Chronic Fatigue · multi-factor + ME/CFS + Long COVID

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Connected to · 7

cofactor · 1

Protein
Not eating enough protein is an easily skipped item in a fatigue work-up, and those at risk are older adults and long-term dieters: when protein runs short, muscle is broken down for raw material first, and strength and stamina fall together.

regulates · 6

Sleep Apnea
The first month of a fatigue work-up is about finding causes that can be reversed, and obstructive sleep apnea is one that is often missed. If it is found, treating it with continuous positive airway pressure (CPAP) does more, more directly, than any supplement.
Vitamin B12
Vitamin B12 deficiency is a routine item in a fatigue work-up, and the high-risk groups are easy to name: older adults, vegans, and people on long-term metformin or proton pump inhibitors (PPIs, a class of acid-suppressing drugs). Once found and corrected, it is a reversible cause and should not be counted as chronic fatigue.
Hashimoto's
An underactive thyroid is a routine item in a fatigue work-up: once found, it is corrected with levothyroxine, which makes it a reversible cause rather than something to be written off as chronic fatigue.
Insomnia
The first month of a chronic fatigue work-up is about ruling out reversible causes one by one, and insomnia is one of them: if it is found, the next step is cognitive behavioral therapy for insomnia (CBT-I), rather than writing the tiredness itself down as the diagnosis.
Vitamin D
In a fatigue work-up, a 25(OH)D below 50 nmol/L (20 ng/mL) is worth checking once and correcting; but once you reach sufficiency, taking more does not bring more energy, and that is the part people often get backward.
Folate
In a fatigue work-up, folate deficiency and B12 deficiency should be checked together: they look alike on blood tests, and taking folate alone can hide the anemia of B12 deficiency while nerve damage keeps progressing behind a normal blood count.

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'Tired' isn't a diagnosis

EVIDENCEGUIDE 2

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Tired is a symptom, not a diagnosis. The same words, I am so tired, can sit on top of completely different states of the body. Split it into four layers and you can tell whether you need a rest or a checkup.

Layer 1 · Ordinary tiredness: a short night, a hard workout, a stressful week at work. A night's sleep or a couple of days off brings you back. This layer does not point to any disease.

Layer 2 · Persistent tiredness (under 6 months): still tired after a full night's sleep, for several weeks in a row. There is usually a trigger, such as an acute illness, a stressful stretch or a change of season, and much of it clears up on its own.

Layer 3 · Chronic tiredness (over 6 months): once it has dragged on past half a year, it is rarely one cause. Sleep, nutrition, hormones, mood and chronic illness tend to stack up, and they need to be checked one by one. Many people end up finding at least one cause that can be corrected.

Layer 4 · ME/CFS (myalgic encephalomyelitis, also called chronic fatigue syndrome): a distinct illness, not tiredness, only worse. Its hallmark is a crash of the whole person after effort; the chapter ME/CFS and crashes after exertion is devoted to it.

Some situations must not be handled as mere tiredness. If tiredness comes with chest pain or severe shortness of breath, blood in the stool or black stools, or thoughts of harming yourself, seek care immediately. Unexplained weight loss, or night sweats with fever, also need prompt medical attention. The full list is in the chapter Checking tiredness step by step.

Educational content, not medical advice — consult a clinician.

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