Boosting Energy - Harvard

A Harvard Medical School Special Health Report
Boosting Your Energy

In this report:
What determines
your energy level?
The roles of food, sleep,
exercise, and stress
Are there energy-
boosting foods?
Finding the cause
of persistent fatigue
When to see a doctor
SPECIAL BONUS SECTION

A 6-step plan
to jump-start your
natural energy
Price: $29
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Harvard Health Publications | Harvard Medical School | 10 Shattuck Street, Second Floor | Boston, MA 02115
BOOTSTING YOUR ENERGY
SPECIAL HEALTH REPORT
Contents
What is energy?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
Medical Editor
Anthony L. Komaroff, MD Physical energy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Simcox-Clifford-Higby Professor of Medicine, Mental energy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Harvard Medical School What determines your energy level?. . . . . . . . . . . . . . . . . . . . . . . 3
Senior Physician, Brigham & Women’s Hospital,
Boston Energy and food . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Executive Editor The basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Anne Underwood Vitamins, minerals, and energy . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Writer Are there energy-boosting foods?. . . . . . . . . . . . . . . . . . . . . . . . . 9
Nancy Monson
Fatty acids and energy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Copy Editor
Robin Netherton Don’t forget fluids! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Creative Director The jolt of stimulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Judi Crouse Do the “energy boosters” work? . . . . . . . . . . . . . . . . . . . . . . . . 12
Production Manager
Lori Wendin Energy and exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Illustrators How activity boosts energy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Scott Leighton, Michael Linkinhoker, How lack of activity drains energy . . . . . . . . . . . . . . . . . . . . . . . 14
Marcia Williams The exercise prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Published by Harvard Medical School
Anthony L. Komaroff, MD, Editor in Chief Energy and sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Patrick J. Skerrett, Executive Editor How sleep boosts your energy . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Getting the right amount of sleep . . . . . . . . . . . . . . . . . . . . . . . 17
In association with
Belvoir Media Group, LLC, 800 Connecticut Avenue, Nor- Energy and stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
walk, CT 06854-1631. Robert Englander, Chairman and Managing the stress response . . . . . . . . . . . . . . . . . . . . . . . . . 20
CEO; Timothy H. Cole, Executive Vice President, Editorial
Director; Philip L. Penny, Chief Operating Officer; Greg SPECIAL SECTION
King, Executive Vice President, Marketing Director; Ron Goldberg,
Chief Financial Officer; Tom Canfield, Vice President, Circulation. A 6-step plan to jump-start your natural energy . . . . . . . 22
Copyright ©2013 by Harvard University. Written permission is
required to reproduce, in any manner, in whole or in part, the Fatigue: Energy’s enemy . . . . . . . . . . . . . . . . . . . . . . . . . . 29
material contained herein. Submit reprint requests in writing to: Changing views of fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Harvard Health Publications How common is fatigue?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
10 Shattuck St., 2nd Floor, Boston, MA 02115
617-432-1485 Fax: 617-432-4719 Two types of fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Website Common causes of fatigue . . . . . . . . . . . . . . . . . . . . . . . . 33
For the latest information and most up-to-date publication
list, visit us online at www.health.harvard.edu.
Depression or anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Sleep difficulties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
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report, or go to our website: www.health.harvard.edu. Various diseases that cause fatigue . . . . . . . . . . . . . . . . . 39
For bulk rates, corporate sales and licensing: Chronic fatigue syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
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ISBN 978-1-61401-057-9 When to see a doctor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
The goal of materials provided by Harvard Health Publications
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report is not intended as a substitute for personal medical
advice, which should be obtained directly from a physician. Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Dear Reader,
In many ways, energy is the elixir of life. With it, you feel ready to take on the world.
Without it, you feel like you’re not fully alive.
Energy is both physical and mental in scope—and lack of energy is a common complaint:
In Gallup-Healthways surveys of one million Americans asking about their well-being, 14%
said they did not have the energy they needed to get things done. Likewise, one in 10 Ameri-
cans surveyed for the National Sleep Foundation’s Sleep in America poll said they experienced
so much daytime sleepiness that they were likely to nod off at inopportune times—such as
during a meeting or while driving.
Often a lack of energy or a feeling of fatigue is to be expected: for example, if you are
recovering from the flu or failing to get enough sleep. Maybe you’re simply trying to do too
much, and the resulting stress is wearing you down. Your exhaustion may be due to some of
the physical changes that accompany aging, such as normal reductions in the amount of deep
sleep or, for menopausal women, frequent hot flashes that disrupt sleep. While no one can
turn back the clock, there are steps you can take to slow or even reverse some aspects of age-
related fatigue. In fact, we’ve created a whole special section in this report on ways to jump-
start your natural energy.
In some cases, though, fatigue is not part of a normal process, but rather a sign of a chronic
illness. For example, fatigue is one of the main symptoms of depression, heart failure, multiple
sclerosis, anemia, hypothyroidism, and diabetes, all of which require medical attention.
Fatigue often subsides when these conditions are treated.
Currently, fatigue cannot be measured scientifically. But advances in understanding the

neurochemical processes involved with brain function are providing insights that could, one
day, pave the way for new tests to measure fatigue and new medications to treat it.
In the meantime, it’s important to know that while a lack of mental or physical energy can
have many different causes, there are a number of lifestyle changes you can make that will
help you regain the energy you need in order to fuel your life.
Sincerely,
Anthony L. Komaroff, M.D.

Medical Editor
Harvard Health Publications | Harvard Medical School | 10 Shattuck Street, Second Floor | Boston, MA 02115
What is energy?
he word “energy” can mean many things. On the directly into usable energy for the trillions of cells
T most basic level, it is the power generated in our
cells that enables our hearts to beat, our brains to
in your body. Each cell has one primary source of
energy: a molecule called adenosine triphosphate, or
think, and our muscles to move. All of us are produc- ATP (see Figure 1, below).
ing energy constantly. You couldn’t function if you Your body stores only a small amount of ATP, but
didn’t. You wouldn’t be able to breathe, get up out of it makes more as quickly as it’s needed. When demand
your chair, or read this report.
But that’s not what most people mean when they
talk about energy. In an absolute sense, their bodies Figure 1: How food and oxygen become energy
are producing energy, but they don’t have energy—that 1. You breathe oxygen
is, they don’t have enough of it to do everything they into your lungs. 4. Mitochondria convert
The food you eat oxygen and nutrients
want with ease. You might need energy in order to take to ATP, providing
is broken down into
on a physical challenge and keep it up for an extended separate nutrients energy to cells.
period—working through a long day, for instance, or in your stomach
and intestine.
running a marathon, biking uphill, sightseeing on vaca-
tion, or doing yard work. Or you might just want to get
through the day without feeling you’ve been flattened
by a steamroller. Whatever your goal, you’ll be happy
to know that there are a lot of lifestyle adjustments you
can make that will help you pick up your game. We’ll
discuss all of them in this report and also tackle some Mitochondria
of the common causes of fatigue. But first it’s helpful to
understand just what energy is and how it’s produced.
2. Oxygen
and
Physical energy nutrients
Though we tend to think of energy as a single phe- travel through
nomenon—you either have it or you don’t—there the bloodstream Muscle
to your cell
are both physical and mental components to energy. muscles.
Physical energy has to do with the literal production
of energy in cells. Red blood cells
Like all machinery, muscles and brain cells must 3. Oxygen and nutrients are transported
have fuel. This fuel comes from the oxygen you from the bloodstream into muscle cells.
breathe and the food you eat. When it comes to food,
The food you eat is digested and absorbed into the bloodstream,
certain nutrients provide raw power, and others help
which delivers it to cells throughout the body. Oxygen from
keep the machinery well oiled. You need an opti- your lungs also travels to your cells, where tiny structures called
mum mix of nutrients to keep the system function- mitochondria use it to convert the food nutrients into a chemi-
ing at its best (see “Energy and food,” page 8). The cal called adenosine triphosphate (ATP). ATP provides energy for
catch is that nutrients and oxygen cannot be turned everything from walking to thinking.
2 Boosting Your Energy w w w.h e a l th.ha r va r d.e du
increases—such as when you are exercising—your classic high-energy type is someone like former Presi-
body must churn out more. To do this, it taps into dent Bill Clinton or craft maven Martha Stewart, both
glucose stored in muscles and the liver, as well as fats of whom say they need little sleep and are always ready
stored around the body. for a social event or a new project (see “Do extroverts
Your body’s ability to create ATP is crucial because have more energy?” on page 6).
it determines your capacity for physical exertion. And But most people are not so lucky. A multitude
the reverse is also true: your physical conditioning of factors can affect your energy level, including the
influences how well you can generate ATP. Insufficient amount and type of stress you’re under, your sleep
sleep also may reduce your capacity to make ATP. So habits, your exercise routine, and your diet. Later
you can see that diet, exercise, and sleep all play cru- chapters will address all of these—and the special sec-
cial roles in generating energy. tion, beginning on page 22, will offer suggestions on
improving them. The final chapter will also discuss
diseases that can sap your energy.
Mental energy In addition to lifestyle choices and illnesses, there
Energy is not just about muscles: it’s also about your are also basic biological factors that affect your energy.
mind and emotions. When you’re mentally energetic, These include your genes, age, hormones, and circa-
you’re curious, you’re alert, you’re “on.” You readily dian rhythms. Remember: just because the person
absorb information by reading, listening, and watch- sitting next to you at work (or sitting across the table
ing. But mental energy is more complicated than from you at breakfast) has more mental or physical
physical energy. energy than you do, that doesn’t necessarily mean
On one level, it’s about energy production in that there’s something wrong with you. It could sim-
cells—specifically, brain cells. Like physical energy, it ply mean that you are at the lower end of the normal
can be enhanced with optimum nutrition, exercise, energy spectrum, or that you’re not a “morning per-
sleep, and stress management. But physical and men- son” and your alertness rises later in the day.
tal energy do not necessarily rise and fall in tandem.
Sometimes, one rises as the other falls. Your genes
That’s because the thing that we call “energy” is There are probably many genes that play into your
not simply a reflection of how much ATP our brain energy level. Scientists are only beginning to tease
cells can generate. It also reflects our emotional state apart what they might be. But here’s one example:
and how interested we are in something. You may Whether you’re a night owl or an early riser, each indi-
have noticed that when you’re really absorbed in an vidual needs roughly a certain number of hours of
activity—in a heightened state known as “flow”—you sleep in order to feel fully rested. However, this num-
feel more energetic than when you are only half-inter- ber can vary widely from one person to the next. Some
ested in it. Passion and motivation can be powerful people feel perky after just seven hours of sleep, while
forces in creating mental energy. If you are mentally others are groggy if they log less than nine hours. The
psyched to do something, typically you will feel physi- discovery of a genetic mutation in two people who
cally energetic enough to do it. By contrast, if you’re need far less sleep than average helps explain at least
bored, you’re likely to feel a lack of energy. This does some of this variation.
not result from inadequate energy in brain cells, The mutation—in a gene called DEC2, which is
although we don’t know how to explain it. known to affect circadian rhythms—was found in a
mother and daughter who were naturally short sleep-
ers, requiring just six hours a night instead of the aver-
What determines your energy level? age of eight. Though many Americans sleep just six
Some people, through a confluence of biology and hours nightly, most of them rely on alarms, caffeine,
personality, are born with vast amounts of energy. The and power naps to awaken and stay awake during the
www. h ealt h . h ar v a rd. e du Boosting Your Energy 3
day. By contrast, these two women awoke naturally within the brain. These cells—collectively known as the
after six hours. Proving the power of this gene, scien- suprachiasmatic nucleus—are in the hypothalamus,
tists then created genetically engineered mice with the the brain center that regulates alertness, appetite, body
same mutation. The mice not only slept less and stayed temperature, and other biological states. The suprachi-
awake longer, they also needed less sleep to recover astmatic nucleus forms an internal “clock” that controls
following sleep deprivation. your circadian rhythms, including the rise and fall of
hormones and other chemicals that influence whether
Your circadian rhythms you feel awake or sleepy.
If you’re like many people, you sometimes feel sleepy Like the other clocks in your life, your internal
or drowsy for no apparent reason. Perhaps you feel clock operates on a 24-hour schedule. According to
like taking a nap in the middle of the day, or you this schedule, people typically feel most energetic in
have trouble concentrating when you watch a movie the morning until early afternoon, when their energy
at night. If you haven’t used up your physical energy, flags after lunch (see Figure 2, below). Many people get
why do you feel sleepy? a second wind later in the afternoon or early evening,
No one feels alert and energetic all day. Instead, but their energy level dips again after the sun goes
most people have times of day when they are at their down, and it doesn’t rebound until the next morning.
best and other times when their energy slumps and In short, the biological clock helps explain why people
alertness fades. Understanding your body’s natu- wake up in the morning and go to sleep at night—and
ral daily biological rhythms (also called circadian why their energy levels fluctuate during the day.
rhythms) will help you match your activities with the Most of us are “morning larks”: our energy levels
times of day when you’re feeling most alert or energetic. rise and fall with the sun. Not everyone follows the
To a large extent, your level of alertness—or its usual pattern, however. Some people are “night owls”
opposite, sleepiness—is dictated by a cluster of cells deep who get a second wind in the evening and have trou-
Figure 2: When are you at your best?
post-lunch dip
post-lunch dip
MEMORY SPEED
ALERTNESS
8 am 10 am 12 pm 2 pm 4 pm 6 pm 8 pm 10 pm 8 am 10 am 12 pm 2 pm 4 pm 6 pm 8 pm 10 pm
Time of day Time of day
Scientists have measured several types of performance, including mental alertness and short-term memory, throughout the day.
These skills usually peak in late morning. Lowest performance levels are usually in the late evening. The best-known temporary decline
in performance is in the early afternoon and is known as the “post-lunch dip.”
Resetting your internal clock: How to reduce jet lag
• Gradually switch before the
trip. For several days before you
Day 2 Day 3
leave, move mealtimes and bedtime 9:30 p.m. 9:00 p.m.
incrementally closer to the schedule Day 1
of your destination (illustration, at Usual bedtime Day 4
right). Even a partial switch may 10:00 p.m. 8:30 p.m.
make the trip easier.
• Switch as rapidly as possible upon
arrival. On a long trip, don’t turn
in until it’s bedtime in the new time
zone. For the first day or two, spend
as much time outdoors as possible to
let daylight reset your internal clock.
• Use the sun. If you need to wake up
earlier in the new setting (flying west
to east), get out in the early morning
sun. If you need to wake up later
(flying east to west), expose yourself
to late afternoon sunlight. When you travel, it usually takes time for your internal clock to reset itself.
• Drink plenty of fluids, but not In the meantime, you feel tired, get hungry at the wrong hours, and want to
caffeine or alcohol. Caffeine and go to sleep at crazy times. However, there are ways to help reset your internal
alcohol promote dehydration, which clock when you travel through time zones. If you’ll be traveling through
worsens the physical symptoms of jet several time zones, as when flying coast to coast, you can gradually adjust
lag. They can also disturb sleep. your sleep time. For example, three days before you plan to travel from the
• Don’t time-shift. On a brief trip
West Coast to the East Coast, go to bed half an hour earlier than usual, and
just one or two time zones away, it get up half an hour earlier the next morning. The next night, go to bed an
may be possible to wake up, eat, and hour earlier than usual and get up an hour earlier. The day before you travel,
sleep on home time. If so, schedule make it 90 minutes. By the fourth day—the day of your trip—you’ll find it
appointments for times when you easier to adjust to your new time zone.
would be alert at home.
ble getting going early in the morning. Although it’s also in charge of regulating metabolism and cell divi-
largely self-regulating, your internal clock responds to sion, which is why shift work has been associated with
daylight as an important clue to external time. Nerve metabolic diseases such as cancer.
fibers connect the hypothalamus to the retina in the
eye. In experiments, when people live for several days Seasons and light
in a windowless laboratory and are exposed to light at Many people in the northern hemisphere fi nd
intervals that are at odds with the outside world, their that they feel energized during spring and sum-
internal clocks reset themselves to match the new pat- mer months when sunlight is abundant, and slug-
tern of light and darkness. The influence of light on gish and depressed in winter. They may even suffer
sleep/wake patterns probably explains why as many as from seasonal affective disorder, or SAD, during
90% of blind people have problems sleeping. the colder months. SAD typically comes on during
When the body has to adjust its internal clock the fall or winter and subsides in the spring. SAD
because of daylight savings time, shift work, or travel affects about 1% to 2% of the population, partic-
to a different time zone (See “Resetting your internal ularly women and young people. Symptoms may
clock: How to reduce jet lag,” above), it disrupts more include lethargy, loss of interest in once-pleasur-
than just your sleep (and energy). The internal clock is able activities, interpersonal problems, irritability,
the daily light-sensitive cycles of melatonin help
Do extroverts have more energy? keep the sleep/wake cycle on track.
Extroverts like former President Bill Clinton often seem Melatonin is widely available in supplement form
to have more energy than introverts. Emerging evidence as a sleep aid and is often recommended for people
supports the idea that a variety of personality traits may with insomnia or jet lag, as well as for shift workers.
play some role in influencing energy levels. For example, a
Dutch study of 765 people who worked at least 20 hours a
However, some melatonin supplements contain ani-
week found that subjects who had low scores for extraver- mal brain and nerve tissue, which carries a risk of
sion, conscientiousness, emotional stability, and excit- contamination with such infectious diseases as mad
ability, and a high score for autonomy, experienced more cow disease and Creutzfeldt-Jakob disease. Melatonin
fatigue than other subjects. And a Japanese study of 125
supplements made synthetically in a lab do not carry
second-year medical students found that people with a
high desire to avoid harm (which is associated with a high the same risk. But because these supplements are not
level of anxiety) tended to experience more fatigue, while government-regulated, and labels are not required to
those who were very self-directed experienced less fatigue. reveal this information, you can’t be sure of the source
It’s not clear, however, how strong a role extroversion of the melatonin you are taking.
itself plays. For example, introverted Apple inventor Steve In addition to melatonin, other chemicals in the
Wozniak was much quieter than the “face” of Apple, body influence our state of alertness. Several neu-
extrovert Steve Jobs, but both had boundless energy.
Wozniak created the first Apple computer alone, working rotransmitters (chemical messengers) play a role in
early in the morning and late at night around his day job arousal. Norepinephrine, epinephrine (often called
at Hewlett-Packard. He was driven by his desire to create adrenaline), and dopamine stimulate wakefulness.
a home computer, an endeavor he described as “the big- Adenosine and gamma-aminobutyric acid (GABA)
gest high ever.” Once again, it’s likely that motivation and
are believed to promote sleep. Individuals differ in
excitement about their work helped give both Jobs and
Wozniak some of their energy. their natural levels of neurotransmitters and in their
sensitivity to these chemicals.
The female menstrual cycle and fluctuations in
inability to concentrate, and a change in sleeping the levels of the sex hormones estrogen and proges-
patterns and appetite. Experts don’t understand terone can also alter energy levels. Many reproduc-
the causes of SAD, but three leading theories have tive-age women suffer from premenstrual syndrome
emerged, placing the blame on an out-of-synch (PMS), which causes them to feel tired, irritable, and
body clock or on improper levels of either the neu- sad before their periods.
rotransmitter serotonin or the hormone melatonin
(see “Hormones and brain chemicals,” below). Obesity
There are well-established connections between obe-
Hormones and brain chemicals sity and fatigue: in one Swiss sample of 220 obese
One way that light influences your alertness is people, 59% reported fatigue. The heavier you are, the
through melatonin, a hormone that induces drowsi- less active you tend to be, and the more tired you feel.
ness. Melatonin is produced in a predictable daily You use much of your energy in moving your body to
rhythm by the pineal gland, located in the middle accomplish normal activities of daily living and meta-
of the brain, between the two hemispheres. Cells in bolic processes, leaving little left over for other activities.
the suprachiasmatic nucleus receive signals from the Links have also been noted between obesity and
eyes about the amount of light in the environment sleep disturbances, including daytime sleepiness and
and send signals to the pineal gland that influence sleep apnea (episodes of not breathing during sleep),
the gland’s production of melatonin. Levels of mela- and between sedentary behavior and obesity. The
tonin begin climbing after dark, which encourages more time you spend sitting (at work, using the com-
the body to sleep, and they ebb after dawn, which puter, driving cars, watching television at home, etc.),
encourages the body to awaken. Scientists think that the less energetic you feel. In this vicious cycle, seden-
tary behavior begets more sedentary behavior. By con- decrease in strength and an increase in fatigue. As
trast, physical activity begets more physical activity. muscles shrink, they become fatigued more rapidly.
With age, your ligaments and joints become stiffer,
Age so you move more slowly. To a large extent, you can
It’s a nearly universal lament of people over age 35: compensate for these changes by exercising regularly
they don’t have as much energy as they did when to maintain strength and flexibility. Weight training
they were younger. One of the most common com- increases muscle strength, and stretching increases
plaints is that they can’t stay up as late and still func- flexibility.
tion normally the next day. People also notice that Along with a decline in physical energy, many
they’re not as strong as they used to be or that their people find that their mental energy falls somewhat
muscles don’t move as quickly. In part, that’s due as they age. They have a harder time concentrating
to lifestyle changes. They may putting in too many and remembering things, and it takes longer to learn
hours at work. Or they may be caring for a sick rela- new information. In part, these difficulties reflect age-
tive, whose care is exhausting—or even be part of related chemical changes in the brain that affect mem-
the “sandwich generation” that is caring for both ory and learning. On the bright side, staying active
older and younger family members at the same time. mentally by reading and learning new mental skills,
But there are also physical changes that contribute. such as languages, games, and music, can help offset
■ Circadian changes. Although increased fatigue this age-related decline.
is not inevitable with increased age, there are certain ■ Illnesses. Aside from normal age-related
age-related factors that make you feel weaker and, in changes, illnesses that become more common with
general, less energetic. age can deplete your energy (see “Other medical con-
For one thing, your circadian cycle advances, ditions,” page 44). Many illnesses can interfere with
making you want to fall asleep earlier at night and sleep. For example, people with heart failure may
wake up earlier in the morning. awaken feeling short of breath because body fluids
Insomnia also becomes more common as peo- accumulate in the lungs while they’re lying down. Peo-
ple get older. In part, that may be because melatonin ple with heartburn often find that their discomfort is
levels decline with age and virtually disappear by old greatest when they lie down and stomach acids back
age. Since melatonin helps you feel sleepy at night, its up into the esophagus. And hundreds of prescription
decline can make it harder to fall asleep. and over-the-counter drugs can cause daytime drowsi-
■ Physical changes. Aging brings a number of ness or fatigue (see “Medications,” page 37).
physical changes that may contribute to a lack of Fatigue is also a common symptom of a wide
energy. In women, the onset of menopause can bring range of diseases, including anemia, kidney disease,
hot flashes, which can interrupt sleep and even lead to multiple sclerosis, diabetes, and cancer. In some cases,
chronic insomnia. such as in cancer, fatigue may be the earliest sign that
In both men and women, muscle mass declines something is wrong. If you suddenly feel listless, it’s
steadily. By age 70, you’ve lost 30% of the muscle mass worth visiting your doctor to make sure nothing seri-
you had at age 20. A drop in muscle mass means a ous is wrong.
Energy and food
ike the car you rely on to get to work, your body underconsumed in the typical American diet and all
L carries its own supply of fuel, and you can replen-
ish it as needed. The food you eat is the stuff of which
of which directly or indirectly affect your energy level.
Similarly, whole grains are an excellent source of B
this energy is made. vitamins, iron, and magnesium, which play a role in
energy production (see “Vitamins,
minerals, and energy,” below). If
The basics nothing else, such a diet, which is
The nutrients in food are converted also recommended for a healthy
into glucose (sugar) and fat, which heart, just makes you feel better.
provide the essential fuel for energy That alone can boost your energy.
production. Unfortunately, changes in the
The equation is not as straight- food industry over the past 70
forward as it seems, however. The years have led to the development
Thinkstock
energy potential of food is mea- of highly processed, chemically
sured in calories. But consuming enhanced, and nutritionally chal-
more calories than you need won’t lenged products (think food in
give you extra energy. In fact, it can boxes). Many of these don’t even
have the opposite effect. Excess cal- deserve to be called real food,
ories are stored as excess pounds, according to Michael Pollan, the
and the heavier you are, the more It’s importaint to pay attention not acclaimed author of Food Rules: An
effort you’ll need to expend in only to total calories, but also to the Eater’s Manual and Cooked. Instead,
walking, pumping blood, and so source of those calories. he calls them “edible foodlike sub-
forth. The more effort you exert, stances.” These products—includ-
the more energy you need to burn—and the more ing cookies, chips, and most breakfast cereals—are
fatigued you’ll inevitably feel. often hard to resist, but they contain empty calories
It’s important to pay attention not only to total that leave you hungry and tired rather than giving you
calories, but also to the source of those calories. To the nutrients and energy you need to feel your best.
provide your body with the optimum fuel, you need
adequate amounts of specific nutrients: fluids, vita-
mins, and minerals, as well as a mix of unrefined or Vitamins, minerals, and energy
minimally refined carbohydrates (vegetables, fruits, Energy production depends on certain vitamins and
and whole grains), proteins (lean meats, poultry, sea- minerals. Deficiencies in these can contribute to
food, eggs, beans and peas, soy products, nuts, seeds, flagging energy levels, so it’s important to consume
and dairy products), and healthy fats (such as olive oil, enough. However, be aware that if your levels of these
canola oil, and avocados). nutrients are normal, taking more will not help.
Such a diet emphasizes unprocessed or minimally ■ Iron. An iron shortage is the most common
processed foods for a very good reason. Vegetables cause of anemia, a shortage of red blood cells (see
and fruits contain vitamins A, C, and K, folate, mag- “Anemia,” page 44). A deficiency of this vital min-
nesium, potassium, and dietary fiber—all of which are eral prevents the bone marrow from making enough
hemoglobin, the oxygen-carrying part of red blood ■ Vitamin D. The most talked-about vitamin in
cells. Thus, anemia impairs the delivery of oxygen to recent years has been vitamin D, which is manufac-
the body’s tissues. Because oxygen is needed to cre- tured in the skin from sunlight. It is also found in
ate ATP, doctors assume that the fatigue that many some types of fish (such as tuna, salmon, mackerel,
people with anemia experience comes from reduced and herring) and fortified products such as milk, soy
production of ATP in the cells. beverages, orange juice, and breakfast cereals. Obser-
Anemia is most common in menstruating vational studies suggest that people with high blood
women, who lose blood (and, hence, iron) with every levels of vitamin D have lower risks for cancer, heart
period. When this blood loss causes iron-deficiency disease, and diabetes. Conversely, vitamin D defi-
anemia, iron-rich foods (such as liver, red meat, ciency can cause loss of bone and muscle strength,
eggs, rice, and beans) and iron supplements can help making you feel weak, which can ultimately impair
restore the body’s iron levels and correct the anemia. your ability to perform everyday tasks. Low levels
If you don’t suffer from an iron deficiency, how- of vitamin D can also depress your mood, another
ever, there’s no evidence that taking iron supplements energy sapper.
will boost your energy. Indeed, this practice can lead In 2011, the Institute of Medicine increased the
to iron overload, which, in some people, can damage Recommended Dietary Allowance (RDA) for vitamin
multiple organs in the body, including the liver and D to 600 international units (IU) per day for adults up
heart. This in itself can lead to fatigue as well as a host to age 70 and to 800 IU per day for those ages 71 or
of serious health problems. older. Some doctors recommend higher doses, around
■ Vitamin B and folic acid. A deficiency in either 1,000 to 2,000 IU per day. The health benefits of such
¹²
of these B vitamins can also cause anemia. Because doses are not yet proven, but are being studied. Do not
many packaged foods, including breads and flour, are exceed the upper level of 4,000 IU per day.
fortified with folic acid, most people get plenty of that Vitamin and mineral deficiencies are easy to diag-
nutrient. However, about 6% of people ages 60 and nose and, for most people, simple to remedy with sup-
older are deficient in vitamin B12, in part because it plements. Older people who are deficient in vitamin D
becomes harder to absorb enough of the vitamin from should take vitamin D3, which is absorbed more easily
foods, such as meat and dairy products. Vitamin B12 than other forms of vitamin D.
deficiency can also be a problem for vegetarians—
particularly vegans, who consume no animal or dairy
products, the main dietary sources of vitamin B12. Are there energy-boosting foods?
Even if your diet contains adequate amounts of Given that food is fuel, it’s only natural to wonder
vitamin B12 and folic acid, illnesses such as inflamma- if certain types of food deliver energy more effi-
tory bowel disease can interfere with their absorption. ciently than others. Beyond the importance of eat-
Some people take vitamin B12 shots for energy, but ing a healthy diet that includes plenty of fruits and
again, this probably won’t increase your energy unless vegetables, whole grains, and healthful sources of fat
you are B12-deficient. and protein, there’s relatively little scientific informa-
■ Magnesium. Magnesium helps break down glu- tion about the effects of specific foods on energy lev-
cose into energy, and low intakes are associated with els (see “Do energy bars pack an extra punch?” on
type 2 diabetes, metabolic syndrome, high blood pres- page 11). However, certain foods can give you more
sure, osteoporosis, migraine headaches, asthma, and energy under specific circumstances.
colon cancer. A study by the Center for Magnesium Because muscles burn carbohydrates first, tests of
Education and Research suggests that 48% of the U.S. physical endurance require a steady supply. Sugar is
population consumes less than the required amount a simple carbohydrate, which means that it’s digested
of magnesium from food (320 mg for women and 420 and absorbed into the blood quickly. When you eat
mg for men). a candy bar or some other sugary food, your blood
Table 1: Glycemic load of popular foods, from worst to best
Glycemic load is a measure of how much a particular food will raise your blood sugar in the short term. It takes into
account both the amount of sugar in the food and the food’s glycemic index (how quickly that sugar is absorbed into your
bloodstream). Eating foods with a low glycemic load may help you keep your energy on a more even keel.
SERVING GLYCEMIC LOAD SERVING GLYCEMIC LOAD

FOODS SIZE PER SERVING FOODS SIZE PER SERVING
High glycemic load Low glycemic load
Pancakes 2 six-inch 46 Ice cream ½ cup 8
Dates, dried 2 ounces 42 All-Bran cereal ½ cup 8
Cornflakes 1 cup 38 Grapes 4 ounces 8
Macaroni and cheese 6 ounces 32 Baked beans 1 cup 7
Raisins 2 ounces 28 Apples 4 ounces 6
Potato, baked 5 ounces 26 Pumpernickel bread 1 slice 5
Coca-Cola 12 ounces 25 Oranges 4 ounces 5
White rice 5 ounces 23 Peaches 4 ounces 5
Raisin Bran cereal 1 cup 21 Pears 4 ounces 4
Pasta 1 cup 20 Green peas 3 ounces 3
Medium glycemic load Carrots 3 ounces 3

Grapefruit 4 ounces 3
Brown rice 5 ounces 18
Hummus (chickpea dip) 1 ounce 0
Whole-grain pasta 6 ounces 17
Oatmeal (rolled oats) 1 cup 13 While it’s useful to know the glycemic load of a particular
food, this shouldn’t be your only criterion for including a food
Banana 1 medium 13
in your diet or avoiding that particular item. For example,
Orange juice 1 cup 12 as shown in the table above, ice cream has a low glycemic
load—but it also has a lot of saturated fat, which is not
Potato chips 50 grams 11
healthy if taken in large amounts.
Adapted from “International tables of glycemic index and glycemic load values: 2002,” by Kaye Foster-Powell, Susanna HA Holt, and Janette C. Brand-Miller in the July
2002 American Journal of Clinical Nutrition, Vol. 62, pp. 5–56. The article includes a list of the glycemic index and glycemic load for 750 foods.
sugar shoots up. You feel more alert and physically wisely. Try to avoid highly refined carbohydrates and
energized. But the effect is short-lived, lasting only focus instead on complex carbohydrates, such as high-
about half an hour, because your pancreas responds fiber whole-grain bread, brown rice, whole-grain
by flooding your bloodstream with large amounts of pasta, and most vegetables. These take longer to break
insulin, the hormone that carries blood sugar (glu- down, so your blood sugar levels rise and fall more
cose) into the cells. This rapidly lowers your blood gradually (see Table 1, above). They also contain more
sugar. Afterward, you may actually feel less energetic vitamins and minerals than refined carbs.
than you did before eating the sweet snack, so unless
you’re heading to the gym, it’s best to avoid sugary
foods, despite the temporary lift they give you. Fatty acids and energy
To keep your blood sugar and energy levels on an Fats also provide energy, but certain types appear
even keel over the long haul, pick your carbohydrates to be better than others at getting you through your
day. Foods that are loaded with saturated fat (say, a
cheeseburger and fries) are not only unhealthy, lead- Do energy bars pack an extra punch?
ing to clogged arteries, but also have a fairly imme- It’s impossible to walk into a drugstore or supermarket
diate soporific effect. One small study of 31 healthy, without seeing shelves lined with “power bars” that
normal-weight people showed that higher saturated supposedly boost your energy. The manufacturers of
such products claim that they’re superior to candy
fat consumption caused more daytime sleepiness. bars because they contain an “ideal ratio” of simple
By contrast, scientists have learned that essen- to complex carbohydrates, along with protein and fat.
tial fatty acids, which are highly concentrated in the However, there’s no proof that such an ideal ratio exists.
brain, support cognitive performance, providing at In fact, only a few studies of these bars have been
least an indirect energy boost. Essential fatty acids conducted. One from Ohio State University compared the
include the omega-3 fatty acids (found in fish, flax- glycemic index of typical energy bars with other sources of
carbohydrates. The power bars were no better than a candy
seeds, soybeans, walnuts, and canola oil). They are bar at providing sustained energy. Another, a military study
called “essential” because your body cannot manu- conducted in Finland, found that high-protein bars were
facture them from other nutrients; they must be no more effective than standard field rations in prevent-
acquired through food or supplements. ing an energy deficit during an eight-day training exercise,
although they did appear to boost mood and satiety.
Researchers are learning more about the role
omega-3s and other fatty acids play in the brain. If you like the convenience of a power/energy bar as a
snack, limit your intake to just one per day and look for a
Numerous studies have linked low intake of omega-3
bar with the fewest and most natural ingredients (whole
fatty acids to a host of cognitive and behavioral grains, nuts, and dried fruit), and the lowest calories (less
problems, including depression, memory problems, than 200). Read the label. Ideally, bars will have more
poor mood, Alzheimer’s disease, and attention defi- than 3 grams of protein and fiber, less than 20 grams of
cit hyperactivity disorder. Deficiency can also ham- sugar, no hydrogenated oils or trans fats, and no high-
fructose corn syrup. Or grab a bag of homemade trail
per the renewal of neural membranes, thus making mix—nuts, seeds, and dried fruits—instead.
the brain age faster. One study that used brain imag-
ing techniques to examine eight people with chronic
fatigue syndrome found reduced levels of essential
fatty acids in the brain. While more research is needed The jolt of stimulants
to know whether consuming more omega-3 fatty Certain substances in food give you an energy boost
acids would alleviate chronic fatigue—much less help because they contain stimulants that speed up the
people with run-of-the-mill energy concerns—it cer- chemical reactions inside cells. Caffeine, the best-
tainly can’t hurt to ensure that you’re getting adequate known stimulant, occurs naturally in coffee, tea,
amounts in your diet. cocoa, and chocolate. It is also added to some soft
drinks and energy drinks and used as an ingredient in
some medications.
Don’t forget fluids! Caffeine has many effects. When you consume a
Water is the main component of blood and is essen- food or drink that contains caffeine, your brain cells
tial for carrying nutrients to the cells and taking fire messages more quickly, improving concentration
away waste products. If you are short on fluids, one and reaction time. The heart pumps blood faster and
of the first signs is a feeling of fatigue and weak- more forcefully, increasing your physical energy. Some
ness. Approximately 50% to 60% of your body weight people are more sensitive than others to caffeine. For
is water, and you are constantly losing water through them, a cup of coffee or a can of cola is all it takes to
urine, sweat, and breathing. This water needs to be have some or all of the stimulating effects. But people
replenished. Consuming a sufficient amount of fluids who consume caffeine on a regular basis develop a tol-
in beverages and water-filled food (such as fruits, veg- erance for it, which means that they need to increase
etables, and soup) will help you maintain your energy. their intake to get the same effect. People can become
Energy drinks: Popular, but potentially problematic
Looking for energy from a bottle? You’re not alone. caffeine. The FDA has also received numerous
Energy drinks and shots—including Monster Energy, Red reports of adverse reactions—such as heart
ENERGY
ENERGY
Bull, Rockstar, 5-Hour Energy, and Amp—have become the palpitations, chest pain, blood pressure
fastest-growing category in the beverage industry. Most elevations, fatigue, anxiety, blurred vision,
popular among teenagers and young adults, these products nausea, vomiting, and flushing—after
are booming at $12.5 billion a year, according to the market consumption of energy drinks.
research firm Packaged Facts. Emergency room visits related to ingestion of energy
But there’s really no magic formula here. What gives these drinks have also increased, going from 1,494 in 2005 to
drinks their jolt is good old-fashioned caffeine. Consumer 20,783 in 2011, the most recent year for which statistics are
Reports tested 27 energy drinks in 2012 and found that the available. Most visits were among 18- to 39-year-olds, but
amount of caffeine ranged from 6 to 242 milligrams (mg) per the largest increase was seen among people 40 or older—
serving—and there is more than one serving in some cans perhaps because of caffeine intolerance, use of prescription
and bottles. As a point of comparison, coffee has roughly 100 drugs that interacted with the drink’s ingredients, or existing
mg of caffeine in a 5- to 8-ounce cup, while 12 ounces of medical conditions.
Coca-Cola has 50 mg. Public health experts have also raised alarms about the
Most of the drinks also contain lots of sugar, which along practice of mixing energy drinks with alcohol, prompting
with the caffeine can lead to a jolt of energy and then a the FDA to warn manufacturers that caffeine is an “unsafe
crash (just like a candy bar). Energy drinks also contain a mix additive” to an alcoholic beverage. The stimulant effect of
of herbs and other substances that are marketed as “energy the energy drinks can counteract the soporific effect of the
boosters,” but they haven’t actually been proven to increase alcohol, allowing a person to keep drinking. In addition, the
energy unless the drinks also contain caffeine (see “Do the caffeine can mask a person’s level of intoxication, the FDA
‘energy boosters’ work?” below). said, and many people may erroneously think the energy
But the bigger concern is that some people, particularly drink will sober them up and make it safe for them to drive.
young adults, may consume too many of these drinks. The bottom line: If you need a quick surge of energy, it
When they do, all that caffeine, a diuretic, can contribute is okay to consume an occasional energy drink—no more
to dehydration and adverse reactions. Since 2009, five than one a day—but this shouldn’t be a daily or long-term
deaths seemingly related to the consumption of Monster practice. If you’re dragging, it’s far better to drink a single
Energy have been reported to the FDA (although the cup of coffee or tea, or better yet, create energy through
company denies any such link). The parents of a 14-year- proven nutritional, exercise, and lifestyle strategies (see the
old girl claim their child died after drinking two 24-ounce special section, “A 6-step plan to jump-start your natural
cans of Monster Energy containing a total of 480 mg of energy,” starting on page 22).
so dependent on caffeine stimulation that they feel tired stances. The fact is, the only pill that’ll reliably boost
and logy when the level of caffeine in their blood drops. your energy is one containing a stimulant, such as
Nicotine in tobacco is also a stimulant, but because caffeine—and the effects of these stimulants wear off
of the detrimental effects of smoking, it should not be within hours. The same holds true for drinks touted
used as an energy booster. Indeed, smoking can cause as energy boosters. Most contain as much caffeine as
insomnia, which can then lead to daytime sleepiness a cup of coffee, and lots of sugar (see “Energy drinks:
and fatigue. Popular, but potentially problematic,” above).
Here’s a look at some of the substances that are
commonly touted as energy boosters.
Do the “energy boosters” work? ■ Chromium picolinate. This trace mineral is widely
Go to the store, and you’ll see a multitude of herbs and marketed to build muscle, burn fat, and increase
other supplements that claim to boost energy. Some energy and athletic performance, but research has not
are even added to soft drinks and other foods for this supported these claims.
purpose. However, there is little or no scientific evi- ■ Coenzyme Q10. This enzyme is found in mito-
dence to support the claims for most of these sub- chondria, the energy factories of our cells. Supple-
ments have been shown to improve exercise capacity you can consume. If you want to boost your energy
in people with heart disease and may do the same in by stimulating your central nervous system, a cup of
people with rare diseases that affect the mitochon- coffee or another caffeinated beverage will work just
dria. In other cases, the effects are not clear. One small as well.
European study suggested that people with chronic ■ Ginkgo biloba. Derived from the maidenhair tree,
fatigue syndrome might benefit from supplementa- ginkgo biloba has been used for centuries in Chinese
tion with coenzyme Q10, but more research is needed. medicine and is now a common dietary supplement
■ Creatine. Creatine is another compound pro- in Western countries. Its effects on cognition (think-
duced by the body; it is largely found in muscle. It is ing), mood, alertness, and memory have been the sub-
widely sold as a supplement. Taken as a supplement, ject of many studies, but many of those studies have
there is evidence that it can build muscle mass and not been of high quality. A Cochrane Collaboration
improve athletic performance requiring short bursts review found the evidence was too weak to conclude
of muscle activity (like sprinting). However, there is that ginkgo biloba improved cognition in people with
little evidence that it can do the same in older adults, Alzheimer’s disease. Regarding memory in people
or that it can reduce a feeling of fatigue in anyone. without dementia, evidence is conflicting. Other stud-
While no adverse effects of taking creatine in the doses ies suggest ginkgo biloba may improve some aspects
recommended on the bottle (typically 2 to 3 grams per of mood, including alertness and calmness, in healthy
day) have been established, there are very few stud- subjects. By making you more alert and calm, it may
ies of sufficient size and duration to allow confidence increase your sense of energy.
about the lack of adverse effects. ■ Ginseng. This is a relatively safe and popu-
■ DHEA. Sometimes marketed as a “fountain of lar herb, said to reduce fatigue and enhance stamina
youth,” this naturally occurring hormone is said to and endurance. It is sometimes called an “adapto-
boost energy as well as prevent cancer, heart disease, gen,” meaning it helps the body cope with mental and
and infectious disease, among other things. The truth physical stress and can boost energy without causing
is that DHEA has no proven benefits and some poten- a crash the way sugar does. Data from human stud-
tially serious health risks. Some research shows that ies are sparse and conflicting. Some studies report
DHEA can damage the liver. It can also lower levels that ginseng improves mood, energy, and physical
of heart-healthy HDL cholesterol. And because this and intellectual performance. Other research con-
hormone is related to estrogen and testosterone, there cludes it doesn’t improve oxygen use or aerobic per-
is concern that it may increase the risk for breast and formance, or influence how quickly you bounce back
prostate cancers. By increasing levels of testosterone, after exercising.
it can also encourage acne and facial hair growth in ■ Guarana. This herb induces a feeling of energy
women. Until further research clarifies the side effects, because it’s a natural source of caffeine. But consum-
it’s wise to avoid taking DHEA. ing a lot of guarana, especially if you also drink cof-
■ Ephedra. Although this product was banned by fee and other caffeinated beverages, could ultimately
the FDA in 2004 because of major safety concerns, lower your energy by interfering with sleep.
including increased risk of heart attack and stroke, ■ Vitamin B . Injections of vitamin B12 are given
¹²
it remains available for sale on the Internet. Any by some doctors as “energy boosters.” But unless they
effectiveness ephedra may have in terms of boosting are given to correct anemia that results from a true
energy probably results from two substances it con- deficiency of the vitamin, there is little evidence that
tains—ephedrine and pseudoephedrine—which may vitamin B12 treatments boost energy (see “Vitamin B12
increase alertness. There is no safe amount of ephedra and folic acid,” page 9).
Energy and exercise
t may sound strange, but in order to get more energy, feel energized (see “Energy and stress,” page 19). Exer-
I you have to do the very thing you don’t feel you have
enough energy to do: exercise. Regular exercise boosts
cise also boosts levels of compounds called endor-
phins, “feel-good” chemicals that lift your mood and
your energy in multiple ways. When you understand are often credited for the “runner’s high.” An elevated
how, you will never again think of it as a tedious rou- mood in itself can be an energy booster.
tine that some health nag wants you to do, but rather as Finally, regular aerobic exercise almost guarantees
a surefire energy enhancer that you can tap into at will. that you will sleep more soundly—a prerequisite for feel-
ing refreshed (see “Energy and sleep,” page 17). Exercise
is the only proven way to increase the amount of time
How activity boosts energy you spend in deep sleep, the type that particularly
There are at least four distinct ways that exercise restores your energy. The more deep sleep you get, the
makes you feel more energetic. less likely you are to awaken in the middle of the night,
For starters, when you engage your muscles in and the more rested you’ll feel the next day. Exercise
any type of exercise, more energy-producing mito- also increases the amount of time you spend in REM
chondria form in your muscle cells. (rapid eye movement) sleep, the
Mitochrondria are the cellular pow- time during sleep when you dream
erhouses that convert glucose and most often and most vividly. More
fat into ATP, the molecule that cells time in REM sleep also restores
use for energy. So while exercise your sense of energy, though not as
burns energy, it also enables muscle much as deep sleep. How exercise
cells to produce more energy. improves both REM and deep sleep
But fueling your cells requires is unknown, although scientists sus-
more than just glucose and fat. Oxy- pect that it leads to the production
gen is also essential to the process, of chemicals that affect alertness.
and exercise increases your body’s In a 2013 poll conducted for the
oxygen-carrying capacity. Any type National Sleep Foundation, people
of regular exercise creates more cap- who exercised vigorously on a reg-
illaries, the tiny blood vessels that ular basis reported sleeping better
Thinkstock
ferry oxygen to your cells. But aero- than more sedentary people, even
bic exercise, by making you breathe though both groups got about seven
the most deeply and increasing your Regular exercise boosts your energy hours of sleep on weekday nights.
in at least four distinct ways.
heart rate the most, gets more oxy- Non-exercisers reported the least
gen circulating. energy and the most sleepiness.
Exercise also affects levels of various hormones
and chemical messengers. When you work out, your
body releases epinephrine and norepinephrine. How lack of activity drains energy
In large amounts, these stress hormones cause the Picture your energy level as a rechargeable battery.
energy-draining fight-or-flight response, but in the You can plug it in and charge it up with exercise, or let
modest amounts induced by exercise, they make you it sit idle and watch the energy drain away.
When you’re inactive, you lose muscle cells, and
Why exercise? Energy and beyond
the cells that remain have fewer mitochondria. It’s
Regular exercise will help you feel, think, and look
remarkable how little time it takes to see the effects. better. Strong evidence from thousands of studies
People who have a limb immobilized because of an shows that engaging in regular exercise helps ward off
injury or illness begin losing muscle cells within just numerous diseases. Among its benefits, it
six hours. With weaker muscles, everything you ask • reduces your risks for heart disease, stroke, high
your muscles to do requires more effort, leaving less blood pressure, and high cholesterol
energy for other activities. • improves blood sugar management and lowers your
It’s particularly important to keep exercising as risk for type 2 diabetes and metabolic syndrome
you age because muscle mass tends to decline over the • reduces the risk of certain cancers, including breast
years. Sarcopenia, the gradual decrease in muscle tis- and colon cancers
sue, starts earlier than you may realize—around age 30. • eases mild to moderate depression
The average 30-year-old can expect to lose about 25% of • reduces your risk for osteoporosis (provided you
muscle mass and strength by age 70 and another 25% by do weight-bearing exercise, meaning exercise where
you work against gravity)
age 90, with resulting effects not only on energy, but a
• helps prevent or ease lower back pain
host of other diseases (see “Why exercise? Energy and
• relieves arthritis pain and expands a limited range
beyond,” at right).
of motion
Lack of exercise also causes changes in your
• helps maintain muscle mass and prevent falls
heart and lungs. They become less efficient at oxy-
• boosts mental sharpness in older adults
genating your blood and pumping that blood (along
• strengthens your muscles, lungs, and heart
with nutrients) to all parts of your body. That in
turn affects your energy level, most noticeably dur- • improves functional abilities in older adults—that is,
being able to walk up stairs or through a store, heft
ing periods of physical exertion. Compared with an
groceries, rise from a chair without help, and perform a
active person, a sedentary person experiences more multitude of other activities that permit independence
fatigue when carrying out a physically demanding • helps prevent weight gain and may aid weight loss
task and has both a higher heart rate and lower oxy- when combined with the proper diet
gen consumption. • lowers the risk for hip fractures.
Inactivity also has psychological effects. The less
Each of the diseases and problems that regular
active you are, the less active you want to be. People exercise helps protect against can rob people of energy.
who don’t exercise have a greater perception of fatigue Thus, regular exercise not only gives you more energy
than people who do. now: it also helps ward off an energy-robbing illness in
the future. In fact, regular exercise does more to protect
your health and energy than any medical treatment ever
invented or discovered. Through regular exercise, you can
The exercise prescription do more to protect your health than your doctor can do
Regular exercise can contribute to a feeling of vitality for you.
and energy, and it can also improve your sleep. But
what type of exercise should you do? You don’t have
to spend a lot of time worrying about this. When it Studies have demonstrated that aerobic exercise
comes to exercise and energy, it’s hard to go wrong. can even reduce fatigue in people who have major
Aerobic exercise is an obvious starting place, health challenges, such as chronic autoimmune condi-
whether you prefer brisk walking, jogging, bicycling, tions or cancer. A review of 36 studies found that 30 to
or swimming. In one study of 427 people ages 45 and 60 minutes of aerobic exercise three times a week (for
older, those with greater cardiovascular (aerobic) fit- at least three months) significantly reduced fatigue in
ness scored higher on a scale measuring vitality than people with diseases such as multiple sclerosis, lupus,
those who were less fit. and rheumatoid arthritis. A similar review of 19 stud-
ies involving people ages 65 and older found that Pilates improved sleep quality in 22 sedentary people
physical activity eased cancer-related fatigue. and lessened daytime sleepiness. But core work may
Most studies linking regular exercise to a greater help improve energy in other, more subtle ways too,
sense of energy have involved aerobic exercise rather beyond enhancing sleep. Among other things, core
than strength training, so it is difficult to say how exercises can help improve your posture whether
strength training compares. However, many people you’re sitting, standing, or moving. Good posture
report an increased sense of energy and alertness from trims your silhouette and projects confidence—and
either kind of regular exercise—and a well-rounded psychologists say the boost to your psyche may give
exercise program should include both. you mental energy.
Fortunately, you don’t have to run for miles or In fact, the only types of exercise that don’t
work out to the point of exhaustion to start reaping appear to have significant effects on energy are
benefits (see “Exercise regularly,” page 24). Even core stretching and balance exercises. That doesn’t mean
exercises may help. One recent study of the core- you should ignore them, however, because they have
strengthening program known as Pilates found that other health benefits.
Energy and sleep
f everything we’ve mentioned so far, there is no he or she will pass quickly through the lighter sleep
O more obvious influence on energy than sleep.
Sleep well, and the next day, everything hums along.
stages into the deeper stages and spend a greater pro-
portion of time there, suggesting that deep sleep fills
Sleep poorly, and you can barely drag yourself through an essential role in a person’s optimal functioning.
the day’s tasks without a jolt of caffeine. Just as deep sleep restores your body, scientists
For centuries, scientists scrutinized minute aspects believe that REM sleep restores your mind, perhaps
of human activity but showed little interest in the time in part by helping clear out irrelevant information.
that people spent in sleep. Sleep seemed inaccessible Studies of students’ ability to solve a complex puzzle
to medical probing and was perceived as an unvarying involving abstract shapes suggest that the brain pro-
period of inactivity—a subject best suited to poets and cesses information overnight; students who got a
dream interpreters who could conjure meaning out of good night’s sleep after seeing the puzzle fared much
the void. Since then, researchers have learned how to better than those asked to solve the puzzle immedi-
study sleep and are gradually starting to unravel the ately. Other studies have found that REM sleep facili-
complex ways that energy depends on adequate sleep. tates learning and memory. People tested to measure
how well they had learned a new task improved their
scores after a night’s sleep. If they were prevented from
How sleep boosts your energy having REM sleep, the improvements were lost. By
Scientists divide sleep into two major types: REM contrast, if they were awakened an equal number of
(rapid eye movement) sleep or dreaming sleep, and times from deep sleep, the improvements in the scores
non-REM or quiet sleep. Surprisingly, they are as dif- were unaffected.
ferent from each other as each one is from waking—
yet both may be important for energy.
Non-REM sleep involves three stages. But sleep Getting the right amount of sleep
specialists believe that the last of them—known as It’s not surprising that getting less sleep than you need
deep sleep or slow-wave sleep—is a time for your body leaves you feeling tired, but you may be taken aback
to renew and repair itself. This stage of sleep appears to learn that getting more than you need can be just
to be the one that plays the greatest role in energy, as bad. Many people find that on days when they
enhancing your ability to make ATP, the body’s energy sleep late, they don’t feel more rested and recharged;
molecule. In deep sleep, blood flow is directed less instead, they may feel more lethargic and unmotivated
toward your brain, which cools measurably. At the than usual. That’s because any significant deviation
beginning of this stage, the pituitary gland releases a from normal sleep patterns can upset your circadian
pulse of growth hormone that stimulates tissue growth rhythms. The best solution is to figure out how many
and muscle repair. Researchers have also detected hours of sleep are right for you and then stick with it—
increased blood levels of substances that activate your even on weekends and vacations.
immune system, raising the possibility that deep sleep For most people, however, the problem is too
helps the body defend itself against infection. Some- little sleep, not too much. There are many causes of
one whose deep sleep is restricted will wake up feeling sleep deprivation. But the most common one is simply
less refreshed than a person who got adequate deep burning the candle at both ends. In this 24/7 world,
sleep. When a sleep-deprived person gets some sleep, we remain tethered to work and electronic devices
well into the night. There are drugs that can help, but day is a potential cause, often the most important fac-
the first line of defense is to make some basic lifestyle tor is weekend changes in sleep habits. When you stay
changes that promote sleep (see “Practice good sleep up late Friday night and sleep Saturday morning, you
hygiene,” page 25, “Limit alcohol,” page 23, and “Exer- are primed to stay up even later Saturday night and
cise,” page 26). And while caffeine can help keep you sleep in the next day. By Sunday evening, your body’s
awake when you’re dragging, too much reliance on clock is programmed to stay up late. People who have
caffeine may make it hard to get a good’s night sleep. developed a pattern of Sunday insomnia may feel their
For some people, even a single cup of coffee in the anxiety mount as they anticipate a difficult night.
morning means a sleepless night. Caffeine blocks the The best way to avoid the Sunday blues is to main-
effects of adenosine, a neurotransmitter thought to tain the same wake-up time and bedtime on the week-
promote sleep. It can also interrupt sleep by increasing ends as during weekdays. If this isn’t possible and you
the need to urinate during the night. end up staying up later than usual on Friday and Sat-
urday, the next best thing is to force yourself to get
Aging up at your weekday wake-up time and take an early
Older people have trouble falling asleep and staying afternoon nap on Saturday and Sunday. This way, you
asleep. They wake up more often, and it takes them maintain the same wake-up time while compensating
longer to fall back asleep, in part because melatonin for your sleep deprivation.
levels decline with age. Furthermore, though they still
spend about 20% of sleep time in REM sleep, as they Health hazards of insufficient sleep
did when younger, they spend less time in energy- The problem with inadequate sleep isn’t just that you
restoring deep sleep. By age 65, people spend less than feel sluggish. A number of studies of hand-eye coordi-
5% of sleep time in deep sleep, compared with about nation and reaction time have shown that sleep depri-
20% when they were in their 20s. vation can be as debilitating as intoxiation.
Other age-related changes can interfere with sleep It also leaves you prone to two potentially danger-
as well. Hot flashes can rob women of rest. According ous phenomena—microsleeps and automatic behav-
to the National Sleep Foundation, 61% of postmeno- ior. Microsleeps are brief episodes of sleep that occur
pausal women have insomnia. (For coping techniques, in the midst of ongoing wakeful activity. They usually
see “Menopause,” page 36.) And with age, people also last just a few seconds but can go on for 10 to 15 sec-
become more prone to snoring, which can be a sign onds—and pose a grave danger if they happen when
of sleep apnea (see “Sleep difficulties,” page 35). If you you’re driving. Automatic behavior refers to a period
think you have sleep apnea, see a doctor for help. This of several minutes or more when you’re awake and
disorder not only drains your energy, but it also raises performing routine duties but not attending to your
the risk of major illnesses such as heart disease. surroundings. Examples include a driver who keeps
As you get older, you’re more likely to make up the car on the road but misses an intended exit or a
for your nighttime sleep deficit by napping. But if you train engineer who continues routine functions but
nap too late in the day or doze too long, the practice fails to notice an obstruction on the track.
can make insomnia worse by keeping you from feeling In addition, long-term sleep deficits can be a con-
tired enough at bedtime. Research comparing 5-, 10-, tributing factor in some significant illnesses. Problems
20-, and 30-minute naps suggests that the optimal nap include a sharp increase in the risks for type 2 diabe-
length for boosting energy and cognitive function is 10 tes, high blood pressure, and major depression. Sleep
minutes. loss has also been linked to weight gain, especially in
younger people; lack of sufficient sleep tends to dis-
Sunday insomnia rupt hormones that control hunger and appetite, and
People often have trouble falling asleep on Sunday the resulting daytime fatigue often discourages a per-
nights. While anxiety about work or school on Mon- son from exercising.
Energy and stress
mminent danger gives you a surge of energy. The

I fight-or-flight response (also known as the stress
response) primes your body to either take on an
Figure 3: The stress response
attacker or run for your life. The body churns out Hypothalamus Pituitary gland
stress hormones such as cortisol, epinephrine, and A
norepinephrine (see Figure 3, at right). In response,
blood flow increases to the brain and heart. Your heart
pumps faster, your blood pressure goes up, and you
take deeper breaths. Glucose floods your bloodstream Senses sharpen
to provide fuel for muscles. This is a survival mecha- Breath quickens
nism that evolved hundreds of thousands of years ago and lungs take
ACTH released in more oxygen
to protect people in life-threatening situations.
But while emergencies and other short-term Blood pressure rises
Heart beats
stressors can energize you temporarily, the stress faster
response guzzles energy, which is why it’s natural to
feel fatigued after a stressful event. Imagine the effect B
Muscles tighten
when you’re under constant low-level stress—whether Adrenal
glands release
from traffic jams, work deadlines, financial pressures, cortisol,
or caring for a sick relative. These, too, evoke the stress epinephrine
(adrenaline),
response. No wonder they make you feel tired. Glucose and fats
and
are released into
According to a 2012 American Psychological norepinephrine
bloodstream
(noradrenaline)
Association poll known as the Stress in America Sur-
vey, seven in 10 Americans reported experiencing
physical and nonphysical symptoms of stress. These
symptoms prominently included fatigue (37%),
changes in sleeping habits (30%), and feeling over- Collectively, the hypothalamus, pituitary gland, and adrenal
whelmed (35%) and irritable or angry (37%). Many glands make up the HPA axis, which plays a pivotal role in
people coped with the excess stress by overeating, eat- triggering the stress response.
ing unhealthy foods, skipping meals, or engaging in The hypothalamus sends a chemical messenger (corticotropin-
sedentary activities like listening to music, watching releasing factor, or CRF) to the nearby pituitary gland, which
TV or movies, or reading. then releases its own chemical messenger (adrenocorticotropic
But here’s the curious thing. People who regu- hormone, or ACTH) into the bloodstream (A). ACTH travels to the
adrenal glands, which respond by releasing a number of stress
larly feel fatigued don’t necessarily have more stressors
hormones into the bloodstream (B).
in their lives than others. In some cases, what is dif-
At the same time, the sympathetic nervous system releases
ferent is their response to stress. Faced with routine
stress hormones, too (not shown). The effects of these hormones
frustrations—a rude remark by a store clerk, a com- are widespread, as this illustration shows. Senses become
puter crashing, an incorrect charge on a credit card— sharper, muscles tighten, the heart beats faster, blood pressure
they may get angrier, more anxious, or more nervous. rises, and breathing quickens. This prepares you to fight or flee
Learning to dial back the stress reponse can help. in the face of danger—but it also consumes a lot of energy.
or with cognitive behavioral therapy, a type of psy-
Practicing mindfulness in daily life chotherapy helps you identify and change negative
Energy can come in different guises. Sometimes it thoughts and behaviors. Mind-body relaxation tech-
seems that nothing but a jolt of sugar and caffeine will niques have become well-accepted as stress-reducing
power through a tough day. But in the long run, you’re
strategies and are commonly recommended by both
better off with the calm, focused energy you get from
mindfulness—a practice that can help you stay “in the mainstream health care providers and integrative
moment.” You can try it no matter what else you’re medicine specialists. Though there are many different
doing, whether it’s washing the dishes or taking a walk. techniques that work, their common goal is to turn
Here’s how: off the stress response by eliciting its opposite—the
• Start by bringing your attention to the sensations in relaxation response. All relaxation techniques empha-
your body.
size a strong connection between the mind and the
• Breathe in through your nose. Let your abdomen expand
body. This once-novel idea is now widely accepted as
fully. Then breathe out through your mouth. Notice the
sensations of each inhalation and exhalation. scientists probe how the brain works and get a better
• Proceed with the task at hand slowly and with full understanding of how biological events such as fatigue
deliberation. relate to mental conditions.
• Engage your senses fully. Notice each sight, touch, and What happens deep inside your cells when you
sound so that you savor every sensation. elicit the relaxation response? Exciting new research
• When you notice that your mind has wandered from the suggests that this simple act temporarily throws a
task at hand, gently bring your attention back to the switch on certain genes, tamping down the activity
sensations of the moment.
of genes associated with the chronic inflammation
Mindfulness is a lifelong practice. Even if you start practic- that many experts believe contributes to heart dis-
ing it as a meditation, you will find it expanding to your
ease, inflammatory bowel disease, and diabetes. At
daily life, helping you to better appreciate simple everyday
experiences. By learning to focus on the here and now, you the same time, it turns up the activity of genes linked
may find yourself less likely to get caught up in worries with the use of energy in the body, particularly the
about the future or regrets over the past. functions of mitochondria, the tiny cellular energy
powerhouses. There is even preliminary evidence
that the relaxation response may slow the aging of
Managing the stress response our cells.
Though your response to stress is partly genetic, you To measure gene activity, the researchers used
can moderate it in several ways. blood samples taken from two small groups of healthy
One of those is through regular exercise. Exercise subjects: long-term practitioners of techniques like
is a great stress reducer, as well as an energy booster yoga, meditation, and repetitive prayer; and novices
in its own right (see “Energy and exercise,” page 14). who hadn’t used these techniques before, but who
Although it is not clear exactly how exercise pro- received training in them as part of the study. While
motes stress reduction, there are some reasonable the long-term practitioners had the most profound
theories. Regular aerobic exercise causes the “stress changes in gene activity, the group with eight weeks of
system”—mainly parts of the brain and the adrenal training also showed significant changes in gene activ-
glands—to generate fewer stress hormones (epineph- ity compared with results posted as complete novices.
rine, norepinephrine, and cortisol) in response to Are you intrigued? See “Practicing mindfulness in
daily stressors. In addition, by prompting the produc- daily life” (above left) and “Quick and easy relaxation
tion of endorphins in the brain, regular exercise also techniques” (page 27) for specific methods to try. In
may have a calming effect that helps in dealing with addition, here are some forms of exercise that incor-
daily stressors. porate mind-body techniques.
You can also learn to moderate the stress response ■ Qigong. This ancient Chinese art melds breath-
with meditation and other mind-body techniques ing, meditation, gentle exercise, and flowing move-
ments. Qi, or chi, is the Chinese word for the life ■A mindful walk. Taking a mindful walk is a good
energy believed to course through the body. Qigong example of exercising with relaxation in mind. As you
aims to unblock and properly balance the flow of qi. move and breathe rhythmically, be aware of the sen-
When practiced regularly, it can lower your blood sations of your body. How does it feel as your breath
pressure, pulse, and demand for oxygen, as do flows in through your nostrils and out through your
other techniques that elicit the relaxation response. mouth? Gradually expand your awareness to the sights
As a bonus, qigong may also enhance balance and and smells around you. Notice the freshly mown grass,
flexibility. flowers, trees, fallen leaves, dappled sun, or gray clouds.
■ Rhythmic, repetitive activities. Rhythmic exer- How does the outside air feel against your body? How
cises, such as walking, jogging, swimming, or bicy- does the surface beneath your feet feel and sound?
cling, can be calming and relaxing. Once you get What thoughts are moving through your head? A slow,
under way, become aware of how your breathing com- mindful walk helps center and relax you. Alternatively,
plements the activity. Breathe rhythmically, repeat- a brisker pace that pushes your limits can be calming
ing a focus word, phrase, or prayer you’ve chosen. and energizing in equal parts. In this case, place more
Remember to adopt a passive attitude. When disrup- emphasis on the sensations of your body, such as your
tive thoughts intrude, gently turn your mind away quickened breathing and heartbeat and the way your
from them and focus on moving and breathing. muscles respond as you tax them.
SPECIAL SECTION
A 6-step plan to jump-start

your natural energy
here is no pill or energy drink in the stores that will mag-
T
from Harvard Health Publications
ically restore the energy of your youth. (Only if you have and the Harvard School of Public
an underlying illness causing fatigue will pills help—by Health came up with a graphical
approach to healthy eating (see Fig-
treating the illness, not by directly boosting your energy.) ure 4, page 23). Harvard’s Healthy
However, certain lifestyle changes—outlined in the six-step Eating Plate clarifies and ampli-
plan below—can go a long way toward improving your energy, fies MyPlate from the U.S. Depart-
mood, and overall health. Because these approaches address ment of Agriculture, pointing you
both the physical and psychological aspects of fatigue, they can to the healthiest choices among the
major food groups. As you’ll see,
improve your strength and ability to exert yourself and sustain half of every meal should consist
your motivation. of fruit and vegetables. Carbs are
You’ll want to tailor the strat- is a well-rounded, healthful diet good, as long as they’re the whole-
egies to your individual needs, so (see “Energy and food,” page 8). It grain variety. For protein, choose
before reading through this sec- gives you the vitamins and miner- fish, fowl, beans, and nuts over red
tion, get a notebook or journal so als you need for generating energy. meat. When you eat a diet packed
that you can write down each step, It gives you the unrefined carbo- with vegetables, fruits, nuts, whole
followed by the specific changes hydrates and healthy unsaturated grains, healthy fats, and lean pro-
you can make to accomplish that fats that supply the reserves you’ll tein, you not only consume the
item. Writing your goals down can need throughout the day. But what finest energy-boosting foods, but
help you stay on track. Making does this healthy, energy-boosting you also promote good health—an
daily entries may help you moni- diet look like? energy booster in itself.
tor your own progress and stay Try these tips. Eat small, frequent meals …
focused. Let the Harvard Healthy Eating but don’t overeat. Where energy
Plate be your guide. With the over- is the issue, it’s better to eat small
1
Eat for energy load of diet advice out there, it can meals and snacks every few hours
STEP ▼
Caffeine and sugar can give be hard to separate objective, scien- than three large meals a day. This
you a temporary lift. But in tific recommendations from those approach can reduce your percep-
the long run, the only diet that will that are slanted by commercial or tion of fatigue because your brain,
keep you functioning at your best other agendas. That’s why teams which has very few energy reserves
22 B o o st in g You r Ene rg y w w w.h e a l th.ha r va r d.e du
A 6-step plan to jump-start your natural energy | SPECIAL SECTION
of its own, needs a steady supply without skimping on essential consumption, so having a cup of
of nutrients. Some people begin nutrients or starving yourself of coffee before going to a meeting
feeling sluggish, headachy, or the calories you need for energy. or starting on a project can help
light-headed after just a few hours Poor nutrition and inadequate sharpen your mind. But it can also
without food. But it doesn’t take calorie intake can cause fatigue. cause insomnia, especially when
much to feed your brain—a piece And remember to eat regularly consumed in large amounts or
of fruit or a few nuts is adequate. throughout the day, even when after 2 p.m. (or even noon, if you’re
Smaller is especially better at you’re dieting. Your brain needs caffeine-sensitive).
lunch. Researchers have observed a steady supply of glucose from Limit alcohol. If you’re going to
that the circadian rhythms of peo- food. When the brain’s glucose lev- drink, do so in moderation at a
ple who eat a lot at lunch typically els are low, some people feel hun- time when you don’t mind having
show a more pronounced after- gry, fatigued, or both, which can your energy wind down. The seda-
noon slump. The reasons for this then trigger a bout of overeating. tive effect of alcohol is especially
are unclear, but it may reflect the Use caffeine to your advantage. strong at midday, when you nor-
increase in blood sugar after eat- Caffeine can increase or decrease mally feel a bit lethargic anyway, so
ing, which is followed by a drop in your energy level, depending on one of the best hedges against the
energy later. when and how much of it you con- midafternoon slump is to avoid
Avoid crash diets. If you need sume. Caffeine does help increase alcohol at lunch. Similarly, avoid
to lose weight, do so gradually, alertness for an hour or two after the five o’ clock cocktail if you
want to have energy in the eve-
ning to pursue a hobby, stay awake
Figure 4: Eating for energy and health through a movie, spend time with
your family, or finish that report
HEALTHY EATING PLATE for work the next day.
That said, many experts advise
against having a nightcap just
Use healthy oils (like WATER before going to bed. Though alco-
Drink water, tea, or coffee
olive and canola oil)
for cooking, on salad, HEALTHY
(with little or no sugar). hol initially relaxes you and causes
Limit milk/dairy
and at the table. Limit OILS drowsiness, several hours later it
(1-2 servings/day) and
butter. Avoid trans fat.
WHOLE juice (1 small glass/day).
GRAINS Avoid sugary drinks. begins to stimulate the brain—
The more veggies— VEGETABLES
and the greater the particularly the sleep/wake cen-
Eat whole grains (like brown
variety—the better.
Potatoes and french fries
rice, whole-wheat bread, ters. For this reason, it may help
and whole-grain pasta).
don't count.
Limit refined grains (like you to fall asleep, but the stimu-
HEALTHY white rice and white bread).
Eat plenty of fruits of FRUITS
PROTEIN lating effect that kicks in two to
all colors. Choose fish, poultry, beans, three hours later may awaken you
and nuts; limit red meat;
avoid bacon, cold cuts, and and make it difficult to get enough
STAY ACTIVE! other processed meats.
© Harvard University
deep, restorative sleep for the rest
Harvard School of Public Health Harvard Medical School of the night.
The Nutrition Source Harvard Health Publications
www.hsph.harvard.edu/nutritionsource www.health.harvard.edu If you do choose to drink alco-
hol, a glass with dinner is a rea-
Sometimes a picture really is worth a thousand words. For a more nutritious diet, sonable choice. And stay within
follow the guidelines of Harvard’s Healthy Eating Plate. the limits of moderation: no more
w ww. h ealt h . h ar v a rd . e du Bo o sti ng You r E n erg y 23
SPECIAL SECTION | A 6-step plan to jump-start your natural energy
syndrome or multiple sclerosis

How fast is brisk? (MS), those who are elderly, or
A brisk walk is generally 3 to 4 miles per hour. But since humans don’t come those who have long been couch
equipped with built-in speedometers, you need some way to measure your
walking speed. One way is to count your steps per
potatoes—should start slowly and
minute. Provided you’re walking on level ground, build gradually. Some evidence
you can use the following as general guidance to indicates, for example, that aerobic
gauge your pace: exercise can aggravate symptoms in
Slow = 80 steps per minute some people with chronic fatigue
Moderate to brisk = 100 steps per minute syndrome. And people with MS
Fast = 120 steps per minute are prone to overheating quickly,
Thinkstock
Race walking = More than 120 steps per minute which can make them feel weak
and fatigued. Check with your doc-
tor for advice based on your own
than two drinks a day for men and can come from a combination of health history before you begin an
one for women. drinks (such as water, milk, coffee, exercise program.
Drink water. What’s the only tea, or soda) and solid foods that Whether you are doing aerobic
nutrient that has been shown to contain water (such as fruits and exercise or strength training, start
enhance performance for most vegetables), so you don’t actually each exercise session with a five-
activities? It’s not some pricey need to drink 16 cups of fluid a day: to 10-minute warm-up. March-
sports drink. It’s water. If your five to eight is good enough. ing in place and gently swinging
body is short on fluids, one of the your arms, dancing to a song on
2
Exercise regularly
STEP ▼
first signs is a feeling of fatigue. the radio, or starting slowly on a

Sports drinks such as Gatorade Exercise is the energy boost- treadmill or exercise bike are excel-
and Powerade combine water with er that is so counterintuitive, lent ways to warm up. At the end of
sugar, vitamins, minerals, and elec- most people don’t even think of it. each session, finish with a five- to
trolytes—sodium, chloride, potas- But it’s a proven way to increase 10-minute cool-down, such as slow
sium, and other substances that your vim and vigor (see “Energy walking, until your heart rate and
help regulate body processes. But and exercise,” page 14). The Physi- breathing return close to normal.
these add-ons won’t give you extra cal Activity Guidelines for Ameri- Stretching is also essential at the
energy for ordinary, everyday activ- cans recommend 150 minutes of end of a session to work out muscle
ities, and these drinks may provide moderate aerobic activity per week kinks and improve range of motion
more calories than you burn. You (for example, half an hour five days and balance.
don’t need them unless your work- a week) or 75 minutes of vigorous Aerobic activity. The most con-
out is extremely strenuous or long, activity, or a mix of the two. The venient and affordable form of
or you sweat profusely and lose guidelines also advise engaging aerobic activity is walking. Stud-
nutrients through perspiration. in two to three strength training ies have shown that brisk walking
How much water do you need? sessions per week. Allow at least 48 for at least half an hour, five times
The Institute of Medicine recom- hours between these muscle-build- a week, has nearly the same health
mends that women consume a total ing workouts to give your body benefits as more vigorous exer-
of about 91 ounces of fluids a day time to recover. cise (see “How fast is brisk?” at the
(about 11.5 cups) and men about However, certain people—par- top of the page). People who take
125 ounces (16 cups). These fluids ticularly those with chronic fatigue brisk walks have a lower risk for
heart disease, diabetes, high blood using strength training machines set of behavioral changes. (If you
pressure, high cholesterol, colon at the gym. suffer from a disorder such as sleep
cancer, osteoporosis, and perhaps Choose weights as light as 2 apnea, however, you’ll need to see
other diseases. Even mental health pounds for your first few strength a doctor who specializes in sleep.)
problems are less frequent in regu- training sessions so you can con- Practice good sleep hygiene.
lar walkers. Although it hasn’t been centrate on good form—you want People who have difficulty sleep-
studied, many regular walkers also to isolate muscles by trying to move ing often come to associate their
believe that this exercise makes only those that you’re exercising. bedroom with the frustration of
them more energetic. After that, add enough weight so trying and failing to get to sleep.
If you are starting an exercise that the maximum number of rep- These associations create anxiety,
program for the first time, begin etitions you can do per set is about worsening the insomnia. Recon-
with a slow walk around the block eight to 12. The last few repeti- ditioning is a behavioral tech-
almost every day. Then, as your tions in each set should require a nique for breaking such negative
energy level rises and your mus- good deal of effort. Aim for two to associations.
cles become conditioned, gradu- three sets per exercise, breathing Here’s what to do:
ally spend more time exercising. out as you lift and breathing in as • Use the bed only for sleeping
Increase the length and intensity you lower the weight. Rest between or sex. Watch TV or read in a
of your walk to a degree that’s chal- sets for a minute to reap the best different room, and keep your
lenging but not overwhelming. strength gains. bedroom dark for sleep. (That
If you are up for more vigor- Be sure to exercise all of the also means covering up lights
ous workouts, you can try running, major muscle groups of the legs, from chargers and electronic
hiking, biking, aerobic dancing, trunk, arms, and shoulders. devices. Better yet, keep laptops,
or swimming. In truth, exercise Yoga and tai chi. Yoga and tai chi cell phones, and other gizmos in
intensity is dictated more by your can enhance energy, too, because a different room.)
level of fitness than the activ- they are proven stress busters with • Go to bed and get up at the same
ity—so even a walk can be termed substantial benefits for the mind. A time every day, including week-
“vigorous” if you pick up the pace 2013 study published in the Jour- ends, to keep your sleep/wake
and boost your heart rate. Many nal of Physical Activity and Health cycle synchronized to your cir-
experts offer the following rule of found that doing 20 minutes of cadian rhythms. Also, try to go
thumb for aerobic exercise: If you yoga postures led to better cogni- outside in natural light early in
can talk easily while performing tive functioning—specifically, an the day. This will help reset your
your routine, exercise harder. If improved ability to focus and take internal clock.
you can’t carry on a conversation at in and use new information—than • If you don’t fall asleep quickly,
all, back off. 20 minutes of aerobic exercise. don’t lie in bed tossing and
Strength training. Resistance turning and worrying about
3
STEP ▼
exercise, such as weight lifting, Get a better night’s sleep not sleeping. Get up and go
is especially beneficial for people Nothing saps your energy to another room to read or do
in their 60s and older because it faster than a poor night’s rest something calming for half an
builds muscle mass. Weight lifting (see “Energy and sleep,” page 17). hour. Then try sleeping again.
doesn’t have to involve heavy bar- But you don’t have to toss and turn Avoid smoking. Smoking harms
bells. Lifting light hand weights can all night. Most ordinary sleep diffi- your health in many ways, includ-
provide adequate resistance, as can culties can be solved with a simple ing increasing your risk for lung
cancer and heart disease. But it For “normal sleepers,” exer- days a week. Even though your
also siphons off your energy by cising at any time of the day or schedule may be very different on
causing insomnia. Smoking can night can be helpful and shouldn’t the weekends, try not to vary your
ruin your sleep with a kind of one- interfere with sleep, according to routine. If you get back to a solid
two punch. As a central nervous experts. This is well-documented seven hours of sleep on weeknights,
system stimulant, the nicotine in in young adults, but less well-doc- you probably won’t have as much
tobacco speeds up your heart rate, umented in older adults. If you find need to “sleep in” on the weekends.
raises blood pressure, and stimu- that you have trouble falling asleep Take sleep medications only as
lates brain-wave activity associ- when you exercise vigorously in a last resort. Although such medi-
ated with wakefulness, making it the evening, you would be wise to cations can be helpful in the short
harder to fall asleep. What’s more, avoid strenuous activity for two to term to break a pattern of insom-
once you do fall asleep, its addic- three hours before you go to bed. nia, when used long-term, they
tive power can kick in and awaken Restrict your sleep. If you think may actually worsen your fatigue by
you with cravings. you may be sleep-deprived, try get- leaving you groggy during the day.
People who quit smoking fall ting less sleep. That’s right: get less In addition, prescription sleep med-
asleep more quickly and wake sleep, at least for a few days. This ications can cause tolerance (the
up less often during the night. advice may sound odd, but the need for progressively larger doses
Although at first many former goal is to determine how much over time to get the same effect).
smokers experience sleep distur- sleep you actually need and to Over-the-counter sleep aids, which
bances and daytime fatigue, they reduce the time you spend in bed typically contain antihistamines,
often report improvements in their not sleeping. This process makes it are often ineffective and, in some
sleep relatively soon. easier to fall asleep and promotes people, cause irritability. However,
Exercise. Exercise is the only more restful sleep in the long run. when used occasionally, they work
proven way to increase the amount Here’s how to do it: well for some individuals.
of time you spend in deep sleep, • Avoid napping during the day.
4
Control stress
STEP ▼
the type of sleep that is most • The first night, go to bed later
restorative for your energy. The than normal and get up after The most common cause of
more deep sleep you get, the less four or five hours of sleep. persistent fatigue is stress
likely you are to awaken in the • If you feel that you slept well and the emotional response to it
middle of the night, and the more during that four-hour period, (see “Energy and stress,” page 19).
rested you’ll feel the next day. add another 15 to 30 minutes Stress-induced emotions consume
The National Sleep Founda- of sleep the next night. huge amounts of energy. Some
tion’s 2012 survey found that even • As long as you’re sleeping soundly people are naturally better than
10 minutes of light, moderate, or the entire time you’re in bed, others at coping with such emo-
vigorous physical activity had a slowly keep adding sleep on suc- tions, but everyone can learn to
beneficial effect on sleep, both its cessive nights. modulate them to some degree.
duration and its quality. In par- You can extend the time you Engage in a hobby. Emerging
ticular, aerobic exercise, which spend in bed until you’re getting data show that knitting, crochet-
increases your heart rate, makes it a full night’s sleep, ideally at least ing, and other rhythmic and repet-
easier to get to sleep and gives you seven hours. Once you’ve done so, itive craft activities can be potent
more hours of energy-enhancing try to establish regular times for stress relievers. For one thing,
deep sleep each night. going to bed and getting up, seven they distract you from your wor-
ries. A seminal study published in

The Journal of the American Medi- Quick and easy relaxation techniques
cal Association found that sewing The next time you’re stuck in traffic or faced with a situation that annoys you,
was more stress-reducing than one of the following quick relaxation techniques may help ease your day.
playing a card game, reading a When you’ve got one minute
newspaper, or other activities. The Place your hand just beneath your navel so you can feel the gentle rise and
researcher concluded that the act fall of your belly as you breathe. Breathe in slowly. Pause for a count of three.
Breathe out. Pause for a count of three. Continue to breathe deeply for one
of performing a craft such as knit-
minute, pausing for a count of three after each inhalation and exhalation.
ting is so absorbing and enjoyable
When you’ve got three minutes
that it is incompatible with worry,
While sitting down, take a break from whatever you’re doing and check your
anger, obsession, and anxiety. Most body for tension. Relax your facial muscles and allow your jaw to fall open
importantly, perhaps, crafts and slightly. Let your shoulders drop. Let your arms fall to your sides. Allow your
hobbies can induce the relaxation hands to loosen so that there are spaces between your fingers. Uncross your
response, the polar opposite of the legs or ankles. Let your legs fall comfortably apart. Feel your shins and calves
become heavier and your feet grow roots into the floor. Now breathe in slowly
stress response. The act of doing
and breathe out slowly. Each time you breathe out, relax even more.
a task over and over again breaks
When you’ve got five minutes
the train of everyday thought and
Try self-massage. Put fingertip pressure on muscle knots. Knead across muscles,
calms both the body and mind. and try long, light, gliding strokes. You can apply these strokes to any part of the
Use relaxation techniques. You body that falls easily within your reach. For a short session like this, try focusing
can’t eliminate stress from your on your neck and head.
life, but you can learn relaxation Massage your face. Make a series of tiny circles with your thumbs or
fingertips. Pay particular attention to your temples, forehead, and jaw muscles.
techniques that work as an anti- Use your middle fingers to massage the bridge of your nose and work outward
dote to stress. Deep breathing, over your eyebrows to your temples.
meditation, progressive muscle End by closing your eyes. Cup your hands loosely over your face and inhale
relaxation, and visualization can and exhale easily for a short while.
evoke a state of rest and release.
These kinds of relaxation exercises
trigger physiological changes, social, or volunteer activities, can handle, don’t take on any more. Set
such as lowering blood pressure, sap your energy level. Everyone your priorities in terms of the most
slowing heartbeat and respiration, needs some downtime to relax and important tasks. Pare down those
and reducing blood lactate levels, restore—even high-energy types. that are less important.
which may be linked with anxiety A good first step toward reducing Overload that’s strictly job-
attacks. If you’re pressed for time, your load is to streamline your list related is particularly hard to con-
mini relaxation exercises and the of “must-do” activities. You don’t trol, especially if you work in a
practice of mindfulness can help need to accept every social invi- company or a profession where
(see “Quick and easy relaxation tation, volunteer for every work very long days are the norm. Learn
techniques,” above right, and assignment, or run the entire com- efficiency techniques that let you
“Practicing mindfulness in daily munity fund-raiser yourself. Some meet your work goals without
life,” page 20). people are overloaded because working harder or longer than
Lighten your load. An overly they have trouble saying “no.” If necessary. Consider asking for
committed schedule, whether it you already have more responsi- extra staff or temporary assistance
consists of professional, family, bilities than you can comfortably at work. Or ask your boss to help
you prioritize your tasks; if noth- contact with nature can benefit why you want to have more energy.
ing else, that will make him or her your health. Is it simply to feel good? Are there
realize how much you’re doing. Evolution may indeed have activities you would enjoy if only
Exercise. Regular aerobic exer- hard-wired us to prefer natural you had more energy? Motivation
cise seems to help control stress. It places. Common sense tells us in itself is an important aspect of
causes the “stress system”—mainly that time spent hiking in the hills,
energy. And reaching goals is enor-
parts of the brain and the adrenal walking in a beautiful garden, or
mously satisfying—the greater your
glands—to generate fewer stress bird watching can help a person sense of well-being, the higher your
hormones (epinephrine, norepi- feel restored. Hospitals and nurs-
energy level is likely to be.
nephrine, and cortisol) in response ing homes widely employ the con- So if you need to reinforce
to daily stressors. Such exercise cept of “healing gardens” for their
your resolve, try this. Get out a
generates the production of pencil and jot down the things
endorphins in the brain, and in your life that have most
these molecules have a calm- inspired you. Have you trained
ing effect. for a marathon? Earned an
advanced degree? Raised
5
Use nature’s energy
STEP ▼
money for charity? Created

Anyone who enjoys the a website? Now make a list
outdoors, whether for of the things that you most
Thinkstock
gardening, hiking, or taking enjoy doing, such as traveling,
walks along the beach, knows gardening, playing a musical
that getting outside can help Research suggests that simply being in nature can instrument, socializing, read-
restore body and soul. There have therapeutic and restorative effects. ing a good book, or playing
aren’t any scientific studies bridge, golf, or tennis. Look
documenting that communing patients. If nothing else, getting at the two lists. Are there ways to
with nature can actually fight fa- outdoors can help reduce stress combine the things you love with
tigue, but scientists are beginning by taking your mind off troubling goals you can accomplish?
to explore this theory. thoughts. And communing with The idea is to find something
Some research suggests that nature often goes hand in hand that will be stimulating and ener-
being in nature can have thera- with exercise, a known energy gizing, not something that’ll feel
peutic and restorative effects. This booster. like just one more chore. Planning
supports a theory developed by a trip can be stimulating, for exam-
6
Keep focused on goals ple, and saving the money for it
STEP ▼
Harvard biologist Edward O. Wil-

son known as “biophilia,” which If you’re having trouble can give you a goal. Try to focus on
holds that humans have an innate making these changes stick, your priorities, so that you channel
connection to the natural world this is a perfect time to step back your energy into the activities that
and to other living things, and that and consider some of the reasons truly matter to you.
Fatigue: Energy’s enemy
hen you lack energy, you feel physically weak, These researchers are using brain imaging technol-
W mentally dull, or both. Effort of any sort can
tire you out quickly. This absence of energy is often
ogy to examine people who are resistant to fatigue, in
hopes of determining whether there is something dif-
referred to as fatigue, and it’s a common phenomenon ferent about these people’s brains compared with peo-
that has been viewed differently over the years. ple who cannot perform well when sleep-deprived. It
Sometimes when you lack energy, you feel tired or may be that people who decide to become pilots self-
drowsy. But fatigue is not just sleepiness: it includes select for this characteristic, the researchers suggest, as
components that are physical (weariness or weak- people who cannot perform well when sleep-deprived
ness), mental (lack of concentration and sharpness), are less likely to become pilots. The scientists also
and emotional (lack of motivation or boredom). hope to find out whether there is a brain chemical that
influences this ability.
Changing views of fatigue

In today’s 24-hour society, fatigue is thought of as How common is fatigue?
something to be avoided, conquered, or, at the very One of the significant challenges facing contemporary
least, denied. But fatigue did not always have a negative scientists studying fatigue is how to measure its preva-
connotation. In medieval writings, for example, fatigue lence. Unlike diabetes, obesity, or other well-defined
is often portrayed as a positive, normal sign that a per- medical conditions, fatigue is very difficult to define
son has reached his or her limit, and it’s time to rest. because it has varied symptoms and, like pain, is both
The notion that fatigue is an unwelcome condition an objective and subjective state.
to be studied and overcome first became popular in Moreover, fatigue is part of the human experi-
the mid-19th century, with the advent of industrial- ence and is, at times, entirely normal. In the absence
ization and its demand for a steady source of indefat- of a clear-cut definition or objective “fatigue test,”
igable factory workers. By 1900, the study of fatigue attempts to measure how many people experience
was in full swing, with fatigue laboratories cropping fatigue—and when it crosses the line from normal to
up throughout Europe and scholarly papers about the abnormal—are imprecise at best. Despite these hur-
new science of ergography, or work capacity, filling dles, researchers who have looked at the results of
scientific journals. numerous epidemiological (population-based) stud-
Interest grew as the military sought to understand ies of fatigue have been able to draw some conclu-
how to boost energy and thereby increase the produc- sions about its prevalence.
tivity of workers in munitions factories during World The first is that fatigue is very common, reported
War I. Later, the focus of military research shifted by anywhere from 5% to 45% of people. In a com-
from physical to mental fatigue as increasing numbers prehensive health survey of more than 9,000 adults
of tasks—from piloting airplanes to operating radar— in Britain, for example, only headache was a more
required sustained mental alertness. common bothersome symptom than fatigue. And
Today, this line of research is changing the way in approximately 5% to 10% of people, bothersome
scientists think about fatigue. Some people are better fatigue persists for at least six months. Fatigue tends
than others at performing well despite a lack of sleep, to become more noticeable with age and chronic ill-
suggest some Air Force scientists working with pilots. nesses, such as arthritis, cancer, or cardiovascular dis-
ease. Perhaps not surprisingly, fatigue is also one of the Two types of fatigue
leading reasons people around the world visit primary Ask any three people what fatigue feels like, and you’re
care providers (see Figure 5, below). One U.S. survey likely to get three different answers. That’s because
concluded that fatigue was responsible for more visits the experience that people call “fatigue” may refer to
to primary care doctors than colds, rashes, headaches, very different things—for example, muscular weak-
or chest pains. ness, lack of endurance, slow reaction times, or poor
Studies have also shown that fatigue can have concentration, among other qualities. The experience
multiple simultaneous causes, and be associated with of fatigue is often classed as one of two general types:
many variables, including demographic, social, cul- muscle fatigue and central (or brain) fatigue.
tural, and psychological factors. One study involving Muscle fatigue and central fatigue are closely
more than 29,000 adults found that fatigue is common related. When you feel fatigued, you’re usually feeling
in urban areas and that the highest levels of fatigue the effects of both muscle and central fatigue. But you
occurred among women and people with lower levels can also experience one without the other. Although
of education and less prestigious jobs. There are many the mechanisms are not well understood, the two
theories as to why women might report higher levels types of fatigue look different inside the body.
of fatigue, ranging from women’s role in society and
the biological differences between women and men, Muscle fatigue
to the higher incidence of depression among women, Muscle fatigue is the weakness you feel in your mus-
which is associated with fatigue. Other studies con- cles when you’ve tired them out. Make a fist with one
ducted in various countries have found that people in hand, then open and close it as fast as you can for one
lower social classes are more fatigued than those of a minute, and you’ll feel some weakness in your hand
higher social standing. muscles. Then repeat the sequence a few more times.
Chances are, your muscles won’t contract as fast as
they did when you first started the experiment.
Figure 5: The front line of fatigue
To understand how muscles become fatigued, it’s
Primary care doctors are often the first to hear from their
patients when fatigue becomes a problem. A 2009 survey
essential to understand the chain of events that makes
revealed the following about patients who reported symptoms them work.
of fatigue to their primary care doctors: The first part of the muscle contraction process
74 % occurs not in the muscles but in the brain. The motor

cortex, the area of the brain that controls movement,
sends a nerve impulse to muscles in your arms and
were female
hands. To reach the appropriate muscles, the nerve
66 % impulse travels down the spinal cord and through a

pathway of nerves to the neuromuscular junction, a
were having tiny space between the end of a nerve and the sur-
trouble sleeping face of a muscle. A chemical signal travels across the
56%
neuromuscular junction to land on the muscle. This,
in turn, triggers a series of chemical reactions in the
24 %
were feeling muscle cells that ultimately leads to the breakdown of
39
were feeling
% stress or worry ATP, which then provides the energy that enables the
symptoms of muscles to contract.
depression were experiencing
When muscles become fatigued, they don’t con-
fatigue lasting more
tract as forcefully or as quickly as muscles that are not
than one year
tired. Fatigued muscles have certain characteristics,
Source: Canadian Medical Association Journal, November 2009. including a buildup of acid, particularly lactic acid.
But it’s not known whether the acid buildup causes
the muscle to become fatigued, or whether it occurs Doc around the clock
along with the fatigue. Therefore, it’s unclear whether Fatigue and sleep deprivation are ongoing concerns for
attempts to change the acid concentration of exercis- medical residents in hospitals and for the patients they
ing muscle—as has been proposed by some fitness treat. Residents typically work long hours, sometimes
with little or no sleep. Fully trained physicians and sur-
professionals—would allow a muscle to work longer geons, too, may work overnight on call and face a regular
and harder without getting fatigued. Although some schedule of patients the next day. As sleep experts
experts suggest that gradually increasing the intensity concluded in an article in The New England Journal of
of your training and eating a combination protein- Medicine, “Sleep deprivation adversely affects clinical
performance and impairs psychomotor performance as
carbohydrate snack within 15 minutes after a workout
severely as alcohol intoxication.”
will help reduce lactic acid, there’s no proof that this
The Accreditation Council for Graduate Medical Education
will increase your endurance or energy level. has published guidelines restricting medical trainees in
Many diseases damage muscle fibers. An example is their first postgraduate year to a maximum of 16 hours of
muscular dystrophy. When some fibers are damaged and continuous work and those in their second postgraduate
cannot function effectively, it puts a strain on the muscle year to 24 hours. Paradoxically, research studies have not
found these restrictions to have improved patient care or
fibers that are not damaged. A vicious cycle ensues that
reduced medical errors.
leads to more muscle damage and muscle fatigue.
If you or someone you know is in the hospital, keep this
Other diseases affect the transmission of signals
issue in mind. At any time, even in the middle of the day,
from nerves to muscles. An example is myasthenia if the doctor appears exhausted, it’s appropriate to ask
gravis. You move a muscle when your brain sends a how long he or she has been on duty. And if a doctor tells
signal to the muscle to move. When disease interrupts you in the evening or at night that you need an emer-
that signal, muscles tire. gency medical or surgical procedure, ask how long that
doctor and the doctors doing the procedure have been
on duty. It’s a perfectly fair question, and if the answer
Central (brain) fatigue is that they have been on duty longer than 16 hours,
When most people say they are fatigued or lack energy, consider asking for a second opinion.
they are describing a brain condition. What they mean
is that they are having trouble paying attention or
concentrating, or feeling motivated to perform. They tional and psychological factors significantly affect
may also mean that they feel sleepy. Specific areas of how fatigued you feel.
the brain, using certain natural brain chemicals, are Scientists have a method of measuring the per-
responsible for attention and concentration. Other ception of fatigue. It’s called the rating of perceptual
areas are centrally involved in motivation. Still others effort, or RPE. To use this method, an exercising per-
are involved in alertness and sleepiness. son is asked to pick a number on a scale ranging from
Central (brain) fatigue is, to a great degree, a per- no fatigue to maximum imaginable fatigue. Scientists
ception or a state of mind. As a result, central fatigue have found that, in general, the more effort you think
is a much less objective and measurable phenomenon you’re expending, the more fatigued you will feel.
than muscle fatigue. Your perception of fatigue usually Like the sensation of pain, the perception of fatigue
increases with your muscle fatigue, but the two aren’t is highly personal. It varies from one individual to
always in sync. Experiments show that a person’s per- the next, depending on personality as well as mood.
ception of fatigue can decline even as the muscles are Fatigue is greater and comes on sooner in people with
expending ever more energy and, in all likelihood, mood disorders such as depression or anxiety than in
showing more signs of fatigue. But sometimes the those who don’t have these illnesses.
opposite happens: your perception of fatigue can be An individual’s perception of fatigue can change
greater than your muscle fatigue. You can feel fatigued depending on the situation. In experiments, research-
without having expended much energy at all. Emo- ers have been able to manipulate people’s RPEs during
physically challenging activities. For example, giving a In the past 20 years, research has also discovered
subject feedback on his or her performance decreases that the immune system can profoundly affect men-
the perception of fatigue, possibly because it helps tal functions. The brain has its own immune system
keep the person motivated to improve. that fights infections and helps repair perceived inju-
Maintaining mental focus on an activity is one ries. In waging this fight—a process called inflamma-
method coaches use to improve athletes’ perfor- tion—immune system cells make natural chemicals
mances. By contrast, distractions tend to increase a (cytokines) that send signals to other immune sys-
person’s perception of fatigue. When people are dis- tem cells to attack. These chemicals can also alter the
tracted, their minds wander. They may think about function of the brain’s neurons—the cells that do the
how tuckered out they should be or anticipate how work of the brain, such as thinking, seeing, feeling,
drained they’re likely to feel if they keep going. They and directing movement. Excessive amounts of cyto-
may also think about easier, more pleasurable things kines produced over a prolonged period can interfere
they’d rather be doing and then, subconsciously, “feel” with attention and concentration, motivation and
fatigued by their present activity. alertness.
Based on experiments with humans and animals, Scientists used to think that the brain was walled
researchers suggest that certain chemical or electri- off from the rest of the body’s immune system. How-
cal stimuli in the brain can alter perceptions of fatigue ever, recent research has revealed that inflammation
during exercise. However, none of these experiments or immune system activation anywhere in the body,
have yet provided a fatigue-preventing treatment that such as the intestines or the kidneys, can affect atten-
can be used to improve performance. tion, motivation, and alertness.
Common causes of fatigue
he cause of fatigue is not always obvious (see Developing knowledge of brain chemistry, genet-
T Figure 6, below). If you have the flu or have just
eaten a big lunch, fatigue is to be expected. But if you
ics, nerve pathways, and the biology of stress has led
to a greater understanding of depression and anxiety.
feel inexplicably groggy throughout the day, not just It’s often said that depression results from a chemical
during the biological trough that normally occurs in imbalance, but that description doesn’t capture how
midafternoon, that’s reason for concern. Report your complex the disease is. Research suggests that depres-
symptoms to your doctor. sion doesn’t spring from simply having too much or
The underlying cause of persistent fatigue can be too little of certain brain chemicals. Rather, depression
hard to identify, but that doesn’t mean the fatigue is has many possible causes, including genetic vulnera-
imaginary. Fatigue often signals that something is bility, stressful life events, and faulty mood regulation
wrong, physically or emotionally, or even with the by the brain.
pace and tempo of your daily schedule. This section Regardless of the cause, getting help for depres-
explores some of the most common causes of an ongo- sion and anxiety is extremely important. Several ther-
ing lack of energy. apies, including medication and psychotherapy, can
Depression or anxiety Figure 6: Causes of fatigue

As many as 20% to 40% of people who seek help for
ongoing fatigue suffer from depression or anxiety. Stress Sleep difficulties
With depression, fatigue can manifest itself in two
ways. One is mental fatigue, specifically a decreased Overwork
drive or motivation to do things that you once Depression & anxiety
enjoyed. Another is a change in sleep patterns— Chronic
some people sleep more than usual, others develop fatigue
syndrome Fibromyalgia
insomnia. Either way, they grow weary during the
day. Depression doesn’t have to be severe to cause
Multiple Medical
fatigue. Dysthymia, a persistent low-level depres- sclerosis illnesses
sion, can make a person feel tired or fatigued much
of the time. Nutritional
Inactivity &
People with anxiety, on the other hand, are prone overweight
factors
to panic, fear, and other high-stress responses, which
cause fatigue by increasing levels of stress hormones.
Medications Alcohol
These people are also more likely to have chronic high-
stress reactions, the most debilitating and energy-
robbing kind. Anxiety causes a host of emotional and
Some causes of fatigue are obvious, such as lack of sleep or a
physical symptoms, including worry, restlessness, and
medical illness, but many others are harder to pinpoint. Depres-
irritability, as well as rapid heartbeat, hyperventila- sion or anxiety, overwork, sedentary living, nutritional factors,
tion, upset stomach, or general aches and pains. Many even a medication could contribute to fatigue or cause a feeling
people with anxiety also suffer from depression. of low energy.
relieve the symptoms of depression within a matter tor can recommend the one that’s best for you.
of weeks. Certain medications to treat anxiety work ■ Psychotherapy. Another effective way to beat
almost immediately. depression is psychotherapy with a qualified coun-
If you suspect that you are suffering from depres- selor, such as a psychiatrist, psychologist, or social
sion or anxiety, start by seeing your primary care doc- worker. The combination of psychotherapy with an
tor. He or she can assess your symptoms with the goal antidepressant is often an effective strategy and has
not only of uncovering depression or anxiety, but also been gaining favor recently.
of diagnosing possible underlying medical problems. ■ Exercise. A sustained exercise program can
improve the mood of people with mild or moder-
Treating depression ate depression. It might also augment antidepressant
If the evaluation points to depression, the doctor may treatment for people with severe depression. You don’t
suggest some combination of antidepressant medication, have to exercise a lot to obtain mental health benefits:
psychotherapy, and lifestyle changes such as exercise. studies have found that doing an average of 30 min-
■ Medication. Antidepressants work by adjusting utes or more of moderate-intensity aerobic exercise at
levels of brain chemicals that play a role in depres- least three times a week can alleviate mild or moderate
sion. Selective serotonin reuptake inhibitors (SSRIs), depression as effectively as antidepressants or cogni-
one class of antidepressants, increase the brain’s level tive behavioral therapy (a form of psychotherapy that
of serotonin, a neurotransmitter that affects mood, aims to correct ingrained patterns of negative thoughts
arousal, anxiety, impulses, and aggression. SSRIs are and behaviors). Besides boosting your mood, exercise
the most commonly prescribed medicines for depres- can also increase your energy level.
sion. Tricyclic antidepressants, an older class of medi-
cation, increase serotonin and also norepinephrine, a Treating anxiety
neurotransmitter that affects mood, anxiety, and drive. As with depression, anxiety can be treated with medi-
Tricyclic antidepressants are often the best choice for cations, psychotherapy, or both. For long-term treat-
someone with sleep problems, although they should ment of anxiety, there are two options: antidepressants
be prescribed with caution in people with known or the anti-anxiety drug buspirone (BuSpar). In addi-
heart disease. In addition, there are some antidepres- tion, short-term psychotherapy is at least as effective
sants that don’t fall neatly into one class or another. as anti-anxiety medications alone. Cognitive behav-
Since side effects vary among medications, your doc- ioral therapy is especially helpful.
Spotting the symptoms of depression and anxiety

Signs of depression Signs of anxiety
Doctors look for the following signs to diagnose depression. Four or more of these Doctors look for excessive anxiety and
symptoms—in addition to feeling sad or burdened or losing interest in nearly all worry occurring more days than not for at
activities on most days for at least two weeks—may indicate major depression: least six months, plus at least three of the
• a change in appetite that sometimes leads to weight loss or gain following symptoms:
• insomnia or, less often, oversleeping • restlessness
• a slowdown in talking or in performing tasks or, conversely, restlessness • being easily fatigued
and an inability to sit still • difficulty concentrating
• loss of energy or feeling tired much of the time • irritability
• feelings of worthlessness or excessive, inappropriate guilt • muscle tension
• problems concentrating or making decisions • disturbed sleep.
• thoughts of death or suicide, or suicide plans or attempts.
Sleep difficulties
Difficulty getting a good night’s sleep is a significant Better work, better play
cause of fatigue. Too little sleep—or counterintui- Yearly surveys by the online travel site Expedia.com
tively, too much sleep—can increase your perception show that millions of Americans don’t take all of their
vacation days each year, and we work more than any other
of fatigue. Many lifestyle habits, foods, or even ill-
industrialized nation in the world.
nesses can interfere with the duration and quality of
However, those who take their vacation time tend to be
your sleep (see “Get a better night’s sleep,” page 25).
more satisfied with their work. According to the 2013
A variety of sleep disorders can also cause problems. Expedia Pleasure Index Survey of 2,076 people:
To assess the quality of your sleep, see “A sample sleep • 47% of people who went on a vacation last year
history questionnaire,” page 36. like their job.
One of the most common sleep disorders is sleep • 71% of people who haven’t vacationed in the past
apnea, which affects about 18 million Americans. This five years don’t like their job.
is a condition in which people stop breathing momen- Source: Expedia Pleasure Index (2013).
tarily during sleep. This occurs when the upper airway
is blocked by excess tissue such as a large uvula, the
tongue, the tonsils, fatty deposits in the airway walls, diovascular disease, diabetes, obesity, cancer, depres-
nasal congestion, or a floppy rim at the back of the pal- sion, and serious gastrointestinal illnesses.
ate. People with sleep apnea tend to have smaller air- Even more challenging than steady night shift work
ways openings then those who don’t. A narrow airway is continually switching back and forth from day hours
makes obstruction all the more likely when airway to night hours. A 2011 study found that nurses who
muscles relax at the onset of sleep. rotated every couple of days from day to night shifts were
A potentially life-threatening lack of oxygen and less alert and more likely to make mistakes when check-
buildup of carbon dioxide, as well as increasing efforts ing medical orders and prescriptions than nurses who
to breathe, cause the sleeper to wake and gasp loudly worked a steadier schedule. In the 2012 Sleep in America
for air until blood oxygen levels return to normal. poll, almost half of train operators and a third of pilots
Some people with sleep apnea repeat this cycle hun- said their work schedules interfered with their ability to
dreds of times a night without being fully aware of it. get adequate sleep; half of both groups said they never got
They don’t realize how little sleep they’re actually get- a good night’s sleep on work nights.
ting and may routinely feel sleepy. If you work the night shift, try to avoid exposure to
If you suspect that you have sleep apnea, talk with sunlight on the way home (which will cue your body
your doctor about having a sleep study. If you have to wake up) or wear sunglasses if it’s already light out.
sleep apnea, the best treatment is usually the use of a Sleep in a very dark room or wear a sleep mask. Give
CPAP (continuous positive airway pressure) machine. yourself a few days to switch over to the new sched-
ule—it takes time, just as it does when you change time
zones. Finally, as you adjust, try to sleep and wake at
Shift work the same time each day, which can improve the quality
About one-fifth of Americans work nonstandard hours, of your slumber and reduce fatigue.
according to the U.S. Bureau of Labor Statistics. Odd
work schedules often go against the body’s natural bio-
logical rhythms and can even pose a health risk. In Overwork
addition to causing fatigue, changes in your work-sleep Overwork is another common cause of persistent lack
schedule in the short term can lead to irritability, trou- of energy. Americans work long hours, particularly if
ble concentrating, slower reflexes, accidents, stomach work at home is added to that in the workplace. Dur-
upset, diarrhea, constipation, and heartburn. Over the ing the 1990s, people added an average of 36 hours of
long term, night shift work can increase the risk of car- work, or nearly a full week, to their work year. Small
A sample sleep history questionnaire
In order to better understand your sleep habits, your doctor may ask you some of the following questions during an
evaluation for a sleep problem. You may find it helpful to write down your answers to these questions and bring the
completed questionnaire to the exam so you and your doctor can discuss it.
1. What bothers you most about your sleep habits? 12. Do you have physical aches and pains that interfere
2. How long have you had trouble sleeping, and what do with sleep?
you think started the problem? Did it come on suddenly? 13. Do you often have indigestion at night?
3. How would you describe your usual night’s sleep? 14. Do you ever feel discomfort or a fidgety sensation in
4. What time do you go to bed, and when do you wake up? your legs and feet when you lie down? Do you have
to get up and walk around to relieve the feeling?
5. What’s your bedroom like?
15. Do you kick or thrash around at night?
6. What do you do in the few hours before bedtime?
16. Do you ever have trouble breathing when you lie down,
7. Do you follow the same sleep pattern during the week
or do you awaken because it’s hard to breathe?
and on weekends? If not, how are weekends different?
17. Does your bed partner or roommate mention that you
8. How well do you sleep on the first few nights when
snore loudly or gasp for air at night?
you’re away from home? At home, do you sleep better
in your bedroom or in another room in the house? 18. Do you ever awaken with a choking sensation or a sour
taste in your mouth?
9. Do you fall asleep at inappropriate times or places?
19. Do you wake up with a headache or with cramps in
10. Do allergies or nasal congestion bother you at night?
your legs?
11. What medications or drugs (including alcohol and
nicotine) do you use? Have you ever taken sleep 20. How have you been feeling emotionally? Does your
medications? If so, which ones? life seem to be going as well as you would like?
wonder that a study by the Families and Work Institute to making you feel as if someone just cranked up the
found that a third of employees in the United States heat, hot flashes often leave you flushed and soaked
said their work drains them so much that they have with perspiration. Not surprisingly, hot flashes that
little energy left over for their personal or family life. occur when you’re sleeping (sometimes called night
Overwork isn’t limited to the time spent working sweats) can awaken you many times during the night.
and commuting. There’s also the “second shift” of meals Even if your hot flashes don’t wake you up, they can
and household chores, as well as social obligations and still disrupt your sleep. And a night of insufficient or
the responsibility of caring for an aging spouse, parent, poor-quality sleep can make you feel fatigued, lethar-
or young children. This second shift is usually longest gic, or sleepy the next day, not to mention irritable
for women, who generally shoulder more of the home and moody.
and family responsibilities even when they work full- Hot flashes eventually stop, usually within three to
time (see “Caring for a family member,” page 37). five years and sometimes sooner. In the meantime, there
are some behavioral changes you can make to reduce
the frequency and intensity of hot flashes, especially at
Menopause night. One is regular practice of a yoga breathing tech-
The hormonal changes that occur during the years nique called paced respiration, in which you breathe
leading up to and following menopause can have a deeply and slowly for several minutes. (You can also try
profound effect on sleep and, as a result, can contrib- it during a hot flash, to lessen its duration.) Weight loss
ute to fatigue. The most common menopausal symp- has also been shown to be effective. Other strategies can
tom is hot flashes, which affect between 75% and 90% help you deal with hot flashes when they occur. Dress-
of women undergoing natural menopause. In addition ing in layers during the day, so that it is easy for you to
remove clothing when you start to feel hot, helps many Just because you’re using a medication that can cause
women, as does keeping a fan or glass of cold water fatigue doesn’t necessarily mean that it’s causing your
at the ready. And using a Chillow (a pillow filled with fatigue. Second, if the drug is the cause of your sleepi-
cool water) or wearing moisture-wicking pajamas may ness or fatigue, your doctor may be able to prescribe
reduce the impact of night sweats on your sleep. another medication that won’t have the same effect.
If lifestyle changes don’t offer adequate relief, talk If there’s no available substitute, you might be able
to your doctor about whether medication may be to reduce the side effects by taking the medication at
right for you. The most effective treatment for reduc- a time of day when drowsiness or fatigue is less of a
ing hot flashes is hormone therapy. Studies show that problem, such as in the evening. For example, people
short-term hormone therapy improves sleep quality in with allergies can often take an oral antihistamine at
women suffering from night sweats and other meno- night, when its sleep-inducing effect isn’t a problem,
pausal symptoms. Because studies have revealed risks and control symptoms during the day with a nasal
of taking hormone therapy for an extended period, corticosteroid spray, such as budesonide (Rhinocort,
experts recommend taking hormones at the lowest Pulmicort), which doesn’t cause drowsiness.
effective dose for the shortest possible duration, to
minimize the potential risks.
If you can’t or don’t want to take hormone therapy, Alcohol
there are other hormonal and nonhormonal options, Alcohol can cause fatigue in two ways. First, as a seda-
including birth control pills, antihypertensives, and tive, it depresses the central nervous system. So drinking
the pain and seizure drug gabapentin (Neurontin). wine, beer, or hard liquor during the day can make you
Some antidepressants can also diminish the intensity feel drowsy or lethargic. If you didn’t sleep well the night
of hot flashes. before, even one drink can make you drowsy, espe-
cially if you drink during one of your usual low-energy
times—for example, midafternoon or late evening.
Medications Second, though a nightcap may make you feel
Hundreds of over-the-counter and prescription drugs drowsy at first, alcohol has delayed effects that can
can cause daytime drowsiness or fatigue. The most interfere with sleep. Several hours after drinking,
common classes of drugs associated with such side alcohol raises the body’s level of epinephrine, a stress
effects are antihistamines, blood pressure medications, hormone that increases the heart rate and generally
antibiotics, antidepressants, and anti-anxiety drugs. stimulates the body, which can result in nighttime
Drugs can cause sleepiness or fatigue in several awakenings. Indeed, alcohol may account for 10% of
ways. Some medications, such as antihistamines for chronic insomnia cases. Alcohol can also interrupt
allergies and colds, do so by depressing the central sleep by relaxing throat muscles, thereby worsening
nervous system. Others initially act as stimulants, nocturnal breathing problems and causing sleep apnea.
but ultimately leave you tired because they keep you It also may disrupt sleep by causing the need to urinate
awake at night. Among these drugs are theophyl- during the night. So while a drink before bedtime may
line, used to treat asthma and other upper respiratory make it easier to fall asleep, it may cause you to awaken
problems, and nicotine patches to help smokers quit. more easily and to spend less time in deep sleep.
Still other medications can cause muscle weakness,
including certain drugs that normalize an irregular
heartbeat (anti-arrhythmic agents). Caring for a family member
If you’re taking a drug that is known to cause Perhaps you are among the one in five American
drowsiness or fatigue, don’t stop without talking with adults helping an elderly or disabled family member
your doctor. First, not all drugs that can cause such with the daily tasks of life. The spectrum of tasks that
side effects do so in every person who takes them. unpaid caregivers undertake is vast. It runs the gamut
Relief for the caregiver
Caregiving can drain your energy and lead to depression Look for shortcuts. Could cooking happen on certain days
and health problems. If you are a caregiver, you owe it to only? If a clean house is important to you, can you make your
yourself and the people you love to stay healthy, reasonably room an oasis of clean and calm while being less strict about
happy, and sane. The tips below are designed to help you other areas? Can you let some jobs slide or hire help to get
take care of yourself so you can regain your vitality. them done?
Ask for help. Tell friends and family the job is too much for Refuse to do it all. Consider outside services that may give
you alone. Ask them to help brainstorm solutions. Always you a little more time for yourself, such as adult day services
accept help when it’s offered. Some people will make once or twice a week, or online grocery shopping. Can other
specific offers of help. You can encourage others to choose family members help pay for these services?
from a list you create of what’s needed or assign jobs you’ve Quell your guilt. Caregiving attracts guilt like a magnet
matched to their capabilities. pulls iron filings. There’s always something else you could be
Tap into religious communities. A religious or spiritual doing or should have done. But odds are good that you do
community can be a strong source of assistance if you or the a great deal. Pat yourself on the back for all you give; don’t
person you are caring for belongs to one. excoriate yourself for failing to give more.
Try a support group. Many organizations, hospitals, health Eat well. Include plenty of vegetables and fruits in your diet,
care plans, and religious groups offer support groups for and choose whole grains over refined-grain products. Limit
caregivers. Support groups are a good place to blow off or cut out unhealthy fats and too many sweets. Keep healthy
steam and share ideas with people who are facing similar snacks available, like air-popped popcorn or fruit.
situations. Stay active. Frequent exercise delivers proven health ben-
Lean on friends. Friends who listen—and offer advice only efits, such as lowering cholesterol and blood pressure. Try to
when you ask directly—are invaluable. Try to choose people get 30 to 60 minutes of moderate exercise a day, most days
who aren’t judgmental. Ask outright if you can use them as of the week.
a sounding board whenever the need arises. Enjoy yourself. Listen to music you like, enjoy a luxurious
bath, take a yoga class, do an activity you enjoy, or go out
Bundle errands. Make a weekly master list of everything
to dinner. Regular time off can renew your spirit and energy
that needs to be done, including appointments, shopping,
and remind you that you’re neither invincible nor completely
drugstore runs, trips to the gas station, and other errands.
irreplaceable.
Dole out simple tasks, if possible, or do as much as you can
in one time slot. Stay connected. Catch up with friends by phone or e-mail.
Establish a weekly walk with a friend or an occasional lunch
Clear your schedule. Set aside time to spend with a
or movie.
partner or family. Start small—just one evening a week or
breakfast out together if you’re caring for someone in your Ease stress. Take time to alleviate stress. Learn meditation
home—and add to it when you can. Always let the answer- or other relaxation techniques. See the stress-relieving tips
ing machine pick up calls during certain hours. and exercises in “Control stress,” page 26.
from grocery shopping, cooking, and cleaning house adult caregivers in the United States suffer from emo-
to helping with baths or personal hygiene or provid- tional and physical stress, which can lead to fatigue.
ing hands-on medical care. As the very embodiment If you are a family caregiver, you frequently act
of love and commitment to others, caregiving is one with someone else’s happiness and health in mind. But
of the most worthwhile jobs you may ever undertake, for the sake of your own health, try to care for yourself
but it can be exhausting and cause undeniable strain. as well (see “Relief for the caregiver,” above). For start-
About six in 10 family caregivers juggle work ers, take a break once in a while to spend time with
responsibilities while caring for someone else. And friends or on activities that make you happy. Check
caregiving itself amounts to a part-time job: the aver- with your employer about what resources might be
age caregiver puts in 21 hours of “helping time” per available to you. Try to find ways to relieve physical
week. Perhaps not surprisingly, many of the 44 million and emotional stress.
Various diseases that cause fatigue
host of illnesses can also cause fatigue, from psychosis, melancholic depression, substance abuse,
A chronic fatigue syndrome and fibromyalgia to
anemia, heart failure, multiple sclerosis, and chronic
dementia, or anorexia nervosa/bulimia.
The symptoms of CFS tend to wax and wane, but
infections, and hormonal disorders. most people remain impaired to some degree, even
on their good days. Unlike other causes of persistent
fatigue, which come on gradually, CFS often appears
Chronic fatigue syndrome suddenly, with an infectious-like illness (having symp-
According to the Centers for Disease Control and toms such as fever, sore throat, or aching muscles).
Prevention, about one to four million adults in the
United States suffer from chronic fatigue syndrome CFS and depression
(CFS), though it sometimes occurs in teenagers and Some doctors have questioned whether CFS is a form
younger children. The condition is about twice as of psychiatric illness, particularly depression. But
common in women as in men. The causes of CFS are most people with CFS have no history of psychiatric
still unknown, and there is no accurate diagnostic test. illness in the years before developing CFS, and a sub-
However, scientists have found abnormalities in the stantial number—25% to 50%—don’t develop depres-
brain and peripheral nervous system, in the immune sion even after the onset of their illness.
system, and in energy metabolism in people with CFS. There is other evidence that CFS is not a mani-
festation of depression. For example, certain brain
CFS: A group of symptoms hormone levels that are often seen in people with
CFS is defined by a set of symptoms. The most widely depression are not seen in people with CFS. Also, one
used definition of CFS was created by a group of experts, well-known study found that the antidepressant fluox-
under the leadership of the CDC. Specifically, CFS is etine (Prozac) did not relieve either fatigue or depres-
characterized by severe and debilitating fatigue that lasts sion in patients with CFS.
for six months or longer and is not relieved by rest, plus
at least four of the following for at least six months: Explaining CFS
• impaired memory or concentration CFS affects many parts of the body, including the ner-
• sore throat vous system, the immune system, and the metabolic
• swollen glands in the neck and under the arms process.
• pain in muscles ■ The brain. Many studies indicate that the symp-
• pain in multiple joints, without redness and toms of CFS are most likely caused by abnormalities
swelling in the brain, particularly in a part of the brain called
• headaches that are different in some way from any the limbic system. These differences in the brain have
experienced before turned up on imaging tests, such as magnetic reso-
• tiredness even after sleeping nance imaging (MRI), and in studies of various brain
• exhaustion following physical exertion. hormones conducted on people with CFS. Several
In addition, the diagnosis of CFS can be made studies find that patients with CFS also have variations
only if a person does not have another active medi- in genes that affect the function of the limbic system.
cal condition that could cause chronic fatigue (such ■ The autonomic nervous system. The autonomic
as anemia, cancer, or multiple sclerosis), nor any nervous system is the part of the nervous system
that controls vital involuntary body functions such has not been proven that any of these infectious agents is
as blood pressure, heartbeat, and body temperature. the cause of the persistent symptoms of CFS. Also, there
Many patients with CFS show a tendency for the are cases of CFS that do not start with an apparent infec-
blood pressure to drop and the heartbeat to race when tion. Most experts think it is unlikely that CFS is caused
they stand up and remain on their feet after sitting or by a single novel infectious agent, in the way that AIDS
lying down. Doctors are testing various medications is caused by a single kind of retrovirus (HIV).
that might correct this condition.
■ Pain sensitivity. The body has built-in mecha- Treating CFS
nisms for reducing pain. The brain makes natural Some people with CFS eventually recover: about 50%
chemicals called endorphins that are as potent as nar- or more of children, but only 15% to 40% of adults.
cotic pain medicines. The brain and spinal cord have For others, certain treatments can help relieve the
mechanisms for inhibiting pain signals that travel symptoms. If you have been told by a doctor that you
from other parts of the body to the brain. The body have CFS, a combination of the following strategies
also has natural mechanisms for reducing pain sensi- may prove helpful.
tivity during exercise. In patients with CFS, it has been ■ Set priorities. Make a list of the things that you
shown that all of these mechanisms are defective. As a want to have more energy to do, and eliminate as
result, people with CFS feel painful stimuli more eas- many nonessential activities and obligations as you
ily. Why people with CFS have this “central sensitiza- can. The goal is to conserve your energy for the most
tion” to pain remains unknown. important activities in your life. At the same time,
■ The immune system. Various parts of the guard against becoming too passive. Push yourself to
immune system are chronically activated in CFS, as your limits, and trust your body to know when you’ve
if the immune system is engaged in a battle against reached those limits.
something it perceives to be foreign. However, there ■ Exercise. An exercise program in which you
is no evidence of an immune system deficiency that gradually increase your activity level can be very effec-
would make people with CFS especially vulnerable to tive in reducing the severity of symptoms. Choose
infection, such as occurs with AIDS. exercise that is light enough that it doesn’t cause
■ Energy metabolism. Every cell in the body makes exhaustion, but challenging enough that it’s invigorat-
the energy it needs to live and perform its function. ing. A review by the Agency for Healthcare Research
In CFS, there appear to be irregularities in cellular and Quality found that exercise may help relieve
energy production and the function of the mitochon- fatigue and improve quality of life for people with
dria—the tiny “power packs” inside every cell where CFS. As your stamina increases, step up the intensity
energy is made. of your exercise regimen or the time you devote to it.
■ Oxidative stress. Oxidants, also known as free ■ Cognitive behavioral therapy. This type of psy-
radicals, are unstable oxygen molecules that damage chotherapy helps you identify and change negative
cell membranes, proteins, and DNA. As the mito- thoughts and behaviors and can reduce symptoms.
chondria generate energy, they produce oxidants as Cognitive behavioral therapy (CBT) requires an expe-
a chemical byproduct. However, the body produces rienced therapist. Combining CBT with exercise may
nutrients and enzymes—known as antioxidants— yield better results. One study showed that CBT with a
that help block or repair such damage. In CFS, there highly experienced therapist, alone or combined with
appears to be a state of “oxidative stress” in which lev- graded exercise therapy, helped improve level of func-
els of oxidants outstrip the levels of antioxidants. tion in many patients. Some smaller studies have not
■ Infections. CFS can follow an infection from which reported clear improvement.
people usually recover promptly, such as infection with ■ Tricyclic antidepressants. Low doses of a tricyclic
Epstein-Barr virus, human herpesvirus-6, parvovirus, antidepressant (such as amitriptyline) seem to improve
and the bacterium that causes Lyme disease. However, it the quality of sleep, reduce pain, and increase energy.
As yet, no scientific studies have been conducted of this bottom of the neck tends to be the most painful. Appar-
treatment in patients with CFS, but studies have found ently, the musculoskeletal pain of fibromyalgia reflects
a clear benefit from low-dose tricyclics in patients with a heightened sensitivity to pain rather than muscular
a similar illness, fibromyalgia (below). problems. People with fibromyalgia appear to have dif-
■ Other medications. If infectious causes of CFS ferent levels of pain-sensing chemicals in the brain and
are proven, it is likely that some of them could be spinal cord than healthy individuals do. One example
treated with available antibacterial and antiviral is substance P, a neurotransmitter that helps transmit
drugs. However, at this time no such treatments are pain signals to and from the brain.
recommended.
The headaches, joint pain, and muscle pain that Treating fibromyalgia
characterize CFS can be relieved with nonsteroidal Given the similarity between fibromyalgia and CFS,
anti-inflammatory drugs (NSAIDs), such as ibupro- it’s not surprising that, in many cases, the same
fen (Advil, Motrin) or naproxen (Aleve), or another treatments are helpful for both. Heat and massage
over-the-counter painkiller, acetaminophen (Tylenol). can relieve musculoskeletal pain in the short term.
There is some evidence that fish oil capsules (3,000 mg Light- to moderate-intensity aerobic exercise—such
per day) may also help reduce the symptoms of CFS. as swimming, walking, biking, or low-impact step
■ Experimental treatments. Among experimen- classes—can also reduce muscle pain and tenderness.
tal approaches currently being explored are medica- Start slowly and gently, and build in intensity as you
tions to treat abnormalities of the autonomic nervous become more fit and tolerant of exercise. It also helps
system, specific antiviral drugs, and drugs that target to perform strengthening and stretching exercises
the immune system. None of these treatments has yet twice a week to build muscle and improve flexibility.
been proved effective.
Figure 7: Tender points in fibromyalgia

Fibromyalgia
Fibromyalgia, which affects 2% to 4% of Americans,
is similar to CFS—so similar that many experts view
them as variants of the same condition. Both disor-
ders are more common among women; both produce
symptoms of unremitting fatigue and muscle pain;
and both can begin following an infection. But in
fibromyalgia, pain, more than fatigue, is the predomi-
nant symptom.
People with fibromyalgia have many of the same
abnormalities of the immune system, endocrine sys-
tem, and nervous system found in those with CFS.
However, some studies have found that, in some tests,
the abnormalities within these systems differ in peo-
ple who have fibromyalgia compared with people who
have CFS. Psychiatric problems, such as depression
and anxiety, are also more common in people with
Areas of tissue that become painful when pressed, particularly
fibromyalgia than in the general population. in the locations shown, are called “tender points.” They often
Fibromyalgia causes pain and stiffness in charac- develop in people with fibromyalgia, occur less frequently in
teristic spots called “tender points” (see Figure 7, at people with other conditions (such as chronic fatigue syndrome),
right). The area between the shoulder blades and the and occur rarely in healthy individuals.
Studies show that tai chi and yoga both may symptoms between the ages of 20 and 40, but a diagno-
be excellent exercises for people with fibromyalgia sis is often delayed because of the transitory nature of
because of their mind-body aspects. If you decide to the disease. People experience symptoms during “flare-
try either of these forms of exercise, however, be sure ups” that could last weeks or months, followed by a
to tell your instructor that you have fibromyalgia, so period of remission before symptoms reappear.
he or she can alert you to modifications for postures The most debilitating part of MS can be severe
that may be difficult or painful for you, and recom- fatigue. Even in the absence of muscular weakness
mend cushions, straps, bolsters, and even chairs to or fatigue, there is often central (brain) fatigue in
lessen the stress on your musculoskeletal system. which general exhaustion and difficulty concentrat-
One medication used to treat seizures—pregaba- ing is so great that it’s difficult to engage in any activ-
lin (Lyrica)—and two medicines that treat depression ity. While most people with MS have fatigue, other
and neuropathy—milnacipran (Savella) and dulox- symptoms can vary significantly from one person to
etine (Cymbalta)—are approved by the FDA to treat the next, depending on the location of affected nerve
fibromyalgia. Another antiseizure medication, gaba- fibers. Symptoms range from mild to severe and can
pentin (Neurontin), also appeared to improve sleep be long-lasting or short-lived. They may include
and reduce pain and fatigue in a significant number anything from vision problems to dizziness, trem-
of people participating in a study sponsored by the ors, bladder and bowel problems, and depression.
National Institute of Arthritis and Musculoskeletal Although most people recover completely between
and Skin Diseases (NIAMS); it is not approved for use flare-ups, some suffer progressive loss of function,
in fibromyalgia, but doctors are allowed to prescribe it which can lead to advanced muscle weakness, paral-
“off label.” Depending on your symptoms, one or more ysis, and blindness.
drugs may be required to relieve fibromyalgia. Imaging studies have shown a correlation between
The mechanism by which these drugs provide MS fatigue and reduced metabolism of glucose in
pain relief is unknown. However, researchers specu- certain areas of the brain responsible for processing
late that they work by blocking the release of mol- and motivation. This may explain why MS fatigue fre-
ecules involved in pain signaling. Side effects can quently includes both muscle and brain fatigue. Some-
include mild-to-moderate dizziness and sleepiness, times, however, fatigue in MS is the secondary effect
blurred vision, weight gain, dry mouth, and swelling of other symptoms. For instance, sleep disturbances
of the hands and feet. caused by bladder problems or nighttime spasms—
In addition, several randomized clinical trials have both common symptoms of MS—can lead to daytime
found that low-dose tricyclic antidepressants improve fatigue. Depression is also a contributor. Yet these
sleep, elevate mood, and relieve muscle pain in patients symptoms can’t explain the full extent of exhaustion
with fibromyalgia. A related drug, the muscle relaxant experienced by most MS patients.
cyclobenzaprine (Fexmid, Flexeril), has been noted to
treat muscle spasms and pain in fibromyalgia, although Recognizing MS fatigue
it is not approved by the FDA for this purpose. In some people who are unaware that they have MS,
fatigue is the most prominent initial red flag, because
other symptoms are minimal. How can someone tell
Multiple sclerosis if fatigue is a symptom of MS? There are certain char-
Multiple sclerosis (MS) is an unpredictable autoim- acteristics that set MS fatigue apart from the fatigue
mune disease affecting about 400,000 people in the typically experienced by healthy individuals. They
United States and about 2.1 million worldwide. With include fatigue that
MS, the body’s immune system mistakenly attacks • is more intense and debilitating than what healthy
myelin, the substance that surrounds and protects people experience after sustained physical, mental,
nerve fibers. Most people with MS experience their first or emotional exertion
• occurs on a daily basis for at least half of all days for ■ Medications. MS is one of the great success stories
six weeks or more in medicine, and numerous disease-modifying drugs
• is exacerbated by heat and humidity are now being marketed to treat it, including injectable
• tends to come on suddenly interferons (Avonex, Betaseron, Extavia, and Rebif)
• interferes with daily activities or duties and glatiramer acetate (Copaxone) and an infusible
• inhibits the ability to concentrate drug called natalizumab (Tysabri). Three oral drugs
• occurs early in the morning, even after a good have recently been released as well: teriflunomide
night’s rest. (Aubagio), dimethyl fumarate (Tecfidera), and fingo-
Usually fatigue is accompanied by another early limod (Gilenya). All of these medications may arrest
sign of MS—such as numbness and tingling in your the progression of the disease and disability, especially
arms, legs, or elsewhere in your body—but sometimes when they are started soon after diagnosis, but they do
it’s the only early indicator. If you are experiencing the not generally affect the symptom of fatigue.
symptoms above, talk to your doctor. He or she will be Short-term clinical trials have shown that amanta-
able to determine if you should be evaluated for MS. dine (Symadine, Symmetrel), a drug that helps restore
the balance of the neurotransmitters in people with
Ways to combat MS fatigue Parkinson’s disease, improves fatigue in patients with
Even if you have MS, there are ways to boost your MS. Other treatments that may improve fatigue are
energy levels. The best approach is a comprehensive • modafinil (Provigil) and armodafinil (Nuvigil),
plan that combines lifestyle changes and medications. drugs used to increase wakefulness in people with
Your doctor can help you identify factors contributing narcolepsy and shift work disorder
to your fatigue, so that you can minimize their impact. • methylphenidate (Concerta, Ritalin) and amphet-
The following are some general tips for increasing amine plus dextroamphetamine (Adderall), drugs
your stamina. used to treat attention-deficit hyperactivity disorder
■ Exercise. Regular exercise can improve car- (ADHD)
diovascular fitness and muscle strength and reduce • aspirin, perhaps because of an effect on quieting the
fatigue in people with MS. Be sure to start slow, and autoimmune attack on the brain and spinal cord that
stop if you become tired. A physical therapist can help is at the heart of MS
develop a regular exercise program tailored to your • progressive resistance training
fitness level and individual needs. • mindfulness training, which helps people with MS
■ Stay cool. MS fatigue can be exacerbated by heat. focus in a nonjudgmental way on their moment-to-
During warmer months, be sure to exercise in the moment experience (see “Practicing mindfulness in
morning or late evening when it’s coolest. So you don’t daily life,” page 20).
overheat, take frequent breaks and consider wearing a The over-the-counter supplement acetyl-L-carni-
cooling vest. tine has been proposed as a treatment for the fatigue
■ Address sleep problems. Treat symptoms that of MS, but there are limited data on it as yet. In one
interfere with sleep, including spasticity (stiffness or small study, carnitine at a dose of 2 grams daily was
spasms in certain muscles) or urinary problems. Talk better tolerated and more effective than amantadine in
to your doctor about sleep medications. Also, see “Get reducing fatigue in people with MS. Another ongoing
a better night’s sleep,” page 25. study is expected to be completed by the end of 2013.
■ Adjust your routines. Plan ahead to bundle errands,
pace yourself, and conserve your energy. Talk to your
employer about reducing your workload, altering your Other neurological conditions
schedule, or working at home some of the time. An Fatigue can be an important problem with several
occupational therapist can help you simplify tasks at other neurological conditions besides multiple scle-
work and home that may be draining your energy. rosis: Parkinson’s disease, strokes, amyotrophic lateral
sclerosis (ALS, also called Lou Gherig’s disease), trau- if your deficiency stems from your stomach’s inability
matic brain injury, myasthenia gravis, autoimmune to absorb vitamin B12, that vitamin can be given by
neuropathies, muscular dystrophy, and postpolio injection. Whether it’s from iron deficiency or vitamin
syndrome. In these diseases, as in multiple sclerosis, B12 deficiency, the anemia and your fatigue should lift
the fatigue can be out of proportion to what would be within three to six weeks after beginning supplements.
expected to result from the neurological symptoms By the way, low levels of vitamin B12 that are not
(such as paralysis and uncoordinated movements). low enough to cause anemia can still cause depres-
The causes of fatigue in these neurological conditions sion, mood swings, and cognitive problems. If your
has not been determined. blood level is close to or below the lower limit of
normal, you might benefit from treatment with 100
micrograms (mcg) of vitamin B12 a day. People who
Other medical conditions are grossly deficient in the vitamin may need a larger
Fatigue is a symptom of numerous illnesses, from initial dose given by an injection.
minor infections such as colds to serious diseases such
as cancer and heart disease. It is a primary symptom Cancer
of the illnesses discussed in this section. Some of these Many different types of cancer can cause loss of
disorders cause fatigue directly, by sapping the body’s appetite and energy, even before the cancer causes
energy supply; others do so indirectly, as the immune other symptoms. Most likely, the fatigue is caused by
system attempts to fight off the illness. Either way, increased levels of cytokines—chemicals made when
once you get treatment or the infection subsides, your the immune system is fighting an infection or a can-
energy level should rebound. cer. While the likelihood of cancer is fortunately small
in a person with a recent loss of appetite and energy, it
Anemia is likely enough to warrant a visit to your doctor about
Anemia is a condition in which the blood has too few it. This is particularly true if you are losing weight
red blood cells and, thus, low levels of hemoglobin, without trying to, or have other worrisome symptoms
the protein inside red blood cells that delivers oxy- such as unexplained fevers, new pain someplace in
gen to tissues throughout the body. Anemia can lead your body, unusual lumps in your breast or testicles,
to fatigue because the cells of your body need oxy- or swelling of the lymph nodes in your neck, under
gen both to create ATP and to liberate energy stored your arms, or in your groin.
as ATP. A shortage of oxygen can therefore mean a
shortage of energy. Chronic infections
Anemia is a common condition, especially among Unlike acute infections such as a cold or flu, which go
women, and is most often caused by iron deficiency. away in a week or two, chronic infections can last for
But iron-deficiency anemia typically does not cause months or years. During that time, the body expends
fatigue unless it’s severe. Another form of anemia, large amounts of energy trying to overcome the infec-
known as pernicious anemia, results from a deficiency tion, which can leave you feeling lethargic and weak.
in vitamin B12; this causes the bone marrow to pro- The immune system mounts an attack on the infection
duce red blood cells that are larger and shorter-lived by unleashing a group of chemicals called cytokines.
than normal red blood cells, thereby reducing the The cytokines are known to cause exhaustion, possibly
number of oxygen-carrying cells. by increasing the production of stress hormones.
Anemia is easily diagnosed with a blood test, and Chronic infections that cause particularly severe
for most types, there are effective treatments. For fatigue include tuberculosis, Lyme disease, and any
example, anemia caused by a deficiency in iron or form of hepatitis. Each of these illnesses has effective
vitamin B12 can be cured with supplements of those treatments, and once treated, most people find that
nutrients. Generally, supplements are taken orally, but their energy level improves. However, a small frac-
tion of patients with Lyme disease, despite prompt Hypothyroidism has several causes. The most
diagnosis and adequate treatment, continue to expe- common is Hashimoto’s thyroiditis, an autoimmune
rience debilitating fatigue for months or years after- disease in which the immune system attacks the cells
ward. Some doctors prescribe long-term antibiotics of the thyroid, causing inflammation and cell destruc-
for these patients, on the theory that the bacteria that tion. Hypothyroidism can be diagnosed with blood
cause Lyme disease may not have been eradicated by tests that measure your levels of various thyroid hor-
the initial treatment. Whether that theory is correct mones. The most commonly measured of these is thy-
and whether such treatment is effective remain sub- roid-stimulating hormone (TSH). Hypothyroidism
jects of controversy. usually is treated with thyroid hormone replacement,
which provides synthetic versions of natural thyroid
Heart failure hormones. When the dose has been adjusted prop-
Heart failure occurs when the heart is unable to pump erly, thyroid hormone replacement is successful and
enough blood to meet the body’s needs. Insufficient energy levels are restored.
blood flow through the brain, kidneys, and muscles Interestingly, particularly in people over age 60,
can cause weakness and fatigue. Compounding the too much thyroid hormone (a condition called hyper-
problem, the failing heart works extra hard to pump thyroidism) also can produce fatigue—along with jit-
blood, using up more than its share of energy. teriness and weight loss despite a good appetite. This
Your doctor can detect heart failure through a condition, called “apathetic hyperthyroidism,” is often
physical examination and diagnostic tests. The dis- overlooked by doctors. It also can be diagnosed by the
ease can be controlled by a combination of appropri- TSH test.
ate medications and lifestyle changes, such as avoiding ■ Diabetes. Blood sugar (glucose) provides energy
salty foods. Depending on the person’s age and the to cells, but first it must get inside the cells to be con-
severity of the condition, treatment can, to some verted to a usable energy form. The pancreas makes
degree, relieve the fatigue. insulin, which helps transport sugar into cells. In type
1 diabetes, the pancreas doesn’t make enough insulin.
Hormonal disorders In type 2 diabetes, the pancreas initially makes more
Hormones, chemicals produced by glands, are respon- than enough insulin, but the cells are resistant to it. In
sible for regulating a wide variety of physical func- either type of diabetes, not enough sugar gets into the
tions, including those associated with digestion, cells, impairing their ability to generate energy. Lack
reproduction, and blood circulation. Unusually high of physical and mental energy is among the many
or low levels of specific hormones are responsible for symptoms of diabetes.
several disorders that can be accompanied by fatigue, Diabetes can be diagnosed with a blood test that
including hypothyroidism, diabetes, and Addison’s measures levels of glucose in the blood. Although
disease. there’s no cure, a variety of treatments can help control
■ Hypothyroidism. This condition occurs when its symptoms, including medications that supply added
the thyroid gland does not produce enough thyroid insulin or increase the body’s insulin sensitivity, and
hormone. If you have hypothyroidism, you may feel lifestyle changes, particularly exercise and weight loss.
lethargic because your metabolism (the breakdown of ■ Addison’s disease. This rare hormonal disorder
food for energy) slows down. Almost 10 million peo- occurs when the adrenal glands don’t make enough of
ple in the United States have hypothyroidism. the hormones cortisol and aldosterone. Its most com-
The condition becomes increasingly common mon cause is an autoimmune disease in which the
with age, and it’s more common in women than in immune system produces antibodies that attack and
men. Women are five times more likely than men to destroy the outer layer of the adrenal glands, reduc-
experience hypothyroidism, according to the Ameri- ing hormone production. Symptoms develop gradu-
can Association of Clinical Endocrinologists. ally and include tiredness and weakness, as well as loss
of appetite, nausea, and dizziness, among others. If doctor’s appointment just to say you lack energy. But
severe or untreated, the disease can be fatal. The treat- don’t wait until you’re so tired you can’t get out of bed
ment is replacement hormones. before seeing a doctor. If you feel so weary or lethargic
that you can’t do particular activities as well or as often
Kidney disease as you once did, it’s important to make an appoint-
Various diseases that damage the kidneys may indi- ment. Perhaps you used to play tennis once a week
rectly cause fatigue by reducing production of eryth- without any problem, but now you get winded during
ropoietin (EPO), a hormone that stimulates the bone the game. Or maybe by the end of the day you often
marrow to make and release red blood cells. The kid- feel too tired to cook dinner or go out to a movie.
neys produce most EPO in your body, so if kidney These are good reasons to see a doctor.
function is impaired, you could develop anemia and Start with your internist or family doctor to find
the accompanying fatigue. out if you have an underlying medical or psycho-
Your doctor can diagnose most kidney diseases logical illness. Because fatigue is a characteristic of
with simple blood and urine tests. In many cases, your many illnesses, you should describe your symptoms
fatigue will be remedied once the underlying kidney in detail to help your doctor narrow down the possi-
problem is treated. If you have chronic kidney disease, ble causes. How, exactly, does the fatigue feel to you?
the first step in treating anemia is usually iron supple- Do you have trouble concentrating? Are you mentally
ments, which enable the EPO you produce naturally fuzzy—for example, do you take longer to think of
to promote production of red blood cells. If this is words or compute simple math problems than you
not sufficient to keep your hemoglobin levels normal, used to? Do you tire more quickly? Do certain activi-
you may be eligible for injections of a synthetic form ties take more effort than they used to? Answers to
of EPO. Particularly for people who are very anemic these questions indicate how severe your fatigue is
(such as those undergoing dialysis for kidney dysfunc- and whether it mainly involves muscle fatigue, cen-
tion), an analysis of multiple studies published in 2012 tral fatigue, or both.
confirmed that injections of EPO increase hemoglo- Be prepared to tell your doctor which activities
bin levels and improve fatigue. Talk with your doctor you’ve had to limit. For example:
about which options are best for you. • You used to enjoy going out to dinner and the the-
ater with friends, but now you can’t stay awake dur-
Mitochondrial disorders ing an evening performance.
Mitochondria produce ATP, the energy molecules that • You no longer wake up feeling refreshed, even after
power all of the chemical reactions inside a cell. There you’ve slept all night.
are rare diseases of the mitochondria that produce • When you exercise, your muscles feel achy and
many severe symptoms, including brain and muscle weak in less time than they once did.
fatigue. In the past 10 years, research has revealed that • You’ve done the newspaper crossword puzzle for
more subtle abnormalities of the mitochondria may years, but now your mind wanders, and you lose
also be important in many major diseases, and may interest before finishing it.
also produce brain and muscle fatigue. How com- This information yields further clues to the nature
monly such subtle mitochondrial abnormalities cause and severity of your fatigue. Timing is also important.
fatigue, and what treatments might counteract these Tell the doctor when you started noticing a decrease in
abnormalities, are areas of active research. your physical or mental energy level. Was the change
gradual or sudden? When fatigue involves stress, over-
work, or psychological problems, it usually comes on
When to see a doctor gradually. However, when the cause is chronic fatigue
Even though fatigue is one of the most common medi- syndrome, fibromyalgia, or a side effect of medication,
cal complaints, you may feel hesitant about making a fatigue often starts suddenly. Did the onset of fatigue
coincide with any other significant change in your life: physical examination, and the results of your tests—
Had you been ill? Did you have an injury? Did you and compare this evidence to the possible causes. Dis-
start taking a new medication? Was there a death in eases and conditions that do not fit your case will be
the family or among your friends? Are you under an discarded, and further testing may be done to exam-
exceptional amount of stress? Your symptoms could ine the diseases that might fit your case. Your primary
be related to any of these factors. care physician can easily treat some conditions, such
Also, make sure to tell your doctor about any other as anemia and diabetes. Others will require the care of
symptoms you might be experiencing. Give details a specialist, for example, a psychiatrist for depression
about when the different symptoms began and whether or a cardiologist for heart disease.
they started together or at different times. Mention For most people suffering from fatigue, however,
physical as well as emotional symptoms. Do you get out a firm diagnosis can’t be made. In such cases, persis-
of breath easily? Do your muscles or joints ache? Do you tent fatigue may be due not to an illness, but rather
have trouble sleeping? Are you feeling unusually sad or to some aspect of a person’s daily life—stress, over-
anxious? Different symptoms accompanying fatigue work, poor sleep habits, overeating, and other issues
suggest different causes. For example, feeling blue and we’ve discussed in this report—or some combination
having trouble sleeping are two signs of depression. of these.
Shortness of breath can be a sign of heart disease. No matter which constellation of causes is the root
Diagnosing the cause of fatigue really amounts to a of your problem, you can find treatments and practi-
process of elimination. Piece by piece, your doctor will cal strategies that can help restore your energy by fol-
review the evidence about you—your symptoms, your lowing the advice in this report. Rest assured.
Resources
Organizations This health care professional organization provides information
about chronic fatigue syndrome, fibromyalgia, and other causes of
American Lyme Disease Foundation
persistent fatigue and pain. Information about scientific studies is
P.O. Box 466
available on the website.
Lyme, CT 06371
www.aldf.com National Fibromyalgia Research Association
This private organization offers reputable information on the P.O. Box 500
prevention and treatment of Lyme disease and other tick-borne Salem, OR 97308
infections. 503-315-7257
www.nfra.net
Caregiver Action Network
This nonprofit activist organization provides information about
10400 Connecticut Ave., Suite 500
fibromyalgia, including updates on scientific research, links to
Kensington, MD 20895
patient organizations, and suggested books and other resources.
301-942-6430
caregiveraction.org National Multiple Sclerosis Society
The leading family caregiver organization, formerly known as 773 3rd Ave., 3rd Floor
the National Family Caregivers Association, offers information New York, NY 10017
to a broad spectrum of the more than 65 million Americans who 800-344-4867 (toll-free)
are caring for loved ones. The nonprofit organization is free to www.nationalmssociety.org
join and offers many educational resources on caregiving topics, This nonprofit group provides the latest research information on
online forums, and peer support. MS, support groups and activities in their 50 state chapters and
online, and resources for coping with MS.
Centers for Disease Control and Prevention (CDC)
1600 Clifton Road National Sleep Foundation
Atlanta, GA 30333 1010 N. Glebe Road, Suite 310
800-232-4636 (toll-free) Arlington, VA 22201
www.cdc.gov/cfs 703-243-1697
The portion of the CDC’s website devoted to chronic fatigue www.sleepfoundation.org
syndrome includes information about diagnosis and treatment, This foundation conducts research on sleep and sleep disorders
help with finding support groups, updates on research, and and provides information on a wide variety of sleep topics,
summaries of peer-reviewed articles on chronic fatigue syndrome including issues related to menopause. The website features an
by experts in the field. interactive sleep diary, as well as links to sleep centers by state.
CFIDS Association of America
P.O. Box 220398 Special Health Reports
Charlotte, NC 28222 Exercise: A Program You Can Live With
704-365-2343 L. Howard Hartley, M.D., and I-Min Lee, M.B., B.S., Sc.D.
www.cfids.org (Harvard Medical School, 2010)
This association offers information about symptoms, diagnosis, This step-by-step guide describes how to start and maintain
and therapies for chronic fatigue syndrome, as well as advice on an exercise program that suits your abilities and lifestyle. You’ll
insurance, workplace issues, and related legal matters. The website find advice on being a savvy consumer when it comes to fitness
provides a reading list and a listing of support groups by state. products, as well as useful tools and tips designed to help make
exercise work for you.
Fibromyalgia Network
P.O. Box 31750 The Harvard Medical School 6-Week Plan for Healthy Eating
Tucson, AZ 85751 Teresa Fung, R.D., Faculty Editor, and
520-290-5508 Kathy McManus, M.S., R.D., Nutrition Editor
www.fmnetnews.com (Harvard Medical School, 2013)
This organization’s website offers free patient and health care It’s not easy to overcome such ingrained habits as diet. But this
provider brochures about fibromyalgia and related disorders such step-by-step plan helps you transition to a healthy diet by making
as chronic fatigue syndrome. Articles provide information on just a few dietary changes each week.
research, medications, coping strategies, and support groups.
Improving Sleep: A Guide to a Good Night’s Rest
International Association for CFS/ME Lawrence Epstein, M.D., Medical Editor
27 N. Wacker Drive, Suite 416 (Harvard Medical School, 2013)
Chicago, IL 60606 This report provides an authoritative discussion of the complex factors
847-258-7248 that can interfere with a good night’s sleep and lead to daytime
www.iacfsme.org fatigue. It also offers practical suggestions for improving sleep.
Resources
Stress Management: Techniques for Preventing and breathing exercises, cognitive restructuring, and guided imagery.
Easing Stress
Herbert Benson, M.D., and Aggie Casey, R.N., Medical Editors Understanding Depression
(Harvard Medical School, 2013) Michael Craig Miller, M.D., Medical Editor
This report teaches you how to identify triggers for stress and
(Harvard Medical School, 2013)
explains the ways in which stress affects your body. It also This report provides comprehensive, in-depth information on one
provides step-by-step instructions for a variety of stress-control of the main causes of fatigue. It includes the latest findings on the
techniques, including meditation, progressive muscle relaxation, underlying biology of depression and the most effective treatments.
Glossary
adenosine triphosphate (ATP): The molecule that carries energy nervous system and that regulates sleep, appetite, body tempera-
for all cells. ture, and other biological states.
anemia: A decline in the number of red blood cells or the amount insomnia: The inability to fall asleep or remain asleep long
of hemoglobin in the blood, which lowers the oxygen-carrying enough to feel rested.
capacity of the blood. insulin: The hormone that carries glucose from the blood into
central (brain) fatigue: A lack of concentration or alertness as the cells.
well as a sense of lethargy and loss of motivation; involves the melatonin: A hormone that induces drowsiness, produced by
central nervous system. the pineal gland as daylight turns to darkness.
chronic fatigue syndrome (CFS): A disorder characterized by at mitochondria: Often called the body’s energy factories, these
least six months of fatigue, together with impaired concentration small, threadlike structures within the cell’s cytoplasm are
or memory and other symptoms. where ATP, the energy molecule, is made.
circadian cycle: The biological clock that regulates sleep and multiple sclerosis (MS): An autoimmune disease in which the
waking and that controls the daily ups and downs of physiologic body’s immune system mistakenly attacks myelin, the sub-
patterns, including body temperature, blood pressure, and the stance that covers nerve fibers.
release of hormones.
muscle fatigue: Weakness you feel in your muscles when
epinephrine: A hormone released by the adrenal glands in you’ve tired them out.
response to a stressful event. It speeds your heart and breathing,
enabling you to respond quickly. Also called adrenaline. non-REM sleep: The type of sleep that includes deep sleep,
the period considered most important for preventing daytime
fatigue: A decrease in the ability to perform a physical or mental fatigue.
task. It includes muscle fatigue as well as central fatigue, which
originates in the central nervous system and influences the per- pineal gland: A gland located in the middle of the brain,
ception of fatigue. between the brain’s two hemispheres, that produces melatonin
in response to declining light.
fibromyalgia: A disorder characterized by pain and tenderness in
muscles and joints, as well as by fatigue. Similar in many respects REM (rapid eye movement) sleep: A period of intense brain
to chronic fatigue syndrome. activity during sleep, often associated with dreams. It is named
for the rapid eye movements that occur during this time.
glucose: A simple sugar that circulates in the bloodstream and
serves as a source of energy for cell metabolism. It’s formed sleep apnea: A sleep disorder in which a person repeatedly
mainly by the digestion of carbohydrates. stops breathing momentarily during sleep. This often causes
daytime drowsiness.
glycemic load: A measure of how much a particular food will
stimulant: A substance, such as caffeine, contained in some
raise your blood sugar. It takes into account both how much
foods or beverages that speeds up chemical reactions inside
sugar is contained in that food and how quickly that sugar is
cells and provides a boost of energy.
absorbed into your bloodstream.
stress: An innate survival response in which certain hormones
heart failure: A disorder that occurs when the heart is unable to
are released, increasing blood flow to the brain or heart. The
pump enough blood to meet the body’s needs. Insufficient blood
stress response leads to an energy surge, enabling a person to
flow can cause weakness and fatigue.
flee dangerous situations. Ongoing stress, however, can sap
hormones: Chemicals, produced by glands, that are responsible energy and damage health.
for regulating a wide variety of physical functions. Many can
suprachiasmatic nucleus: A small group of nerve cells, located
influence energy level.
in the hypothalamus, that controls the sleep/wake cycle and
hypothalamus: The part of the brain that controls the autonomic functions as the body’s internal clock.
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A Harvard Medical School Special Health Report

Boosting Your Energy

SPECIAL BONUS SECTION

Here’s what you CAN do Here’s what you CAN’T do

Licensing, Bulk, and Corporate Sales

Harvard Health Publications

Currently, fatigue cannot be measured scientifically. But advances in understanding the

Anthony L. Komaroff, M.D.

2 Boosting Your Energy w w w.h e a l th.ha r va r d.e du

www. h ealt h . h ar v a rd. e du Boosting Your Energy 3

Figure 2: When are you at your best?

Time of day Time of day

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6 Boosting Your Energy w w w.h e a l th.ha r va r d.e du

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8 Boosting Your Energy w w w.h e a l th.ha r va r d.e du

www. h ealt h . h ar v a rd. e du Boosting Your Energy 9

SERVING GLYCEMIC LOAD SERVING GLYCEMIC LOAD

Potato, baked 5 ounces 26 Pumpernickel bread 1 slice 5

Coca-Cola 12 ounces 25 Oranges 4 ounces 5

White rice 5 ounces 23 Peaches 4 ounces 5

Raisin Bran cereal 1 cup 21 Pears 4 ounces 4

Pasta 1 cup 20 Green peas 3 ounces 3

Medium glycemic load Carrots 3 ounces 3

10 Boosting Your Energy w w w.h e a l th.ha r va r d.e du

www. h ealt h . h ar v a rd. e du Boosting Your Energy 11

12 Boosting Your Energy w w w.h e a l th.ha r va r d.e du

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14 Boosting Your Energy w w w.h e a l th.ha r va r d.e du

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16 Boosting Your Energy w w w.h e a l th.ha r va r d.e du

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18 Boosting Your Energy w w w.h e a l th.ha r va r d.e du

mminent danger gives you a surge of energy. The

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20 Boosting Your Energy w w w.h e a l th.ha r va r d.e du

www. h ealt h . h ar v a rd. e du Boosting Your Energy 21

A 6-step plan to jump-start

22 B o o st in g You r Ene rg y w w w.h e a l th.ha r va r d.e du

w ww. h ealt h . h ar v a rd . e du Bo o sti ng You r E n erg y 23

syndrome or multiple sclerosis

first signs is a feeling of fatigue. the radio, or starting slowly on a

24 B o o st in g You r Ene rg y w w w.h e a l th.ha r va r d.e du

w ww. h ealt h . h ar v a rd . e du Bo o sti ng You r E n erg y 25

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ries. A seminal study published in

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money for charity? Created

Harvard biologist Edward O. Wil-

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Changing views of fatigue

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74 % occurs not in the muscles but in the brain. The motor

66 % impulse travels down the spinal cord and through a

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Depression or anxiety Figure 6: Causes of fatigue

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Spotting the symptoms of depression and anxiety

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