Fatigue and IBD

What is fatigue?

Fatigue is defined as a lack of energy, or exhaustion, which is out of proportion to the amount of physical activity we have done, with limitation of daily activities, and which is not relieved by rest. 

For those of us with IBD we know all too well what this feels like – struggling to lift our head off the pillow or to put one foot in front of the other, and even completing the simplest of tasks can feel like climbing a mountain.

Figures show that nearly 50% of patients with inflammatory bowel disease (IBD) experience fatigue. Despite this, as a symptom fatigue often goes under-recognized and untreated in IBD which can really affect our quality of life.

Lots of studies have shown that fatigue is associated with disease severity and below I discuss some of the reasons why we get fatigued in IBD and, for each one, what we can do about it.

Why do we get fatigued with IBD?

Inflammation

Inflammation may directly impact fatigue in IBD – put simply, inflammation puts stress on our bodies and causes the release of our stress hormone, cortisol, which has effects throughout our body, including our brain, resulting in fatigue. This helps to explain why we often feel more fatigued during a flare than when we are in remission. In addition, when inflammation is present the amount of energy we use when just doing nothing to be higher than it would normally be, again contributing to fatigue.

Controlling Inflammation in IBD

Controlling inflammation is really important - we know that fatigue in IBD is associated with how severe the disease is and its activity so reduce inflammation and work towards remission may help. Medication is important to help do this and finding the right one for you is vital. What we eat and the way we live (e.g. stress, movement) can also have an impact on inflammation so diet and lifestyle focus is an important component in recovery too.

Anaemia

Iron Deficiency Anaemia

Statistics show that about one third of patients with IBD have iron deficiency anaemia (IDA). We need iron for many roles in our bodies, one of them is to make red blood cells which transport oxygen around our bodies – if we don’t have enough, this can lead to fatigue.  

IDA in Crohns and Colitis can happen if we reduce the amount of iron rich foods we eat, if we have difficulty absorbing iron in the duodenum and upper jejunum (more common in Crohn’s Disease affecting these areas), and if we are bleeding from inflammation of the lining of the intestine - very common in Ulcerative Colitis. You can read more about iron in IBD here.

Macrocytic Anaemia

Macrocytic anaemia can be caused by vitamin B12 and folate deficiency and can also be linked to weakness and fatigue. Folate deficiency can be caused by methotrexate (MTX), low dietary intake of folate and difficulty absorbing folate. B12 deficiency can occur in Crohn’s that affects the ileum (ileitis), and with an ileal resection, as this is where these nutrients are absorbed.

Managing anaemia in IBD

Blood testing is really important in identifying whether you are deficient in iron, B12 or folate. Regular blood tests are recommended in IBD and if you have not had these nutrients checked for a while, ask your doctor to check them next time you have a blood test if you are experiencing fatigue.

If iron deficiency is detected, you will be prescribed iron injections or iron tablets to help correct this.

If B12 or folate deficiency is detected, you will be advised to supplement. If you have had more than 60 cm of ileum resected or have CD-related ileal inflammation which is impacting B12 absorption, you will often be prescribed B12 injections.

Preventing anaemia in IBD

Its very common in IBD for people to restrict food intake but this can be a problem and increase the risk of anaemia reoccurring. We get iron, B12 and folate from the foods we eat so diet can play a huge part in the long term management and prevention of anaemia in IBD.

Aim to include foods that contain iron daily, such as meat, fish, eggs, tofu, spinach, broccoli, dried apricots, and pumpkin seeds. Eating the plant sources of iron with some vitamin C containing foods can help absorption of the iron from these foods.

Foods that contain B12 include meat, fish, eggs, dairy and fortified foods. Anyone following a vegan diet may have to supplement with B12 but speak to your healthcare professional before taking any supplements.

Foods that contain folate, which should be eaten daily, include dark leafy greens - broccoli, brussels sprouts, spinach - asparagus, peas, chickpeas, liver (but avoid this during pregnancy), and fortified breakfast cereal.

Other Nutrient Deficiencies

Deficiency of other nutrients, both macro (protein, carbohydrates and fats) and micronutrients (vitamins and minerals) may also impact fatigue in IBD. Deficiencies can happen if we aren’t absorbing our food, if we have diarrhoea, if we don’t eat enough and if we don’t eat nutritious food. Removing food groups without proper guidance can also leave us open to deficiencies, for example, gluten-free foods can be deficient in calcium, iron, niacin, and thiamine unless they are fortified.

Deficiencies of vitamin B6, vitamin B12, folate, ferritin, and zinc have all been linked to increased disease activity which could have a knock-on impact on fatigue. Vitamin D deficiency, which is common in IBD, has also been linked with fatigue - you can read more about vitamin D and IBD here.

Managing and preventing deficiencies in IBD

Testing for deficiencies, and replacing the deficient nutrient, as well as ensuring you are consuming a nutritionally balanced diet is vital and could help to improve symptoms of fatigue. If you’re worried about your diet and need help a dietician or nutritionist, like me, can help you make sure you are getting all the nutrients you need.

Medication

Less commonly, fatigue can be a side effect of medications we take for Crohns disease and ulcerative colitis, such as azathioprine, mercaptopurine, methotrexate, vedolizumab and infliximab. Whilst steroids in the short term can increase energy and even cause insomnia, long-term use can cause fatigue. 

Management of Medications in IBD

This one is a bit more tricky as medications are an important part of the management of Crohns and Colitis but regular reviews of the medications you are taking is important. If all other factors have been ruled out as a cause for fatigue, a change in medication may be necessary if its hugely decreasing your quality of life. Any changes in medications must be discussed with your consultant.   

Sleep

Research shows that almost half of people with Crohns and colitis experience sleep disturbance, and this increases to 70-80% during relapses.

We know that sleep is vitally important for our health and we should be aiming for around 8 hours per night. Lack of sleep has been linked with worsening IBD symptoms, and can cause fatigue, reduce our quality of life and may increase the risk of a flare even in clinically inactive disease (3 times greater risk of relapse in patients with poor sleep).

Supporting sleep in IBD

I have written another article all about sleep and IBD, including 8 useful tips that you can find here.

You can find an interesting review paper here if you want to know more.

I have written a free e-book to help you find a way forward for your everyday life with Inflammatory Bowel Disease. Whether you are right at the beginning of your journey with IBD or have been living with your condition for years and feel like you have tried almost everything, there are things you can do everyday, beyond the medication you are taking, to help you take back control.

Disclaimer: All content found on the nalmclinic.com website, including: text, video, or other formats have been created for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your doctor, consultant or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.

We are all wonderfully unique and what works for one person may not work for another so please seek help and advice before changing your diet to work out the right way forward for you.