I have many people reach out to me that feel tired and/or fatigued, or just not really thriving on a plant-based diet. They may have recently transitioned, been ‘vegan’ for five years, ‘tried everything’, and many other permutations on the theme of thinking the cause is something intrinsic to their diet.
Whilst of course, individuals have different backgrounds, histories, stories and more, and I always recommend consulting with medical professionals if you are having health issues, this is more a general answer I wanted to get out there, to help the countless people who contact me, basically asking the same thing… ‘why do I have no energy? ‘Is it my diet?’’.
The first step, and I ask everyone their height and weight (or measure it in clinic) for a reason, is calculate your BMI (body mass index). There are many online aps for this, and I have no affiliation to any of them. Use your morning fasted weight after a bowel movement if possible for accuracy. Whilst this is just a tool, and can be less helpful in athletes and those with high muscle mass, it is a good screening tool for the average person. I am not looking here, as may be expected, for those that are obese. Almost every obese person does not need a calculator to tell them they are overweight, so I don’t waste my time with that. What I use it for is to highlight two types of people:
Those that are clinically underweight (and may have an eating disorder, or body dysmorphia).
Those dieting and trying to lose weight, but are actually within a healthy weight range for their height (and may have unrealistic or unhealthy body goals).
So if you do this calculation and your BMI is less than 19-20, it is likely you feel ‘less than ideal’ as you are underweight (for the majority of the population), and are likely under-eating and/or overexercising to maintain this weight, which is likely lower than your body functions optimally at. If this is you, I strongly suggest your first step is to increase your caloric intake, and reduce exercise expenditure to attain and maintain a healthy body weight. In many cases this may require the enlistment of professionals such as dietitians, medical doctors, and psychologists. Remember your ideal weight is predetermined by your body, not your mind. You should strive to be at a weight that makes you feel great, not one necessarily at the absolute minimum of the healthy weight range because you equal thin with health. Just because the bottom of a medically ‘healthy’ weight range is 18.5, doesn’t mean this is the optimal weight to aim for and try and stay at. The vast majority of people will attain and maintain a healthy BMI on a plant-based diet, but where that lies between 18.5-25 for optimal health is more up to your body than your mind. Accept that, and aim for health and feeling great, not the lowest acceptable number possible.
If and when you pass step one, the next step is to evaluate if you are under-eating. Now this can be a challenge to figure out, but it is usually easy to screen those at the extremes. Whilst I do not recommend counting calories pretty much ever, if we are evaluating why you aren’t feeling great, a ballpark figure may be useful. Most calorie calculators notoriously under-calculate calories in my experience. Probably one of the best I have found is this: http://www.health-calc.com/diet/energy-expenditure-advanced. I would still use this as an absolute minimum, as it still seems low for many. As a ballpark estimate, very few females thrive eating less that 2,000-2,5000 and few males thrive eating less than 2,500 - 3,500 per day, from whole plant foods. Even if you are meeting these as minimums, it can be worth a trial of increasing food intake, start with about 200-500 per day, and see if this improves how you feel. Continue to increase over several weeks and re-evaluate.
Are you getting sufficient good quality sleep? One of the most common reasons to be tired is, believe it or not, insufficient sleep! There are numerous things that can impact sleep, and if you are feeling tired, especially waking up unrefreshed, your ‘sleep hygiene’ can be useful to evaluate. Questions such as how much caffeine are you using? How late are you using computers/phones/television? Is your room cool, dark and comfortable at night? Are you trying to sleep hungry or overfull? Have you exercised too close to bedtime? Are you stressed? Have you tried relaxation techniques or meditation before bed? Do you need to prioritize sleep to get more hours? If you are not sleeping with good quality, long enough, and/or relying on caffeine, sleep issues could be a major contributor to why you aren’t feeling energized!
How much exercise or physical activity are you doing? Whilst physical activity/movement/play/incidental exercise is great to keep humans fit and healthy, too much or not enough, can make a huge impact on energy levels. Most people contacting me with this question are doing far too much, usually combined with not enough food, rest, and at an underweight BMI. For these people (especially if step six is also you) I strongly recommend taking a break from all scheduled exercise, at least until menstruation returns for at least 3 consecutive months, then very cautiously adding it back in, and at a much lower intensity. There are very few people that feel good doing more than 30-60 minutes of exercise per day, especially at moderate intensity or higher. Most people read something on the internet, and apply it to themselves and think ‘no pain no gain’, and have unrealistic expectations. Just because some instagram ‘fitspo model’ states they do an hour of HIIT and cardio and weights and who knows what else does not mean it is healthy or ideal for you. There is nothing wrong with a rest day if you are tired. There is no need to go crazy with exercise for health. Most people feel great with either gentle movement throughout the day (such as an active job, walking or gardening) or light exercise such as yoga, walking, jogging, cycling, or weights, if you have a desk job. Something like 20-60 minutes, light intensity, most days of the week, is sufficient for most people… once you are healthy and feeling great. For those not answering yes to step one, two, three, five and six at a minimum, the ideal exercise for you is probably nothing! You need rest, relaxation and stress reduction. Exercise is stressful! Only consider adding it once you are healthy, well fed, well rested and have the ability to cope with added stress!
How is your stress management? Most people that are contacting me struggling with tiredness and fatigue are stressed and anxious through the roof! Stressed about how little can they eat, what they should be eating and not eating, their weight, how to fit in all their exercise, how to get abs, how to be an A-grade student, how to be popular on social media, get a partner, be a good parent/child/sibling/friend, and the list goes on. Their cortisol and stress hormones are often way too high and this constant mental drain can cause fatigue and tiredness in and of itself! If this is you, and it probably is, I highly recommend enlisting the support of a counsellor or psychologist, or some kind of mental support system. Most of us have some kind of underlying issues that we push aside and keep trying to be better, when really we should probably do the hard and uncomfortable work now, in order to thrive in the future. Psychological distress cannot be underrated! Get help, start meditating or doing gentle yoga/breath work, journal, go sit outside, take a break… daily! You deserve it and very much need it!
STEP SIX (Men skip to step seven):
Do you have a regular menstrual period? If not (and provided you don’t have a valid reason not to), you need one! By valid reason I mean big things, such as you have had a total hysterectomy, are pregnant, are XO phenotypically female, have recently had a baby and are breastfeeding, or some other medically diagnosed reason. Not because someone on the internet/fitness coach told you it was ok! Otherwise, this is a BIG RED FLAG, and is almost always due to one or more of the following: you are underweight, you do too much exercise, or you have too much stress. Re-address steps one through five. See a medical professional. Have your hormones tested. Get help. This is not something that is ‘convenient’, ‘natural’ or that can be ignored. Fix this asap!
What do your labs look like? Have you ever had your labs tested? Do you have deficiencies? As a medical doctor, maybe I am biased, but let’s at least look objectively for a cause! At a very minimum, you should present to your doctor to be worked up for common causes of tiredness/fatigue, which lab-wise should include at minimum a CBC, CMP, iron panel if HGB low, B12 (preferably with homocysteine and MMA), A1c, TSH (preferably with free T3/T4, even reverse T3), vitamin D, FIT (if over 50 or having blood in stool), hormone panel (if menses absent), and potentially iodine and zinc levels. Other labs that can be considered would be a screen for celiac disease, CRP/ESR/ANA if autoimmune cause is suspected, lyme if in endemic area, cortisol levels if adrenals are suspected, and other specific labs based on symptoms and history, at your doctor’s discretion. If these are all normal, but you don’t feel comforted, seek a second opinion! If all seems fine, and you are a case of ‘everything is fine’, but you are NOT FINE, readdress the above and below steps, and continue to seek professional help!
Are you eating a wide variety of foods? There many many a crazy diet out there, and sure, whilst there may be case studies or anecdotal evidence that may make these appealing, the best evidence we have is for nutrition to be of wide variety, and predominantly from whole-grains, legumes, fruits, vegetables, nuts and seeds. If you have been trialing something more restrictive, such as all fruit, all juice, fasting, low carb, or whatever, I recommend a trial of expanding your food choices. Whilst deficiencies are rare, there are people that may be more sensitive, or due to restriction, may be missing some vital nutrients. Some basics to start with are:
Adequate caloric intake (see step two).
Wide variety of foods, minimal restrictions. This includes psychological restriction, such as labelling foods ‘good’ and ‘bad’, carrying pre-packed food when socializing and avoiding social events to avoid food, going on a diet, following food rules such as ‘raw’, ‘low carb’, ‘fruitarian’ etc.
Sufficient intake from all macronutrients (carbohydrates, proteins and fats - yes this can be done easily on a non-restrictive, plant-based diet! - more coming to the blog soon)
A reliable source of omega three, be it an algal based, preformed DHA/EPA supplement, and/or daily flax/chia/walnuts.
A reliable source of B12 (typically supplemental).
A reliable source of vitamin D, to keep blood levels in range, be it sunshine or a supplement.
A reliable source of iodine, be it a supervised low dose supplement, or regular servings of sea vegetables.
A reliable source of selenium, such as 1 x Brazil nut a few days a week.
Sufficient iron rich foods (or supplement if indicated) to keep levels in healthy ranges, such as beans, greens, nuts/seeds, dried fruits and whole-grains.
Whilst typically, a well balanced, calorically adequate plant-based diet provides sufficient nutrients, if you aren’t feeling great, it can be helpful to address and trial. I don’t recommend most supplements, especially long term, but sometimes things need to be tailored for individual success and optimal health. This is, of course, after the above steps have all been optimized! You cannot supplement your way out of a poor diet, stressed or tired body!
Are you digesting your food? Are you coming from a background of restrictive food intake, or from eating lots of processed/refined foods or lots of animal products? Have you been ill or taken antibiotics recently? Have you been on extreme or fad diets? All of these things (and more!) can alter your gut microbiome and make optimal food absorption and assimilation a problem. This can result in indigestion, gas, bloating and fatigue. The first step is to refer to step seven and see a professional to ensure there is no underlying health issues, such as inflammatory bowel disease, celiac disease, H.pylori infection, gastrointestinal infection or bleeding or other inflammation, infection or disease. If everything comes back ‘unremarkable’ but you still don’t feel great, you can try many of the steps underlined in my IBD article. Many people just need an adjustment period of a few months for the microbiome to adjust and re-establish, fed by the nutrients of a whole food plant based diet. Some may need to follow a blended or lower fiber diet for a few months, increasing fiber slowly as the body adjusts. Some people my need evaluation and treatment for leaky gut (search resources by Dr Klaper). Some may benefit from 1-3 months of probiotics to kick start things. If digestion is a real issue I recommend seeking help from a health professional to address underlying issues, possibly trial elimination diets/allergy testing, low FODMAPs temporarily, or tailored nutrition to feel your best. Typically however, the most common cause of poor digestion/gastrointestinal upset is not addressing the above steps!
Finally, if you can honestly say you have addressed and optimized all of the above, you probably need to see a medical professional and have a thorough medical history taken, medication review, and further workup to address the underlying cause. Don’t ignore your body’s warning signs!
Stay strong and positive, the mind influences our health to a great deal, beyond we probably can even image. Work through the steps, it may take some time, but your issues did not develop overnight either! Don’t feel afraid, ashamed or feel like you have to struggle in silence! Reach out, get help, be honest with yourself and others and start healing!
To health and happiness and no longer feeling fatigued!