairly frequent. Restless legs (tingling in the calves and uneasy feet) can cause sudden nighttime awakenings and extreme exhaustion; check iron and magnesium in that context.

Actively change three things this week and give each two weeks to show effect: improve meal composition (protein + fiber + vegetables, avoid late bread-heavy snacks), schedule consistent wake/sleep times, and add 20–30 minutes of light aerobic or resistance exercise at least 3 times weekly. If you find no improvement, see a clinician for targeted tests and a medication review – many prescriptions and over-the-counter antihistamines reduce alertness. Along with labs, ask about mood screening and daytime activity levels; talking openly about stressors can reveal treatable contributors.

For diagnosis, request the specific tests above and an overnight oximetry or polysomnography when daytime sleepiness is significant. Some clinicians, including Verma, recommend combining diet adjustments with twice-weekly resistance training and iron repletion when ferritin is low – that mix often yields measurable gains in energy within 4–6 weeks. Note any sudden change in fatigue, unexplained weight loss, fevers, or focal symptoms and seek urgent evaluation if present. Follow these steps, track results, and you should begin to feel more refreshed rather than trapped by exhaustion.

Iron deficiency as a specific cause of persistent fatigue

Order diagnostic tests now: CBC with indices, ferritin, transferrin saturation (TSAT) and CRP; conduct these tests before you start supplements so treatment targets true iron deficiency.

• When to suspect iron deficiency: long-lasting or unexplained fatigue, pica, restless legs, brittle nails, hair loss, pallor, shortness of breath on exertion, and sleep disruption. Early clues often include cravings for nonfood items and reduced exercise tolerance.
• Laboratory thresholds: ferritin <30 ng/mL generally indicates deficiency. If inflammation or rheumatoid disease elevates ferritin, consider ferritin <100 ng/mL with TSAT <20% as suggestive of deficiency; use CRP to interpret ferritin.
• Investigate sources: in adults conduct stool occult blood testing and GI evaluation for hidden bleeding; in menstruating people assess bleeding pattern and hormones with a gynecologist; refer for colonoscopy if age or symptoms indicate.

Treatment and timelines

• Oral iron: typical strategy uses 60–120 mg elemental iron daily or 60–100 mg every other day to improve absorption and reduce side effects. One ferrous sulfate 325 mg tablet ≈ 65 mg elemental iron. Expect hemoglobin to rise roughly 1 g/dL every 2–4 weeks and energy often to improve within 2–4 weeks; continue therapy for about 3 months after hemoglobin normalizes to replete stores.
• IV iron: choose IV iron when anemia is severe, oral therapy is not tolerated, absorption is impaired, or ongoing blood loss exists. IV formulas require prescription and administration by trained practitioners; discuss risks and benefits with your provider.
• Medication interactions and side effects: iron commonly causes GI upset, constipation, or nausea. Avoid taking iron with calcium, antacids or tea/coffee drinks within one hour. Take iron with a glass of vitamin C–rich juice to boost absorption. If tablets irritate your throat, switch to liquid or take with extra water and remain upright for several minutes to prevent pill-induced esophagitis.

Practical steps for yourself

1. Get tested and keep results updated in your chart; don’t self-treat without tests.
2. If you have allergy to a formulation or severe side effects, talk to your practitioner about alternative oral forms or IV options.
3. Review diet: add heme iron sources (red meat, poultry), legumes, iron-fortified cereals and pair with vitamin C. Reintroduce foods you enjoyed before treatment as tolerance improves.
4. Track response: note changes in sleep quality, energy and concentration; record hemoglobin and ferritin values so you and your clinician can adjust therapy within set milestones.
5. Address contributing conditions: heavy menstrual bleeding may require hormonal management; inflammatory illnesses such as rheumatoid arthritis often cause anemia of chronic disease and need coordinated care between rheumatology and primary care.
6. If fatigue affects mood or functioning, talk with a counselor while medical treatment proceeds; behavioral strategies can help maintain routines and activity levels during recovery.

Do not leave suspected iron deficiency untreated: identify the cause, follow monitored treatment, and coordinate care among primary care practitioners, specialists and, when needed, a counselor to restore iron stores and reduce persistent fatigue.

How low ferritin and hemoglobin directly reduce energy and cause breathlessness

Get a CBC, ferritin and transferrin saturation now and start iron replacement if labs and symptoms match: treat oral iron (60–100 mg elemental iron daily or every other day per updated absorption guidance) or switch to IV iron when oral therapy fails or hemoglobin is very low.

Low hemoglobin cuts arterial oxygen content by roughly 1.34 mL O2 per dL for every 1 g/dL drop in Hb, so the body must raise cardiac output and breathing rate to keep tissues oxygenated. That increase forces a faster heartbeat, can trigger an irregular rhythm in vulnerable people, and creates chest pressure and visible shortness of breathing, especially during exertion or exercises. If you also have an obstructive lung condition, symptoms compound and you feel breathless at lower workloads.

Low ferritin limits iron-dependent enzymes in the mitochondrial electron transport cycle, reducing ATP production and causing profound daily fatigue and slowed recovery. Low iron impairs muscle oxygen extraction, so simple tasks and carbohydrate metabolism (timing with carbs) feel harder and energy levels slump down. Correct ferritin improves cellular energy before hemoglobin fully recovers.

Identify causes: chronic blood loss (including GI losses from nonsteroidal anti-inflammatory use), celiac disease or other malabsorption, recent surgery, heavy menses, or certain medical conditions and medications. Order tests for these causes when deficiency appears in men or postmenopausal women. If pills irritate the throat or gut, try liquid formulations, take with vitamin C, and avoid taking iron with dairy, calcium, coffee, tea or high-fiber carbs at the same time.

Treatment results: expect hemoglobin to rise ~1 g/dL every 2–3 weeks with adequate dosing and symptom relief within 2–6 weeks; ferritin may need 3–6 months to refill, so continue therapy to stop relapse. Monitor CBC and ferritin throughout therapy and adjust dosing if absorption problems persist or if fatigue keeps getting worse. Seek urgent care for severe breathlessness, fainting, chest pain, or rapidly stops-worsening symptoms.

When iron replacement alone does not improve energy or breathlessness, evaluate other types of anemia and cardiopulmonary causes; a focused cardiology or pulmonary assessment often explains remaining symptoms and will give the next therapeutic steps.

Which symptoms and exam findings suggest iron deficiency rather than sleep or mood problems

Order a CBC with ferritin and iron studies immediately when fatigue appears together with pallor, pica (ice/soil craving), brittle or spoon-shaped nails, or restless legs; these signs point toward iron deficiency rather than a primary sleep or mood disorder.

On exam look for conjunctival pallor (inspect the lower eyelid even if youre wearing glasses), pale palmar creases, koilonychia, smooth tender tongue (atrophic glossitis) and mild tachycardia or a soft systolic flow murmur. Musculoskeletal or joint pain suggests an inflammatory process such as rheumatoid disease, which can cause anemia of chronic disease and requires different testing.

Order lab thresholds that favor iron deficiency: hemoglobin below sex-specific norms (eg <13 g/dL men, <12 g/dL women), MCV <80 fL (microcytosis), ferritin consistently low (<30 ng/mL; aim for >50 ng/mL if restless legs syndrome), transferrin saturation <20% and elevated TIBC. Be aware that ferritin rises upon inflammation – add CRP or ESR to interpret ferritin; research shows ferritin can mask deficiency when inflammation is present.

Differentiate from sleep or mood problems by testing: mood or insomnia alone usually shows normal hemoglobin, normal indices and normal ferritin; daytime sleepiness that improves after a restful night or changes with sleep hygiene or sanctuary-like bedroom adjustments points away from iron deficiency. If youre fatigued every morning despite adequate sleep, and labs show microcytic anemia or low ferritin, suspect iron deficiency.

Ask targeted questions about risk and causes: years of heavy menstrual bleeding, long-term poor dietary intake (little meat or high-carb diets that displace iron-rich foods), vegetarian patterns, prior gastric surgery or celiac disease, chronic NSAID or anticoagulant medication intake, or family history of bleeding disorders. Check for GI blood loss with fecal occult testing and consider endoscopy if risk is present.

Manage accordingly: if labs confirm deficiency, start oral iron and counsel about common GI intolerance; if oral iron causes intolerance or there is a true allergy, arrange IV iron and consult a hematology consultant. Expect a reticulocyte rise within 7–10 days and a measurable hemoglobin increase within weeks; reassess thyroxine and other contributors such as hypothyroidism or inflammatory causes (eg rheumatoid) if improvement is little or whats suspected is anemia of chronic disease. Add dietary guidance, discuss added supplements only when indicated, and schedule follow-up labs to confirm response.

What blood tests to order, target values to watch, and how to interpret borderline results

Order a focused panel: CBC with indices, ferritin plus iron studies (serum iron, TIBC, transferrin saturation), TSH and free T4, morning (8 AM) cortisol, 25‑OH vitamin D, vitamin B12 with methylmalonic acid if borderline, CMP (electrolytes, liver, creatinine), fasting glucose and A1c, CRP, pregnancy test if applicable, and D‑dimer only if pulmonary embolism is suspected.

Target values to watch (common laboratory ranges and practical thresholds): hemoglobin (men ≥13.0 g/dL, women ≥12.0 g/dL; anemia <13/12 g/dL), ferritin (<30 ng/mL = iron deficiency; aim >50 ng/mL for symptomatic recovery), transferrin saturation (<20% suggests iron deficiency), TSH (0.4–4.0 mIU/L typical lab range; many practitioners treat if TSH >4.5 with symptoms or anti‑TPO positive; consider treatment if TSH >10), free T4 (approx. 0.8–1.8 ng/dL), vitamin B12 (deficiency <200 pg/mL, borderline 200–300 pg/mL; elevated methylmalonic acid confirms deficiency), 25‑OH vitamin D (<20 ng/mL deficiency, 20–30 insufficiency, target 30–50 ng/mL), morning cortisol (>10 µg/dL reassuring; <5 µg/dL suggests adrenal insufficiency; 5–10 µg/dL is borderline and requires ACTH stimulation testing), A1c (<5.7% normal, 5.7–6.4% prediabetes, ≥6.5% diabetes), CRP (<3 mg/L low, >10 mg/L suggests acute inflammation).

Interpret borderline results with stepwise actions: if ferritin sits 30–50 ng/mL and you feel fatigued, repeat testing in 4–8 weeks while treating diet and menstrual blood loss; consider an oral iron trial (alternate‑day dosing 60–100 mg elemental iron) for 8–12 weeks and recheck ferritin – move to IV iron if oral is poorly tolerated, levels remain low, or ongoing uterine bleeding causes recurrent loss. If hemoglobin falls suddenly or very low, pursue urgent evaluation because severe anemia can be life‑threatening, including death in extreme cases.

If B12 is 200–300 pg/mL with neurologic symptoms (numbness or sore, burning, or tingling in the feet), order methylmalonic acid; start intramuscular B12 shots for confirmed deficiency or malabsorption and reassess functional improvement within 4–6 weeks. For borderline B12 without neurologic signs, offer oral high‑dose replacement and repeat levels at 8–12 weeks.

For TSH modestly elevated between 4.5 and 10 mIU/L with normal free T4, check anti‑TPO antibodies and consider lipids and symptoms: many practitioners treat if antibodies are positive, pregnancy is planned, or symptoms are convincing; otherwise monitor TSH every 6–12 weeks. For TSH in the high‑normal range (2.5–4.5) with clear sluggish cognition, weight gain, and high cholesterol, some clinicians perform a therapeutic trial of levothyroxine depending on individual risk and patient preference (document baseline labs and reassess).

When cortisol is borderline (5–10 µg/dL), do an ACTH stimulation test rather than diagnosing adrenal insufficiency from a single value; avoid interpreting “low‑normal” cortisol as adrenal failure without stimulation results. If testing during acute illness, defer interpretation until recovery because stress‑related elevations can mask insufficiency.

Address lifestyle and reversible contributors: reduce ultra-processed foods and limit caffeinated drinks that fragment sleep; screen for sleep apnea if daytime sleepiness persists – arrange sleep testing and, if diagnosed, use CPAP because untreated sleep apnea produces ongoing fatigue despite normal labs. Consider pulmonary evaluation (spirometry, imaging) if shortness of breath accompanies tiredness.

Handle borderline inflammatory or autoimmune signals (mildly elevated CRP, positive ANA) with clinical correlation and targeted follow‑up tests rather than immediate broad treatment; added specialty referral makes sense when symptoms localize to other systems. Use repeat testing 4–12 weeks after initial abnormality, track trends between visits, and document any hard changes such as weight loss, fevers, or new neurologic signs that prompt urgent workup.

When labs remain nondiagnostic and you stay fatigued, combine objective testing with functional trials: correct iron or B12 deficiency, optimize sleep and CPAP adherence, reduce ultra-processed food and high caffeinated intake, treat treatable thyroid or glucose abnormalities, and consider referral for sleep studies or cardiopulmonary testing. Some practitioners (including Konomi) report benefit from treatment trials guided by symptoms and labs, but tailor decisions depending on age, comorbidities, and patient goals.

Dietary changes and oral iron strategies: best timing, foods that help or block absorption, and common side effects

Take oral iron 60–90 minutes before breakfast or two hours after a meal; if side effects hit, switch to alternate-day dosing (60–120 mg elemental iron every other morning) to improve absorption and tolerance.

Ferrous sulfate 325 mg provides ~65 mg elemental iron; many treatment protocols use 65–130 mg elemental daily for deficiency, but recent studies shows alternate-day single dosing raises fractional absorption by avoiding the post-dose rise in hepcidin, a liver hormone that stops iron uptake for ~24 hours. This mechanism explains why alternate-day dosing often reduces nausea and the sleepy feeling some patients report while improving net iron gain.

Boost absorption by taking iron with 200–250 ml orange juice or 250–500 mg vitamin C; vitamin C chemically reduces ferric to ferrous iron and forms soluble complexes. Prevent absorption loss by separating iron from calcium (dairy, supplements) by at least 2–4 hours, and avoid tea, coffee and cocoa within one hour before and two hours after a dose because tannins and polyphenols bind the substance. Phytates in whole grains and legumes and soy products also reduce uptake; soak or ferment those foods to lower phytate content. If you take levothyroxine, tetracycline, quinolone antibiotics or an antacid drug, separate dosing by four hours to avoid interactions.

Side effects: common complaints are constipation, dark stools, abdominal cramping and nausea; less common are metallic taste and diarrhea. If constipation is limiting, try ferrous gluconate (lower elemental iron) or divide the total daily dose, add a daily stool softener or a fiber increase, and ensure hydration. Slow-release formulations reduce GI upset but reduce absorption and are not preferred for repletion. Allergic reactions are rare; if you develop rash, swelling, breathing difficulty or vision changes, call your clinic or visit the emergency department immediately–these symptoms may indicate an allergy or severe reaction.

Overdose risk: iron tablets are toxic in children; keep pills out of reach of small hands. Signs of toxicity include severe abdominal pain, vomiting, bloody stools, fainting and tachycardia; if any of these occur, call emergency services. Lab exam and serum ferritin/hemoglobin guide therapy; do not continue high-dose iron alone without follow-up labs because excess iron can inflame the liver and gut mucosa and raise long-term risk profile.

Women of reproductive age often need replacement because menstrual blood loss and hormonal fluctuations increase requirements; pregnant women require ~27 mg elemental daily as part of antenatal care. Correcting iron deficiency shows benefit for energy, mood and sleep quality in many patients and reduces restless sensations in hands and feet. Recent cleveland articles and health clinics suggests that targeted counseling about timing and food interactions increases adherence and therapeutic success.

Practical checklist: bring your pill bottle to the exam, tell clinicians about all supplements and drugs you take, report any allergy history, and ask for an iron formulation if GI side effects are hitting you hard–your clinician here explains alternatives and dosing adjustments. If thoughts of stopping treatment occur because of side effects, call your clinic for a tailored plan rather than stopping alone.

When to consider intravenous iron, investigate sources of blood loss, or refer to hematology

Start IV iron when oral therapy is not tolerated, fails to raise hemoglobin after an adequate monitored course, malabsorption prevents sufficient intake from foods or supplements, or rapid repletion is required for symptomatic anemia (for example Hb <100 g/L [10 g/dL]).

Order a focused panel before giving IV iron: CBC, ferritin, transferrin saturation (TSAT), CRP, renal function, reticulocyte count, thyroid hormones and B12/folate. Absolute iron deficiency commonly shows ferritin <30 ng/mL; consider IV iron if ferritin is <100 ng/mL with TSAT <20% in the context of chronic disease. For heart failure patients the american trial data and guidelines support IV iron for ferritin <100 or ferritin 100–300 with TSAT <20%.

Investigate sources of blood loss aggressively when iron deficiency appears without clear dietary reasons or recent low intake: men and postmenopausal women need GI tract evaluation (faecal occult testing, colonoscopy and upper endoscopy guided by symptoms); premenopausal women deserve a menstrual and pelvic assessment for heavy or changing bleeding that leads to deficiency. Screen for anticoagulant use, surgical history, and family bleeding disorders; refer to a specialist if stool guaiac is positive or if weight loss or change in bowel habit occurs.

Use IV iron formulations that match the clinical need: some preparations give 500–1,000 mg in a single visit while others require the total dose split twice. Expect symptomatic improvement–energy and lethargy often improve within 2–4 weeks and iron stores normalize over up to eight weeks, but recheck ferritin and Hb at 4–8 weeks to confirm response. Check allergies and prior infusion reactions before administration; have resuscitation equipment available per local protocols.

Refer to hematology when the anemia does not respond to adequate replacement, when the blood film shows unexplained abnormalities, when there is recurrent or transfusion-dependent anemia, suspected hemolysis or pancytopenia, or when marrow pathology is suspected. Ask your clin or family doctor to arrange a consultant hematologist review for complex cases or if testing reveals red flags. If fatigue feels out of proportion to the lab results, consider related causes such as endocrine changes or psychiatry input for mood disorders while hematology investigations proceed.