Dr. Sarah Vadeboncoeur, ND
Episode Summary
Why are you tired all the time even when you feel like you're doing everything right—and how do you know whether fatigue is caused by iron deficiency, insulin resistance, poor sleep, burnout, depression, perimenopause or something else?
In this episode of Girls Gone Wellness, Jeanette and Victoria speak with Dr. Sarah Vadeboncoeur, ND, a naturopathic doctor whose clinical focus is fatigue and host of The Fatigue Fixer podcast. The conversation explores fatigue in women, iron deficiency, vitamin B12 and vitamin D deficiency, hypothyroidism, Hashimoto's thyroiditis, insulin resistance, blood sugar, burnout, cortisol, adrenal fatigue, post-viral fatigue, chronic fatigue syndrome, perimenopause, menstrual-cycle fatigue, sleep, depression, nutrition, fasting, low-carbohydrate diets, exercise and supplements for fatigue. Dr. Vadeboncoeur's full name and ND designation were also confirmed from her professional website.
One of the first distinctions Dr. Vadeboncoeur makes is between being tired, fatigued and burned out. Feeling tired after being awake all day is normal. Fatigue or exhaustion becomes more concerning when low energy begins interfering with work, parenting, exercise, relationships or other daily activities. Burnout, as discussed in the episode, involves exhaustion alongside reduced work capacity and increasing mental distance, cynicism or negativity toward work.
When evaluating physical causes of fatigue, Dr. Vadeboncoeur discusses three major areas she investigates: nutrient deficiencies, thyroid function and metabolic health. In her practice, iron deficiency is a particularly common contributor in menstruating women, alongside vitamin B12 and vitamin D deficiency. She also discusses hypothyroidism and Hashimoto's thyroiditis, but notes that many patients who are convinced their thyroid is causing their fatigue ultimately have another explanation. Her metabolic assessment includes blood sugar and insulin because insulin resistance can be present even when blood glucose is still within a normal range.
The episode takes a detailed look at cortisol and “adrenal fatigue.” Dr. Vadeboncoeur does not consider adrenal fatigue a valid diagnosis and explains why burnout is not diagnosed using cortisol testing. She does, however, emphasize that cortisol is physiologically important for circadian rhythm, stress responses and maintaining blood glucose. Rather than immediately reaching for an “adrenal cocktail” or cortisol supplement, she focuses on fundamentals such as morning light exposure, regular meals, adequate sleep and stress management.
Why do so many people crash around 2 or 3 p.m.? Dr. Vadeboncoeur discusses the normal daytime decline in cortisol alongside inadequate food intake, decision fatigue and the enormous cognitive load of modern work. The conversation also addresses post-viral fatigue and chronic fatigue syndrome, including fatigue following COVID-19 and the association discussed between Epstein-Barr virus (EBV), mononucleosis and chronic fatigue syndrome.
Women's hormonal life stages also matter. The episode explores perimenopause fatigue, changing sleep, worsening PMS, mood symptoms and the mental load many women experience while simultaneously managing careers, children and aging parents. Menstrual-cycle energy changes are also discussed, including feeling more fatigued before and during a period and potentially more energetic approaching ovulation.
Sleep receives its own deep dive, including deep sleep, rapid eye movement (REM) sleep, sleep apnea, unrefreshing sleep and “wired but tired” insomnia. Dr. Vadeboncoeur explains why somebody can sleep seven to nine hours and still feel exhausted if another issue—such as nutrient deficiency, thyroid disease, depression, burnout or a sleep disorder—is present.
Finally, the episode challenges common wellness advice around fasting, low-carb diets, coffee, cardio, cortisol testing and supplements. Dr. Vadeboncoeur discusses regular meals, protein, fruits and vegetables and whole-grain carbohydrates as practical foundations for energy. Supplements including iron, vitamin B12, vitamin D, ashwagandha, rhodiola and saffron are discussed in context—not as replacements for addressing the reason someone is exhausted.
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What is the difference between being tired, fatigued and burned out?
Being tired is a normal physiological experience, particularly after being awake and active all day. Dr. Sarah Vadeboncoeur describes fatigue or exhaustion as low energy that begins interfering with normal activities such as work, parenting or social life. Burnout involves exhaustion plus reduced work capacity and increasing mental distance, negativity or cynicism toward work.
What are common physical causes of fatigue in women?
Dr. Vadeboncoeur commonly investigates iron deficiency, vitamin B12 deficiency, vitamin D deficiency, thyroid disorders and metabolic problems such as insulin resistance. She also discusses sleep disorders, depression, autoimmune illness, post-viral illness and perimenopause as potential contributors. The appropriate evaluation depends on the individual's history and symptoms.
Can iron deficiency cause fatigue?
Yes. Dr. Vadeboncoeur describes iron deficiency as one of the most common physical contributors to fatigue she sees in menstruating women. The episode emphasizes testing rather than automatically assuming fatigue is caused by stress, hormones or the thyroid.
Can you have insulin resistance with normal blood sugar?
Yes. Dr. Vadeboncoeur explains that blood glucose can remain within the normal range while the body is producing more insulin to maintain it. For that reason, she discusses evaluating both blood glucose and insulin when insulin resistance is clinically relevant rather than assuming normal glucose automatically rules it out.
Is adrenal fatigue a real diagnosis?
Dr. Vadeboncoeur does not consider “adrenal fatigue” a valid diagnosis. She explains that the adrenal glands do not simply become tired and stop producing cortisol; cortisol secretion is regulated through signalling involving the brain and adrenal glands. She also distinguishes adrenal-fatigue claims from established adrenal disorders and from burnout.
Does high cortisol cause fatigue?
Not all fatigue is caused by high cortisol. Cortisol normally rises and falls throughout the day and plays important roles in waking, stress responses, circadian rhythm and maintaining blood glucose. Dr. Vadeboncoeur rarely uses cortisol testing as her first step because the result often would not change the foundational strategies she recommends.
Why do I get so tired around 2 or 3 p.m.?
The afternoon energy slump can have several contributors. Dr. Vadeboncoeur discusses the natural daytime decline in cortisol, inadequate breakfast or lunch, running low on available fuel and decision fatigue from hours of work, emails, meetings, notifications and responsibilities.
Can a viral infection cause long-term fatigue?
Yes, post-viral fatigue is discussed as a real potential cause of persistent exhaustion. Dr. Vadeboncoeur notes that some people develop fatigue that begins around an infection and does not fully resolve, and she discusses chronic fatigue syndrome in relation to post-viral illness, including COVID-19 and previous Epstein-Barr virus (EBV) infection.
Can perimenopause cause fatigue?
Yes. Dr. Vadeboncoeur discusses fatigue during perimenopause as potentially related to hormonal fluctuations, changes in sleep, worsening PMS, mood changes and mental-emotional fatigue. She also emphasizes that midlife often comes with substantial career, parenting and caregiving demands that can add to exhaustion.
Does your menstrual cycle affect energy levels?
Yes, energy can fluctuate across the menstrual cycle. Dr. Vadeboncoeur discusses feeling more tired in the days before and during menstruation and potentially experiencing more energy as the period ends and hormones rise approaching ovulation. She does not recommend rigidly restructuring an entire exercise routine around cycle phases.
Why am I still tired after sleeping eight hours?
Getting enough hours of sleep does not guarantee that sleep is restorative. The episode discusses sleep apnea, restless legs, disrupted sleep quality, nutrient deficiencies, thyroid conditions, depression and burnout as possible reasons someone may sleep seven to nine hours and still wake unrefreshed.
What does “wired but tired” mean?
“Wired but tired” describes feeling physically exhausted while the brain remains too activated to fall asleep. Dr. Vadeboncoeur discusses stress, rumination, late caffeine, emotionally stimulating media and mistimed bedtimes as possible contributors. She emphasizes creating an evening environment that allows the brain to settle rather than immediately assuming cortisol needs to be tested.
Can fasting or a low-carb diet make fatigue worse?
Dr. Vadeboncoeur argues that both can worsen fatigue for some women. She describes prolonged fasting as an additional physiological stressor and emphasizes that carbohydrates provide an important source of energy, particularly for the brain and physical activity. Her general nutrition framework includes protein, fruits and vegetables and whole-grain carbohydrate sources.
Can depression cause fatigue?
Yes. Fatigue can be a major symptom of depression, but Dr. Vadeboncoeur explains that the relationship works in both directions: prolonged fatigue can also worsen mood because people lose the energy to participate in activities they enjoy. She distinguishes having low energy but still wanting to do things from depression that may also involve reduced interest, pleasure, motivation and desire.
What supplements are used for fatigue?
The episode discusses iron, vitamin B12 and vitamin D when deficiencies are present, as well as adaptogenic herbs including ashwagandha and rhodiola and the use of saffron in some patients. Dr. Vadeboncoeur stresses that supplements should support—not replace—nutrition, sleep, stress management, mental-health care and changes to circumstances contributing to exhaustion.
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This transcript has been edited for clarity and readability while preserving the substance of the conversation.
Jeanette
Welcome to Girls Gone Wellness, Dr. Sarah.
Dr. Sarah Vadeboncoeur
Thank you so much for having me.
Jeanette
Of course. We are so excited to have you here today.
This is a conversation we haven't actually talked about yet on the podcast, which is fatigue. It's such a common symptom that people experience, so we're really excited to get this information out to our listeners.
Dr. Sarah Vadeboncoeur
It's something I'm very passionate about talking about, so I'm really excited to have this conversation with you both today.
Victoria
Us too.
Tell us a little bit about how you got into naturopathic medicine and, specifically, your interest in fatigue.
Dr. Sarah Vadeboncoeur
I always joke that I knew nothing when I signed up for naturopathic school.
I always knew I wanted to be in healthcare. Like many of us, I originally thought I wanted to be a medical doctor.
The more I learned about health in my undergrad, the more I realized health was so much more than medicine and surgery and that there were so many lifestyle factors at play.
I happened to learn about naturopathic medicine almost by accident. I literally signed up because I thought, “That philosophy sounds interesting.”
It was a huge investment in both time and money, but luckily I made the right decision, and I absolutely love being a naturopathic doctor.
What brought me specifically into the fatigue space was that no matter what women were coming in with—and I see mostly women in my practice—almost all of them had fatigue as one of their concerns or symptoms.
I started to realize how prevalent it was and wanted to understand why women were so tired.
I've also struggled with fatigue myself.
I always joke that I feel like I should have more energy than I do. I feel like I do, quote-unquote, all the right things, which I think is how so many women feel.
They're saying, “I feel like I'm doing the right things. Why am I so tired?”
I can relate to that.
That's what started my journey of peeling back the layers and trying to understand why women are tired.
What I love about the work I do is that I'm often starting with the physical reasons women are tired.
Once we've dealt with those, there are often really important conversations to have about some of the mental and emotional reasons women are tired.
Then a big part of what I explore on my podcast is all the societal reasons we're tired.
You'll probably be upset to learn that there's going to be no simple answer.
But I think there's so much opportunity to explore your own health and your life if you're trying to have more energy and address fatigue.
That's something I love supporting women through.
Victoria
Absolutely.
I think fatigue is such an interesting area to focus on, especially in naturopathic medicine.
I'm not bashing the conventional system at all, but something like fatigue requires a lot of time and investigation. That's something we don't have enough of in the conventional system right now.
So many people just deal with it.
Or they see a doctor and it can feel like, “Here's an antidepressant. I don't really know what else to tell you.”
I think it's amazing that you've focused on such a massive topic but one that can really benefit people.
I don't actually know anyone else who specifically focuses on fatigue.
Dr. Sarah Vadeboncoeur
It's true, which is kind of shocking when you say it that way.
It's a really great entry point, and there are so many parts to it, which keeps me excited as a clinician too.
Victoria
You use the word “tired” too, so I want to establish this right off the bat because “fatigue” gets used a lot and it can be hard to differentiate.
What is the difference between fatigue, exhaustion, burnout and just being plain tired?
Dr. Sarah Vadeboncoeur
Being tired is normal, and I think that's really important to say.
Because we live in such a productivity- and hustle-focused culture, a lot of us have completely unrealistic expectations about how much energy we should have.
You should get tired.
Once you've been awake for 10, 12 or 14 hours, you're going to be tired, and that's normal.
If we didn't get tired, we'd have a really hard time falling asleep.
Being tired at the end of the day or having an occasional day when you're tired is perfectly normal. It doesn't mean there's anything wrong.
When we start talking about fatigue and exhaustion, that's typically when you're so tired that it's starting to interfere with your ability to do your normal activities.
Maybe you're struggling to get through your workday.
Maybe you're struggling to parent your kids at night.
It's starting to interfere with the things you want to do throughout the day.
There are different types of fatigue and exhaustion.
There can be physical causes, which we'll get into, and there can also be mental-emotional fatigue.
Burnout is a little different because it's not like iron deficiency where we can give you a blood test.
Burnout is usually the result of workplace stress that hasn't been successfully managed.
There are three specific things we tend to see.
One is fatigue or exhaustion.
In addition, you start seeing a reduction in your capacity to fulfill your job.
There's also often mental distancing from work, where people become negative or cynical.
They may start thinking, “What's the point? Why am I doing this work? I don't really get it.”
Burnout is typically more workplace-specific, although there is also something called parental burnout, where parenting becomes a major source of the exhaustion.
So being tired is normal.
Fatigue and exhaustion are starting to get in the way of your life.
Burnout is usually a situation where work is draining your energy in a way that makes it really difficult to continue doing that job.
Victoria
Burnout is a real diagnosis too, right?
Dr. Sarah Vadeboncoeur
Yes.
Jeanette
Do you find that patients come in saying, “I'm so burned out,” but after you assess them, they're actually more in a fatigued or exhausted state?
Dr. Sarah Vadeboncoeur
It really depends.
Just a couple of days ago, I had a patient use the word burnout.
When I prompted her, she said, “I don't know if I'm actually burned out. I just kind of said that.”
Then we assessed her, and she genuinely met the criteria for burnout.
These words get thrown around a lot.
A big part of my job is helping someone figure out where the fatigue is actually coming from.
The first thing I do with my patients, after asking them a million questions, is send them for blood work.
There are three big categories I'm screening for.
The first is nutrient deficiencies.
This is by far the number-one physical cause of fatigue I see among women, and within that, iron deficiency is the biggest one.
There's also vitamin B12 deficiency and vitamin D deficiency.
Those are some of the main nutrient deficiencies I'm screening for.
The second area is thyroid function.
I'm screening for things such as Hashimoto's thyroiditis and hypothyroidism.
Then the third area is metabolic function.
I'm checking blood sugar, insulin, inflammation and cholesterol.
What I find interesting is that women often come in convinced they have a thyroid problem or a quote-unquote hormonal imbalance.
When we test them, it's relatively uncommon in my practice that the primary issue is actually the thyroid.
It's much more common for me to see a nutrient deficiency, insulin resistance or inflammation.
Victoria
That's interesting.
I hear “I think I have a thyroid problem” all the time in clinic too.
I'm like, “I don't want to say I wish you had a thyroid problem just because I love working with thyroid issues, but I really don't think that's what's happening here.”
Dr. Sarah Vadeboncoeur
Those are important conversations.
Women have been dismissed for so long in the medical system, particularly with symptoms such as fatigue, and they're often told there's nothing wrong.
Sometimes I frame testing by saying, “This is actually great news. You don't have a thyroid problem.”
Iron deficiency or insulin resistance can be much more straightforward to address.
Testing helps us narrow where we put our time, energy and resources.
Another thing that tires women out is trying to do everything.
They're doing the thyroid stuff, the inflammation stuff, the weight-loss stuff, and they're completely overwhelmed.
Sometimes I'm helping them stop worrying about certain things and saying, “This is where I really want you to focus.”
If somebody needs iron, I might say, “Your iron supplement is non-negotiable for the next three months. Please take it every day.”
It helps them figure out where to put their energy.
Victoria
The insulin-resistance piece is fascinating.
If you went to your conventional doctor and had a standard workup for fatigue, you might not get a workup for insulin resistance.
Your labs may come back showing no obvious thyroid problem and no iron deficiency, and then you think, “I guess it's all in my head.”
Dr. Sarah Vadeboncoeur
What's important to understand about insulin resistance is that your blood sugar can still be normal.
Patients will tell me, “My doctor checked my blood sugar and it was fine.”
That's great, but it doesn't necessarily mean there isn't insulin resistance.
To assess insulin resistance, I'm interested in both blood sugar and insulin.
One of the conversations I have with patients all the time is about meal timing.
Everybody is excited to talk about what to eat.
Before I even worry about exactly what's on your plate, I'm asking: can we start eating breakfast?
Can we eat lunch before four o'clock?
Can we get some protein?
I treat a lot of government workers because I live in Ottawa, and the number of women who don't take a lunch break or run out the door with barely any breakfast is incredible.
To me, that's a major part of the metabolic conversation.
It isn't only what we eat. It's also when we eat.
From an energy perspective, you're expecting your brain and body to function for half the day with very little fuel.
Maybe there's nothing coming in other than coffee.
Then by lunch you're saying, “Why can't I think straight? Why am I so tired?”
Because you've had a coffee and maybe a granola bar if you're lucky.
Insulin resistance has many contributing factors, but one of my first conversations is simply: start eating regular meals.
I know that sounds basic.
We're all looking for magical, sophisticated answers, while the obvious things that can be very powerful are being overlooked.
I've been in practice for almost 15 years.
When I first started, I was excited about IVs and fancy interventions.
Now I'm saying, “Drink some water. Eat some breakfast.”
The basics are powerful.
If you do them consistently, you often don't need all the fancy stuff.
Jeanette
Vic and I talk about this all the time.
It must be partly psychological.
The basic things aren't sexy enough.
People assume a supplement or fancy intervention must work better because it's more interesting.
Then when you actually nail the foundations, you realize you may not need ten supplements or all these IVs.
Dr. Sarah Vadeboncoeur
When we look at populations that live long, healthy lives, they're not necessarily using red-light therapy, taking endless supplements or cold plunging.
They're eating whole foods.
They're walking.
They're eating dinner with their family.
They're doing meaningful work.
They're not stressing themselves to death the way we often do.
I remind myself of that.
I don't personally take a million supplements.
I don't have a red-light setup or a cold plunge.
Those things can be nice.
If you have the time and money and want to do them, knock yourself out.
But in my experience, consistency with the basics is going to have one of the most powerful effects on your health.
And consistency is the hardest part.
Jeanette
We can't talk about fatigue without talking about adrenal fatigue.
We've debunked it on the podcast before, but I'd love to hear it directly from you.
Is adrenal fatigue a real diagnosis?
When people talk about burnout online, everything seems to be about the adrenals.
Is that actually where we should be focusing?
Dr. Sarah Vadeboncoeur
My answer is yes and no.
First, adrenal fatigue isn't a real diagnosis, even though I used to diagnose my patients with it all the time before I learned more.
Second, burnout isn't diagnosed through a cortisol or adrenal test.
Burnout is assessed through its clinical criteria and questionnaires.
It isn't about your adrenal glands.
Cortisol is important, but not in the way influencers often make it sound when they're telling everybody to be scared of coffee or high-intensity exercise.
Two of the major hormones involved in our sleep-wake cycle are cortisol and melatonin.
When you wake up in the morning, during roughly the first 30 to 60 minutes, you should get a nice surge of cortisol.
Cortisol peaks around that first hour after waking and then gradually declines throughout the day.
That's an important part of your circadian rhythm, which affects energy.
When we look at things that influence that rhythm, one of the most important is light.
Not electrolytes.
Not a fancy adrenal cocktail.
Light.
If you want to support that morning cortisol rhythm, go outside.
Sit outside for five or ten minutes while you drink your coffee.
Go for a loop around the block.
Morning light is a powerful signal for your circadian system.
Cortisol is also a stress hormone.
Where I think people go wrong is assuming cortisol is inherently bad.
It isn't.
It's essential.
There can certainly be problems when stress is excessive or prolonged, but cortisol itself isn't the enemy.
Another thing women don't always realize is that not eating enough can trigger a stress response.
If your brain senses that blood glucose is falling, it wants to preserve a steady glucose supply.
It can signal the adrenal glands to release cortisol, and one of cortisol's functions is helping increase available glucose.
So again, one of the simple things you can do is eat breakfast, lunch and dinner.
I joke that if you get “hangry,” you may need to look at your meal timing.
If you're getting shaky and irritable because you've gone too long without eating, that's a sign you may be pushing things too far.
The classic theory behind adrenal fatigue is that the adrenal glands get tired and eventually can't produce enough cortisol.
That's not what's happening.
The adrenals aren't just producing cortisol randomly.
They're responding to signals from the brain.
If you're late for work or get an angry email from your boss, your brain recognizes the stress, signals the adrenal glands and cortisol helps you respond.
If stress continues for months, years or decades, the signalling can change.
That doesn't mean the adrenal gland itself became “tired” or ran out.
The communication within the stress-response system changes depending on the nature and duration of stress.
Victoria
That's the first time I've heard it described that way.
It makes a lot of sense.
I admit I'm often on the other side of the spectrum saying, “Please, everybody stop talking about cortisol.”
But I searched fatigue on social media to prepare for this episode and it was the cortisol coach, the cortisol healer, cortisol this and cortisol that.
We need to chill out for a second.
Those are the people telling you to drink an adrenal mocktail.
Nobody is talking about eating three meals a day.
Dr. Sarah Vadeboncoeur
Because it isn't sexy.
Nobody is going to build an Instagram following saying, “Eat breakfast, lunch and dinner.”
They're going to get a following by making a 12-ingredient adrenal cocktail to have instead of coffee.
And speaking of coffee: coffee is not automatically raising your cortisol in some dangerous way.
You can have your coffee.
I'm very pro-coffee.
You do not need to eliminate it simply because you're tired.
Coffee is associated with a number of positive health outcomes.
The important considerations are timing and context.
Drink it early enough that it doesn't disrupt your sleep.
Make sure coffee isn't suppressing your appetite to the point that you're not eating breakfast.
Women will tell me, “I'm not hungry in the morning.”
Sometimes I'll say, “Try giving up your morning coffee briefly and see how hungry you actually are.”
Have your coffee, but try to have at least some food with or around the same time.
Another myth is that cardio or high-intensity exercise is ruining your cortisol.
Exercise temporarily raises cortisol.
That's a normal response.
Any type of exercise can do that.
That does not mean it raises cortisol chronically in a harmful way.
Please don't avoid exercise if you love cardio, spin classes or OrangeTheory because somebody told you it's destroying your hormones.
Victoria
It's important to remember that cortisol is supposed to change throughout the day.
It's the same thing with glucose.
People panic about a glucose spike after eating cake.
It's sugar.
You're supposed to have a glucose response.
Dr. Sarah Vadeboncoeur
Exactly.
Glucose isn't inherently bad either.
Your brain is saying, “Fuel. Amazing. I have energy to do things.”
Victoria
What about the 2 p.m. or 3 p.m. energy slump?
I see it all the time in practice, and I've experienced it myself.
You're just exhausted at that hour.
What's happening?
Dr. Sarah Vadeboncoeur
It's usually a combination of things.
Physiologically, if you looked at a normal cortisol curve, there's a significant decline between lunchtime and around four o'clock.
In other countries, some cultures accommodate that natural rhythm with a siesta or a nap and then continue their day.
We don't tend to do that here.
We expect constant productivity.
So part of the afternoon slump is simply that we're working through a natural lower-energy period.
Another part is fuel.
If you skipped breakfast and had hummus and crackers for lunch, by two or three o'clock you may simply be running out of energy.
You've been sitting at your desk working since nine and haven't adequately fuelled yourself.
Then there's mental and decision fatigue.
Think about how many decisions you've made by two o'clock.
Before you even leave your house, you've decided what to eat, what to wear, what to do with your hair, what to pack and what needs to happen that day.
If you have kids, you're also being asked a million questions while trying to organize yourself.
Then most of us work on computers.
There are emails, notifications, meetings and constant demands for attention.
Our brains weren't designed to filter this amount of information all day.
Of course we're exhausted by two o'clock.
Jeanette
We've talked about common physical causes of fatigue, but what about chronic fatigue syndrome or post-infectious fatigue that never seems to improve?
Dr. Sarah Vadeboncoeur
We're seeing more of that post-COVID.
One positive thing to come from so many people experiencing COVID is that people are more willing to recognize that post-viral illness is real.
For a long time, people with chronic fatigue syndrome were dismissed and told it was all in their head.
Now there's more awareness that post-viral fatigue can happen.
It isn't something I see constantly in my own practice, but it is one type of fatigue.
If your fatigue began with an illness and you never really recovered, a viral illness may be relevant.
We also know that people with a history of Epstein-Barr virus, which causes mononucleosis, appear to have an association with chronic fatigue syndrome.
So some fatigue may have a significant immune component, whether that's post-viral illness or autoimmune-related fatigue.
In the history, I want to know what someone's immune system has been like.
Do you get sick constantly?
Does it take three weeks to recover every time?
Did you have mono?
Do you have recurrent infections?
Those details help me understand whether the immune system may be part of the picture.
Jeanette
When you do see post-infectious fatigue, are you focusing more on the immune system or starting with the same basic foundations?
Dr. Sarah Vadeboncoeur
I may put more emphasis on immune support.
That often includes looking at gut health because we're learning so much about the relationship between the gastrointestinal system and immune function.
Stress management is also important because chronic stress can affect immune function.
You two are students, so you know what happens.
You finish your exam and wake up the next day feeling terrible.
Victoria
Yes.
I always say CCNM fatigue needs its own category.
The minute I finish an exam everybody asks, “You must feel so good. You must be so relieved.”
No.
I feel like a pile of garbage.
I usually have an ear infection during or after exams for some reason.
All of us talk about this after exam season.
Dr. Sarah Vadeboncoeur
When you're in that high-stress period, cortisol is helping you manage the demand.
Then the stressor stops and people sometimes experience a letdown.
The immune system is one place that can show up.
If you get sick every time you finally go on vacation or every Christmas holiday, that can be a sign that stress deserves more attention.
Sleep is important too.
If you're consistently getting less than seven hours, that's another factor that can affect immune function and recovery.
Jeanette
You also talk a lot about perimenopause and fatigue.
Can you touch on that?
Are there other age groups where you see a lot of fatigue?
Dr. Sarah Vadeboncoeur
Perimenopause is really interesting because we're learning that many symptoms during the menopause transition are neurologically mediated.
The brain is adapting to a very different hormonal landscape.
Hormones are fluctuating more dramatically and eventually declining.
That can contribute to fatigue, particularly mental and emotional fatigue.
A lot of women have worsening PMS.
Anger and irritability can show up.
Mental health can worsen.
Sleep often starts deteriorating.
All of those things make you more tired.
Then we also have to look at life stage.
If you're in your mid- to late 40s, you may be at the peak of your career.
You may still have children you're caring for.
Your parents may now need more support.
Your energy is being pulled in multiple directions.
So yes, we want to manage perimenopause symptoms and support sleep.
But we may also need to talk about boundaries and prioritizing time for yourself when there are so many demands on you.
Jeanette
Do you refer patients to psychologists or therapists?
Dr. Sarah Vadeboncoeur
Every day.
My favourite patients to work with are often already doing therapy because it's such an important piece.
Many of the women I work with are high achievers.
We did well in school.
We perform well at work.
We're the people everyone can count on.
We're hard workers.
Those are wonderful qualities.
But if you don't learn how to manage them, you can work yourself into burnout.
It's important to ask: what is driving my need to work this hard?
Why do I need to help everybody except myself?
Therapy and mindset work can be very powerful here.
I've had several patients choose to change jobs and move into what they describe as a “lower-level” position.
They'll call it a demotion, which I hate.
What they're realizing is, “I can't do everything. This job is sucking away my energy, joy and health, and I'm not willing to sacrifice my health for it anymore.”
I'm very pro-therapy.
I recommend it all the time.
Jeanette
I want to circle back to something you mentioned about gut health, digestion and fatigue.
Patients often tell us they have food sensitivities or self-diagnosed food sensitivities and say, “Whenever I eat this food, I get tired or brain fog.”
Or their gut health feels off and they feel tired.
Do you see that?
Dr. Sarah Vadeboncoeur
I do.
There are a couple of things.
People who have a lot of bloating, gas and irritable bowel syndrome-type symptoms are also more likely to have mental-health conditions, particularly anxiety.
Sometimes people have digestive symptoms that they blame on food sensitivities, when part of the issue may actually involve the gut-brain connection.
I know it feels like everything we're talking about comes back to the brain, but the brain directs so much of what the body is doing.
Some of the most interesting work I've been doing around gut health lately involves getting people to stop obsessing over food.
Everybody asks, “What do I have to cut out? Give me a food-sensitivity test.”
I'm saying, “Save your money. That's not necessarily what you need.”
Instead, sometimes we're working on the gut-brain connection without changing their food at all.
Sometimes we make dietary changes too, but the nervous-system component can make a significant difference.
There are situations where gastrointestinal disease can directly contribute to fatigue.
If someone has celiac disease, Crohn's disease or ulcerative colitis, for example, malabsorption or blood loss can be relevant.
But in somebody without those conditions who has bloating or IBS symptoms, fatigue and digestive symptoms may sometimes occur together in the context of a heightened stress response.
Then I do another radical intervention.
Once you're eating three meals a day, I ask you to eat them at a table.
Sit down.
Chew your food.
Very radical.
People are often more willing to put themselves on a highly restrictive diet than to put down their phone, sit at a table, chew properly and let a meal take 15 or 20 minutes.
For many people, that may be more useful than automatically cutting out gluten, dairy or whatever food happens to be the villain that week.
Victoria
It goes back to consistency.
The liver detox you're about to do—are you going to do that for the rest of your life?
Probably not.
Dr. Sarah Vadeboncoeur
And what exactly is it detoxing?
Victoria
Your liver, obviously.
Dr. Sarah Vadeboncoeur
Obviously. Because everything is toxic.
The seed oils! You've got to detox the seed oils.
Victoria
Don't get us started.
Dr. Sarah Vadeboncoeur
I listened to that episode. We don't have to rehash it today.
But yes: put down the liver detox, put down the adrenal supplement and put down the thyroid supplement.
First, speak to someone before you buy those things.
Second, if you're not doing the foundations, stop trying to jump a hundred steps ahead.
People want to do step 382 when they're not doing steps one through five.
Victoria
Jeanette, we're going to have to post four audio clips a day from this episode.
There are so many.
Jeanette
I know.
Victoria
What about fatigue related to the menstrual cycle?
Is cycle-related fatigue real?
Dr. Sarah Vadeboncoeur
It is real.
Understanding what's happening through your menstrual cycle is one of the most powerful things a woman can do because most of us don't understand our cycles very well.
We know we get a period, but that's often where the knowledge ends.
Energy can fluctuate across the cycle.
Just like you may naturally feel tired by eight or nine at night, you may notice more fatigue in the week before your period and during your period.
You're bleeding.
We sometimes forget that menstruation is a real physiological event that requires resources.
So it's reasonable that some people feel more tired during that time.
On the other side, when your period ends and hormones start rising as you move toward ovulation, many women notice more energy, confidence and generally feel better.
I like encouraging women to connect with all parts of the menstrual cycle.
We focus so much on the negative—the cramps, PMS and bleeding—that we forget there can be times in the cycle when we feel great.
Our cycles can teach us about natural ebbs and flows in energy.
It's not realistic to expect yourself to have high energy all day, every day.
A few days before your period, maybe you're not going to want to dance at a club until two in the morning.
Maybe you want to eat popcorn, drink tea and watch Emily in Paris.
Let yourself do that.
You can go clubbing when you feel more energetic if that's what you want.
Victoria
This is the kind of cycle syncing I can get behind.
Clubbing when you're ovulating and Emily in Paris when you're menstruating.
Dr. Sarah Vadeboncoeur
Exactly.
And briefly on cycle syncing: you do not need to completely cycle your exercise routine, and you don't need to eat seeds in a specific order.
If you love cardio and feel good doing spin on your period, do it.
If you're tired and want to do yoga, do yoga.
We've made things so complicated.
You do not need to change your entire wellness routine every week based on your menstrual cycle.
Listen to your body.
If you have lots of energy, do a bigger workout.
If you're having a lower-energy day, do something calmer, regardless of where you are in your cycle.
Jeanette
We've talked about cycle syncing before.
Similar to the cortisol-coach trend, there are fitness influencers who have built entire businesses around cycle syncing.
I don't necessarily think everybody is intentionally trying to mislead women, but the part that bothers me is when they're telling women they have to exercise this way.
Dr. Sarah Vadeboncoeur
A lot of things make me angry on the internet.
This is one of them.
Women already have such a negative relationship with the word “hormones,” as though hormones are out to get us.
They're not.
These hormones are part of a reproductive system that's literally capable of creating life, whether or not someone chooses to do that.
But we treat hormones like this horrible thing happening to us every month.
At the same time, many women don't exercise enough.
They don't eat enough fruits and vegetables.
They don't get enough fibre.
When we make healthy living more complicated by saying you can only do certain things at certain times, we overwhelm people and make them less likely to do anything.
I want women to exercise.
Pick something you like and do it.
There is no single “bad” form of exercise.
Would it be ideal to eventually get a mix of cardiovascular exercise, strength training and flexibility or mobility work? Sure.
But start by picking something you enjoy because that's what makes you more likely to build the habit.
Jeanette
It goes back to decision fatigue.
Dr. Sarah Vadeboncoeur
Completely.
Jeanette
Let's talk about sleep because it's obviously a huge pillar of health.
What about deep sleep and REM sleep?
Somebody can say, “I sleep eight hours, but I wake up and never feel refreshed.”
Can sleep quality contribute to fatigue even if the number of hours looks good?
Dr. Sarah Vadeboncoeur
Absolutely.
During the first half of the night, you tend to get more deep sleep.
Deep sleep is where a lot of physical restoration and repair occurs.
Then during the second half of the night, you tend to get more rapid eye movement sleep, or REM sleep, which is when we do much of our dreaming.
I like the phrase “emotional first aid” for REM sleep.
That's not my phrase—I believe it comes from Matthew Walker.
During REM sleep, your brain is processing experiences and emotions.
Sleep is incredibly important for both physical and mental energy.
If you wake up and don't feel rested, we first ask whether there's a sleep problem or sleep disorder.
Are you tossing and turning?
Are there signs of sleep apnea?
That's something I screen my patients for.
Are there restless legs?
Leg cramps?
Something physical disrupting the sleep?
We want to make sure the sleep itself is good quality.
If you appear to be getting good-quality sleep, you're sleeping somewhere in the seven- to nine-hour range and you still don't feel rested, some common things I think about include nutrient deficiencies, thyroid conditions, depression and burnout.
I also think we need to reset our expectations.
People think they're supposed to wake up and immediately bounce out of bed.
I've never bounced out of bed in my life, which maybe isn't great marketing for somebody known as the Fatigue Fixer.
That's just not my morning style.
I like to ease into my morning.
It's okay not to leap out of bed feeling like a million dollars.
But once you've been awake for 30 to 60 minutes, if you're still extremely sleepy and groggy, that's something to pay attention to.
Jeanette
What about the opposite problem: wired but tired?
You're exhausted, but then you can't fall asleep.
What's happening there?
Dr. Sarah Vadeboncoeur
If you're having trouble falling asleep, one possibility is that your bedtime is mistimed.
Let's say you wake up at seven.
From the time you wake up, you begin building what we call sleep pressure.
That pressure tends to become strong around 14 to 16 hours after waking.
For somebody who wakes at seven, that puts an appropriate bedtime window somewhere around nine to eleven at night.
Within that window, you ideally wait until you feel sleepy, not just tired.
Sleepy means your eyelids are heavy and you genuinely feel like you could fall asleep.
If you go to bed in that window, your body feels tired and sleepy but your brain is still racing, that's classic “wired but tired.”
Your body is exhausted, but your brain hasn't shut down.
Stress is one of the biggest things I see contributing to this.
In a healthy circadian pattern, cortisol should be much lower at night while melatonin rises before sleep.
Things that can interfere include drinking coffee late in the day and doing stressful or highly stimulating things in the evening.
Maybe you watch a murder mystery where your brain is thinking, “There's a murderer next door!”
Then the show ends and you say, “That was fun. Time for bed.”
Your brain is saying, “Excuse me? There's a murderer next door. We can't sleep.”
One of the conversations I have with patients is that the brain needs to feel safe enough to sleep.
Historically, being asleep made humans vulnerable.
Our brains still respond to perceived threat.
Most of us now live in houses where we can lock the doors, so physical danger is generally lower, but we constantly create psychological threat.
We watch horrific news.
We watch intense television.
We scroll through people arguing online.
Your brain doesn't necessarily respond by thinking, “These are just people on my phone.”
It's receiving information about conflict, danger and stress.
If you're prone to anxiety, rumination or overthinking, you may need to be especially intentional about what you're exposing your brain to in the evening.
The goal is to create an evening routine that allows the nervous system to settle.
Victoria
The evening news is such a good example.
They'll warn you that what they're about to show may be “troubling to some viewers.”
Troubling?
Sometimes it's horrifying.
It's awful that terrible things are happening in the world, but constantly exposing ourselves to graphic or distressing information and then expecting to sleep peacefully is a lot to ask of our brains.
Dr. Sarah Vadeboncoeur
Exactly.
Our brains are stressed out.
Victoria
When someone presents as wired but tired, are you immediately testing cortisol?
Do you test cortisol much?
Dr. Sarah Vadeboncoeur
Honestly, I rarely test cortisol.
We can test it.
It may cost a patient a few hundred dollars.
But in many situations, I'm probably going to give them the same foundational recommendations I could have given without the test.
There are situations where we've explored everything else and the patient is convinced cortisol is an issue, and then I may test it.
But it isn't something I routinely start with.
Victoria
That's what I figured.
So many patients come in saying, “I need you to test my cortisol.”
And I'm thinking, “I already know you're stressed.”
Dr. Sarah Vadeboncoeur
Exactly.
Sometimes we can save you the test and acknowledge that stress is part of the picture.
Victoria
We've talked about meal timing, but what about the actual food?
Two big trends are low-carb diets and fasting.
Can those affect energy?
What kinds of dietary additions do you find helpful?
Dr. Sarah Vadeboncoeur
I would say both fasting and aggressive carbohydrate restriction are more likely to make some women tired over the long run.
I don't love fasting for many of the women I work with because fasting itself is a physiological stressor.
Most of the women I know aren't looking to add more stress.
If you're asking your brain and body to function through half the day in a fasted state, that's an additional demand.
So if your goal is to reduce stress and improve energy, a very simple starting point can be: eat breakfast.
Then we have the obsession with carbohydrates being responsible for all our problems.
They're not.
Carbohydrates are a useful energy source.
The brain uses glucose as an important fuel source.
Carbohydrates can be very useful for energy, particularly when you're physically active.
They can also provide fibre.
I'm a big fan of women including carbohydrates rather than being afraid of them.
My general plate guideline is going to sound incredibly unsexy.
I want protein.
I want plenty of fruits and vegetables.
And I want some carbohydrate sources, ideally including whole grains.
We've made nutrition so complicated.
When you look at populations that tend to live healthy lives, they're not necessarily all following keto, carnivore or vegan diets.
They're eating food.
I sometimes think we overemphasize tiny nutritional details because we're constantly trying to make a diet “perfect.”
If you eat a balanced diet consistently most of the time, you're going to get most of the benefit.
Obsessing over the last tiny percentage can consume a lot of time and energy while taking attention away from things that may matter more—exercise, therapy, relationships, meditation, walking, reading a book and getting off your phone.
I'd rather people spend less time obsessing about the perfect macro breakdown or whatever food is supposedly toxic this week.
Jeanette
A lot of listeners are going to ask: what supplements help fatigue?
We learn about adaptogens for stress and fatigue and things like B12 injections.
Without giving individual medical advice, what kinds of supplements do you use in practice?
Dr. Sarah Vadeboncoeur
I start with basic nutrients.
Does the person need iron, vitamin B12 or vitamin D?
Living in Canada, vitamin D supplementation is often relevant during winter because sunlight exposure is limited and getting enough vitamin D through food alone can be difficult.
B12 injections can be great when somebody actually has low B12.
If you aren't B12 deficient, repeated B12 shots may not do much for you.
If somebody is deficient, they can be very helpful.
In terms of adaptogens, I do use them.
I use ashwagandha quite a bit.
I use rhodiola.
I also use saffron, particularly sometimes in the perimenopause transition, although I wouldn't necessarily classify saffron exactly the same way as an adaptogen.
Ashwagandha and rhodiola are probably the two classic adaptogens I use most.
But I give them with context.
A supplement is there to support the diet and lifestyle changes.
A supplement is not going to fix the fact that you're in a terrible relationship.
It's not going to magically undo burnout or an unsustainable workload.
But if something gives you a little more support or energy and that helps you start implementing the bigger changes, then it can have a useful role.
Victoria
That's exactly how saffron felt for me.
It gave me enough of a boost that I wanted to go for a walk.
I wanted to call my friends.
I didn't want to shut everybody out the way I sometimes do when I'm dealing with seasonal depression.
The supplement didn't solve my entire problem.
It gave me a little boost that helped me do the foundational things.
I was sleeping better.
I felt happier.
On that topic, I never really appreciated how strongly depression and fatigue are connected.
When I was dealing with thyroid issues and was both fatigued and depressed, my doctor wanted to prescribe an antidepressant.
I used to talk about how awful I thought that was.
Now I understand the reasoning more.
What's the connection?
Dr. Sarah Vadeboncoeur
Fatigue is a major symptom of depression.
What can be tricky is teasing apart cause and effect.
When someone is tired, they may no longer have enough energy to see friends or get things done.
That naturally affects mood.
Then they're showing symptoms that overlap with depression.
So are they clinically depressed, or are they understandably upset and low because they've been exhausted for a long time?
The two can go hand in hand.
I've become much more active about screening for depression.
One of the biggest eye-openers when I entered practice was how many women are dealing with anxiety, depression or both.
Coming out of naturopathic school, I had a more negative view of antidepressants.
My thinking has changed.
I don't think they should automatically be prescribed for every symptom, but they are a tool.
For some people, they're an incredibly important, even life-saving tool.
When I discuss depression, I use a biopsychosocial model.
There are three broad buckets.
The first is biology.
That can include brain chemistry, nutrient deficiencies, thyroid health, sleep and other physical factors.
We often hear the simplistic idea that depression is just a serotonin deficiency.
That hasn't been established as a complete explanation for depression.
But biology can still matter, and medication can absolutely be helpful for some people.
The second bucket is psychological.
That's beliefs, behaviours, mental-health patterns and the areas where therapy can be incredibly important.
The third is social.
We're social animals.
We saw mental health deteriorate during the pandemic when people experienced increased social isolation.
So I don't think the complete treatment for depression can be “give somebody an antidepressant and send them on their way.”
We want to support their physical body, psychological health and social connections.
Fatigue can absolutely be part of depression.
One distinction I sometimes make is that someone who is physically fatigued may desperately want to go out, exercise or see friends but feel like they don't have the energy.
Someone who is depressed may additionally lose the desire, interest or pleasure associated with those things.
It's not a perfect distinction, but it can help us understand what someone is experiencing.
Jeanette
I'm glad we made that distinction.
It's time for rapid fire.
You can answer myth, truth or “it depends.”
First: Fatigue is caused by high cortisol.
Dr. Sarah Vadeboncoeur
Myth.
Jeanette
Napping more often will fix fatigue.
Dr. Sarah Vadeboncoeur
It depends.
Napping can be helpful.
If you need a nap occasionally because you're tired that day, enjoy the nap.
That's not automatically a problem.
If you need a nap every day and cannot make it through the day without one, that's something I would want to investigate.
But occasional naps are absolutely fine.
Jeanette
Fatigue is almost always associated with iron deficiency.
Dr. Sarah Vadeboncoeur
If you're a woman who menstruates, iron deficiency is very important to consider.
Jeanette
Okay. Not awesome, but good to know.
Dr. Sarah Vadeboncoeur
Exactly.
Jeanette
Fatigue in perimenopause or menopause is normal.
Dr. Sarah Vadeboncoeur
It can be a normal part of the transition, and there are things we can do to improve quality of life.
That's one of my biggest messages with perimenopause.
Perimenopause is a normal life stage.
It isn't a disease state.
But that doesn't mean we ignore symptoms that are interfering with someone's quality of life.
Jeanette
You should not exercise when you're fatigued.
Dr. Sarah Vadeboncoeur
It depends.
If you're tired, you start exercising and then you feel good during and afterward, keep exercising.
Sometimes the hardest part is simply getting started.
If you consistently feel more tired after exercise, you may need to reduce the intensity or duration.
If that's happening frequently, particularly with significant soreness or malaise afterward, then we may need to consider something more significant such as burnout or chronic fatigue syndrome.
Jeanette
Your blood sugar or insulin might be contributing to fatigue.
Dr. Sarah Vadeboncoeur
True.
But again, I want to understand the habits affecting blood sugar and insulin rather than simply treating a number.
Victoria
That was a good round.
We ask every guest one question at the end of the episode.
We've been myth-busting this entire time, but is there one fatigue myth you'd like to bust once and for all?
Dr. Sarah Vadeboncoeur
We've already talked about it, but we have to stop hating on coffee.
Coffee is not automatically the cause of your fatigue.
Coffee doesn't actually make you more tired.
What caffeine does is temporarily block you from noticing how tired you are.
Throughout the day after you wake up, you build sleep pressure.
One of the chemicals involved in that sleep pressure is adenosine.
Caffeine blocks adenosine receptors temporarily, so you drink coffee and think, “I feel great.”
When the caffeine wears off, you can feel tired again, and you've also accumulated more sleep pressure during that time.
So you may feel more tired an hour or two later, but the coffee didn't create all that fatigue.
More time passed and the underlying sleep pressure was still building.
Victoria
I love that.
I genuinely didn't know that.
Jeanette
That's interesting.
Dr. Sarah Vadeboncoeur
There you go.
We learn something new every day on the podcast.
Victoria
We really do.
You also have an amazing podcast called The Fatigue Fixer. It's one of my favourites.
I know everyone is going to want to listen after this episode.
You were such an incredible speaker. Thank you so much for being here.
Where else can listeners find you?
Dr. Sarah Vadeboncoeur
This was so much fun.
You can find me on Instagram at @sarahvadeboncoeur, and you can learn more about my services at drsarahv.ca.
Victoria
Amazing.
Thank you so much, Dr. Sarah.
Dr. Sarah Vadeboncoeur
My pleasure.
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It wasn’t until the pandemic forced me to actually slowdown that I realized how exhausted I was. How my obsession with productivity and getting through my impossibly long to-do lists was draining me. And I was seeing the same patterns in the exhausted women showing up in my office desperately looking for answers.
That’s when I became obsessed with figuring out what was making women so tired. In my case, that meant more exercise, improving my sleep quality and correcting my iron deficiency.
stuff…
I have a Bachelor of Health Science & graduated from the Canadian College of Naturopathic Medicine in 2010. I’ve been a Naturopathic Doctor since then and have had the pleasure of working with over 2000 women in my 1-on-1 practice over the past decade.